Principles of TMJ. This information is property of Lang Ho and should not be reproduced without permission. 1. The Plan / Objectives.

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1 Principles of TMJ Examination and Treatment The Plan / Objectives 1. Identify common elements in the history/symptoms of a patient with TMD. 2. Discuss TMD screening tools and methods and the principles behind them. 3. Suggest interventions that can provide relief to patients with TMD. 4. Discuss referral to other healthcare providers. History/Symptoms Pain Location Activity Onset Trauma or Hx of Trauma Long-standing problem Joint noises Motion Limits Locking Other permission. 1

2 History/Symptoms Pain Location History/Symptoms Pain Activities Chewing Yawning/Opening Talking/Laughing Smiling Oral Hygiene Brushing/Flossing Dental Cleanings Generally worse in the morning Clenching Grinding History/Symptoms Onset Stress Trauma Facial Non-facial Insidious/Unknown permission. 2

3 History/Symptoms Joint Noises Click/Pop Grind (Crepitus) Clunk History/Symptoms Motion Limits Limited Opening Locking Closed Lock Open Lock History/Symptoms Other Doesn t look like TMD, but is Headache Tooth pain Ear Symptoms Ringing Fullness Hearing Loss Dizziness Looks like TMD, but isn t Cardiac Issues Cervical Muscle Dysfunction permission. 3

4 96% Jaw symptoms pain, limited opening, popping, locking. 69% Neck pain 74% of those had headaches concurrent with neck pain 67% Bruxism 60% Ear symptoms Pain, ringing, fullness, subjective hearing loss 951 consecutive patients Eight times higher in those with TMD (30 of 82 ; 38 of 869) Examination Joint noises Crepitus Click Clunk ROM Direction of opening Amount of opening Palpation Joint (pain, movement) Muscle Headache permission. 4

5 Structural Components of the TMJ Structural Component Disc Structural Components - Condyle permission. 5

6 Structural Components - Eminence The Yoint Video Subluxation (Clunk) Anatomy permission. 6

7 Subluxation (Clunk) Muscles of Mastication Elevators Masseter Temporalis Lateral Excursion Medial Pterygoid Lateral Ptreygoid Depression Suprahyoids Range of Motion Abnormal Opening Unilateral deviation C-Curve S-Curve Limited Opening Excessive Opening Limited Lateral Excursion permission. 7

8 Unilateral Deviation C-Curve S-Curve permission. 8

9 Opening (40mm) Restricted Opening (< 40mm) Excessive Opening permission. 9

10 Lateral Excursion (7mm) Temporomandibular Joint Muscles: Masseter permission. 10

11 Muscles: Temporalis Muscles: Medial Pterygoid Muscles: Lateral Pterygoid permission. 11

12 Anterior Capsule/Disc Connection Headaches Primary headaches Migraine Tension-Type Trigeminal Autonomic Cephalalgia Cervicogenic Headache Myogenic Headache / Referred Muscle Pain permission. 12

13 Classification Group I: Masticatory Muscle Disorders Myofascial pain Myofascial pain with limited opening Group II: Disc Displacements Disc displacement with reduction Disc displacement without reduction with limited opening Disc displacement without reduction without limited opening Group III: Joint Dysfunction Arthralgia Osteoarthritis Osteoarthrosis Group I: Masticatory Muscle Disorders Painful muscles Pain-free opening of 40+mm <40mm is designated as with limited opening permission. 13

14 Group II: Disc Displacement With Reduction: Reproducible clicking Opening, excursion, or protrusion Without Reduction w/ Limited Opening Limited opening, contralateral lateral excursion Previously had a click, but not currently Without Reduction w/o Limited Opening History of locking No major opening limitations Imaging to confirm disc displacement Group III: TMJ Arthralgia/Capsulitis Arthralgia TMJ pain No crepitus Osteoarthritis Crepitus TMJ pain Osteoarthrosis Crepitus No TMJ Pain Physical Therapy Treatments Patient Education Myofascial Treatment/Soft Tissue Mobilization Joint mobilizations Exercises Rocabado s 6x6 Range of Motion Relaxation/Breathing Posture/Ergonomics: Sleep, Work Modalities: US, E-Stim, Ionto, Heat, Cold, Spray and Stretch, Kinesiotape permission. 14

15 Patient Education Parafunction/Oral Habits Avoid chewing tough foods, hard foods, or gum Bagels, Steak, hard veggies, etc. While irritable, chew on uninvolved side Progress to chewing with both sides simultaneously Reduce caffeine intake Avoid extra pressure to the jaw Sleep position Leaning on hands Myofascial Treatment/Soft Tissue Mobilization Masseter Supine Gentle pressure Be aware of the Perotid Gland Temporalis Supine Pterygoids Sitting Sustained Pressure Alternative techniques Graston Dry Needling TMJ Mobilization Distraction Grade I-IV Distraction + Anterior Glide Grade III-IV Medial/Lateral Glide permission. 15

16 Joint Mobilization Exercises: Rocabado s 6x6 Tongue positioning Controlled TMJ Rotation Mandibular Rhythmic Stabilization Upper Cervical Flexion Lower Cervical Retraction Scapular Depression/Retraction 6x6 Tongue Positioning Resting on the roof of the mouth permission. 16

17 6x6 TMJ Rotation Palpate the TMJ on both sides 6x6 Rhythmic Stabilization Resist against light pressure in all directions Exercises: Tongue Depressor Stretch Resting in the back molars permission. 17

18 Exercises: Knuckle Stretch Exercises: Self-Overpressure Finger Stretch Exercises: Lateral Excursion AROM permission. 18

19 Exercises: Relaxation Coach on Diaphragmatic Breathing Use of calming sounds/music Combine with tongue resting position and soft tissue work Sleep Posture Evidence Efficacy of Treatment Manual Therapy Manual Therapy and Therapeutic Exercise Massage and Occlusal Splint Rocabado s 6x6 permission. 19

20 Moderate-to-High grade evidence: Myofascial Release and Massage was better than nothing, but the same as botulinum injections Upper cervical mobilization/manipulation was effective Thoracic manipulation was not effective Low quality evidence due to high or unclear risk of bias Manual therapy alone or in combination with exercise at the jaw or cervical level showed promising effects. No significant influence on Electromyographic activity of the masseter or anterior temporal muscles Combination of therapies reduced the intensity of signs and symptoms in those with severe TMD and bruxism permission. 20

21 6x6 Mixed Evidence Does not support Mulet, 2007, J of Orofacial Pain 45 patients with primary myofascial pain in the masticatory muscles Self-care vs. self-care and 6x6 Jaw pain, neck pain, change in head posture showed significant improvement in both groups p < 0.01 Does support Mulla, 2015, Int J Physiother 30 subjects with TMD Conventional TMJ exercises vs 6x6 and conventional exercises VAS, TMJ ROM, Fonseca s questionnaire and JFLS scores significantly improved p < 0.05 Other Treatments/Providers Physicians Pharmacotherapies Dentists Splint Therapy Arthrocentesis Trigger Point Injection Psychiatrists/Psychologists Cognitive Behavioral Therapy Splint Therapy Ebrahim, 2012, JADA Moderate quality evidence suggests reduced pain Low quality evidence suggests no impact on quality of life or depression permission. 21

22 Arthrocentesis Vos, 2014, Journal of Cranio-Maxillo-Facial Surgery Arthrocentesis yielded faster improvements in pain and maximal mouth opening compared to conservative treatments Both approaches appeared to reach similar outcomes by 26 weeks. Trigger Point Injection Ozkan, 2011, Agri Trigger point injections with splint therapy were more effective than splint therapy alone for jaw pain in myofascial TMD patients. Cognitive Behavioral Therapy Ferrando, 2012, Oral Medicine CBT, including hypnosis, had better reductions in pain frequency and emotional distress than conservative standard treatment alone. permission. 22

23 Ask of the audience Ask your patients about this Where were you four years ago? Take a moment and consider which patients on your schedule might have TMD symptoms. Ask them at their next appointment. References Armijo-Olivo, S., Pitance, L., Singh, V., Neto, F., Thie, N., & Michelotti, A. (2016). Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis. Phys Ther, 96(1), doi: /ptj Buergers, R., Kleinjung, T., Behr, M., & Vielsmeier, V. (2014). Is there a link between tinnitus and temporomandibular disorders? J Prosthet Dent, 111(3), doi: /j.prosdent Calixtre, L. B., Moreira, R. F., Franchini, G. H., Alburquerque-Sendín, F., & Oliveira, A. B. (2015). Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: a systematic review of randomised controlled trials. J Oral Rehabil, 42(11), doi: /joor Coskun Benlidayi, I., Salimov, F., Kurkcu, M., & Guzel, R. (2016). Kinesio Taping for temporomandibular disorders: Single-blind, randomized, controlled trial of effectiveness. J Back Musculoskelet Rehabil, 29(2), doi: /bmr Dwyer, A., Aprill, C., & Bogduk, N. (1990). Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Spine (Phila Pa 1976), 15(6), Ebrahim, S., Montoya, L., Busse, J. W., Carrasco-Labra, A., Guyatt, G. H., & Group, M. U. S. R. (2012). The effectiveness of splint therapy in patients with temporomandibular disorders: a systematic review and meta-analysis. J Am Dent Assoc, 143(8), Ferrando, M., Galdón, M. J., Durá, E., Andreu, Y., Jiménez, Y., & Poveda, R. (2012). Enhancing the efficacy of treatment for temporomandibular patients with muscular diagnosis through cognitive-behavioral intervention, including hypnosis: a randomized study. Oral Surg Oral Med Oral Pathol Oral Radiol, 113(1), doi: /j.tripleo References Gomes, C. A., El Hage, Y., Amaral, A. P., Politti, F., & Biasotto-Gonzalez, D. A. (2014). Effects of massage therapy and occlusal splint therapy on electromyographic activity and the intensity of signs and symptoms in individuals with temporomandibular disorder and sleep bruxism: a randomized clinical trial. Chiropr Man Therap, 22(1), 43. doi: /s Grondin, F., Hall, T., Laurentjoye, M., & Ella, B. (2015). Upper cervical range of motion is impaired in patients with temporomandibular disorders. Cranio, 33(2), doi: / z Harrison, A. L., Thorp, J. N., & Ritzline, P. D. (2014). A proposed diagnostic classification of patients with temporomandibular disorders: implications for physical therapists. J Orthop Sports Phys Ther, 44(3), doi: /jospt Ho, S. (2011). The Temporomandibular Joint: Physical Therapy Patient MAnagement Utilizing Current Evidence: Orthopaedic Section, APTA, Inc. Kraaijenga, S., van der Molen, L., van Tinteren, H., Hilgers, F., & Smeele, L. (2014). Treatment of myogenic temporomandibular disorder: a prospective randomized clinical trial, comparing a mechanical stretching device (TheraBite ) with standard physical therapy exercise. Cranio, 32(3), doi: / z Kraus, S. L. (2014). Characteristics of 511 patients with temporomandibular disorders referred for physical therapy. Oral Surg Oral Med Oral Pathol Oral Radiol, 118(4), doi: /j.oooo permission. 23

24 References La Touche, R., Fernández-de-las-Peñas, C., Fernández-Carnero, J., Escalante, K., Angulo-Díaz- Parreño, S., Paris-Alemany, A., & Cleland, J. A. (2009). The effects of manual therapy and exercise directed at the cervical spine on pain and pressure pain sensitivity in patients with myofascial temporomandibular disorders. J Oral Rehabil, 36(9), doi: /j x Mulet, M., Decker, K. L., Look, J. O., Lenton, P. A., & Schiffman, E. L. (2007). A randomized clinical trial assessing the efficacy of adding 6 x 6 exercises to self-care for the treatment of masticatory myofascial pain. J Orofac Pain, 21(4), Mulla, N. S., K, V. B., N, S. K., & Rizvi, S. R. (2015). EFFECTIVENESS OF ROCABADO S TECHNIQUE FOR SUBJECTS WITH TEMPOROMANDIBULAR JOINT DYSFUNCTION A SINGLE BLIND STUDY. In (Vol. 2, pp ): International Journal of Physiotherapy. Ozkan, F., Cakır Özkan, N., & Erkorkmaz, U. (2011). Trigger point injection therapy in the management of myofascial temporomandibular pain. Agri, 23(3), Piovesan, E. J., Kowacs, P. A., Tatsui, C. E., Lange, M. C., Ribas, L. C., & Werneck, L. C. (2001). Referred pain after painful stimulation of the greater occipital nerve in humans: evidence of convergence of cervical afferences on trigeminal nuclei. Cephalalgia, 21(2), Schiffman, E., Ohrbach, R., Truelove, E., Look, J., Anderson, G., Goulet, J. P.,... Orofacial Pain Special Interest Group, I. t. A. f. t. S. o. P. (2014). Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache, 28(1), References Stelzenmueller, W., Umstadt, H., Weber, D., Goenner-Oezkan, V., Kopp, S., & Lisson, J. (2016). Evidence - The intraoral palpability of the lateral pterygoid muscle - A prospective study. Ann Anat, 206, doi: /j.aanat Travell, J., & Simons, D. (1996). Travell & simons' trigger point flip charts (1st ed.). Baltimore, Maryland: Williams and Wilkins. Travell, J. G., & Simons, D. G. (1983). Myofascial pain and dysfunction : the trigger point manual. Baltimore: Williams & Wilkins. von Piekartz, H., & Hall, T. (2013). Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Man Ther, 18(4), doi: /j.math Vos, L. M., Huddleston Slater, J. J., & Stegenga, B. (2014). Arthrocentesis as initial treatment for temporomandibular joint arthropathy: a randomized controlled trial. J Craniomaxillofac Surg, 42(5), e doi: /j.jcms permission. 24