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Temporomandibula
r Disorders

Clinic Case

JD is a 29 yo F new patient who presents for refill

on Vicodin for TMJ. Has headache, pain, decreased
jaw ROM over the past 1 1/2 years

PMH:

TMJ syndrome, gastritis/dyspepsia, depression

SH:

3 children (8,4,3), marital discord (reconciled

after separation), verbal abuse, beginning
career as realtor

Definition of TMD

1996 NIH Consensus Conference:

A collection of medical and dental conditions

affecting the TMJ and/or the muscles of
mastication as well as contiguous tissue
components

Definition of TMD

3 Main Categories;

Myofascial pain (jaw muscles, neck muscles,

shoulder muscles)

Internal derangement of the joint (dislocated

joint, displaced disk, condylar trauma)

Degenerative joint disease (OA, RA)

Anatomy of TM Joint

Anatomy of TM Joint

Epidemiology

60-70% of general population have one sign

Prevalence by self report: 5-15% (one source

estimates 10% of women, 6% of men)

5% or less seek treatment

Women>men 4:1 seek treatment

Epidemiology

Early adulthood (ages 20-40)

Many TMD are self-limiting or fluctuate over time

without progression

5% require surgery

Etiology

Multifactorial

Predisposing factors

Precipitating factors

Musculoskeletal

Trauma, clenching, grinding

Perpetuating factors

Chronic MSK dysfunction, psychogenic

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Clinical Manifestations

Pain

Joint clicking

Restricted jaw range of motion

Other symptoms are not specific to TMD:

Headache, ear ache, neck and shoulder pain

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Diagnosis: History

Pain

Worsens with jaw use

Centered anterior to tragus

Radiates to ear, temple, cheek, mandible

Clicking/joint noise

Restricted ROM

Tight feeling, catching, locking

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Diagnosis: History

Habits

Clenching, grinding,cradling phone, back packs

SH: stressors

PMH: related disorders, trauma, dental problems

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Diagnosis: Exam

Inspection:

ROM:

Facial asymmetry, posture, eccentric jaw

movements
Vertical (42-55 mm), lateral, protrusion

Palpation:

Pre-auricular/anterior to tragus: joint mobility,

joint sounds (audible, palpable)

Masseter, temporalis, pterygoid, suprahyoid,

SCM, cervical

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Diagnosis: Exam

Oral function: occlusion, swallowing, breathing

Postural/musculoskeletal:

Forward head posture, systemic hypermobility,

joint problems elsewhere

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Treatment Goals

Educate patient about TMD and self-management

Reduce or eliminate pain and joint noise

Improve function

Avoid unproven treatments that can cause

problems

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Treatment: NIH guidelines

Phase I: Conservative and Reversible

Patient education

Physical Therapy/Occupational Therapy

Psychotherapy

Medications

Bite splint/Occlusal Splint

Stress management

(Multidisciplinary approach)

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Treatment: NIH guidelines

Phase II: only after conservative measures

exhausted

Surgery: arthrocentesis, arthroscopy, open joint

surgery, orthognathic
5%

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Treatment: Patient Education

About TMD

Avoid painful activities

Avoid clenching grinding

Normal resting position of jaw

Tongue up, teeth apart, lips together

Moist heat/ice

Gentle stretching

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Treatment: PT/OT

Patient assessment

Postural assessment

Patient education

Joint mobilization/manual therapy

Iontophoresis in selected cases

Home therapy program

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Treatment: Pharmacologic

NSAIDS-scheduled dosing

Muscle relaxants

Tricyclics

Opioids

Steroid injection

Botox injection

*UW TMD clinic does not find muscle relaxants very

useful, does not use tricyclics, rarely opioids

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Treatment: Bite Splint

Indications:

AM symptoms, daytime clenching, teeth are worn

Worn only at night

Does not move jaw (not an anterior repositioning

splint)

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Evidence Based Medicine

Limited Evidence, recommended

NIH Phase I and II treatments discussed

previously

Limited Evidence, needs further study

Acupuncture

EMG biofeedback

Limited Evidence, not recommended

Occlusal adjustments that permanently alter a

patients occlusion (Grinding teeth down,
anterior repositioning splints)

Alloplastic implants

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Indications for Referral

Trauma to the face at onset of pain

Joint noise PLUS dysfunction

Locking/catching of TMJ

Limitation of opening/ROM

Pain in jaw and muscles of mastication on

awakening

Orofacial pain aggravated by jaw function