TMJ Pathology and Diagnosis Part II Flashcards
_____ of the general population reported pain in the head, face or neck
10%
_____ reported facial pain in the previous 6 months
12%
______ reported headaches in the previous 6 months
26%
______ of general population in america experienced 1 of 5 orofacial pain types in the past 6 months
22%
____ reported toothache in the past 6 months
12%
_____ reported TMJ pain in the last 6 months
5%
______ reported face or cheek pain in the past 6 months
1.4%
______ of patients reporting to an orofacial pain center had pain sources beyond the trigeminal systemic (chronic back pain)
81%
what are the comorbid medical conditions with TMD
- fibromyalgia
- chronic fatigue syndrome
- headache
- gastroesophageal reflux disorder
- IBS
- multiple chemical sensitivity
- PTSD
what are the diagnostic criteria for disc derangement disorders
-disc displacement with reduction
- disc displacement without reduction: acute and chronic
describe articular disc displacement
-abnormal relationsuip/misalignment of articular disc and condyle
- displacement is usually anterior or anteromedial direction
- pain or mandibular symptoms are not specific for disc derangement disorders
describe disc displacement with reduction
- from a closed mouth position the temporarily misaligned disc reduces or improves its structural relation with the condyle during translation resulting in a joint noise (clicking or popping)
- reciprocal click (opening/closing click)
- asymptomatic clicking does not require treatment
- also called internal derangement
what is the etiology of disc displacement with reduction
- macrotrauma - direct trauma/injury to the jaw
- microtrauma- chronic bruxism
- poor lubrication
- lateral pterygoid hyperactivity
- joint hypermobility/ligament laxity
what diagnostic criteria must be present to diagnose disc displacement with reduction
- reproducible joint noise occurring during opening and closing
- soft tissue imaging reveals displaced disc which improves its position during opening
- absence of extensive degenerative bone changes
what is the treatment for clicking/popping with no pain or locking
no treatment.
eliminate parafunctional habits
what is the tx if there is pain with clicking or popping
- arthocentesis
- narcotics
- NSAIDs
- muscle relaxants
- exercises/PT
- occlusal guard
-REST (soft liquid diet x 2 weeks) - heat/ice therapy (10 mins 2x/day)
what diagnostic criteria must be present to dx disc displacement with intermittent non reduction
- persistent limited mouth opening less than 35mm with hx of sudden onset and pain. may last seconds to a few minutes
- deflection to affected side on mouth opening
- marked limited laterotrustion to the contralateral side (if unilateral disorder)
- patient can apply pressure to the affected joint, relax and wait for disc to reduce
describe disc displacement without reduction
- disc is non reducing or permanently displaced
- disc does not improve irs relation with the condyle on translation
- closed lock
- MRI shows no disc recapture on mouth opening
describe disc displacement without reduction - acute
- sudden and marked limited mouth opening due to jamming or fixation of disc
- secondary to disc adhesion, deformation or dystrophy
- pain is often present when attempting to open mouth
- straight line deflection to affected side on opening
what are the diagnostic critera that must be present to dx disc displacement without reduction
- persistent limited mouth opening less than 35mm with hx of sudden onset
- deflection to affected side on mouth opening
- marked limitation laterotrusion to the contralateral side (if unilateral disorder)
- MRI reveals displaced disc without reductio. x rays show no extensive osteoarthritic changes
the majority of patients with disc dispalcement with reduction _____ progress to disc displacement without reduction
do not
describe the arthrocentesis procedure
- needle is inserted into the superior joint space and lactated Ringer’s solution is used to distend joint space. done under IV sedation
- a second needle is then placed into the superior joint space and the TMJ is lavaged
- during athrocentesis, the jaw can be gently manipulated to increase range of motion since patient is sedated
- local anesthetic and/or steroids are injected at completion of procedure for pain management
once arthrocentesis is done pt will need:
PT and possibly an anterior repositioning splint to deep disc from becoming non reducing and to help prevent re-formation of fibrous adhesions or capsular constriction
- the disc may displace in the future
what are the arthocentesis indications
- for treatment of intra articular joint restrictions of jaw movement
- acute closed lock with limited ROM that does not resolve
- acute pain in TMJ is not responsive to medications and conservative treatment (splint therapy, PT or intra articular steroid injection)
when is the best success for arthrocentesis
if procedure is done within 2-3 weeks following jaw locking
what diagnostic criteria must be present to dx disc displacement without reduction (chronic)
- hx of sudden onset of limited mouth opening that occurred greater than 4 months ago
- MRI reveals displaced disc without reduction
- hard tissue imaging reveals no extensive osteoarthritic changes
what is arthroscopy for
visualization of the glenoid fossa and superior aspect of the disc
what is used in arthroscopy
- forceps, scissors, sutures, medication, needles, cautery probes, burs and shavers can be used through the arthroscope to correct problem
- small canula is inserted into the superior joint space and is connected to a TV camera and video monitor
- lasers can be used to eliminate adhesions, inflamed tissue, and incise tissue within the joint
arthroscopy surgically corrects a variety of intracapsular disorders including:
- disc displacement without reduction, hypomobility as a result of fibrosis or ahdesions, degenerative joint disease and hypermobility. it is useful for minor debridement and lavage, incision of minor adhesions and biopsies
- patients receive physical therapy following surgical treatment
what are the indications for arthroscopy
- chronic tmj pain with limited range of opening that has failed to respond to conservative treatment or arthrocentesis
- always re-evaluate patient prior to arthroscopy
what are the inflammatory disorders of the TMJ
- synovitis/capsulitis/arthralgia
- polyarthritides
what is synovitis/capsulitis (arthralgia)
inflammation of synovial lining of TMJ due to trauma or infection
what are the diagnostic criteria that must be present to dx synovitis/capsulitis (arthralgia)
- localized TMJ pain exacerbated by function (especially posterior or superior loading)
- no extensive osteoarthritic changes seen on xrays
what are the minor criteria that may be present to dx synovitis/capsulitis (arthralgia)
- localized TMJ pain at rest
- limited ROM secondary to pain
- fluctuant swelling (due to effusion) that decreases ability to occlude on ipsilateral posterior teeth
- for ear pain
- bright MRI signal when fluid is present
describe synovitis/capsulitis (arthralgia)
- inflammation of the synovial structures
- occurs after trauma, bruxism, or wide opening
- continuous pain in TMJ
- movement of TMJ increases pain
- palpation over capsule increases pain
- limited mandibular opening due to pain
- edema can cause inferior displacement of the mandible due to swelling creating a malocclusion. edema is visible on MRI of TMJ
- posterior teeth do not occlude on closing
what is retrodiscitis
- inflammation of retrodiscal tissue (posterior attachment)
- occurs following trauma, bruxism or wide opening
- occurs after constant clicking or dislocation
- constant deep pain
what are the types of polyarthritides
- rheumatoid arthritis
- juvenile arthritis
- ankylosing spondylitis
- psoriatic arthritis
- infectious arthritis
- gout (crystal induced disease)
what are the diagnostic criteria for polyarthritides
- pain with jaw function
- point tenderness on TMJ palpation
- limited range of motion secondary to pain
- radiographic evidence of extensive TMJ changes
what may be present with polyarthritides
- any of characteristics of osteoarthritis
- pain while mandible is at rest
- positive laboratory serology test (Rheumatoid factor, sedimentation rate, antinuclear antibody - ANA)
- crepitus (grinding noises) with condylar translation
what are the non inflammatory disorders
- osteoarthritis
- osteoarthrosis
what must be present to dx osteoarthritis diagnostic criteria
- no other identifiable etiological factor
- pain with jaw function and movement
- point tenderness on TMJ palpation
- radiographic evidence of structural bony change (not as extensive as seen in inflammatory arthritis)
what may be present in osteoarthritis
- limited range of motion, deviation to the affected side
- crepitus or multiple joint noises
describe osteoarthrosis
- chronic arthritis of non inflammatory character
- no pain report or pain on palpation
- coarse crepitus in TMJ during any movement
- no radiographic degenerative changes
describe arthralgia
- pain with jaw function
- pain on TMJ palpation
- No TMJ noises
what is the tx for arthralgia
- arthroscopy and steroids
- occlusal guard if clenching
- NSAIDs and steroids
- REST (soft diet x2 weeks) , heat/ice therapy (10min, 2x day), eliminate parafunctional habits
what is the dental management of orofacial pain patients
- keep appointents shorter than 1-2 hours. frequent rest periods during appt
- limit jaw opening
- use sonic scaler when possible to go faster
- NSAIDs or tylenol 30 minutes prior to appt and for 24 hours
- ethyl chloride spray during appt
what are the potential problems related to dental care in orofacial pain pts
- oral hygiene may be less than optimal due to restricted range of motion and/or pain on opening
- patients pain may increase following hygiene appt due to length of time required to keep mouth open
- clenching/bruxism may cause teeth to be sensitive to percussion and temperature changes
- restricted range of motion and muscle tiredness may make it difficult for patient to remain open for extended period of time
- sensation of malocclusion may occur due to trigger point sensation with shortening of muscles seen in myofascial pain
- locking may occur during appt
- clicking sounds in the TMJ may result from dysfunction of the lateral pterygoid muscle
