Temporomandibular Disorders (TMD)

Question 1

Describe temporomandibular disorders (TMD)

Answer 1

A group of conditions affecting the temporomandibular joint and/or the muscles of mastication

Question 2

Describe TMD epidemiology

Answer 2

• Common cause of pain
• Annual average incidence 4%
• Prevalence 10-15%
• F > M
• Peak incidence 18 to 44 years of age

Question 3

TMD aetiology continued

Answer 3

Multifactorial
- Biological
- Psychological
- Behavioural

Biopsychosocial

Question 4

Describe TMJ examination

Answer 4

palpate just in front of ear (where the jaw clicks)

• Palpate lateral pole
  Does palpation elicit the patient’s familiar pain?
  3 repetitions each of opening, closing, lateral, protrusive movements
• Any noises palpable?
• Any noises audible to the patient?

Question 5

describe TMD palpation of muscles (temporalis and masseter)

Answer 5

• Does palpation elicit the patient’s familiar pain?
  (Temporalis)
• palpate when teeth clenched above the ear and forwards above the eye
  (masseter)
• Bimanual palpation (two fingers inside the mouth pressing cheek other two fingers pressing outer cheek

Question 6

describe TMD mouth opening

Answer 6

• deviation on opening
• extent of opening - unassisted and assisted 40mm including incisal overlap

Question 7

describe TMD (Intra-oral) soft tissues

Answer 7

• Ridging buccal mucosa at level of occlusal plane
• Scalloping of borders of tongue
• Tooth wear

Question 8

What are the TMD investigations?

Answer 8

• Plain radiographs not normally indicated
• Cone Beam Computed Tomography (CBCT)
• Magnetic Resonance Imaging (MRI)

Question 9

Describe TMD diagnosis

Answer 9

• Pain related TMDs
  Myalgia:
• Local myalgia
• Myofascial pain
• myofascial pain with referral
  Arthralgia
• Headache related TMD
• Intra-articular TMDs
  Disc displacement with reduction
  disc displacement with reduction with intermittent locking
  Disc displacement without reduction with limited opening
  Disc displacement without reduction without limited opening

Degenerative joint disease
Subluxation

Question 10

TMD - Myalgia

Answer 10

Description:
Pain of muscle origin, affected by jaw movement, function or parafunction
Replication of this pain on provocation testing of the masticatory muscles
History:
Pain in jaw, temple, in front of the ear or in the ear and
Modified with jaw movement, function or parafunction
Examination:
Confirmation of pain location (s) in the temporalis or masseter muscle
and
familiar pain in masseter or temporalis muscle with at least one of the following provocation tests:
palpation of temporalis or masseter muscle
or maximum unassisted or assisted opening movements

Question 11

What are the subtypes of myalgia

Answer 11

• Local Myalgia
• Myofascial pain
• Myofascial pain with referral

Question 12

TMD - Arthralgia

Answer 12

Description
Pain of joint origin affected by jaw movement, function or parafunction and replicated by provocation testing of the TMJ
History
Pain in the jaw, temple, ear or in front of the ear in the past month
AND
Pain modified with jaw movement, function and parafunction
On examination:
Confirmation of pain location in area of TMJ (s)
and
familiar pain:
on palpation of lateral pole
or
on maximum unassisted or assisted opening, right or left lateral or protrusive movements

Question 13

TMD - disc displacement with reduction

Answer 13

description:
Intracapsular biomechanical disorder involving the condyle-disc complex. In the closed mouth position the disc is in an anterior position relative to the condylar head and the disc reduces on mouth opening. Clicking, popping snapping noises may occur with disc reduction
History:
History of ‘noise’ in past 30 days in movement/function
or
patient report of any noise during examination

Question 14

Continued

Answer 14

On examination
- clicking popping and or snapping during opening and closing movements on palpation during at least one of three repetitions of jaw opening and closing
or
clicking popping and or snapping during opening or closing movements on palpation during at least one of three repetitions of jaw opening
and
clicking popping and or snapping during at least one of three repetitions of left or right lateral or protrusive movements

Question 15

TMD - disc displacement without reduction with limited opening

Answer 15

Description
the disc does not reduce with opening. Persistent limited mandibular movement which does not reduce when the patient or clinician performs a manoeuvre. Closed lock
History
Jaw locked so that the mouth would not open all the way
Limitations in jaw opening significant to limit jaw opening and interfere with ability to eat
Examination
Maximum assisted opening (passive stretch movement <40mm including vertical incisal overlap

Question 16

TMD - Degenerative joint disease

Answer 16

Description
A degenerative disorder involving the joint characterized by deterioration of articular tissue with concomitant osseous changes in the condyle and/or articular eminence
History
History of ‘noise’ in past 30 days on jaw movement or in function
or
Patient report of any noise during examination
Examination
Crepitus detected with palpation during at least one of the following; opening, closing, right or left lateral or protrusive movements

Question 17

TMD - Subluxation (open lock)

Answer 17

Description
A hypermobility disorder involving the disc condyle complex and the articular eminence
Open mouth disc condyle complex is anterior to the articular eminence and is unable to return to a normal closed position without a manipulative manoeuvre
Momentary or prolonged duration
If patient can manoeuvre the joint back into position = subluxation
if assistance of clinician required = luxation
History
In the last 30 days jaw locking or catching in a wide mouth open position, even for a moment, so could not close from the wide-open position
And
Inability to close the mouth form a wide open position without a manipulative manoeuvre
Examination
No examination findings required but if disorder present at time of clinical examination then:
Inability to return to a normal closed mouth position from a wide open position without the patient performing a manipulative manoeuvre

Question 18

TMD- Management

Answer 18

Initial management in Primary Care:
- Reversible and Conservative
- Explanation
- Advice focusing on self-management
- Analgesia

Question 19

Describe conservative management

Answer 19

Rest and relaxation
Modify diet
Avoid wide mouth opening
Regular application of gentle heat - chronic conditions
Regular application of cold pack - acute onset pain &/or restricted mouth opening
Jaw Exercises
NSAIDs e.g. ibuprofen if not contra-indicated 14 day course
Muscle spasm or disc displacement without reduction with limited opening: diazepam 5 day course so long as not contra-indicated

Question 20

TMD - when to refer

Answer 20

• Chronic TMD symptoms lasting for more than 3 months
• Persistent or worsening symptoms despite primary care treatment.
• An uncertain diagnosis
• Marked psychological distress associated with symptoms and/or occlusal reoccupation (persistent hyperawareness or hypervigilance of their bite)
• Unexplained persistent pain or chronic widespread pain