1i - TMJ PT Flashcards
what are previous consultations you want to know about in the pt hx and why
dentist
oral surgeon
orthodontist
ENT
tell you if had a recent oral screen
- good tooth and gum health
what are previous treatments you want to know about in the pt hx
meds
mouth guards
why do you want to know the date of onset in the pt hx
what stage of tissue healing are you in
what is the most common MOI
unknown
- just gets worse over time and don’t know why
what are the 3 main types of MOI
unknown
macro-trauma
micro-trauma
what are examples of macro-trauma for a possible MOI
physical impact on TMJ
recent major dental work
- prolonged opening, force by dentist
MVA, falls, etc.
what are examples of micro-trauma
parafunctional habits
- non functional uses of jaw
what could the time of day of the pain tell you
pain in morning = grinding at night
pain at end of day = maybe from what doing in work
what are questions to ask when trying to suss out provocation vs alleviation
position
activities - eating, talking, yawn
time of day
sleeping
how could sleeping be a provocative activity
stomach sleeping position
-> asymmetrical translation of mandible -> pillow and pressure ipsilaterally results in medial ipsilateral translation and a lateral contralateral translation
what are common locations for pain (5)
jaw
ear
face
neck
temple
what are other sx besides pain to ask about in the pt hx
HAs - temporal & occipital
tinnitus
stuffiness
dizziness
facial fatigue
locking/catching/clicking
what is a validated scale that is helpful for its dx properties
Jaw Functional Limitation Scale
how are scores interpreted from the jaw functional limitation scale
higher score = more severe limitation
what are components of the anatomy screen
dental screen
cranial anatomy (CNs)
secondary TMJ ms
AO, cervical facet (C2-3) joints
suboccipitals, SCM, scap ms
why is a dental screen included
look at teeth, gums, tongue
- if caused by tooth pain -> refer out
could have secondary ms guarding that causes pain but still have to treat tooth first
why is the SCM part of the anatomy screen
postural component
also SCM has referral pattern into jaw
why is a CN screen included in the anatomy screen
CN V innervates the area
what is an important part of your observations
cervical/head and thoracic posture
- forward head posture and rounded shoulders
why do we care about if someone is resting their head on their hand
asymmetrical compression on one side while leveraging the other
- creates stretching of capsule
what observations can help with our CN screen
facial asymmetries
- speaking
- smiling
- blinking
what should you look for during your pt exam
parafunctional habits
- biting lip
- chew nails
- gum
what do you look for when having them open and close their mouth
opening
- any limitations
closing
- bite symmetry
- occlusion b/w maxillary and mandibular teeth
- how does it feel when teeth touching
how does forward head posture impact the TMJ
posterior rotation of cranium on AO joint
- upper cpsine ext, lower flex
stretch infrahyoid ms -> inferior force on hyoid -> stretch suprahyoid ms -> MANDIBLE PULLED INTO RETRUSION AND DEPRESSION
altered resting position of condyle
why is the altered resting position of the condyle from forward head posture significant
excessive disc compression
- disc might be more at articular eminence than fossa
chronic lateral pterygoid spasm to counter the position
more effort to maintain closed position bc of stretched ms
- ms overuse to pull jaw back
what does the evidence say about the relationship of head/neck posture (like forward head posture) and TMD
while makes sense, poor evidence
- enough to support using cervical and postural interventions
what are the 2 main opening and closing abnormalities
c-curve or deflection
s-curve or deviation
what is c-curve or deflection abnormality and what is it likely caused by
gradually jaw moves to one side throughout range
- unilateral hypo (dec ipsi) or hypermobility (inc contra)
what are reasons for hypo or hypermobility seen in a c-cerve or deflection
hypo:
- capsular
- ms spasm
- OA
- disc displacement w/o reduction (closed lock)
hyper:
- EDS
- dislocation
what is an s-curve or deviation abnormality and why might this be pain-free or painful
deviate to one side and then comeback to midline
painfree
- ms imbalance
- ms incoordination
painful
- disc displacement w reduction (joint sound)
what is the range of motion for opening/depression to be WFL
38mm
how is range of motion of opening/depression measured
use therabite lined up from edge of mandibular center incisor to edge of maxillary center incisor
what is the smallest detectable change in ROM of opening/depression
5mm
what are the norms of females and males for opening/depression ROM
females = 45-50mm
males = 40-45
when taking a ROM measurement of opening/depression, why might you take it twice
take it 1st just as sitting on table
then take it again after correcting posture
- can get several more mm after taking it again
what are 5 things that can impact the ROM measured of opening/depression
ms disorder
ADDWOR - ant disc displacement w/o reduction
capsular adhesions
OA
fear of movement
how is lateral deviation measured
therabite from line b/w mandibular center incisors to line b/w maxillary center incisors
what is the norm for lateral deviation ROM
1/4 of depression ROM
or 8-10mm
what is the norm for protrusion ROM
6-9mm
what is the norm for retrusion ROM
3-4mm
how is protrusion and retrusion measured
therabite measures distance b/w mandibular and maxillary incisors
what are 3 things that can impact lateral deviation, protrusion, and retrusion ROM
ADDWOR (ant disc displacement w/o reduction)
capsular involvement
ms incoordination
what ms is intra-oral palpation reliable for
TMJ
masseter
temporalis
how can the TMJ be palpated extra-orally
lateral - ant to ear
post - thru ear
what ms can be palpated extra-orally
temporalis
masseter
suprahyoids
infrahyoids
medial pterygoids
- med aspect of mandib angle
what else should be palpated besides TMJ joint, and primary and secondary TMJ ms
cervical and scap ms
facet assessment
what ms can be palpated intraorally and where
outside max teeth to coronoid process
- masseter
- temporalis tendon (expose w inc opening)
- lateral pterygoid
inside max teeth back and inferior
- medial pterygoid
how can medial and lateral glides be palpated
extraorally:
- stabilize contra temporal bone
- mobilize ipsilateral mandible medially
- we like this one better, easier to stabilize and feel**
intraorally:
- thumb on medial or lateral aspect of mandibular posterior molar
how is most joint mobility assessed
intraorally
what is a consideration if trying to assess an anterior glide
need to be opened ~20-26mm
what is the significance of assessing antero-caudal translation
mimics TMJ mvmt w full opening
what are 2 considerations to set up of how you conduct resisted testing
apply broad contact w hand to disperse force
start w mouth open a little bit so less provocative and not compressive
what are the resisted movements you test
depression
elevation
lateral deviation
protrusion
what ms are assessed w resisted depression (3)
lateral pterygoids
suprahyoids
infrahyois
what ms are assessed w resisted elevation (3)
temporalis
masseter
medial pterygoid
what ms are assessed w resisted lateral deviation (4)
ipsilateral:
- temporalis
- masseter
contralateral:
- medial and lateral pterygoids
what ms are assessed with resisted protrusion testing (3)
masseter (deep fibers)
temporalis
suprahyoids (digastric)
what is the separation-clench test used for
to distinguish b/w joint arthralgias and ms disorders
what is the procedure of the separation-clench test
biting on tongue depressors placed b/w back molars
- acts as joint spacer
- bilateral placed depressors
- unilateral placed depressor
reproduction of pain w bilaterally placed depressors w the separation-clench test indicates what
ms or tendon disorder/pain source
ipsilateral reproduction of pain w unilateral placed depressor w the separation-clench test indicates what
muscular or tendon disorder/pain source
contralateral reproduction of pain w unilateral placed depressor w the separation-clench test indicates what
there is joint compression on the contralateral side to testing
possible joint arthralgia, capsulitis/synovitis, disc, etc.
what are (+) separation-clench test results
reproduction of pain
what is cervical dysfunction
dysfunction in anatomical, functional relationships b/w cspine and TMJ & their pathophysiological connections
what are s/sx of cervical dysfunction (4)
posture
changes in or pain w ROM
changes in cerv joint mobility
- w possible segmental referral
pain w palpation
- w possible referral to face/jaw
what are peripheral and cranial neuralgias
nerve tissue damage or irritation
- burning, tingling, shooting pains, hyperalgesia, etc. in a C2 and C3 dermatomes
what is trigeminal neuralgia and how does it present
severe paroxysmal facial pain (~2min) d/t nerve entrapment
facial and TMJ sensation input
ms of mastication motor & proprioception input
what are red flags (7)
tooth-related pain
primary & secondary HAs
recent fevers or infections
- ear or sinus
pain w eye mvmt, change in vision
hx of cancer
psych disorders
recent trauma (broken jaw?)
what do we think if someone has pain w eye mvmt and changes in vision
optic neuritis
why are psych disorders considered a red flag
TMJ might be location of stress
- if not getting intervention for stress, doesn’t matter what you do
what are secondary headaches caused by
systemic
related to:
- cspine
- teeth
- sinus and ear infections
- TMD
what are red flags that are an immediate referral
CNS signs
- change in gait/balance
- sudden onset severe HA
- sudden onset paresis/paralysis
- slurred speech (new)
- hx of CVA
- altered mental status
sx and hx of cardiac path
5Ds and 3Ns
why are sx and hx of cardiac path a red flag immediate referral (3)
referral to orofacial area
angina manifest as neck pain
HTN can cause severe, systemic HAs
what are intra-articular TMJ dysfunctions
internal disc displacements
- ant (w or w/o reduction)
- post
joint arthralgias
- hypermobility
- hypomobility
what are extra-articular TMJ dysfunctions
ms disorders
- ms spasms
- tendinopathy
- myofascial pain syndrome
what is anterior disc displacement w reduction
disc ant to condylar head at rest
with opening, reduction of disc with closing, dislocation of disc
what are causes of anterior disc displacement w reduction
macrotrauma - damage to or laxity of retrodiscal tissue ligaments
- progression of hypermobility
- lateral pterygoid spasm
microtrauma - repetitive excessive force on disc
- disc thinning or perforations
what are secondary problems that can be caused by anterior disc displacement w reduction
secondary retrodiscal tissue, joint, and/or ms pain (guarding)
how is opening ROM impacted in anterior disc displacement w reduction
normal opening ROM
- secondary ms spasm, guarding, or capsulitis can change the amt of opening and the opening opattern
describe what happens during opening with an anterior disc displacement w reduction
reduction of disc - “click”
- can be painful as disc reduces over posterior aspect of disc which is vascularize and innervated
- disc can heisitate and pop bc thicker posterior aspect to get over
S-curve /deviation to affected side
ant translation w condyle
describe what happens during closing with an anterior disc displacement w reduction
dislocation of disc w “click”
- at rest disc anterior to condyle
what is the significance of reciprocal joint sounds often heard w anterior disc displacement w reduction
don’t use for dx, use for part of exam
how should anterior disc displacement w reduction be treated (3)
joint mob
proprioception
STM
what is anterior disc displacement without reduction
permanently ant dislocated disc
- no reduction, will always stay in front of condyle
at are causes of anterior disc displacement without reduction
ruptured and maximally stretched ligaments and/or dec elasticity of retrodiscal fibers
-> hx of reciprocal joint noise (progression of ADDWR)
what is a common sx of anterior disc displacement without reduction and why
TMJ and/or ear pain
- retrodiscal inflammation, inc joint compression and friction, capsulitis/synovitis, ms spasms
(extra pressure on the synovial membrane and fibrocartilage w every bite bc disc not there anymore)
how is opening affected by anterior disc displacement without reduction
limited opening (<20-30mm)
- closed lock
- c-curve / deflection to affected/limited side bc disc is in way (and prevents ant translation of condyle and the other side keeps going)
what movements are impacted by anterior disc displacement without reduction
opening
lateral deviation (to unaffected)
protrusion w deviation to affected
how is anterior disc displacement without reduction treated (3)
joint mobs
STM
proprioception to dec joint compression
what is a posterior disc displacement
disc is posterior to condyle
- condyle pops off anterior part of disc
what type of disc displacement is less common than the other
posterior disc displacement is rare
what are causes of posterior disc displacement
excessive opening beyond normal physiological ROM (opening beyond range over and over again) -> general hypermobility
yawning
prolonged mouth opening
- dental work
what motion does a posterior disc displacement affect and how
closing
“open lock”
- unable to close mouth d/t posterior disc displacement blocking condylar movement
why is pain a common sx of posterior disc displacement
if disc permanently dislocated, biting thru lateral pterygoid
what are treatment interventions for posterior disc displacement (4)
motor control/proprioception to avoid end range (work in mid-range)
altered eating
- cut things up to avoid end range
manual therapy
postural exercises
when is hypermobility considered a red flag and what does this indicate and what should you do
excessive AROM
- opening >40-50mm d/t excessive condylar anterior translation
subluxation or dislocation
send to ED
what are 7 common s/sx of hypermobility
excessive AROM
TMJ/capsule TTP but no crepitus
painful ms guarding
may be asymptomatic
joint sound at end range open
deflection contra in end open
hyper accessory jt motion
why might someone w hypermobility be asymptomatic
body may have accommodated it and stretched joint capsule
what can hypermobility lead to
disc displacement bc of altered joint mechanics
what are interventions for general hypermobility (3)
stability program
- ms activation
- body awareness
- joint proprioception
avoid end range
manual therapy
what are 2 reasons for hypomobility
arthritis
capsulitis/synovitis
what are 2 arthritis can can cause hypomobility at TMJ
OA
RA
what are 5 s/sx of OA in TMJ
limited opening AROM
pain w closing
pain w TMJ palpation
crepitus thru entire ROM
radiographic evidence
why is crepitus seen in OA
degeneration of articular cartilage d/t chemical changes
what is seen in radiographs of OA in TMJ
osteophyte formation
subchondral bone changes
what are 3 interventions for arthritis and resulting hypomobility
joint mobs
- grade 1 and 2 to calm down
postural strengthening
- give joint support
joint protection strategies
is it important to differentiate capsulitis from synovitis
not really
treat the same
what are 2 causes of capsulitis and synovitis
macrotrauma or microtrauma
tears or lengthening
–> altered disc movement
how does a capsular pattern manifest in s/sx for capsulitis
limited opening <25mm
C-curve/deflection to affected
dec unaffected lateral excursion
what is a movement that is limited in both capsulitis and synovitis and why
protrusion on affected side
- deflection bc of lack of anterior translation d/t tight capsule or synovial membrane
where/when is pain seen in capsulitis and synovitis (5)
biting
at rest
end range accessory motion
ROM testing
palpation of lat capsule & TMJ
- esp posterior
what are 3 interventions for capsulitis and synovitis
joint mobilizations
proprioception
- optimize joint mechancis
postural exercises
what is often the result of chronic capsulitis and how is this often treated
capsular fibrosis
- adhesion formation
hard to treat conservatively
what direct injuries lead to ms disorders at the TMJ (3)
traumatic blows to mandible
overstretching w dentistry
- ms spasms (esp temp, mass)
overuse w parafunctional habit
- ms strain
- tendinopathy
what indirect injuries can lead to ms disorders at the TMJ (2)
ms guarding
- stress (manifests here)
- dental path, TMD conditions, cspine disorders
central sensitization
- trigger points
- hypersensitivity
- up-regulation of pain
what is the risk of ms guarding if prolonged
contracture
what are common sx (other than pain) of ms disorders (3)
no joint sounds
inconsistent mandibular control
- deviation or deflection
altered dental occlusion w mouth closed/at rest
how is pain reproduced with ms disorders
palpation of ms
- referred pain patterns
ipsilateral pain w activation
ipsilateral pain w end range
- stop themselves before that point -> dec ROM
what are the 3 ms most often affected by ms disorders
masseter
temporalis
lateral pterygoid
how is the masseter and/or temporalis impacted by a ms disorder (3)
pain w palpation (trigger points)
pain w stretching at end range opening
pain w activation when clenching
how can a masseter and/or temporalis ms disorder impact ROM
opening may be limited <40mm
how is the lateral pterygoid impacted by a ms disorder (2)
lateral facial pain
- esp in periauricular area (ear)
pain w:
- protrusion
- opening
- contralateral lateral deviation
what are interventions for ms disorders and why (6)
STM
postural exercises
- dec extra strain on ms
motor control
- trigger points
ms relaxation
isometrics (relax!)
pt ed to dec parafunctionals
- don’t want to add insult to injury
what is myofascial pain syndrome
very common form of TMD
pain originates from myofascial structures
- often chronic w presence of trigger points (central sensitization)
what are 4 common areas of referral for myofascial pain syndrome
temporalis
masseter
lateral pterygoid
medial pterygoid
what is the temporalis referral pattern for myofascial pain syndrome (4)
maxillary teeth
TMJ
retro-orbital area/temple
around eyebrow
what is the masseter referral pattern for myofascial pain syndrome (3)
maxillary and mandibular teeth
ear (may cause tinnitus)
sinuses
what is the lateral pterygoid referral pattern for myofascial pain syndrome (1)
sinuses/cheek bone
what is the medial pterygoid referral pattern for myofascial pain syndrome (1)
ear or lateral TMJ
what are sx of myofascial pain syndrome (5)
facial, ear, jaw, tooth pain
HAs
dizziness
limited opening ROM
swallowing difficulties
what are interventions for myofascial pain syndrome (4)
STM
ms relaxation
motor control exercises
postural exercises
why is it crucial to treat both sides/TMJs
right and left function together but act independently
- TMJ mvmt requires bilateral action, so have to function together
- influence each other
- abnormal function on one side interferes w function of other
what is one function that each TMJ does asymmetrically
mastication
what are the 4 main goals of manual therapy
pain control
dec ms tension/guarding
improving joint mobility
inc proprioception to area
what are 4 manual therapy interventions
STM, manual release
joint mobs
PROM
stretching
what manual therapy intervention did the evidence say helped to improve opening and clenching
intra-oral temporalis, medial and lateral pterygoid releases
what does the literature say about cspine treatment with TMD
greater improvements w cspine treatment
no improvement in opening w adding cervical manips
according to the evidence, who did trigger point releases help specifically
HA patients
what are the 4 main goals of ther-ex
reduce ms tension
pain control
inc ROM
inc motor control/strength
why is the goal with ther-ex to work on motor control instead of strengthening
ms are probably already pretty strong
- more ab working on motor control, activation and fear of activation
what are the 2 main ther-ex interventions
TMJ isometrics
postural exercises
what is a consideration of TMJ isometrics and how do you progress them
careful, the ms may be in spasm or overused
gradually inc hold times
what are 3 types of postural exercises
scap retraction (rows, ER)
pec stretching
cervical mobility/strength
- chin tucks
what are the 3 main goals of NM re-ed
relaxation
joint proprioception
ms activation/coordination
what are 3 types of NM re-ed interventions
relaxation techniques
ms coordination
joint proprioception
what are 2 relaxation techniques
breathing exercises
contract-RELAX
what are ms coordination exercises
opening/closing patterns
“touch and bite”
- have them open/do different motions/deviation and bite same spot on finger each time
what are joint proprioception exercises
resting position
-> open-packed position, teeth slightly parted and tongue against hard palate
- have them maintain this position with breathing or other exercises
controlled opening/closing
- manually guided
- mirror
isometrics and stabilization
- start in neutral and progress to different ROMs
what is the most commonly used PT exercise plan
Rocabado 6x6
how does Rocabado 6x6 target its exercises
tope 3 are TMJ
- resting position
- controlled opening
- rhythmic stabilizations
other 3 are cervical and posture
- OA flex/mobs
- chin tuck
- scap retraction
what modality actually has good evidence backing it
dry needling
what are the 4 main goals of modalities
pain control
promote ms relaxation
inc blood flow
dec inflammation
what modality do most people w TMD prefer
heat
why is TENS not a great modality to use w the TMJ
so much sensory input already for this area
what ms has successful EBP for dry needling and what are the outcomes
lateral pterygoid
dec in pain w mastication
inc in ROM for opening, L/R lateral deviation, and protrusion
what are 7 important pt education points
can’t fix disc or ligaments
minimize painful movements
- ie end range
eating soft foods/avoid hard, chewy foods
- chew on uninvolved side
change sleeping habits
relaxation techniques
body awareness and posture
pain science
what about body awareness and posture should you educate the pt on (3)
work set up/ergonomics
stopping parafunctional habits
proper TMJ resting position
what about pain science should you educate the pt on (3)
central sensitization w chronic pain
prognosis
general exercise/aerobic plan
- aerobic is one of the best things for pain bc help w upregulation of pain and settle it in
what are other types of treatment for TMDs besides PT (5)
pharmacologic
acupuncture
occlusion splint therapy/mouth guards
surgery
psychosocial
what are pharmacologic treatment options for TMDs (5)
ms relaxants
NSAIDs
trigger point injection
intra-articular corticosteroid or local anesthetic injections
botox
what surgeries can be done for TMDs (3)
arthroscopic to release adhesions
repositioning of disc
total joint replacements
- last resort, poor outcomes
what are psychosocial treatment options for TMDs (3)
stress management
behavioral modification
addressing depression/anxiety
