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TMD > TMD Exam 1 > Flashcards

TMD Exam 1 Flashcards

1
Q

What is an immediate side shift

A

NO CONDYLAR TRANSLATION

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2
Q

What is a PROGRESSIVE side shift

A

Increases as the condyle translates

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3
Q

What is a progressive and immediate side shift limited by?

A

MEDIAL WALL OF TMJ

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4
Q

What are all the MOMs innervated by

A

V3

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5
Q

What is the posterior digastric innervated by

A

CN 7

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6
Q

what are the MOMs

A

masseter, temporalis, medial pterygoid, lateral pterygoid

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7
Q

What type of joint is the TMJ?

A

ginglymoarthrodial (hinge and gliding)

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8
Q

what innervates the TMJ

A

auriculotemporal nerve (post and lateral TMJ)
deep temporal nerve (anterior TMJ)
branches off V3

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9
Q

What kind of joint is the TMJ

A

loaded joint
knees, hips, are loaded joints
finger joints are unloaded

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10
Q

The glenoid fossa and condyle are covered with

A

FIBROCARTILAGE – not hyaline cartilage

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11
Q

what are the cardinal signs and symptoms of TMD

A 
masseter muscle pain
TMJ pain
temporalis pain
mouth opening limitations
TMJ sounds

PAIN is the biggest reason why people seek treatment

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12
Q

when is TMD most often reported

A

20-40s

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13
Q

what percent of population has at least ONE TMD symptom

A

33%

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14
Q

Do TMD symptoms fluctuate with time?

A

Yes. they correlate with PARAFUNCTIONAL habits – clenching, grinding, masticatory muscle tension

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15
Q

TMD PTs with POOR psychosocial adaptation…

A

have significantly GREATER symptom improvement when dentist’s therapy is combined with cognitive-behaviorl intervention

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16
Q

What are some other things TMD canc ause

A 
non-otologic otalgia
dizziness
tinnitus
neck pain
toothache
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17
Q

TMD can CONTRIBUTE TO (not cause)

A

migraine and tension headaches
muscle pain in region
many other types of pain

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18
Q

Females > Males

A

Females have more TMD issues

their symptoms are less likely to resolve than a males

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19
Q

TMD is a ____ disorder

A

multifactorial

To treat, you can do many things:

  • -Treat muscles and cervical region
  • -Provide relaxation, stress management, cognitive-behavioral therapy, psychosocial therapy
  • -Improve occlusal stability (ortho, prosth)
  • -Decrease TMJ inflammatory mediators
  • -Medication
  • -Self management strategies
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20
Q

Generally recommend TMD therapy if PT has significant

A 
Temporal headaches
Preauricular pain
Jaw pain
TMJ catching or locking
Loud TMJ noises
Restricted opening
Difficulty eating, due to TMD
Non-otologic otalgia, due to TMD
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21
Q

Primary Diagnosis

A

This is the diagnosis that causes the pain
it is most responsible for the PT’s CC
-Can be TMD origin or non-TMD (pulpal, sinus, cervical headache)

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22
Q

Secondary, Tertiary diagnosis

A

these also contribute to PT’s TMD BUT less so

If the PT has some underlying disorder that is contributing to pain, you don’t call that a secondary diagnosis… that is now a CONTRIBUTING FACTOR

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23
Q

Perpetuating contributing factors

A

these do not allow the disorder to resolved

  • -night time parafunctional habits
  • -gum chewing
  • -stress
  • -neck pain
  • -daytime clenching
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24
Q

What are the patterns of symptoms?

A

Time of day? – worse when i wake up – worse during the day

Location pattern – it starts at my neck and moves to my jaw

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25
Q

What is secondary gain

A

the PT BENEFITS from having the disorder
they don’t want to get better
usually rarely seen in TMD patients

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26
Q

What is the most common pain quality for TMD

A

PAD:

pressure
ache
dull

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27
Q

What do you suspect if the PT has throbbing pain

A

migraine

reffered pain from tooth

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28
Q

What are the parameters for pain

A

intensity
frequency
duration

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29
Q

What are some NON-MASTICATORY contributors to TMD

A

Cervical pain
PTSD
Fibromyalgia

**If the PT has one of the above 3, they do not respond well to TMD therapy

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30
Q

When a PT says they cannot open wide…

A

think TMJ or muscle disorder

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31
Q

if the inabilty to open wide is INTERMITTENT with RAPID ONSET

A

With rapid onset and resolution, probably acute disc displacement without reduction

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32
Q

If inability to open is intermitten with SLOW ONSET

A

, probably myofascial pain and/or TMJ inflammation

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33
Q

How can you identify limiting source?

A

ask pt to stretch wider and see what causes the pain

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34
Q

TMJ dislocation (inability to close)

A

45 mm or greater

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35
Q

TMJ disc displacement WITH REDUCTION

A

10-35 mm

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36
Q

Giant Cell Temporal Arteritis

A

mimics mild TMD symptoms
PT is > 50
Reduced blood flow to head and neck - muscle tires out fast

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37
Q

what are the minimal normal openings

A

40 mm opening
7mm lateral
6mm protrusive

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38
Q

TMJ Noises - pops and clicks

A

Very prevalent among TMD and normal population

Commonly related to disc displacement with reduction

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39
Q

TMJ noises - crepitus/grating/crackling

A

Roughness on articular surface(s)

Could be secondary to osteoarthritis, chronic DD WITHOUT reduction

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40
Q

What are the initial TMD palpations

A 
Temporalis
TMJ
Masseter
Carotid arteries
Thyroid
Suboccipiatl region
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41
Q

PT presents with tooth pain –

A

think it might be referred pain from a masticatory structure – masseter comomonly invovled
Don’t do ENDO if the pain is not eliminated even after you anesthetize the tooth

if you see EXCESSIVE forces on a tooth or a few teeth – think parafunctional etiology

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42
Q

How do you palpate more intensely

A

find and load trigger points or nodules of spot tenderness

  • -feels like firm knots within muscle and more tender than the surrounding muscle
  • apply pressure to the nodules
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43
Q

What kind of radiographic change do you see in a TMD PT?

A

Begins on condyle’s lateral pole

Primarily caused by TMJ inflammation

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44
Q

How far behind do radiographic changes lag in terms of clinical findings

A

Radiographic changes lag by as much as 6 months behind clinical findings

Therefore TMD treatment generally directed towards symptoms, not toward radiographic findings

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45
Q

How do you view the soft tissue part of TMJ

A

MRI

You are looking to see the disc position whent he mouth is opened as wide as possible and when mouth is closed

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46
Q

What do you use a plain radiogrpah for

A

screen for gross changes

Transcranial can be made with standard dental X-ray unit

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47
Q

Why is a pano bad

A

Lateral pole superimposed within condyle image

So cannot view early condylar demineralization

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48
Q

What provides TRUE lateral projection

A

Axially corrected sagittal tomography

Lets you

Can view osseous changes of the articular surface
Evaluate condylar translation

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49
Q

What is a CT used for

A

Sectional images of TMJ and region

Used for viewing TMJ ankylosis, neoplastic conditions, anomalies, etc.
Used to fabricate 3-D stereolithic model for better comprehending surgery and to fabricate custom TMJ implant

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50
Q

CBCT

A

Currently only provides view of hard-tissues

High quality TMJ images with low radiation from comparatively small inexpensive unit

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51
Q

Does having disc displacement mean you ahve TMD?

A

NO

9 to 31% of asymptomatic TMJs have a disc displacement

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52
Q

What is arthrography

A

Displays contrast media injected into TMJ
Rarely used
Due to very painful and radiation exposure

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53
Q

What is high-res ultrasound?

A

Helps you see hard and soft tissue of TMJ

BUT, it is inferior to CBCT and MRI

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54
Q

Primary diagnosis

A

Disorder most responsible for chief complaint

If multiple structures reproduce chief complaint, the diagnosis for structure that most readily reproduces it

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55
Q

When do you see a pseudodisc

A

In healthy TMJ, adaptive changes form pseudodisc in retrodiscal tissue
Comparatively withstands TMJ loading

TMJ DD with reduction

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56
Q

Click or Pop

A

TMJ DD with reduction

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57
Q

In TMJ DD with Reduction

A

Does not usually progress unless patient has pain or intermittent locking
Noise does not respond as well to TMD therapy as pain responds

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58
Q

Acute disc displacement without reduction (closed lock)

A

Patient has sudden onset of limited opening (35 mm or less)

No increase in pain when closing into MI
Teeth occlude into normal position
Often have history of occurring intermittently

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59
Q

If the Limited opening is due to a lateral pterygoid myospasm

A

A significant increase in pain when closing into MI

Teeth do not occlude into normal position

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60
Q

acute DD WITHOUT reduction can be due to two other things

A

Can be due to other stuff too:
Limited opening can be due to closure muscle (masseter muscle) disorder

Limited opening could be due to a lateral pterygoid myospasm

61
Q

Chronic disc displacement without reduction

A

PTs have history of acute disc displacement without reduction (<35 mm opening) and gradually regain their opening (greater than 35 mm) over time (few weeks to months)

Opening increase due to stretching of the retrodiscal tissue, moving the disc anterior, enabling greater condylar translation

Course crepitus is most common noise

62
Q

What is the most common noise in chronic DD WITHOUT reduction

A

Course Crepitus/crackling

63
Q

What is a dislocation (Subluxation)

A

Inability to close from maximal opening

64
Q

How can you ID inflammatory TMJ diseases

A

Identified by TMJ palpation tenderness
TMJ Inflammation – the TMJ deteriorates – tender – Synovitis, capsulitis

Polyarthritides - systemic condition

65
Q

Osteoarthritis

A

Diagnosed when TMJ tender to palpation and hard-tissue imaging reveals bony changes

66
Q

Primary Osteoarthritis

A

when due to TMJ overloading (e.g., clenching)

67
Q

Secondary osteoarthritis

A

when due to direct trauma

68
Q

Ankylosis

A

Very limited opening, generally not associated with pain
Can attempt to force mouth open wider to determine restrictive structure
Conservative TMD therapies not beneficial and patient will need TMJ surgery

Can be fibrous or bony

69
Q

Masticatory Muscle Disorderss

A 
Myofascial Pain (not myofacial)
Most common diagnosis for TMD pain

Aggravated by muscle use, stress, cold, etc.

If muscle is tender to palpation and none of the other muscle diagnoses better describe the patient’s condition, recommend be diagnosed as myofascial pain
Traditional TMD therapies have been shown to reduce masticatory myofascial pain

70
Q

Myositis

A

Muscle inflammation due to spreading infection, external muscle trauma, or muscle strain

71
Q

Myospasm - inferior lateral pterygoid

A

Inferior lateral pterygoid myospasm

Painful or unable to move mandible from partially translated position
Painful or unable to occlude teeth into MI
Contralateral canines usually first to occlude
Painful or unable to open wide

72
Q

Myospasm - medial pterygoid

A

secondary to inferior alveolar nerve block

Stretch muscle to tolerance, 30 to 60 seconds
Ibuprofen and diazepam
If does not resolve, refer to physical therapist

73
Q

Myofibrotic Contracture

A

Fibrous adhesions within muscle causes muscle to not be able to stretch to full length
Painless unless combined with other painful muscle disorder
If due to closure muscle
Causes limited opening

Practitioner can forcibly stretch mouth to determine if restriction from muscle or TMJ origin

74
Q

How does myofibrotic contracture occur in the inferior lateral pterygoid muscle

A

From continuous wear of anterior positioning appliance

75
Q

the most common TMD diagnosis among the general population

A

TMJ DD WITH REDUCTIOn

76
Q

the most common muscle pain diagnosis

A

myofaSCial pain

77
Q

most common TMJ pain diagnosis

A

TMJ Inflammation

78
Q

Know the difference between the three contributing factors

A

Predisposing contributing factors
Initiating contributing factors
Perpetuating contributing factors

79
Q

Predisposing Contributing Factors

A

Elements making individual more susceptible to develop TMD
Fingernail biting, nocturnal parafunctional habits, daytime parafunctional habits, etc.
Cause individuals to be predisposed to TMD

80
Q

Initiating Contributing Factors

A

Event that caused TMD to develop
Trauma to jaw, placement of crown, etc.

Perform cursory TMD evaluation prior to dental treatment
Suggests patient’s TMD propensity

81
Q

Perpetuating Contributing Factors

A

Directly or indirectly aggravate masticatory system and prevent TMD symptoms from resolving

82
Q

Awakes with symptoms that rapidly resolve

Whats the pattern?

A

Primary contributing factors occur at night, e.g., nocturnal parafunctional habits, stomach sleeping, etc

83
Q

Awakes without symptoms and develop as day progresses

Whats the pattern

A

Primary contributing factors occur during day
Generally due to excessive muscle activity
Holding excessive tension in masticatory muscles
Performing excessive parafunctional activities
Generally increase when individual busy, frustrated, concentrating, e.g., using computer, driving, etc.
Daytime contributing factors under patient’s control to change

84
Q

Awakes with symptoms and has symptoms throughout day

A

Suggests patient has daytime and nocturnal contributing factors

85
Q

Contributing factyors are in a broad continuum

A

biological, behavioral, emotional, cognitive, social, and environmental

86
Q

Biologic contributing factors

A 
Neck pain
Poor posture
Malocclusion
Insomnia
Systemic diseases
Fibromyalgia
Rheumatoid arthritis
87
Q

Behavioral contributing factors

A 
Holding excessive tension in the masticatory muscles
Clenching
Fingernail biting
Stomach sleeping
Telephone cradling
88
Q

Emotional contributing factors

A 
Prolonged negative emotions
Depression
Worry
Anxiety
Anger
89
Q

Cognitive Contributing Factors

A

Harmful thought processes or low cognitive skills

Negative self-statements

Poor reasoning skills making it difficult for patient to work with self-management or other instructions

90
Q

Social Contributing Factors

A 
Interactions with others that contribute to TMD symptoms or poor therapeutic response
Coworker difficulties
Lack of social support
Secondary gain
Benefit from disorder
Social modeling
We want to be like those we admire
91
Q

Environmental Contributing Factors

A

Usually difficult to identify, so infrequently explored among TMD patients
Food additive causingmigraine headaches
Seasonal affective disordercausing depression

92
Q

TMD therapies generally ARE NOT

A

directed at physically changing diagnosis
For example, myofascial pain

INSTEAD, Directed at reducing perpetuating contributing factors
Body then able to heal itself

93
Q

Social Contributing Factors

A 
Interactions with others that contribute to TMD symptoms or poor therapeutic response
Coworker difficulties
Lack of social support
Secondary gain
Benefit from disorder
Social modeling
We want to be like those we admire
94
Q

Environmental Contributing Factors

A

Usually difficult to identify, so infrequently explored among TMD patients
Food additive causingmigraine headaches
Seasonal affective disordercausing depression

95
Q

TMD therapies generally ARE NOT

A

directed at physically changing diagnosis
For example, myofascial pain

INSTEAD, Directed at reducing perpetuating contributing factors
Body then able to heal itself

96
Q

Do most TMD PT’s have chronic or acute Symptoms>

A

CHRONIC
Pain intensity fluctuates over time
Primarily treat by altering perpetuating contributing factors

97
Q

If you try pharm intervention instead of targetting perpetuating factors… what will happen

A

the pharm intervention will take a LONG TIME.

You really want to AVOID using muscle relaxers

only recommend Try cyclcic antidepressants and NSAIDs on a NEEDED BASIS

98
Q

An ACUTE TMD Condition presents as

A

a recent onset or flare up of chronic condition

99
Q

Pharm intervention is more common with acute or chronic TMD?

A

ACUTE

–short term use of relaxers and anti-inflammatorys

100
Q

TMD can present secondary to trauma… what are the three ways

A

Direct trauma - blow to jaw
Indirect - jolt to jaw during whiplash
Microtrauma - chronic parafunctional habits

101
Q

what can trauma cause

A 
Muscle pain
TMJ pain
TMJ inflammation
Intracapsular changes
Decreased condylar growth
In child or adolescent
102
Q

When do the symptoms of trauma present?

A

not until weeks or month after the traumatic event – this is NOT ACUTE

103
Q

When you evaluate a trauma PT, consider these things

A

bone fracture
referred odontogeni pain secondary to TOOTH TRAUMA
cervical disorder
psychological issues related to trauma
anything else that needs a referall (neuro or cognitive stuff)

104
Q

What determines the treatment results for a trauma PT

A

trauma severity and perpetuating contributing factors

May range from no or minimal treatment to extensive multidisciplinary treatment
Results are quite variable and some patients do not improve

105
Q

b.i.d stands for

A

twice daily

106
Q

t.i.d

A

three times a day

107
Q

q.i.d

A

four times a day

108
Q

h.s

A

at bedtime

109
Q

if the PT’s pain is constantly a 3 or below..

A

800 mg ibuprofen, t.i.d.

110
Q

if the pt’s pain is above 3/10 constantly and primariyly muscle pain…

A

5 mg diazepam, 1-2 tabs h.s.

½ tab in morning and afternoon if significant daytime pain; warn about drowsiness

111
Q

PT’s pain is above a 3/10 constantly but due to TMJ inflammation

A

500 mg naproxen, 1 tablet b.i.d.

112
Q

Above constant 6-7/10 and primarily TMJ inflammation

A

DexPak 6-Day Taperpak-naproxen regimen

113
Q

In a healthy adult, can an anti-inflammatory and muscle relaxant be taken together?

A

YES.

If additional analgesic relief is needed, acetaminophen can be added

114
Q

WHAT ARE THE two types of coronal incomplete tooth fractures

A

oblique

vertical

115
Q

when might you suggest a temporary soft appliance or an acrylic long term one

A

Just as other therapies for PT based on PT history

116
Q

how can a NONPRONE pt end up with TMD

A

Excessive and/or prolonged forces during dental treatment may cause non-prone patient to develop TMD

117
Q

You should always do a TMD eval – to see if the pt will be more prone to TMD with routine treamtment.

what is included in a cursory TMD eval (prior to treatment)

A

Measure opening
Identify presence or history of TMJ noise
Palpate anterior region of temporalis and masseter muscles, TMJs, and lateral pterygoid areas

118
Q

what are some POST-OP causes for TMD symptoms

A

referred pain from treated tooth
myositis from infected tooth
medial pterygoid myospasm from an IA injection
Muscle, TMJ and tooth pain - from inharmonious occlusion
Muscle and TMJ pain - from prolong stretching – their night guard doesnt work as well

119
Q

If you know a PT is TMD prone, what can you do during treatment to help them

A

Patient to ask for stretching breaks
Use bite block if patient finds it beneficial
Patient does not bite on it, but rests teeth on it
Make appointments for when symptoms are minimal

Balance all applied force with other hand
Patient may desire premedication and/or postoperative medication
maybe use N20

120
Q

What if the TMD PT need an occlusal appliance, but also needs many restorations?

A

first give them a temporary appliance
then start doing restorative work on the arch that needs the LEAST amount of work.
then make the appliance for that arch once all the work is done
Pharmaceutically manage TMD symptom until a temporary or long-term occlusal appliance can be provided

121
Q

Medial Pterygoid Muscle Pain

A

Most common postoperative disorder observed
Generally seen after multiple inferior alveolar injections
Symptoms
Significant medial pterygoid muscle pain and limited opening

122
Q

how can you treat medial pterygoid muscle pain

A

self management therapies
stretch
if nothing works, refer to PT

123
Q

Medial pterygoid myositis

A

Symptoms similar to medial pterygoid myospasm
Often due to bacterial infection as from extracting infected third molar
May be able to differentiate myositis from myospasm by fever and lymphadenopathy
Treat with antibiotics
Follow patients to ensure anticipated results are achieved

124
Q

Inability to Close into Maximum Intercuspation (MI)

A

seen at the END of a dental procedure
–the lateral pterygoid is fatigured and can hold the condyle forward
–inflamed TMJ can cause condyle to stay fwd too
you can palpate to determine the source

125
Q

What happenes if you make restorations that are NOT in harmomy with rest of occlusion?

A

TMJ pain
Muscle pain
TMJ noise
On ipsilateral and/or contralateral side

126
Q

obstructive sleep apnea

A

some OSA pts can develop TMD from wearing an OSA appliance
the TMD usually starts right after they start wearing the appliance but it goes away within a year
the PTs need to exercise and stretch or can be provided wth other TMD therapies

127
Q

Lateral Pterygoid Myospasm

A

EMERGENCY PTs usually present with this
PT cannot close into MI and cannot open wide
constnat pain and palpation tenderness at lateral pterygoid area

It can happen right after the dentist finishes working ont hem.. Or a day or two later

Lateral pterygoid in partially shortened state
Holds condyle in partially translated position

128
Q

what are the 4 ways the condyle can be held FORWARD

A

Lateral pterygoid myospasm
TMJ inflammation*
Combination of both disorders
Tumor or other retrodiscal growth

129
Q

How can you isolate the problem if there are 4 ways the condyle can be held forward?

A

palpation
if you stretch the lateral pterygoid and the pain goes away, you know its due to that
if symptoms get worse, you may cosider TMJ inflammatio

130
Q

TMJ inflammation can causes

A

May force condyle forward

Lateral pterygoid may contract to protect inflamed tissue

131
Q

Messing with the mandible if the retrodsical tissue is inflamed is very…

A

PAINFUL

132
Q

initail treatment is a tiered approach for TMD

A

self management

lateral pterygoid stretches – 6 stretches – 6 times a day == 30 secs per stretch

133
Q

Should you go ahead and change the PT’s occlusion before doing self management?

A

NO.

the TMD may resolve and then the PT will be infraoclusion

134
Q

Acute TMJ DD WITHOUT REDUCTIOn

A

Sudden onset of limited opening (35 mm or less) caused by disc restricting condylar translation
Clicking, popping, and/or transient locking no longer present

135
Q

what are the SIMILARTIES between lateral pteryoid myospasm and acute TMJ DD without reduction

A

Limited opening

Contralateral and protrusive movements generally restricted

136
Q

What are the DIFFERENCES between lateral pterygid myospasm and TMJ DD without reduction

A

No increase in pain when closing into MI
Teeth occlude as normal
A

137
Q

Along with latereal pterygoid myospasm… wat else is usually present

A

TMJ pain
Inflammation

As mandible attempts to open wide, condyle pushes against disc

When retrodiscal tissue is stretched, painand inflammatory mediators are released intosynovial fluid

138
Q

What is a predisposing factor to lateral pterygoid myospasm

A

Repeated retrodiscal tissue loading
Through muscle tension and parafunctional habits
Retrodiscal tissue thins and joint space narrows
TMD pain

139
Q

Intermittent Acute TMJ Disc Displacement Without Reduction

A

Transient locking

Daily pattern of its onset suggests when primary predisposing factors are occurring (night time day time etc)

140
Q

You can Teach patient to release intermittent form by….

A

Place finger about ½ inch anterior to TMJ, press medial and posterior, and move mandible side to side
Consciously relax and massage the temporalis and masseter muscles*
Slide mandible as far as possible to contralateral side and then open maximally

141
Q

always try to resolve intermittent TMD bc it can easily progress to

A

continuous form

142
Q

if the PT presents with continous acute TMJ DD without reduction

A

practitioner can distract TMJ and attempt to move condyle forward into disc’s intermediate zone

if successful, the PT needs tow ear a temporary appliacne bc the condyle will tend to lock again when it is retruded off the disc

143
Q

what can you use to make a temporary TMD appliacne

A

crown putty

Adjust appliance so it is retentive for mandibular teeth and has only approximately 1- to 2-mm-deep incisal indentations for maxillary teeth

tell PT to initially wear 24 hrs a day but then they can wear it only at night after the first 2-4 days

144
Q

is unlocking the TMJ by dentist usually successful

A

NO.

Retrodiscal tissue can be stretched so the disc moves forward, allowing the condyle to fully translate, and the individual regains a normal opening
Stretching forces may unintentionally occur when the individual talks, laughs, puts food in the mouth

145
Q

If surgical intervention chosen as first line of treatment,

A

the contributing factors that caused this to develop (e.g., parafunctional habits, etc.) often need to be dealt with or TMD symptoms are likely to return

146
Q

TMJ Dislocation

A

Patients present with or relate history of momentary or prolonged inability to close mandible from maximal open position
Condyle in front of the articular eminence and posterior movement obstructed by articular eminence and/or disc

Unable to retrude condyle because of tension in closure muscles

147
Q

how can you try and fix a TMJ displacement in your office

A

As patient attempts to open wider, bilaterally press down on molars, pull up on chin, and slowly slide the condyles inferior and posterior*

148
Q

hwo can you help the PT prevent recurrence

A

Educate about mechanism and how limitation of opening will prevent its recurrence
Provide stabilization appliance worn at night
Patient chooses next preference
(maybe refer to surgeon)

TMD (1 decks)

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