TMD and Orofacial Pain Flashcards
Axis 1 includes
Masticatory mm disorders
Disc displacements
Joint dysfunction
Masticatory mm disorders includes
with normal openin
with limited opening
Disc displaceemnt includes
With reduction
Without reduction without limited opening
Without reduction with limited opening
Joint dysfunction includes
OA
Arthralgia
Osteoarthritis
Masticatory muscles
Masseter
Temporalis
Lateral Pterygoid
Medial Pterygoid
Necessary components of central sensitization
Abnormal inc of perceived pain in brain
Dec in brains input to inhibit pain
Hyperexcitability in spinal cord neurons
Repetitive firing of pain receptors in periheral NS
Possible micro and macro trauma that could cause damage to disc
Dental procedure that requires pronlonged mouth opening
Parafunctional activites
Oral sex
Most common position of displacement of the disc
Anterior
If the disc gets injured, prognosis for improvement?
Good - is vascularized and innervated
DDWR
two clicks occur
Condyle rides on the middle part of the disc with mouth open and rolls off when mouth closes
DDWR - if worsens what can happen
DDWOR
If DDWOR occurs with limited opening, what happened
The disc moved so ant that the condyle rides up on the disc and biomechanically the TMJ cant fully open
Arthralgia
Joint pain
Osteoarthritis
Involves inflammatory process
Osteoarthrosis
Does not involve inflammatory process but still have joint degeneration
Axis 1 dx related to
muscle, disc, joint pathology
Axis 2 dx related to
psychological issues that cause or maintain pain
Other causes of orofacial pain that need to be ruled out besides axis 1 and 2
Cervical spine Cranial nerves Eyes, ears Sinuses Toothache or dental issues Headaches Systemic problems RA Peripheral neuralgias - trigeminal too
What does complete exam for orofacial pain have to include
TMJ musculoskeletal eval Psychological exam Cranial nerve screen Cervical screen Systems screen Heart attack can refer to face
History
Have you had pain or stiffness in the face, jaw, temple, in front of the ear, or in the ear in the past month?
Are the symptoms altered by any of the following jaw activities: chewing, talking, singing, yawning, kissing, moving the jaw?
Have you ever had your jaw lock or catch so that it would not open all the way? If so, was this limitation in jaw opening severe enough to interfere with your ability to eat? Have you ever noticed clicking, popping, or other sounds in your joint?
Examples of parafunctional activites
Gum chewing
Nail biting
Bruxism (grinding, clenching)
Bx that could irritate TMJ
Leaning head on chin Forward head posture Eating hard food Grinding teeth Clenching jaw
Scales to rule in/out psychological problems
Patient health questionnaire for anxiety and depression
Graded chronic pain scale
Medical practitioners with whom you might communicate with
Dentist Oral surgeon Speech therapist Family med doc/internist EMT Psych Nutritionist Neurologist Rheumatologist Ophthalmologist
Tests and measures to rule in/out disorders not in axis 1
Cranial nerve testing Psych exam Cervical screen Vital signs Palpation of temporal artery Observation
Central occlusion
Asking them to bite
Normal is mandible will go about half way down - touch equally at molars
Crossbite
Mandibular teeth are lateral to maxillary teeth on one side and medial on the other side
Underbite
Mandibular teeth are anterior to maxillary teeth
Overbite
Maxillary incisors extend below mandibular incisors when jaw is in central occlusion
Overjet
Measure of how far top incisor teeth are ahead of bottom incisors
Mobility - opening
Active without pain Active into pain End feel Resist opening and closing Measurement - 40 to 50 mm with firm capsular end feel 3-4 fingers btw teth
Limited opening may be cause by
mm tightness
capsular tightness
DDWR
Lateral movement with opening may indicate
restriction on one side, mm tightness or asymmetrical mm contraction of DDWR on one side
Mobility - closing
Teeth to teeth end feel
Lateral deviation
Perform AROM before pain, into pain, overpressure with endfell and measure
Normal ROM - mandibular central incisors move lateral to maxilla central incisors 8-11 mm
Protrusion/Retrusion
AROM to pain, into pain, overpressure, end feel
No measurement for normal ROM - madibular teeth should move past maxillary teeth
Deflection will occur on side of joint pathology with protrusion
Palpation
TMJ - ant tragus of ear, lateral pole with mouth opening
Cervical spine, boney prominences of face
Mm of mastication
Joint noise - listening for clicks and pops
Palpate while moving through ROM
Can use stethoscope on TMJ
Differential Dx related to noise - clicking on opening and closing
DDWR (Sp = .90) or nothing is wrong
Differential Dx related to noise - Hx of noise that has now reduced
DDWOR with limited opening (Sp = .90) or normal opening
Differential Dx related to noise - Hx of noise that has reduced and now no pain
DDWR or DDWOR that has healed
Differential Dx related to noise - crepitus with pain
Joint arthralgia
Differential Dx related to noise - TMJ pain without crepitus
Joint arthralgia without joint degeneration
Temporalis
Attaches on coronoid process
Palpate from temporal line of skull, post to ant to ear
Palpate externally to mandibular ramus, slightly open mouth to be able to reach coronoid
Temporalis referral patter
to upper teeth, temporal area and area around the eye
Temporalis - intraoral palpation
Follow ant ramus of mandible sup to the coronoid process
Masseter
Zygomatic arch to ramus of mandible
Palpation of outer angle of mandible - clench teeth
Masseter trigger points refer to
lower teeth, lateral face, and around eye
Medial Pterygoid
Palpate externally on medial portion of inf mandible
Resist protrusion to palpate
Medial Pterygoid - trigger points refer to
ear, ant to ear and cervical spine just post to mandible
Lateral pterygoid
Unable to directly palpate REsist protrusion (inf portion) Clench teeth (sup portion)
Lateral Pterygoid - trigger points refer to
Ear, perauricular area, and lateral face
Joint mobility - ligament stress tests
Caudal glide - lateral TMJ ligament
Post glide - INtrinsic ligament - ipsilateral deviation with post glide
Joint mobility
Ant glide
Post glide
Medial and lateral glides
Special tests -
Power stroke
Unilateral joint loading
Joint compression
VAS related to functional activity
Special tests - power stroke
Clenching teeth - biting bilaterally on tongue depressors - causes mm contraction but joint is somewhat unloaded
May point to problems more in mm than in joint