R.C.R.S. Fsd.

Assignment of: Emergency prcedures

Topic: TMJ Dysfunction
Submitted to: Dr. Bareera Amjad
Submitted by: Khirman Batool
Submission date: 13-06-2019

Resources
 Langendoen, J; Müller, J; Jull, GA, Retrodiscal Tissue of the Temporomandibular
Joint: Clinical Anantomy and its Role in Diagnosis and Treatment of
Arthropathies, Manual Therapy, 2(4), 191-198, 1997.
 Mark, BM; Kessler, CS, All Pain is not the Same, A unique Perspective on
Headaches, TMJ Disorders and Facial Pain, JimSam Inc., 2010.
 Peterson, C. The TMJ Healing Plan, Hunter House, 2010.
 Randolph, CS; Greene, CS; Moretti, R Conservative Management of
Temporomandibular Disorders: A post treatment comparison between patients
from a university clinic and private practice. American Journal Orthod Dentofac
Orthop 98: 77-82, 1990.
 Read, K. Course Notes, Craniomandibular Disorders for Physiotherapists, Uni of
Qld, Sep, 2009.
 St George, F; Elliott, P, Course Notes: TMJ / Cranial Techniques, Physiotherapy
Coaching Academy Australia, 2011.
 Zito, G. Difficulties with the Differential Diagnosis of Cervicogenic and
Temporomandibular Headache, MPA In Touch, Issue 2, 2008
 Temporomandibular Disorder (TMD)

Temporomandibular Disorder (TMD) is a broad term that encompasses disorders

of the temporomandibular joint and its associated anatomical structures. The
disorder may be intra-articular, due to inflammation, internal structural changes
(internal derangement) or degeneration, or it may be extra- articular due to
imbalance or over-activity of the jaw muscles, commonly the muscles of
mastication or the cervical muscles. There is a strong correlation between postural
dysfunction of the cervical spine and TMD.

TMJ Anatomy
The lateral pterygoid muscle was connected to the medial aspect of the joint
capsule, meniscus and the condyle pterygoid fovea in more than half of the
specimens. That indicates that the muscle might have a specific contribution to the
TMD.

Causes of TMD
Intra-Articular Causes
1. Inflammatory conditions caused by direct trauma, such as a blow to the chin
or jaw, indirect trauma, such as a whiplash injury, heavy chewing, grinding
(bruxism), clenching of the jaw or loss of dental height due to worn down or
missing teeth.

 Synovitis - The synovium or the capsule may be inflamed. There is often pain at
rest and limited range or pain at the end of range.
 Retrodiscitis - The retrodiscal tissue (the posterior attachment of the articular disc
to the mandibular fossa) is highly vascular and innervated and if inflamed, can
cause severe pain. The jaw may deviate away from the painful side at rest and
with opening.
2. Internal derangement describes conditions where there are structural changes
within the joint.

 Disc displacement with reduction – The articular disc can become displaced in
any direction, but will most commonly displace anteriorly. The disc will be
pushed forward during opening and will bunch up. At a certain point in range the
disc will reposition or reduce itself causing an audible or palpable click. The jaw
will often deviate towards the affected side.
 Disc displacement without reduction – In this more severe version the disc will
not reduce causing pain and a loss of range. This is called closed lock. The jaw
will often deviate towards the affected side. There will be no click but the patient
may report that there was a click at the time when their jaw locked.
3. Arthritis
 Degenerative Arthritis can occur in the TMJ. It can often be seen on plain x-ray or
OPG as a flattening of the condylar head, often with some osteophytic formation
MRI gives more information with views done in open and closed positions. This
shows the position of the joint and disc at the start and end of range. Crepitus can
often be felt or can be heard with a stethoscope. It can be age related degeneration,
usually seen in the over 50s, or secondary to trauma occurring at a younger age.
 Inflammatory Joint Diseases can affect the TMJ, including rheumatoid arthritis,
ankylosing spondylitis, infectious arthritis, Reiter syndrome and gout.
4. Hyper mobility can result in excessive anterior movement of the jaw and the
articular disc. This will result in deviation of the jaw away from the affected side.
There are usually some clicking sounds in the TMJ and there may or may not be
pain. Long term hyper mobility can cause the articular disc to elongate and
degenerate. The disc can then fail to reduce on closing, causing the TMJ to
become stuck in an open position (Open Lock). This can often occur after
opening the mouth to an extreme position, such as when singing or yawning or
after a prolonged dental procedure.

Extra-Articular Causes
1. Muscle Spasm can cause significant pain and limitation of movement of the
jaw. This is referred to as trismus. It affects commonly muscles of mastication,
especially masseter, temporalis and pterygoid muscles. Causes include prolonged
dental procedures or anaesthetics where the mouth has been held open for
extended periods of time, stress, bruxism and postural dysfunction.
2. Cervical Postural Disorders can cause jaw pain. The anterior belly of the
digastic muscle runs from the point of the chin to hyoid bone. This attachment
means that when the head is protracted forward the digastrics will exert a posterior
force on the mandible. With prolonged cervical protraction mandibular condyle is
pushed back against the retrodiscal tissue, eventually causing swelling, pain and
gradual degeneration of the disc.
3. Temporal Tendonopathy is caused by excessive contraction of the temporalis
muscle usually as a result of bruxism. There is tenderness and swelling of the
anterior portion of the temporalis tendon palpable just above the zygomatic arch.
There may also be tenderness of the temporalis tendon where it inserts onto the
coronoid process, palpable just below the zygomatic arch when the jaw is slightly
open.
4. Fractures of the mandible. Treatment can usually begin within a week or two
of surgery to begin early mobilisation of the TMJ and to restore function.

Diagnosis
There are different clinical protocols used to establish TMD diagnoses but the
Research Diagnostic Criteria for TMD (RDC/TMD) could promote the level of
consistency between in research studies, it may also be practical in clinical usage.

Assessment of TMD
A thorough history needs to be taken. The examination should include assessment
of the patient’s posture (position of the jaw, tongue and neck); palpation of the
TMJ to assess for swelling, muscle spasm and stiffness or hypermobility of one or
both TMJ; assessment of range and quality of movement of the jaw and neck,
particularly noting any deviation or deflection of the jaw and assessment of the
patient’s bite. Also check signs of sleep bruxism (grinding or clenching during
sleep). Often the patient will have been told by their sleep partner that they brux
or their dentist may have noticed excessive wearing of their teeth. Other signs
include waking with teeth clenched, waking with muscle soreness or temporal
headache or indentations in the tongue or cheeks If the patient has OPG Xrays or
MRI, these can give more information on the condition of the joint and the disc
and, if open views are available, on the amount of movement of the joint.

Treatment of TMD
TMD is a recurring, but self limiting condition that tends not to be progressive.
Non-invasive, conservative treatments have found to be effective. Physiotherapy
treatment is very effective in relieving and managing TMD, even when the
symptoms are long-standing and severe. With appropriate physiotherapy most
patients will see a significant improvement in their symptoms within 3 to 6 weeks.
Treatment needs to address the issues identified in the assessment. If the patient’s
symptoms are acute and inflammatory then their condition is likely to be irritable
and one should proceed very gently with the aim of first relieving pain, swelling
and muscle spasm. When the pain begins to settle then start to restore jaw
movement and alignment. Treatment may include soft tissue releases to affected
muscles and joint mobilisation techniques. It is also important to treat any
associated neck pain and headaches. Posture correction is essential and should
address head, neck, shoulder and tongue position. The patient should be taught
exercises to improve coordination, stability and alignment of the jaw.
If the patient has signs of sleep bruxism then should discuss with their dentist
whether and occlusal splint would be appropriate for them. Occlusal splints hold
the TMJ slightly apart as the patient clenches or grinds, preventing compression of
the TMJ. This can help to relax jaw muscles and reduce swelling and
inflammation. There is some evidence to supporting the use of splints to reduce
long term degeneration of the TMJ, disc and teeth. Other dental problems, such as
cavities, that are causing pain or uneven chewing, lack of dental height or missing
teeth may also need to be addressed.
The patient should be taught strategies to help them manage their condition. This
may include posture education, long-term continuance of their home exercise
programme, good sleep habits including sleeping positions, stress management
and diet modification - a soft food diet while the condition is acute can help to
reduce the pain and swelling more quickly. The patient should also be taught ways
to reduce stress on the TMJ by avoiding activities such as resting the chin on the
hand, pencil chewing, jaw clenching while awake, wide mouth yawning, nail
biting. They should avoid chewy foods, chewing gum, eating foods that need a
 wide opening like large hamburgers and chewing hard foods such as nuts and
apples.

Manual Therapy
A systematic review was published in 2015 [9] to summarize the effectiveness of
manual therapy on signs and symptoms of TMD. It showed that protocols of
mixed manual therapy techniques, upper cervical mobilization or manipulation,
had considerable evidence for TMD symptom control and improvement in
maximum mouth opening. The manual techniques included intra-oral myofascial
release and massage therapy on masticatory muscles, atlanto-occipital joint thrust
manipulation, and upper cervical spine mobilization.
Therapists should be trained, follow the guidelines and standard procedures to
perform the cervical thrust manipulation if it is indicated.

Other Causes of TMJ and Facial Pain

It is important to be aware that there are other causes of pain and dysfunction in
the oro-facial region that need to be distinguished from TMD. Below are some of
the more common [10][11].
1. Referred Pain – Noxious input from the trigeminal nerve, C1, C2 and C3
nerves all feed into the trigeminocervical nucleus in the brainstem and can cause
referred pain. “The trigeminocervical nucleus is a region of the upper cervical
spinal cord where sensory nerve fibers in the descending tract of the trigeminal
nerve (trigeminal nucleus caudalis) are believed to interact with sensory fibers
from the upper cervical roots. This functional convergence of upper cervical and
trigeminal sensory pathways allows the bidirectional referral of painful sensations
between the neck and trigeminal sensory receptive fields of the face and head.”
2. Neuropathic Pain

 Trigeminal Neuralgia (Tic Doloreaux) is characterised by severe, shooting pain in

the distribution of one or more of the three branches of the trigeminal nerve
(Cranial Nerve V). It can be caused by sensatisation of the trigeminal nerve or by
compression or impingement of the nerve. It is usually one sided.
 Trigeminal Neuritis is due to inflammation of the trigeminal nerve.
 Complex Regional Pain Syndrome is characterised by a continuous burning pain,
not necessarily in the path of a particular nerve. It is usually secondary to a
traumatic injury and is worsened by fear or anxiety. As it worsens there can be
skin changes and sweating in the area of pain. These patients need early referral to
a pain specialist to prevent worsening of their condition.
Bell’s Palsy is a palsy of the facial nerve (Cranial Nerve VII). In approximatel 80% of
cases it resolves withing 6 to 8 weeks. Early treatment with prednisone can
significantly reduce the recovery time. Physiotherapy may be required if there is
residual weakness.

 Shingles (Herpes Zoster) usually affects the opthalmic division of the trigeminal
nerve and manifests as pain and a blister rash along the path of the nerve.
 Atypical Odontalgia presents as tooth pain with no obvious dental cause.
 Central Sensatisation is sensatisation of the dorsal horn and central structures that
causes secondary hyperalgesia in the uninjured tissue around the injured site.

3. Vestibular Dysfunction can cause secondary headache and jaw pain. "The
vestibular system is a complex system that includes the balance component of the
inner ear and central nervous system structures. It's primary functions are to sense
linear and angular accelerations of the head, coordinate head and eye movements,
and assist with the maintenance of equilibrium". Dysfunction of the vestibular
system can cause dizziness, vertigo, nausea, anxiety, neck pain and can also cause
ear and jaw pain. As these symptoms can be similar to the symptoms of TMD, the
vestibular system must be considered as a possible alternate cause of jaw pain.
4. Parotid Blockage by stones can cause pain and swelling over the parotid gland.
This condition needs to be accurately diagnosed in order to exclude parotid
tumours. Parotid blockage can respond to effleurage type massage and higher
intensity ultrasound.

5. Benign or Malignant Tumours need to be excluded. They can cause

ankylosis, contracture, loss of function and pain. These secondary problems may
require treatment, once treatment of the tumour has been addressed.
6. Sinus Pain is caused by inflammation of the lining of the maxillary sinus. It is
characterised by facial pain, headache, pain in the upper teeth, and a feeling of
fullness on the affected side. Sinus pain may result in secondary cervical and TMJ
pain.
7. Vascular pain or Headache

 Migraine with or without aura can be accompanied by nausea, vomiting, visual or

auditory sensitivity.
 Cluster Headaches are usually one sided and come in bouts lasting 30-60 minutes,
with 1-3 attacks a day. It is more common in men and the pain is often
excruciating. This type of headache doesn’t usually respond to physio, but
treatment may help any secondary cervical or TMJ symptoms.
 Arterio-Venous Malformations such as temporal arteritis, can cause a moderate to
severe headache in the temporal region. The pain is usually one sided and can
refer to the face and neck. It is more common in older people, especially women
and can be related to polymyalgia rheumatica. These patients need quick referral
to a specialist as vision can be lost.
8. Psychogenic Pain

 Chronic Facial Pain occurs when pain becomes chronic and psychological factors
cause the pain to continue despite complete resolution of the original injury.
 Bipolar Disorder and other psychosis disorders.