The Temporomandibular Joint Flashcards
What is orofacial pain?
Pain perceived in the face and/or oral cavity. May occur with neck and headache pain.
The 1-year prevalence of orofacial pain has been estimated to be over ___ % in the adult population.
16%
List 5 questions that the PT should ask a patient experiencing TMJ pain.
- Does the jaw grate, click pop, snap or lock?
- Does the patient have headaches or ear problems?
- Is the patient’s pain worse upon awakening?
- Does the patient have any habits such as gum chewing, smoking, or clenching or grinding that could cause an overuse of the TMJ?
- What is the patient’s dental history - has the patient had any dental surgery, or braces or other appliances?
The presence of grating can indicate _______ changes.
osteoarthritic
What 3 symptoms can indicate displacement of the TMJ disc?
- Clicking
- Popping
- Snapping
What 2 symptoms indicate subluxation or dislocation caused by TMJ hypermobility?
- Clicking
2. Locking
Locking of the jaw in the full open position is called ______ or the full closed position which is called ______.
- Open lock: locking in full open position
2. Closed lock: locking in full closed position
What activities usually precede locking of the jaw in a full open position?
- Yawning
2. Opening the mouth wide to eat
What may be indicated if a patient’s pain is worse upon waking?
May indicate that the patient is clenching or grinding their teeth while asleep
In relation to dental work, what is a common cause of TMJ?
Prolonged mouth opening with dental surgery
What is malocclusion?
Manner in which the teeth fit together during biting or clenching
Aside from the usual items, what 4 items should be observed in patients with TMJ?
- Posture (forward head/protracted scapulae)
- Facial structure (asymmetry, under/overdeveloped lip)
- Jaw position (overjet)
- Resting position of the mouth
What is an overjet?
An occlusal impairment, with the teeth together, greater than a 2 mm horizontal distance between the back of the upper teeth and the front of the lower teeth
What is the normal resting position of the lips, teeth and tongue?
- Teeth should be between 2 and 5 mm apart
- Lips should be together
- Tongue should be resting on the roof of the mouth
What pressure exists in the mouth in resting position? What is the advantage of this?
- Slight negative intraoral pressure
2. Advantage: position can be maintained with minimal muscle contraction
If the mouth is open, the jaw muscles must ______ to keep the lower jaw from dropping downward. This can be a cause of_____ of the jaw muscles.
contract
overuse
What condition can cause TMJ pain if the tongue is not on the roof of the mouth in the resting position?
Tongue thrust
If the teeth are clenched together, the jaw muscles are _____.
Overworking
What position should the jaw be in?
Centric position: mandibular condyle positioned in the center of the temporal fossa
A mandible that is positioned too far ____as well as one positioned too far _____ can cause TMJ pain.
anterior
posterior
What can be used to hear TMJ joint noises?
Stethescope
List 6 muscles that should be palpated for tenderness and spasm in patients with TMJ pain.
- masseter
- Temporalis
- Medial pterygoid
- Lateral pterygoid
- Anterior/lateral/posterior neck muscles
- Posterior suboccipital muscles
What is normal ROM into opening? How is this measured?
40 mm or 3 fingers
Measured with a tape measure from the tip of the front upper and lower teeth
What movement should also be assessed with opening of the mouth?
Anterior translation
What 3 ROM limitations will a patient with a hypomobile left TMJ?
- Decrease in range of motion with deviation to the left when opening,
- Decrease in range of motion with deviation to the left with protrusion, and
- Decrease in range of motion with side gliding to the right.
What 3 ROM limitations will a patient with a hypermobile left TMJ?
- Increase in range of motion into opening with a deviation to the right (less mobile side),
- Increase in range of motion into protrusion with a deviation to the right (less mobile side), and
- More range of motion with side gliding to the right than side gliding to the left
How does one assess PROM at the TMJ?
Placing fingers inside the patient’s mouth (wear gloves)
MMT of the jaw muscles is typically performed _____.
Isometrically
What 2 muscles act as a force couple to open the mouth?
- Lateral Pterygoid (protrudes jaw)
2. Suprahyoid (opens the jaw)
What will happen if the lateral pterygoid over pulls?
Patient will translate too much anteriorly when opening the jaw
What 3 muscles are responsible for closing the jaw?
Masseter
Medial Pterygoid
Temporalis
What 2 muscles are responsible for side gliding (lateral deviation)?
Ipsilateral lateral pterygoid
Contralateral medial pterygoid
What 2 muscles are responsible for protrusion?
Medial Pterygoid
Lateral Pterygoid
What muscle is responsible for pretrusion?
Suprahyoids
How is the integrity of the trigeminal nerve (CNV) assessed?
Jaw jerk
List 6 common causes of TMJ pain.
- Disc dislocation
- Joint dislocation / hypermobility
- Joint hypo mobility
- Muscle weakness
- Muscle spasm
- Decreased muscle length
What is an occasionally dislocating disc?
Characterized by a soft opening click, which occurs intermittently.
Click when opening an no closing click occurs when the disc relocates with opening and not with closing.
What is a reducible disc?
Characterized by a soft opening click and a soft closing click that occurs at different parts of the range of motion as the mandible moves onto and back off of the disc.
What is a irreducible disc? What will this present as?
Characterized by a jaw that used to click but no longer clicks, and a decrease in jaw range of motion. The disc is now taking up space in the anterior aspect of the temporomandibular joint.
Presents as joint hypomobility
What is hypermobility with joint dislocation?
Characterized by a hard opening and a hard closing click. The hard click is caused by the two bones dislocating and relocating.
True or False: Disc dislocation are rarely the direct cause of pain at the TMJ.
TRUE
What 4 impairments should be treated in patients with dislocating discs and reducible discs?
- Impaired posture
- Excessive anterior translation with opening
- Muscle imbalance (esp. excessive contraction of the lateral pterygoid)
- Joint hypo/hypermobility
What intervention may be used to treat irreducible discs?
Surgery
List 4 interventions used to treat joint hypermobility at the TMJ.
- Stabilization exercises
- Instructions to avoid end range positions
- Joint mobilizations
- Stretching
List 6 general intervention considerations used to treat TMJ pain.
- Correct postural abnormalities (including sleeping posture)
- Instruct the patient to maintain good oral posture; lips together, teeth apart, tongue in the roof of the mouth
- Instruct the patient to eat soft foods, don’t eat bulky foods, take small bites
- Instruct the patient to yawn
- Refer patient for intraoral device
- Instruct patient not to smoke, chew gum, or grind/clench teeth
How often should the patient perform the Rocabado’s 6 exercises?
6 times each, 6 times a day
List the 6 Rocabado exercises.
- Clucking
- Tongue positioning
- Rhythmic stabilization
- Nodding
- Axial extension
- Shoulder positioning
What is the purpose of clucking for TMJ pain?
Provides proprioceptive input regarding the correct location of the tongue
Describe Rocabado’s tongue positioning exercise. What is the purpose of this exercise?
- Place your tongue flat on the roof of your mouth. Keep your tongue in this position, and open and close your mouth while breathing through your nose
- Purpose is to train the patient to minimize mandible protrusion with opening
Describe Rocabado’s rhythmic stabilization exercise. What is the purpose of this exercise?
- Start by assuming the start position described under “tongue positioning”. Place your index finger on your chin. Very gently, push against your chin in an upward direction, in a downward direction, and to each side, without allowing your chin to move in any direction
- Purpose is to strengthen TMJ muscles and stabilize the TMJ
Describe Rocabado’s nodding exercise. What is the purpose of this exercise?
- Start with both hands holding the back of your neck with your eyes horizontal. Gently nod your head slowly in approximately a 15 degree arc of motion.
- Purpose is to increase suboccipital mobility
Describe Rocabado’s axial extension exercise. What is the purpose of this exercise?
- Start with your face vertical and eyes horizontal. Press one finger gently over the base of your nose. Allow your finger to guide your head back, keeping your face and eyes aligned horizontal
- Purpose is to increase suboccipital mobility, to train the patient to maintain correct posture
Describe Rocabado’s shoulder positioning exercise. What is the purpose of this exercise?
- Start by assuming the start position described under “tongue positioning”, and the end position described under “axial extension”. Grasp your hands together behind your back. Slowly raise your arms up and pinch your shoulder blades together.
- Purpose is to train patient to maintain correct posture
True or False: No evidence exists to direct clinicians toward which exercises, if any, may be useful in the conservative management of TMD.
TRUE
List 2 patient education recommendations when treating patients with TMD.
- Reducing parafunctional habits
2. Providing pain science education
______ and ______ have been shown to produce a temporary analgesic effect, potentially lasting as little as 30 minutes.
- Interferential current
2. TENS
What is the indication for using biofeedback with patient with TMD? Is biofeedback effective?
To teach the patient to discriminate between muscles in spasm and those not in spasm, and to teach them to relax these muscles
YES, very effective in 70% of patients
This is abundant evidence to suggest that _____ is not warranted to treat TMD.
Ultrasound
_____ is not mentioned in relation to orofacial pain in any review article.
Laser
True or False: Myofascial release and massage techniques applied on the masticatory muscles are more effective than Botox injections in treating TMD.
FALSE
Myofascial release and massage are AS EFFECTIVE as Botox injections
______ approaches are effective for treating TMD/
Musculoskeletal manual approaches
