TMJ Lecture 2 (Evaluation and Treatment) Flashcards
What are the 3 subcategories of the musculoskeletal treatment of TMD?
- Regional (C-spine/ T-spine)
- Neuromotor control
- TMJ
How strong is the evidence supporting PT of TMD?
Limited
What is the design flaw in many studies of PT in relation to TMD?
- “PT” performed by dental assistants
Is PT more or less effective than arthroscopic surgery or arthroplasty?
About the same
What is the advantage of manual therapy of TMD in comparison to dental work?
- Less expensive, and less side effects than dental work
In Nicolakis’ study, how many patients had excellent pain improvement immediately post treatment? How many had excellent function improvement immediately post treatment?
- 80 % pain
- 85 % function
At the 6 month follow up, how many patients had excellent improvement in pain, function, and mouth opening?
> 80 %
What are the 6 elements of the historical exam of TMD?
- Body chart (focus on cranial region)
- Red Flag Screening
- Yellow Flag Screening
- Dental Behavior
- Symptom History and Behavior
- Outcome Measure
What is the 5 item red flag screen?
- Night pain?
- Chills?
- Sweats?
- Unexplained weight loss/ gain?
- Medical screen form
What may be used in place of a set yellow flag screening questionairre?
- Depression questions
- Fear Avoidance Belief Questionairre
What are important Dental Behavior questions?
- Do you have any current treatments (appliances)
- Have you had any work done (mouth open for an extended period of time)
- Dental history
What 3 components should be considered when assessing symptom history or behavior?
- Symptom Onset, frequency, intensity (relation to one another)
- Joint locking - open or closed
- Joint clicking
What is a useful outcome measure for TMD?
Temporomandibular Disorder Disability Index (Not validated)
What non-musculoskeletal pathology can mimic patterns of internal derangement of the TMJ?
- Tumors or ganglion cysts
What is the most common malignancy of the TMJ?
- Metastasized osteosarcoma
What benign tumors may affect the TMJ?
- Osteomas
- Giant cell tumors
What 2 cranial nerves should be tested during the physical exam?
CN V: Trigeminal
CN VII: Facial nerve
What spinal segments should be considered during the physical exam of the TMJ?
C2 - C4
What 3 things should be palpated during the physical exam?
- TMJ, mandible, hyoid
- Upper quarter landmarks (C-spine/ T-spine)
- Muscles of mastication for trigger or tender points
What is the 4 step approach to mobility testing?
- Observed
- Measured
- Overpressured
- Acessory
What is the 2 knuckle quick test?
- Can you fit 2 - 3 knuckles in your mouth?
- Associate with symptoms and change in pain (VAS)
Describe the TMJ ROM graph.
- Cross with protrusion and opening at north and south poles, and right and lateral translation at west and east poles.
- Will deviate from cross pattern with movement incoordination
What are the landmarks for mouth opening measurement?
- Incising edges between maxillary and mandibular central incisors
What are the landmarks for lateral translation of the mandible?
- Point on the mandibular teeth that coincides with the medial edge of the maxillary central incisors
When may overpressure of the TMJ be required?
If symptoms cannot be reproduced with active movements
Describe opening overpressure.
- Grip the side of the mandible and pull down with head stabilization
Describe lateral glide overpressure.
- Grip the side of the mandible, and translate
Describe protrusion overpressure.
- Don glove
- Anterior force at central mandibular incisors
- Stabilize head
What is the most predictive movement of CMD?
- Static and dynamic tests either with isotonic muscle contraction
Describe distraction of TMJ.
- Raise finger/hand or grunt if it becomes painful
- Stabilize PT’s head and torso against Pt’s forehead and cranium
- Hand along back of head is palpating TMJ line and stabilizing head against rib cage
- Mobilizing thumb along 3rd and 4th mandibular molars
- 2nd IP along bottom of mandible
- Don’t use too much pressure on mandibular fossa
- Light bite; relax
- Pressure in inferior direction through thumb
- Can move into mobilization with arm
Describe an anterior/ anteromedial glide of the TMJ.
- Raise finger/hand or grunt if it becomes painful
- Stabilize PT’s head and torso against Pt’s forehead and cranium
- Hand along back of head is palpating TMJ line and stabilizing head against rib cage
- Mobilizing thumb along 3rd and 4th mandibular molars
- 2nd IP along bottom of mandible
- Don’t use too much pressure on mandibular fossa
- Light bite; relax
- Slight distraction on the TMJ
- Pull anteriorly/ anteromedially with shoulder
How much mouth opening must a patient have in order to perform an anterior glide of the TMJ?
> 15 mm
Describe an anterior glide in a patient with less than 10 mm of opening.
- Pt supine
- Head rotated towards contralateral side
- Cranial hand stabilizes from a superior direction
- Thumb is against back side of manible
- Finger holds front of mandible
- Push forward with thumb
What 3 components does cervical clearing consist of when evaluating the TMJ?
- Active ROM with and without OP
- Upper cervical protraction and retraction
- Quadrant positions
What other assessment may be performe don the cervical spine aside from clearing?
- Accessory mobility assessment
What 2 c-spine joints should be payed special attention in assessment of the TMJ?
- OA
- AA
Describe a OA distraction HVT.
- Pt supine over end of plinth
- Rotate patients head to contralateral side of PT
- Grasp occiput
- Remove pressure through TMJ and provide traction through PT’s chest and hand
Describe an OA gapping HVT.
- Pt in supine with slight amount of cervical flexion
- Rotate head left or right short of end range
- Introduce right side bending force into pillow through zygomatic arch and temporal bone
- Gentle sidebend thrust
Describe 2 methods of self-mobilization into mouth opening.
1: - Palm of hands against mandible - Move into opening 2: - Pressure inferiorly on chin with mouth opening with pads of fingers (a paper towel can be used to lessen the pressure)
What are 4 variables for tube exercises for TMJ?
- Start slow and predictable
- Increase speed
- Increase complexity
- Increase total time
Describe Tube Exercise 1 (lateral glide).
- Patient places plastic tube between anterior teeth
- Patient rolls tube by laterally translating the mandible away from the symptomatic TMJ
- Pt instructed that it should be pain free with no abnormal sounds
- Start slow and predictable
- Increase speed and total time
- Use a mirror for feedback
Describe Tube Exercise 2 (lateral glide II)
- With mirror for feedback
- Laterally glide away from symptomatic side, bite, release, return
- Pain-free and no abnormal sounds
- Start slow predictable
- Increase speed and total time
Describe Tube Exercise 3 (lateral glide III)
- Mirror for feedback
- Laterally glide away from symptomatic side
- Bite
- Hold bite while returning to neutral
- Pain-free and no abnormal sounds
- Start slow predictable
- Increase speed and total time
Describe Tube Exercise 4 (Protrusion)
- Mirror for feedback
- Protrusion (Tip the tube upwards)
- Pain-free and no abnormal sounds
- Start slow predictable
- Increase speed and total time
Describe Tube Exercise 5 (Protrusion II)
- Mirror for feedback
- Protrusion
- Bite, Release, Return to neutral
- Pain-free and no abnormal sounds
- Start slow predictable
- Increase speed and total time
Describe Tube Exercise 6 (Protrusion III)
- Mirror for feedback
- Protrusion
- Bite
- Hold while returning to neutral
- Pain-free and no abnormal sounds
- Start slow predictable
- Increase speed and total time
Describe Tube Exercise 7 (Resistance)
- Mirror for feedback
- Bite tube
- Hold and resist gentle protrusion, retraction, and lateral glides
(Isometrics) - Pain-free and no abnormal sounds
- Start slow predictable
- Increase speed and total time
What are Rocabado’s 6X6?
- 6 exercises
- 6 repetitions each
- 6 times a day
- Tongue rest and nasal breathing
- Controlled opening
- Rhythmic stabilization
- Craniocervical flexion
- Cervical retraction
- Shoulder retraction
Describe Rocabado’s Tongue Rest Position with Nasal Breathing.
- Make a cluck sound with the tongue
- Rest forward 1/3 of tongue on roof of mouth
- Diaphragmatically breathe through the nose
Describe Rocabado’s Controlled Opening.
- Hold anterior 1/3 of tongue on the roof of the mouth
- Pt opens mouth as far as they can without the tongue leaving the roof of the mouth
- Prevent anterior gliding (monitor with hands)
Describe Rocabado’s Rhythmic Stabilization.
- Anterior 1/3rd of tongue on roof of mouth
- Maintain jaw is slightly open position (teeth just apart)
- Hold isometric rhythmic contractions of lateral translation to the right and left, and mouth opening and closing
- Don’t use excessive force
Describe Rocabado’s Craniocervical flexion
- Anterior 1/3rd of tongue on roof of mouth
- Hand stabilizes C-spine
- Gentle OA nod
Describe Rocabado’s cervical retraction.
- Anterior 1/3rd of tongue on roof of mouth
- Finger tips on maxilla, mandible, or zygomatic arch for proprioceptive cue
- Retract the head
Describe Rocabado’s shoulder retraction.
- Anterior 1/3rd of tongue on roof of mouth
- Retract and depress shoulder girdle gently
- Instruct patient to avoid forward head posture
What are the 7 classifications of TMD?
- Capulitis/ Synovitis
- Capsular FIbrosis
- Disorders of the Muscles of Mastication
- Hypermobility
- Anterior Disc displacement With Reduction
- Anterior Disc Displacement Without Reduction
- Osteoarthrosis
Which classification group is related to micro/ macro trauma?
- Capsulitis/ Synovitis
What are 4 signs and symptoms of a patient classified into the Capsulitis/ Synovitis group?
- Tender to palpation of lateral condyle or posterior compartment
- Pain with contralateral biting
- Pain with retraction overpressure
- Pain with end-range accessory motion testing
What are 4 treatments for patients categorized into the capsulitis/ synovitis group?
- Iontophoresis (dex or xylocane)
- Manual therapy
- Soft tissue mobilization of muscles of mastication
- Thrust and non-thrust mobs of TMJ, T and C-spine
- Postural and TMJ proprioception exercise
Which category of patients are categorized by chronic inflammation, trauma, immobilization, and entrapped discs?
- Capsular fibrosis
What are 4 signs and symptoms of a patient categorized into the capsular fibrosis group?
- Less than 25 mm mouth opening
- Limited joint accessory motion
- No joint sounds
- Ipsilateral deviation of mandible when opening
What are 5 treatments for patients categorized into the capsular fibrosis group?
- Heat prior to manual therapy
- TMJ mobilization, manipulations
- Prolonged stretching
- AROM
- Proprioceptive exercise
What category are patients with overuse tendonitis of the temporalis muscle typically classified into?
Disorders of the muscles of masticaiton
What are 4 signs and symptoms of a patient categorized into the disorders of the muscles of mastication group?
- Painful to palpation of muscles (potential TrPs)
- Possible alteration in mandibular active control
- Parafunctional oral behaviors
- Pain with ipsilateral biting
What are 5 treatments of patients classified into the disorders of the muscles of mastication group?
- Heat at begining of treatment
- Controlled opening/ closing muscle reeducation
- Stretching
- Intraoral and extraoral soft-tissue mobilization
- Patient education, and activity modificaiton
Patients categorized into which category can be asymptomatic?
Hypermobility
How much mouth opening do patients with hypermobility typically have? What else is present?
> 40 mm with a click
What loosens in patients categorized into hypermobility? What is the hypermobility a precursor to?
- Loosened collaterals
- Precursor to disc displacement
What are 2 signs and symptoms of a patient categorized into the hypermobility group?
- Excessive mouth opening ROM
- Hypermobility of accessory motions
What are 4 treatments for patients with hypermobility?
Avoid end range positions - Tongue on roof of mouth when yawning - Avoid taking large bites Exercise - Proprioception exercises - Stabilization exercises
Patients with laxity in the collaterals and retrodiscal laminae are categorized into which group?
Articular disc displacement with reduction
What are 4 signs and symptoms of articular disc displacement with reduction?
- Pain from recent dysfunction
- Abnormal mandibular motion
- Click on closing due to disc staying anteriorly and condyles slipping over articular eminence
- Click on opening due to condyles recapturing disc
What are 5 treatments for patients categorized into the articular dis displacement with reduction group?
- TMJ mobilization
- Soft tissue mobilization
- Posture ROM
- Isometric stabilization exercises
- Splints (outside realm of treatment)
Patients are categorized into what category with an anterior displacement of the disc that remains anterior to condyle?
Articular disc displacement without reduction
Patients with articular disc displacement without reduction are limited in opening by how much, and deviate in which direction?
> 25 mm opening
Ipsilateral deviation
What are 5 treatments for patients with articular disc displacement without reduction?
- TMJ mobilizations
- C-spine mobilizations/ manipulations
- Posture exercises
- C-spine exercises
- Patient education
Patients with joint pain with crepitis on ausciltation are classified into which treatment group?
TMJ OA
What structural impairment is often present in TMJ OA?
- Disc perforation
What are 4 treatments for TMJ OA?
- TMJ, C-spine, T-spine mobs
- AROM/ PROM
- Soft tissue mobilization
- Postural exercises (C and T spine also
What are 3 ways the cervical spine may be integrated into TMJ treatment?
- C-spine ROM with/without TMJ
- DNF with/without TMJ movement
- Scapular stabilization with/without TMJ movement
