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Temporomandibular Disorders

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

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  1. Temporomandibular Disorders Primary Care Conference 2/23/05

  2. 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

  3. 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

  4. 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)

  5. Anatomy of TM Joint

  6. Anatomy of TM Joint

  7. 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

  8. Epidemiology • Early adulthood (ages 20-40) • Many TMD are self-limiting or fluctuate over time without progression • 5% require surgery

  9. Etiology • Multifactorial • Predisposing factors • Musculoskeletal • Precipitating factors • Trauma, clenching, grinding • Perpetuating factors • Chronic MSK dysfunction, psychogenic

  10. Clinical Manifestations • Pain • Joint clicking • Restricted jaw range of motion • Other symptoms are not specific to TMD: • Headache, ear ache, neck and shoulder pain

  11. 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

  12. Diagnosis: History • Habits • Clenching, grinding,cradling phone, back packs • SH: stressors • PMH: related disorders, trauma, dental problems

  13. 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

  14. Diagnosis: Exam • Oral function: occlusion, swallowing, breathing • Postural/musculoskeletal: • Forward head posture, systemic hypermobility, joint problems elsewhere

  15. 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

  16. Treatment: NIH guidelines • Phase I: Conservative and Reversible • Patient education • Physical Therapy/Occupational Therapy • Psychotherapy • Medications • Bite splint/Occlusal Splint • Stress management (Multidisciplinary approach)

  17. Treatment: NIH guidelines • Phase II: only after conservative measures exhausted • Surgery: arthrocentesis, arthroscopy, open joint surgery, orthognathic • 5%

  18. 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

  19. Treatment: PT/OT • Patient assessment • Postural assessment • Patient education • Joint mobilization/manual therapy • Iontophoresis in selected cases • Home therapy program

  20. 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

  21. Treatment: Bite Splint • Indications: • AM symptoms, daytime clenching, teeth are worn • Worn only at night • Does not move jaw (not an anterior repositioning splint)

  22. 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

  23. 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

  24. 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

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