TMD Exam 1 Flashcards
(148 cards)
1
Q
What is an immediate side shift
A
NO CONDYLAR TRANSLATION
2
Q
What is a PROGRESSIVE side shift
A
Increases as the condyle translates
3
Q
What is a progressive and immediate side shift limited by?
A
MEDIAL WALL OF TMJ
4
Q
What are all the MOMs innervated by
A
V3
5
Q
What is the posterior digastric innervated by
A
CN 7
6
Q
what are the MOMs
A
masseter, temporalis, medial pterygoid, lateral pterygoid
7
Q
What type of joint is the TMJ?
A
ginglymoarthrodial (hinge and gliding)
8
Q
what innervates the TMJ
A
auriculotemporal nerve (post and lateral TMJ)
deep temporal nerve (anterior TMJ)
branches off V3
9
Q
What kind of joint is the TMJ
A
loaded joint
knees, hips, are loaded joints
finger joints are unloaded
10
Q
The glenoid fossa and condyle are covered with
A
FIBROCARTILAGE – not hyaline cartilage
11
Q
what are the cardinal signs and symptoms of TMD
A
masseter muscle pain TMJ pain temporalis pain mouth opening limitations TMJ sounds
PAIN is the biggest reason why people seek treatment
12
Q
when is TMD most often reported
A
20-40s
13
Q
what percent of population has at least ONE TMD symptom
A
33%
14
Q
Do TMD symptoms fluctuate with time?
A
Yes. they correlate with PARAFUNCTIONAL habits – clenching, grinding, masticatory muscle tension
15
Q
TMD PTs with POOR psychosocial adaptation…
A
have significantly GREATER symptom improvement when dentist’s therapy is combined with cognitive-behaviorl intervention
16
Q
What are some other things TMD canc ause
A
non-otologic otalgia dizziness tinnitus neck pain toothache
17
Q
TMD can CONTRIBUTE TO (not cause)
A
migraine and tension headaches
muscle pain in region
many other types of pain
18
Q
Females > Males
A
Females have more TMD issues
their symptoms are less likely to resolve than a males
19
Q
TMD is a ____ disorder
A
multifactorial
To treat, you can do many things:
- -Treat muscles and cervical region
- -Provide relaxation, stress management, cognitive-behavioral therapy, psychosocial therapy
- -Improve occlusal stability (ortho, prosth)
- -Decrease TMJ inflammatory mediators
- -Medication
- -Self management strategies
20
Q
Generally recommend TMD therapy if PT has significant
A
Temporal headaches Preauricular pain Jaw pain TMJ catching or locking Loud TMJ noises Restricted opening Difficulty eating, due to TMD Non-otologic otalgia, due to TMD
21
Q
Primary Diagnosis
A
This is the diagnosis that causes the pain
it is most responsible for the PT’s CC
-Can be TMD origin or non-TMD (pulpal, sinus, cervical headache)
22
Q
Secondary, Tertiary diagnosis
A
these also contribute to PT’s TMD BUT less so
If the PT has some underlying disorder that is contributing to pain, you don’t call that a secondary diagnosis… that is now a CONTRIBUTING FACTOR
23
Q
Perpetuating contributing factors
A
these do not allow the disorder to resolved
- -night time parafunctional habits
- -gum chewing
- -stress
- -neck pain
- -daytime clenching
24
Q
What are the patterns of symptoms?
A
Time of day? – worse when i wake up – worse during the day
Location pattern – it starts at my neck and moves to my jaw
25
What is secondary gain
the PT BENEFITS from having the disorder
they don't want to get better
usually rarely seen in TMD patients
26
What is the most common pain quality for TMD
PAD:
pressure
ache
dull
27
What do you suspect if the PT has throbbing pain
migraine
| reffered pain from tooth
28
What are the parameters for pain
intensity
frequency
duration
29
What are some NON-MASTICATORY contributors to TMD
Cervical pain
PTSD
Fibromyalgia
**If the PT has one of the above 3, they do not respond well to TMD therapy
30
When a PT says they cannot open wide...
think TMJ or muscle disorder
31
if the inabilty to open wide is INTERMITTENT with RAPID ONSET
With rapid onset and resolution, probably acute disc displacement without reduction
32
If inability to open is intermitten with SLOW ONSET
, probably myofascial pain and/or TMJ inflammation
33
How can you identify limiting source?
ask pt to stretch wider and see what causes the pain
34
TMJ dislocation (inability to close)
45 mm or greater
35
TMJ disc displacement WITH REDUCTION
10-35 mm
36
Giant Cell Temporal Arteritis
mimics mild TMD symptoms
PT is > 50
Reduced blood flow to head and neck - muscle tires out fast
37
what are the minimal normal openings
40 mm opening
7mm lateral
6mm protrusive
38
TMJ Noises - pops and clicks
Very prevalent among TMD and normal population
| Commonly related to disc displacement with reduction
39
TMJ noises - crepitus/grating/crackling
Roughness on articular surface(s)
| Could be secondary to osteoarthritis, chronic DD WITHOUT reduction
40
What are the initial TMD palpations
```
Temporalis
TMJ
Masseter
Carotid arteries
Thyroid
Suboccipiatl region
```
41
PT presents with tooth pain --
think it might be referred pain from a masticatory structure -- masseter comomonly invovled
Don't do ENDO if the pain is not eliminated even after you anesthetize the tooth
if you see EXCESSIVE forces on a tooth or a few teeth -- think parafunctional etiology
42
How do you palpate more intensely
find and load trigger points or nodules of spot tenderness
- -feels like firm knots within muscle and more tender than the surrounding muscle
- apply pressure to the nodules
43
What kind of radiographic change do you see in a TMD PT?
Begins on condyle’s lateral pole
| Primarily caused by TMJ inflammation
44
How far behind do radiographic changes lag in terms of clinical findings
Radiographic changes lag by as much as 6 months behind clinical findings
Therefore TMD treatment generally directed towards symptoms, not toward radiographic findings
45
How do you view the soft tissue part of TMJ
MRI
| You are looking to see the disc position whent he mouth is opened as wide as possible and when mouth is closed
46
What do you use a plain radiogrpah for
screen for gross changes
Transcranial can be made with standard dental X-ray unit
47
Why is a pano bad
Lateral pole superimposed within condyle image
| So cannot view early condylar demineralization
48
What provides TRUE lateral projection
Axially corrected sagittal tomography
Lets you
Can view osseous changes of the articular surface
Evaluate condylar translation
49
What is a CT used for
Sectional images of TMJ and region
Used for viewing TMJ ankylosis, neoplastic conditions, anomalies, etc.
Used to fabricate 3-D stereolithic model for better comprehending surgery and to fabricate custom TMJ implant
50
CBCT
Currently only provides view of hard-tissues
High quality TMJ images with low radiation from comparatively small inexpensive unit
51
Does having disc displacement mean you ahve TMD?
NO
9 to 31% of asymptomatic TMJs have a disc displacement
52
What is arthrography
Displays contrast media injected into TMJ
Rarely used
Due to very painful and radiation exposure
53
What is high-res ultrasound?
Helps you see hard and soft tissue of TMJ
| BUT, it is inferior to CBCT and MRI
54
Primary diagnosis
Disorder most responsible for chief complaint
| If multiple structures reproduce chief complaint, the diagnosis for structure that most readily reproduces it
55
When do you see a pseudodisc
In healthy TMJ, adaptive changes form pseudodisc in retrodiscal tissue
Comparatively withstands TMJ loading
TMJ DD with reduction
56
Click or Pop
TMJ DD with reduction
57
In TMJ DD with Reduction
Does not usually progress unless patient has pain or intermittent locking
Noise does not respond as well to TMD therapy as pain responds
58
Acute disc displacement without reduction (closed lock)
Patient has sudden onset of limited opening (35 mm or less)
No increase in pain when closing into MI
Teeth occlude into normal position
Often have history of occurring intermittently
59
If the Limited opening is due to a lateral pterygoid myospasm
A significant increase in pain when closing into MI
| Teeth do not occlude into normal position
60
acute DD WITHOUT reduction can be due to two other things
Can be due to other stuff too:
Limited opening can be due to closure muscle (masseter muscle) disorder
Limited opening could be due to a lateral pterygoid myospasm
61
Chronic disc displacement without reduction
PTs have history of acute disc displacement without reduction (<35 mm opening) and gradually regain their opening (greater than 35 mm) over time (few weeks to months)
Opening increase due to stretching of the retrodiscal tissue, moving the disc anterior, enabling greater condylar translation
Course crepitus is most common noise
62
What is the most common noise in chronic DD WITHOUT reduction
Course Crepitus/crackling
63
What is a dislocation (Subluxation)
Inability to close from maximal opening
64
How can you ID inflammatory TMJ diseases
Identified by TMJ palpation tenderness
TMJ Inflammation – the TMJ deteriorates – tender -- Synovitis, capsulitis
Polyarthritides - systemic condition
65
Osteoarthritis
Diagnosed when TMJ tender to palpation and hard-tissue imaging reveals bony changes
66
Primary Osteoarthritis
when due to TMJ overloading (e.g., clenching)
67
Secondary osteoarthritis
when due to direct trauma
68
Ankylosis
Very limited opening, generally not associated with pain
Can attempt to force mouth open wider to determine restrictive structure
Conservative TMD therapies not beneficial and patient will need TMJ surgery
Can be fibrous or bony
69
Masticatory Muscle Disorderss
```
Myofascial Pain (not myofacial)
Most common diagnosis for TMD pain
```
Aggravated by muscle use, stress, cold, etc.
If muscle is tender to palpation and none of the other muscle diagnoses better describe the patient’s condition, recommend be diagnosed as myofascial pain
Traditional TMD therapies have been shown to reduce masticatory myofascial pain
70
Myositis
Muscle inflammation due to spreading infection, external muscle trauma, or muscle strain
71
Myospasm - inferior lateral pterygoid
Inferior lateral pterygoid myospasm
Painful or unable to move mandible from partially translated position
Painful or unable to occlude teeth into MI
Contralateral canines usually first to occlude
Painful or unable to open wide
72
Myospasm - medial pterygoid
secondary to inferior alveolar nerve block
Stretch muscle to tolerance, 30 to 60 seconds
Ibuprofen and diazepam
If does not resolve, refer to physical therapist
73
Myofibrotic Contracture
Fibrous adhesions within muscle causes muscle to not be able to stretch to full length
Painless unless combined with other painful muscle disorder
If due to closure muscle
Causes limited opening
Practitioner can forcibly stretch mouth to determine if restriction from muscle or TMJ origin
74
How does myofibrotic contracture occur in the inferior lateral pterygoid muscle
From continuous wear of anterior positioning appliance
75
the most common TMD diagnosis among the general population
TMJ DD WITH REDUCTIOn
76
the most common muscle pain diagnosis
myofaSCial pain
77
most common TMJ pain diagnosis
TMJ Inflammation
78
Know the difference between the three contributing factors
Predisposing contributing factors
Initiating contributing factors
Perpetuating contributing factors
79
Predisposing Contributing Factors
Elements making individual more susceptible to develop TMD
Fingernail biting, nocturnal parafunctional habits, daytime parafunctional habits, etc.
Cause individuals to be predisposed to TMD
80
Initiating Contributing Factors
Event that caused TMD to develop
Trauma to jaw, placement of crown, etc.
Perform cursory TMD evaluation prior to dental treatment
Suggests patient’s TMD propensity
81
Perpetuating Contributing Factors
Directly or indirectly aggravate masticatory system and prevent TMD symptoms from resolving
82
Awakes with symptoms that rapidly resolve
| Whats the pattern?
Primary contributing factors occur at night, e.g., nocturnal parafunctional habits, stomach sleeping, etc
83
Awakes without symptoms and develop as day progresses
Whats the pattern
Primary contributing factors occur during day
Generally due to excessive muscle activity
Holding excessive tension in masticatory muscles
Performing excessive parafunctional activities
Generally increase when individual busy, frustrated, concentrating, e.g., using computer, driving, etc.
Daytime contributing factors under patient’s control to change
84
Awakes with symptoms and has symptoms throughout day
Suggests patient has daytime and nocturnal contributing factors
85
Contributing factyors are in a broad continuum
biological, behavioral, emotional, cognitive, social, and environmental
86
Biologic contributing factors
```
Neck pain
Poor posture
Malocclusion
Insomnia
Systemic diseases
Fibromyalgia
Rheumatoid arthritis
```
87
Behavioral contributing factors
```
Holding excessive tension in the masticatory muscles
Clenching
Fingernail biting
Stomach sleeping
Telephone cradling
```
88
Emotional contributing factors
```
Prolonged negative emotions
Depression
Worry
Anxiety
Anger
```
89
Cognitive Contributing Factors
Harmful thought processes or low cognitive skills
Negative self-statements
Poor reasoning skills making it difficult for patient to work with self-management or other instructions
90
Social Contributing Factors
```
Interactions with others that contribute to TMD symptoms or poor therapeutic response
Coworker difficulties
Lack of social support
Secondary gain
Benefit from disorder
Social modeling
We want to be like those we admire
```
91
Environmental Contributing Factors
Usually difficult to identify, so infrequently explored among TMD patients
Food additive causing migraine headaches
Seasonal affective disorder causing depression
92
TMD therapies generally ARE NOT
directed at physically changing diagnosis
For example, myofascial pain
INSTEAD, Directed at reducing perpetuating contributing factors
Body then able to heal itself
93
Social Contributing Factors
```
Interactions with others that contribute to TMD symptoms or poor therapeutic response
Coworker difficulties
Lack of social support
Secondary gain
Benefit from disorder
Social modeling
We want to be like those we admire
```
94
Environmental Contributing Factors
Usually difficult to identify, so infrequently explored among TMD patients
Food additive causing migraine headaches
Seasonal affective disorder causing depression
95
TMD therapies generally ARE NOT
directed at physically changing diagnosis
For example, myofascial pain
INSTEAD, Directed at reducing perpetuating contributing factors
Body then able to heal itself
96
Do most TMD PT's have chronic or acute Symptoms>
CHRONIC
Pain intensity fluctuates over time
Primarily treat by altering perpetuating contributing factors
97
If you try pharm intervention instead of targetting perpetuating factors... what will happen
the pharm intervention will take a LONG TIME.
You really want to AVOID using muscle relaxers
only recommend Try cyclcic antidepressants and NSAIDs on a NEEDED BASIS
98
An ACUTE TMD Condition presents as
a recent onset or flare up of chronic condition
99
Pharm intervention is more common with acute or chronic TMD?
ACUTE
| --short term use of relaxers and anti-inflammatorys
100
TMD can present secondary to trauma... what are the three ways
Direct trauma - blow to jaw
Indirect - jolt to jaw during whiplash
Microtrauma - chronic parafunctional habits
101
what can trauma cause
```
Muscle pain
TMJ pain
TMJ inflammation
Intracapsular changes
Decreased condylar growth
In child or adolescent
```
102
When do the symptoms of trauma present?
not until weeks or month after the traumatic event -- this is NOT ACUTE
103
When you evaluate a trauma PT, consider these things
bone fracture
referred odontogeni pain secondary to TOOTH TRAUMA
cervical disorder
psychological issues related to trauma
anything else that needs a referall (neuro or cognitive stuff)
104
What determines the treatment results for a trauma PT
trauma severity and perpetuating contributing factors
May range from no or minimal treatment to extensive multidisciplinary treatment
Results are quite variable and some patients do not improve
105
b.i.d stands for
twice daily
106
t.i.d
three times a day
107
q.i.d
four times a day
108
h.s
at bedtime
109
if the PT's pain is constantly a 3 or below..
800 mg ibuprofen, t.i.d.
110
if the pt's pain is above 3/10 constantly and primariyly muscle pain...
5 mg diazepam, 1-2 tabs h.s.
| ½ tab in morning and afternoon if significant daytime pain; warn about drowsiness
111
PT's pain is above a 3/10 constantly but due to TMJ inflammation
500 mg naproxen, 1 tablet b.i.d.
112
Above constant 6-7/10 and primarily TMJ inflammation
DexPak 6-Day Taperpak-naproxen regimen
113
In a healthy adult, can an anti-inflammatory and muscle relaxant be taken together?
YES.
If additional analgesic relief is needed, acetaminophen can be added
114
WHAT ARE THE two types of coronal incomplete tooth fractures
oblique
| vertical
115
when might you suggest a temporary soft appliance or an acrylic long term one
Just as other therapies for PT based on PT history
116
how can a NONPRONE pt end up with TMD
Excessive and/or prolonged forces during dental treatment may cause non-prone patient to develop TMD
117
You should always do a TMD eval -- to see if the pt will be more prone to TMD with routine treamtment.
what is included in a cursory TMD eval (prior to treatment)
Measure opening
Identify presence or history of TMJ noise
Palpate anterior region of temporalis and masseter muscles, TMJs, and lateral pterygoid areas
118
what are some POST-OP causes for TMD symptoms
referred pain from treated tooth
myositis from infected tooth
medial pterygoid myospasm from an IA injection
Muscle, TMJ and tooth pain - from inharmonious occlusion
Muscle and TMJ pain - from prolong stretching -- their night guard doesnt work as well
119
If you know a PT is TMD prone, what can you do during treatment to help them
Patient to ask for stretching breaks
Use bite block if patient finds it beneficial
Patient does not bite on it, but rests teeth on it
Make appointments for when symptoms are minimal
Balance all applied force with other hand
Patient may desire premedication and/or postoperative medication
maybe use N20
120
What if the TMD PT need an occlusal appliance, but also needs many restorations?
first give them a temporary appliance
then start doing restorative work on the arch that needs the LEAST amount of work.
then make the appliance for that arch once all the work is done
Pharmaceutically manage TMD symptom until a temporary or long-term occlusal appliance can be provided
121
Medial Pterygoid Muscle Pain
Most common postoperative disorder observed
Generally seen after multiple inferior alveolar injections
Symptoms
Significant medial pterygoid muscle pain and limited opening
122
how can you treat medial pterygoid muscle pain
self management therapies
stretch
if nothing works, refer to PT
123
Medial pterygoid myositis
Symptoms similar to medial pterygoid myospasm
Often due to bacterial infection as from extracting infected third molar
May be able to differentiate myositis from myospasm by fever and lymphadenopathy
Treat with antibiotics
Follow patients to ensure anticipated results are achieved
124
Inability to Close into Maximum Intercuspation (MI)
seen at the END of a dental procedure
--the lateral pterygoid is fatigured and can hold the condyle forward
--inflamed TMJ can cause condyle to stay fwd too
you can palpate to determine the source
125
What happenes if you make restorations that are NOT in harmomy with rest of occlusion?
TMJ pain
Muscle pain
TMJ noise
On ipsilateral and/or contralateral side
126
obstructive sleep apnea
some OSA pts can develop TMD from wearing an OSA appliance
the TMD usually starts right after they start wearing the appliance but it goes away within a year
the PTs need to exercise and stretch or can be provided wth other TMD therapies
127
Lateral Pterygoid Myospasm
EMERGENCY PTs usually present with this
PT cannot close into MI and cannot open wide
constnat pain and palpation tenderness at lateral pterygoid area
It can happen right after the dentist finishes working ont hem.. Or a day or two later
Lateral pterygoid in partially shortened state
Holds condyle in partially translated position
128
what are the 4 ways the condyle can be held FORWARD
Lateral pterygoid myospasm
TMJ inflammation*
Combination of both disorders
Tumor or other retrodiscal growth
129
How can you isolate the problem if there are 4 ways the condyle can be held forward?
palpation
if you stretch the lateral pterygoid and the pain goes away, you know its due to that
if symptoms get worse, you may cosider TMJ inflammatio
130
TMJ inflammation can causes
May force condyle forward
| Lateral pterygoid may contract to protect inflamed tissue
131
Messing with the mandible if the retrodsical tissue is inflamed is very...
PAINFUL
132
initail treatment is a tiered approach for TMD
self management
| lateral pterygoid stretches -- 6 stretches -- 6 times a day == 30 secs per stretch
133
Should you go ahead and change the PT's occlusion before doing self management?
NO.
| the TMD may resolve and then the PT will be infraoclusion
134
Acute TMJ DD WITHOUT REDUCTIOn
Sudden onset of limited opening (35 mm or less) caused by disc restricting condylar translation
Clicking, popping, and/or transient locking no longer present
135
what are the SIMILARTIES between lateral pteryoid myospasm and acute TMJ DD without reduction
Limited opening
| Contralateral and protrusive movements generally restricted
136
What are the DIFFERENCES between lateral pterygid myospasm and TMJ DD without reduction
No increase in pain when closing into MI
Teeth occlude as normal
A
137
Along with latereal pterygoid myospasm... wat else is usually present
TMJ pain
Inflammation
As mandible attempts to open wide, condyle pushes against disc
When retrodiscal tissue is stretched, pain and inflammatory mediators are released into synovial fluid
138
What is a predisposing factor to lateral pterygoid myospasm
Repeated retrodiscal tissue loading
Through muscle tension and parafunctional habits
Retrodiscal tissue thins and joint space narrows
TMD pain
139
Intermittent Acute TMJ Disc Displacement Without Reduction
Transient locking
| Daily pattern of its onset suggests when primary predisposing factors are occurring (night time day time etc)
140
You can Teach patient to release intermittent form by....
Place finger about ½ inch anterior to TMJ, press medial and posterior, and move mandible side to side
Consciously relax and massage the temporalis and masseter muscles*
Slide mandible as far as possible to contralateral side and then open maximally
141
always try to resolve intermittent TMD bc it can easily progress to
continuous form
142
if the PT presents with continous acute TMJ DD without reduction
practitioner can distract TMJ and attempt to move condyle forward into disc’s intermediate zone
if successful, the PT needs tow ear a temporary appliacne bc the condyle will tend to lock again when it is retruded off the disc
143
what can you use to make a temporary TMD appliacne
crown putty
Adjust appliance so it is retentive for mandibular teeth and has only approximately 1- to 2-mm-deep incisal indentations for maxillary teeth
tell PT to initially wear 24 hrs a day but then they can wear it only at night after the first 2-4 days
144
is unlocking the TMJ by dentist usually successful
NO.
Retrodiscal tissue can be stretched so the disc moves forward, allowing the condyle to fully translate, and the individual regains a normal opening
Stretching forces may unintentionally occur when the individual talks, laughs, puts food in the mouth
145
If surgical intervention chosen as first line of treatment,
the contributing factors that caused this to develop (e.g., parafunctional habits, etc.) often need to be dealt with or TMD symptoms are likely to return
146
TMJ Dislocation
Patients present with or relate history of momentary or prolonged inability to close mandible from maximal open position
Condyle in front of the articular eminence and posterior movement obstructed by articular eminence and/or disc
Unable to retrude condyle because of tension in closure muscles
147
how can you try and fix a TMJ displacement in your office
As patient attempts to open wider, bilaterally press down on molars, pull up on chin, and slowly slide the condyles inferior and posterior*
148
hwo can you help the PT prevent recurrence
Educate about mechanism and how limitation of opening will prevent its recurrence
Provide stabilization appliance worn at night
Patient chooses next preference
(maybe refer to surgeon)
