1. TMD Diagnosis & Therapeutic Intervention
 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%
3/8/14
T. Henkelmann, PT, MS, CCTT

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

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

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

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

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

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

9. Diagnostic Tests Panorex or panoramic x-ray Tomography MRI
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
3/8/14
T. Henkelmann, PT, MS, CCTT

10. Malocclusion This is primarily the dentists’ domain
Wesley Shankland states in TMJ: It’s Many Faces, 2nd 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.”
3/8/14
T. Henkelmann, PT, MS, CCTT

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

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

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

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

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

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

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

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

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

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

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

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, 1999
10/18/13
T. Henkelmann, PT,MS,CCTT

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

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

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

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

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. 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

31. 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; :2
Consider this a 2nd 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

32. Electrical Stimulation vs TENS
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

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

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

41. 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 secs.
3/8/14
T. Henkelmann, PT, MS, CCTT

42. 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
3/8/14
T. Henkelmann, PT, MS, CCTT

43. Pharmacolgic Coinsiderations
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) – 1st generation type, bad side effects
Doxapin (Sinequan)
Nortriptylene (Pamelar
3/8/14
T. Henkelmann, PT, MS, CCTT

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

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

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

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