Up Date on TMD WHAT IS TMD? Temporomandibular Disorders (TMD)*: Donald Nixdorf DDS, MS

Transcription

1 Up Date on TMD Donald Nixdorf DDS, MS Associate Professor Division of TMD and Orofacial Pain WHAT IS TMD? Temporomandibular Disorders (TMD)*: MUSCLE and JOINT DISORDERS * Temporomandibular Muscle and Joint Disorders (TMJD) Temporalis Temporomandibular joint Lateral pterygoid Massester Medial pterygoid 1

2 Presentation HISTORY: No experience of pain or locking EXAM: No TMJ noises Active opening 40 mm Lateral movement 7 mm No pain with range of motion of jaw IMAGING: No positive findings 2

3 DC/TMD Axis I: Clinical TMD Conditions I. Pain Disorders" II. 1. Myalgia " 2. Myofascial pain referral "" 3. Headache attributed to TMD" 4. Arthralgia "" Extra and Intra-articular Disorders" 1. Disc displacement with reduction" 2. Disc displacement with intermittent limited opening "" 3. Disc displacement without reduction with limited opening " 4. Disc displacement without reduction without limited opening" 5. Degenerative joint disease" 6. Dislocation " " Diagnostic Criteria for Myalgia History: Location of pain confirmed during exam 1. In the last 30 days, have you had pain in the face, jaw, temple, in front of the ear, or in the ear? AND 2. Is this pain changed with jaw movement, function or parafunction? PLUS Examination: 1. Palpation results in report of FAMILIAR pain (1 kilogram) a. Temporalis muscle: posterior, middle, and anterior, or b. Masseter muscle: origin, body, and insertion OR 2. Opening movements results in FAMILIAR pain (temporalis or masseter muscles) a. Maximum unassisted, or b. Maximum assisted opening Familiar pain is pain that is similar or like their pain complaint Sensitivity 90% / Specificity 99% Presentation of TMD Myalgia HISTORY: Dull achy pain in the face (bilateral), 1-6/10 intensity, frequency of continuous to episodic, made worse with chewing, made better with rest & NSAIDs, ±sensation of muscle stiffness / tightness EXAM: ±TMJ noises, normal to restricted opening 20 (soft end feel), muscle palpation reproduces complaint of pain. No dental or sinonasal disease. IMAGING: No positive findings History: Diagnostic Criteria for Myofascial Pain with Referral 1. Same as Myalgia Examination: 1. Same as Myalgia PLUS AND 2. Report of pain with palpation at a site beyond the boundary of the muscle(s) being palpated. Sensitivity 86%; Specificity 98% Masseter Muscle Simons and Travell: Temporalis Muscle Simons and Travell: 3

4 Lateral Pterygoid Muscle Simons and Travell: Anterior Digastric Muscles Simons and Travell: ARTHRALGIA/ ARTHRITIS (Synovitis/capsulitis) Diagnostic Criteria for Arthralgia History: location of pain confirmed during exam" 1. In the last 30 days, have you had pain in the face, jaw, temple, in front of the ear, or in the ear? " AND" 2. Is this pain changed with jaw movement, function or parafunction?" PLUS" Examination:" 1. Palpation of any joint site results in FAMILIAR joint pain" a. Lateral pole with fingertip applying (0.5 kilogram), or" b. Around the lateral pole (1 kilogram)." OR" 2. Range of motion results in FAMILIAR joint pain " a. Maximum unassisted opening, or " b. Maximum assisted opening, or" c. Lateral or protrusive movements" Familiar pain is pain that is similar or like their pain complaint Sensitivity 89% / Specificity 98% " Presentation of TMD Arthralgia HISTORY: Dull achy ear pain (unilateral), 1-6/10 intensity, frequency of continuous to episodic, made worse with chewing, made better with rest & NSAIDs, ±feeling of teeth not fitting, ±feeling of hearing changes EXAM: ±TMJ noises (click, grinding), palpation pain of joint duplicating complaint, restricted opening 30 (soft or hard end feel). No ear disease. IMAGING: CT reveals degenerative joint disease and/ or MRI reveals disc displacement 4

5 Disc Displacement with Reduction Disc Displacement without Reduction Flattening and Sclerosis Degenerative Joint Disease HOW COMMON IS TMD? Etiology: Role of Occlusion Prevalence of TMD pain in adults: 10% AGE (less pain with older age) GENDER (3:2 women>men & women report more pain) Incidence of TMD pain: 3% per year Demand for TMD treatment: 3% Treatment need is higher: ~8%...Occlusal therapy: Much controversy surrounds the use of occlusal therapy....based on available information, however, occlusal adjustments that permanently alter a patient s occlusion should be avoided. National Institutes of Health: Technology Conference: Management of Temporomandibular Disorders, JADA 1996: Second International Conference on Evidence-based Dentistry, 2006: Occlusal therapy should be avoided. This statement is still current today. 5

6 Etiology: Risk Factors Maixner et al, 2011 Trauma (macro & micro) ++ Anatomy (local & general)? Bruxism Chronic TMD - Acute TMD + Psychosocial +++ Genetic + Hormonal + Other pain disorders +++ HOW DO YOU TREAT TMD? Self Care Physical Therapy Health Psychology Appliance Therapy Pharmacotherapy Surgery Radiotherapy Targets of Treatment Contributing factors (initiate, perpetuate, or resultant) Biological Behavioral Social Environmental Emotional Cognitive Goals of Treatment Short term: Palliative: decrease pain & increase function Protective: prevent / minimize reoccurrence Therapeutic: encourage healing Long term Maintain control over symptoms If reoccurrence, home based management strategies Self Care Label (i.e., diagnosis) & reassure = optimistic counseling Awareness of oral parafunctional habits Jaw relaxation, posture, ways to limit exacerbations Diet alterations and nutritional supplements Discuss contributing factors (i.e. sleep positioning) Heat / ice application Avoid caffeine intake and chewing gum use Over-the-count medication use 6

7 Physical Therapy Education Rotation Relaxation Stretch Self mobilization Strengthening Coordination TENS / MENS Phonophoresis / Iontophoresis Health Psychology Education Management of mood disorders Behavior modification (sleep hygiene, oral parafunction, treatment compliance) Autonomic regulation (biofeedback tools) Relaxation (reduce muscle hyperactivity) Interpersonal therapy Appliance Therapy Flat-plane Appliance Often referred to as bite guard, splint, oral device, Research clearly demonstrates efficacy for a flatplane appliance (a.k.a. stabilization appliance) is helpful. Fricton et al, 2011 Problems: Only Anterior Support (NTI) Problems: Only Posterior Support 7

8 Pharmacotherapy NSAID analgesics and Acetaminophen Steroids Muscle relaxants Antidepressants Sedative and hypnotic agents Local anesthetics Opioid analgesics (almost never) Surgery <1% of patients proceed to surgery Minimally invasive treatment, joint lavage and/or arthrocentesis Orthagnathic surgery is NOT indicated Occlusal adjustments are NOT indicated RELATED to other DISORDERS? Prognosis worse with co-occurs with Fibromyalgia (FM) Irritable Bowel Syndrome (IBS) Chronic fatigue syndrome (CFS) Interstitial cystitis (IC) Vulvar vestibulitis syndrome (VVS) Chronic daily headaches WHAT IS THE OUTCOME? Groupings of factors: 1) Difficulty obtaining a diagnosis 2) Difficulty obtaining pain control A. Mental health, personality disorders and psychopathology (management issues) B. Pathology underlying the symptom of pain (things not to miss ) C. Pain-related conditions & health factors affecting the somatosensory and/or musculoskeletal systems Difficulty with Treatment Impacts of Pain Prior failed Treatment Communication issues Language Culture and social norms Co-morbid presentation of disorders Other pain conditions General health conditions Psychopathology Wrong diagnosis! 8