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 Module 2 .  Epidemiology of TMD & Orofacial Pain  Lipton et al surveyed 45,711 American households (1993)  22% reported at least 1 of 5 types of.

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Presentation on theme: " Module 2 .  Epidemiology of TMD & Orofacial Pain  Lipton et al surveyed 45,711 American households (1993)  22% reported at least 1 of 5 types of."— Presentation transcript:

1  Module 2 

2  Epidemiology of TMD & Orofacial Pain  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% 3/8/14T. Henkelmann, PT, MS, CCTT2

3   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 3/8/14T. Henkelmann, PT, MS, CCTT3

4  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 3/8/14T. Henkelmann, PT, MS, CCTT4

5  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  Consider having resources available to refer patients to, such as counselors, psychologists, women’s crisis hotline 3/8/14T. Henkelmann, PT, MS, CCTT5

6  Cardinal Symptoms of TMD  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 3/8/14T. Henkelmann, PT, MS, CCTT6

7  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 3/8/14T. Henkelmann, PT, MS, CCTT7

8  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 3/8/14T. Henkelmann, PT, MS, CCTT8

9   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 Diagnostic Tests 3/8/14T. Henkelmann, PT, MS, CCTT9

10  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.” 3/8/14T. Henkelmann, PT, MS, CCTT10

11   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% 3/8/14T. Henkelmann, PT, MS, CCTT11

12   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 3/8/14T. Henkelmann, PT, MS, CCTT12

13   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 3/8/14T. Henkelmann, PT, MS, CCTT13

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 3/8/14T. Henkelmann, PT, MS, CCTT14

15  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 3/8/14T. Henkelmann, PT, MS, CCTT15

16  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 3/8/14T. Henkelmann, PT, MS, CCTT16

17  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  Lateral excursion: decreased to the opposite side of the involved joint; normal to the same side of the involved joint 3/8/14T. Henkelmann, PT, MS, CCTT17

18  Pathological TMJ Function During Opening  Stage I Disc Displacement (Disc Displacement with Reduction)  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

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21  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) 3/8/14T. Henkelmann, PT, MS, CCTT21

22  Cervical Spine Disorder and TMD 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 3/8/14T. Henkelmann, PT, MS, CCTT22

23 10/18/13T. Henkelmann, PT,MS,CCTT23

24  Posture Correction is a Priority  “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, /18/13T. Henkelmann, PT,MS,CCTT24

25  1.Chin tucks – start in supine if poor motor control 2.Shoulder blade squeezes 3.Corner stretch 4.Anterior neck stretch – “The office workers’ stretch” 3/8/14T. Henkelmann, PT, MS, CCTT25 Exercises for Posture

26   Time for everyone to stand up and stretch back! 3/8/14T. Henkelmann, PT, MS, CCTT26

27   Arthrogenous  Arthralgia  Hypermobility  Disc displacements  DDwR  DDwoR Myogenous Masticatory Muscle Pain:  Myofascial trigger points  Trismus  Lateral Pterygoid spasm 3/8/14T. Henkelmann, PT, MS, CCTT27 Comprehensive Treatment of TMD Diagnostic subsets of TMD

28   Modalities  Therapeutic Procedures  Behavioral Modification 3/8/14T. Henkelmann, PT, MS, CCTT28 Treatments for TMD

29  Treatment Considerations Acute Inflammation and Pain (acute, chronic)  Modalities  Cold pack first 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, 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

30   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;  This is a mainstay in my therapeutic toolbox 3/8/14T. Henkelmann, PT, MS, CCTT30 Ultrasound

31   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; :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” 3/8/14T. Henkelmann, PT, MS, CCTT31 Iontophoresis

32   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 3/8/14T. Henkelmann, PT, MS, CCTT32 Electrical Stimulation vs TENS

33  Stage I Disc Displacement  Dentist may prescribe intraoral appliance to take stress off disc and posterior attachment to allow 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

34  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

35  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)

36  Intraoral Massage Myofascial and trigger point release techniques to  Temporalis  Masseter – intraorally  Lateral & medial pterygoids  SCM  Upper cervical paraspinal muscles

37   Partial Opening with Guidance  1 finger-width side glides & protrusion  Cervical rotation with overpressure (for SCM)  Upper trapezius stretch 3/8/14T. Henkelmann, PT, MS, CCTT37 Basic Stretches

38  Neuromuscular Control Exercises  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

39  Isometric Stabilization & Strengthening Exercises  Isometrics in resting position: opening, side glide, protrusion  Isometrics with mouth open 1 finger breadth and tongue up  Isometrics with 2 finger breadth opening

40   Use in masseter muscle relaxation training  Use to stop clenching behavior  Problems  Not very practical  Is not covered by insurances 3/8/14T. Henkelmann, PT, MS, CCTT40 Surface EMG Biofeedback

41   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 secs. 3/8/14T. Henkelmann, PT, MS, CCTT41 Short Upper Lip

42   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 3/8/14T. Henkelmann, PT, MS, CCTT42 Overview of Surgeries

43   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 3/8/14T. Henkelmann, PT, MS, CCTT43 Pharmacolgic Coinsiderations

44   Trigeminal Neuralgia  Glossopharyngeal Neuralgia  Burning Mouth Syndrome 3/8/14T. Henkelmann, PT, MS, CCTT44 Other Diagnoses Brief overview

45   Use care in the use of “TMJ” and “TMJ Disorder” on documentation and TMJ diagnostic codes  ICD-9 Codes recommended:  Jaw pain  Muscle spasm  Headache or face pain  Cervicocranial syndrome  Myofascial pain  ICD-9 Codes not recommended (unless MC, Auto, WC)  524 & 526 codes 3/8/14T. Henkelmann, PT, MS, CCTT45 Practical Matters

46   To Dentists  To Oral surgeons  To Orthodontists 3/8/14T. Henkelmann, PT, MS, CCTT46 Marketing Suggestions

47   QUESTIONS? 3/8/14T. Henkelmann, PT, MS, CCTT47 Thank you for Your Attention

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