TMJ diagnosis


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Oral Diagnosis II
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TMJ diagnosis

  1. 1. Tempromandibular Joint Diagnosis By Dr. Hassan M. Abouelkheir BDS, MSC, Phd.
  2. 2. Diagnosis of TMJDs • History: What are the Common Symptoms of TMJ Disorders? 1- Headache: 80% of patients with a TMJ disorder complain of headache, and 40% report facial pain. Pain is often made worse while opening and closing the jaw. • 2- Ear pain: 50% of patients with a TMJ disorder notice ear pain but do not have signs of infection. • 3- Sounds: Grinding, crunching, or popping sounds, medically termed crepitus, are common for patients with a TMJ disorder. These sounds may or may not be accompanied by increased pain.
  3. 3. Diagnosis of TMJDs (cont) • 4- Dizziness: 40% of patients with a TMJ disorder report a vague dizziness or imbalance. • 5- Fullness of the Ear: 33% of patients with a TMJ disorder describe muffled, clogged, or full ears. They may notice ear fullness and pain during airplane takeoffs and landings. • 6- Ringing in the Ear - Tinnitus: For unknown reasons, 33% of patients with a TMJ disorder experience noise or ringing (tinnitus).
  4. 4. Pain dysfunctionl syndrome Characterized by 5 signs/symptomes. 1- pain on TMJ palpation. 2- pain on palpation of associated muscles. 3-Limitations or deviation of mandibular movement. 4- Joint sounds. 5- headache.
  5. 5. Diagnosis of TMJDs (cont.) • Clinical Examination: • 1- passive mouth opening: maximum interincisal opening with assistance of clinician without pain. Max. opening ≥40mm.
  6. 6. Clinical Examination (cont.): 2- masticatory muscle tenderness on palpation: • All of the examination procedures should be accompanied by questioning the patient about the production of pain and the site of pain during the particular examination procedure. • Palpation of the joint and the muscles for pain should be done with the muscles in a resting state.
  7. 7. TMJ palpation
  8. 8. TMJ palpation (cont.) • Palpation of the TMJ will reveal pain and irregularities during condylar movement, described as clicking or crepitus. • The click that occurs on opening and closing and that is eliminated by bringing the mandible into a protrusive position • before opening is most often associated with → articular disk displacement with reduction.
  9. 9. Masseter palpation
  10. 10. Temporalis palpation
  11. 11. Lateral pterygoid muscle •Behind the maxillary tuberosity.
  12. 12. Medial pterygoid muscle •Retromolar area at the medial surface of mandibular angle.
  13. 13. interincisal opening measurement
  14. 14. Reduction in the vertical range of movements: Due to conditions: 1- pain → muscular problem. 2- physical obstruction → Disc displacement. Deviation in movements: Multifactorial; A- Diagonal straight line from the beginning to end point → Joint adhesion. B- vertical until before the end of maximum opening where there is deviation.→ anterior disc displacement without reduction . C- vertical with lateral movement at the meddle of opening which then returns to the same vertical plane→ Disc displacement with reduction.
  15. 15. 3- Computerized mandibular scan: • Misalignment of the jaws with upper & lower teeth meeting in the wrong place can be at the root of TMDs. To trace this malocclusion or unhealthy bite . • The computerized Mandibular Scan (CMS) is a tracking device that records in 3D the delicate functioning movements of the jaw with accuracy in the tenths of a millimeter.
  16. 16. Radiology • MRI is best technique for joint space pathology • CT is best technique for bony pathology • Plain films with arthrography sometimes useful, although largely replaced by MRI and CT • Arthroscopy is also diagnostic
  17. 17. Assessment of Parafunctional Habits • 1. Teeth grinding and teeth clenching (bruxism) increase the wear on the cartilage lining of the TMJ. Many patients awaken in the morning with jaw or ear pain. • 2. Habitual gum chewing or fingernail biting. • 3- Dental problems and misalignment of the teeth (malocclusion). Patients may complain that it is difficult to find a comfortable bite. Chewing on only one side of the jaw can lead to or be a result of TMJ problems.
  18. 18. Parafunctional Habits (cont.) • 4. Trauma to the jaws. Previous history of broken jaw or fractured facial bones. • 5. Stress frequently leads to unreleased nervous energy. They either consciously or unconsciously grinding and clenching their teeth • 6. Occupational tasks such as holding the telephone between the head and shoulder.
  19. 19. Classification of TMJ Disorders •Muscle Disorders (Extra capsular) 1.Myofacial pain 2.Myositis 3.Myospasm •TMJ Disorders (Intracapsular) 1.Inflammatory conditions 2.Internal derangement •Disc sticking •TMJ dislocation •Disc displacement with reduction •Disc displacement without reduction •Osteoarthritis.
  20. 20. Muscle Disorders (Extracapsular): 1.Myofacial pain: Myofacial pain as “ a regional, dull, aching muscle pain with the presence of localized tender sites (trigger point) in muscle, tendon, or fascia”. • TMD patients may have masticatory and/or cervical myofacial pain.
  21. 21. Signs and Symptoms: History: • Pain with function (chewing, talking). • Parafunctional habits or postural problem. • Headache ( tension type ). • Acute recurrent malocclusion • Ear symptoms ( earache, tinnitus, stuffiness, sense of disequilibrium ). • Toothache ( but endodontic tests are within normal limits)
  22. 22. Signs and Symptoms (Cont.): Clinical finding: • limited interincisal opening. • altered mandibular range of motion. • limited cervical range of motion. • Dull pain. • masticatory muscles and/or cervical muscles tender to palpation, manipulation. • Trigger points referring pain to other sites. • Diagnosis: • History • Generalized dull aching pain and trigger points with pain referral are key findings for a myofacial pain diagnosis.
  23. 23. Treatment: Step 1 Patient education and self-care Step 2 Behavior modification a) identify specific parafunction and/or postural problem. b) cognitive-behavioral self-regulation exercises. c) myotherapy/physical therapy referral. Step 3 Pharmacotherapy a) analgesic appropriate for pain level b) muscle relaxant c) tricyclic antidepressant d) anxiolytic
  24. 24. Treatment (cont.) Step 4 Trigger-point management. a) injection with local anesthetic. b) physical therapy: vapocoolant spray or ice and stretching. Step 5 Orthopedic appliance therapy: muscle relaxation splint.
  25. 25. 2- Myositis: • Constant, acute muscle pain; swelling; tissue reddening; and increased temperature over the entire muscle. • The condition generally arises secondary to direct trauma to the muscle or a spreading infection.
  26. 26. Sign and Symptoms History • constant muscle pain that increases with function. • limited mandibular opening. • swelling and/or tissue reddening. • history of trauma or infection. • parafunction habit. Clinical finding • limited range of motion. • tendonitis (inflammation of the tendinous attachment of the muscle ). • swelling and increased temperature over the muscle.
  27. 27. Diagnosis: • A localized, constant muscle pain secondary to trauma, infection, or overuse of a muscle. Treatment: Step 1 If infection is diagnosed, it must be treated with appropriate antibiotics and procedures to eliminate the source of the infection. Step 2 Patient education. Step 3 Behavior modification: identify and manage any parafunction that may be aggravating the condition. a) cognitive-behavioral self-regulation exercises. b) orthopedic appliance therapy.
  28. 28. Treatment (cont.): Step 4 Pharmacotherapy: analgesics appropriate for level pain. a) sever pain: short-duration narcotic analgesic. b) moderate pain: NSAID for analgesic and anti-inflammatory effect. Step 5 Local anesthetic block to relieve pain Step 6 Local anesthetic with corticosteroid for tendonitis
  29. 29. 3- Myospasm: • Acute muscle disorder characterized by a sudden involuntary tonic muscle contraction. • This condition is commonly referred to as trismus. • Myospasm is currently believed to be rare and not a common cause of masticatory muscle pain in patient with orofacial pain.
  30. 30. Signs and Symptoms Clinical finding • limited range of motion. • significantly reduced interincisal opening. • acute malocclusion. • increased surface electromyography (EMG) activity. • trismus found secondary to odontogenic infection. • Diagnosis • Acute pain and a significant reduction in mandibular range of motion are key findings.
  31. 31. Treatment Step 1 Patient education Step 2 Local anesthetic for initial management of acute pain. a) nerve block. b) injection in affected muscle. Step 3 Pharmacotherapy a) analgesic appropriate for level of pain. b) combination of analgesic and muscle relaxant. Step 4 Behavior modification a) identify and manage any associated parafunction. b) cognitive-behavioral self-regulation exercises.
  32. 32. II Intracapsular TMJ disorders: • 1- Inflammatory Conditions: Synovitis, capsulitis, retrodiscitis. • Signs and Symptoms: • History: • TMJ pain at rest and/or with function. • limited mandibular opening. • ear pain. • patient reports of fluctuating swelling with associated occlusal changes ( inability to occlude the teeth on the involved side).
  33. 33. Signs and Symptoms (cont.): Clinical finding: • positive findings upon palpation of the TMJ • localized TMJ pain that may be exacerbated by function, especially during compression of the involved tissue • osteoarthritis changes as evidenced by hard tissue imaging • limited mandibular range of motion • Diagnosis: • The temporomandibular joint and preauricular area is tender to palpation, manipulation, and/or vertical loading. • Patient generally reports pain with mandibular function.
  34. 34. Treatment Step 1 Patient education and self-care Step 2 Pharmacotherapy a) analgesic/NSAID for pain and inflammation b) muscle relaxant, if muscle splinting is determined Step 3 Control of parafunctional behavioral activities a) Cognitive-behavioral self-regulation exercises Step 4 Physical therapy directed at enhancing reduction of inflammation and ridding the area of inflammatory mediators or by- products Step 5 Orthopedic appliance therapy:Stabilization appliance.
  35. 35. 2- Internal derangement: • a -Disk Sticking: • Disc sticking is an alteration in normal, smooth, harmonious movement of the TMJ articular disc without frank displacement. • This condition may be secondary to an alteration in quality or availability of the synovial fluid, resulting in impaired lubrication of the joint. • Altered synovial lubrication via bruxing/clenching may cause repeated microtrauma. • If overt trauma or macrotrauma occurs, concerns about the potential for bleeding within the TMJ and the development of adhesions must be addressed.
  36. 36. Signs and Symptoms: History: • occasional popping or clicking. • jaw feels stiff in the morning, until I pop it. • inability to open as wide as before. Clinical finding • intermittent painless or painful clicking ( usually on opening only ). • Usually experienced after a period of stasis, such as upon awakening • If painful, patient may exhibit limited mandibular range of motion
  37. 37. Diagnosis: • Based on intermittent, asymptomatic popping, clicking, or stiffness in the temporomandibular joint. • Treatment Step 1 Patient education and self-care Step 2 Reduction of parafunctional behavior: cognitive- behavioral self-regulation exercises Step 3 If painful, analgesic/NSAID Step 4 Physical therapy referral a) gentle ROM exercise b) gentle distraction and mobilization step 5 Orthopedic appliance therapy: stabilization appliance
  38. 38. b-TMJ Dislocation: • An anatomical relationship in which the lateral pterygoid muscle advances the condyle anterior and superior to the crest of the articular eminence, and due to muscle spasm in the elevator muscles and/or specific anatomical relationships, the patient is unable to return to a closed position.
  39. 39. Signs and Symptoms: History • inability to close mouth without manipulation • possible pain during the dislocation • complaints of residual pain following return to closed position. Clinical finding • radiographic evidence that the condyle is anterior and superior to the crest of the articular eminence • joint sounds near maximum opening, prior to subluxation • decreased mandibular range of motion due to residual pain
  40. 40. Diagnosis • Diagnosis of a temporomandibular dislocation is made when the patient has opened wide and is unable to return to a closed position. Treatment: Step 1 Patient education Step 2 Manual reduction Step 3 Pharmacotherapy a) if pain is intolerable, use an auriculotemporal nerve block to alleviate TMJ pain and reduce muscle splinting. b) intravenous sedation, if manual reduction with nerve block is unsuccessful. c) muscle relaxant. d) analgesic/NSAID for residual pain. Step 4 Avoidance training.
  41. 41. C- Disc Displacement with Reduction
  42. 42. Signs and Symptoms History: • reproducible joint noise (clicking) that occurs at variable positions during mandibular opening and closing • pain, if present, which may be constant or precipitated/aggravated by mandibular movement • reduced mandibular opening Clinical finding: • deviation to the affected side prior to click, with a return toward midline following the click • episodic and momentary “catching” of smooth mandibular movement during opening that self-reduces • limited mandibular range of motion secondary to joint/muscle pain.
  43. 43. Diagnosis: • The patient displays joint noise (clicking or popping) on opening and closing, with or without pain, or change in range of motion. • Treatment: Step 1 Patient education and self-care. Step 2 Control of parafunctional behavior: cognitive- behavioral self-regulation exercises. Step 3 Restriction of mandibular function during painful episodes. step 4 Pharmacotherapy a) analgesic/NSAID. b) muscle relaxant if significant muscle involvement is identified. Step 5 Orthopedic appliance therapy: stabilization. Step 6 Monitoring of patient response; assess progression.
  44. 44. D-Disc Displacement Without Reduction:
  45. 45. Signs and Symptoms History • sudden onset of pain in the temporomandibular joint, but no joint sounds • limited mandibular opening • prior history of TMJ clicking if not associated with overt trauma. Clinical finding: • persistent, marked limited mouth opening (less than 35 mm) with a history of sudden onset • mandibular deviation to the affected side on opening • pain precipitated or exacerbated by forced mandibular movement, and associated with palpation of the affected joint • hyperocclusion on the affected side if condition is acute.
  46. 46. Diagnosis: • Sudden, painful onset of persistent, marked limited interincisal opening with loss of previous TMJ sounds. Treatment: Step 1 Patient education and self-care Step 2 Control of parafunctional behavior: cognitive- behavioral self-regulation exercises Step 3 Manual reduction/mobilization Step 4 Pharmacotherapy Step 5 Restriction of mandibular movement Step 6 Orthopedic appliance therapy a) stabilization appliance is treatment of first choice. b) anterior repositioning appliance if stabilization orthodontic is not effect in reducing pain.
  47. 47. e- Osteoarthritis: DJD is non inflammatory disorder of joints characterized by joint deterioration and proliferation. Signs and Symptoms: History: • pain with function. • crepitus or multiple joint noises. • trauma to the temporomandibular joint. • TMJ infection. • active systemic arthritis. Clinical finding: • pain tenderness with palpation. • limited range of motion with mandibular deviation to the affected side on opening. • radiographic evidence of hard tissue osteoarthritic change.
  48. 48. Diagnosis: • Pain in the temporomandibular joint with palpation and function, crepitus and radiographic evidence of hard tissue osteoarthritic change. • Treatment: Step 1 Patient education and self-care Step 2 Restriction of mandibular function Step 3 Pharmacotherapy a) analgesic/NSAID b) muscle relaxant Step 4 Control of parafunctional behavior a) cognitive-behavioral self-reduction exercises Step 5 Orthopedic appliance therapy Step 6 Physical therapy a) gentle ROM exercise b) iontophoresis.