1. Temporomandibular Disorders
Primary Care Conference
2/23/05

2. 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

3. 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

4. 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)

5. Anatomy of TM Joint

6. Anatomy of TM Joint

7. 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

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

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

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

11. 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

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

13. 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

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

15. 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

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

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

18. 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

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

20. 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

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

22. 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

23. 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

24. 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