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MSPT II > Examination & Interventions for Pts w/ TMJ Dysfunction > Flashcards

Examination & Interventions for Pts w/ TMJ Dysfunction Flashcards

1
Q

Prevalence and Incidence of TMD

A
  • Prevalence:
    • 10mil cases/year US
    • ** >prevalence in Females (20-40yo)
  • Incidence:
    • Approx 1mil NEW cases/yr US
    • 20-25% pop exhibits sx’s TMJ dysf
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2
Q

Factors that contribute to TMD

A
  • Gender
    • F>M (20-40yo)
  • Malocclusion→ teeth/bite probs
  • Poor posture
  • Parafunctional habits**
    • biting nails, grinding teeth, hard candies
  • Emotional stress, anxiety, psycho issues
    • + correlation bw higher anxiety lvls and chronic orofacial pain in university students
  • Connect tissue OR rheumatologic disease
    • lupus, RA, systemic sclerosis
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3
Q

Differential Dx of Orofacial Pain

*not always TMD!

A

see pics

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4
Q

Burning Mouth Syndrome

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5
Q

TMD Examination Components

A
  • Thorough Hx
  • UQ Postural assess.
    • FHP?
  • Observation/Inspection
  • Occlusion
  • AROM
    • mandibular dynamics (deviation? deflection? (doesnt return to midline) Early translation?)
    • Excursion: Therabite ROM scale
    • Jt sounds?
  • Provocation tests
    • retrusive overpressure
    • U/L joint loading
  • Iso resistance tests
  • Passive jt mobility tests
  • Palpation
    • mm’s, joints
  • “Recapture Tech’s”
    • specifically for patients w/ ADD w/ Reduction and reciprocal click*****
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6
Q

Why** is it important to screen the **CS in pts w/ suspected TMD?

All reasons first, later broken down into components

A
  • Postural/soft tissue relationships
  • Trigemino-cervical complex
  • Bruxism may occur in response to neck pain
  • Masticatory mm’s contact in response to contraction of CS mm’s and visa versa→ synergistic relationship under norm circumstances
  • Whiplash injuries can involve both CS and TMJ
    • “Mandibular Whiplash”
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7
Q

Why** is it important to screen the **CS in pts w/ suspected TMD?

*Postural/Soft tissue relationships

A
  • FHP→ elongates supra/infrahyoids→ they create retrusive force on TMJ
  • CS positioning (LF and/or Rot)
    • affects occlusion which affects TMJ alignment and load distribution→ also affects mandibular rest pos. and thus affects path of closure and may affect initial tooth contact
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8
Q

Why** is it important to screen the **CS in pts w/ suspected TMD?

Trigemino-cervical Complex

A
  • TMJ and mms of mastication innervated by trigeminal nerve
  • Afferent input from Upper CS (C1-3) pain converges on trigeminal motor neurons in trigeminocervical nucleus→ inc’d masticatory mm activity and pain referral
    • CS tissues can also refer pain to head and orofacial areas
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9
Q

Why** is it important to screen the **CS in pts w/ suspected TMD?

Masticatory muscles contract in response to contraction of CS mm’s and visa versa

usually a synergistic relationship under normal circumstances

A
  • Spasm or prolonged postural contractions of CS mm’s and cause activity in mm’s of mastication
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10
Q

Why** is it important to screen the **CS in pts w/ suspected TMD?

Whiplash injuries can involve both CS and TMJ

A

Mandibular Whiplash

*head flies back and then chin can hit sternum on forward motion

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11
Q

Common Symptoms of TMD

A
  • Big 3
    • Clicking/jt sounds
    • Jt pain
    • Limited ROM
  • Others
    • malocclusion
    • hypOmobility or locking
    • HAs
    • dizzy/nausea
    • ear pain
    • barohypoacusis
    • tinnitus
    • craniofacial pain
    • tooth ache
    • pain w/ oral function
    • Upper CS pain
    • crepitus
    • hyperalgesia→ easier pain provocation
    • Allodynia
      • something that shouldnt cause pain DOES ex. shaving
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12
Q

TMD

Causes of Joint Sounds

*Clicking/Popping

A
  • Disc derangements
    • clicking or snapping sounds due to recapturing and/or derangement of disc
  • HypERmobility
    • may be a dull “thud” or “pop” toward the end of opening as condyle subluxes
  • Muscle INcoordination
  • articular surf incongruency
  • Vacuum formation
    • pop or crack→ like cracking knuckles→ time must pass before occurs again
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13
Q

TMD

Observation

A
  • UQ/CS posture
  • Mandible pos→ midline @ rest?
  • swelling
  • occlusion
    • use tongue blade inside cheek and pull soft tissue laterally
    • ask pt to gently bite and open slightly several times
    • move tongue blad to other side, repeate
      • Findings:
        • overbite
        • underbite
        • cross bite
        • missing teeth
  • AROM: opening, lat dev, protrusion
    • gently palp condyles
    • Note deviation or deflection or jt sounds
    • Note painful motions or pain @ end range
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14
Q

Quick Assessment of Opening ROM

A
  • 3 finger (or knuckle) test
    • Normal= 3 fingers or knuckles
    • Min for basic function= 2 fingers or knuckles
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15
Q

Therabite ROM Scale

A

measures active opening and lateral deviation

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16
Q

Retrusive Overpressure

Jt. Loading

LAB

A

see pics

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17
Q

U/L Loading Test

A
  • Dental cotton roll placed b/w molars on 1 side, and pt instructed to “clench”
  • Which TMJ experiences the greatest loading?
    • The OPP side of cotton role→ greater JRFs
  • Take home point: Pain may be provoked on either side, BUT more likely on side CONTRAlateral to cotton roll
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18
Q

Isometric Resistance Tests

How To:

A
  • Pts teeth slightly apart, use 2 fingers on the mandible to provide iso resistance to the following motions.
  • Build up force slowly over 5-6s, and note strength and provocation of symptoms
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19
Q

Isometric Resistance

Opening (depression)

What mm’s?

A

GRAVITY + lateral pterygoids and digastrics

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20
Q

Isometric Resistance

Closing (elevation)

What mm’s?

A

Masseter, Temporalis, Medial pterygoid

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21
Q

Iso Resistance

LEFT Lateral Deviation (would be OPP going to right)

What mm’s?

A
  • LEFT masseter
  • Left horizontal temporalis + Left lateral pterygoid→ Force Couple
  • Right lateral pterygoid
  • Right medial pterygoid

*NOTE: bolded are the major players

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22
Q

Iso Resistance

Protrusion

What mm’s?

A

Lateral pterygoids, medial pterygoids, masseters

NOTE: bolded are major players

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23
Q

Passive Joint Mobility Tests

A
  • Done intraorally; wear gloves, check BOTH sides and compare

See Pics

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24
Q

Palpation

A

*see pics

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25
Q

Medial Pterygoid Palpation

A

see pics

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26
Q

Recapture Techniques for pts w/ ADD w/ Reduction (Reciprocal Click)

A
  • have pt perform active opening w/ the conditions below (1 at a time):
    • Postural correction
    • Edge to edge pos’ing
      • line up teeth so protrude slightly
    • appliance placement
    • immediately following distraction/manipulation
  • During ea, palpate condyles and closely observe. Does clicking stop?
    • If so, good sign disc can be recaptured
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27
Q

TMD Classification: Dual Axis System

A
  1. Axis I: Tissue Related
    1. muscle
    2. disc
    3. joint
  2. Axis II: Behavior/psychosocial related factors
    1. Pain
    2. Parafunctional behaviors
    3. Psychological distress
    4. Psychosocial function
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28
Q

TMJ Disorders (TMD)

What are the 3 major categories of disorders?

A
  1. Muscle disorders
  2. Disc Displacements (derangements)
  3. Arthralgia, Arthritis, Arthrosis→ Joint related
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29
Q

TMJ Disorders (TMD)

Muscle disorders

A
  • Myofascial pain
  • Trismus
    • gen term for diff opening mouth; assoc’d w/ mm tightness
  • Bruxism→ grinding teeth
30
Q

TMJ Disorders TMD

Disc displacements

A

2nd category: Derangements or issues dealing directly w/ disc itself

31
Q

TMJ Disorders TMD

Arthralgia, Arthritis, Arthrosis

Joint-related

A
  • assoc’d terms and conditions:
    • capsulitis, retrodiscitis, capsular tightness
  • Types of arthritis:
    • infectious
    • post-traumatic (s/p fx, disloc, etc..)
    • gout
    • DJD
    • RA
32
Q

Alignment or patho factors that may contribute to TMD

A
  • Growth disorders (bone hypER/hypOplasia)
  • Occlusal disorders
  • Neoplasms
  • Connect tissue dis’s
    • ex. Lupus
33
Q

Bruxism

A
  • Grinding of teeth
    • wears down molars
  • often nocturnal
  • overactivity of muscles mastication→ irritation retrodiscal pad
    • starts as muscle disorder, but can progress to arthritis/arthralgia and/or disc derangement
  • Morning sx’s → tenderness in mm’s, HAs, TMJ pain
  • Interventions:
    • relaxation
    • stress mgmt
    • night guard (oral splint)
34
Q

Disc Displacement (Derangement)

Kircos et al. 1987

A

n=21

no hx of TMD

MRI: 32% pts had ADD

35
Q

Disc Displacements (Derangement)

Partial ADD

A

Early opening click

**hat starting to slide Ant

36
Q

Disc Displacements (Derangement)

ADD w/ Reduction

*Reciprocal Click

A
  • Reciprocal click
    • aka Opening click is good bc condyle gets under disc again, then when closing disc falls out again → reciprocal click
37
Q

Disc Displacements (Derangement)

ADD w/ Intermittent Locking

A

Somewhere b/w the two

bw ADD w/ Reduction and w/out Reduction

38
Q

Disc Displacements (Derangement)

ADD W/OUT Reduction

*Closed Lock

A
  • Closed Lock
  • No click bc condyle cannot get under disc
  • Often times cannot fully open mouth
  • No opening and click cannot be reduced
39
Q

NOTE about ADD’s

A

Disc typ deranged @ rest. The opening click is “recapturing” of the disc that occurs as the condyle translates ant/inf and establishes a “normal” relationship w/ disc

40
Q

Pts w/ progressive worsening of an ADD will transition over time from:

A

Single opening click→ reciprocal click→ NO click

41
Q

Disc Displacements (Derangement)

Other types less common

A
  • Post
  • Lat
  • Med
42
Q

ADD w/ Reduction (Reciprocal Click)

aka disc displacement w/ reduction (DDwR)

A
  • Typ pattern of opening is a “C” Curve deviation towards the involved side
  • Before opening click occurs, the deranged disc impairs normal motion and thus the mandible deviates towards the involved side
  • After the disc is recaptured via the opening click, the motion is no longer impaired and the mandible returns to midline by the end of opening
43
Q

ADD W/OUT Reduction

*Closed Lock

A
  • Typ pattern of opening is a deflection (does not return) toward the involved side, and limtd ROM for depression
  • On the involved side, the ADD w/out reduction is “blocking” normal motion from occurring in the involved TMJ
  • The contralateral TMJ is free to move normally, and thus the mandible will deflect toward the involved side
44
Q

Arthralgia, Arthritis, Arthrosis

*Joint pathology

A
  • RA, OA, Gout, Infectious Arthritis, Post-traumatic arthritis
  • Inflammation (may be assocd w/ arthritis)
    • capsulitis
    • retrodiscitis
  • Fibrous adhesions/caps tightness/hypOmobility
    • may follow immobilization after fx or post-traumatic arthritis
  • HypOmobility
    • early translation
      • can be due to mm incoord.
      • may be due to hypomobility in lower compart. of joint (limtd rotation)
  • Sublux
  • Dislocation
    • “Open Lock”→ cannot close mouth
    • Manually reduced on field or ER; see pt several weeks later if sx’s of post-traumatic arthritis emerge
45
Q

Principles of Mgmt of TMD

A
  • assess irritability
    • acute/highly irritable vs. chronic/less irritable
  • control pain/inflamm
  • eliminate myofascial trigger pts in UQ
  • facilitate normal TMJ jt mechs and mm function
  • restore normal TMJ ROM
  • normalize UQ posture
  • treat any concurrent CS dysf
  • eliminate or control parafunctional habits
    • ex. nail biting, hard candy
  • Self-Care
    • HEP
    • pt edu
  • Interdisciplinary Team approach
    • referral→ dentist
    • PT
    • psychologist
    • orthodontist
46
Q

Principles of Mgmt of TMD

For pts w/ Disc Derangements

A

Stabilize disc position when possible

47
Q

Mgmt of TMD: Systematic Review and Meta Analysis

List and Axelsson

A
  • SOME evidence following effective:
    • occulsal appliances
    • acupuncture
    • behavioral tx
    • jaw ex’s
    • postural training

*Evidence for effect of electrophys modals and sx insufficient

*occlusal adjustment seems to have no effect

*variation in methodology b/w primary studies made definitive conclusions impossible

48
Q

Interventions for Muscle Related TMD

*remember 3 categories: 1. muscle 2. disc 3. joint

A
  • adjunctive modals
  • biofeedback and relaxation techs
  • STM
  • NMSK re-ed and ex’s
  • eliminate parafunctional habits
    • refer for night guard→ Bruxism
49
Q

Interventions for Muscular Disorders TMDs

A

Study:

The Add. Value of a Home PT Regimen vs. Pt Edu Only for the Tx of Myofascial Pain of the Jaw Muscles: Short Term Results of RCT

*see pics

50
Q

Extra-Oral TMJ Depression

*sliding down the cheeks one

A

Manual tech for jt decompression/unloading and relaxation/stretch of Masseter

*see pics

51
Q

Intraoral Masseter Release

Temporalis Release

A

see pics

52
Q

Interventions for Disc Derangements

*3 categories: 1. muscular 2. disc 3. joint

A
  • Sx mgmt
    • modals
    • Man tx
  • Disc recapture efforts→ for pts w/ ADD W/ Reduction/Reciprocal Click
    • exercise
    • oral appliances
    • Jt mobs
      • discuss mech of effect of a mob tech such as intraoral distraction
  • Postural correction and re-ed
  • stress mgmt
53
Q

ADD w/ Reduction

*STUDY on Appliance Tx

A

see pics

54
Q

Mgmt of ADD w/ Intermittent Locking

when sx’s and clicking persist despite tx

*in b/w ADD w/ or w/out reduction

IMPORTANT***

A
  • If symptomatic reciprocal clicking or intermittent locking cannot be managed successfully w/ Tx geared toward disc recapture→ another approach is therex and jt mobs specifically intended to further the derangement to an ADD w/OUT reduction
    • essentially making them WORSE initially to make them BETTER later
    • this eliminates clicking
    • Pt learns to “function” on the post retrodiscal tissue
    • Criteria for this approach:
      • persist jt noises that are disturbing to pt
      • intermittent catch/lock during opening
      • Pt understands this Tx approach may cause pain and/or limted mouth opening INITIALLY OR might lead to need for sx if pain and limtd opening do not improve w/ time
      • Pt has consulted w/ dentist or oral surgeon
55
Q

ADD w/OUT Reduction

*Closed Lock→ no way to recapture

*STUDY

A

see pics

56
Q

Interventions for Jt-related TMDs

*Arthritis, arthralgia, etc.

Interventions for hypOmobility/Capsular tightness

A

*Warm it up, stretch it out!

  • Adjunctive modalities
    • Moist heat
    • US
  • Jt mobs
  • self-stretch ex’s and ROM
  • Therabite (see pics)
57
Q

Interventions for Jt-related TMDs

*Arthritis, arthralgia, etc.

Intraoral TMJ Mobilization

4:

A
  1. Caudal (INF) distraction
  2. Caudal distraction + translation (anterior)
  3. Caudal Distraction + passive opening
  4. Caudal distraction w/ Lat glide (deviation)→ NO PICTURE
58
Q

IntraOral TMJ Mobilization

Self-distraction w/ tongue blades

aka Dr. Kietrys magic trick

A

See pics but you just keep sticking tongue blades in mouth to further Opening ROM

59
Q

Interventions for Jt-related TMDs

*Arthritis, arthralgia, etc.

*Interventions for HypERmobility or subluxations

A
  • HEP→ emphasis on NMSK control and coordination
  • Pt education
    • avoid excessive opening
      • cut food into sm pieces
      • block yawn w/ fist
60
Q

Interventions for Jt-related TMDs

*Arthritis, arthralgia, etc.

*Interventions for TMD OA (DJD)

A

*Nicolakis, et al. 2001

  • Subjects
    • radiographic evidence of OA
  • Tx
    • PROM, AROM, Manual Tx, Postural correction, relaxation
  • Outcomes
    • DEC pain, Improved ROM and function*****
61
Q

Interventions for Jt-related TMDs

*Arthritis, arthralgia, etc.

Rocabado’s 6x6 Exercise Program

*ANY TYPE OF TMD

KNOW THIS!!!

A

SEE ATTACHED

62
Q

TMJ Exercises for Mobility

*use mirror feedback→ helps pt perform mvmt in midline with improved NMSK control

A

See pics for explanations

  • Controlled-ROM Lat. Excursion
  • Protrusion ROM
  • Self-stretch into Opening
  • Self-distraction Mobilization into Opening
63
Q

TMJ Splints aka IntraOral Appliances; Bite Plates

Explanation first

A
  • Adj’d by dentist over several visits; 2-3x/month Tx period
  • Proposed indications:
    • myalgia/myofascial pain
    • arthralgia/arthritis
    • disc derangements
    • bruxism
    • HAs assoc’d w/ bruxism
    • select dental probs→ atypical odontalgia
    • temp. occlusion
    • cracked/chipped/worn teeth
64
Q

TMJ Splints aka IntraOral Appliances; Bite Plates

Total Contact “Stabilization” Splints

A
  • Effects:
    • provides centric relation occlusion→ pos of jaw when mm’s are relaxed
    • reduce abnorm NMSK activity
    • promote NMSK balance
    • obtain stable occlusal relationships w/ uniform tooth contacts
    • Inc “freeway space” b/w teeth→ jt unloading
    • behavioral effects→ reduce clenching
65
Q

TMJ Splints aka IntraOral Appliances; Bite Plates

Other Split Types

2:

A
  • Distraction (pivot) splints (partial coverage)
    • Built in pivot→ Anterior guidance on Ant. teeth
      • allows contact of Ant. teeth w/out contact of post. teeth during jaw mvmt
  • Mandibular Oral Repositioning Appliance (MORA) aka Ant. Repositioning Splint or ARS
    • built in “ramps” promote slight ANT. translation/repositioning of mandible to facilitate disc recapture in pts w/ ADD w/ Reduction
66
Q

Distraction (pivot) splints and MORA are more controversial than Stabilization splints

WHY???

A

SE’s

Long term changes in pos. of mandible/bite → dental issues later on + more

67
Q

TMJ Splints: Evidence

Main Takeaways:

A
  • Splint or no splint?
    • probably DO NOT NEED
  • Splint Tx w/ PT
    • Improvements shown
  • Splint alone?
    • insuff. evidence
68
Q

TMJ Exercises for Control, Coordination, and Stabilization

*use w/ pts with muscular imbalance/incoordination and/or hypERmobility

A
  • Mandibular Rhythmic Stabilization→ see Rocabado 6x6
  • Controlled Rotation during Opening→ see Rocabado 6x6
  • Resisted Lateral Deviation Out of Neutral→ see pics for explanation
  • Isometric Contractions of Supra/Infra-hyoid Muscles→ see pics for explanation
69
Q

TMJ Exercises for Relaxation

*MAKE SURE YOU DO ALL OF THESE!!!

A
  • Resisted Jaw Opening→ see pics for explanation
  • Controlled Opening in Forward Trunk Flexion→ see pics for explanation
70
Q

Condylar Remodeling Exercise Program

*Rocabado 2006

6 Phases

A
  • Phase I→ to enhance Mobility
    • painfree lateral deviation away from side of pain of hypERmobility w/ .5 inch piece of sx tubing resting bw incisors
  • Phase II→ for controlled NMSK stabilization
    • If Phase I was pain free, a bite is incorporated during mvmt, w/ pt relaxing upon return to midline (do not bite when returning to midline)
  • Phase III→ also for controlled NMSK stabilization
    • Maintain contraction (bite) during return to midline (bite down whole time now)
  • Phase IV-VI→ SAME AS ABOVE, but for protrusion

**Recommended Dose: 6 reps every 2 hrs

71
Q

TMD Clinical Wisdom…

2 Key Points:

A
  1. Pts w/ post-traumatic TMD or recent onset dysfunction or largely posture-related
    1. generally progress quickly
    2. Once mech. dysfunctions are corrected, emphasis of tx focuses on maintenance of good posture and oral habits
  2. Pts w/ chronic TMD of a NON-traumatic nature
    1. LESS likely to progress quickly
    2. may be systemically hypERmobile w/ LESS than optimal connect tissue quality
    3. Important pt understands this and recognize the need for long-term personal commitment to rehab and MSK fitness
      1. Axis II components

MSPT II (20 decks)

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