Temporomandibular Joint Disorder
The
temporomandibular joint (TMJ) is the articulation between the jaw and head. It
is the most active joint in the body, opening and closing up to 2,000 times per
day to account for a full day’s worth of chewing, talking, breathing,
swallowing, yawning, and snoring. The
jaw, cervical spine, and alignment of the teeth are integrally related. Dysfunction in one of these regions may lead
to a TMJ disorder, which is a term used to describe a variety of clinical
disorders resulting in jaw pain or dysfunction. TMJ disorder is commonly viewed as a
repetitive motion disorder of the masticator structures. Pain during function
or at rest is usually the primary reason patients seek treatment.Reduction of
pain is the primary goal of physical therapy for patients with TMJ. Patients
also seek physical therapy for TMJ locking, masticatory stiffness, limited
mandibular range of motion, TMJ
dislocation and unexplained change in mouth closing or opening.
The
etiology of TMJ disorder is often multifactorial and may be due to stress, jaw
malocclusion, habitual activities including bruxism, postural dysfunction,
inflammatory conditions and trauma. TMJ
disorders are more commonly seen in females
most specifically over the age of
55. Some authors have suggested that there may be a connection between hormones
and women and TMJ dysfunction. It is suspected that 50%-75% of the general
population has experienced unilateral TMJ dysfunction on a minimum of one
occasion. It is also suspected that at least 33% of people have experienced a
minimum of one continuing persistent symptom.
The
TMJ is formed by the articulation of the condyle of the mandible with the
articular eminence of the temporal bone and an interposed articular disk. It is
a synovial joint with surfaces that are covered by dense collagenous tissue
that is considered to be fibrocartilage. The mandible is the distal or moving segment
of the TMJ. The proximal or stable
segment of the TMJ is the temporal bone. The articular disk allows the surfaces of the TMJ
to remain congruent throughout the motion available to the joint. The primary
ligaments of the TMJ are the temporomandibular ligament, stylomandibular
ligament and the sphenomandicular ligament.The loose packed position of TMJ is
with the mouth slightly open and the tongue resting on the hard palate. The
close-packed position is with the mouth closed with the teeth clenched. All motions of the TMJ are limited by the
temporomandibular ligaments in all directions, and the capsular pattern of
restriction is limitation of mouth opening.
The joint
articulation of the TMJ consists of two joint spaces divided by the disk. The
lower joint of the TMJ is a hinge joint formed by the anterior surface of the
condyle of the mandible and the inferior surface of the articular disk. The
upper joint of the TMJ is a gliding joint formed by the articular eminence of
the temporal bone and the superior surface of the articular disk. The disk
provides three advantages to the TMJ: increased congruence of the joint surfaces,
the shape of the disk allows it to conform to the articular surfaces, and self
centers itself on the condyle.
The
motions available to the TMJ include mouth opening/mandibular depression, mouth
elevation/mandibular elevation, jutting the chin forward/ mandibular protrusion,
sliding the teeth backwards/ mandibular retrusion and sliding the teeth to either side/ lateral
deviation of the mandible. Mandibular
elevation and depression occurs in two sequential phases of rotation and
gliding. Mandibular protrusion and
retrusion occurs when all points of the mandible move forward at the same
amount. This motion is pure translation and occurs in the upper joint
alone. During mandibular lateral
deviation, one condyle spins around a vertical axis while the other condyle
translates forward.
The TMJ is
one of the most frequently used joints in the body. Most of the TMJ motions are
empty mouth movements, which occur with no resistance from food or contact
between the upper and lower teeth. The
associated musculature is designed to provide power and intricate control.
Muscle
|
Action
1, 8
|
Digastric
|
Primary muscle for mandibular depression
|
Medial pterygoid
|
Mandibular elevation; Assists in protrusion
|
Lateral pteryogid
|
Mandibular depression
|
Temporalis
|
Mandibular elevation
|
Masseter
|
Mandibular protrusion
|
The
TMJ and most of the muscles of mastication are innervated by the mandibular
branch of the trigeminal nerve, (cranial nerve V [CN V]). Pain may be referred
to adjacent areas on the face in the distribution of CN V.
The
cervical spine and TMJ are connected via muscular attachments. Muscles that
attach to the mandible also have attachments to the hyoid bone, cranium and
clavicle. These muscles can act upon the mandible, atlanto-occipital joint or
the cervical spine. Position of the head
and neck can also affect tension of the muscles and therefore affect the
position or function of the mandible. It
is important to remember to examine the cervical spine in conjunction with the
TMJ due to these muscular connections.
Basic
pathologies of the TMJ involve inflammation and degeneration in arthritic
disorders and structural aberrations in growth disorders. Overall, the etiology
of the most common types of TMJ disorders is complex and still largely
unresolved. This list below includes some
of the main agreed upon categories of TMJ disorders:
a) Arthritic: Characterized mainly by pain. As
the disease progresses symptoms can lead to internal derangement and facial
deformity.Painful crepitus or grating sounds is common in patients with TMJ
osteoarthritis.Treatment is aimed at controlling risk factors and inflammatory
response.
b) Growth disorders: Characterized mainly by facial
deformity. Treatment is aimed at removing the tumor and correcting the
deformity
c) Non-arthritic disorders:
Characterized mainly by mechanical derangement, which can include luxation and
acute (traumatic) disc dislocation. Myofascial pain and dysfunction are present
due to a primary muscle disorder resulting from oral function habits. Some of
the habits can be related to headache, chronic back pain, irritable bowel
syndrome, stress, anxiety and depression. Internal derangement refers to a
problem with the articular disc with an abnormal position leading to mechanics
interference and restriction of mandibular activity. A patient who presents with
internal joint derangement will have continuous pain that will be exacerbated
by jaw movement. Clicking and locking
will result in restricted mandibular opening or deviation of mandibular movements
during opening and closing.Treatment is aimed at reducing the mechanical
obstruction.
In
2010 authors Stedenga et al developed a categorization for TMJ disorder that
focuses on intra-articular positional changes of the disc (internal
derangement). The authors noted that these internal derangements can explain
most of the mechanical manifestations occurring in the joint. This newer
classification system seems to further describe the “non arthritic disorders”
listed in the list noted above.
a) Disc derangements, which explains clicking sounds and movement
restriction because of the obstruction of condylar movement by the disc
b) Subluxation and luxation of the disc-condyle complex, which
represents TMJ hypermobility disorders
c) Adherence, adhesion, and ankylosis of joint surfaces, which
results in TMJ hypomobility
Indications for Treatment:
- Pain
- Clicking, crepitus or popping
- Decreased ROM in mouth opening
- Locking of the jaw with mouth opening
- Difficulty with functional activities of the TMJ: chewing, talking, yawning
Contraindications / Precautions
for Treatment:
Post-operative
patients may have surgeon specific precautions regarding physical therapy
progression. Contact the surgeon, as
appropriate, to clarify case-specific precautions.
Evaluation:
Medical
History:
Review computerized longitudinal medical record (LMR), review of systems
and intake health screening tool.
History
of Present Illness: Note course of symptoms and presence of
trauma (MVA, assault), previous surgery (dental implants, ORIF), and/or repetitive
trauma (see habitual activities below).
Signs and symptoms of TMJ dysfunction are
often unilateral but can be bilateral. Clicking may or may not be present at
the time of the evaluation. Note any
history of clicking and locking. Note
current or past use of mouth orthotics or splints, the results and the reason
the patient stopped using the appliance, if applicable. Also inquire about
nocturnal symptoms and daytime symptoms. A patient may wake up with TMJ pain
which lasts for only minutes to hours, which suggest the nocturnal factors are
the primary contributors to the symptoms.
Other patients awake symptom free and the TMJ symptoms develop later in
the day, suggesting that daytime factors are the primary contributors. Some
patients may have pain during the night and daytime, so both of these symptoms
producers need to be considered. Typically
patient may have more pain in the morning and sore teeth due to clenching.
There is often a history of stress and difficulty in sleeping.
Social
History: Note daily habitual activities such as
smoking, bruxism (clenching), chewing gum, snoring, leaning on chin, biting
nails, lip biting, clenching teeth, etc. can all contribute to the presenting
symptoms. Consider work, household
responsibilities, hobbies and/or recreational activities that may involve
repetitive stress and sustained postures, e.g. computer work. Emotional stress can trigger nervous habits
or poor postural responses, which can lead to TMJ symptoms.
Medications:
Note relevant medications including NSAIDS, muscle relaxants, and other
analgesics. Some patients may be taking
Amitriptyline, Nortriptyline, or
Diazepam before bedtime to reduce EMG activity at the TMJ.
Diagnostic
Imaging:
Plain film radiography is the gold standard to evaluate the TMJ. A/P and
lateral views are used to assess the normal shape and contours of the condyles,
the position of the condylar heads in open and closed mouth positions and to
measure the amount of movement available.
Periapical images can exclude problems with the teeth. Magnetic resonance imaging (MRI) can be used
to assess the disk position and shape and is used primarily when a nonreducing
disk is suspected clinically. Since disk
displacement is common in assymptomatic subjects, MRI evidence of disk
displacement is not considered significant unless ROM is restricted or a
nonreducing disk is suspected clinically. Computed tomography (CT) and
arthroscopy have been advocated but ordering these tests should be at the
discretion of the specialist oral and maxillofacial surgeons.
Examination
This
section is intended to capture the most commonly used assessment tools for this
case type/diagnosis. It is not intended to be either inclusive or exclusive of
assessment tools.
Observation:
·Opening and closing of mouth: Inspect that the teeth normally close symmetrically and that the
jaw is normally centered.
· Alignment of teeth: Take note of a cross
bite, under or over bite. Identify any missing teeth.
·Symmetry of facial structures (eyes,
nose, mouth): Note of any facial deformity
which can range from very subtle to severe and readily visible deformation.
Examine both soft tissue and bony contours between left and right halves. Pay
special attention to muscular paralysis, such as ptosis of the eyelid or
drooping of the mouth, which may be associated with Bells Palsy. Also determine
whether the upper and lower lip frenulums are properly aligned.
·Posture: Note the presence of forward head posture, rounded shoulders and
scapular protraction.Also be aware of scoliosis or cervical torticollis, which
affect the length tension relationships of the muscles attaching to both sides
of the mandible causing an uneven pull to one side.
·Breathing pattern: Assess if diaphragmatic breathing occurs or if there is an accessory
pattern to breathing.
·Tongue:
Examine for presence of bite marks, scalloping (tongue resting between teeth)
resulting from tongue not properly resting on the hard palate or from tongue
being excessively wide. A dry or white appearance of the tongue is an
abnormality and may indicate bacterial infections, dysfunction of salivary
glands or adverse reaction to medications.
Pain:
The
main complaint may include orofacial pain, joint noises, restricted mouth opening
or a combination of these. It is helpful to evaluate pain in terms of onset, nature, intensity, site,
duration and aggravating and relieving factors. Also consider how the pain relates
to features such as joint noise and restricted mandibular movement. Determine
which movements cause pain, including opening or closing of mouth, eating,
yawning, biting, chewing, swallowing, speaking, or shouting. The patient may also present with headaches
and cervical pain. Pain may also be present in the distribution of one of the
three branches of the trigeminal nerve (CN V). Pain is generally located with
the masseter muscle, preauricular area, and anterior temporalis muscle regions.
The pain is usually an ache, pressure, or a dull pain which may include a
background burning sensation. There may also be episodes of sharp pain and
throbbing pain. This pain can be intensified by stress, clenching and eating.
Pain may be relieved by relaxing, applying heat to the painful area or taking
over the counter analgesics.
TMJ disorders are distinguished from other possible diseases by
the location of pain. TMJ pain is specifically centered in and around the
preauricular region and may be accompanied by clicking or grating sounds with
mandibular function and restricted mouth opening.
Cervical spine and upper quadrant
screen:
Assess
cervical and shoulder A/PROM, muscle length including deep cervical flexors,
myotomes, dermatomes and reflexes.
·
TMJ:
Palpate the TMJ bilaterally while the patient opens and closes the mouth
several times.Assess for joint integrity and structural deviations. The
mandibular condyles on both sides should move smoothly and equally.If the
examiner feels one side rotate before the other or shift laterally while the
mandible is moving, this may indicate TMJ dysfunction.
·
Muscles of mastication: Palpate and compare bilaterally, assess for pain and/or muscle
spasm
o
Some of the muscle to be palpated
can include: lateral pterygoid (intraorally), insertion of temporalis
(intraorally), medial pterygoid (externally), masseter (externally)
o
It is recommended that the masseter,
anterior temporalis and TMJs be palpated to ensure that it intensifies or
reproduces the patient’s pain in order to determine the primary source of pain.These
areas can be palpated by having the patient clench the jaw and palpating the
muscle over its origin and muscle belly.Areas of tenderness, trigger points and
patterns of pain referrals should be noted. Joint sounds and their location
during opening, closing and lateral excursion may be palpated or detected with
a stethoscope placed over the preauricular area.
AROM: Range of motion can be measured from top tooth
edge to bottom tooth edge marking on a tongue depressor and measuring the
distance in millimeters.Opening and closing of mouth
Normal
opening = 35-50 mmFunctional opening = 25-35 mm or at least two knuckles
between teethProtrusion of mandible
Normal
= 5 mmLateral deviation of mandible
Normal
= 8-10 mmNote asymmetrical movements, snapping, clicking, popping or jumps.
Mechanical derangements account for the common clinical signs of clicking and
locking.
·
Record deviations: lateral movements with return to
midline
·
Record deflections: lateral movements without return to
midline
PROM: Apply overpressure at the end range of AROM to assess end feel
Strength:
·
Deep cervical flexors and scapular
stabilizers should be assessed. Refer to a manual muscle testing (MMT) text
such as Daniels and Worthingham’s Muscle Testing or Kendell and Kendell for
complete description of MMT techniques.
·
Resisted opening, closing, lateral
deviations and protrusion of the jaw should also be tested. Upon testing, the patient should have the
mouth open one to two centimeters and therapist should place a stabilizing hand
on the forehead. A gradual onset of force should be used so that the patient
can resist the motion appropriately. Pain and/or weakness with the resisted
testing are positive findings.
Assess
upper quadrant dermatomes, C1, C2, C3, cutaneous nerve supply of the face,
scalp and neck, cranial nerves V – XII.
Joint sounds:
·
Crepitation: A sound that is
continuous over a long period of time of jaw movement, like grating or
grinding.
·
Clicking: A distinct, very brief
sound with a clear beginning and end.
Caudal
traction, ventral glide (protrusion), medial/lateral glide. Refer to joint
mobilization texts for appropriate techniques, e.g. Edmond, Maitland
·
Load contralateral TMJ - bite on
cotton roll.
·
Compression of bilateral TMJ –
Grasp the mandible bilaterally and tip the mandible down and back to compress
the joints.
·
Distraction of bilateral TMJ –
Grasp the mandible bilaterally, distract both joints at the same time.
·
A positive finding to dynamic
loading is pain.
Assess
chewing, swallowing, coughing, and talking.
Either have patient demonstrate task or ask for patient’s subjective
report. Include changes the patient has
made to their own diet to accommodate for their pain and dysfunction.
Approximately
70% of patients presenting with TMJ disorders also have cervical spine
impairments according to Rocobado.It is important to screen the cervical spine
and upper quadrant as part of the TMJ evaluation.
Non-musculoskeletal
disorders may also cause facial and jaw pain including infection, dental
problems including malocclusion, trigeminal neuralgia, parotid gland disorder,
or other lesions of the face, mouth or jaw.
If non-musculoskeletal origin of pain is suspected, refer to the primary
care physician for further work-up.
Patients who
present with TMJ pain may also have symptoms related to tooth pain. Tooth
related pain includes: pain that occurs or intensifies upon drinking hot or
cold beverages, throbbing pain that occurs spontaneously, throbbing pain that
awakens the patient from sleep. If these symptoms are present, a referral to a
Dentist would be appropriate.
Patients with TMJ disorder may also report a feeling of fullness
of the ear, tinnitus and/or vague dizziness.
These symptoms are seen in approximately 33-40% of patients with TMJ
dysfunction and usually resolve after treatment.
Assessment:
Establish Diagnosis and Need for Skilled Services
Often
patients with TMJ dysfunction present with pain, forward head posture,
protracted shoulders, mouth and accessory muscle breathing patterns, abnormal
resting position of the tongue and mandible, and abnormal swallowing
mechanism. Patients with these clinical
signs will benefit from skilled physical therapy intervention to correct these
upper quarter muscle imbalances and to restore the normal biomechanics and
motor control of the TMJ.
Problem
List:
Potential
Impairments:
Increased pain
Limited A/PROM
Impaired posture
Impaired motor control/strength
Decreased knowledge of habit modification, relaxation techniques
Potential
Functional limitations:
Inability to chew, cough, sneeze, swallow or talk without pain
Prognosis:
Medlicott and Harris published a systematic review in Physical
Therapy July 2006, analyzing 30 research studies that tested the effectiveness
of various physical therapy interventions for temporomandibular joint disorder. The authors conclusions and recommendations
are as follows:
1. Active exercises and joint mobilizations, either alone or in
combination, may be helpful for mouth opening in patients with acute disk
displacement, acute arthritis, or acute or chronic myofascial pain.
2. Postural training may be used as an adjunct to other treatment
techniques as it’s effectiveness alone is not known.
3. The inclusion of relaxation techniques, biofeedback, EMG training,
proprioception education may be more effective than placebo or occlusal splints
in decreasing pain and mouth opening in patients with acute or chronic
myofascial pain.
4. A combination of active exercises, manual therapy, postural
training, and relaxation training may decrease pain and increase mouth opening
in patients with acute disk displacement, acute arthritis, or acute myofascial
pain. It is not known, however, if
combination therapy is more effective than providing a single treatment
intervention.
A study by Kurita et al explored the natural course of symptoms
for patients with internal disk displacement without reduction over a 2.5 year
period. They found that approximately
40% of patients were asymptomatic at the end of the study period, 33% of
patients had a reduction in symptoms and 25% of patients did not improve. These figures, which show a wide range of
results, were similar to another study looking at TMJ outcomes over a one-year
time frame and were not dependent on splinting treatment.
Some studies suggest that patients with TMJ with cervical or
widespread pain will not obtain the same
degree of improvement as other patients with TMJ who do not have these pains.
Goals
Short
term (2-4 wks) and long term (6-8 wks) goals may include but are not limited
to:
- Reduce or independently self manage pain symptoms or joint noises
- Normal ROM and sequence of jaw movements
- Maximize strength and normalize motor control of muscles of mastication, cervical spine and periscapular region
- Maximize flexibility in related muscles as indicated
- Maximize postural correction in sitting and/or standing
- Correct ergonomic set-up of workstations at home and/or at work
- Independence with home exercise program
- Independence with relaxation techniques
Age Specific Considerations
Younger women 20-40 years of age are most likely to report TMJ
disorder symptoms. Adolescents and elderly men are least likely to report TMJ
dysfunction.
Treatment Planning / Interventions
Established
Pathway
___ Yes, see attached. _X_
No
Established
Protocol
___ Yes, see attached. _X_
No
Interventions
most commonly used for this case type/diagnosis.
This section is intended to
capture the most commonly used interventions for this case type/diagnosis. It
is not intended to be either inclusive or exclusive of appropriate
interventions.
Non-surgical treatments such as
counseling, pharmacotherapy and occlusal splint therapy continue to be the most
effective way of managing over 80% of patients. 12
Treatment strategies may include
but are not limited to:
·
Modalities for pain control: Heat, ice, electrical stimulation, TENS, ultrasound, phonophoresis
·
A/AA/PROM
·
Stretching: active, assisted and passive stretching, can use tongue
depressors or cork as needed. Refer to physical therapy texts for specific
techniques.
·
Joint mobilization or manipulation: Restore normal joint mechanics of the TMJ, cervical and/or
thoracic spine as appropriate. Refer to appropriate texts for treatment
techniques.9,19, 21
·
Soft tissue mobilization,
myofascial release and deep friction massage
·
Muscle energy techniques
·
Neuromuscular facilitation: hold-relax, contract-relax, alternating isometrics. For specific
exercises refer to physical therapy references e.g. Hertling and Kessler’s
Management of Common Musculoskeletal Disorders.19
·
Relaxation techniques: learning to relax masticatory muscles and maintain this relaxed
state during the day; learning stress
management and coping skills4
·
Biofeedback and EMG training to promote muscle control and relaxation 4
·
Therapeutic exercises: Including Rocobado 6 x 6 isometrics program.22 Cervical
stability exercises.
Frequency
& Duration:
The
frequency and duration of follow up treatment sessions will be individualized
based on the specific impairments and functional limitations with which the
patient presents during the initial evaluation.
On average, the frequency may range from 1-2 times per week for 4-6
weeks.
Patient / family education:
·
To stop or change poor habits including
grinding or clenching teeth. An
over-the-
counter mouthguard or an occlusal
orthotic from the Dentist may be helpful for
nighttime use.4 The occlusal orthotic can be helpful for
masticatory muscle pain,
TMJ pain, TMJ noises, restricted jaw
mobility, and TMJ dislocation.4
·
Postural re-education and maintenance
correct resting position of the tongue and mandible
·
Diaphragmatic breathing
·
Body mechanics training
·
Home exercise program instruction
Recommendations
and referrals to other providers.
·
Speech and Language Pathologist
for assessment and treatment of speech or swallowing dysfunction associated
with the TMJ dysfunction
·
Rheumatologist
·
Psychologist/Psychiatrist
·
If conservative measures do not
alleviate the patient’s symptoms, surgical management may be considered. Surgical interventions may include dental
implants, condylectomy, condylotomy, ORIF or surgical manipulation. It is
beyond the scope of this standard to discuss the specifics of the above listed
procedures. Potential surgical referrals
could include:
1. Otolaryngologist (ENT)
2. Dentist or oral surgeon
3. Orthopedic surgeon
Re-evaluation / assessment
Reassessment should be completed every thirty days in the
outpatient setting unless warranted sooner.
Possible triggers for an earlier reassessment include a significant
change in status or symptoms, new trauma, plateau in progress and/or failure to
respond to therapy.
Discharge Planning
Commonly
expected outcomes at discharge:
·
Resolution or independent
management of pain symptoms
·
Functional, active motion of
mandible
·
Resume normal functional
activities with jaw, including chewing and talking
·
Modifications of parafunctional or
habitual activities that are associated with the cause of the patient’s TMJ
dysfunction
·
Ability to self-correct and
maintain normal postural alignment of the head, neck and trunk
·
Correct ergonomic set up of
workspace
·
Independent home exercise program
and self progression of program
Patient’s
discharge instructions
·
Home exercise program
·
Relaxation techniques
·
Habit modification
No comments:
Post a Comment