temporomandibular disorders primary care conference 2/23/05
TRANSCRIPT
TemporomandibuTemporomandibular Disorderslar DisordersPrimary Care ConferencePrimary Care Conference
2/23/052/23/05
Clinic CaseClinic Case
JD is a 29 yo F new patient who presents JD is a 29 yo F new patient who presents for refill on Vicodin for TMJ. Has for refill on Vicodin for TMJ. Has headache, pain, decreased jaw ROM over headache, pain, decreased jaw ROM over the past 1 1/2 yearsthe past 1 1/2 years
PMH: PMH: TMJ syndrome, gastritis/dyspepsia, depressionTMJ syndrome, gastritis/dyspepsia, depression
SH:SH: 3 children (8,4,3), marital discord (reconciled 3 children (8,4,3), marital discord (reconciled
after separation), verbal abuse, beginning after separation), verbal abuse, beginning career as realtorcareer as realtor
Definition of TMDDefinition of TMD
1996 NIH Consensus Conference:1996 NIH Consensus Conference:
A collection of medical and dental A collection of medical and dental conditions affecting the TMJ and/or the conditions affecting the TMJ and/or the muscles of mastication as well as muscles of mastication as well as contiguous tissue componentscontiguous tissue components
Definition of TMDDefinition of TMD
3 Main Categories;3 Main Categories; Myofascial pain (jaw muscles, neck Myofascial pain (jaw muscles, neck
muscles, shoulder muscles)muscles, shoulder muscles)
Internal derangement of the joint Internal derangement of the joint (dislocated joint, displaced disk, (dislocated joint, displaced disk, condylar trauma)condylar trauma)
Degenerative joint disease (OA, RA)Degenerative joint disease (OA, RA)
EpidemiologyEpidemiology
60-70% of general population have 60-70% of general population have one signone sign
Prevalence by self report: 5-15% Prevalence by self report: 5-15% (one source estimates 10% of (one source estimates 10% of women, 6% of men)women, 6% of men)
5% or less seek treatment 5% or less seek treatment Women>men 4:1 seek treatmentWomen>men 4:1 seek treatment
EpidemiologyEpidemiology
Early adulthood (ages 20-40)Early adulthood (ages 20-40)
Many TMD are self-limiting or Many TMD are self-limiting or fluctuate over time without fluctuate over time without progressionprogression
5% require surgery5% require surgery
EtiologyEtiology
MultifactorialMultifactorial Predisposing factorsPredisposing factors
Musculoskeletal Musculoskeletal Precipitating factorsPrecipitating factors
Trauma, clenching, grindingTrauma, clenching, grinding Perpetuating factorsPerpetuating factors
Chronic MSK dysfunction, psychogenicChronic MSK dysfunction, psychogenic
Clinical ManifestationsClinical Manifestations
PainPain Joint clickingJoint clicking Restricted jaw range of motionRestricted jaw range of motion Other symptoms are not specific to Other symptoms are not specific to
TMD:TMD: Headache, ear ache, neck and shoulder Headache, ear ache, neck and shoulder
painpain
Diagnosis: HistoryDiagnosis: History
PainPain Worsens with jaw useWorsens with jaw use Centered anterior to tragusCentered anterior to tragus Radiates to ear, temple, cheek, Radiates to ear, temple, cheek,
mandiblemandible Clicking/joint noiseClicking/joint noise Restricted ROMRestricted ROM
Tight feeling, catching, lockingTight feeling, catching, locking
Diagnosis: HistoryDiagnosis: History
HabitsHabits Clenching, grinding,cradling phone, Clenching, grinding,cradling phone,
back packsback packs SH: stressorsSH: stressors PMH: related disorders, trauma, PMH: related disorders, trauma,
dental problemsdental problems
Diagnosis: ExamDiagnosis: Exam Inspection:Inspection:
Facial asymmetry, posture, eccentric jaw Facial asymmetry, posture, eccentric jaw movementsmovements
ROM:ROM: Vertical (42-55 mm), lateral, protrusionVertical (42-55 mm), lateral, protrusion
Palpation:Palpation: Pre-auricular/anterior to tragus: joint mobility, Pre-auricular/anterior to tragus: joint mobility,
joint sounds (audible, palpable)joint sounds (audible, palpable) Masseter, temporalis, pterygoid, suprahyoid, Masseter, temporalis, pterygoid, suprahyoid,
SCM, cervicalSCM, cervical
Diagnosis: ExamDiagnosis: Exam
Oral function: occlusion, swallowing, Oral function: occlusion, swallowing, breathingbreathing
Postural/musculoskeletal:Postural/musculoskeletal: Forward head posture, systemic Forward head posture, systemic
hypermobility, joint problems elsewherehypermobility, joint problems elsewhere
Treatment GoalsTreatment Goals
Educate patient about TMD and self-Educate patient about TMD and self-managementmanagement
Reduce or eliminate pain and joint Reduce or eliminate pain and joint noisenoise
Improve functionImprove function Avoid unproven treatments that can Avoid unproven treatments that can
cause problemscause problems
Treatment: NIH Treatment: NIH guidelinesguidelines
Phase I: Conservative and ReversiblePhase I: Conservative and Reversible Patient educationPatient education Physical Therapy/Occupational TherapyPhysical Therapy/Occupational Therapy PsychotherapyPsychotherapy MedicationsMedications Bite splint/Occlusal SplintBite splint/Occlusal Splint Stress managementStress management
(Multidisciplinary approach)(Multidisciplinary approach)
Treatment: NIH Treatment: NIH guidelinesguidelines
Phase II: only after conservative Phase II: only after conservative measures exhaustedmeasures exhausted Surgery: arthrocentesis, arthroscopy, Surgery: arthrocentesis, arthroscopy,
open joint surgery, orthognathicopen joint surgery, orthognathic 5%5%
Treatment: Patient Treatment: Patient EducationEducation
About TMDAbout TMD Avoid painful activitiesAvoid painful activities Avoid clenching grindingAvoid clenching grinding Normal resting position of jawNormal resting position of jaw
Tongue up, teeth apart, lips togetherTongue up, teeth apart, lips together Moist heat/iceMoist heat/ice Gentle stretchingGentle stretching
Treatment: PT/OTTreatment: PT/OT
Patient assessmentPatient assessment Postural assessmentPostural assessment Patient educationPatient education Joint mobilization/manual therapyJoint mobilization/manual therapy Iontophoresis in selected cases Iontophoresis in selected cases Home therapy programHome therapy program
Treatment: Treatment: PharmacologicPharmacologic
NSAIDS-scheduled dosingNSAIDS-scheduled dosing Muscle relaxantsMuscle relaxants TricyclicsTricyclics OpioidsOpioids Steroid injectionSteroid injection Botox injectionBotox injection
*UW TMD clinic does not find muscle *UW TMD clinic does not find muscle relaxants very useful, does not use relaxants very useful, does not use tricyclics, rarely opioidstricyclics, rarely opioids
Treatment: Bite SplintTreatment: Bite Splint
Indications:Indications: AM symptoms, daytime clenching, teeth AM symptoms, daytime clenching, teeth
are wornare worn Worn only at nightWorn only at night Does not move jaw (not an anterior Does not move jaw (not an anterior
repositioning splint)repositioning splint)
Evidence Based MedicineEvidence Based Medicine
Limited Evidence, recommendedLimited Evidence, recommended NIH Phase I and II treatments discussed NIH Phase I and II treatments discussed
previouslypreviously Limited Evidence, needs further studyLimited Evidence, needs further study
AcupunctureAcupuncture EMG biofeedbackEMG biofeedback
Limited Evidence, not recommendedLimited Evidence, not recommended Occlusal adjustments that permanently alter a Occlusal adjustments that permanently alter a
patient’s occlusion (Grinding teeth down, patient’s occlusion (Grinding teeth down, anterior repositioning splints)anterior repositioning splints)
Alloplastic implantsAlloplastic implants
Local ResourceLocal Resource
UW TMD Clinic: 263-7502UW TMD Clinic: 263-7502 Lisa M. Dussault, OTR, John F. Doyle Lisa M. Dussault, OTR, John F. Doyle
DDSDDS Imaging as indicatedImaging as indicated Referral to specialists as indicatedReferral to specialists as indicated
Rehab Med psychologist, Rehab Med psychologist, Oral/craniofacial surgery, Oral/craniofacial surgery, speech/swallow, etcspeech/swallow, etc
Indications for ReferralIndications for Referral
Trauma to the face at onset of painTrauma to the face at onset of pain Joint noise PLUS dysfunctionJoint noise PLUS dysfunction Locking/catching of TMJLocking/catching of TMJ Limitation of opening/ROMLimitation of opening/ROM Pain in jaw and muscles of Pain in jaw and muscles of
mastication on awakeningmastication on awakening Orofacial pain aggravated by jaw Orofacial pain aggravated by jaw
functionfunction