TMD Diagnosis & Therapeutic Intervention

Report
 Module 2 
Epidemiology of TMD &
Orofacial Pain

 Lipton et al surveyed 45,711 American households
(1993)
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3/8/14
22% reported at least 1 of 5 types of orofacial pain
Most common = toothache – 12.2%
TMJ pain = 5.3%
Face or cheek pain = 1.4%
T. Henkelmann, PT, MS, CCTT
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 Studies of non-patient populations
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75% have at least one sign of TMD
33% have at least one symptom
Average age = 33
Women to men ratio:
 Non-patient population is equal
 Patient population: 3:1 to 9:1 Why?
 I am seeing a great increase in teenager referrals
 I surmise 3 possible reasons: increased stress levels,
worsening posture, increased use of computers/hand-held
devices
3/8/14
T. Henkelmann, PT, MS, CCTT
3
Classification of TMD

Three major categories:
 Malocclusion = “bad bite”
 Arthrogenous = Joint-related
 Myogenous= Muscle-related
As PT’s, we can primarily effect only the latter two
categories
 These often overlap
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T. Henkelmann, PT, MS, CCTT
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Comorbid Conditions

 Orofacial pain is seldom an isolated complaint in just
the trigeminal system
 Fibromyalgia, chronic fatigue syndrome, headache,
depression, panic disorder, gastroesophageal reflux
disorder, irritable bowel syndrome, or posttraumatic
stress disorder may coexist with this condition
 Consider having resources available to refer patients
to, such as counselors, psychologists, women’s crisis
hotline
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T. Henkelmann, PT, MS, CCTT
5
Cardinal Symptoms of
TMD

 Pain/discomfort located in the preauricular area
which increases with jaw movement (chewing,
talking, yawning)
 Joint noises during movement of jaw (Note that
clicking & popping without pain or other
symptoms does not normally require
intervention, other than education)
 Limitation or difficulty in jaw movement
3/8/14
T. Henkelmann, PT, MS, CCTT
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Red/Yellow Flags for Neoplasm
in Head & Neck Region

 Neurologic signs (e.g. numbness)
 Swelling and/or lymphadenopathy
 Nosebleed or stuffiness, drainage, and dysphagia
 Unexplained weight loss
 Auditory complaints (hearing loss, tinnitus)
 Constant pain unrelated to jaw movements
 Unchanging or worsening symptoms in spite of
several different treatments
Note: the last 3 are not as obvious or clear-cut according
to Steven Kraus (Kraus SL, 1994) = yellow flags
3/8/14
T. Henkelmann, PT, MS, CCTT
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
Symptoms that may suggest referral to
otolaryngologist (ENT):
 Tinnitus, sensations of blockage, fullness,
pressure, or fluid accumulation in the ears may
suggest a primary otologic disturbance
Symptoms that may suggest referral to neurologist:
 Sensory loss, hemifacial spasms (tic), visual
disturbance, vestibular disturbance
3/8/14
T. Henkelmann, PT, MS, CCTT
8
Diagnostic Tests

 Panorex or panoramic x-ray
 r/o fracture, confirm DJD, neoplasm
 Tomography
 Two cone beam best choice, but not commonly done
 MRI
 Most common secondary test, should be done with
contrast if looking to r/o tumor
 Best way to visualize disc
 Insurance often won’t cover; really unneeded unless
surgery is seriously being considered
3/8/14
T. Henkelmann, PT, MS, CCTT
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Malocclusion

 This is primarily the dentists’ domain
 Wesley Shankland states in TMJ: It’s Many Faces, 2nd
edition
“One important comment must be made about
malocclusion. Virtually every dentist believes that
malocclusion can cause a TMJ problem. However,
there has never been a scientifically controlled study
to prove this concept.”
3/8/14
T. Henkelmann, PT, MS, CCTT
10

 However, Shankland also states in the same section
that malocclusion may be one cause of bruxism,
setting up a “vicious cycle”
 Review of literature by McNamara, et al found the
relationship of TMD to occlusion was minor,
estimated the total contribution of occlusal factors to
TMD was 10-20%
3/8/14
T. Henkelmann, PT, MS, CCTT
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 Occlusal factors implicated:
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3/8/14
1. Skeletal anterior open bite
2. Overjets > 6-7 mm
3. RCP/ICP slides > 4 mm
4. Unilateral lingual crossbite
5. Five or more missing posterior teeth
T. Henkelmann, PT, MS, CCTT
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
 The conclusion is that malocclusion should not be
considered a major factor in the etiology of TMD
 Despite this, a lot of money is spent in dentist or
orthodontist offices’ “correcting the bite”
 This can create potential conflict with orthodontists
and neuromuscular dentists
3/8/14
T. Henkelmann, PT, MS, CCTT
13
Diagnostic Procedures by PT’s

 Evaluation of patient’s chief complaint by taking
a history, to include parafunctional behaviors
 Basic physical examination techniques
performed by skilled PT’s, to include cervical
screen
 Obtaining screening radiographs, such as
panorex (if not done prior to referral) - optional
3/8/14
T. Henkelmann, PT, MS, CCTT
14
Diagnosing Inflammation

 History: pain/discomfort are influenced by
functional and/or parafunctional activities
 Receives some relief from use of heating pad, antiinflammatory medicine, e.g. ibuprophen
 Physical exam: TMJ palpation & joint loading
3/8/14
T. Henkelmann, PT, MS, CCTT
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Diagnosing Hypermobility

 History: Patient reports that jaw goes “out of place”
when opening mouth wide, i.e. h/o open lock
 Physical exam: Palpating the lateral poles during
opening and closing, a “jutter” is felt at the end of
mouth opening and at the beginning of mouth
closing
 Occlusal opening >60mm
3/8/14
T. Henkelmann, PT, MS, CCTT
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Diagnosing Hypomobility

 These are the classic signs of unilateral joint
hypomobility:
 Mandible depression: deflection to the side of the
involved joint
 Mandible protrusion: deflection to the side of the
involved joint
 Lateral excursion: decreased to the opposite side of the
involved joint; normal to the same side of the involved
joint
3/8/14
T. Henkelmann, PT, MS, CCTT
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Pathological TMJ Function
During Opening

 Stage I Disc Displacement (Disc Displacement
with Reduction)
 Aka Disc displacement with reduction (DDwR)
 Stage II Disc Displacement (Disc Displacement
without Reduction)
 Aka Disc Displacement without reduction (DDwoR)
 Stage III Disc Displacement
 DJD, osteoathrosis – characterized by crepitus, sand-paper
feeling, crunching; has h/o clicking & popping and limited
opening
3/8/14
T. Henkelmann, PT, MS, CCTT
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3/8/14
T. Henkelmann, PT, MS, CCTT
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T. Henkelmann, PT, MS, CCTT
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Diagnosing Masticatory
Muscle Hyperactivity

 History: Patient aware of clenching and grinding
(sleep bruxism). In AM, pt. aware of
soreness/tension in the area of the TMJ
 Physical exam: Increased tone and/or tenderness of
the masseter, temporalis, and medial pterygoid
muscles (though all masticatory muscles can be
considered)
3/8/14
T. Henkelmann, PT, MS, CCTT
21
Cervical Spine Disorder
and TMD

Proposed influences of the cervical spine on TMD
 May cause parafunctional activity (e.g.
clenching, forward head posture, etc.)
 May influence mandibular mobility and
positioning
 May be primary source of cephalic symptoms,
thus mimicking symptoms thought to be related
to TMD
3/8/14
T. Henkelmann, PT, MS, CCTT
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3/8/14
T. Henkelmann, PT, MS, CCTT
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Posture Correction is a
Priority

 “Restoration of normal posture, particularly normal
head positioning, is the crucial first step in the
management of almost any chronic head and neck
pain condition. This is because myofascial trigger
points are almost always a contributing, if not
causative factor, and anterior head positioning
perpetuates these.” – Jaeger B, 1999
3/8/14
T. Henkelmann, PT, MS, CCTT
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Exercises for Posture
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1. Chin tucks – start in supine if poor motor control
2. Shoulder blade squeezes
3. Corner stretch
4. Anterior neck stretch – “The office workers’ stretch”
3/8/14
T. Henkelmann, PT, MS, CCTT
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Time for everyone to stand
up and stretch back!
3/8/14
T. Henkelmann, PT, MS, CCTT
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Comprehensive Treatment of TMD
Diagnostic subsets of TMD
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 Arthrogenous
 Arthralgia
 Hypermobility
 Disc displacements
 DDwR
 DDwoR
3/8/14
Myogenous
Masticatory Muscle
Pain:
 Myofascial trigger points
 Trismus
 Lateral Pterygoid spasm
T. Henkelmann, PT, MS, CCTT
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Treatments for TMD
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 Modalities
 Therapeutic Procedures
 Behavioral Modification
3/8/14
T. Henkelmann, PT, MS, CCTT
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Treatment
Considerations

Acute Inflammation and Pain (acute, chronic)
 Modalities
 Cold pack first 24-48 hrs., can be used after if tolerated
 Moist heat thereafter – 2 cervical hp’s, one around
neck, one around jaw fastening around crown of head
 Pulsed (50%) ultrasound, 1.3-1.4 w/cm² x 6-8 minutes
 Iontophoresis (if not responding to above two within
3-4 visits)
 TENS vs. Pre-Mod Interferential E. S.
 NSAIDS
 Rest - soft diet
3/8/14
T. Henkelmann, PT, MS, CCTT
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Ultrasound

 US energy is absorbed mostly in tissues with high
collagen content. Primary tissues would be muscle,
ligament, capsule, tendon, and scar tissue
 US encourages healing in the soft tissues, decreases
inflammation, and reduces pain
 Therapeutic ultrasound in the treatment of musculoskeletal conditions. Falconer
J., Hayes MA, Chang TW. Arthritis & Rheumatism Vol. 3 (2), 1990; 85-91
 This is a mainstay in my therapeutic toolbox
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T. Henkelmann, PT, MS, CCTT
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Iontophoresis

 Is an efficient and desirable method to administer
topical steroids (dexamethasone) to localized regions
of inflammation

Schiffman E. TMJ Iontophoresis: a double-blind randomized clinical trial. JOP; 1996
10:2
 Consider this a 2nd phase intervention, when not
seeing results from HP-US-TENS/ES
 Need prescription from referring dentist/doctor
 “Dex-meth for ionto., 4mg/ml in 30 ml vial”
3/8/14
T. Henkelmann, PT, MS, CCTT
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Electrical Stimulation vs
TENS

 From Steve Kraus, PT: Pre-Mod Interferential
Current
 Less discomfort than other electric stimulation
 Penetrates deeper than other forms of ES
 Increase in localized blood flow for better muscle
relaxation
 Pain reduction is better than other forms of ES
 TENS: 1 or 2 channels, Continuous, Modulated
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T. Henkelmann, PT, MS, CCTT
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Stage I Disc Displacement
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 Dentist may prescribe intraoral appliance to take
stress off disc and posterior attachment to allow
healing. Ideally, should be thin, hard acrylic with
shallow stops (so not locked into only one
position when closed)
 Neuromuscular control exercises to correct
deviations, re-teach proper opening
 Remember that this usually does not need rx,
unless associated with pain & limited opening
3/8/14
T. Henkelmann, PT, MS, CCTT
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Stage II Disc Displacement

 Joint mobs. to attempt reduction, using
distraction combined with anterior translation. If
successful, patient should obtain an appliance
from dentist
 Sometimes, we just control the pain and stretch it
out.
 Follow-up with modalities, neuromuscular
control exercises
3/8/14
T. Henkelmann, PT, MS, CCTT
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Capsular Restrictions
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 Stretch capsule with joint mobs -distraction,
translation, lateral excursion intraorally
 Tongue blade self-distraction techniques and low
load prolonged stretch (often do during moist heat,
and have do at home)
3/8/14
T. Henkelmann, PT, MS, CCTT
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Intraoral Massage

Myofascial and trigger point release techniques to
 Temporalis
 Masseter – intraorally
 Lateral & medial pterygoids
 SCM
 Upper cervical paraspinal muscles
3/8/14
T. Henkelmann, PT, MS, CCTT
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Basic Stretches
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 Partial Opening with Guidance
 1 finger-width side glides & protrusion
 Cervical rotation with overpressure (for SCM)
 Upper trapezius stretch
3/8/14
T. Henkelmann, PT, MS, CCTT
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Neuromuscular Control
Exercises
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 Resting tongue position on palate
 Tongue hanging – is subtle. Mouth open, tongue
hanging out, fully relaxed, use mirror, 10 secs. each
 Making cluck-like sounds
 Tongue up and open without deviation done with
mirror feedback, first with finger on chin, then
without finger as gains control
 Rhythmic stabilization – brief side-to-side isometrics
3/8/14
T. Henkelmann, PT, MS, CCTT
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Isometric Stabilization &
Strengthening Exercises
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 Isometrics in resting position: opening, side glide,
protrusion
 Isometrics with mouth open 1 finger breadth and
tongue up
 Isometrics with 2 finger breadth opening
3/8/14
T. Henkelmann, PT, MS, CCTT
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Surface EMG
Biofeedback

 Use in masseter muscle relaxation training
 Use to stop clenching behavior
 Problems
 Not very practical
 Is not covered by insurances
3/8/14
T. Henkelmann, PT, MS, CCTT
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Short Upper Lip

 Short upper lip results in an increase in mandibular
elevator muscle activity
 Upper lip should cover ¾ of maxillary central
incisors
 Constant state of parafunction
 Stretching results in approx., 1mm of month increase
in length
Stretch it down manually – hold 30-60 secs.
3/8/14
T. Henkelmann, PT, MS, CCTT
41
Overview of Surgeries

 Arthrocentesis
 Arthroscopy
 Modified condylectomy
 Arthrotomy:
 Disc repositioning
 Discectomy
 TMJ replacement
 Due to resection of condyle, the lateral pterygoid muscle
is no longer working, so cannot side glide
3/8/14
T. Henkelmann, PT, MS, CCTT
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Pharmacologic
Considerations

 Use of OTC ibuprophen for short-term use to reduce
inflammation/synovitis/capsulitis
 Muscle relaxant before bed for sleep bruxism
 Flexoril, Soma
 Dentists are comfortable with this
 Tricyclic Antidepressants (TCAs) for sleep bruxism
 Amitryptyline (Elavil) – 1st generation type, bad side
effects
 Doxapin (Sinequan)
 Nortriptylene (Pamelar)
3/8/14
T. Henkelmann, PT, MS, CCTT
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Other Diagnoses
Brief overview

 Trigeminal Neuralgia
 Glossopharyngeal Neuralgia
 Burning Mouth Syndrome
3/8/14
T. Henkelmann, PT, MS, CCTT
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Practical Matters

 Use care in the use of “TMJ” and “TMJ Disorder” on
documentation and TMJ diagnostic codes
 ICD-9 Codes recommended:
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784.92 Jaw pain
728.85 Muscle spasm
784.0 Headache or face pain
723.2 Cervicocranial syndrome
729.1 Myofascial pain
 ICD-9 Codes not recommended (unless MC, Auto, WC)
 524 & 526 codes
3/8/14
T. Henkelmann, PT, MS, CCTT
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Marketing Suggestions
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 To Dentists
 To Oral surgeons
 To Orthodontists
3/8/14
T. Henkelmann, PT, MS, CCTT
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Thank you for Your
Attention
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QUESTIONS?
3/8/14
T. Henkelmann, PT, MS, CCTT
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T. Henkelmann, PT, MS, CCTT
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