Temporomandibular Disorders (TMD) & Facial Pain A Clinical View  Module 1  By Todd Henkelmann, PT, MS, CCTT UPMC Centers for Rehab Services

Introductory Remarks Today’s lecture and demonstrations will be primarily about the basics. Plan to pair up at times! [Suggest to bring with you: vinyl/non-latex disposable gloves, small tape measure] What questions would you like answered? If you delve deeper into the problem of TMD, you’ll discover a very complex and controversial disorder and perhaps the best way to approach it is K.I.S.S. A good place to start is the AAOP – aaop.org 3/8/14 T. Henkelmann, PT, MS, CCTT

What’s in a Name? “I’ve got TMJ” – Yes, you have two, one on each side… TMJ Disorder = TMD Orofacial Pain = OFP American Academy of Orofacial Pain Craniofacial Pain = CFP American Academy of Craniofacial Pain Craniomandibular Disorder = CMD European Academy of Craniomandibular Disorders 3/8/14 T. Henkelmann, PT, MS, CCTT

Conservative treatment of TMD This is our role as physical therapists; why you can successfully work in conjunction with dentists and oral surgeons, have a successful niche practice We need to not let 3rd party private payers prevent treatment of this devastating condition Medicare & Medicaid cover it’s treatment The TMJ Association – www.tmj.org, Terrie Cowley, President 3/8/14 T. Henkelmann, PT, MS, CCTT

Functional Anatomy Stomatognathic system Bony structures Temporal bone: mandibular fossa, external auditory meatus, articular eminence (a.k.a. tubercle), mastoid & styloid processes Mandible: condyle (head of the mandible), neck, coronoid process, ramus, angle, and body Zygoma, teeth Hyoid bone Upper cervical spine 3/8/14 T. Henkelmann, PT, MS, CCTT

3/8/14 T. Henkelmann, PT, MS, CCTT

Joint Classification: TMJ A synovial, condylar joint of 2 types: Ginglymus (hinge) – 0 to 25mm (+/- 2-3) for rotation Arthrodial (gliding) - 25-50mm for translation As a synovial joint, it has a joint capsule and synovial fluid. The bony surfaces are covered by fibrocartilage (not hyaline cartilage…too soft). Fibrocartilage remodels – why it can heal. 3/8/14 T. Henkelmann, PT, MS, CCTT

Joint Capsule and Ligaments Thin, synovial joint capsule, stabilized by the following ligaments: Medial: sphenomandibular lig. – suspends mandible during wide opening, stylomandibular lig. – acts as a stop to extreme opening Lateral: Lateral (temporomandibular) lig. – prevents excessive A-P and lateral movements TMJ is stabilized primarily by ligaments and convex on concave relationships above & below by the bi-concave articular disc 3/8/14 T. Henkelmann, PT, MS, CCTT

The Disc (Meniscus) Fibrocartilagenous structure – areas of collagen fibers, loose connective tissue, blood vessels, and nerve fibers Function of disc is to act as shock absorber, improve congruency, and enhance joint stability during movement 3/8/14 T. Henkelmann, PT, MS, CCTT

Attached to capsule, poles of the condyle via collateral ligs Attached to capsule, poles of the condyle via collateral ligs., and superior belly of lateral pterygoid muscle. It divides the joint into 2 distinct cavities Posterior attachment (also called ‘retrodiscal tissue’) has a superior (elastic) and inferior (vascular & neural) stratum that serve to keep disc from moving too far anteriorly 3/8/14 T. Henkelmann, PT, MS, CCTT

3/8/14 T. Henkelmann, PT, MS, CCTT

Cervical spine Forward head posture: Loss of cervical lordosis Backward bent OA Effects orientation of TMJ Leads to early DDD and DJD Can cause neural impingement! 3/8/14 T. Henkelmann, PT, MS, CCTT

3/8/14 T. Henkelmann, PT, MS, CCTT

Neurology Trigeminal nerve (CN V) is the principle nerve supplying the structures of the TMJ Ophthalmic branch (V1) – sensory to upper face, eye, nose, frontal sinuses, dura Maxillary branch (V2) – sensory to cheek, upper lip, lower sinuses, maxillary teeth, dura Mandibular branch (V3) – sensory to lower face, mandibular teeth, chin & jaw (but not angle of jaw =C2 & C3); motor to muscles of mastication 3/8/14 T. Henkelmann, PT, MS, CCTT

Location of C2-C3 dermatomes 3/8/14 T. Henkelmann, PT, MS, CCTT

Trigeminocervical nucleus 3/8/14 T. Henkelmann, PT, MS, CCTT

Time for everyone to stand up and stretch back! 3/8/14 T. Henkelmann, PT, MS, CCTT

Overview of TMD Evaluation History Cervical screen Posture Active TMJ ROM Strength – cervical, mandible Specific TMJ tests – palpation & loading Special tests: sensory exam, jaw jerk, facial nerve Muscle palpation Outcome measure 3/8/14 T. Henkelmann, PT, MS, CCTT

1. History When did it start, what were you doing? Gradual or sudden onset What tests have been done? Panorex x-ray, CT scan, MRI – provide “clues” Have you suffered a blow to the jaw? Volleyball, soccer ball, fist, MVA Do you have a click/pop now or in past? Was there period of prolonged immobilization? Mouth wired shut? Could cause capsular restriction 3/8/14 T. Henkelmann, PT, MS, CCTT

What makes the pain worse? What makes the pain better? “What do you do to get any relief?” “What can’t you do because of this problem?” Have you worn braces and for how long? Ask about parafunctional habits Start the education process here 3/8/14 T. Henkelmann, PT, MS, CCTT

Parafunctional Habits Clenching teeth (daytime) – teeth touching at rest? Bruxing at night Chewing gum, fingernails, ice Habitually chewing hard-to-chew items Hand rest on jaw Holding phone with shoulder against head Tongue thrusting High stress level – we all have stress, ask if worse in the past 6 months Prone sleep position 3/8/14 T. Henkelmann, PT, MS, CCTT

2. Cervical Screen Take AROM – Rot, SB, Flex, Ext Alar & transverse ligament tests – See next slide Spurling’s test Cervical compression & distraction tests I do not do anything else, unless there is a reason to If the patient has radicular symptoms, then you need to recognize that you’re dealing with 2 different problems – not part of TMD per se 3/8/14 T. Henkelmann, PT, MS, CCTT

3/8/14 T. Henkelmann, PT, MS, CCTT

3. Posture First thing: just observe head, neck & face at rest Look for overt asymmetry or swollen area Before you say anything about posture, look at head/neck posture from the side Minimal, moderate, severe forward head? Are they missing teeth? Does bite come together evenly? Malocclusion vs. unilateral joint effusion vs. unilateral muscle spasm 3/8/14 T. Henkelmann, PT, MS, CCTT

4. AROM of TMJ Mandible depression: 0mm to 40-60mm (adult) Measure R incisors, unless unavailable Side glide (aka, lateral excursion): 0mm to 8mm (I don’t usually measure) Protrusion: 0mm to 6-9mm (I don’t usually measure) Retrusion (aka, retraction): Not measured Watch for deviation or deflection with depression & protrusion – can confirm or deny disc displacement 3/8/14 T. Henkelmann, PT, MS, CCTT

TMJ Muscle Actions Depression (opening): Lateral Pterygoid – inferior belly, Anterior Digastric, and gravity Elevation (closing): Temporalis, Masseter, Medial Pterygoid Lateral Excursion: To Right : R Lat. Pterygoid, L med. Pterygoid, to Left: L Lat. Pterygoid, R med. Pterygoid Protrusion: Lat. Pterygoids – inferior belly, acting bilaterally, Med. Pterygoids – indirect 3/8/14 T. Henkelmann, PT, MS, CCTT

5. Strength Testing Manual muscle tests of: Cervical SB, Rot, Flex, Ext Mandible SB, Depression, & elevation Note: It is not common to see weakness, in my experience. Roughly 90% of all orofacial pain patients I see don’t test (+) for weakness. Don’t know that MMT is the best way to test strength in this population 3/8/14 T. Henkelmann, PT, MS, CCTT

6. Specific TMJ tests Force biting test Lateral condyle palpation test Teeth together, mouth opened Retrussive overpressure test External auditory meatus test 3/8/14 T. Henkelmann, PT, MS, CCTT

7. Special Tests Sensory testing - I consider this crucial, yet doctors and many therapists don’t take the time… Test V1, V2, V3, & C2 Pain sensation, light touch sensation Slightly diminished can be caused by mm. spasm, greater involvement in V2, V3 may mean a tumor Jaw Jerk reflex Indicative of upper motor neuron condition, but is not diagnostic Facial nerve screen – go through all facial mov’ts. 3/8/14 T. Henkelmann, PT, MS, CCTT

8. Muscle Palpation Internally: masseter, medial & lateral pterygoids Externally: temporalis, digastric, sternocleidomastoid (SCM), suboccipitals, upper trapezius Others for consideration: zygomaticus, buccinator, tensor veli palatini, frontalis 3/8/14 T. Henkelmann, PT, MS, CCTT

3/8/14 T. Henkelmann, PT, MS, CCTT

3/8/14 T. Henkelmann, PT, MS, CCTT

3/8/14 T. Henkelmann, PT, MS, CCTT

3/8/14 T. Henkelmann, PT, MS, CCTT

Outcome Measures TMD Disability Index Questionnaire (TDI) Similar to Oswestry or Neck Disability Index Used by Joshua Cleland, et al in research studies (see bibliography) Published by a chiropractor and has not undergone validation studies Scoring method is on last page of handout It’s not perfect, but it’s all I have to recommend at this time For Medicare: I am also using AMPAC 4 3/8/14 T. Henkelmann, PT, MS, CCTT

Take a Break Stand up and stretch backward Relax your jaw – were your teeth touching? How’s your posture? Are you setting a good example for your patients?  3/8/14 T. Henkelmann, PT, MS, CCTT

3/8/14 T. Henkelmann, PT, MS, CCTT