Evaluation & Treatment of TMD Presented by: Christy Dauner, OTR Laurie Applebee, PT Susan Vaughn, MS, OTR

Learning Objectives Identify TMD risk factors and related diagnoses Differentiate joint and muscle disorders Understand goals of Occupational Therapy for TMD Understand OT treatments for TMD and muscle disorders Perform assessment and treatment approaches for TMD

Disorders of the TMJ Myofascial Dysfunction Internal Derangement Capsulitis Subluxation Arthritis

Risk Factors for TMD Trauma such as blow to the jaw, whiplash injuries, MVA, dental work, opening the mouth too wide or for too long, prolonged chewing Oral parafunctional habits such as clenching and bruxism that place continued strain on the masticatory system Malocclusion causes bite instability or functional interference during chewing that places postural strain on the masticatory system Stressful life events can trigger parafunctional habits and muscle guarding/tension Emotional factors such as depression or anxiety decreases the ability to cope with pain and can increase parafunctional habits.

TMJ Evaluation History & Symptoms (referred pain) Functional Limitations Tests, Measures & Palpation AROM (active/passive incisal opening, lateral excursion, and protrusion) PROM – scissor stretch TMJ Noise Muscle Palpation

Differential Diagnosis Scissor stretch test: if opens further - muscular, if not - internal derangement Clench test: bite down on tongue depressor for 10 – 15 seconds. Pain on same side – muscle, opposite side – joint “S” vs. “C” curve with opening

Occupational Therapy Goals for TMD Increase ROM to >40mm Decrease pain Teach joint protection (decrease parafunctional habits, limited opening) Improve function (eating, yawning, DDS visit tolerance, oral hygiene, talking, sleep, work) HEP independence Neutral posture (head on neck, jaw, scapular position, TUTA)

Myofascial Pain Dysfunction Most common disorder Referred muscle pain Muscle pain aggravated by jaw function or parafunction HA’s Tenderness of muscles w/o mechanical symptoms Loss of motion or painful motion

Myofascial Pain Dysfunction Caused by an underlying related disorder – malocclusion, arthritis, internal derangement, poor posture Education is key! – posture, parafunction, stress management Often chronic and cyclical Often a myofascial component with all diagnoses

Myofascial Dysfunction Myofascial contributors may include: * Lateral pterygoid * Medial pterygoid * Temporalis * Masseter * Digastrics * Muscles of the cervical spine

Lateral Pterygoid Origin: Lateral Pterygoid Plate of Sphenoid Insertion: Condylar Neck, Ramus of Mandible and Disc

TMJ Muscles – Lateral Pterygoid #1 myofascial source of pain Due to attachment to disc it can cause disc and jaw to be unable to return to normal resting position and cause clicking or popping. Malocclusion of teeth/missing teeth

Referral pattern – zygomatic arch, TMJ

Medial Pterygoid Origin: Inner Surface of Lateral Pterygoid Plate Insertion: Ramus of Mandible by the Angle

TMJ Muscles – Medial Pterygoid Stuffiness in ear Swallowing difficulty as restriction in protrusion of jaw

Referral pattern – posterior mandible, mouth, below and behind TMJ including internal ear – not teeth

Temporalis Origin: Temporal Fascia, Superior to Zygomatic Arch Insertion: Coronoid Process of Mandible

TMJ Muscles - Temporalis Significant postural muscle (the only time it isn’t working is when you’re lying supine) Perpetual clenching

Referral pattern – lower jaw, molar teeth and gum, maxilla, lower portion of mandible, temple eyebrow and external ear

Masseter Origin: Zygomatic Arch Insertion: Mandibular Angle and Ramus

TMJ Muscles - Masseter “Sinusitis”

Referral pattern - temple, along eyebrow, behind eye or upper teeth

Digastrics Origin: Mastoid Notch (posterior), Symphysis of Mandible (anterior) Insertion: Join by a Common Tendon to the Hyoid Bone

TMJ Muscles - Digastrics Rarely in spasm due to forward head posture (stretch weakness)

Referral pattern – behind mandible toward back of ear, lower incisors

Cervical Spine Muscles Form stable base for TMJ on which to work Poor posture – condyle rotates backward – change of biomechanics Referral pattern from the cervical spine-Temporal Headaches, SCM Assess for tension in upper traps, scalenes, and SCM

Parafunctional Behaviors Gum/candy chewing (chewing limited to 15 – 20 minutes/day!) – including chewing on one side Clenching/bruxing/grinding Leaning on chin/jaw Biting nails, pencils, cheeks Sleep position Caffeine use Musical instruments Mouth breathing Phone cradling

Treatment – Myofascial Pain Dysfunction Modalities: US - 1.0 – 1.2 w/cm2, 3 MHz, x5 minutes to joint or muscle, heat, electrical stimulation Manual Therapy – joint mobs/distraction, MFR – including upper cervical region HEP/Lifestyle changes Tongue positioning (TUTA) Self-joint distraction &/or MFR Eliminating parafunctional behaviors Postural instruction Conjunction with splint therapy &/or counseling (Referral to psychology for CBT as needed for stress and anxiety management)

Resting Joint Position Capsule – anterior/posterior only

Normal Joint Motion

Internal Derangement

Disc Disorder Internal Derangement Disc held in place by collateral ligaments and posterior ligament, w/ movement dictated by lateral pterygoid Click, pop, lock Pain at joint “S” shaped opening/closing to reposition jaw Eye pain History of trauma

Treatment – Internal Derangement Modalities: Iontophoresis, electrical stimulation, cold – ice massage Manual therapy – Joint distraction Joint protection techniques: Limit motion to no noise, soft food diet or chewing behaviors Home exercise instruction Change parafunctional behaviors Self joint distraction techniques Tongue positioning for relaxation (TUTA) Postural instruction and controlled opening/neuromuscular re-education

Treatment - Other Capsulitis Subluxation Usually a result of another disorder unless post surgery Modalities, MT and HEP Subluxation Excess opening (>40 mm) Usually a component of myofascial pain dysfunction, and treated as this, with addition of stab exercises and controlled opening

Treatment - Other Arthritis phono/iontophoresis, E-stim) Generalized joint pain and inflammation Usually seen in conjunction w/ other Dx Joint protection, rest Stretching, therapeutic exercise Modalities (cold vs. heat, pulsed US, phono/iontophoresis, E-stim)

Intervention: Dentist Assess occlusion Parafunctions of clenching/bruxing Malocclusions Pressure on back teeth activate temporalis an superior head of lateral pterygoid, anterior teeth activate masseters

Lab - Evaluation AROM (Therabite) Active Incisal Opening (Normal 40-60 mm) Passive Incisal Opening (Normal 42-62 mm) Lateral Excursion (Normal >7 mm) Protrusion (Normal > 7 mm)

Lab - Evaluation TMJ Palpation/Observation Quality of Motion: Smooth/Rigid/Jerky/Guarded/Fasciculation/ Thrusting TMJ Noise: Opening Click, Closing Click, Reproducible Visually Assess Opening (S or C Shaped Curve)

Lab Muscle Palpation Medial Pterygoid (elevation, protrusion, and lateral deviation to opposite side) Place index finer on muscle at inside of bottom teeth in mouth. Place opposite thumb under jaw line below ear. Apply pressure to muscle as if to touch finger and thumb. Move along gum line until reach incisors in front. Hold until relaxes 1-2X/day Lateral Pterygoid (elevation, protrusion, and lateral deviation to opposite side) Place index finger inside mouth, under cheek bone. Point finger up and towards opposite eye. Apply pressure to muscle until it relaxes. To check positioning of finger, actively move jaw in opposite direction and muscle will contract under finger. Hold until relaxes 1-2X/day

Lab Manual Therapy Trigger point release Joint distraction Place thumb on back, bottom molar and wrap fingers under jaw Press down as you lift on jaw in scooping motion Do NOT pull jaw forward

Thank You Feel free to contact Christy at 952-908-2567 or at Christyd@pdrclinics.com with questions. PDR Clinic Locations: Edina, Burnsville, Maplewood, Burnsville, Chanhassen Specializing in the treatment of chronic neck, back and TMJ pain.