Transcript Temporomandibular Disorders

Temporomandibular
Disorders
Primary Care Conference
2/23/05
Clinic Case
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JD is a 29 yo F new patient who presents for
refill on Vicodin for TMJ. Has headache, pain,
decreased jaw ROM over the past 1 1/2 years
PMH:
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TMJ syndrome, gastritis/dyspepsia, depression
SH:
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3 children (8,4,3), marital discord (reconciled after
separation), verbal abuse, beginning career as realtor
Definition of TMD
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1996 NIH Consensus Conference:
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A collection of medical and dental conditions
affecting the TMJ and/or the muscles of
mastication as well as contiguous tissue
components
Definition of TMD
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3 Main Categories;
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Myofascial pain (jaw muscles, neck muscles,
shoulder muscles)
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Internal derangement of the joint (dislocated
joint, displaced disk, condylar trauma)
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Degenerative joint disease (OA, RA)
Anatomy of TM Joint
Anatomy of TM Joint
Epidemiology
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60-70% of general population have one
sign
Prevalence by self report: 5-15% (one
source estimates 10% of women, 6% of
men)
5% or less seek treatment
Women>men 4:1 seek treatment
Epidemiology
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Early adulthood (ages 20-40)
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Many TMD are self-limiting or fluctuate
over time without progression
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5% require surgery
Etiology
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Multifactorial
Predisposing factors
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Precipitating factors
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Musculoskeletal
Trauma, clenching, grinding
Perpetuating factors
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Chronic MSK dysfunction, psychogenic
Clinical Manifestations
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Pain
Joint clicking
Restricted jaw range of motion
Other symptoms are not specific to TMD:
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Headache, ear ache, neck and shoulder pain
Diagnosis: History
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Pain
Worsens with jaw use
 Centered anterior to tragus
 Radiates to ear, temple, cheek, mandible
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Clicking/joint noise
Restricted ROM
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Tight feeling, catching, locking
Diagnosis: History
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Habits
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Clenching, grinding,cradling phone, back
packs
SH: stressors
PMH: related disorders, trauma, dental
problems
Diagnosis: Exam
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Inspection:
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ROM:
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Facial asymmetry, posture, eccentric jaw movements
Vertical (42-55 mm), lateral, protrusion
Palpation:
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Pre-auricular/anterior to tragus: joint mobility, joint
sounds (audible, palpable)
Masseter, temporalis, pterygoid, suprahyoid, SCM,
cervical
Diagnosis: Exam
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Oral function: occlusion, swallowing,
breathing
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Postural/musculoskeletal:
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Forward head posture, systemic
hypermobility, joint problems elsewhere
Treatment Goals
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Educate patient about TMD and selfmanagement
Reduce or eliminate pain and joint noise
Improve function
Avoid unproven treatments that can cause
problems
Treatment: NIH guidelines
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Phase I: Conservative and Reversible
Patient education
 Physical Therapy/Occupational Therapy
 Psychotherapy
 Medications
 Bite splint/Occlusal Splint
 Stress management
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(Multidisciplinary approach)
Treatment: NIH guidelines
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Phase II: only after conservative measures
exhausted
Surgery: arthrocentesis, arthroscopy, open
joint surgery, orthognathic
 5%
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Treatment: Patient Education
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About TMD
Avoid painful activities
Avoid clenching grinding
Normal resting position of jaw
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Tongue up, teeth apart, lips together
Moist heat/ice
Gentle stretching
Treatment: PT/OT
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Patient assessment
Postural assessment
Patient education
Joint mobilization/manual therapy
Iontophoresis in selected cases
Home therapy program
Treatment: Pharmacologic
NSAIDS-scheduled dosing
 Muscle relaxants
 Tricyclics
 Opioids
 Steroid injection
 Botox injection
*UW TMD clinic does not find muscle relaxants
very useful, does not use tricyclics, rarely
opioids
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Treatment: Bite Splint
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Indications:
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AM symptoms, daytime clenching, teeth are
worn
Worn only at night
Does not move jaw (not an anterior
repositioning splint)
Evidence Based Medicine
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Limited Evidence, recommended
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Limited Evidence, needs further study
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NIH Phase I and II treatments discussed previously
Acupuncture
EMG biofeedback
Limited Evidence, not recommended
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Occlusal adjustments that permanently alter a
patient’s occlusion (Grinding teeth down, anterior
repositioning splints)
Alloplastic implants
Local Resource
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UW TMD Clinic: 263-7502
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Lisa M. Dussault, OTR, John F. Doyle DDS
Imaging as indicated
Referral to specialists as indicated
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Rehab Med psychologist, Oral/craniofacial
surgery, speech/swallow, etc
Indications for Referral
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Trauma to the face at onset of pain
Joint noise PLUS dysfunction
Locking/catching of TMJ
Limitation of opening/ROM
Pain in jaw and muscles of mastication on
awakening
Orofacial pain aggravated by jaw function