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Oral Disease > Temporomandibular Joint Disorders > Flashcards

Temporomandibular Joint Disorders Flashcards

1
Q

What percentage of the population have TMD with signs?

A

50-75%

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2
Q

What percentage of the population have TMD with symptoms?

A

20-25%

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3
Q

What percentage of the population have TMD who seek tx?

A

3-4%

Women more likely

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4
Q

What skeletal components make up the masticatory system?

A

Temporal bone
Maxilla
Mandible - condyle, angle (masseter overlies) , coronoid process

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5
Q

What muscles attaches to the mastoid process?

A

SCM

Digastric muscles

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6
Q

What does the masseter overly?

A

Zygomatic arch

Angle of mandible

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7
Q

How does the TMJ work?

A

The fibrous articular capsule envelopes the joint
Reinforced by the temporomandibular ligament
Articular disc divides joint into upper and lower compartments
Lower compartment - condyle rotates below the disc (hinge like motion)
Upper compartment condyle and disc translate along the articular eminence (gliding)

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8
Q

How far can the TMJ move open?

A

35-50mm

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9
Q

What types of movement are made within the TMJ?

A

1st part of movement is mainly hinging (rotation of condyle in the fossa)
2nd half of opening mainly forward translation of condyle along eminence (gliding)

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10
Q

What muscles are involved in the opening of the joint?

What do the muscles facilitate?

A

Muscle action facilitates rotation and translation
Geniohyoid and digastric pull chin down and backwards
Lateral pterygoid - forward translation of condyles and discs

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11
Q

What muscles are involved in the closing of the joint?

A

Temporalis (posterior fibres) - backward translation of condyles

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12
Q

Which muscles elevate the mandible?

A

Temporalis, masseter and medial pterygoid

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13
Q

How does protrusion occur? How far can we protrude?

A

Symmetrical forward translation of both condyles
Both lateral pterygoids pull condyles and discs forward
Can protrude 10mm

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14
Q

What is retrusion? How does retrusion occur?

A

= The return to rest position from the protrusion position

Both temporalis muscles (posterior fibres) pull condyles back

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15
Q

How far can we move the jaw laterally? How does lateral excursion occur?

A

10mm
The condyle on opposite side is pulled forward
Condyle on the same side performs minimal rotation around a vertical axis
Contraction of lateral pterygoid muscles on the opposite side
Combined with temporalis muscle on the same side contracting to hold the rest position of the condyle

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16
Q

What can TMD be mistaken for?

A

Dental pain
Salivary gland pain
Pharynx pain

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17
Q

What are the types of uncommon/specific TMDs?

A

Inflammatory arthritis
Neoplasms
Growth disturbance

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18
Q

Common TMD types?

A

Acute or chronic >3 months

Muscular
Articular
- Disc displacement
- Degenerative joint disease
- Subluxation
Mixed diagnosis
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19
Q

How to diagnose common TMD?

A

History and examination

Account for 90% of referrals

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20
Q

Define TMD

A

A collective term embracing a number of clinical problems that involve:

  • The masticatory muscles
  • Temporomandibular joint and associated structures
  • Or both
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21
Q

Classifications of common musculoskeletal TMD?

A

Masticatory muscle disorders

  • Myalgia:
    1. Local myalgia
    2. Myofascial pain
    3. Myofascial pain with referral

Temporomandibular joint disorders

  • Arthralgia
  • Disc disorders:
    1. DD and R
    2. DD and R with intermittent locking
    3. DD-R with limited opening
    4. DD-R without limited opening
  • Degenerative joint disease
  • Subluxation

Headache
- Attributed to TMD

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22
Q

Signs and symptoms of masticatory muscle disorders?

A

Familiar pain in muscles on jaw function/parafunction, palpation and movement tests

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23
Q

Myofascial pain with referral?

A

Report of pain at a site beyond the boundary of the muscle being palpated

  • Headache
  • Earache
  • Toothache
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24
Q

Myofascial pain with referral?

A

Report of pain at a site beyond the boundary of the muscles being palpated - may feel like toothache, headache and earache

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25
Q

TMJ arthralgia signs and symptoms?

A

Familiar pain in the TMJ on jaw function/parafunction, palpation or movement tests

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26
Q

TMJ - disc displacement with reduction?

Signs and symptoms?

A

Common
The disc position is no longer maintained on the condyle throughout the range of motion - disk is anteriorly displaced and reduced

TMJ clicking on function and movement tests (e.g. opening)
Familiar pain in TMJ on function, palpation and movement tests
Ipsilateral deviation with opening (which corrects)

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27
Q

TMD - Signs and symptoms of disc displacement with reduction with intermittent locking?

A

Intermittent TMJ locking/sticking

A maneuvre may be required to open mouth

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28
Q

TMD - Disc displacement without reduction?

A

Progression of disc displacement with reduction

Here the disc no longer relocates

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29
Q

TMD - Disc displacement without reduction signs and symptoms?
Disc displacement without reduction without limited opening?

A

Acute/subacute - closed lock

  • Limited mouth opening <25mm - interferes with ability to eat
  • Limited contralateral excursion
  • Familiar pain in TMJ on function, palpation or movement tests
  • Ipsilateral deviation with opening that does not correct

Chronic
- Joint can become stretched to allow nearly full ROM
= Disc displacement without reduction without limited opening

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30
Q

TMD - Degenerative joint disease - what is seen on the radiograph?

A

On OPT:

  • Joint space narrowing
  • Osteophytes
  • Subchrondral scelrosis (increased opacity)
  • Subchrondral cysts and erosions

Common and may be an added source of pain and limited ROM

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31
Q

TMD - degenerative joint disease signs and symptoms?

A

Common and may be an added source of pain and limited ROM

Crepitus on function and movement tests
Familiar pain in TMJ on function, palpation or movement tests
Limited mouth opening

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32
Q

TMD - What can hypermobility result in?

A

TMJ hypermobility can result in condyle subluxation

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33
Q

TMD subluxation signs and symptoms?

A

TMJ clicking and locking in a wide open position
Excessive mouth opening >50mm
Familiar pain on function, palpation and movement tests

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34
Q

How to differentiate hypermobility and subluxation?

A

If the pt is able to reduce the dislocation = subluxation

If the dislocation requires an interventional reduction = luxation

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35
Q

Headache attributed to TMD signs and symptoms?

A

Familiar headache in temporal area on function, palpation of temporalis muscle and movement tests

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36
Q

How to take a history regarding the TMJ?

A

PC
- SOCRATES

Clicking

  • On opening or closing
  • Aggravating/relieving
  • Timing
  • Temp or persistent
  • Associated with pain

Other joint noises

History of disorder:
Limitation of opening/trismus:
- Duration
- Aggravating/relieving
- Associated with pain
Locking
- On opening or closing
- Timing 
- Temporary or persistent
- Associated with pain 
Altered occlusion
Sensory disturbance
History of trauma
Parafunctional activity
- Clenching/grinding
- Nail biting
- Lip biting

PMH

  • Systemic arthritis
  • Previous malignancy
  • Mental health (depression/anxiety)
  • Fibromyalgia
  • Hypermobility syndrome
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37
Q

Chronic pain - what can TMD that lasts for a long time lead to?

A

Psychological distress and behavioural reactions:

  • Not working
  • Restricted social pattern
  • Depression

= Dysfunctional pain

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38
Q

Risk factors for chronic/dysfunctional pain regarding TMD?

A

Predisposing - trauma
Initiating - microtrauma and strain
Perpetuating - psychological and parafunctional

39
Q

What is fibromyalgia?

A

Widespread pain and sensitivity to palpation at multiple anatomically defined tissue sites
Often accompanied by depression and insomnia
Thought to be due to CNS neurosensory amplification

40
Q

What suggests intracranial pathology of cardiac ischaemia?

A

Pain that is abrupt in onset, severe or precipitated by exertion, coughing or sneezing
Interrupts sleep

41
Q

What can swelling of the TMJ, mandible or parotid gland suggest?

A

Tumour
Infection
Inflammatory arthropathy

42
Q

What can facial asymmetry indicate?

A

Tumour

43
Q

What suggests giant cell arteritis?

A

Unilateral headache, scalp tenderness, jaw claudication (cramping pain) or visual symptoms

44
Q

What can a neck mass or persistent cervical lymphadenopathy suggest?

A

Infection or tumour

45
Q

What can changes in occlusion suggest?

A

Tumour or bone growth (e.g. acromegaly) around the TMJ, or inflammatory arthritis

46
Q

What can an increase in pain or limitation of function suggest after initial management?

A

Tumour

47
Q

Contributing factors to TMJ pain?

A

8 removal = macrotrauma
Parafunctional activity = trauma

Hypermobility and fibromyalgia = Systemic condition

Overclosed or occlusal interference = abnormal position

Nail biting, stress and anxiety = Grinding/clenching = Parafunctional activity

48
Q

What to note on extraoral examination?

A 
Masseter muscle atrophy 
Protrusive habit 
Clenching
Poor neck postural habits
Asymmetry 
Lymph nodes
Arteries - superficial temporal artery and temporal arteritis
49
Q

What to note on intraoral examination?

A

Signs of clenching/grinding:

  • Tooth scalloping/buccal mucosa ridging
  • Attrition/wear facets
  • Hypertrophic masseter muscles

Occlusal assessment

  • Interfering contacts
  • Recent changes in occlusal scheme
  • Skeletal pattern - class II

Mucoskeletal examination:

  • Observation
  • Range of movement (ROM): Gap between 2 upper and 2 lower central incisors, deviations, joint sounds
  • Local palpation of M of M intraorally and TMJ
50
Q

How to examine the range of movement (ROM)?

A

Reference point - gap between 2 upper and 2 lower front incisors
Overpressure
Joint sound
Deviations

51
Q

What to palpate?

A

M of M - intraorally

TMJ

52
Q

How to treat TMJ pain?

A 
Education
- Info
- Principles of tx
- Reassurance
Physical therapy
Splint therapy
Medication
Psychological 
Occlusal adjustments
Botulinum toxin
Surgery
Review
53
Q

What are the aims of intervention?

A

Decrease pain
Improve jaw function
Improve psychological status
Self management

54
Q

Guidelines for safe and effective management?

A

Early diagnosis and intervention to help prevent development of chronic symptoms
Use of conservative, reversible and evidence based interventions
- Education, physical therapy, splints, medication and psychological support
- Don’t produce irreversible changes/less risk of harm

Even longstanding and severe symptoms do not usually require invasive tx
Failure of conservative interventions does not indicate need for irreversible tx e.g. occlusal adjustment surgery
2ndry care = physiotherapy referrals

55
Q

How to reduce stress/strain on TMJ and muscles?

A

Avoid oral habits

  • Tooth contact, Grinding, clenching
  • Nail biting
  • Pen chewing
  • Chewing gum
  • Lip sucking
  • Habital protrusion

Monitor oral habits
Tongue to roof of mouth
Check jaw rest position
Avoid a forward head posture

Eat a soft diet
Chew slowly
Avoid caffeine = increased muscle activity

Avoid sleeping on front

56
Q

Physical intervention to treat TMJ pain?

A

Self management to promote sense of control and to improve coping

Soft tissue techniques to facilitate muscle relaxation and reduce pain

Acupuncture as an adjunct can reduce pain and facilitate muscle relaxation

Manipulative therapy to help restore TMJ mobility

57
Q

What is active assisted stretch?

A

Slowly open mouth as wide as comfortable
Gently assist opening with your index fingers and thumbs - Thumbs on upper canines, index on lower incisors
Hold gentle stretch for 5 seconds
3x daily

58
Q

What is an occlusal splint?

A

Removable device usually made of acrylic resin, which fits between the maxillary and mandibular teeth

59
Q

How do splints work?

A 
Occlusal disengagement
Maxillo-mandibular realignment
Restored vertical dimension
TMJ repositioning
Cognitive awareness
Placebo
60
Q

What are the types of splint?

A

Directive - anterior repositioning splint

Permissive

  • Soft bite guard
  • Anterior bite plane - lucia jig
  • Stabilisation splint - michigan, tanner
61
Q

What does an anterior repositioning splint do?

A

Used to direct the mandible more anterior to ICP

Provides better condyle disc relationship to allow time for the tissues to adapt or repair

62
Q

Indications for anterior repositioning splint?

A

Disc derangement disorders (especially with anterior disc displacement with reduction)
Can be useful for intermittent/chronic locking of the joint (often caused by disc displacement)

63
Q

Advantages of soft splints?

A

Sometimes tolerated better by patients
Easily constructed
Cheap

64
Q

Disadvantages of soft splints?

A

Difficult to adjust
Can encourage pt to brux
In some cases muscle pain either does not change or occasionally increases

65
Q

What does a lucia jig do?

A

Used to disclude posterior teeth and allow relaxation of the M of M
Patients forget their ICP position

Uses:
Helps locate centric relation
As a diagnostic tool for pts with TMD symptoms
As a quick fix for pts with acute symptoms, prior to constructing a more definitive appliance

66
Q

Other names for a stabilisation splint?

A 
Michigan splint (upper)
Tanner appliance (lower)
Interocclusal appliance
Occlusal splint
Ramfjord appliance
67
Q

Features of stabilisation splint?

A

Maxillary splint
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
= Splint creates an artificial ideal occlusion

68
Q

Clinical stages of splint construction?

A

Visit 1

  • Upper and lower alginate impressions
  • Jaw registration in centric relation
  • Facebow transfer

Visit 2

  • Fit splint - seat and adjust fitting surface as necessary (bilaminate splints make fitting easier)
  • Adjust contacts in lateral and protrusive excursions
  • ICP=RCP
  • Anterior guidance and lateral guidance

Subsequent visits
- Review and adjust as necessary

69
Q

When should TMD patients wear a splint?

A

Every night
During periods of increased muscular stress/activity
For pts with severe symptoms, as often as possible

70
Q

Design features of the tanner appliance?

A 
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
71
Q

What to do following splint therapy?

A

If successful in reducing/eliminating symptoms consider long term splint wear
Do not assume further intervention will provide same benefit

72
Q

What should be considered as one of the first line treatments for pts with TMD?

A

Provision of an inter-occlusal appliance (usually upper hard acrylic splint)

73
Q

Medications for TMD?

A

Paracetamol
NSAID - ibuprofen

Anxiolytics

  • Tricyclic antidepressants - muscle relaxation and analgesic
  • Benzodiazepines - caution

Botulinum toxin

Arthrocentesis

  • Injection of steroids
  • Upper joint space

Arthroscopy

  • Adhesiolysis
  • Lavage
  • Biopsy
  • Miniscal plication
74
Q

Advantages of arthrocentesis and arthroscopy?

A

Minimally invasive

Diagnostic info

75
Q

Disadvantages of arthrocentesis and arthroscopy?

A

Limited scope for reconstructive surgery

Requires a high level of operator skill

76
Q

Surgical options for TMD?

A 
Condylar hyperplasia
Trauma
Ankylosis 
Tumours
Internal derangement and severe chronic pain - that is refractory to non-surgical treatment
77
Q

Surgical risks?

A 
Auriculotemporal nerve
Facial nerve (zygomatic, temporal branches)
78
Q

What is diskoplasty?

A

Disc repositioning (plication)

79
Q

What is diskectomy?

A

Disc removal and alloplastic material / temporalis muscle flap

80
Q

Trauma that can cause TMD?

A

Traumatic arthritis/effusion
Dislocation
Fracture

81
Q

What is osteoarthritis?

A

Also known as degenerative arthritis or degenerative joint diseases or osteoarthritis, is a group of mechanical abnormalities involving degradation of joints - including articular cartilage and subchondral bone

= Painful inflammatory erosive phase lasting 3 yrs followed by a period of resolution

82
Q

Clinical features of osteoarthritis?

A 
Pain centred on the joint
Tender joint
Crepitus
Limitation of mouth opening
Limitation of translatory movement 
Radiological signs (erosions, spurs)
83
Q

Osteoarthritis treatment?

A

Symptomatic

  • Splint
  • BRA
  • NSAID

Arthrocentesis = syringe to collect synovial fluid from a joint capsule

84
Q

Infective arthritis - where can it spread?

A

Spread to middle cranial fossa therefore must be treated urgently

85
Q

Clinical features of infective arthritis?

A 
Pyrexia
Very restricted opening
Suppuration
Erythema
Swelling
Long term ankylosis
86
Q

Infective arthritis treatment?

A

IV antibiotics

Drainage

87
Q

Extracapsular ankylosis and limited opening?

A

Opening normally more than 40mm
Trauma = fibrosis (burns, trauma, lacerations)
Infection
Tumours (fibrosarcomas)
Periarticular fibrosis (radiation, prolonged immobilisation)
Inflammation (dental)

88
Q

Intracapsular ankylosis and limited opening?

A

Opening normally more than 40mm
Trauma = fracture (forceps delivery at birth)
Infection
Systemic arthritis
Tumours
Synovial chondromatosis (multiple cartilaginous nodules within the TMJ) - very rare

89
Q

Pseudo-ankylosis?

A

Opening normally more than 40mm

Mechanical interference with mouth opening (e.g. zygomatic fracture)

90
Q

Trismus checklist - for pts with reduced mouth opening?

A

Opening less than 15mm
Progressively worsening trismus
Absence of history of clicking
Pain of non-myofascial origin (neuralgia)
Swollen lymph glands
Suspicious intra-oral soft tissue lesion

If any of the answers are yes - consider radiograph and arrange review with senior clinician

91
Q

How to treat recurrent dislocation of TMJ?

A

Physiotherapy
Botulinum toxin (lateral pterygoid)
Fibrosis of the tissues
Surgical

92
Q

Types of inflammatory arthritis?

A 
Rheumatoid (also juvenile)
Psoriatic
SLE
Ankylosis spondylitis
Gout
93
Q

How and when to replace the TMJ?

A

Made of 2 parks - ball and socket system

Reserved for cases where all other tx modalities have failed

Oral Disease (42 decks)

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