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Temporomandibular Disorders. Primary Care Conference 2/23/05. Clinic Case. 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: TMJ syndrome, gastritis/dyspepsia, depression SH:

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temporomandibular disorders

Temporomandibular Disorders

Primary Care Conference

2/23/05

clinic case
Clinic Case
  • 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:
    • TMJ syndrome, gastritis/dyspepsia, depression
  • SH:
    • 3 children (8,4,3), marital discord (reconciled after separation), verbal abuse, beginning career as realtor
definition of tmd
Definition of TMD
  • 1996 NIH Consensus Conference:
    • A collection of medical and dental conditions affecting the TMJ and/or the muscles of mastication as well as contiguous tissue components
definition of tmd4
Definition of TMD
  • 3 Main Categories;
    • Myofascial pain (jaw muscles, neck muscles, shoulder muscles)
    • Internal derangement of the joint (dislocated joint, displaced disk, condylar trauma)
    • Degenerative joint disease (OA, RA)
epidemiology
Epidemiology
  • 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
epidemiology8
Epidemiology
  • Early adulthood (ages 20-40)
  • Many TMD are self-limiting or fluctuate over time without progression
  • 5% require surgery
etiology
Etiology
  • Multifactorial
  • Predisposing factors
    • Musculoskeletal
  • Precipitating factors
    • Trauma, clenching, grinding
  • Perpetuating factors
    • Chronic MSK dysfunction, psychogenic
clinical manifestations
Clinical Manifestations
  • Pain
  • Joint clicking
  • Restricted jaw range of motion
  • Other symptoms are not specific to TMD:
    • Headache, ear ache, neck and shoulder pain
diagnosis history
Diagnosis: History
  • Pain
    • Worsens with jaw use
    • Centered anterior to tragus
    • Radiates to ear, temple, cheek, mandible
  • Clicking/joint noise
  • Restricted ROM
    • Tight feeling, catching, locking
diagnosis history12
Diagnosis: History
  • Habits
    • Clenching, grinding,cradling phone, back packs
  • SH: stressors
  • PMH: related disorders, trauma, dental problems
diagnosis exam
Diagnosis: Exam
  • Inspection:
    • Facial asymmetry, posture, eccentric jaw movements
  • ROM:
    • Vertical (42-55 mm), lateral, protrusion
  • Palpation:
    • Pre-auricular/anterior to tragus: joint mobility, joint sounds (audible, palpable)
    • Masseter, temporalis, pterygoid, suprahyoid, SCM, cervical
diagnosis exam14
Diagnosis: Exam
  • Oral function: occlusion, swallowing, breathing
  • Postural/musculoskeletal:
    • Forward head posture, systemic hypermobility, joint problems elsewhere
treatment goals
Treatment Goals
  • Educate patient about TMD and self-management
  • Reduce or eliminate pain and joint noise
  • Improve function
  • Avoid unproven treatments that can cause problems
treatment nih guidelines
Treatment: NIH guidelines
  • Phase I: Conservative and Reversible
    • Patient education
    • Physical Therapy/Occupational Therapy
    • Psychotherapy
    • Medications
    • Bite splint/Occlusal Splint
    • Stress management

(Multidisciplinary approach)

treatment nih guidelines17
Treatment: NIH guidelines
  • Phase II: only after conservative measures exhausted
    • Surgery: arthrocentesis, arthroscopy, open joint surgery, orthognathic
    • 5%
treatment patient education
Treatment: Patient Education
  • About TMD
  • Avoid painful activities
  • Avoid clenching grinding
  • Normal resting position of jaw
    • Tongue up, teeth apart, lips together
  • Moist heat/ice
  • Gentle stretching
treatment pt ot
Treatment: PT/OT
  • Patient assessment
  • Postural assessment
  • Patient education
  • Joint mobilization/manual therapy
  • Iontophoresis in selected cases
  • Home therapy program
treatment pharmacologic
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

treatment bite splint
Treatment: Bite Splint
  • Indications:
    • AM symptoms, daytime clenching, teeth are worn
  • Worn only at night
  • Does not move jaw (not an anterior repositioning splint)
evidence based medicine
Evidence Based Medicine
  • Limited Evidence, recommended
    • NIH Phase I and II treatments discussed previously
  • Limited Evidence, needs further study
    • Acupuncture
    • EMG biofeedback
  • Limited Evidence, not recommended
    • Occlusal adjustments that permanently alter a patient’s occlusion (Grinding teeth down, anterior repositioning splints)
    • Alloplastic implants
local resource
Local Resource
  • UW TMD Clinic: 263-7502
    • Lisa M. Dussault, OTR, John F. Doyle DDS
  • Imaging as indicated
  • Referral to specialists as indicated
    • Rehab Med psychologist, Oral/craniofacial surgery, speech/swallow, etc
indications for referral
Indications for Referral
  • 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