4. TMJ Disorders

Question 1

Definition of TMD

Answer 1

encompases a group of musculoskeletal and neuromuscular conditions that involve the TMJ, masticatory muscles and all associated tissues

Question 2

DC/TMD stands for

Answer 2

Diagnostic criteria for TMD

Question 3

DC/TMD includes what in addition to a clinical exam

Answer 3

history questionaire for pain

Question 4

What is the difference between Axis I and II

Answer 4

Axis I= Diagnostic criteria

Axis II= psycho-social criteria

Question 5

What are the TMD conditions with validated diagnoses

Answer 5

• Myalgia
• Myofascial pain with referral
• Arthralgia
• Headache attributed to TMD

Question 6

What does is mean to say that the diagnoses have been validated

Answer 6

high specificity and sensitivity levels –> validation (determines how certain you are in identifying true false positives and negatives)

Question 7

What are the two main groups of Axis I classification

Answer 7

paint related TMD

Intra-articular TMD

Question 8

The TMD condition that most commonly affects the muscles is

Answer 8

myalgia

Question 9

Define Myalgia

Answer 9

• Pain of origin is muscle
• Pain modified by jaw movement, function and parafunction
• Replication of pain with provocation testing of masticatory muscles

Question 10

Describe the history and clinical components that must be present for a diagnosis of myalgia

Answer 10

Hx

• Presence of pain in the jaw, temple, ear or in ear region
• Pain is modified by jaw movement, function and parafunciton

Clinical
-Familiar pain in the temporalis and masseter with at least one of these tests (palpation of temporalis/masseter or familiar pain during max. unassisted opening, lateral or protrusive movements)

Question 11

MUO +MAO =?

Answer 11

Vertical range of motion

Question 12

What percentage of myalgia cases don’t occur in the temporalis and masseter region

Answer 12

1-2%

Question 13

Define myofascial pain with referral

Answer 13

• Pain of muscle origin
• With referral of pain beyond the boundary of the muscle being palpated
• Spreading pain may also be present

Question 14

Describe the historic and clinical features of the exam that test positive for myofascial pain with referral

Answer 14

Hx

• Pain in the jaw, temple, ear or in ear region
• Pain modified by jaw movement, function and parafunction

Clinical

• Confirmation of pain in the temporalis or masseter region
• Report familiar pain with palpation of temporalis or masseter
• Report pain at a site beyond the boundary of palpation

Question 15

How much kg of pressure are used when palpating at the lateral pole and around the TMJ

Answer 15

Around the TMJ= 1 kg

Lateral pole= 0.5 kg

Question 16

Define Arthralgia

Answer 16

• Pain of joint origin
• Pain is affected by jaw movement, function and parafunction
• Replication of pain though provocation testing of the TMJ

Question 17

Describe the historic and clinical findings associated with Dx of arthralgia

Answer 17

History

• Presence of pain in the jaw, temple, ear and in ear regions
• Pain is modified by jaw movement, function and parafunction

Clinical

• Confirmation of pain in area of TMJ
• Pain upon palpation of the lateral pole or around the lateral pole OR
• Pain with max unassisted opening, protrusion, lateral movement

Question 18

What are the four activities you ask about when asking the patient if performing any of these activities makes thier pain better or worse

Answer 18

• Chewing hard/tough food
• Opening your mouth or moving your jaw forward or to the side
• Jaw habits such as clenching, grinding, chewing gum
• Other jaw activities such as talking, kissing, yawning

Question 19

When evaluating the patients mandibular range of motions when do you ask if the patient is experiencing familiar pain

Answer 19

MUO

MAO

Question 20

What are the only headaches we treat as headache and how do we treat them

Answer 20

Headache associated to TMD (treat by treating the TMD because the headaches are secondary to TMD)

Question 21

Define Headache attributed to TMD

Answer 21

• Headache in temple region secondary to pain-related TMD
• Affected by jaw movement, function and parafunction
• Replication of headache through provocation testing of masticatory system

Question 22

Describe the historical and clinical dx findings for headache attributed to TMD

Answer 22

Hx

• Headache of any type in the temple region
• Headache modified by jaw movement, function and parafunciton

Clinical

• Confirm headache in temple region (temporalis)
• Report familiar headache in temple area with are least on of the following (pain on palpation of temporalis or pain upon max. unassited opening, protrusion or lateral movements)

Question 23

For specificity and sensitivity percentages anything about _ is great

Answer 23

80%

Question 24

Pain related TMD conditions have (high/low) diagnostic validity

Answer 24

high

Question 25

Other muscle condiitons that are not validated are

Answer 25

- Muscle spasms - Contracture - Myostitis - Hypertrophy

Question 26

Define muscle space

Answer 26

-Involuntary, reversible, sudden tonic contraction of a muscle

Question 27

Examination of muscle spasms must confirm what two factors for Dx

Answer 27

- Immediate onset of myalgia (muscle pain) | - Immediate limited ROM

Question 28

What is the gold standard for Dx of muscle spasms

Answer 28

elevated EMG (This is the reference standard for muscle spasms)

Question 29

Define contracture

Answer 29

Shortening of a muscle due to fibrosis of a tendon, ligament or muscle fibers

Question 30

Pain can occur in contracture if

Answer 30

muscle is over-extended

Question 31

People with contracture tend to have a history of

Answer 31

radiation, trauma or infection

Question 32

Progression of contracture leads to

Answer 32

loss of ROM (range of motion) MUO and MAO are limited

Question 33

Define myositis

Answer 33

Pain is of muscle origin with clinical characteristics of inflammation or infection

Question 34

Myositis generally arises how

Answer 34

- Direct trauma (acute) | - Autoimmune disease (chronic)

Question 35

Myostitis ossificans includes what findings

Answer 35

- muscle calcification - local myalgia - presence of edema, erythema, and increased temp - serologic tests for inflammation

Question 36

What is the most accepted treatment for traumatic myosistis ossificans (TMO)

Answer 36

excision followed by physiotherapy

Question 37

TMO has a (high/low) rate of recurrance and why

Answer 37

low because may be concealsed due to short term follow up

Question 38

Etiologies of hypertrophy include

Answer 38

- Familial/genetic origin | - Secondary to overuse and/or chronic tensing of the muscles

Question 39

Hypertrophy typically (is/isn't) associated with pain

Answer 39

isn't .

Question 40

Describe the vicisous cycle theory

Answer 40

- Proposed me chanism of myogenous pain (not currently accepted) - Muscle pain became chronic because stimulation of nociceptors led to tonic excitation of motoneurons (hyperactivity) - This lead to spasm, fatigue, and overwork and this then led to further stimulation of nociceptors resulting in a pain-spasm-pain cycle

Question 41

Why is the vicious cycle theory no longer accepted

Answer 41

- No difference in EMG between rest cases and controls | - Pain reduces muscle contraction

Question 42

Describe the pain adaptation model

Answer 42

Pain related changes should be viewed as adaptive because they help prevent further damage and promote healing

Question 43

Describe the integrated pain adaptation model

Answer 43

-Effect of pain on motor activity relies on the complex interaction of bio-psychosocial characteristics as well as anatomical and functional complexitiy of the individual sensory-motor system

Question 44

People with chronic pain diseases typically have a (high/low) pain threshold... what affect will this have on TMD dx

Answer 44

low... more likely to experience pain upon palpation (these people thus have a higher likelihood of having a pain related TMD Dx)

Question 45

Review the cases

Answer 45

ok