Temporomandibular Disorders Primary Care Conference
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Temporomandibular Disorders Primary Care Conference

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Temporomandibular Disorders Primary Care Conference Temporomandibular Disorders Primary Care Conference Presentation Transcript

  • 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
      • 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
      • 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
      • Clenching, grinding,cradling phone, back packs
    • SH: stressors
    • PMH: related disorders, trauma, dental problems
  • Diagnosis: Exam
    • Inspection:
      • 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
      • 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