TMJ disorders

1. Conservative management of
TMJ disorder
By:
ABD ALRAHMAN AKRAM

2. Introduction
 Pain related to temporomandibular disorders (TMD) is a common problem
in modern societies.
 The term TMD is not a diagnosis but it is an umbrella term for pain and
dysfunction involving the masticatory muscles & temporomandibular joints,
headache, disturbances in jaw movements and sounds in joints during
opening and closing the mouth.
 Impaired function of the temporomandibular joints and associated muscles
may lead to the painful impairment in stomatognathic system functioning.
 The causes of these diseases/symptoms are numerous and include trauma,
systemic, iatrogenic, occlusal and mental health disorders.

4. 1. Behavioural therapy
2. Pharmacotherapy
3. Splint therapy
4. Occlusal management
5. Physiotherapy

5. Specific
InterventionsPharmacologic
Management
Biobehavioral
interventions

6.  Effective communication techniques
 Appropriate terms to describe pain.

7. To reduce or eliminate overload over masticatory system as
well as emotional stress.
Provide accurate information to the patients about their
conditions .
Methods (instructions) for self-care:
♦Eat without increasing pain
♦Control parafunctional activities
♦Manage sustained activity of the jaw
♦Monitor your symptoms

8.  Two kinds of breathing, upper chest (thoracic) and lower
chest (diaphragmatic).
 Take a long, slow breath in through
your nose, first filling your lower
lungs, then your upper lungs.
 Hold your breath to the
count of "three.“
 Exhale slowly through pursed lips
 Practice this Calming Breath at least
ten times a day for several weeks.

9.  Biofeedback is a technique used to help a patient gain
control over their physiological response to a stressor
 A polygraph is used to record muscular activity, which is
displayed on a monitor visible to the patient.

10.  CBT is a psycho-social intervention that focuses on
changing unhelpful cognitive distortions .
Interventions:
♦ Self-instructions (e.g. distraction, imagery, motivational
self-talk).
♦ Development of adaptive coping strategies (e.g.
minimizing negative or self-defeating thoughts).
♦ Changing maladaptive beliefs about pain .

11. Categories of Medications Used to Treat TMDs:
 Anti-inflammatory (PPT its necessary?)
 Analgesics
 Muscle relaxants
 Antidepressants
 Anticonvulsants
 Anxiolytics

12. • Ibuprofen (Brufen)
400 mg t.i.d. for 7 days
Naproxen (Naprofen)
500 mg tab t.i.d for 1month
• Diclofenac Na
(Voltaren 25, 50 mg tab)
Up to 150 mg daily in 3 divided
doses for 1month
Acute pain (< 3months) Chronic pain (˃ 3months)
• Diazepam(Anxolytics)
(Valium 2.5mg, 10mg) 2-5mg
t.i.d. for 10 days
• Imipramine
Tofranil 25 mg
25 mg t.i.d. for 1-3months

13.  Is a removable device, usually made of hard acrylic, which
fits over the occlusal and incisal surfaces of the teeth in
one arch, creating precise occlusal contact with the teeth
of the opposing arch .
 It is commonly referredto as an occlusal splint, bite guard,
night guard, interocclusal appliance .

14. Proper appliance selection :
 No single appliance is useful with all TMDs
 Select the splint that will best affect the major contributing
etiologic factor causing the disorder.
 Some TMDs do not respond to appliance therapy at all..

15.  When it is in place, the condyles are in their most
musculoskeletally stable position at the time that the teeth
are contacting evenly and simultaneously.
 The teeth are contacting evenly and simultaneously.
Canine disocclusion of the posterior teeth during eccentric
movement is also provided.

16. Indication
1. Muscle pain reduced disorder.
2. Treated for retrodiscitis post traumatic.
Criteria for stabilizing appliance:
1. Retention & stability on maxillary teeth.
2. Flat surface in occlusal
3. Mandibular canine must contact with force.
4. Only mand. Canine have latertrotrusive contact on the
appliance.
5. Posterior teeth contact the appliance more heavily than
anterior.

17.  The Anterior positioning appliance is an inter occlusal
device that encourages the mandible to assume a position
more anterior than the inter cuspal position (ICP)
 The goal of treatment is change the position temporarily
to enhance adaptation of retrodiscal tissue and eliminate
the joint sound .

18. Indication
1. Treat disc displacements and disc
dislocations with reduction .
2. In patients who complains from clicking .
3. Intermittent or chronic locking of the joint
can also be treated with it .
Criteria for stabilizing appliance:
1. Retention & stability on maxillary teeth.
2. All mandibular teeth should be contact .
3. The forward position should be eliminate
the joint symptoms .
4. Should be smoothly polished and compatible
with adjacent soft tissue .
5. The lingual retrusive guidance ramp should
contact and on closure.

19.  The primary goal of this appliance to eliminate the
influence on the function of masticatory system by
disengage the posterior teeth .

20. Indication
1. Treatment of muscle disorders that result in
change the occlusal condition .
2. Reduce Para function habits .
Complication
Because this appliance covers apportion of one arch ,
the unopposed posterior teeth have potential to super
erupt , so this appliance therapy must be closely
monitored .

21.  The primary goal of this appliance to achieve major
alteration in vertical dimension and mandibular positioning.

22. Indication
1. Use in case of severe loss of vertical dimension .
2. This devise may be helpful for certain disc
derangement disorders .
Complication
Because this appliance covers apportion of one arch ,
the unopposed anterior teeth have potential to super
erupt , so this appliance therapy must be closely
monitored .

23.  There is widespread use of occlusal adjustment in the treatment of TMD.
Adjustment is listed as the second most common form of treatment .
 Thomas et al 2017 in his review found no evidence that occlusal
adjustments (grinding on teeth) are more or less effective than a placebo
in the treatment of TMD pain.
 All studies were restrictive in recommending the use of occlusal
adjustments for treatment of TMD pain, especially since this therapy is
non-reversible.

24. Pro :
To prevent, reduce, or eliminate lateral stresses on teeth.
1. Improvements can be made in directing occlusal loading
along the long axis of teeth.
2. If one joint degenerates so severely that no occlusal contact
occurs on the contralateral side, adjustment may stabilize
the occlusion on the affected side. Restoration of teeth on
the contralateral side is an alternative.
3. If unilateral surgery is required, adjustment may be needed
on the affected side to improve the final occlusal contacting
relation.
Con :
Adjustment should not be made with an anticipation of pain
relief.

25. Physical therapy techniques may include :
 Jaw exercises to strengthen muscles and improve
flexibility and range of motion.
 Heat therapy to improve blood circulation in the jaw.
 Ice therapy to reduce swelling and relieve pain.
 Massage to relieve overall muscle tension.
 Ultrasound therapy, which uses high-frequency sound
waves directed to the TM joint, to reduce pain and swelling
and improve circulation.

26.  Transcutaneous electric nerve stimulation (TENS) : Is the
application of a mild electrical current to the skin over the jaw joint.
Clinically, TENS is applied at varying requencies, intensities, and pulse
durations of stimulation.
 Depending upon frequency of stimulation, TENS is broadly
classified into 2 categories:
1. High frequency TENS (> 50Hz) operates via the gates
theory (activation of descending pain-inhibitory pathways) producing only
short term analgesia .acute pain
2. Low frequency TENS (<10 Hz) operates through release of
endogenous opioids which causes a more systemic and long-term
response , chronic pain

27.  Low level laser therapy :
The Low level laser therapy seems to have no superiority over
placebo laser application in reducing pain severity and in
improving of range of mandibular motion.