Facial pain Flashcards
What percentage of the population have signs and symptoms of TMJ disorders?
- Signs at some point in their life 50-75%
- Symptoms at some point in their life 20-25%
- Percentage of population who seek treatment 3-4%
- Women are more likely to seek treatment
What is the TMJ?
It is made up from the condyle fitting into the fossa. There is a fibrous articular capsule which envelops the joint. The articular disc divides the joint into upper and lower compartments and it is biconcave.
The masseter muscle passes over the angle of the mandible and the temporalis attaches to the coronoid process.
What are the parts of the temporal bone?
The mastoid process is just behind the ear and the sternocleidomastoid and digastric muscle attach to this. The zygomatic arch has the masseter muscle attaching to the top border. The external auditory meatus is behind the TMJ which is why you can hear the joint clicking.
How does the TMJ move?
It is a hinge joint with a moveable socket. There is the lower compartment which is where the condyle rotates below the disc (hinge like motion) and the condyle stays in the fossa for this movement. The upper compartment is when the condyle and disc translate along the eminence (gliding) which is held in place by the posterior ligament. Normal opening is 35-50mm. The first half of opening is mainly hinging (rotation of the condyle in the fossa) and the second half is mainly forward translation of the condyle along the eminence.
How do the muscles cause opening of the mouth?
A combination of muscle action facilitates this rotation and translation. The geniohyoid and digastric pull the chin down and backwards. The lateral pterygoid facilitates forward translation of condyles and discs. When closing the temporalis (posterior fibres) facilitate backward translation of the condyles. The temporalis, masseter and medial pterygoid elevate the mandible.
How do the muscles cause protrusion of the jaw?
Protrusion is symmetrical forward translation of both condyles. Both lateral pterygoids pull the condyles (and discs) forward. This is 10mm. Retrusion is the return to rest position from the protrusion position. Both temporalis muscles (posterior fibres) pull the condyles back. Lateral excursion can be 10mm. The condyle on the opposite side if pulled forward. The condyle on the same side performs minimal rotation around the vertical axis. This is caused by contraction of the lateral pterygoid muscles on the opposite side combined with temporalis muscle on the same side contracting to hold the rest position of the condyle.
What is the diagnostic classification for pain from TMD?
- Non-TMDs (other facial pains including dental, salivary gland, pharynx etc)
- Uncommon TMDs (specific) - inflammatory arthritis, neoplasms, growth disturbance etc
- Common TMDs which can be acute or chronic (>3 months)
What are the common TMDs?
Common temporomandibular disorders account for over 95% of all referrals. Diagnosis is made on the basis of history and examination. Temporomandibular disorder has been defined as: a collective term embracing a number of clinical problems that involve the masticatory muscles, the temporomandibular joint and associated structures or both. The types of common TMD:
- Muscular
- Articular
- Disc displacement
- Degenerative joint disease
- Subluxation
- Mixed diagnosis
How are common TMDs further classified?
Masseter muscle disorders (mainly affect masseter and temporalis): - Myalgia - Local myalgia - Myofascial pain - Myofascial pain with referral Temporomandibular joint disorders: - Arthralgia - Disc disorders - DD+R - DD+R with intermittent locking - DD-R with limited opening - DD-R without limited opening - Degenerative joint disease - Subluxation Headache: - Headache attributed to TMD
What are masticatory muscle disorders?
The related muscles are the masseter and the temporalis. The signs and symptoms are familiar pain in the muscles on jaw function/parafunction, palpation and movement tests. In myofascial pain with referral there will be report of pain at a site beyond the boundary of the muscle being palpated. It may present as toothache, headache or earache. Referral patterns can cause confusion and awareness helps with differential diagnosis.
What are the signs and symptoms of TMJ arthralgia?
There is familiar pain in the TMJ on jaw function/parafunction, palpation or movement tests.
What is disc displacement with reduction (DD+R)?
The disc position is no longer maintained on the condyle throughout the range of motion. The normal position of the disc is between the fossa and the condyle, but in this the disc is anteriorly displaced. Through the opening cycle the disc reduces (goes back) to its normal position. This is when you hear the click when it reduces or moves anteriorly again.
What are the signs and symptoms of DD+R?
- TMJ clicking on function and movement tests e.g. opening
- Familiar pain in TMJ on function, palpation and movement tests
- Intermittent TMJ locking/sticking
- A manoeuvre may be required to open the mouth
The movement pattern is ipsilateral deviation with opening (which corrects).
What is DD-R (disc displacement without reduction)?
DD-R without reduction is a progression of disc displacement with reduction but here the disc no longer relocates. The disc simply folds in front of the condyle on forward movement.
What are the signs and symptoms of DD-R?
Acute/subacute - closed lock:
- Limited mouth opening <25mm - interferes with ability to eat
- Limited contralateral excursion
- Familiar pain on TMJ on function, palpation or movement tests
There will often be ipsilateral deviation with opening which doesn’t correct.
Chronic:
- Joint can become stretched to allow nearly full range of movement
- This is disc displacement without reduction without limited opening
What can be seen on an OPG/CT in degenerative joint disease?
CT is the gold standard.
- Joint space narrowing
- Osteophytes
- Subchondral sclerosis (increased opacity)
- Subchondral cysts and erosions
This is very common and may be an added source of pain and limited range of movement (may not be reason for pain).
What are the signs and symptoms of degenerative joint disease?
- Crepitus on function and movement tests
- Familiar pain in TMJ on function, palpation or movement tests
- Limited mouth opening
What is hypermobility and subluxation?
TMJ hypermobility can result in recurrent condyle subluxation – where the condyle comes off the end of the eminence. The signs and symptoms are:
- TMJ clicking and locking in a wide open position ( patient may yawn and jaw locks)
- Excessive mouth opening >50mm
- Familiar pain on function, palpation and movement tests
If the patient is able to reduce this dislocation it is termed subluxation and if the dislocation requires an intervention it is termed luxation.
What is a headache attributed to TMD and the signs and symptoms?
It is a headache affecting temporalis. The signs and symptoms are a familiar headache in the temporal area on function, palpation of temporalis muscle and movement tests. A combination of disorders is very common (all three groups).
What history of presenting complaint questions should you ask with TMD?
- Pain - SOCRATES
- Clicking - on opening or closing, aggravating/relieving, timing, temporary or persistent, associated with pain
- Other joint noises
- Limitation of opening/trismus - duration, aggravating/relieving, associated with pain
- Locking - on opening or closing, timing, temporary or persistent, associated with pain
- Altered occlusion - lateral open bite due to increased joint space
- Sensory disturbance - wouldn’t be expected with TMD, may say face feels tingly due to muscles working, usually comes and goes if associated with TMD, if tumour it would be progressive
- History of trauma
- Parafunctional activity - clenching/grinding, nail biting, lip biting
What can chronic pain from TMD lead to?
If over a considerable amount of time it can lead to substantial psychological distress and behavioural reactions. For example not working, restricted social pattern, depression. This is then termed dysfunctional pain.
What are the risk factors for chronic pain?
- Predisposing - trauma
- Initiating - microtrauma and strain
- Perpetuating - psychological and parafunctional
What past medical history can link to TMD?
- Systemic arthritis
- Previous malignancy
- Mental health (depression/anxiety)
- Fibromyalgia
- Hypermobility syndrome
Fibromyalgia is widespread pain and sensitivity to palpation at multiple anatomically defined tissue sites. It is often accompanied by depression and insomnia. It is thought to be due to CNS neurosensory amplification.
What are the red flags?
- History of cancer (may suggest metastasis)
- Pain that is abrupt in onset, severe or precipitated by exertion, coughing or sneezing or that interrupts sleep (may suggest intracranial pathology or cardiac ischaemia)
- Weight loss (may suggest cancer)
- Fever (may suggest septic arthritis, osteomyelitis, intracranial abscess, tooth abscess or mastoiditis)
- Neurological symptoms or signs (may suggest a tumour or other intracranial pathology)
- Swelling of the temporomandibular joint, mandible or parotid gland (may suggest tumour, infection or inflammatory arthropathy)
- Facial asymmetry (may indicate a tumour)
- Unilateral headache or scalp tenderness, jaw claudication or visual symptoms (suggests giant cell arteritis)
- Nasal symptoms – persistent loss of smell (anosmia), purulent discharge, nasal blockage, or epistaxis (may suggest a nasopharyngeal tumour)
- Neck mass or persistent cervical lymphadenopathy (may suggest infection or tumour)
- Change in occlusion (how the teeth meet together when the jaws are closed) this may suggest a tumour or bone growth (for example acromegaly) around the temporo-mandibular joint, or inflammatory arthritis; but can also be seen in other temporomandibular disorders
- Decreased hearing on the ipsilateral side (may suggest a nasopharyngeal tumour)
- Increasing pain or limitation in function despite initial management (may suggest a tumour)
What are the contributing factors to TMDs?
- Trauma - macrotrauma, parafunctional activity, third molar removal
- Systemic condition - hypermobility, fibromyalgia
- Parafunctional activity - nail biting, grinding/clenching, stress, anxiety
- Abnormal position - overclosed, occlusal interference
What should you look at during an extraoral exam for TMD?
- Masseter muscle hypertrophy
- Protrusive habit
- Clenching habit
- Poor neck postural habit
- Asymmetry/lumps/swelling
- Lymph nodes (infection, inflammation, neoplasm)
- Vascular/arteries (anyone over age of 50) - superficial temporal artery, temporal arteritis
- Neurological - check cranial nerves
What should you look at intraorally for TMD?
- Signs of clenching/grinding such as tongue scalloping/buccal mucosa ridging, attrition/wear facets, hypertrophic masseter muscles
- Occlusal assessment - interfering contacts, recent changes in occlusal scheme, skeletal pattern - class II posturing (for aesthetics and eating)
What should you look at in a musculoskeletal examination for TMD?
- Observation
- Range of movement ROM
- Local palpation of muscles - masseter (intraoral and extraoral) and temporalis and lateral pterygoid intraorally. Palpate TMJ over condyle or just behind and look for pain.
How do you measure ROM and lateral excursions?
Ask patient to open as wide as possible and this should be more than 40mm. Lateral excursions are measured by using the gap between 2 upper and 2 lower incisors as the reference point. Measure the gap. Expect about 10mm. if there is a significant difference between the two joints there is a problem. You can also use overpressure (assisted opening). If they can open more with assisted pressure it indicates a muscular problem rather than a joint problem. If joint problem they wouldn’t be able to open more. Palpate joint sounds as the patient opens the mouth. You can also observe deviations but this is no longer in classification.
What do TMD investigations help with?
Most patients do not require investigation. It will only help with joint related problems and not muscular. Do a sectional OPT.
What are the types of joint related problems seen on an OPT and other investigations that can be done?
Type I-IV (see notes for images). For more information on the bone and the disc you can do an MRI in function. You can see the movement of the disc relative to the condyle. CT scan would show bone and not in function so often not used.
What are the treatment options for TMD?
- Education - crucial, takes time, some patients are very receptive, includes information, principles of treatment and reassurance
- Physical therapy
- Splint therapy
- Medication
- Psychological
- Occlusal adjustments
- Botulinum toxin
- Arthrocentesis
- Surgery
- Review
What are the aims of intervention?
- Decrease pain
- Increase jaw function
- Increase psychological status
- Self manage
- Be safe
What are the guidelines for safe and effective management?
- Early diagnosis and intervention helps prevent development of chronic symptoms
- Use of conservative, reversible and evidence based interventions
- E.g. education, physical therapy, splints, medication and psychological support
- Don’t produce irreversible changes/less risk of harm
- Even longstanding and severe symptoms don’t usually require invasive treatment
- Failure of conservative interventions does not indicate a need to progress to irreversible treatment e.g. occlusal adjustments or surgery
- TMD is a dental specialism
- In secondary care, physiotherapy referrals are usually from dental and maxillofacial specialists
- For referrals to physiotherapy from non-dental health professionals we advise patient to see their GDP for intraoral screening and to consider modalities e.g. splint therapy
What should you inform the patient in TMD education?
Education is crucial for addressing psychological driving factors. There is an information leaflet to give patients at CCDH. When explaining use skull and images to help reinforce understanding. Tell patient how pain can be referred. How joint and muscles work, where the disc is, how it moves. Inform patient how common disorder is and that it is not a serious medical problem. Patient education helps to make sense of disorder. Reinforce benign diagnosis. Reduces threat of symptoms. Give rationale for treatment. Tell patient how they can reduce stress and strain on joint and muscles by avoiding oral habits.
What are oral habits?
Oral habits are well established patterns of inappropriate muscle activity. They increase strain on TMJ and muscles and may contribute to symptoms and act as barrier to recovery. They include:
- Tooth contact, clenching, grinding
- Nail biting
- Chewing gum
- Pen chewing
- Lip sucking
- Habitual protrusion - movement of lower jaw forwards
Ask patient to monitor the oral habit. Show patient how to check relaxed jaw rest position. Avoid forward head posture as this causes muscle and joint loading. Eat a soft diet, chew slowly on both sides, avoid caffeine – increased muscle activity, avoid repeated wide mouth opening e.g. yawning, avoid sleeping on front.
Read notes from now
What is poor sleep an indicator of?
Advise on sleep hygiene. Increasingly poor sleep over time is a substantial predictor of new onset TMDs. Sleep hygiene – things to avoid and try before bed.
How can physiotherapy and acupuncture be used?
Physiotherapy involves soft tissue techniques to facilitate muscle relaxation and reduce pain and then gives patient a handout so they can continue themselves. Acupuncture can be used as an adjunct and can reduce pain and facilitate muscle relaxation.
What is done for muscle overactivity, reduced control and hypomobility?
For muscle over-activity we can give jaw relaxation techniques. For reduced control e.g. subluxation we can give patient jaw control exercises. For joint hypomobility (stiff joints) there are manipulative therapies for TMJ to help restore mobility. Patients can do active assisted stretch at home. None of these techniques should be painful.
Why should the neck also be assessed?
TMJ interacts with other areas. Patients with neck disorders and TMD often have similar signs and symptoms therefore neck should be assessed in patients with facial pain.
What is an occlusal splint and how do they work?
An occlusal splint is a removable device usually made of acrylic resin, which fits between the maxillary and mandibular teeth. They work by:
- Occlusal disengagement
- Maxilla-mandibular realignment
- Restored vertical dimension
- TMJ repositioning
- Cognitive awareness
- Placebo effect
What are the types of splint?
- Directive - anterior repositioning splints ARPS
- Permissive
- Soft bite guard
- Anterior bite plane - lucia jig
- Stabilisation splint (Michigan, Tanner)
What is an anterior repositioning splint and the indications?
An anterior repositioning splint is used to direct the mandible more anterior to ICP. It provides a better condyle disc relationship to allow time for the tissues to adapt or repair. Indications:
- Disc derangement disorders (especially anterior disc displacement with reduction)
- Can be useful for intermittent/chronic locking of the joint (often caused by disc displacement)
What are the advantages and disadvantages of soft splints?
Advantages: - Sometimes tolerated better by patients - Easily constructed - Cheap Disadvantages: - Difficult to adjust - Can encourage patient to brux - In some cases muscle pain either does not change or occasionally increases
What are lucia jigs and the uses?
Lucia jigs are used to disclude posterior teeth and allow relaxation of the muscles of mastication. Patients ‘forget’ their ICP position (neuromuscular deprogramming). Uses:
- To help locate centric relation
- As a diagnostic tool for patients with TMD symptoms
- As a quick fix for patients with acute symptoms prior to constructing a more definitive appliance (a few days)
What are the types of stabilisation splint (hard splint)?
- Michigan splint (upper)
- Tanner appliance (lower)
- Interocclusal appliance
- Occlusal splint
- Ramfjord appliance
What are the features of a stabilisation splint? (upper)
- Heat cured acrylic
- Full coverage to prevent over-eruption
- Uniform contact in centric relation canine guidance to separate posterior teeth in eccentric excursions
- Anterior guidance to separate posterior teeth in protrusion
- i.e. the splint creates an artificial ideal occlusion
What are the clinical stages of splint construction?
Visit 1: - Upper and lower alginate impressions - Jaw registration in centric relation - Facebox Visit 2: - Fit splints - can be tedious, seat splint and adjust fitting surface as necessary Subsequent visits - Review and adjust as necessary
When should TMD patients wear the splint?
- Every night
- During periods of increased muscular activity/stress
- For patients with severe symptoms as often as possible during day also
What are the features of a Tanner appliance?
- Mandibular appliance
- Heat cured acrylic resin
- Full occlusal coverage
- Simultaneous even contacts with all opposing teeth in RCP
- Appropriate anterior guidance
- Absence of posterior interferences
What should be done following splint therapy?
If splint therapy is successful in reducing/eliminating symptoms consider long-term splint wear. Do not assume that further intervention e.g. occlusal adjustment will provide the same benefit. Provision of an inter-occlusal appliance (usually an upper hard acrylic splint) should be considered one of the first line treatments for patients with TMD. Full occlusal coverage is important for splints.
What medications can be used for TMD?
Analgesia:
- Paracetamol
- NSAID - ibuprofen
- Anxiolytics
such as:
- Tricyclic antidepressants (muscle relaxation, analgesia, a low dose of this is useful for facial pain)
- Benzodiazepines (addictive and will work so patient will want more when pain recurs, not to be given long term - caution)
How can the botulinum toxin be used for TMD?
Botox is given to reduce muscular activity. It will reduce activity in muscles and take away pain. It carries risk – injecting over nerve stops the nerve working, injecting into vein can cause problems as it goes elsewhere. After 6 months it will wear off so is not good for long term. It is a temporary removal of symptoms. It is expensive. If you keep injecting you can get muscle wasting. This can be useful in some cases but not used routinely.
