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Oral Disease > TMD Diagnosis and Management > Flashcards

TMD Diagnosis and Management Flashcards

1
Q

Definition of TMD

A

TMD is a collective term embracing a number of clinical problems that involve the masticatory muscles, the TMJ and associated structures

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2
Q

What can the aetiology be classified into?

A
  1. Parafunction
    - Bruxism/clenching/gum chewing
  2. Psychological
    - Stress/anxiety/depression/hypervigilance
  3. Pathology
    - Trauma/inflammatory disease/neoplasms/arthritides/infection
  4. Occlusion
    - Severe skeletal discrepancy/occlusal interferences
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3
Q

What is the diagnostic criteria for TMD involving the muscles of mastication?

A
  • Myalgia (muscle pain) - pain localised to one muscle
  • Myofacial pain (muscle and fascia pain ± referral)
  • Regional pain involving multiple muscles
  • Tender muscles to palpation (usually temporalis or masseter)
  • Possible limited mandibular function due to pain
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4
Q

What is the diagnostic criteria for TMD involving the TMJ?

A
  • Arthralgia
  • Headache attributed with TMD
  • Disc displacement disorders
  • Inflammatory disorders: capsulitis, arthritis
  • Subluxation/dislocation
  • Deviation in form: congenital or developmental
  • Ankylosis
  • Fracture
  • Tumour
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5
Q

Epidemiology of TMD

A
  • 15-30 years - dysfunction
  • 40+ years - degenerative
  • however, elderly not immune to dysfunction and young not immune to degenerative
  • F:M 2:1
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6
Q

What are signs and symptoms relating to muscles of mastication (myalgia, myofacial pain)

A
  • Regional, dull, aching pain
  • Masseter and temporalis affected
  • Pain at rest, aggravated during function
  • May be more painful in the morning
  • Limited movement
  • Radiated pain - headache, neck, ear
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7
Q

What are the signs and symptoms relating to TMJ arthralgia?

A
  • Localised sharp pain
  • Situated in TMJ, surrounding tissues, ear
  • Aggravated during loading and function
  • Often associated with displaced or dysfunctional articular disk, locking/clicking
  • Limitation of movement possible
  • TMJ arthritis - crepitus
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8
Q

What are other signs and symptoms associated with TMD

A
  1. Pain: most common problem; pre-auricular or referred
  2. Muscle tenderness
  3. Joint noises: click or crepitus
  4. Locking of joint: occasional
  5. Trismus: on waking, after eating
  6. Occlusion: variable
  7. Oral habits: 50% parafunction
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9
Q

What do you look for during a joint examination?

A
  • Pain evoked by digital palpation of TMJ and wide opening
  • Joint sounds on opening, closing and excursions
    1. Click: movement of disc relative to condyle
    2. Crepitus: degenerative disease
  • Dislocation: produces anterior open/cross bite
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10
Q

What do you look for during a muscle examination?

A
  • Digital palpation of
    1. Neck and shoulder muscles
    2. E/O muscles of mastication (masseter and temporalis - test attachment to bone only, check for tenderness/hypertrophy)
    3. I/O muscles of mastication (lateral pterygoind palpation unsatisfactory - resistance to lateral excursions better)
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11
Q

What do you look for during a functional examination?

A
  • Deviation and pattern of opening
  • Locking (malposition/distortion of disc)
  • Vertical range of motion
    1. maximum pain-free opening
    2. maximum possible opening ~3 finger widths
    3. maximum pain-free lateral excursion
    4. maximum possible lateral excursion
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12
Q

What do you look for during an intraoral examination?

A
  • Examination for bruxism: muscle hypertrophy, fasciculation, tongue scalloping, linear alba, tooth/restoration wear and fracture, dentine sensitivity
  • Occlusal derangement
  • High restorations
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13
Q

What clinical features of a headache can help associate it with TMD?

A
  • Temporal region
  • Dull
  • On waking
  • No photophobia/nausea
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14
Q

What psychological considerations should be given when assessing TMD?

A
  • Depression: x5 more common in TMD
  • Anxiety
  • Stress
  • Somatoform disorders (including hypochondria)
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15
Q

What is the reversible conservative management that can be done by a GDP?

A
  1. Identify cause
  2. Exclude organic disease
  3. Pt education and reassurance
  4. Soft diet; no chewing gum
  5. Occlusal splints
  6. Limited mouth opening
  7. Analgesia
  8. Heat/cold application
  9. Behavioural: reduces stress, relaxation techniques, psychotherapy, rest
  10. Physiotherapy
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16
Q

What reversible specialist treatment can be done?

A
  1. Psychological support (CBT)
  2. Anti-depressant medication (anxiolytics, tricyclic antidepressants)
  3. Muscle relaxants (baclofen/diazepam)
  4. Botulinium toxin (if severe bruxism)
  5. Intramuscular/intra-joint LA: for both diagnosis and for treatment
  6. Intra-articular steroids (depo-madrone) helps to decrease inflammation
17
Q

What specialist irreversible tx can be done?

A
  • Phase 2
    1. Occlusal rehabilitation
    2. Restorative treatment
    3. Orthodontics
    4. Prosthetic rehabilitation
    5. Orthognathic surgery for severe skeletal discrepancy
  • Phase 3
    1. Surgery (Rare)
    2. Perforation of disc
18
Q

What specialist irreversible tx can be done?

A
  • Phase 2
    1. Occlusal rehabilitation
    2. Restorative treatment
    3. Orthodontics
    4. Prosthetic rehabilitation
    5. Orthognathic surgery for severe skeletal discrepancy
  • Phase 3
    1. Surgery (Rare)
    2. Perforation of disc
19
Q

What types of occlusal splints can be made

A
  • Soft
  • Localised occlusal interference splint
  • Stabilisation splint
  • Anterior bite plane
  • Anterior repositioning splint
20
Q

What are the aims of occlusal splints

A
  • Alter occlusal forces, muscle length, structure relationships in TMJ
  • Reduces wear, mobility, muscle tone, pain, parafunction, reflex activity
  • Habit breaking (cognitive awareness)
  • Placebo effect
  • Cheap and reversible
21
Q

Which conditions require surgical correction

A
  • Mandibular growth disturbances
  • Ankylosis: congenital, inflammatory, traumatic (fracture of zygomatic arch), neoplastic, idiopathic, coronoid enlargement
  • Tumours
22
Q

What are the aims and types of surgical treatment?

A
  • Aims - improve mandibular function, alleviate pain, prevent disability
  • Types
    1. Manipulation under GA
    2. Arthrocentesis - remove fluid from joint
    3. Arthroscopy - lysis and lavage, diagnostic and therapeutic; keyhole surgery
    4. Arthrotomy - disc repositioning, meniscectomy, High condylar shave
    5. Extra articular surgery (including ankylosis release) - condylotomy, Condylectomy, whole joint replacement, orthographic surgery
23
Q

What diseases can be misdiagnosed as TMD and what are the red flags

A

Giant cell arteritis (temporal arteritis)
• 1st >50yrs
• Unilateral pain with jaw
• claudication

Trigeminal neuralgia
• Paroxysmal, unilateral lancinating
pain

Malignancy
• History of malignancy
• Facial asymmetry, lymphadenopathy or neck masses
• Trismus
• Occlusal changes
• Sensory or motor changes (e.g. loss of hearing = acoustic neuroma, neuralgia from adenoid cystic carcinoma)
• Recurrent epistaxis, purulent nasal discharge or anosmia (loss of smell)
• Lymph nodes
• Unusual pain

Angina 
• Jaw or throat pain
• Association with exercise / after eating
• May not be chest or arm pain
• May be bilateral
• Jaw pain may be first sign
• May be ear pain as well / alone
• Toothache (...? in the edentulous)
• Not necessarily history cardiac condition/diabetes

Oral Disease (43 decks)

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