Temporomandibular Disorders Primary Care Conference 2/23/05

Clinic Case JD is a 29 yo F new patient who presents for refill on Vicodin for TMJ. Has headache, pain, decreased jaw ROM over the past 1 1/2 years PMH: TMJ syndrome, gastritis/dyspepsia, depression SH: 3 children (8,4,3), marital discord (reconciled after separation), verbal abuse, beginning career as realtor

Definition of TMD 1996 NIH Consensus Conference: A collection of medical and dental conditions affecting the TMJ and/or the muscles of mastication as well as contiguous tissue components

Definition of TMD 3 Main Categories; Myofascial pain (jaw muscles, neck muscles, shoulder muscles) Internal derangement of the joint (dislocated joint, displaced disk, condylar trauma) Degenerative joint disease (OA, RA)

Anatomy of TM Joint

Anatomy of TM Joint

Epidemiology 60-70% of general population have one sign Prevalence by self report: 5-15% (one source estimates 10% of women, 6% of men) 5% or less seek treatment Women>men 4:1 seek treatment

Epidemiology Early adulthood (ages 20-40) Many TMD are self-limiting or fluctuate over time without progression 5% require surgery

Etiology Multifactorial Predisposing factors Precipitating factors Musculoskeletal Precipitating factors Trauma, clenching, grinding Perpetuating factors Chronic MSK dysfunction, psychogenic

Clinical Manifestations Pain Joint clicking Restricted jaw range of motion Other symptoms are not specific to TMD: Headache, ear ache, neck and shoulder pain

Diagnosis: History Pain Clicking/joint noise Restricted ROM Worsens with jaw use Centered anterior to tragus Radiates to ear, temple, cheek, mandible Clicking/joint noise Restricted ROM Tight feeling, catching, locking

Diagnosis: History Habits SH: stressors Clenching, grinding,cradling phone, back packs SH: stressors PMH: related disorders, trauma, dental problems

Diagnosis: Exam Inspection: ROM: Palpation: Facial asymmetry, posture, eccentric jaw movements ROM: Vertical (42-55 mm), lateral, protrusion Palpation: Pre-auricular/anterior to tragus: joint mobility, joint sounds (audible, palpable) Masseter, temporalis, pterygoid, suprahyoid, SCM, cervical

Diagnosis: Exam Oral function: occlusion, swallowing, breathing Postural/musculoskeletal: Forward head posture, systemic hypermobility, joint problems elsewhere

Treatment Goals Educate patient about TMD and self-management Reduce or eliminate pain and joint noise Improve function Avoid unproven treatments that can cause problems

Treatment: NIH guidelines Phase I: Conservative and Reversible Patient education Physical Therapy/Occupational Therapy Psychotherapy Medications Bite splint/Occlusal Splint Stress management (Multidisciplinary approach)

Treatment: NIH guidelines Phase II: only after conservative measures exhausted Surgery: arthrocentesis, arthroscopy, open joint surgery, orthognathic 5%

Treatment: Patient Education About TMD Avoid painful activities Avoid clenching grinding Normal resting position of jaw Tongue up, teeth apart, lips together Moist heat/ice Gentle stretching

Treatment: PT/OT Patient assessment Postural assessment Patient education Joint mobilization/manual therapy Iontophoresis in selected cases Home therapy program

Treatment: Pharmacologic NSAIDS-scheduled dosing Muscle relaxants Tricyclics Opioids Steroid injection Botox injection *UW TMD clinic does not find muscle relaxants very useful, does not use tricyclics, rarely opioids

Treatment: Bite Splint Indications: AM symptoms, daytime clenching, teeth are worn Worn only at night Does not move jaw (not an anterior repositioning splint)

Evidence Based Medicine Limited Evidence, recommended NIH Phase I and II treatments discussed previously Limited Evidence, needs further study Acupuncture EMG biofeedback Limited Evidence, not recommended Occlusal adjustments that permanently alter a patient’s occlusion (Grinding teeth down, anterior repositioning splints) Alloplastic implants

Local Resource UW TMD Clinic: 263-7502 Imaging as indicated Lisa M. Dussault, OTR, John F. Doyle DDS Imaging as indicated Referral to specialists as indicated Rehab Med psychologist, Oral/craniofacial surgery, speech/swallow, etc

Indications for Referral Trauma to the face at onset of pain Joint noise PLUS dysfunction Locking/catching of TMJ Limitation of opening/ROM Pain in jaw and muscles of mastication on awakening Orofacial pain aggravated by jaw function