Temporomandibular Dysfunction Flashcards
Describe the TMJ
Gliding joint made up of: convex articular condyle of the mandible and concave articular fossa on squamous portion of temporal bone
Separated by a fibrocartilaginous articular disc — 3 parts of disc: thick anterior band, thin intermediate zone, thick posterior band
Describe TMJ changes in terms of the meniscus with mouth closed vs. mouth open
Meniscus with mouth closed: condyle is separated from the articular fossa of the temporal bone by the thick posterior band
Meniscus with the mouth open: condyle is separated from the articular eminence of the temporal bone by the thin intermediate zone
Muscles of mastication that depress mandible initially, then pterygoids take over
Digastric, suprahyoid
Action of left lateral and medial pterygoids
Move mandible lateral and forward to the right
Muscles of mastication responsible for tight jaw closure
Temporalis, masseter, medial pterygoid
Actions of buccinator, depressor labii inferior, depressor anguli oris and platysma, mentalis
Buccinator = approximates lips and compresses cheeks (blowing)
Depressor labii inferior = protrudes lower lip (pouting)
Depressor anguli oris and platysma = draws corners of mouth down
Mentalis = draws tip of chin upward
Actions of orbicularis oris, zygomatic minor, and levatror anguli oris
Orbicularis oris - approximates and compresses lips
Zygomatic minor - protrudes upper lip
Levator anguli oris - lifts upper border of lip on one side without raising lateral angle (snarl)
Actions of zygomaticus major and risorius mm
Zygomaticus major = raises lateral angle of the mouth
Risorius = approximates lips and draws lips and corners of mouth lateral (grimace)
Symptoms/signs of TMJ dysfunction
Most often c/o facial pain, HA, ear sxs, TMJ pain, or sxs of jaw dysfunction
Cephalgia, otalgia, neck pain, eye pain, shoulder/back pain, tinnitus, dizziness
May describe pain as a dull ache with difficulty opening mouth (click/crepitans), lateral jaw deviation, spasm within facial muscles, onset of TMJ symptoms may correspond with onset of stress or added stressors
Behavioral associations with TMJ
Nocturnal bruxism (controversial)
Jaw clenching (anxiety, stress)
Types of TMJ dysfunction
Opening click
Closing click (reciprocal clicking)
Inability to fully open jaw (close-locked)
Inability to close if TMJ symptoms are bilateral
Crepitus and grating
Fusion of the joint (ankylosis)
Causes of jaw clicking
Almost always d/t disc displacement (after disc is thin/stretched)
other causes: Adhesions, uncoordinated muscle action of pterygoids, tear or perforation of disc, osteoarthritis, occlusion imbalance
Important components of patient hx to ask about when pt c/o TMJ symptoms
PMH of jaw trauma Sleep habits/position Symptoms of bruxism Use of mouth orthotics Occupation/hobbies Symptoms of depression/anxiety Recent stressful events
Also personal habits like usual posture, nail biting, or frequent gum chewing
General Etiologies of TMJ dysfunction
Trauma (direct, whiplash, third molar extraction, intubation)
Malocclusions of maxillary and mandibular teeth
Muscle strain (oral habits, postural/work, sports)
MSK problems or Somatic dysfunction
Compensatory changes (short leg syndrome, scoliosis)
Developmental abnormalities (condylar hypoplasia/agenesis)
Mood disorders (anxiety, depresion, PTSD, hx of abuse)
Endocrine, hypocalcemia (Chvostek’s sign, Trousseau sign)
What type of TMJ injury results from direct blow to the joint with a closed mouth?
Posterior capsule injury
Types of malocclusion
Class 1 = 1st molars normal, problems elsewhere
Class 2a = lower 1st molar posterior to upper mandibular retrusion (overbite)
Class 2b = lower 1st molar posterior to upper to greater degree (larger overbite)
Class 3 = lower 1st molar anterior to upper mandibular protrusion (underbite)
Intracapsular problems
Infection RA OA Gout Metastatic Ca Articular disc displacements
Extracapsular problems
Myofascial pain of masticatory muscles — TMJ myofascial pain syndrome, TMJ dysfunction syndrome, TMJ syndrome
NIH preferred terminology = temporomandibular muscle and joint disorder (TMJD)
Epidemiology of TMJ dysfunction
2 cause of facial pain (HA is #1)
Affects about 20% of American population
MORE common in young women
More recent data suggest a 12-15% prevalence with 5% seeking tx due to pain/disability
Patients with RA are more likely to develop temporomandibular pain
Components of OSE for TMJ complaints
Cranial (note facial asymmetry)
C-spine
Scoliosis
Leg length (innominate shear/rotation, sacrum, SI joints)
Palpate joints for crepitans/clicks, palpate mastication muscles w/ 2-3 lbs of presure for tenderness, ROM + observe for jaw deviation, observation for cavities, suspicious lesions in mouth, teeth alignment
Components of ROM exam for TMJ complaint
Active — patient opens mouth 3-6 cm, laterally 1-2 cm, and then retracts and protrudes mandible — observe jaw movements for deviation
Passive — move pts jaw medially and laterally, with gloves feel muscles inside mouth and check for tissue texture asymmetry
[normal functional opening is 35-55 mm, functional opening in TMD pts is usually < 25 mm and often associated with pain]
What PE findings might suggest TMD?
Abnormal mandibular movements
Decreased ROM of TMJ
Tenderness of muscles of mastication
Pain with dynamic loading
Bruxism (signs of tooth wear)
Postural asymmetry
Neck and shoulder muscle tenderness
Normal CN exam
Differential diagnoses for TMD
Migraine-related disorders: carotodynia
Inflammatory dz: local infection, RA, giant cell arteritis
Dental problems: posterior teeth support loss
Neuralgias: trigeminal, glossopharyngeal
Parotid gland disorders
Lymphoproliferative disorders
Microbiology and pathology: C.tetani, odontogenic cysts, sclerosing osteomyelitis of Garre, monocystic fibrous dysplasia, acromegaly leading to prognathism
Medication side effects (steroids and avascular necrosis, bisphosphonates and osteonecrosis of the jaw)
Eagle’s syndrome (stylohyoid syndrome): elongated styloid process
Radiological exam for TMD is usually not helpful. When would you choose to do it?
Suspect dental problems
Pt with severe symptoms that don’t improve with conservative tx
Concern for alternative cause
Recent, severe trauma
[periapical radiographs can r/o tooth problems]
When radiological testing is done for TMD, what is the procedure of choice and why?
MRI — used to see position and shape of disc
[disc is commonly displaced in asymptomatic pts; MRI findings alone not significant unless TMJ movement is restricted or there is clinical suspicion for disc dislocation]
EBM TMJ level 1 interventions
CBT for chronic TMJ reduces activity interference, pain, and depression at 1 year
EBM TMJ level 2 interventions
Amitriptyline Glucosamine sulfate for OA of TMJ Benzodiazepine Botox Accupuncture OMT Therapeutic exercise Physical self-regulation CBT + biofeedback Oral habit reversal tx Hypnorelaxation NSAIDs (usually not adequate)
EBM TMJ level 3 interventions
OMT PT + counseling Occlusal adjustment Biofeedback alone Occlusal splints (mouth guard) Surgery (arthrocentesis, arthroscopy, orthgnathic surgery, joint replacement)
T/F: OMT used to tx TMJ has been associated with less NSAIDs and muscle relaxant use
True
Types of OMT techniques used for the correction of structural imbalances with TMD
Counterstrain MET Craniosacral BMT/BLT HVLA
Non-pharmacologic holistic tx for TMD
Patient education — avoiding triggers, nature of condition, rationale for tx choice
Self-care aimed at improving pain and function — changing head posture, sleeping position, aggravating parafuncitonal oral behaviors (nail biting, pen chewing, etc.), eliminate jaw stress
Bite plate appliance may help, dental care PRN, adjust diet to easier foods to chew
MSK biofeedback, relaxation techniques
What factors are associated with poorer prognosis with TMD?
High levels of disability
Prolonged or excessive use of opiates, benzodiazepines, alcohol, or other drugs
Pre-existing psychological distress
When examining contours of the face, what are the landmarks for dividing the face into thirds to note asymmetry?
Hair line to bipupital line
Bipupital line to nose line
Nose line to chin line
What muscles are you testing when you have the pt depress the jaw against mild resistance?
Digastric and suprahyoid
5 models considerations for TMJ
Biomechanical: cranial, TMJ specific, cervical manipulation
Psych/behavioral: lifestyle changes to remove exacerbating factors (CBT)
Neurologic: CN V - mandibular division to mm of mastication, CN VII
Metabolic: r/o metabolic cause/tx underlying dz — Ca deficiency, renal dz, side effects of meds
Respiratory circulatory: lymphatic techniques
