Temporomandibular joint Disorders Hello, my name is Jessica Shipley from here at the Fayette campus and I was assigned temporomandibular joint disorders, also know as TMD from my acute condition presentation. Jessica Shipley, RN BSN PHRN

TMD/TMJ disorder True etiology is not understood Possibly due to improper jaw positioning Ultimately- and issue with the synovial joint Patients who present with symptoms of head, neck, face, and jaw pain may represent temporomandibular joint disorder. People often refer to this as “TMJ” however TMJ stands for temporomandibular joint, so if we get technical we all have TMJ.. But 10 million people in the US actually have TMD, this is a disorder of that temporomandibular joint. Originally these disorders were believed to have been due to malocclusions or improper jaw position for any of many different reasons. The true etiology of TMD is not understood. This joint is a synovial joint essentially connecting the jaw to the skull. You can find this joint by placing you fingers infront of both ears.

Rotation and translation are the two motions whereby the condyle rotates in the fossa, all of this is basically lubricated with by that synovial joint with a disk, making movement smooth. When TMD occurs there is alterations in that smooth working, well oiled hinge.

Nocturnal jaw clenching/teeth grinding Head and cervical posture Pathogenesis Alterations in the TMJ Joint trauma Nocturnal jaw clenching/teeth grinding Head and cervical posture Pain perception The TMJ gets inflammed and irritated if there is any alterations in its hinge-like-action. Pathogenesis and development of the disorder can be from joint trauma, behavioral factors such as nocturnal jaw clenching or teeth grinding, and head and cervical posture.. Trauma can lead to intraarticular inflammation, this swelling in the joint causes friction and ultimately irritating that area. It is also believed that certain people suffer from associated pain of this disorder due to their own personal pain thresholds. Its been seen that females at the low estrogen phase of menstration are more likely to suffer from chronic TMD associated pain at this time.

Clinical Manifestations Localized facial pain to area of mandible Often unilateral, can be bilateral symptoms Pain may radiate to ears, neck, shoulders, head Asymmetric jaw movements Jaw clicking, grinding, popping, locking Female to male ratio is 9:1 Many people present with a variety of symptoms and when it comes to disorders of the TMJ it is difficult to pinpoint what caused these problems. The most common symptom is a localized facial pain, this pain is located unilaterally but like I said every case is personalized and bilateral symptoms occur as well. Pain is localized in the area of the mandible and musculature surrounding is tender to palpation. Pain can radiate and this is why we will see many patients initially present with a nagging lingering headache that is worse in the morning. A thorough assessment should be completed and often if this is associated with TMD patients will admit to jaw fatigue. Patients may also complain of aching shoulders, neck, or an inner ear ache and tinnitus. Asymmetric jaw movements can help with diagnosing some patients but this sign is not always present. If a disorder is more progressed and the jaw locks frequently you may see asymmetric jaw movements. The second most common clinical manifestation behind facial pain are the clicks, pops, grinding, and locking of that joint. Sometimes this can be heard by the provider assessing but most often times it is felt during examination. TMD is most common in women and peaks in occurance in people from 20-50 years old.

Clinical Manifestations Physical Exam Asssesing TMJ Testing mandibular ROM Palpation and auscultation Dentition exam Everyone locate your tragus which is the cartilage in the center of your ear, place your index and middle fingers directly beside your tragus like seen in the picture, now open and close your mouth. Move your jaw laterally several times all while keeping your fingers directly on the joint. What you feel bulging is the condyle, if a pop or click occurs here its safe to say that the disk may be displaced and making movement of the condyle in the fossa a rough rigid movement. Now that we know how to locate it when youre assessing a patient you should have them in a sitting up and looking forward, it is important to avoid extension to flexion of the head- so we want to keep them as neutral as possible. A normal mandibular opening is generally 40-43 mm and it is measured by having the patient open their mouth as wide as they can, even if it causes pain.. If needed the examiner can provide assistance by gently stretching the pts jaw.. We will not try this on each other today as I’m sure that’s invasion of your personal space for a lot of us. We also will assess lateral excursions, and this is just the pts ability to move the jaw from far left and then to far right. Along with palpaton we also can auscultate that joint, pts early in the disorder may only have joint sounds that can be heard with a stethoscope. Also a dentition exam in important, especially when ruling out differentials because it is common that tooth abscesses and decay can mimic TMD symptomts.

Diagnostic Testing No workup unless suspicious Panoramic radiography MRI CT If a patient with TMD is suspected to have polyarticular inflammatory joint disease then a full workout should be ordered and a consult is most likely indicated. However if pain is tolerable and moderate there may be nothing done, panoramic radiograph is helpful in identifying degenerative changes in the TMJ, this will aid in the diagnosis of osteoarthritis or rheumatoid arthritis, which we know can be two of the many causes of TMJ disorders. MRI’s offer the visualization of surrounding tissues and that along with CT scans are only used if treatment of pain relief has failed.

Differentials Cluster headaches Dental infections Mandible fracture Trigeminal neuralgia Giant Red Cell Arteritis, or temporal arteritis TMD is difficult to diagnose due to the complicated anatomy of the jaw/neck/and head, and the vague and different symptoms each case presents with. It is important to play by process of elimination and evaluate these patients for these common differentials. Cluster headaches can be ruled out if the patient has any crepitus in the condyle/fossa movement. Dental infections can be ruled out by a thorough dentition exam. A mandible fracture should be dealt with delicately and if suspected as a differential, an x-ray should be obtained prior to vigorous physical exam. Trigeminal neuralgia can be ruled out because it is often associated with a facial spasm or tic that is not present in TMJ disorders. An uncommon red flag that should be considered, especially in patients over 50 years old is giant red cel arteritis or temporal arteritis, common signs and symptoms of this are neck and shoulder discomfort, headaches, jaw claudication, and tenderness and visual disturbances. If this is suspected a stat MRI should be obtained.

Treatment Home care/remedies Physical therapy Relaxation techniques NSAIDS Narcotics Muscle relaxants Glucocorticosteriods Dental appliances Surgical intervention Treatment is started the least invasive way possible and our overall goal is for pain management and for the patient to be able to return to their normal daily living without being impacted by this disorder. Home care and remedies like jaw rest, avoiding gum chewing and yawning, making dietary modifications like avoiding chewy foods, and applying heat with gentle massage of the surrounding musculature. If home care is not successful physical therapy can be a second resort. Passive motion has shown to be successful and therapy can consist of manual manipulation, massage, and intense heat therapy. Relaxation techniques and stress relieving exercises may be helpful, because it has been showing that noctural grinding and jaw clenching is due to stress. If these treatments have failed NSAIDS for inflammation reduction can be initiated, always being careful of GI bleeding and GI upset. Narcotics and muscle relaxants can be used but are often placed on the back burner and for only extreme cases, for obvious reasons. Some physicians in severe cases will administer intraarticular steriod injections to reduce friction on the TMJ. Dental appliances are common, night time retainers and spacers are often a “go to” for chronic pain and morning jaw fatigue. Surgical intervention is the last resort and often times surgeons like for extreme cases to go 6 months with failed treatment before considering. Arthoscopy is often first then in rare cases a joint replacement is necessary.

Outcomes & Goals Pain Management! TMD is not curable, therefore our overall goal is pain management. All treatments effect all patients differently so we as providers must enter every case with an open mind to what might work. Treatment for uncurable disorders is almost trial and error, our outcome should be to make the patient comfortable and able to complete every day living with minimal affect from their disorder. Outcomes & Goals Pain Management!

References Goroll, A. H., & In Mulley, A. G. (2014). Primary care medicine: Office evaluation and management of the adult patient. Scrivani, S. J., & Mehta, N. R. (2015, May 6). Temporomandibular disorders in adults. Retrieved from http://www.uptodate.com/contents/temporomandibular-disorders-in- adults#H1144190418 Tsai, V. (2015, March 24). Temporomandibular Joint Syndrome: Background, Pathophysiology, Epidemiology. Retrieved from http://emedicine.medscape.com/ article/809598-overview Walczyńska-Dragon, K., Baron, S., Nitecka-Buchta, A., & Tkacz, E. (2014). Correlation between TMD and Cervical Spine Pain and Mobility: Is the Whole Body Balance TMJ Related? BioMed Research International, 2014, 1-7. doi:10.1155/2014/582414 Zakrzewska, J. M. (2013). Differential diagnosis of facial pain and guidelines for management. British Journal of Anaesthesia, 111(1), 95-104. doi:10.1093/bja/ aet125