Examination & Interventions for Pts w/ TMJ Dysfunction Flashcards
(71 cards)
1
Q
Prevalence and Incidence of TMD
A
-
Prevalence:
- 10mil cases/year US
- ** >prevalence in Females (20-40yo)
-
Incidence:
- Approx 1mil NEW cases/yr US
- 20-25% pop exhibits sx’s TMJ dysf
2
Q
Factors that contribute to TMD
A
- Gender
- F>M (20-40yo)
- Malocclusion→ teeth/bite probs
- Poor posture
- Parafunctional habits**
- biting nails, grinding teeth, hard candies
- Emotional stress, anxiety, psycho issues
- + correlation bw higher anxiety lvls and chronic orofacial pain in university students
- Connect tissue OR rheumatologic disease
- lupus, RA, systemic sclerosis
3
Q
Differential Dx of Orofacial Pain
*not always TMD!
A
see pics
4
Q
Burning Mouth Syndrome
5
Q
TMD Examination Components
A
- Thorough Hx
- UQ Postural assess.
- FHP?
- Observation/Inspection
- Occlusion
- AROM
- mandibular dynamics (deviation? deflection? (doesnt return to midline) Early translation?)
- Excursion: Therabite ROM scale
- Jt sounds?
- Provocation tests
- retrusive overpressure
- U/L joint loading
- Iso resistance tests
- Passive jt mobility tests
- Palpation
- mm’s, joints
- “Recapture Tech’s”
- specifically for patients w/ ADD w/ Reduction and reciprocal click*****
6
Q
Why** is it important to screen the **CS in pts w/ suspected TMD?
All reasons first, later broken down into components
A
- Postural/soft tissue relationships
- Trigemino-cervical complex
- Bruxism may occur in response to neck pain
- Masticatory mm’s contact in response to contraction of CS mm’s and visa versa→ synergistic relationship under norm circumstances
- Whiplash injuries can involve both CS and TMJ
- “Mandibular Whiplash”
7
Q
Why** is it important to screen the **CS in pts w/ suspected TMD?
*Postural/Soft tissue relationships
A
- FHP→ elongates supra/infrahyoids→ they create retrusive force on TMJ
-
CS positioning (LF and/or Rot)
- affects occlusion which affects TMJ alignment and load distribution→ also affects mandibular rest pos. and thus affects path of closure and may affect initial tooth contact
8
Q
Why** is it important to screen the **CS in pts w/ suspected TMD?
Trigemino-cervical Complex
A
- TMJ and mms of mastication innervated by trigeminal nerve
- Afferent input from Upper CS (C1-3) pain converges on trigeminal motor neurons in trigeminocervical nucleus→ inc’d masticatory mm activity and pain referral
- CS tissues can also refer pain to head and orofacial areas
9
Q
Why** is it important to screen the **CS in pts w/ suspected TMD?
Masticatory muscles contract in response to contraction of CS mm’s and visa versa
usually a synergistic relationship under normal circumstances
A
- Spasm or prolonged postural contractions of CS mm’s and cause activity in mm’s of mastication
10
Q
Why** is it important to screen the **CS in pts w/ suspected TMD?
Whiplash injuries can involve both CS and TMJ
A
Mandibular Whiplash
*head flies back and then chin can hit sternum on forward motion
11
Q
Common Symptoms of TMD
A
-
Big 3
- Clicking/jt sounds
- Jt pain
- Limited ROM
- Others
- malocclusion
- hypOmobility or locking
- HAs
- dizzy/nausea
- ear pain
- barohypoacusis
- tinnitus
- craniofacial pain
- tooth ache
- pain w/ oral function
- Upper CS pain
- crepitus
- hyperalgesia→ easier pain provocation
-
Allodynia
- something that shouldnt cause pain DOES ex. shaving
12
Q
TMD
Causes of Joint Sounds
*Clicking/Popping
A
-
Disc derangements
- clicking or snapping sounds due to recapturing and/or derangement of disc
-
HypERmobility
- may be a dull “thud” or “pop” toward the end of opening as condyle subluxes
- Muscle INcoordination
- articular surf incongruency
-
Vacuum formation
- pop or crack→ like cracking knuckles→ time must pass before occurs again
13
Q
TMD
Observation
A
- UQ/CS posture
- Mandible pos→ midline @ rest?
- swelling
- occlusion
- use tongue blade inside cheek and pull soft tissue laterally
- ask pt to gently bite and open slightly several times
- move tongue blad to other side, repeate
-
Findings:
- overbite
- underbite
- cross bite
- missing teeth
-
Findings:
-
AROM: opening, lat dev, protrusion
- gently palp condyles
- Note deviation or deflection or jt sounds
- Note painful motions or pain @ end range
14
Q
Quick Assessment of Opening ROM
A
- 3 finger (or knuckle) test
- Normal= 3 fingers or knuckles
- Min for basic function= 2 fingers or knuckles
15
Q
Therabite ROM Scale
A
measures active opening and lateral deviation
16
Q
Retrusive Overpressure
Jt. Loading
LAB
A
see pics
17
Q
U/L Loading Test
A
- Dental cotton roll placed b/w molars on 1 side, and pt instructed to “clench”
-
Which TMJ experiences the greatest loading?
- The OPP side of cotton role→ greater JRFs
- Take home point: Pain may be provoked on either side, BUT more likely on side CONTRAlateral to cotton roll
18
Q
Isometric Resistance Tests
How To:
A
- Pts teeth slightly apart, use 2 fingers on the mandible to provide iso resistance to the following motions.
- Build up force slowly over 5-6s, and note strength and provocation of symptoms
19
Q
Isometric Resistance
Opening (depression)
What mm’s?
A
GRAVITY + lateral pterygoids and digastrics
20
Q
Isometric Resistance
Closing (elevation)
What mm’s?
A
Masseter, Temporalis, Medial pterygoid
21
Q
Iso Resistance
LEFT Lateral Deviation (would be OPP going to right)
What mm’s?
A
- LEFT masseter
- Left horizontal temporalis + Left lateral pterygoid→ Force Couple
- Right lateral pterygoid
- Right medial pterygoid
*NOTE: bolded are the major players
22
Q
Iso Resistance
Protrusion
What mm’s?
A
Lateral pterygoids, medial pterygoids, masseters
NOTE: bolded are major players
23
Q
Passive Joint Mobility Tests
A
- Done intraorally; wear gloves, check BOTH sides and compare
See Pics
24
Q
Palpation
A
*see pics
25
Medial Pterygoid Palpation
see pics
26
Recapture Techniques for pts w/ **ADD w/ Reduction (Reciprocal Click)**
* have pt perform **active opening** w/ the conditions below (1 at a time):
* Postural correction
* Edge to edge pos'ing
* line up teeth so protrude slightly
* appliance placement
* immediately following distraction/manipulation
* During ea, palpate condyles and closely observe. **Does clicking stop?**
* If so, **good sign disc can be recaptured**
27
TMD Classification: **Dual Axis System**
1. **Axis I: Tissue Related**
1. muscle
2. disc
3. joint
2. **Axis II: Behavior/psychosocial related factors**
1. Pain
2. Parafunctional behaviors
3. Psychological distress
4. Psychosocial function
28
TMJ Disorders (TMD)
What are the 3 major categories of disorders?
1. **Muscle disorders**
2. **Disc Displacements (derangements)**
3. **Arthralgia, Arthritis, Arthrosis→ _Joint related_**
29
TMJ Disorders (TMD)
## Footnote
**Muscle disorders**
* Myofascial pain
* Trismus
* gen term for diff opening mouth; assoc'd w/ mm tightness
* Bruxism→ grinding teeth
30
TMJ Disorders TMD
## Footnote
**Disc displacements**
2nd category: Derangements or issues dealing directly w/ disc itself
31
TMJ Disorders TMD
## Footnote
**Arthralgia, Arthritis, Arthrosis**
**Joint-related**
* assoc'd terms and conditions:
* capsulitis, retrodiscitis, capsular tightness
* Types of arthritis:
* infectious
* post-traumatic (s/p fx, disloc, etc..)
* gout
* DJD
* RA
32
Alignment or patho factors that may contribute to TMD
* Growth disorders (bone hypER/hypOplasia)
* Occlusal disorders
* Neoplasms
* Connect tissue dis's
* ex. Lupus
33
Bruxism
* Grinding of teeth
* wears down molars
* often **nocturnal**
* overactivity of muscles mastication→ **irritation retrodiscal pad**
* starts as muscle disorder, but can progress to _arthritis/arthralgia and/or disc derangement_
* Morning sx's → tenderness in mm's, HAs, TMJ pain
* **Interventions:**
* relaxation
* stress mgmt
* night guard (oral splint)
34
Disc Displacement (Derangement)
Kircos et al. 1987
n=21
no hx of TMD
MRI: 32% pts had ADD
35
Disc Displacements (Derangement)
## Footnote
**Partial ADD**
Early opening click
\*\*hat **starting to** slide Ant
36
Disc Displacements (Derangement)
## Footnote
**ADD w/ Reduction**
**\*Reciprocal Click**
* Reciprocal click
* aka Opening click is good bc condyle gets under disc again, **then** when closing disc falls out again → reciprocal click
37
Disc Displacements (Derangement)
## Footnote
**ADD w/ Intermittent Locking**
Somewhere b/w the two
bw ADD w/ Reduction and w/out Reduction
38
Disc Displacements (Derangement)
## Footnote
**ADD W/OUT Reduction**
**\*Closed Lock**
* Closed Lock
* No click bc condyle cannot get under disc
* Often times cannot fully open mouth
* No opening and **click cannot be reduced**
39
NOTE about **ADD's**
Disc typ deranged **@ rest.** The opening click is **“recapturing”** of the disc that occurs **as the condyle translates ant/inf** and establishes a **“normal”** relationship w/ disc
40
Pts w/ **progressive worsening of an ADD** will transition over time from:
Single opening click→ reciprocal click→ NO click
41
Disc Displacements (Derangement)
## Footnote
**Other types less common**
* Post
* Lat
* Med
42
**ADD w/ Reduction (Reciprocal Click)**
**aka disc displacement w/ reduction (DDwR)**
* Typ pattern of opening is a “C” Curve deviation **towards the involved side**
* Before opening click occurs, the deranged disc **impairs normal motion** and thus the mandible **deviates towards the involved side**
* After the disc is recaptured via the opening click, **the motion is no longer impaired** and the mandible **returns to midline by the end of opening**
43
**ADD W/OUT Reduction**
**\*Closed Lock**
* Typ pattern of opening is **a deflection (does not return) toward the involved side,** and limtd ROM for depression
* On the involved side, the ADD w/out reduction is **“blocking”** normal motion from occurring in the **involved TMJ**
* The **contralateral TMJ is free to move normally,** and thus the mandible will **deflect toward the involved side**
44
Arthralgia, Arthritis, Arthrosis
\***Joint pathology**
* RA, OA, Gout, Infectious Arthritis, Post-traumatic arthritis
* Inflammation (may be assocd w/ arthritis)
* **capsulitis**
* **retrodiscitis**
* Fibrous adhesions/caps tightness/hypOmobility
* **may follow immobilization after fx or post-traumatic arthritis**
* HypOmobility
* **early translation**
* can be due to mm incoord.
* may be due to hypomobility in **lower compart. of joint (limtd rotation)**
* Sublux
* Dislocation
* **“Open Lock”→ cannot close mouth**
* Manually reduced on field or ER; see pt several weeks later if sx's of post-traumatic arthritis emerge
45
Principles of Mgmt of TMD
* assess irritability
* acute/highly irritable vs. chronic/less irritable
* control pain/inflamm
* eliminate myofascial trigger pts in UQ
* facilitate normal TMJ jt mechs and mm function
* restore normal TMJ ROM
* normalize UQ posture
* treat any concurrent CS dysf
* eliminate or control parafunctional habits
* ex. nail biting, hard candy
* **Self-Care**
* HEP
* pt edu
* Interdisciplinary Team approach
* referral→ dentist
* PT
* psychologist
* orthodontist
46
Principles of Mgmt of TMD
*For pts w/ _Disc Derangements_*
Stabilize disc position **when possible**
47
Mgmt of TMD: Systematic Review and Meta Analysis
List and Axelsson
* SOME evidence following effective:
* occulsal appliances
* acupuncture
* behavioral tx
* jaw ex's
* postural training
\*Evidence for effect of electrophys modals and sx insufficient
\*occlusal adjustment seems to have **no effect**
\*variation in methodology b/w primary studies made definitive conclusions impossible
48
Interventions for **Muscle Related TMD**
## Footnote
**\*remember 3 categories: 1. muscle 2. disc 3. joint**
* adjunctive modals
* biofeedback and relaxation techs
* STM
* NMSK re-ed and ex's
* eliminate parafunctional habits
* refer for night guard→ Bruxism
49
Interventions for Muscular Disorders TMDs
Study:
The Add. Value of a Home PT Regimen vs. Pt Edu Only for the Tx of Myofascial Pain of the Jaw Muscles: Short Term Results of RCT
\*see pics
50
Extra-Oral TMJ Depression
\*sliding down the cheeks one
Manual tech for jt decompression/unloading and relaxation/stretch of **Masseter**
## Footnote
**\*see pics**
51
Intraoral Masseter Release
Temporalis Release
see pics
52
Interventions for **Disc Derangements**
## Footnote
**\*3 categories: 1. muscular 2. disc 3. joint**
* Sx mgmt
* modals
* Man tx
* **Disc recapture efforts→ for pts w/ ADD W/ Reduction/Reciprocal Click**
* exercise
* oral appliances
* Jt mobs
* discuss mech of effect of a mob tech such as intraoral distraction
* Postural correction and re-ed
* stress mgmt
53
ADD w/ Reduction
\*STUDY on **Appliance Tx**
see pics
54
Mgmt of **ADD w/ Intermittent Locking**
***when sx's and clicking persist despite tx***
**\*in b/w ADD w/ or w/out reduction**
**IMPORTANT\*\*\***
* If symptomatic reciprocal clicking or intermittent locking cannot be managed successfully w/ Tx geared toward **disc recapture**→ another approach is **therex and jt mobs specifically intended to _further the derangement to an ADD w/OUT reduction_**
* essentially making them WORSE initially to make them BETTER later
* this eliminates clicking
* Pt learns to “function” on the **post retrodiscal tissue**
* **_Criteria for this approach:_**
* persist jt noises that are disturbing to pt
* intermittent catch/lock during opening
* Pt understands this Tx approach may cause pain and/or limted mouth opening **INITIALLY OR might lead to need for sx if pain and limtd opening do not improve w/ time**
* **Pt has consulted w/ dentist or oral surgeon**
55
**ADD w/OUT Reduction**
**\*Closed Lock→ no way to recapture**
\***STUDY**
see pics
56
Interventions for Jt-related TMDs
\*Arthritis, arthralgia, etc.
**Interventions for hypOmobility/Capsular tightness**
\*Warm it up, stretch it out!
* Adjunctive modalities
* Moist heat
* US
* Jt mobs
* self-stretch ex's and ROM
* Therabite (see pics)
57
Interventions for Jt-related TMDs
\*Arthritis, arthralgia, etc.
**Intraoral TMJ Mobilization**
**4:**
1. Caudal (INF) distraction
2. Caudal distraction + translation (anterior)
3. Caudal Distraction + passive opening
4. Caudal distraction w/ Lat glide (deviation)→ NO PICTURE
58
IntraOral TMJ Mobilization
Self-distraction w/ tongue blades
aka Dr. Kietrys magic trick
See pics but you just keep sticking tongue blades in mouth to further Opening ROM
59
Interventions for Jt-related TMDs
\*Arthritis, arthralgia, etc.
\***Interventions for HypERmobility or subluxations**
* HEP→ **emphasis on NMSK control and coordination**
* Pt education
* **avoid _excessive opening_**
* cut food into sm pieces
* block yawn w/ fist
60
Interventions for Jt-related TMDs
\*Arthritis, arthralgia, etc.
\***Interventions for TMD OA (DJD)**
\*Nicolakis, et al. 2001
* **Subjects**
* radiographic evidence of OA
* **Tx**
* PROM, AROM, Manual Tx, Postural correction, relaxation
* **Outcomes**
* DEC pain, Improved ROM and function\*\*\*\*\*
61
Interventions for Jt-related TMDs
\*Arthritis, arthralgia, etc.
**Rocabado's 6x6 Exercise Program**
**\*ANY TYPE OF TMD**
**KNOW THIS!!!**
SEE ATTACHED
62
TMJ Exercises for **Mobility**
## Footnote
**\*use mirror feedback→ helps pt perform mvmt in _midline_ with _improved NMSK control_**
See pics for explanations
* Controlled-ROM Lat. Excursion
* Protrusion ROM
* Self-stretch into Opening
* Self-distraction Mobilization into Opening
63
TMJ Splints aka IntraOral Appliances; Bite Plates
## Footnote
**Explanation first**
* Adj'd by dentist over several visits; 2-3x/month Tx period
* **Proposed indications:**
* myalgia/myofascial pain
* arthralgia/arthritis
* disc derangements
* bruxism
* HAs assoc'd w/ bruxism
* select dental probs→ atypical odontalgia
* temp. occlusion
* cracked/chipped/worn teeth
64
TMJ Splints aka IntraOral Appliances; Bite Plates
## Footnote
**Total Contact “Stabilization” Splints**
* **Effects:**
* provides centric relation occlusion→ **pos of jaw when mm's are relaxed**
* reduce abnorm NMSK activity
* promote NMSK balance
* obtain stable occlusal relationships w/ uniform tooth contacts
* Inc “freeway space” b/w teeth→ **jt unloading**
* behavioral effects→ reduce clenching
65
TMJ Splints aka IntraOral Appliances; Bite Plates
## Footnote
**Other Split Types**
**2:**
* **Distraction (pivot) splints (partial coverage)**
* Built in pivot→ **Anterior guidance on Ant. teeth**
* allows contact of Ant. teeth w/out contact of post. teeth during jaw mvmt
* **Mandibular Oral Repositioning Appliance (MORA)** aka **Ant. Repositioning Splint or ARS**
* built in “ramps” promote **slight ANT. translation/repositioning** of mandible to **facilitate disc recapture** in pts w/ **_ADD w/ Reduction_**
66
Distraction (pivot) splints and MORA are **more controversial than Stabilization splints**
## Footnote
**WHY???**
SE's
Long term changes in pos. of mandible/bite → dental issues later on + more
67
TMJ Splints: **Evidence**
## Footnote
**Main Takeaways:**
* Splint or no splint?
* probably DO NOT **NEED**
* Splint Tx w/ PT
* **Improvements shown**
* Splint alone?
* insuff. evidence
68
**TMJ Exercises for Control, Coordination, and Stabilization**
**\*use w/ pts with _muscular imbalance/incoordination and/or hypERmobility_**
* Mandibular Rhythmic Stabilization→ **see Rocabado 6x6**
* Controlled Rotation during Opening→ **see Rocabado 6x6**
* Resisted Lateral Deviation Out of Neutral→ **see pics for explanation**
* Isometric Contractions of Supra/Infra-hyoid Muscles→ **see pics for explanation**
69
TMJ Exercises for **Relaxation**
## Footnote
**\*MAKE SURE YOU DO ALL OF THESE!!!**
* Resisted Jaw Opening→ **see pics for explanation**
* Controlled Opening in Forward Trunk Flexion→ **see pics for explanation**
70
Condylar Remodeling Exercise Program
\*Rocabado 2006
6 Phases
* **Phase I→** to enhance **Mobility**
* painfree lateral deviation **away from side of pain of hypERmobility** w/ .5 inch piece of sx tubing resting bw incisors
* **Phase II→** for **controlled NMSK stabilization**
* _If Phase I was pain free,_ **a bite is incorporated during mvmt,** w/ pt relaxing upon return to midline (do not bite when returning to midline)
* **Phase III→** also for **controlled NMSK stabilization**
* _Maintain contraction (bite)_ during return to midline **(bite down whole time now)**
* **Phase IV-VI→** SAME AS ABOVE, **but for _protrusion_**
**_\*\*Recommended Dose:_ 6 reps every 2 hrs**
71
TMD **Clinical Wisdom…**
## Footnote
**2 Key Points:**
1. Pts w/ **post-traumatic TMD** or **recent onset dysfunction** or **largely posture-related**
1. generally progress quickly
2. Once mech. dysfunctions are corrected, emphasis of tx focuses on **maintenance of good posture and oral habits**
2. Pts w/ **chronic TMD of a NON-traumatic nature**
1. LESS likely to progress quickly
2. may be systemically hypERmobile w/ LESS than optimal connect tissue quality
3. **Important pt understands this and recognize the need for _long-term personal commitment_ to rehab and MSK fitness**
1. Axis II components
