Temperomandibular Dysfunction Flashcards
What are the potential causes of TMD?
Myofascial pain
Disc displacement- anterior with reduction or anterior without reduction.
Degenerative disease
- Localised- osteoarthritis
- Generalised- rheumatoid arthritis
Chronic recurrent dislocation
Ankylosis
Hyperplasia- usually of the condyles
Neoplasia
Infection
What is the pathogenesis of TMD?
Inflammation in the MOM or TMJ secondary to a parafunctional habit
Trauma- either directly to eh joint to indirectly- i.e. sustained opening during dental treatment.
Stress
Psychogenic
Occlusal abnormalities- i.e. a high restoration.
- Class II jaw relationship.
- Deep bite
What is anterior disc displacement with reduction?
As the patient opens, the condyle moves downward and forwards until it reaches over the articular eminence.
With anterior disc displacement- the condyle and the articular disc are displaced anteriorly to the articular eminence- the disc is anterior to the condyle.
- causes stretching of the bilaminar zone.
As the condyle moves backwards, so does the disc- you will hear a click as the disc pops back into the correct position.
- bilaminar zone I pulling the disc back into place.
Signs- reciprocal clicking on closing.
What is anterior disc displacement without reduction?
The candle and disc move anteriorly, the disc is consistently kept anterior to the articular eminence.
- Disc is folded downwards.
The bilaminar zone is stretched too far during displacement of the disc, the disc cannot be put back into the joint cavity.
Pt will C/O being unable to close their mouth.
What is degenerative joint disease?
Disc has degenerated- nothing in between the condyle and the glenoid fossa.
What aspects of the history would you want to know from the patient who you suspect has TMD?
C/O- SOCRATES
When is the pain worse? morning or night? Are you doing anything in particular when the pain gets bad?
Any other associated pain elsewhere?
History of trauma to the area?
PMH- particularly drug history
PDH
SH- very important.
- What do they do for work
- Stressful circumstances/lifestyle
- Home circumstances
- recent bereavement
- Relationships
- Living situation
- Habits
- Hobbies
What aspects if the examination would you want to do?
E/O
- MOM
- Joints- clicks, crepitus, tenderness on opening
- Jaw movements- forwards, backwards, side to side, deviation of the mandible on closing
- Facial asymmetry
I/O
- Interincisal mouth opening- measure using Willis Bite gauge, ruler, wooden sticks
- Soft tissues- linea Alba, tongue scalloping, cheek biting, NCTSL.
What would be considered as a normal intercostal width on opening?
35-45mm, less than 35mm is heading towards trismus.
What would crepitus indicate?
Degenerative changes within the joint.
What would clicking suggest?
Anterior disc displacement with reduction.
What signs would suggest there is condylar hyperplasia?
Asymmetry that is getting worse
If there is suspicion of pathology, what special investigations would you suggest?
OPT
CT/CBCT of the joints
MRI
Transcranial view
Nuclear imaging (Technitium-99)
Arthroscopy
Ultrasound
What are the common clinical features of TMD?
Females more than males
Usually aged 18-30
Intermittent pain of several months ir years duration
Muscle/joint/ear ache- particularly in the morning
Trismus/locking
Clicking/popping joint noises
- May have crepitus as well
Headaches
What are your differential diagnoses?
Dental pain
Headache
Earache
Salivary gland pathology
Referred neck pain
Atypical facial pain
Trigminal neuralgia
Angina
Condylar fracture
Temporal arteritis
What is the first port of call for treatment of TMD?
Counselling- conservative advice.
Stick to a soft diet
Chew on both sides
No wide opening of the mouth
No chewing gum
Don’t incise foods
Cut food into small pieces
Stop grinding, nail biting
Support mouth on opening- i.e. when yawning.
Reduce caffeine intake
When you have a flare up, take regular Ibuprofen.
- 1 x 400mg tablet 4 times per day.
- Maximum dosage is 2.4g in 24 hours.
Can provide patient with a soft lower splint.
Show patient exercises
- Tongue to roof of mouth, open but keep tongue there and then close.
- Deviation of the mandible under tension.
What could you provide the patient with to help with their TMD?
Soft lower splint
- Made in acrylic.
Hard splint- Michigan splint
Bite raising splint
Anterior repositioning splint.
Can use a screw.
What other reversible treatments are available?
Physiotherapy
Massage/heat to area
Acupuncture
Ultrasound therapy
TENS
Hypnotherapy
How do bite raising appliances work?
Stabilise the occlusion and improve the function of the masticatory muscles- thereby decreasing abnormal acitivyt.
Protect the teeth from grinding also.
What are the signs and symptoms of disc displacement with reduction?
Clicking on closure
Deviation of the mandible on closure before returning to the midline
Jaw tightness/locking.
If anterior disc displacement with reduction is not treated, what could it lead to?
Osteoarthritis
Why might someone have Trismus?
Prolonged dental treatment
IDB gone wrong
Infection
Trauma to the joint
What equipment do you have to to help with trismus?
Physiotherapy
Therabite
Jaw screw
When would you refer?
Conservative management has not helped.
Severe trismus
History of trauma in the area
What surgical procedures may be indicated for TMD?
Disc plication
Eminectomy- removal of the articular eminence
Menisectomy
Condylectomy
Reconstructive procedures
What are the intra- and post-operative complications of TMJ surgery?
Middle ear perforation
Glenoid fossa perforation
Extravasation
Haemorrhage
Haemarthrosis
Damage to trigmeneal nerve and facia nerve
Infection
Perforation of tympanic membrane
Laceration of EAM
