TEMPOROMANDIBULAR DISORDERS - PowerPoint Presentation

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TEMPOROMANDIBULAR DISORDERS

Dr

Gitanjali

Khulbe

MDS, OMR

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Introduction:

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.

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Functional 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.

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Condylar

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.

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The superior head of the lateral

pterygoid

is also thought to be active during closing movements.

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Unilateral 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

.

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Translation 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.

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Contraction of the

digastric

muscle produces a depression and retro-positioning of mandible.

The

buccinator

helps position the cheek during chewing movements of the mandible.

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Etiology 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.

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Several 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.

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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.

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It 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.

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Masticatory 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

.

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Waking

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.

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Central 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.

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Psychological 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.

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Trauma:

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.

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Classification 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.

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I. 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

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D.

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

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2. Contracture

3. Hypertrophy

4. Neoplasm

5. Movement disorders

6.

Masticatory

muscle pain attributed to systemic/central

pain disorders.

III. Headache

IV. Associated structures

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Assessment 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.

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History:

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.

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Regional

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.

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Diagnostic 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.

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Scintigraphy

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.

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Diagnostic 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.

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Management:

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.

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Treatments should be relatively accessible, affordable, safe and reversible.

A sequence of the following events can be taken into consideration.

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1. 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.

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2. 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.

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3. 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.

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4. 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

.

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5. 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.

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6. 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.

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A 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.

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7. 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.

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8. 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.

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Conclusion:

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.