Temporomandibular Disorders Primary Care Conference 2/23/05
Clinic Case <ul><li>JD is a 29 yo F new patient who presents for refill on Vicodin for TMJ. Has headache, pain, decreased ...
Definition of TMD <ul><li>1996 NIH Consensus Conference: </li></ul><ul><ul><li>A collection of medical and dental conditio...
Definition of TMD <ul><li>3 Main Categories; </li></ul><ul><ul><li>Myofascial pain (jaw muscles, neck muscles, shoulder mu...
Anatomy of TM Joint
Anatomy of TM Joint
Epidemiology <ul><li>60-70% of general population have one sign </li></ul><ul><li>Prevalence by self report: 5-15% (one so...
Epidemiology <ul><li>Early adulthood (ages 20-40) </li></ul><ul><li>Many TMD are self-limiting or fluctuate over time with...
Etiology <ul><li>Multifactorial </li></ul><ul><li>Predisposing factors </li></ul><ul><ul><li>Musculoskeletal  </li></ul></...
Clinical Manifestations <ul><li>Pain </li></ul><ul><li>Joint clicking </li></ul><ul><li>Restricted jaw range of motion </l...
Diagnosis: History <ul><li>Pain </li></ul><ul><ul><li>Worsens with jaw use </li></ul></ul><ul><ul><li>Centered anterior to...
Diagnosis: History <ul><li>Habits </li></ul><ul><ul><li>Clenching, grinding,cradling phone, back packs </li></ul></ul><ul>...
Diagnosis: Exam <ul><li>Inspection: </li></ul><ul><ul><li>Facial asymmetry, posture, eccentric jaw movements </li></ul></u...
Diagnosis: Exam <ul><li>Oral function: occlusion, swallowing, breathing </li></ul><ul><li>Postural/musculoskeletal: </li><...
Treatment Goals <ul><li>Educate patient about TMD and self-management </li></ul><ul><li>Reduce or eliminate pain and joint...
Treatment: NIH guidelines <ul><li>Phase I: Conservative and Reversible </li></ul><ul><ul><li>Patient education </li></ul><...
Treatment: NIH guidelines <ul><li>Phase II: only after conservative measures exhausted </li></ul><ul><ul><li>Surgery: arth...
Treatment: Patient Education <ul><li>About TMD </li></ul><ul><li>Avoid painful activities </li></ul><ul><li>Avoid clenchin...
Treatment: PT/OT <ul><li>Patient assessment </li></ul><ul><li>Postural assessment </li></ul><ul><li>Patient education </li...
Treatment: Pharmacologic <ul><li>NSAIDS-scheduled dosing </li></ul><ul><li>Muscle relaxants </li></ul><ul><li>Tricyclics <...
Treatment: Bite Splint <ul><li>Indications: </li></ul><ul><ul><li>AM symptoms, daytime clenching, teeth are worn </li></ul...
Evidence Based Medicine <ul><li>Limited Evidence, recommended </li></ul><ul><ul><li>NIH Phase I and II treatments discusse...
Local Resource <ul><li>UW TMD Clinic: 263-7502 </li></ul><ul><ul><li>Lisa M. Dussault, OTR, John F. Doyle DDS </li></ul></...
Indications for Referral <ul><li>Trauma to the face at onset of pain </li></ul><ul><li>Joint noise PLUS dysfunction </li><...
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Temporomandibular Disorders Primary Care Conference

  1. 1. Temporomandibular Disorders Primary Care Conference 2/23/05
  2. 2. Clinic Case <ul><li>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 </li></ul><ul><li>PMH: </li></ul><ul><ul><li>TMJ syndrome, gastritis/dyspepsia, depression </li></ul></ul><ul><li>SH: </li></ul><ul><ul><li>3 children (8,4,3), marital discord (reconciled after separation), verbal abuse, beginning career as realtor </li></ul></ul>
  3. 3. Definition of TMD <ul><li>1996 NIH Consensus Conference: </li></ul><ul><ul><li>A collection of medical and dental conditions affecting the TMJ and/or the muscles of mastication as well as contiguous tissue components </li></ul></ul>
  4. 4. Definition of TMD <ul><li>3 Main Categories; </li></ul><ul><ul><li>Myofascial pain (jaw muscles, neck muscles, shoulder muscles) </li></ul></ul><ul><ul><li>Internal derangement of the joint (dislocated joint, displaced disk, condylar trauma) </li></ul></ul><ul><ul><li>Degenerative joint disease (OA, RA) </li></ul></ul>
  5. 5. Anatomy of TM Joint
  6. 6. Anatomy of TM Joint
  7. 7. Epidemiology <ul><li>60-70% of general population have one sign </li></ul><ul><li>Prevalence by self report: 5-15% (one source estimates 10% of women, 6% of men) </li></ul><ul><li>5% or less seek treatment </li></ul><ul><li>Women>men 4:1 seek treatment </li></ul>
  8. 8. Epidemiology <ul><li>Early adulthood (ages 20-40) </li></ul><ul><li>Many TMD are self-limiting or fluctuate over time without progression </li></ul><ul><li>5% require surgery </li></ul>
  9. 9. Etiology <ul><li>Multifactorial </li></ul><ul><li>Predisposing factors </li></ul><ul><ul><li>Musculoskeletal </li></ul></ul><ul><li>Precipitating factors </li></ul><ul><ul><li>Trauma, clenching, grinding </li></ul></ul><ul><li>Perpetuating factors </li></ul><ul><ul><li>Chronic MSK dysfunction, psychogenic </li></ul></ul>
  10. 10. Clinical Manifestations <ul><li>Pain </li></ul><ul><li>Joint clicking </li></ul><ul><li>Restricted jaw range of motion </li></ul><ul><li>Other symptoms are not specific to TMD: </li></ul><ul><ul><li>Headache, ear ache, neck and shoulder pain </li></ul></ul>
  11. 11. Diagnosis: History <ul><li>Pain </li></ul><ul><ul><li>Worsens with jaw use </li></ul></ul><ul><ul><li>Centered anterior to tragus </li></ul></ul><ul><ul><li>Radiates to ear, temple, cheek, mandible </li></ul></ul><ul><li>Clicking/joint noise </li></ul><ul><li>Restricted ROM </li></ul><ul><ul><li>Tight feeling, catching, locking </li></ul></ul>
  12. 12. Diagnosis: History <ul><li>Habits </li></ul><ul><ul><li>Clenching, grinding,cradling phone, back packs </li></ul></ul><ul><li>SH: stressors </li></ul><ul><li>PMH: related disorders, trauma, dental problems </li></ul>
  13. 13. Diagnosis: Exam <ul><li>Inspection: </li></ul><ul><ul><li>Facial asymmetry, posture, eccentric jaw movements </li></ul></ul><ul><li>ROM: </li></ul><ul><ul><li>Vertical (42-55 mm), lateral, protrusion </li></ul></ul><ul><li>Palpation: </li></ul><ul><ul><li>Pre-auricular/anterior to tragus: joint mobility, joint sounds (audible, palpable) </li></ul></ul><ul><ul><li>Masseter, temporalis, pterygoid, suprahyoid, SCM, cervical </li></ul></ul>
  14. 14. Diagnosis: Exam <ul><li>Oral function: occlusion, swallowing, breathing </li></ul><ul><li>Postural/musculoskeletal: </li></ul><ul><ul><li>Forward head posture, systemic hypermobility, joint problems elsewhere </li></ul></ul>
  15. 15. Treatment Goals <ul><li>Educate patient about TMD and self-management </li></ul><ul><li>Reduce or eliminate pain and joint noise </li></ul><ul><li>Improve function </li></ul><ul><li>Avoid unproven treatments that can cause problems </li></ul>
  16. 16. Treatment: NIH guidelines <ul><li>Phase I: Conservative and Reversible </li></ul><ul><ul><li>Patient education </li></ul></ul><ul><ul><li>Physical Therapy/Occupational Therapy </li></ul></ul><ul><ul><li>Psychotherapy </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Bite splint/Occlusal Splint </li></ul></ul><ul><ul><li>Stress management </li></ul></ul><ul><li>(Multidisciplinary approach) </li></ul>
  17. 17. Treatment: NIH guidelines <ul><li>Phase II: only after conservative measures exhausted </li></ul><ul><ul><li>Surgery: arthrocentesis, arthroscopy, open joint surgery, orthognathic </li></ul></ul><ul><ul><li>5% </li></ul></ul>
  18. 18. Treatment: Patient Education <ul><li>About TMD </li></ul><ul><li>Avoid painful activities </li></ul><ul><li>Avoid clenching grinding </li></ul><ul><li>Normal resting position of jaw </li></ul><ul><ul><li>Tongue up, teeth apart, lips together </li></ul></ul><ul><li>Moist heat/ice </li></ul><ul><li>Gentle stretching </li></ul>
  19. 19. Treatment: PT/OT <ul><li>Patient assessment </li></ul><ul><li>Postural assessment </li></ul><ul><li>Patient education </li></ul><ul><li>Joint mobilization/manual therapy </li></ul><ul><li>Iontophoresis in selected cases </li></ul><ul><li>Home therapy program </li></ul>
  20. 20. Treatment: Pharmacologic <ul><li>NSAIDS-scheduled dosing </li></ul><ul><li>Muscle relaxants </li></ul><ul><li>Tricyclics </li></ul><ul><li>Opioids </li></ul><ul><li>Steroid injection </li></ul><ul><li>Botox injection </li></ul><ul><li>*UW TMD clinic does not find muscle relaxants very useful, does not use tricyclics, rarely opioids </li></ul>
  21. 21. Treatment: Bite Splint <ul><li>Indications: </li></ul><ul><ul><li>AM symptoms, daytime clenching, teeth are worn </li></ul></ul><ul><li>Worn only at night </li></ul><ul><li>Does not move jaw (not an anterior repositioning splint) </li></ul>
  22. 22. Evidence Based Medicine <ul><li>Limited Evidence, recommended </li></ul><ul><ul><li>NIH Phase I and II treatments discussed previously </li></ul></ul><ul><li>Limited Evidence, needs further study </li></ul><ul><ul><li>Acupuncture </li></ul></ul><ul><ul><li>EMG biofeedback </li></ul></ul><ul><li>Limited Evidence, not recommended </li></ul><ul><ul><li>Occlusal adjustments that permanently alter a patient’s occlusion (Grinding teeth down, anterior repositioning splints) </li></ul></ul><ul><ul><li>Alloplastic implants </li></ul></ul>
  23. 23. Local Resource <ul><li>UW TMD Clinic: 263-7502 </li></ul><ul><ul><li>Lisa M. Dussault, OTR, John F. Doyle DDS </li></ul></ul><ul><li>Imaging as indicated </li></ul><ul><li>Referral to specialists as indicated </li></ul><ul><ul><li>Rehab Med psychologist, Oral/craniofacial surgery, speech/swallow, etc </li></ul></ul>
  24. 24. Indications for Referral <ul><li>Trauma to the face at onset of pain </li></ul><ul><li>Joint noise PLUS dysfunction </li></ul><ul><li>Locking/catching of TMJ </li></ul><ul><li>Limitation of opening/ROM </li></ul><ul><li>Pain in jaw and muscles of mastication on awakening </li></ul><ul><li>Orofacial pain aggravated by jaw function </li></ul>
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