Easiest Clinical approach for General Dentist in

Diagnosis of TMJ Dysfunction

Xin Chào

Dr Lisa Chong (BDS OTAGO, MBA Bond)

info@painfreedentistsydney.com.au
@cosmeticpainfreedentistsydney
+61404158873
TMJ Courses, BOTOX,
Surgical training
info@painfreedentistsydney.com.au
+61404158873
TMJ and The Whole Body Connection
Forward head / shoulder posture
● Occupational posture: forward or backward leaning of head for long durations, slouched or relaxed sitting,
faulty sitting posture while using computer or screen.
● Effect of gravity: slouching, poor ergonomic alignment.
● Other faulty postures like pelvic and lumbar spine posture.
● Sleeping with head elevated too high.
● Poor posture maintained for long durations.
● Lack of development of back muscle strength.
● Big Chested woman
● Class 2 skeletal
● Brachiocephalic profile
● Mouth breather
● Airway obstruction
● Sleep apnoea
● Too much time on Mobile phone
● Orthodontic retraction mechanics
Ear Symptoms related TMJD
● Stuffy Ears (Tensor Palatini, Velli
Palatini muscles dysfunction)
● Dizziness, Vertigo (Osteopathic-
Semicircular Canals )
● Ear Pain , Tinnitus (Discomalleolar
Ligament Stretched, Dysfunctional
Lateral Pterygoid muscle)
● Hearing problem
● ENT ruling out ear issues are
related to TMJD

Treatment
● Orthotics
● Myofascial release
● Osteopathic manipulation (Refer to
Osteopath)
What is TMJ disorder
Temporomandibular disorders (TMDs) are a group of more than 30 conditions that cause pain and dysfunction in the jaw
joint and muscles that control jaw movement.

1. Disorders of the joints, including degenerative disc without reduction, osteoarthritis, chronic locked jaw.
2. Disorders of the muscles used for chewing (masticatory muscles).
3. Headaches associated with a TMD.

I will be focusing on 2,3 which as general dentists we can treat this with non-surgical
methods. Whereas 1 requires referral to an Oral Maxillofacial surgeon that can do the
surgical intervention to treat the joint/ disc / TMJ pathology.
TMJ Assessment and Treatment
1. Background 2. Assessment

Trauma a. Imaging
b. Posture
Previous orthodontic treatments
c. Muscle Palpation
Breathing d. Intra- and extra-oral examination
e. Soft tissue assessment
Allergies
3. Treatment
Biting
Splint Therapy
Sleep
● Impression for Splint therapy
Medications
● Bite registration
Psychological conditions ●
Botox
ENT issues
Adjunctive Physiotherapy treatment
Pain
Composite built up
Myofunctional test
Crowns and full mouth rehabilitation
Habits
Long term Stabilisation
1. Background
a. Trauma
Background
b. Retraction mechanics in Orthodontic treatments
Background
C. Breathing

● Airway obstruction

Including mouth breathing, snoring, sinus issues, enlarged tonsils, asthma

 1. Disorders of the joints, including
disc disorders.

2. Disorders of the muscles used for

chewing (masticatory muscles).
Background
● Myofunctional test
Including tongue function; swallowing, thrust, mentalis, buccinator activity (anterior
open bite), tongue resting position.
Background

● Tongue tie treatment and how it affects TMJ

Dysfunction.
Background
D. Allergies,

Breathing through the mouth,

Vertical jaw growth

Background
E. Biting
● Wisdom teeth
● Missing teeth
● Overeruption
● Premature Contact
Background
E. Biting
● Loss of posterior contact/vertical dimension
● Wear of teeth/abrasion/bruxism
F. Sleep disorder(s) : Sleep Apnoea, UARS , Sleep Study, CBCT : nasopharyngeal airway
obstruction. CPAP, Somnomed
Background
G. Medication history
Linked Bruxism
related to SSRI
100* more
chewing forces.
Zoloft, Paxil,
Lexapro,
Prozac, Celexa
Background
H. Psychological conditions
- Including any mental disorders and
life stressors.
- Nocturnal Bruxism
- Diurnal Bruxism
- Triggers
- Habits
 Background
I. ENT issue
Meniere's Disease

Tinnitus

Vertigo

Eagle's Syndrome

Eustachian tube Dysfunction

Nasal airway blockage

Vagus nerve overstimulation

● Digestion.
● Heart rate, blood pressure and respiration (breathing).
● Immune system responses.
● Mood.
● Mucus and saliva production.
● Skin and muscle sensations.
● Speech.
● Taste.
● Urine output.
● Neck (between your carotid artery and jugular vein).
● Chest (thorax).
● Heart.
● Lungs.
● Abdomen and digestive tract.
Background
J. Pain
● TMJ muscle pains
● Ear pain
● Headache/migraines
● Jaw pain/problems
● Shoulder pain/problems
● Trigeminal nerve neuralgia
● Atypical trigeminal neuralgia (ATN),
● Occipital neuralgia,
● Glossopharyngeal neuralgia
● Postherpetic neuralgia ( shingles,herpes)
● Nerve Blocks.
Background
K. Habits
Nail biting

Cheeks chewing

Teeth clenching
2. Assessments
A. Imaging- CBCT Airway
Cross sectional skull view to check vertebrae and midline
Tmj CBCT view
OPG View
TMJ open and close view
B. Extraoral Photos- Posture (before)
(after 3 weeks of splint therapy)
Assessments
C. Muscle palpation
Muscles
 Assessments
D. Intra-oral photos
Assessments
E. Extra-oral examination
F. Soft tissue Assessment

- Tongue Tie
- Tongue position
- Tongue tonality
- Tongue thrust
- Incorrect swallowing with mentalis

labial mental activity

- Buccinator activity
Frenectomy

- Refer to speech pathologist

for tongue training before

and after frenectomy.

- Check tongue position,

- Tongue tonality
- Tongue function

-Correct tongue swallowing

Airway Obstruction
 Local Anaesthetic block for referred pain and differential diagnosis

Spot local anaesthetic with

Articaine or lignocaine with

adrenaline to condylar space

- Purpose to determine

source of pain from joint or

referred pain
Other consideration
- Incompetent lips
- Mouth breathing
- SNORING
- Venous pooling of eyes
- Restless sleep
- ADHD
- Asthma
- Allergies
- Thumbsucking
- Habits
- Throat infection
- Sinus
- Hay fever
- Sleep study
TMD Screening
- Headaches, nausea, dizzy, pain locality
- Difficulty in opening mouth wide or yawning
- Ear pain, loss of hearing, stuffiness of ear, tinnitus or ringing, grating noise
- Neck pain
- Joint pain
- Muscles pain
- Clenching activity( when,how sore,diurnal or nocturnal bruxism )
- Medications
- Wisdom teeth
- Car accidents
- Whiplash
- Jaw lock
- Jaw click
- Pain in joint
- Jaw tired after sleep
Dental Alignment

- Crowding(upper/lower)
- Spacing (upper/lower)
- Proclined or retroclined teeth (upper/lower)
- Arch form(narrow, hourglass,flatten,tipped posteriors, normal)
- Occlusion
- Cross bite(anterior/posterior)
- Open bite (anterior/posterior)
- Bite relationship overjet and overbite in mm
- Midline discrepancy
- Facial development class 1,2,3,4 profile
- Deficiency in facial profile
3. Treatment
A. Splint Therapy

● Impression
● Bite registration
-You should look for Mentalis
contraction while
assessing their Swallowing
- click/ pop/ disc displacement
with reduction

- patient only wants Botox

- referral to OMS for arthroscopy
- Arthrocentesis
3D Splint therapy Mechanics
coronal correction,

horizontal correction

sagittal correction

Skeletal changes:

Dropping the side of maxilla that is higher

Expansion of the maxilla (opening up sinus and nasal passages)

Correction of the AP maxilla (enabling straight posture- Centre of Gravity change)

Brain changes were found in pathways responsible for
abnormal pain perception, including the classic
trigemino-thalamo-cortical system and the lateral and
medial pain systems. Dysfunction and maladaptive
changes were also identified in the default mode network,
the top-down antinociceptive periaqueductal gray-raphe
magnus pathway, as well as the motor system.

TMD patients displayed altered brain activations in

response to both innocuous and painful stimuli
compared with healthy controls. Additionally, evidence
indicates that splint therapy can alleviate TMD-related
symptoms by inducing functional brain changes.

TMD patients may have pain in other body areas and there is
high comorbidity with functional syndromes such as
fibromyalgia and irritable bowel syndrome . Such evidence
implicates central nervous system dysfunction in pain
associated with TMD
B. Botox

Botulinum Toxin Injections to affected Muscles ie Masseters, Temporalis, Occipitalis,

Sternocleidomastoid

Use:

1: Reduction of muscle spasm/ hypertrophy muscles

2: Patients who want to see results asap.

3: 3 months therapeutic effects and have to re-dose again.

Botulinum Toxin : BOTOX
Botulinum toxin Type A works by relaxing muscles. It is FDA-approved for some medical conditions (like
migraines). Studies have looked at injecting botulinum toxin Type A into the chewing muscles to reduce
muscle spasm and pain.
Injection to the masseter muscles to reduce the bulk, inability to clench if enough dosage is given,
relaxing the muscle of mastication in turn, allowing the mandible have a lower resting position ie
downward and forward.
C. Adjunctive Physiotherapy treatment
Physical Therapy The goal of physical therapy is to maintain, improve, or bring back movement and physical function.
There are several types of physical therapy. Manual therapy has been shown to help improve function and relieve pain.
Myofascial Release
Lateral Pterygoid release

Medial Pterygoid release

Temporalis release

Masseter release

SCM release

Trapezius release

Microwavable neck pillow,

Theragun massager

See your physiotherapist, Osteopath

Nutrition
● Anti-inflammatories (Ginger, curcumin), Anti-anxiety Tryptophan, Taurine, Collagen
● 600mg Calcium, 300mg Magnesium supplement Vit D, B complex, VIT B12, B6, B5, B1, C

Many patients diagnosed with TMD may also suffer one or more systemic
conditions, often also characterized by pain, which include chronic fatigue,
syndrome, chronic headache, endometriosis, fibromyalgia, interstitial cystitis,
irritable bowel syndrome, low back pain, sleep disorders, and vulvodynia. Having
more than one painful condition can further diminish one's appetite and affect food
choices. Whatever your situation may be, it is clear that TMD alone can impact
your quality of life and lead to poor nutrition if the jaw pain and oral disability
seriously affects your diet.
D. Composite built up

Worn dentition before treatment

After composite build ups to worn dentition

E. Full mouth rehabilitation with porcelain crowns and
porcelain veneers
Upper full arch rehabilitation with porcelain veneers and crowns.
Temporisation with Essix suck down and composite within
I snore! Do I have sleep Apnoea Doc?
Sleep Treatment with Somnomed appliance and sleep
study -
- Refer to medical DR for blood
test for hormones
- Sleep study
- Sleep habit review
- Physical examination
- As dentist we prescribe
Somnomed appliance and
Airway obstruction refer to
ENT.
To summarize

● Sleep Assessment
● Airway obstruction
● Botox treatment to relax hyperactive muscles ( masseter, temporalis, SCM
etc)
● Splint therapy (2D, 3D)
● Orthodontic treatment to correct deep class 2, div 2 after splint therapy
● Composite resin build up
● Crowns or onlays
● Partial Essic build up
● Frenectomy
● Full mouth rehabilitation
Patient Presentation

Checklist:

1: History, MH, DH, TMJ and Myofunctional Forms

2: Clinical examination and record taking IO, EO photos, posture, X-rays

3: Pain assessment, Nerve Blocks, (Differential Diagnoses)

4: Proposal to Diagnoses

5: Treatment plan,quotations, Referral to other specialist, Oral maxillofacial

surgeon, ENT,prosthodontist,Orthodontist, Physiotherapist, Speech pathologist

6: Provide some form of relief possible or not.

Myofunctional forms
Snoring, Sleep Study, tongue function, position, tonality.
Competence of lip
Tongue Swallowing
Tongue thrust
Pain on Muscles Pterygoid, Masseter, Temporalis, SCM,
Palate, Midline discrepancies, Skeletal, Dental relationship
Mouth Breathing or Nasal breathing
It is a teamwork so Refer to other Physiotherapist, OMFS,
Orthodontist and ENT when required
Referral letter to physiotherapist
Referral to OMFS
Referral to orthodontists
- Team referral to complete the patient’s

treatment plan
ENT referral for adenotonsillectomy turbinate reduction
Speech pathologist
Before Frenectomy and After frenectomy

Speech and function of tongue tie

Release will be affected after frenectomy

Thank you for time
We would like your feedback and course preferences
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