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Module 2

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3/8/14 

Epidemiology of TMD &

 Lipton et al surveyed 45,711 American households (1993)     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 2

3/8/14   Studies of non-patient populations  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 T. Henkelmann, PT, MS, CCTT 3

3/8/14

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 T. Henkelmann, PT, MS, CCTT 4

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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 3/8/14  Consider having resources available to refer patients to, such as counselors, psychologists, women’s crisis hotline T. Henkelmann, PT, MS, CCTT 5

3/8/14

Cardinal Symptoms of

  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 T. Henkelmann, PT, MS, CCTT 6

3/8/14 

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 T. Henkelmann, PT, MS, CCTT 7

 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

3/8/14   

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 T. Henkelmann, PT, MS, CCTT 9

3/8/14 

Malocclusion

 This is primarily the dentists’ domain  Wesley Shankland states in TMJ: It’s Many Faces, 2 nd 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.” T. Henkelmann, PT, MS, CCTT 10

3/8/14   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% T. Henkelmann, PT, MS, CCTT 11

3/8/14   Occlusal factors implicated:      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 12

3/8/14   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 T. Henkelmann, PT, MS, CCTT 13

3/8/14

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 T. Henkelmann, PT, MS, CCTT 14

3/8/14 

Diagnosing Inflammation

 History: pain/discomfort are influenced by functional and/or parafunctional activities  Receives some relief from use of heating pad, anti inflammatory medicine, e.g. ibuprophen  Physical exam: TMJ palpation & joint loading T. Henkelmann, PT, MS, CCTT 15

3/8/14 

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 T. Henkelmann, PT, MS, CCTT 16

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 3/8/14  Lateral excursion: decreased to the opposite side of the involved joint; normal to the same side of the involved joint T. Henkelmann, PT, MS, CCTT 17

3/8/14

Pathological TMJ Function

  Stage I Disc Displacement (Disc Displacement  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 T. Henkelmann, PT, MS, CCTT 18

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3/8/14 

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) T. Henkelmann, PT, MS, CCTT 21

3/8/14

Cervical Spine Disorder

 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 T. Henkelmann, PT, MS, CCTT 22

3/8/14 T. Henkelmann, PT, MS, CCTT 23

3/8/14 

Posture Correction is a

 “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 T. Henkelmann, PT, MS, CCTT 24

3/8/14 1.

Exercises for Posture

 Chin tucks – start in supine if poor motor control 2.

Shoulder blade squeezes 3.

Corner stretch 4.

Anterior neck stretch – “The office workers’ stretch” T. Henkelmann, PT, MS, CCTT 25

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Time for everyone to stand up and stretch back!

3/8/14 T. Henkelmann, PT, MS, CCTT 26

3/8/14 

Comprehensive Treatment of TMD Diagnostic subsets of TMD

 Arthrogenous  Arthralgia Myogenous Masticatory Muscle Pain:  Hypermobility  Disc displacements  Myofascial trigger points  DDwR  Trismus  DDwoR  Lateral Pterygoid spasm T. Henkelmann, PT, MS, CCTT 27

3/8/14 

Treatments for TMD

 Modalities  Therapeutic Procedures  Behavioral Modification T. Henkelmann, PT, MS, CCTT 28

3/8/14

Treatment

 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 T. Henkelmann, PT, MS, CCTT 29

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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 3/8/14 T. Henkelmann, PT, MS, CCTT 30

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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 2 nd 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 31

Electrical Stimulation vs

  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 3/8/14 T. Henkelmann, PT, MS, CCTT 32

3/8/14

Stage I Disc Displacement

  Dentist may prescribe intraoral appliance to take 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 T. Henkelmann, PT, MS, CCTT 33

3/8/14

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 T. Henkelmann, PT, MS, CCTT 34

3/8/14 

Capsular Restrictions

 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) T. Henkelmann, PT, MS, CCTT 35

3/8/14

Intraoral Massage

 Myofascial and trigger point release techniques to  Temporalis  Masseter – intraorally  Lateral & medial pterygoids  SCM  Upper cervical paraspinal muscles T. Henkelmann, PT, MS, CCTT 36

3/8/14 

Basic Stretches

 Partial Opening with Guidance  1 finger-width side glides & protrusion  Cervical rotation with overpressure (for SCM)  Upper trapezius stretch T. Henkelmann, PT, MS, CCTT 37

3/8/14 

Neuromuscular Control

 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 T. Henkelmann, PT, MS, CCTT 38

3/8/14 

Isometric Stabilization &

 Isometrics in resting position: opening, side glide, protrusion  Isometrics with mouth open 1 finger breadth and tongue up  Isometrics with 2 finger breadth opening T. Henkelmann, PT, MS, CCTT 39

3/8/14 

Surface EMG

 Use in masseter muscle relaxation training  Use to stop clenching behavior  Problems   Not very practical Is not covered by insurances T. Henkelmann, PT, MS, CCTT 40

3/8/14 

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.

T. Henkelmann, PT, MS, CCTT 41

3/8/14 

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 T. Henkelmann, PT, MS, CCTT 42

3/8/14   

Pharmacologic

 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) – 1 st generation type, bad side effects   Doxapin (Sinequan) Nortriptylene (Pamelar) T. Henkelmann, PT, MS, CCTT 43

3/8/14 

Other Diagnoses

 Trigeminal Neuralgia  Glossopharyngeal Neuralgia  Burning Mouth Syndrome T. Henkelmann, PT, MS, CCTT 44

3/8/14   

Practical Matters

 Use care in the use of “TMJ” and “TMJ Disorder” on documentation and TMJ diagnostic codes ICD-9 Codes recommended:   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 T. Henkelmann, PT, MS, CCTT 45

3/8/14 

Marketing Suggestions

 To Dentists  To Oral surgeons  To Orthodontists T. Henkelmann, PT, MS, CCTT 46

3/8/14

Thank you for Your

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QUESTIONS?

T. Henkelmann, PT, MS, CCTT 47

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