TMD, classification, pain cycle, interrelation of various TMD, Definitive therapy- reversible and irreversible occlusal therapy, patient awareness, restrictive use, relaxation therapy, Supportive therapy- Pharmacotherapy, Physiotherapy, Manual Techniques,exercises.

1. PRESENTED BY:
DR GAYATRI MEHROTRA

2.  Temporomandibular Disorders (TMDs),
also referred to as craniomandibular
disorders, consist of a group of pathologies
affecting the masticatory muscles, the
tempromandibular joint (TMJ) and related
structures.

3.  TMD’s RDC groups are:
I Group: Muscle disorders:
Ia) Myofascial pain
Ib) Myofascial pain with limited opening
II Group: Disc Displacement (DD):
IIa) DD with reduction
IIb) DD without reduction with limited
opening
IIc) DD without reduction without limited
opening

4. III Group: Other common joint disorders:
IIIa) Arthralgia
IIIb) Osteoarthritis
IIIc) Ostoarthrosis

7. “ TMD is a complex and multifactorial
condition; so also our patients”- JPO

8. Disc derangement
disorder
Masticatory muscle
disorder
Inflammatory
disorder
Mandibular
hypmobility disorder
Trauma

9. Those which provide
basically conservative
reversible therapy
Non conservative,
irreversible therapy
All treatment methods
used for TMD can be
categorized into:
1) Definitive
treatment
2) Supportive
therapy

10. DEFINITIVE
THERAPY

11.  Intended to directly eliminate or alter the
causes of a disorder
Normal
function
An
event
Physiologic
tolerance
Temporomandibular
disorder symptoms

12. Definitive
treatment
For
occlusal
factors
For
emotional
stress
For trauma
For deep pain
input and
parafunction
al activity

13. DEFINITIVE TREATMENT CONSIDERATIONSFOR OCCLUSAL
FACTORS
 Reversible Occlusal therapy:
 Best accompalished with occlusal appliance

14.  Irreversible occlusal therapy:
Selective
grinding of
teeth
Restorative
procedures
Orthodontic
treatment
Surgical
procedures

15. DEFINITIVE TREATMENT CONSIDERATIONSFOR
EMOTIONAL STRESS
 Emotional stress is one of several
pyschologic factors that need to be
considered
 Increase emotional stress Increase
resting activity
alters muscle function or bruxism

16. Common
personality traits:
Perfectionistic
Compulsive
Introvert
Neurotic
Dis-satisfied and
self destructive
Common emotional
stress:
High level of
anxiety
Apprehension
Frustation
Anger
Fear
Depression
Hostility

17. TMD patients with chronic fear
Increase level of anxiety,
frustation and anger
Increased level of emotional
stress
Contribute to TMD

18.  Types of emotional stress therapy:
1) Patient awareness-
 Educate the patient and make the patient
aware that stress is a common everyday
experience
2) Restrictive use-
 Painful movements should be avoided as
it may further lead to cyclic muscle pain

19.  Alter the diet
3) Voluntary avoidance-
 Patient should be instructed that teeth
should be quickly disengaged any time
they come in contact.
 Other oral habits like biting on objects or
cradling telephone between mandible and
shoulder aggravate TMD symptom

20. • Buffering a little air between lips and teeth
• Allows jaw to assume a relaxed position
• Lips brought together and teeth left slightly apart
• This position decreases muscle activity
• Minimizes interarticular pressure
• Promotes joint repair

21. 4) Relaxation Therapy -
 Substitutive Relaxation therapy:
 Substitution for stress (any activity that is
enjoyable- sports, hobbies or recreational
activity)
 Active relaxation therapy:
 Technique used in dentistry are
modification of Jacobsons method,
developed in 1968.

22. Pt is trained to
relax symptomatic
muscles voluntarily
Blood flow
to these
tissues is
increased
Metabolic
waste
substances
that
stimulate
pain
receptors
are
eliminated
Diminishes
pain

23.  Patient tenses the muscles and then relaxes
them untill relaxed state can be felt and
maintained
 Another form uses a reverse approach
( muscles are passsively stretched and
relaxed)
 This technique has one major advantage
over Jacobson technique

24.  Self hypnosis, meditation and yoga also
promote relaxation
5) Biofeedback –
 It is a technique that assist
patient in regulating bodily
functions that are generally
controlled unconsciously.

25.  It is accompalished by
electromyographically monitoring state of
muscles through surface electrodes placed
over muscles to be monitored.
 Biofeedback units give auditory feedback
 When patient clenches, high readings will
appear or elevated tone is heard

28.  Negative Biofeedback:
 Devices are small and worn throughout day
and night
 If clenching or bruxism occurs, biofeedback
mechanism is activated and loud sound is
heard.

29.  A review of 30 studies of physical therapy
modalities for treating TMD concluded that
biofeedback may be more effective than
placebo or occlusial splints
 (Medlicott MS, Harris SR. A systematic review of the effectiveness of
exercise, manual therapy, electrotherapy, relaxation training, and
biofeedback in the management of temporomandibular disorder. Phys
Ther 2006;86:955–973.)

30. DEFINITIVE TREATMENT CONSIDERATIONSFOR trauma
 Trauma is one of the causative factor that
can lead to TMD
Macrotrauma:
 Only supportive therapy is helpful (trauma
has already occurred, so definitive therapy
is of no use)
 Preventive measures are helpful

31. Microtrauma
 Result from repeated loading of joint
structures, such as bruxism or clencing
 Occlusal appliances help in achieving a
favorable condyle disc relationship that will
unload retrodiscal tissues and load the disc.

32. DEFINITIVE TREATMENT CONSIDERATIONSFOR deep pain
input
 Some TMD may be secondary to another
source of deep pain eg cervical injury
 Appropriate history and examination

33. DEFINITIVE TREATMENT CONSIDERATIONSFOR
parafunctional activity
 For many years, dentists were convinsed
that bruxism and clenching were major
causes of TMD.
 This is true, but not always the case

34.  Keep the teeth apart
 Nocturnal bruxism- (more due to emotional
stress level and sleep pattern)
 Effectively reduced by occlusal applianec
therapy
 Morning pain associated with nocturnal
bruxism

35. SUPPORTIVE
THERAPY

36.  Supportive therapy mainly includes:
 Pharmacologic therapy
 Physical therapy

37. PHARMACOLOGICTHERAPY
 If medications are prescribed on “take as
needed” basis, then drugs are abused by
patients.
 Continued use lead to frequent pain cycles
and less drug effectiveness
 Analgesics and Tranquilizers

38.  Acute TMD pain
 Analgesics
 Corticosteroids
 Anxiolytics
 Chronic orofacial pain
 Tricyclic
antidepressants
 Both acute and
chronic condition
 NSAID
 Muscle relaxant
 Local Anesthetics
DRUGS USED

39. 1) Analgesics:
 Important part of supportive therapy
 Opiates or non opiates
 First medication of choice for moderate pain
relief is Calpol (acetaminophen)
 Stronger analgesics (codeine combined with
either salicylate or acetaminophen can be
helpful)

40. 2) Non Steroidal antiinflammatory drugs:
 Chief application is in the treatment of
muscoloskeletal pain
 In presence of tissue injury, that certain
chemical mediators are released into the
injured site.
 NSAID inhibit action of cycloxygenase, an
enzyme used to synthesize prostaglandin.

41. NSAID
INDOLES
•Indomethacin
PROPIONIC
ACID
DERIVATIVE
•Ibuprofen
•Naproxen
•Fenoprofen
COX-2
INHIBITOR
S
•Celecoxib
•Rofecoxib

42. 3) Anti-inflammatory agents:
 These drugs do not immediately achieve
good blood levels, therefore need to be
taken on a regular schedule for a
minimum of 3 weeks

43. 4) Corticosteroids
 Significant dose to be given followed by
gradual reduction in dosage
 Injecting anti-inflammatory such as
hydrocortisone into the
joint has been
advocated

45. 5) Anxiolytic drugs-
 When high level of emotional stress are
thought to contribute to TMD, antianxiety
(anxiolytic agents ) should be used
 Bezodiazepine (Diazepam)- prescribed on
daily basis

46.  Single dose of diazepam (2.5- 5 mg) at bed
time to relax the muscles and perhaps
lessen nocturnal parafunctional habit.
6) Muscle relaxants:
 They have a central effect that sedates the
patient.
 Perhaps, this sedation is the main
explanation for the positive response of the
patient

47.  Skeletal muscle relaxants in combination
with analgesics
 Chlorzoxazone with acteaminophen
(Parafon Forte)
Orphenadrine citrate with aspirin and
caffeine (Norgesic Forte)
Cyclobezaprine (Flexeril)- single dose of 10
mg before sleep

48. 7) Antidepressants:
 Low dose of amitriptyline (10 mg) just
before sleep can have analgesic on chronic
pain but has little effect on acute pain
8) Local anesthetics:
 Can be used to differentiate true source of
pain from a site of pain

49.  Two most common local anesthetics drugs
used for short duration pain reduction in TMD
 2% Lidocaine (Xylocaine)
 3% Mepivacaine ( Carbocaine)
 Solution without vasoconstrictor should be
used for muscle injections
 Intracapsular injection- sodium Hyaluronate

50. PHYSICAL THERAPY
 It is important part of successful
management of many TMD
 Includes :
 a) Modalities
 b) Manual technique

51. PHYSICAL THERAPY MOdALITIES
 Thermotherapy
 Coolant therapy
 Ultrasound
 Phonophoresis
 Iontophoresis
 EGS therapy
 TENS
 Acupuncture
 Laser

52. 1) Thermotherapy:
 Uses heat as a prime mechanism as it
increases circulation to the applied area.
 Apply hot moist towel over symptomatic
area.
 Not to exceed 30 min (10-15 min)

53. 2) Coolant therapy:
 Cold encourages relaxation of muscles that
are in spasm and thus relieve the pain
associated.
 Apply directly to affected area
 After a period of warming, second
application may be desirable

54. Initially, pt experience uncomfortable feeling
Quickly turn into burning sensation
Continued icing
Mild aching
Numbness begins
Remove the ice

55.  Common coolant therapy uses vapor spray:
 Ethylchloride
Fluoromethane
 Apply the spray to desired area from
a distance of 1 to 2 feet for approx 5 sec
 Action – associated with stimulation of
cutaneous nerve fibers

56.  In myofascial pain, a technique is used “
Spray and stretch” tech.
 Spraying over a muscle with a trigger point
and then immediately passively stretching
the muscle.

57. 3) Ultrasound therapy :
 It is a method of producing an increase in
temperature at the interface of the tissues
and therefore affects the deeper tissues
than does surface heat.
 Improves the flexibility and extensibility of
connective tissues.

59. 4) Phonophoresis:
 Ultrasound has been used to administer
drugs through the skin by a process known
as phonophoresis.
 Example- 10% hydrocortisone cream is
applied to an inflammed joint and
ultrasound transducer is then directed at
the joint.

60. 5) IONTOPHORESIS:
 It is a technique by which certain
medications can be introduced into the
tissues without affecting any other organs
 Medication is placed in a pad and the pad
is placed on the desired area. Then, a low
electrical current is passed though the pad

62. 6) ELECTROGALVANIC STIMULATION THERPAY:
 Works on principle that electrical
stimulation of a muscle cause it to contract
 Uses high voltage, low amperage,
monophasic current of varied frequency

63.  Repeated contraction and relaxation
 Help to breakup the myospasm and
increase blood flow to the muscles

64. 7) TRANSCUTANEOUS ELECTRICAL NERVE
STIMULATION:
 Continuous stimulation of cutaneous nerve
fibers at a subpainful level.
 Uses a low voltage, low amperage, biphasic
current of varied frequency.

65. 8) ACUPUNCTURE:
 Uses bodys own antinociceptive system to
reduce the level of pain felt

68. Stimulation of certain areas (acupuncture points)
Release of endorphins
Causes flooding of the afferent
interneurons and subthreshold stimuli
Reduce painful sensation
Block transmission of noxious impulses

69. 9) COLDLASER:
 Cold or soft laser has been investigated for
wound healing and pain relief
Cold laser accelerates collagen
synthesis
Increasing vascularity of
healing tissues
Decreases number of
microorganisms
Decrease pain

70. Manual techniques
 Manual techniques are the “hands on”
therapies provided by
the physiotherapaist
for the reduction of
pain and dysfunction.
3 main categories
Soft tissue
mobilization
Joint mobilization
Muscle
conditioning

71. 1) SOFTTISSUE MOBILIZATION:
 Includes superficial and deep massage
 Helps in mobilizing the tissues, increasing
blood flow to the area and eliminating the
trigger points

72. Deep heat tends to relax
muscles
Decrease the pain
Enhance effectiveness of deep
massage

73. 2) Joint mobilization:
 Mobilization of TMJ is useful in
decreasing interarticular pressure and
increasing range of joint movement
 Useful in managing acute disc dislocation
without reduction

75.  If distraction ellicits pain, then therapist
should think of inflammatory disorder and
discontinue distraction procedure.
 When cervical traction is used, care must
be taken not to place usual forces on
condyle
 Keep the teeth in together while undergoing
traction

76. 3) Muscleconditioning:
 Patients who experience TMD symptoms
often decrease use of their jaw because of
pain muscle becomes atrophy
 Instruct self administered exercises to
restore the normal function and range of
movement

77. Passive muscle
stretching
Assisted muscle
stretching
Resistance
exercises
Postural training
MUSCLE
CONDITIONING

78. a) Passive muscle stretching-
Shortened muscle length
Decreases blood flow
Accumulation of algogenic
substances
Muscle pain

79.  Patient is instructed to open the mouth
slowly and deliberately untill pain is felt
 Look in mirror and then perform, so that
patient makes a straight pathway without
deflection or deviation
 Use a vapocoolant spray which will reduce
pain and then perform.

80. b) Assisted muscle stretching:
 Stretching should be performed with
gentle intermittent force that is gradually
increased.
 Simons and Travelle described spray and
stretch technique.

82. c) Resistance exercises:
 Use concept of reflex relaxation
 Instruct the patient to place the fist under
the chin and open the mouth against
resistance
 Repeat 10 times each session, 6 sessions
per day

92. d) Postural training-
 Posture of head, neck and shoulders can
contribute to TMD symptoms.
 Postural self regulation training was
developed by Drs Peter Bertrand and
Charles Carlson in 1993.
A forward head
position has drawn
the most attention

93. Forward and rotated
head position
Produces elongation of
suprahyoid and
infrahyoid muscles
Closes posterior space
between atlas and axis

94. Specific
disorders and
their
treatment

95. 1) Disc displacement:
 Splint therapy
 Physical therapy
 Anti-inflammatory drugs
 Arthrocentesis
 Arthroscopic lysis and lavage
 Arthroplasty
 Vertical ramus osteotomy

96. 2) CONNECTIVE TISSUE DISORDERS
(Osteoarthritis, RA, spondyloarthropathies)
 Treatment of systemic disease
 Jaw self care
 Physiotherapy
 Oral appliance therapy
 Topical NSAID
 Intra-articular corticosteroid injection

97.  Arthrocentesis (conservative procedure)
 Arthroscopy, arthroplasty, arthrotomy
(surgical procedures)
3) DEVELOPMENTAL DEFECTS and fractures:
 Surgical intervention

98. 4) DISLOCATION:
 Surgical intervention
 IV diazepam for severe pain
 Reduction and stabilization
 Caution- not to open the mouth wide open
 Injection of sclerosing agents

99. 5) ANKYLOSIS:
 Severe surgical procedures
 Gap arthroplasty
6) Bruxism:
 Oral appliance therapy
 Biofeedback
 Injecting botulinum toxin

100. 7) ORALDYSKINESIA:
 Clonazepam
 Baclofen
 Tetrabenazine
 Injection of botulinum toxin

101.  It is important for dentists to rule out
disorders that mimic TMD, to identify non-
TMD disorders that may negatively impact
the patient’s TMD symptoms, and to offer
the patient therapies that will provide the
most cost-effective long-term symptom
relief.

102.  Temporomandibular disorders (TMD) are
the most prevalent orofacial pain conditions
for which patients seek treatment.
 A multidisciplinary pain management
approach should be considered for the
optimal treatment of orofacial pain
disorders including both non-
pharmacological and pharmacological
modalities.

103. 1) Textbook of mangement of temporomandibular
disorders and occlusion - Okeson Jeffrey P- 5 th
edition
2) Manual of Temporomandibular joint- Shivalal M
Rawlani
3) Burkets Oral Medicine-11 Edition-by Greenberg
And Glick And Ship
4) Mina et al. Effectiveness of Dexamethasone
Iontophoresis for Temporomandibular Joint
Involvement in Juvenile Idiopathic Arthritis.
Arthritis care an research; Nov 2011
5) Orofacial pain management: current perspectives

104. 6) Sala Horowitz. Biofeedback Applications- A survey of
clinical research; Alternative and complimentary
therapies – Dec 2006
7) Wright E et al. Management and Treatment of
Temporomandibular Disorders: A clinical Perspective.
The journal of manual and manipulative therapy
8) Temporomandibular joint exercises. Therapies
Directorate
9) Chin S et al. Application of acupuncture in
temporomandibular disorder. Journal of prosthodontics
and Implantology 2013
10) Ardehali et al. Temporomandibular joint dislocation
reduction technique. Annals of plastic surgery 2009

105.  Is osteoarthritis an inflammatory or non-
inflammatory disorder. Justify your answer
 Role of Iontophoresis in treatment of TMD
 Classification of TMD

106.  Signs and symptoms of TMD
 Function of occlusal splints
 What is biofeedback
 Surgical treatment modalities for TMD