TMD Flashcards
where is and what is the temporomandibular joint?
> Anterior to the tragus of the ear.
> Articulation between the condyle and glenoid fossa
> Biconcave intraarticular disk
> Surrounded by a ligamentous capsule lined by a synovial membrane
what are movements of the TMJ produced by?
> the muscles of mastication
what muscles open the TMJ?
> Lateral pterygoid
> Geniohyoid
> Mylohyoid
> Digastric
what muscles close the TMJ?
> Temporalis
> Masseter
> Medial pterygoid
what is temporomandibular disorder? (TMD)
> Group of musculoskeletal and neuromuscular disorders
> Major cause of non dental pain in orofacial region
> Patients will frequently initially present to GDP/GMP
what is the epidemiology of TMD?
> Most common cause of non-dental orofacial pain
> Third most common chronic pain
> Peak incidence is 2nd – 3rd decade
> F>M
> Significant cost associated with TMD (eg time out of work, time finding cause)
what factors are associated with the development of TMD?
> Multifactorial =
- Predisposing (susceptibility)
- Precipitating (things that trigger an attack)
- Perpetuating (maintain problem once its started)
(Can also occur in the absence of these factors)
what precipitating factors are associated with the development of TMD?
> strong = parafunction (day time), nutrition, smoking, sleep disorders
> moderate = dental interventions, occlusions
> low = orthodontic treatment
> no association = parafunction (night time)
what predisposing factors are associated with the development of TMD?
> strong = gender
> moderate = age, genotype
> low = ethnicity
what perpetuating factors are associated with the development of TMD?
> strong = endogenous pain modulation, peripheral/ central sensitisation, catastrophising, fibromyalgia
> moderate = stress, depression, childhood events, headache, lower back pain, IBS, chronic wide spread pain
> low = personality disorders
how is TMD classified?
- Muscular diagnosis
a. myofascial pain
b. myofascial pain with limited opening - Disk displacement
a. disk displacement with reduction
b. disk displacement without reduction and with limited opening
c. disk displacement without reduction and without limited opening - Arthralgia, osteoarthritis and osteoarthrosis
a. arthralgia
b. TMJ osteoarthritis
c. TMJ osteoathrosis
what is the difference between acute and chronic TMD?
> ACUTE
- identifiable cause
- short duration
- identifiable trigger
- resolves
> CHRONIC
- pain exceeds three months
- becomes biopschosocially destructive
- chronic pain behaviour
how does TMD present to a clinician ?
> Vary in presentation
> Often involve more than one component of masticatory system
> Four major signs/symptoms
- Pain
- Limited range of motion
- TMJ sounds
- Headache related to temporalis pain
what are the clinical features of TMD?
- Pain
> Pre-auricular region
> Head, neck, shoulders - Muscular tenderness
> Face (masseter, temporalis, posterior digastric, mylohyoid)
> Mouth (medial or lateral pterygoids)
> Neck and shoulder (? Cervical problems) - Joint noises
> Clicking
> Crepitus (grinding) - Locking
> Open
> Closed - Ear complaints
> Otalgia
> Tinnitus - Non-specific toothache or sensitivity
- Psychosocial effects
what are key questions to ask when you’re considering TMD to be a cause?
- Have you had pain in your face, jaw, temple, in front of the ear, in the ear in the last month? – Indicative of TMD
- Have you had any clicking or grinding noises from your jaw joint in front of your ear – Disc disorder or arthritides
- Have you ever had your jaw lock or catch so it won’t open all the way ? – Disc displacement without reduction
when carrying out a medical history what is important to find out regarding TMD?
> Conditions =
- Other chronic pain conditions
- Systemic conditions
- Hypermobility
- Growth disturbances
> Medications
- Antidepressants
when carrying out a social history what is import to find out regarding TMD?
> Occupation
> Lifestyle
> Habits
when carrying out an extra oral examination on a patient with suspected TMD what are checking ?
> Asymmetry
> Opening/pathway
> TMJ/MOM
> Lymph nodes
> Cranial nerves
when carrying out an intraoral examination in a patient suspected to have TMD what are you looking out for ?
- Hard tissues
- Occlusion
- Attrition
- Abfraction
- Wear facets - Soft tissues
- Tongue scalloping
- Linea alba - Tori
- TMD, Migraine > Controls
what conditions may mimic TMD?
> dental conditions - caries, cracked tooth, dry socket
> giant cell arteritis
> migraine headache
> neuropathic conditions - glossopharyngeal neuralgia, postherpetic neuralgia, trigeminal neuralgia
> salivery stone
> sinusitis
what special investigations are used for aiding diagnosis of TMD?
> used in Adjunct with each other
> Radiographic changes consistent with degenerative joint disease often doesn’t correlate with symptomology
> OPT
> MRI
> US
how many patent require treatment for TMD?
> 5-10%
> 40% of patient resolve problems spontaneously
how do we manage TMD?
> multidisciplinary approach
> Do not cause harm to the patient
> Encourage self management
> goal = Reduce the (impact of) pain
> Decrease functional limitation
when treating TMD what model is usually applied?
> Biopschosocial Modell of illness
> medical factors + psychological factors + social factors
> all managed at once
what are the 3 categories of management for a TMD patient?
> conservative
> pharmacological
> surgery
what is the first thing you should do when you suspect they have TMD?
> provide them with information
> Explanation
> Aetiology
> Self limiting condition
> Patient information leaflets
what self management techniques are recommended to patients?
> Sleep hygiene
> Caffeine consumption
> Smoking cessation
> Avoidance of parafunctional activities/habits
> Relaxation techniques
> Local measures
> Strategies on how to manage exacerbations of symptoms
is physical therapy good as a management for TMD?
> yes and no
> Evidence - weak
> Active v passive techniques
> Improves muscle strength
> Coordination
> Relaxation
> Range of movement
Is physical excercise good as a management of TMD?
> yes
> Graded physical exercise
- Aerobics, Tai chi, Yoga, Pilates, Stretching
> Reduces pain
> Improve function and wellbeing in other chronic musculoskeletal conditions with similarities to TMD
is acupuncture good as a management of TMD?
> can be used Alone or as an adjunct
> 15-30 mins; 6-8 sessions
> Systematic review suggests it may help to:
- reduce pain intensity
- masseteric tenderness
what is an occlusal splint?
> retainer which can reduce TMD symptoms aswell as stop -ve problems associated with parafunctional habits
> need appropriate design, hard? soft? hard-soft?
> upper = michigan, lower = tanner
what are the functions of an occlusal splint?
> Stabilise joint
> Protect teeth
> Redistribute forces
> Relax elevator muscles
> Reduce bruxism
> Decrease joint loading
> Masticatory muscle relaxation
what drugs/ phmarcotherapy will you use for acute onset TMD?
> NSAIDS
> Paracetamol
> Benzodiazepines
what drugs/ pharmacotherapy will you use for chronic TMD?
> Antidepressants
> Muscle relaxants
> Gabapentinoids
> Botox
when would you refer someone for surgery with TMD?
> Non surgical therapy has been ineffective
> Moderate to severe pain/dysfunction that is disabling
> Articular disorders
> Disc derangement
when should you refer patients to a specialist?
> Multiple unsuccessful treatments
> Psychological distress
> Trismus
> Chronic widespread pain
> Disc displacement without reduction
How should you manage a person at the initial presentation of temporomandibular joint disorder?
- If serious pathology is suspected or there is markedly limited mouth opening refer the person urgently to secondary care
- For other people with temporomandibular disorders:
> Exclude an odontogenic cause
> Explainthat the condition is benign and that symptoms often resolve with advice and symptomatic treatment.
3.Advisethe patient to:
> Eat soft foods, avoid foods that need a lot of chewing, and avoid wide yawning, singing, chewing gum, and biting their nails or chewing pencils.
> Massage affected muscles and apply gentle heat (for example a heat pad, hot towel, or hot-water bottle; being careful to avoid burns).
> Identify sources of stress (stress management programs)
- If necessary, advise or prescribe simple analgesia for short-term use(for example paracetamol, or a non-steroidal anti-inflammatory drug such as ibuprofen)
- If symptoms are severe, consider a short course of a benzodiazepine(for example diazepam 2mg to 5mg at night or up to three times daily; for a maximum of 2weeks).
- Watch out for any potentially harmful habits (such as teeth grinding or jaw clenching) and try to stop them (splint).
- Refer patients to secondary care if symptoms persist for six or more weeks
