TMD - Hx and Exam

Question 1

How investigate P/C of pt?

Answer 1

SOCRATES
Ask about clicking
Joint noises

Question 2

What need to find out about clicking?

Answer 2

Is it on opening or closing
Temporary or persistent
Associated pain

Question 3

What other q ask get full hx of disorder?

Answer 3

Is opening limited
Get locking? - open or closing
Change in occlusion
Hx of trauma
Parafunctional activities

Question 4

What parafunctional activities ask about?

Answer 4

Clenching
Grinding
Nail biting

Question 5

Any medical conditions to be aware of w/ TMD?

Answer 5

Systemic arthritis
Previous malignancy 
Mental health disorder
Fibromyalgia 
Hypermobility syndrome

Question 6

What is chronic pain?

Answer 6

Pain considerable period of time leading psychological distress and behaviour reactions

Question 7

Risk factors chronic pain?

Answer 7

Predisposing = trauma
Initiating = microtrauma/ strain
Perpetuation = pyschologica. parafunctional

Question 8

What is fibromyalgia?

Answer 8

Pain in musculature and tendons = widespread pain/ sensitivity to multiple tissue sites
Pt low threshold pain = pain develop easily

Question 9

What is likely cause of fibromyalgia?

Answer 9

CNS neurosensory amplification

Question 10

Example hypermobility condition?

Answer 10

Elhers Danlos

Question 11

Red flag signs when examining for TMJ disorders may suggest malignancy?

Answer 11

Hx cancer - metastasis
Weight loss 
Facial asymmetry 
Neck mass/ cervical lympadenopathy 
Nasal symptoms 
Decreased hearing

Question 12

What may fever suggest?

Answer 12

Septic arthritis
Osteomyeleitis
Tooth abscess

Question 13

What might unilateral headache/ scalp tenderness sugest?

Answer 13

Giant cell arteritis

Question 14

Contributing factors TMJ disorders?

Answer 14

Trauma
Systemic conditions
Parafunction
Abnormal positon

Question 15

What look for on EO exam?

Answer 15

Muscle hypertrophy - masseter 
Habits - protrusion/clenching 
Poor neck posture
Asymmetry 
Lymph nodes 
Arteries

Question 16

What look for in IO exam?

Answer 16

Signs clenching/grinding

Occlusal assessment

Question 17

What are signs clenching/gridning?

Answer 17

Scalloped tongue
Buccal mucosa ridging
Hypertrophic masseter
Attrition and wear facets

Question 18

What should be included in muscoskeletal exam?

Answer 18

Look ROM - measure active opening/ lateral excursion

Palpitation of MOM

Question 19

How measure lateral excurusion?

Answer 19

Gap between 2 upper and 2 lower incisors

Question 20

Summary exam for TMJ disorders?

Answer 20

EO
IO
Muscoskeletal

Question 21

Is imaging waranted for dx?

Answer 21

Diagnosis often through hx and clinical exam

If crepitus may want OPT

Question 22

Mainstay of tx for TMJ disorders?

Answer 22

Education
Physical therapy 
Splint therapy 
Medication 
Other

Question 23

What other methods can be used for tx of TMJ?

Answer 23

Psychological
Occlusal adjustment
Botox
Surgery

Question 24

Aims of TMJ tx?

Answer 24

Reduce pain
Increase function
Allow pt management

Question 25

Benefit of early dx?

Answer 25

Prevent chronic symptoms

Question 26

What pt education?

Answer 26

Explain condition - info sheet/ models Explain principle of tx Reassure

Question 27

Practical information to reduce stress/strain jaw muscle?

Answer 27

``` Avoid habits: clenching, grinding, nail biting, pen chewing, lip sucking, protrusion Want pt to be aware oral habits so can reduce Keep jaw at rest position Avoid forward head posture Soft diet Chew slowly Avoid caffeine Avoid repeated/ prolonged mouth opening Don't rest chin hands SImple analgesic/ NSAIDs ```

Question 28

What is rest position of jaw?

Answer 28

Teeth apart and tongue to roof of mouth

Question 29

What physical interventions can be used?

Answer 29

Jaw relaxation to help over activation muscle Sleep hygiene - sleep pattern related chronic pain Massage/stretch technique

Question 30

What splints can help?

Answer 30

Occlusal splint - removable device of acrylic

Question 31

How do splints work?

Answer 31

``` Occlusal disengagement Maxilo-mandibular realignment Restore OVD TMJ repositioning Cognitive awareness ```

Question 32

Two types of splints?

Answer 32

Directive | Permissive

Question 33

Example of directive splint?

Answer 33

ARPS | Anterior repositining splint

Question 34

Example permissive splint?

Answer 34

Soft bite guard Anterior bite plane -lucia jig Stabalisation splint

Question 35

How to ARPs work?

Answer 35

Direct mandbile anterior to ICP - providing better condyle disc relationship

Question 36

Indication ARPs?

Answer 36

Disc derangement ANTERIOR DISC DISPLACMEENT DD +R w/ or w/o intermittent locking

Question 37

Adv of soft splints?

Answer 37

Cheap Easily construction Well tolerated

Question 38

Disadv soft splints?

Answer 38

Difficult to adjust | Can encourage bruxism - increase symptoms

Question 39

Use of Lucia Jig?

Answer 39

Anterior bite plane - disclude posterior teeth allow relaxation MOM

Question 40

How to Lucia Jig work?

Answer 40

Neuromuscular deprogramming - forget ICP position

Question 41

When should pt not wear Lucia Jig?

Answer 41

At night - risk airway obstruction

Question 42

Use of lucia jig?

Answer 42

Locate CR | Quick fix for acute symptoms

Question 43

Example of stabalisation splint?

Answer 43

Michigan splint = upper | Tanner appliance = lower

Question 44

Use of stabalisation splint?

Answer 44

Create artificial ideal occlusion Uniform contact CR Canine guidance separate posterior teeth Anterior guidance separate post teeth in protrusion

Question 45

Clinical stage of providing splint?

Answer 45

Imps Jaw reg in CR Face bow Fit splint

Question 46

How should TMJ pt wear splints?

Answer 46

Every night During period increase muscular stress/activity If severe - day as well

Question 47

First line of tx for pt?

Answer 47

Inter-occlusal appliance - usually upper hard acrylic splint

Question 48

Issue partial coverage splints?

Answer 48

Overeruption

Question 49

What medications can be used in primary care manage TMD?

Answer 49

Analgesia - paracetamol/NSAID

Question 50

What medication can be used in secondary care?

Answer 50

Anxolytics | Benzodiazepines

Question 51

Why are anxolytics used?

Answer 51

Tricyclic antidepressants e.g amitriptyline | Muscle relaxation

Question 52

Why are benzodiazepines used? What is issue?

Answer 52

Muscle relaxation | Highly addictive

Question 53

How can botox help?

Answer 53

Botulinum toxin injected muscle to reduce activity

Question 54

Disadv botox?

Answer 54

Limited action until neural receptor regenerate | Risk injecting wrong site

Question 55

What is arthrocentesis?

Answer 55

Injection of steroid into upper joint space Synovial fluid washed out Needs high level of skill

Question 56

What is arthroscopy?

Answer 56

Invasive procedure - scope placed upper joint see what going on Joint can be washed and biopsy taken

Question 57

Is surgery ever indicated?

Answer 57

Rarely in joint dysfunction

Question 58

Indication for jaw surgery?

Answer 58

Tumours Condylar hyperplasia Trauma Ankylosis