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Evaluation & Treatment of TMD Presented by: Christy Dauner, OTR Laurie Applebee, PT Susan Vaughn, MS, OTR.

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Presentation on theme: "Evaluation & Treatment of TMD Presented by: Christy Dauner, OTR Laurie Applebee, PT Susan Vaughn, MS, OTR."— Presentation transcript:

1 Evaluation & Treatment of TMD Presented by: Christy Dauner, OTR Laurie Applebee, PT Susan Vaughn, MS, OTR

2 Learning Objectives Identify TMD risk factors and related diagnoses Identify TMD risk factors and related diagnoses Differentiate joint and muscle disorders Differentiate joint and muscle disorders Understand goals of Occupational Therapy for TMD Understand goals of Occupational Therapy for TMD Understand OT treatments for TMD and muscle disorders Understand OT treatments for TMD and muscle disorders Perform assessment and treatment approaches for TMD Perform assessment and treatment approaches for TMD

3 Disorders of the TMJ Myofascial Dysfunction Myofascial Dysfunction Internal Derangement Internal Derangement Capsulitis Capsulitis Subluxation Subluxation Arthritis Arthritis

4 Risk Factors for TMD Trauma such as blow to the jaw, whiplash injuries, MVA, dental work, opening the mouth too wide or for too long, prolonged chewing Trauma such as blow to the jaw, whiplash injuries, MVA, dental work, opening the mouth too wide or for too long, prolonged chewing Oral parafunctional habits such as clenching and bruxism that place continued strain on the masticatory system Oral parafunctional habits such as clenching and bruxism that place continued strain on the masticatory system Malocclusion causes bite instability or functional interference during chewing that places postural strain on the masticatory system Malocclusion causes bite instability or functional interference during chewing that places postural strain on the masticatory system Stressful life events can trigger parafunctional habits and muscle guarding/tension Stressful life events can trigger parafunctional habits and muscle guarding/tension Emotional factors such as depression or anxiety decreases the ability to cope with pain and can increase parafunctional habits. Emotional factors such as depression or anxiety decreases the ability to cope with pain and can increase parafunctional habits.

5 TMJ Evaluation History & Symptoms (referred pain) History & Symptoms (referred pain) Functional Limitations Functional Limitations Tests, Measures & Palpation Tests, Measures & Palpation AROM (active/passive incisal opening, lateral excursion, and protrusion) AROM (active/passive incisal opening, lateral excursion, and protrusion) PROM – scissor stretch PROM – scissor stretch TMJ Noise TMJ Noise Muscle Palpation Muscle Palpation

6 Differential Diagnosis Scissor stretch test: if opens further - muscular, if not - internal derangement Scissor stretch test: if opens further - muscular, if not - internal derangement Clench test: bite down on tongue depressor for 10 – 15 seconds. Pain on same side – muscle, opposite side – joint Clench test: bite down on tongue depressor for 10 – 15 seconds. Pain on same side – muscle, opposite side – joint “S” vs. “C” curve with opening “S” vs. “C” curve with opening

7 Occupational Therapy Goals for TMD Increase ROM to >40mm Increase ROM to >40mm Decrease pain Decrease pain Teach joint protection (decrease parafunctional habits, limited opening) Teach joint protection (decrease parafunctional habits, limited opening) Improve function (eating, yawning, DDS visit tolerance, oral hygiene, talking, sleep, work) Improve function (eating, yawning, DDS visit tolerance, oral hygiene, talking, sleep, work) HEP independence HEP independence Neutral posture (head on neck, jaw, scapular position, TUTA) Neutral posture (head on neck, jaw, scapular position, TUTA)

8 Myofascial Pain Dysfunction Most common disorder Most common disorder Referred muscle pain Referred muscle pain Muscle pain aggravated by jaw function or parafunction Muscle pain aggravated by jaw function or parafunction HA’s HA’s Tenderness of muscles w/o mechanical symptoms Tenderness of muscles w/o mechanical symptoms Loss of motion or painful motion Loss of motion or painful motion

9 Myofascial Pain Dysfunction Caused by an underlying related disorder – malocclusion, arthritis, internal Caused by an underlying related disorder – malocclusion, arthritis, internal derangement, poor posture derangement, poor posture Education is key! – posture, parafunction, stress management Education is key! – posture, parafunction, stress management Often chronic and cyclical Often chronic and cyclical Often a myofascial component with all diagnoses Often a myofascial component with all diagnoses

10 Myofascial Dysfunction Myofascial contributors may include: * Lateral pterygoid * Lateral pterygoid * Medial pterygoid * Medial pterygoid * Temporalis * Temporalis * Masseter * Masseter * Digastrics * Digastrics * Muscles of the cervical spine * Muscles of the cervical spine

11 Lateral Pterygoid Origin: Lateral Pterygoid Plate of Sphenoid Insertion: Condylar Neck, Ramus of Mandible and Disc

12 TMJ Muscles – Lateral Pterygoid #1 myofascial source of pain #1 myofascial source of pain Due to attachment to disc it can cause disc and jaw to be unable to return to normal resting position and cause clicking or popping. Due to attachment to disc it can cause disc and jaw to be unable to return to normal resting position and cause clicking or popping. Malocclusion of teeth/missing teeth Malocclusion of teeth/missing teeth

13 Referral pattern – zygomatic arch, TMJ

14 Medial Pterygoid Origin: Inner Surface of Lateral Pterygoid Plate Insertion: Ramus of Mandible by the Angle

15 TMJ Muscles – Medial Pterygoid Stuffiness in ear Stuffiness in ear Swallowing difficulty as restriction in protrusion of jaw Swallowing difficulty as restriction in protrusion of jaw

16 Referral pattern – posterior mandible, mouth, below and behind TMJ including internal ear – not teeth

17 Temporalis Origin: Temporal Fascia, Superior to Zygomatic Arch Insertion: Coronoid Process of Mandible

18 TMJ Muscles - Temporalis Significant postural muscle (the only time it isn’t working is when you’re lying supine) Significant postural muscle (the only time it isn’t working is when you’re lying supine) Perpetual clenching Perpetual clenching

19 Referral pattern – lower jaw, molar teeth and gum, maxilla, lower portion of mandible, temple eyebrow and external ear

20 Masseter Origin: Zygomatic Arch Insertion: Mandibular Angle and Ramus

21 TMJ Muscles - Masseter “Sinusitis”

22 Referral pattern - temple, along eyebrow, behind eye or upper teeth

23 Digastrics Origin: Mastoid Notch (posterior), Symphysis of Mandible (anterior) Insertion: Join by a Common Tendon to the Hyoid Bone

24 TMJ Muscles - Digastrics Rarely in spasm due to forward head posture (stretch weakness) Rarely in spasm due to forward head posture (stretch weakness)

25 Referral pattern – behind mandible toward back of ear, lower incisors

26 Cervical Spine Muscles Form stable base for TMJ on which to work Form stable base for TMJ on which to work Poor posture – condyle rotates backward – change of biomechanics Poor posture – condyle rotates backward – change of biomechanics Referral pattern from the cervical spine- Temporal Headaches, SCM Referral pattern from the cervical spine- Temporal Headaches, SCM Assess for tension in upper traps, scalenes, and SCM Assess for tension in upper traps, scalenes, and SCM

27 Parafunctional Behaviors Gum/candy chewing (chewing limited to 15 – 20 minutes/day!) – including chewing on one side Gum/candy chewing (chewing limited to 15 – 20 minutes/day!) – including chewing on one side Clenching/bruxing/grinding Clenching/bruxing/grinding Leaning on chin/jaw Leaning on chin/jaw Biting nails, pencils, cheeks Biting nails, pencils, cheeks Sleep position Sleep position Caffeine use Caffeine use Musical instruments Musical instruments Mouth breathing Mouth breathing Phone cradling Phone cradling

28 Treatment – Myofascial Pain Dysfunction Modalities: US – 1.2 w/cm2, 3 MHz, x5 minutes to joint or muscle, heat, electrical stimulation Modalities: US – 1.2 w/cm2, 3 MHz, x5 minutes to joint or muscle, heat, electrical stimulation Manual Therapy – joint mobs/distraction, MFR – including upper cervical region Manual Therapy – joint mobs/distraction, MFR – including upper cervical region HEP/Lifestyle changes HEP/Lifestyle changes Tongue positioning (TUTA) Tongue positioning (TUTA) Self-joint distraction &/or MFR Self-joint distraction &/or MFR Eliminating parafunctional behaviors Eliminating parafunctional behaviors Postural instruction Postural instruction Conjunction with splint therapy &/or counseling (Referral to psychology for CBT as needed for stress and anxiety management) Conjunction with splint therapy &/or counseling (Referral to psychology for CBT as needed for stress and anxiety management)

29 Resting Joint Position Capsule – anterior/posterior only

30 Normal Joint Motion

31 Internal Derangement

32 Disc Disorder Internal Derangement Disc held in place by collateral ligaments and posterior ligament, w/ movement dictated by lateral pterygoid Disc held in place by collateral ligaments and posterior ligament, w/ movement dictated by lateral pterygoid Click, pop, lock Click, pop, lock Pain at joint Pain at joint “S” shaped opening/closing to reposition jaw “S” shaped opening/closing to reposition jaw Eye pain Eye pain History of trauma History of trauma

33 Treatment – Internal Derangement Modalities: Iontophoresis, electrical stimulation, cold – ice massage Modalities: Iontophoresis, electrical stimulation, cold – ice massage Manual therapy – Joint distraction Manual therapy – Joint distraction Joint protection techniques: Limit motion to no noise, soft food diet or chewing behaviors Joint protection techniques: Limit motion to no noise, soft food diet or chewing behaviors Home exercise instruction Home exercise instruction Change parafunctional behaviors Change parafunctional behaviors Self joint distraction techniques Self joint distraction techniques Tongue positioning for relaxation (TUTA) Tongue positioning for relaxation (TUTA) Postural instruction and controlled opening/neuromuscular re-education Postural instruction and controlled opening/neuromuscular re-education

34 Treatment - Other Capsulitis Capsulitis Usually a result of another disorder unless post surgery Usually a result of another disorder unless post surgery Modalities, MT and HEP Modalities, MT and HEP Subluxation Subluxation Excess opening (>40 mm) Excess opening (>40 mm) Usually a component of myofascial pain dysfunction, and treated as this, with addition of stab exercises and controlled opening Usually a component of myofascial pain dysfunction, and treated as this, with addition of stab exercises and controlled opening

35 Treatment - Other Arthritis Arthritis Generalized joint pain and inflammation Generalized joint pain and inflammation Usually seen in conjunction w/ other Dx Usually seen in conjunction w/ other Dx Joint protection, rest Joint protection, rest Stretching, therapeutic exercise Stretching, therapeutic exercise Modalities (cold vs. heat, pulsed US, Modalities (cold vs. heat, pulsed US, phono/iontophoresis, E-stim) phono/iontophoresis, E-stim)

36 Intervention: Dentist Intervention: Dentist Assess occlusion Assess occlusion Parafunctions of clenching/bruxing Parafunctions of clenching/bruxing Malocclusions Malocclusions Pressure on back teeth activate temporalis an superior head of lateral pterygoid, anterior teeth activate masseters Pressure on back teeth activate temporalis an superior head of lateral pterygoid, anterior teeth activate masseters

37 Lab - Evaluation AROM (Therabite) AROM (Therabite) Active Incisal Opening (Normal mm) Active Incisal Opening (Normal mm) Passive Incisal Opening (Normal mm) Passive Incisal Opening (Normal mm) Lateral Excursion (Normal >7 mm) Lateral Excursion (Normal >7 mm) Protrusion (Normal > 7 mm) Protrusion (Normal > 7 mm)

38 Lab - Evaluation TMJ Palpation/Observation TMJ Palpation/Observation Quality of Motion: Smooth/Rigid/Jerky/Guarded/Fasciculation/ Thrusting Quality of Motion: Smooth/Rigid/Jerky/Guarded/Fasciculation/ Thrusting TMJ Noise: Opening Click, Closing Click, Reproducible TMJ Noise: Opening Click, Closing Click, Reproducible Visually Assess Opening (S or C Shaped Curve) Visually Assess Opening (S or C Shaped Curve)

39 Lab Muscle Palpation Muscle Palpation Medial Pterygoid (elevation, protrusion, and lateral deviation to opposite side) Medial Pterygoid (elevation, protrusion, and lateral deviation to opposite side) Place index finer on muscle at inside of bottom teeth in mouth. Place opposite thumb under jaw line below ear. Apply pressure to muscle as if to touch finger and thumb. Move along gum line until reach incisors in front. Hold until relaxes 1-2X/day Place index finer on muscle at inside of bottom teeth in mouth. Place opposite thumb under jaw line below ear. Apply pressure to muscle as if to touch finger and thumb. Move along gum line until reach incisors in front. Hold until relaxes 1-2X/day Lateral Pterygoid (elevation, protrusion, and lateral deviation to opposite side) Lateral Pterygoid (elevation, protrusion, and lateral deviation to opposite side) Place index finger inside mouth, under cheek bone. Point finger up and towards opposite eye. Apply pressure to muscle until it relaxes. To check positioning of finger, actively move jaw in opposite direction and muscle will contract under finger. Hold until relaxes 1-2X/day Place index finger inside mouth, under cheek bone. Point finger up and towards opposite eye. Apply pressure to muscle until it relaxes. To check positioning of finger, actively move jaw in opposite direction and muscle will contract under finger. Hold until relaxes 1-2X/day

40 Lab Manual Therapy Manual Therapy Trigger point release Trigger point release Joint distraction Joint distraction Place thumb on back, bottom molar and wrap fingers under jaw Place thumb on back, bottom molar and wrap fingers under jaw Press down as you lift on jaw in scooping motion Press down as you lift on jaw in scooping motion Do NOT pull jaw forward Do NOT pull jaw forward

41 Thank You Feel free to contact Christy at or at with questions. Feel free to contact Christy at or at with PDR Clinic Locations: Edina, Burnsville, Maplewood, Burnsville, Chanhassen PDR Clinic Locations: Edina, Burnsville, Maplewood, Burnsville, Chanhassen Specializing in the treatment of chronic neck, back and TMJ pain. Specializing in the treatment of chronic neck, back and TMJ pain.


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