TemporomandibuTemporomandibular Disorderslar DisordersPrimary Care ConferencePrimary Care Conference

2/23/052/23/05

Clinic CaseClinic Case

JD is a 29 yo F new patient who presents JD is a 29 yo F new patient who presents for refill on Vicodin for TMJ. Has for refill on Vicodin for TMJ. Has headache, pain, decreased jaw ROM over headache, pain, decreased jaw ROM over the past 1 1/2 yearsthe past 1 1/2 years

PMH: PMH: TMJ syndrome, gastritis/dyspepsia, depressionTMJ syndrome, gastritis/dyspepsia, depression

SH:SH: 3 children (8,4,3), marital discord (reconciled 3 children (8,4,3), marital discord (reconciled

after separation), verbal abuse, beginning after separation), verbal abuse, beginning career as realtorcareer as realtor

Definition of TMDDefinition of TMD

1996 NIH Consensus Conference:1996 NIH Consensus Conference:

A collection of medical and dental A collection of medical and dental conditions affecting the TMJ and/or the conditions affecting the TMJ and/or the muscles of mastication as well as muscles of mastication as well as contiguous tissue componentscontiguous tissue components

Definition of TMDDefinition of TMD

3 Main Categories;3 Main Categories; Myofascial pain (jaw muscles, neck Myofascial pain (jaw muscles, neck

muscles, shoulder muscles)muscles, shoulder muscles)

Internal derangement of the joint Internal derangement of the joint (dislocated joint, displaced disk, (dislocated joint, displaced disk, condylar trauma)condylar trauma)

Degenerative joint disease (OA, RA)Degenerative joint disease (OA, RA)

Anatomy of TM JointAnatomy of TM Joint

Anatomy of TM JointAnatomy of TM Joint

EpidemiologyEpidemiology

60-70% of general population have 60-70% of general population have one signone sign

Prevalence by self report: 5-15% Prevalence by self report: 5-15% (one source estimates 10% of (one source estimates 10% of women, 6% of men)women, 6% of men)

5% or less seek treatment 5% or less seek treatment Women>men 4:1 seek treatmentWomen>men 4:1 seek treatment

EpidemiologyEpidemiology

Early adulthood (ages 20-40)Early adulthood (ages 20-40)

Many TMD are self-limiting or Many TMD are self-limiting or fluctuate over time without fluctuate over time without progressionprogression

5% require surgery5% require surgery

EtiologyEtiology

MultifactorialMultifactorial Predisposing factorsPredisposing factors

Musculoskeletal Musculoskeletal Precipitating factorsPrecipitating factors

Trauma, clenching, grindingTrauma, clenching, grinding Perpetuating factorsPerpetuating factors

Chronic MSK dysfunction, psychogenicChronic MSK dysfunction, psychogenic

Clinical ManifestationsClinical Manifestations

PainPain Joint clickingJoint clicking Restricted jaw range of motionRestricted jaw range of motion Other symptoms are not specific to Other symptoms are not specific to

TMD:TMD: Headache, ear ache, neck and shoulder Headache, ear ache, neck and shoulder

painpain

Diagnosis: HistoryDiagnosis: History

PainPain Worsens with jaw useWorsens with jaw use Centered anterior to tragusCentered anterior to tragus Radiates to ear, temple, cheek, Radiates to ear, temple, cheek,

mandiblemandible Clicking/joint noiseClicking/joint noise Restricted ROMRestricted ROM

Tight feeling, catching, lockingTight feeling, catching, locking

Diagnosis: HistoryDiagnosis: History

HabitsHabits Clenching, grinding,cradling phone, Clenching, grinding,cradling phone,

back packsback packs SH: stressorsSH: stressors PMH: related disorders, trauma, PMH: related disorders, trauma,

dental problemsdental problems

Diagnosis: ExamDiagnosis: Exam Inspection:Inspection:

Facial asymmetry, posture, eccentric jaw Facial asymmetry, posture, eccentric jaw movementsmovements

ROM:ROM: Vertical (42-55 mm), lateral, protrusionVertical (42-55 mm), lateral, protrusion

Palpation:Palpation: Pre-auricular/anterior to tragus: joint mobility, Pre-auricular/anterior to tragus: joint mobility,

joint sounds (audible, palpable)joint sounds (audible, palpable) Masseter, temporalis, pterygoid, suprahyoid, Masseter, temporalis, pterygoid, suprahyoid,

SCM, cervicalSCM, cervical

Diagnosis: ExamDiagnosis: Exam

Oral function: occlusion, swallowing, Oral function: occlusion, swallowing, breathingbreathing

Postural/musculoskeletal:Postural/musculoskeletal: Forward head posture, systemic Forward head posture, systemic

hypermobility, joint problems elsewherehypermobility, joint problems elsewhere

Treatment GoalsTreatment Goals

Educate patient about TMD and self-Educate patient about TMD and self-managementmanagement

Reduce or eliminate pain and joint Reduce or eliminate pain and joint noisenoise

Improve functionImprove function Avoid unproven treatments that can Avoid unproven treatments that can

cause problemscause problems

Treatment: NIH Treatment: NIH guidelinesguidelines

Phase I: Conservative and ReversiblePhase I: Conservative and Reversible Patient educationPatient education Physical Therapy/Occupational TherapyPhysical Therapy/Occupational Therapy PsychotherapyPsychotherapy MedicationsMedications Bite splint/Occlusal SplintBite splint/Occlusal Splint Stress managementStress management

(Multidisciplinary approach)(Multidisciplinary approach)

Treatment: NIH Treatment: NIH guidelinesguidelines

Phase II: only after conservative Phase II: only after conservative measures exhaustedmeasures exhausted Surgery: arthrocentesis, arthroscopy, Surgery: arthrocentesis, arthroscopy,

open joint surgery, orthognathicopen joint surgery, orthognathic 5%5%

Treatment: Patient Treatment: Patient EducationEducation

About TMDAbout TMD Avoid painful activitiesAvoid painful activities Avoid clenching grindingAvoid clenching grinding Normal resting position of jawNormal resting position of jaw

Tongue up, teeth apart, lips togetherTongue up, teeth apart, lips together Moist heat/iceMoist heat/ice Gentle stretchingGentle stretching

Treatment: PT/OTTreatment: PT/OT

Patient assessmentPatient assessment Postural assessmentPostural assessment Patient educationPatient education Joint mobilization/manual therapyJoint mobilization/manual therapy Iontophoresis in selected cases Iontophoresis in selected cases Home therapy programHome therapy program

Treatment: Treatment: PharmacologicPharmacologic

NSAIDS-scheduled dosingNSAIDS-scheduled dosing Muscle relaxantsMuscle relaxants TricyclicsTricyclics OpioidsOpioids Steroid injectionSteroid injection Botox injectionBotox injection

*UW TMD clinic does not find muscle *UW TMD clinic does not find muscle relaxants very useful, does not use relaxants very useful, does not use tricyclics, rarely opioidstricyclics, rarely opioids

Treatment: Bite SplintTreatment: Bite Splint

Indications:Indications: AM symptoms, daytime clenching, teeth AM symptoms, daytime clenching, teeth

are wornare worn Worn only at nightWorn only at night Does not move jaw (not an anterior Does not move jaw (not an anterior

repositioning splint)repositioning splint)

Evidence Based MedicineEvidence Based Medicine

Limited Evidence, recommendedLimited Evidence, recommended NIH Phase I and II treatments discussed NIH Phase I and II treatments discussed

previouslypreviously Limited Evidence, needs further studyLimited Evidence, needs further study

AcupunctureAcupuncture EMG biofeedbackEMG biofeedback

Limited Evidence, not recommendedLimited Evidence, not recommended Occlusal adjustments that permanently alter a Occlusal adjustments that permanently alter a

patient’s occlusion (Grinding teeth down, patient’s occlusion (Grinding teeth down, anterior repositioning splints)anterior repositioning splints)

Alloplastic implantsAlloplastic implants

Local ResourceLocal Resource

UW TMD Clinic: 263-7502UW TMD Clinic: 263-7502 Lisa M. Dussault, OTR, John F. Doyle Lisa M. Dussault, OTR, John F. Doyle

DDSDDS Imaging as indicatedImaging as indicated Referral to specialists as indicatedReferral to specialists as indicated

Rehab Med psychologist, Rehab Med psychologist, Oral/craniofacial surgery, Oral/craniofacial surgery, speech/swallow, etcspeech/swallow, etc

Indications for ReferralIndications for Referral

Trauma to the face at onset of painTrauma to the face at onset of pain Joint noise PLUS dysfunctionJoint noise PLUS dysfunction Locking/catching of TMJLocking/catching of TMJ Limitation of opening/ROMLimitation of opening/ROM Pain in jaw and muscles of Pain in jaw and muscles of

mastication on awakeningmastication on awakening Orofacial pain aggravated by jaw Orofacial pain aggravated by jaw

functionfunction