Evaluation & Treatment of Temporomandibular Joint Dysfunction

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Evaluation & Treatment of

TMD

Presented by:

Christy Dauner, OTR

Laurie Applebee, PT

Susan Vaughn, MS, OTR

Learning Objectives

Identify TMD risk factors and related diagnoses

Differentiate joint and muscle disorders

Understand goals of Occupational Therapy for

TMD

Understand OT treatments for TMD and muscle disorders

Perform assessment and treatment approaches for TMD

Disorders of the TMJ

Myofascial Dysfunction

Internal Derangement

Capsulitis

Subluxation

Arthritis

Risk Factors for TMD

Trauma such as blow to the jaw, whiplash injuries, MVA, dental work, opening the mouth too wide or for too long, prolonged chewing

Oral parafunctional habits such as clenching and bruxism that place continued strain on the masticatory system

Malocclusion causes bite instability or functional interference during chewing that places postural strain on the masticatory system

Stressful life events can trigger parafunctional habits and muscle guarding/tension

Emotional factors such as depression or anxiety decreases the ability to cope with pain and can increase parafunctional habits.

TMJ Evaluation

History & Symptoms (referred pain)

Functional Limitations

Tests, Measures & Palpation

AROM (active/passive incisal opening, lateral excursion, and protrusion)

PROM – scissor stretch

TMJ Noise

Muscle Palpation

Differential Diagnosis

Scissor stretch test: if opens further muscular, if not - internal derangement

Clench test: bite down on tongue depressor for 10 – 15 seconds. Pain on same side – muscle, opposite side – joint

“S” vs. “C” curve with opening

Occupational Therapy

Goals for TMD

Increase ROM to >40mm

Decrease pain

Teach joint protection (decrease parafunctional habits, limited opening)

Improve function (eating, yawning, DDS visit tolerance, oral hygiene, talking, sleep, work)

HEP independence

Neutral posture (head on neck, jaw, scapular position, TUTA)

Myofascial Pain Dysfunction

Most common disorder

Referred muscle pain

Muscle pain aggravated by jaw function or parafunction

HA’s

Tenderness of muscles w/o mechanical symptoms

Loss of motion or painful motion

Myofascial Pain Dysfunction

Caused by an underlying related disorder

– malocclusion, arthritis, internal derangement, poor posture

Education is key! – posture, parafunction, stress management

Often chronic and cyclical

Often a myofascial component with all diagnoses

Myofascial Dysfunction

Myofascial contributors may include:

* Lateral pterygoid

* Medial pterygoid

* Temporalis

* Masseter

* Digastrics

* Muscles of the cervical spine

Lateral Pterygoid

Origin: Lateral Pterygoid Plate of Sphenoid

Insertion: Condylar Neck, Ramus of Mandible and Disc

TMJ Muscles – Lateral Pterygoid

#1 myofascial source of pain

Due to attachment to disc it can cause disc and jaw to be unable to return to normal resting position and cause clicking or popping.

Malocclusion of teeth/missing teeth

Referral pattern – zygomatic arch,

TMJ

Medial Pterygoid

Origin: Inner Surface of Lateral Pterygoid Plate

Insertion: Ramus of Mandible by the Angle

TMJ Muscles – Medial Pterygoid

Stuffiness in ear

Swallowing difficulty as restriction in protrusion of jaw

Referral pattern – posterior mandible, mouth, below and behind TMJ including internal ear – not teeth

Temporalis

Origin: Temporal Fascia, Superior to Zygomatic Arch

Insertion: Coronoid Process of Mandible

TMJ Muscles - Temporalis

Significant postural muscle (the only time it isn’t working is when you’re lying supine)

Perpetual clenching

Referral pattern – lower jaw, molar teeth and gum, maxilla, lower portion of mandible, temple eyebrow and external ear

Masseter

Origin: Zygomatic Arch

Insertion: Mandibular Angle and Ramus

TMJ Muscles - Masseter

“Sinusitis”

Referral pattern - temple, along eyebrow, behind eye or upper teeth

Digastrics

Origin: Mastoid Notch (posterior), Symphysis of Mandible

(anterior)

Insertion: Join by a Common Tendon to the Hyoid Bone

TMJ Muscles - Digastrics

Rarely in spasm due to forward head posture (stretch weakness)

Referral pattern – behind mandible toward back of ear, lower incisors

Cervical Spine Muscles

Form stable base for TMJ on which to work

Poor posture – condyle rotates backward – change of biomechanics

Referral pattern from the cervical spine-

Temporal Headaches, SCM

Assess for tension in upper traps, scalenes, and SCM

Parafunctional Behaviors

Gum/candy chewing (chewing limited to 15 – 20 minutes/day!) – including chewing on one side

Clenching/bruxing/grinding

Leaning on chin/jaw

Biting nails, pencils, cheeks

Sleep position

Caffeine use

Musical instruments

Mouth breathing

Phone cradling

Treatment – Myofascial Pain

Dysfunction

Modalities: US - 1.0 – 1.2 w/cm2, 3 MHz, x5 minutes to joint or muscle, heat, electrical stimulation

Manual Therapy – joint mobs/distraction, MFR – including upper cervical region

HEP/Lifestyle changes

Tongue positioning (TUTA)

Self-joint distraction &/or MFR

Eliminating parafunctional behaviors

Postural instruction

Conjunction with splint therapy &/or counseling (Referral to psychology for CBT as needed for stress and anxiety management)

Resting Joint Position

Capsule – anterior/posterior only

Normal Joint Motion

Internal Derangement

Disc Disorder

Internal Derangement

Disc held in place by collateral ligaments and posterior ligament, w/ movement dictated by lateral pterygoid

Click, pop, lock

Pain at joint

“S” shaped opening/closing to reposition jaw

Eye pain

History of trauma

Treatment – Internal Derangement

Modalities: Iontophoresis, electrical stimulation, cold – ice massage

Manual therapy – Joint distraction

Joint protection techniques: Limit motion to no noise, soft food diet or chewing behaviors

Home exercise instruction

Change parafunctional behaviors

Self joint distraction techniques

Tongue positioning for relaxation (TUTA)

Postural instruction and controlled opening/neuromuscular re-education

Treatment - Other

Capsulitis

Usually a result of another disorder unless post surgery

Modalities, MT and HEP

Subluxation

Excess opening (>40 mm)

Usually a component of myofascial pain dysfunction, and treated as this, with addition of stab exercises and controlled opening

Treatment - Other

Arthritis

Generalized joint pain and inflammation

Usually seen in conjunction w/ other Dx

Joint protection, rest

Stretching, therapeutic exercise

Modalities (cold vs. heat, pulsed US, phono/iontophoresis, E-stim)

Intervention: Dentist

Assess occlusion

Parafunctions of clenching/bruxing

Malocclusions

Pressure on back teeth activate temporalis an superior head of lateral pterygoid, anterior teeth activate masseters

Lab - Evaluation

AROM (Therabite)

Active Incisal Opening (Normal 40-60 mm)

Passive Incisal Opening (Normal 42-62 mm)

Lateral Excursion (Normal >7 mm)

Protrusion (Normal > 7 mm)

Lab - Evaluation

TMJ Palpation/Observation

Quality of Motion:

Smooth/Rigid/Jerky/Guarded/Fasciculation/

Thrusting

TMJ Noise: Opening Click, Closing Click,

Reproducible

Visually Assess Opening (S or C Shaped Curve)

Lab

Muscle Palpation

Medial Pterygoid (elevation, protrusion, and lateral deviation to opposite side)

Place index finer on muscle at inside of bottom teeth in mouth. Place opposite thumb under jaw line below ear.

Apply pressure to muscle as if to touch finger and thumb.

Move along gum line until reach incisors in front. Hold until relaxes 1-2X/day

Lateral Pterygoid (elevation, protrusion, and lateral deviation to opposite side)

Place index finger inside mouth, under cheek bone. Point finger up and towards opposite eye. Apply pressure to muscle until it relaxes. To check positioning of finger, actively move jaw in opposite direction and muscle will contract under finger. Hold until relaxes 1-2X/day

Lab

Manual Therapy

Trigger point release

Joint distraction

Place thumb on back, bottom molar and wrap fingers under jaw

Press down as you lift on jaw in scooping motion

Do NOT pull jaw forward

Thank You

Feel free to contact Christy at 952-908-2567 or at Christyd@pdrclinics.com

with questions.

PDR Clinic Locations: Edina, Burnsville,

Maplewood, Burnsville, Chanhassen

Specializing in the treatment of chronic neck, back and TMJ pain.

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