Dr Gitanjali Khulbe MDS OMR Introduction The TMJ is a ginglymoarthroidal multiaxial synovial joint of the condylar type Its articular surfaces are subjected to loads of 520 N ID: 911500
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Slide1
TEMPOROMANDIBULAR DISORDERS
Dr
Gitanjali
Khulbe
MDS, OMR
Slide2Slide3Introduction:
The TMJ is a
ginglymoarthroidal
,
multiaxial
, synovial joint, of the
condylar
type.
Its
articular
surfaces are subjected to loads of 5-20 N.
Temporomandibular
disorder (TMD) is a collective term embracing a number of clinical disorders that involve the
masticatory
muscles, the TMJs and associated structures, or both.
Slide4Slide5Functional Anatomy of TMJ:
Average rotation of the
condyle
is estimated to be 24°.
During translation, the
condyle
-disc complex glides along the posterior slope of the
articular
eminence.
Slide6Condylar
translation extends 13-15 mm before achieving maximum mouth-opening.
Mandibular
movements toward tooth contact are performed by contraction of the
masseter
,
temporalis
and medial
pterygoid muscles.
Slide7The superior head of the lateral
pterygoid
is also thought to be active during closing movements.
Slide8Unilateral contraction of the medial
pterygoid
contributes to
contralateral
movement of mandible.
Posterior part of the
temporalis
contributes to
mandibular
retrusion.
Masseter
contraction contributes to moving the
condylar
head toward the anterior slope of
mandibular
fossa
.
Slide9Slide10Translation of the
condylar
head onto the
articular
eminence is produced by contraction of the lateral
pterygoid
.
The inferior head is thought to be active during protrusive and opening movements.
Slide11Contraction of the
digastric
muscle produces a depression and retro-positioning of mandible.
The
buccinator
helps position the cheek during chewing movements of the mandible.
Slide12Etiology and Classification of TMDs:
Exact etiology of the TMDs is largely unknown.
Multiple factors often when present together, contribute to the initiation, aggravation and/or perpetuation of the disorder.
Slide13Several causes have been hypothesized, which can be broadly grouped into:
-
occlusal
disharmony
- muscle hyperactivity
- central pain mechanisms
- psychological distress
- trauma
A final initiating event, occurring in conjunction with already existing risk factors,
may lead to a TMD.
Occlusal disharmony:
Evidence for
occlusal
disharmony as a primary etiology does not exist.
Significant differences in
occlusal
characteristics are not found between patients with
myofascial
pain compared with control subjects.
A relationship between tooth loss and
osteoarthrosis
has been observed.
Slide15It is equally logical to assume a reversed causal pattern.
Some patients with unilateral non-reducing ADD have reported
hyperocclusion
of the molars on
ipsilateral
side.
Slide16Masticatory muscle hyperactivity:
Muscle hyperactivity is separated into sleep
bruxism
and waking
parafunction
.
A variety of studies have linked sleep
bruxism
to pain.
However, empirical data demonstrates that TMJ pain and clicking are unrelated to severe tooth wear from
bruxism
.
Slide17Waking
parafunction
includes tooth clenching and muscle guarding.
Tooth clenching might be a source of pain in some individuals………
Oral
parafunctional
behaviors exhibit a substantial association with chronic TMD pain.
Slide18Central pain mechanisms:
The Pain-Adaptation model is based on observations that EMG activity and force output of the muscle are lower in TMD patients.
Number of experimental studies support the hypothesis that pain is caused by altered CNS processing.
It may also be a result of TMD pain, rather than the cause.
Slide19Psychological distress:
Two pathways by which psychological distress leads to TMD have been proposed.
Distress leads to
parafunctional
behaviors which in turn causes muscle pain.
It may result in overall increased risk for an individual to experience pain in response to an event.
Psychological distress might also be a consequence of chronic pain.
Slide20Trauma:
Conflicting conclusions emerge from different studies.
In a case-control study, individuals with chronic TMD reported trauma at a high rate.
However, trauma may also be a perpetuating factor.
More research is needed to establish a definite relationship.
Slide21Classification of TMDs:
Several classification systems have been proposed.
The American Academy of
Orofacial
Pain has devised a taxonomic classification for TMDs, currently called DC/TMD.
It allows for multiple TMD diagnoses for an individual, broadly classifying TMDs into TMJ and
masticatory
muscle disorders.
Slide22I. TMJ disorders
1. Joint pain
A.
Arthralgia
B. Arthritis
2. Joint disorders
A. Disc disorders
B.
Hypomobility
disorders other than disc disorders C.
Hypermobility
disorder
3. Joint diseases
A. Degenerative joint disease
B. Systemic
arthritides
C. Idiopathic
condylar
resorption
Slide23D.
Osteochondritis
dissecans
E.
Osteonecrosis
F. Neoplasm
G. Synovial
chondromatosis
4. Fractures
5. Congenital/developmental disorders
II.
Masticatory
muscle disorders
1. Muscle pain
A.
Myalgia
B. Tendonitis
C.
Myositis
D. Spasm
Slide242. Contracture
3. Hypertrophy
4. Neoplasm
5. Movement disorders
6.
Masticatory
muscle pain attributed to systemic/central
pain disorders.
III. Headache
IV. Associated structures
Slide25Assessment of TMDs:
A thorough history, clinical examination and diagnostic imaging are the main approaches.
Diagnostic imaging is of value in selected conditions but not routinely.
If the choice of treatment depends on a more accurate diagnosis, imaging is preferred.
Slide26History:
The most common symptom is pain, other chief complaints being restricted jaw movement, painful or loud clicking or
crepitus
, and jaw locking.
Pain severity or intensity is a subjective measure which can be rated, either verbally or on a numeric scale.
For rating prior pain periods, a time span is required, commonly last 30 days, 3 months and 6 months.
Slide27Regional
myofascial
pain should be influenced by
mandibular
function, in order to be a TMD.
Other symptoms commonly reported in association with a TMD include earache, facial swelling, redness of eyes, nasal congestion, numbness, tingling or burning, altered vision, muscle twitching and jaw misalignment.
Slide28Diagnostic Imaging:
Imaging should be ordered only when a clinical hypothesis can be answered using the image.
CT is the imaging of choice for
osteodegenerative
joint disease.
MRI is the method of choice for diagnosing alterations in
articular
disc form and position.
Radioisotope scanning has been used to detect
condylar
hyperplasia.
Slide29Scintigraphy
is sensitive but not specific for TMJ disease.
CBCT can detect degenerative changes of flattening, erosion,
osteophytes
,
subcondylar
cysts and sclerosis.
Ultrasonography
has been widely employed to detect TMJ effusion and disc displacements.
Slide30Diagnostic nerve blocks:
Injections of anesthetics into the joint or muscles may
nhelp
confirm a differential diagnosis.
Injecting should eliminate pain from the site and also the referred pain associated with the trigger point.
However, a positive result does not ensure a specific diagnosis.
Slide31Management:
Treatment goals for TMDS can be divided into levels:
Control of pain, improvement in
mandibular
motion, restoring function
Monitoring impact to the person by pain, methods to restore general functioning and strategies for relapse prevention.
Slide32Treatments should be relatively accessible, affordable, safe and reversible.
A sequence of the following events can be taken into consideration.
Slide331. Education and information
Explaining the nature of the disorder and giving time in an unhurried environment.
Allowing the patient to express his/her concerns and to participate in the treatment protocol.
Slide342. Self-management:
The core activities which can be performed by the patient include muscle stretching, use of thermal agents, avoidance of strain or overuse, and
parafunctional
behavior control.
Monitoring is best achieved by the patient using a mirror.
Education plus home physical therapy has been found to be effective.
Slide353. Physiotherapy:
It is a reasonable part of initial therapy.
Passive modalities such as ultrasound, cold laser, and
transcutaneous
electrical nerve stimulation (TENS) are typically used to reduce pain.
Active stretching can be used to increase the ROM gradually.
A physiotherapist trained in managing TMDs can also be consulted.
Slide364. Intraoral appliances:
Splints or bite guards or night guards are the appliances used in the treatment.
A decrease in
masticatory
muscle activity has been associated with splint therapy.
Appliance therapy provides joint stabilization, protect the teeth, redistribute forces, relax elevator muscles and decrease effects of
bruxism
.
Slide375. Pharmacotherapy:
Mild analgesics, NSAIDs, muscle relaxants are medications used as part of initial treatment.
A combination of acetaminophen and ibuprofen is more effective.
Topical NSAIDs have demonstrated significant pain-reducing effects.
Clonazepam
and
amitriptyline
have proven to be effective in chronic
orofacial
pains.
Slide386. Behavioral therapy and Relaxation techniques:
A clinician competent in behavioral therapy has a greater chance of addressing the issues.
Relaxation techniques generally decrease sympathetic activity.
Cognitive behavioral therapy (CBT) is focused on changing patterns of negative thoughts.
Slide39A six-session CBT intervention has shown to enhance the treatment effect of usual TMD treatment.
Biofeedback is a treatment that provides continuous feedback of the patient in monitoring the electrical activity of muscle or peripheral temperature.
Slide407. Trigger point therapy:
This makes use of two modalities.
“Spray and stretch” therapy is performed by cooling the skin with a refrigerant spray (
fluoromethane
) and stretching the involved muscle.
Intramuscular trigger point injection involves
durect
injection of LA into the muscle.
Slide418. Other treatments:
Acupuncture has been shown to be effective in the management.
Botulinum
toxin has been tried but yet not proven to be beneficial.
Acupressure, massage therapy, naturopathic and homeopathic remedies and herbal agents are the other options.
Slide42Conclusion:
With the increasing stressful and challenging life situations, TMDs are becoming more prevalent in the society.
It is time we incorporate a comprehensive and multi-modality approach towards the understanding and management.