TMJ Flashcards
How reliable are subjective scales of sleepiness?
Not very. For example, average Epworth score for patient without somnolence is 7.9 + or - 4.
What is the likely issue if snoring does not improve or worsens with OAT?
Nasal passage obstruction.
What is the gender-specific relationship between vertical opening and size of airway?
Males tend to need vertical opening more than females.
How effective is muscle palpation in assessing muscular issues?
It is objectively supported by EMG instrumentation and is a good objective way to establish a baseline, gather data for diagnosis, and to measure progress.
What is a trigger point?
Focus of hyper-irritability in a tissue that when compressed is locally tender and can give rise to referred pain and tenderness. It is only a few muscle fibers rather than an entire muscle.
What is the difference between an active and a latent trigger point?
Active: causes pain
Latent: clinically silent with respect to pain, but may cause restriction of movement and weakness of the affected muscle.
Both cause dysfunction, only active causes pain.
What is the difference between autonomic and somatic pain?
Autonomic: pain felt in places besides the source of the pain
Somatic: pain felt only at the source of pain
Trigger points activate autonomic pain and somatic pain
What are the perpetuating factors of trigger points?
Hypothyroid, nutrition (deficiency of B vitamins, vit C), hormones, skeletal alignment, airway (paradoxical breathing), ergonomics, sleep, degenerative diseases (diabetes, etc.)
Which muscle is mot often beset by myofascial trigger points?
The trapezius. It is a frequently overlooked source of temporal headaches. There are 6 TPs with distinctive pain patterns found in the upper, middle, and lower portion; 2 TPs in each region.
Where is pain referred to from the upper portion of the trapezius?
Unilaterally upward along the posterolateral aspect of the neck to the mastoid process – tension neckache
When the referred pain is intense, it extends to the side of the head, centering in the temple and back of the orbit, or sometimes in the angle of the jaw (“toothache” in lower 2nd molar)
What are the insertion points of the trapezius?
It extends from the occiput to the lateral end of the clavicle to T12.
What are the two insertion points of the sternocleidomastoid?
Origin is the mastoid process. The insertions are on the sternum and the about a third of the way into the clavicle from the sternum (two separate insertions)
What are the TPs in the sternal head of the SCM?
The entire length of the muscle, from mastoid to sternum. Pain is referred to back of head and lateral to the eye up into the eyebrow area.
What are the TPs in the clavicular head of the SCM?
Palpate the length of the muscle. Pain is referred to the ear and frontal right above the eyes.
What are the main muscles of respiration?
Intercostals and diaphragm
Why is disordered breathing a potential source of trigger points in the SCM?
If there is restriction of the airway, head position may change to open the airway – SCM is involved in those movements and trigger points may develop.
Which three muscles are the mandibular elevators?
Masseter, medial pterygoid, temporalis
What are the trigger points in the masseter?
Upper molars and 2nd bicuspid Lower molars and bicuspids Right above the eye (eyebrow) Angle of the jaw TMJ area or ear
What is the common source of trigger points in the masseter?
Nighttime parafunction
What is the attachment and insertion of the temporalis?
Temporal fossa to coronoid process of the mandible.
What are the trigger points in the anterior temporalis?
Maxillary incisors, eyebrow
Trigger points of middle temporalis?
Maxillary canine, maxillary bicuspids and maxillary molars
What is a common source of trigger points in the temporalis?
Clenching/bruxing
What is the relationship between clenching, trigger points caused by clenching, and airway?
SDB can cause clenching, which can incite trigger points in the three main elevator muscles (masseter, temporalis, and medial pterygoid).
What is the insertion of the external or lateral pterygoid?
Origin is lateral surface of lateral pterygoid plate. Insertion is the disc and the neck of the condyle.
What is the function of the superior lateral pterygoid?
Power stroke of the mandible. On working side of mandible, the superior lateral pterygoid shortens to keep the disc and condyle together.
What is the function of the inferior lateral pterygoid?
Protrusion of the mandible.
What is the origin and insertion of the medial (internal) pterygoid?
Origin is the medial surface of the lateral pterygoid plate. Insertion is the medial surface of the ramus and the angle of the mandible.
What is the main function of the medial pterygoid muscle?
Elevation of the mandible
What are the trigger points of the lateral pterygoid muscle?
Right over the TMJ and right above the zygomatic process
Anterior digastric origin and insertion?
From the digastric fossa (internal, inferior surface of chin) to the hyoid bone.
Insertion and origin of the posterior digastric?
Hyoid to the mastoid notch of the temporal bone.
Function of the digastric muscles?
Mandibular depressors (opening) and to raise the hyoid bone.
Trigger points of the posterior digastric?
Region of the styloid process to the inferior portion of the ear
Trigger points of the anterior digastric?
Mandibular incisors
What is a source of trigger points in the digastric muscles?
Chronic close-lock (condyle always pushing up against disc, patient can’t open, digastrics become overloaded)
How do the scalene muscles become involved with breathing?
The intercostals and diaphragm are primary breathing muscles. Accessory breathing muscles, including the scalene and SCM, become involved when the airway is compromised.
Trigger points of scalene muscles?
Brachioplexus can become impinged upon with hyperactivity of scalenes (known as thoracic output syndrome), leading to pain in the arm, dorsal surface of hand, and superior aspect of scapula.
How much of the opening cycle is purely rotation? How does this help with diagnosis of TMJ conditions, and what are other implications of the condition that affects opening?
About the first 20mm – a patient should be able to open this far if the problem is solely ACUTE anterior disc displacement without reduction (closed lock). When the condition is unilateral, we will see a deflection to the side that has the pathology. Lateral movement will be limited on the side opposite the pathology.
What happens with chronic anterior disc displacement without reduction?
If the displacement is not treated, with time there will be a trend toward normalization – maximum opening will get closer to normal, deflection will become attenuated, lateral movements will become closer to normal – because the ligaments lengthen and the disc moves further forward.
Differential diagnosis of TMJ clinical exam
ROM. Vertical <40 = non-reducing dislocation (probably) or muscle
ROM. Deflection to L/R in direction of non-reducing dislocation (probably) or muscle
ROM. Lateral excursions less on contralateral side of NR
Higher frequency noise in joint = more chronic disease (degenerative joint disease) – condyle will not be rounded
An early reducing dislocation is more likely to be corrected than one at wider openings because ligaments are less elongated
Tenderness to palpation or joint indicates acute inflammation
Differential diagnosis of temporal pain
Temporalis muscle – bicuspid or cuspid contact
SCM – nasal obstruction (tipping of head to breathe/clear nasal passages)
Trapezius – tipping head forward
Suboccipital – cervical rotation stretches trapezius/occipitalis muscles
Differential diagnosis of pain in TMJ/ear
Deep masseter – bruxism
External pterygoid – mouth breathing
Internal pterygoid – bruxism/OSA
SCM – paradoxical breathing (accessory muscle of respiration)
Differential diagnosis of cervical pain (back of head)
Paradoxical breathing
Rotation or subluxation of cervical vertebrae
Trapezius trigger points
TMJ – potential of bidirectional referred pain
Tongue thrust
TP in cervical muscles – mostly from forward head posture
Perpetuating factors of TMD
Bruxism/parafunction – address “why bruxing?” – Pain, Airway, Stress
Sleep disorders – muscle tenderness is greater in pts with disrupted slow-wave sleep
Cervical and body asymmetry
Mouth breathing and nasal obstruction – head becomes subluxed, muscles tense (SCM, trapezius, external pterygoid)
Dysfunctional swallow
Nutritional deficiencies (B1, B6, B12, folic acid, etc.)
Hypothyroid
Hypoglycemic/diabetes
Ergonomics
Occlusion – increased freeway space
Occlusion – premature contacts (force a shift)
Depression
Medication and drugs – SSRIs and others that increase Stage 2 of sleep (bruxism occurs in Stage 2)
What are the main pharyngeal dilator muscles?
Genioglossus and palatoglossus
Does bruxism reduce with age?
Studies say yes, but in the biggest studies 50% of the elderly were edentulous, so we don’t know that the bruxism really stopped.
Diagnosis of bruxism (nocturnal)
A recent history of tooth grinding sounds occurring at least 3-5 nights per week over 6 months (if sleep alone???)
Presence of tooth wear (not reliable; past SB episodes)
Morning masticatory muscle pain or headache and/or fatigue and/or fatigue
?? Masseter muscle hypertrophy (parotid ??)
What is the occurrence of waking clenching in nocturnal bruxers?
70%
How many nocturnal bruxers experience myalgia?
9% females
5% males
(Cunali PA, J Orofacial Pain 2009; Kato T, Sleep & Breathing 2012)
Relationship between TMD/myalgia and OSA, pain-related awakening, or insomnia
20-30% with TMD/myalgia report those problems
Smith MT, Sleep 2009; Benoliel R, J Orofacial Pain 2009
OR of OSA in TMD patients
3
Saunders, Mainxner et al, Chapel Hill, UNC
What percentage of OSA patients have TMD?
As many as 50%
Cunali PA, J Orofacial Pain 2009; Kato T, Sleep & Breathing 2012
OR of orofacial pain in bruxers
3
Does classic NG/splint therapy reduces bruxism?
Yes, for about 2 weeks, then the bruxism events return to pre-treatment levels
Does behavioral management help with bruxism?
Elimination of clenching teeth and bracing jaw during daytime in reaction to life pressures
Lifestyle changes; introduction of sleep hygiene, relaxation, autohypnosis, and winding down before sleep
Physical therapy and training in relaxation and breathing
Psychologic therapy to manage stress and life pressure
Questionable effect – Weak evidence so far but patient report subjective well being!
(Winocur, in Sleep Med for Dentist, Quintessence,2009)
Do benzodiazepines reduce bruxism events?
One study found that valium and clonazepam taken in the evening produced a short-term reduction in bruxism events
(RCT from Saletu et al 2005)
Do muscle relaxants reduce bruxism events?
There is no data. Unknown.
Which medication was found to be most effective in reducing bruxism events?
Clonidine reduced events by 60%, but 20% of patients had morning hypotension. Not recommended.
(Huynh et al, SLEEP 2006)
What are the different kinds (4) of sleep-related headaches, as defined in ICSD 2005?
Morning headaches or awakening headaches
Migraine
Cluster headaches (related to circadian rhythms and REM sleep stage)
Hypnic headache (a rare condition occurring yp ( g upon awakening from REM sleep)
Sleep apnea headache diagnostic conditions
- occurs on >15 days per month, 2. bilateral, pressing quality and not accompanied by nausea photophobia or phonophobia by nausea, photophobia or phonophobia, 3. each headache resolves within 30 minutes and sleep apnoea (Respiratory Disturbance Index >5) is demonstrated by overnight polysomnography.
Headache is present upon awakening and ceases within 72 hours, and does not recur, after effective treatment of sleep apnea.
(Int Headache Society, 2004)
What is a morning/tension headache?
a frequent complaint affecting 7.6% of the general population (Ohayon 2004)
empirically defined as a recurrent, bilateral and pressing (sometimes throbbing) pain, present at awakening ≥3 times/week and lasting from 30 min up to 4 hrs
What is the incidence of headache/migraine in bruxers?
50% in bruxers
20% in controls
What is the incidence of neck pain in bruxers?
70% in bruxers
25% in controls
Incidence of morning headaches in bruxers
40%
Morning fatigue in bruxers
50%
10% in controls
MAD and morning headache in bruxers
57% reduction in headache severity (VAS) in centric occlusion and advance to 50% of protrusion – free splint had similar result to 50% protruded, centric was slightly better
Effect of MAD on incidence of bruxism events
Centric and free splint showed a 25% reduction
50% protrusion showed a 70% reduction in bruxism events
Morning headache differential diagnosis
apnea, medication overuse, circadian rhythm, tension headache/migraine, etc
Sleep hygiene and Cognitive and behavioural therapy (CBT) and physical therapy (sleep position, neck pain, etc)
Modification caffeine habits (caffeine withdrawal)
MOH= medication overuse headache (low prevalence but high impact)
Morning headache treatment options
Pharmacological treatments: *non-steroidal anti-inflammatories for acute or chronic headache; chronic headache; *antidepressives medication *triptans etc for more severe headaches
TMD patients: what to look for initial exam
– Current use of SSRI antidepressants – Trauma – Rheumatoid Arthritis/inflammatory diseases – Migraine headaches: temporalis headaches – Previous treatment
Normal maximum opening
Three fingers (48-52 mm) without pain
Differential diagnosis of TMD problems that are most likely to occur with OAT
• Capsulitis • Myalgia and Myofascial Pain • Internal derangements (disc displacement with or without reduction)
Diagnosis of capsulitis
NO PAIN WHEN CLENCHING ON A TONGUE DEPRESSOR!
– History of Trauma (including use of an OA) – Continuous TMJ Pain – Tenderness to Palpation – ROM not necessarily reduced – Acute malocclusion on injured side – Pain with Clenching
Treatment of capsulitis
– Anti-inflammatories (600 mg Ibuprofen q6h for 4-7 days or Medrol dose pack if they have had good experience already with steroids)
– Physical Therapy (iontophoresis or phonophoresis)
– Aqualizer or soft splint (Any splint for acute capsulitis should be temporary—for use until the inflammation is resolved. The perfect splint for a capsulitis case would self adjust as the inflammation reduces (Aqualizer Ultra)…
– Hard splint if necessary
Diagnosis of discal dislocation without reduction
Maximum opening of approximately 26mm. – Typically deflection to the affected side. – History of reducing disc displacement. – Often, history of locking episodes. – History of a traumatic event (accident, injury, bruxism, iatrogenic, etc.), or the patient will usually wake locked. – If chronic, usually no pain and range may slowly increase
Treatment of discal dislocation without reduction
Acute: Attempt to Reduce (yourself or give the patient exercises) and Treat with splint, PT and meds
Chronic: Attempt to Reduce? • No treatment • Palliative (meds, home PT, splint)
Avoiding/predicting potential TMD problems with OAT patients
Patients with RDD – Jaw may desire to stay more anterior. Tell them they may have to dislocate their jaw each morning.
- Patients with NRDD – Added stress may result in previously asymptomatic problem becoming symptomatic
- These patients still need to be treated—just inform them!!
Avoiding problems with OAT therapy
Consent, Educate and Consent Some More!! – Explain to the patient that side effects will most likely occur – Explain that if the patient pays attention to side effects and communicates with you that serious side effects can be avoided – LOWER EXPECTATIONS!!
If capsulitis presents after initiation of OAT, what is the likely problem with the appliance?
Typically due to over protrusion or excessive VDO
Diagnosis and treatment of capsulitis secondary to OAT
Confirm capsulitis (tongue blade test) – Temporarily discontinue appliance use or back off protrusive positioning – Aqualizer Ultra, anti-inflammatories, iontophoresis, ice/moist heat, acupuncture, etc. After acute capsulitis is resolved: begin moving forward again if indicated and if necessary – Check for midline problems, posterior support issues and VDO
If muscle pain presents as a result of OAT, what is the likely problem?
Typically due to lack of or improper posterior support (imbalanced or interferences)
Diagnosis and treatment of muscle problems secondary to OAT
Confirm muscle pain (spray and stretch) Add posterior support if there currently is none Adjust posterior support It is generally not necessary to discontinue use of the appliance If the muscle pain is severe, consider anti-inflammatories, iontophoresis, laser, ice/moist heat, acupuncture, etc.
Why might muscle pain with OAT not be directly related to the OAT?
Non-Intuitive Bruxism Model Since bruxism/clenching may be due to the brain’s attempt to protect the airway, in some cases, the correct treatment may be to protrude the mandible further forward. This diagnosis is based on symptoms such as: Snoring Signs of wear on the appliance Non restorative sleep
If the diagnosis is correct, further protrusion should help within a day or two
What is the best muscle relaxant?
Flexeril is best
