Dr.

Susan Roche
ODRP 811
Spring Qtr 2018
Dr Chunhua Chilton
Dr Luz House
Dr Jean B. Joseph
Dr Peggy K. Ram
Dr Prasad Manjunath
 45 yr. old Hispanic lady.
 Hx of Polio since child hood.
 Sleep disorder and anxiety.
 Currently taking citalopram(Pharmacologic
Category:
 Antidepressant, Selective Serotonin Reuptake
Inhibitor
 (Can cause xerostomia and prolong bleeding)
 S: Pt came to urgent care with CC: pain under
bridge(#2 to #5).
 O: there is defective restoration on area of #2 to
#5. Also #2 needs RCT (endo testing revealed
irreversible pulpitis)
 A: Tooth#2 – irreversible pulpitis
 P: sectioning bridge from #2 to #5 and RCT on
#2
S: Pt found new problem. She was not able to find
her bite. She complained of pain in Orofacial
region . Temporary bridge broke two times.
O: There is broken temporary in area of
#2 - 5.
A: There is problem with occlusion.
P: TMD consult
 Pt. mentioned that she had pain after placement of her
right side bridge.(dull itching pain since 3 years ago)
 Her jaw has a click since she remembers.
 She said after placement of her bridge , she started
grinding her front teeth as well.
 After we cut her bridge off for RCT on #2 , muscle pain
got worse and now , she can not find her bite.
 Pain is dull and rated 7/10 in muscle exam and 9/10 in
chewing.
 She has jaw catching since she remembers. It takes a few
seconds to come back to comfort position. (It happens
occasionally like twice a month). She is able to unlock it
with lateral movements.
Range of motion
 Comfort opening: 45mm

 Active opening (assisted): 50mm

 Passive opening (unassisted): 57mm

 Protrusion: 5mm

 Right lateral: 13mm

 Left lateral: 13mm

 Right : Corrected deviation

 Left: Corrected deviation

 Tongue ridging: Negative
 Cheek ridging: Negative
 Attrition : in anterior teeth (Mand and Max)
 Muscle palpation exam : Lat Pterygoid and
Masseter pain on both sides.
 Pain on palpation in both joints .
1. Myalgia (muscle pain on opening and closing
and excursion)
2. Arthralgia (joint pain report-no crepitus)
3. Anterior disc displacement with reduction
(right joint)
4. Muscle incoordination with pt contacting in
anterior teeth due to protrusive movement
habit.
1. Sent pt for physical therapy for 4 weeks for
Masseter and Lateral Pterygoid muscle
massage and treatment. Hinge axis exercise.
2. Anti- inflammatory medications
3. Home care program includes exercise (“N-
position” stretch)
1. Patient had a comfortable occlusion and pain
relief. She was able to find her bite.
2. Physical therapist wanted to have the patient
equilibrate to the new bite so requested that
the dental student replace the temporary
bridge in this new bite.
BEFORE

AFTER
 Group #4
Group leader: Dr. Ammar Rasheed
March 2015
 72 year old female
 Chief complaint: chipped
porcelain crown #18
 Health history:
- Autoimmune: systemic lupus
erythematosus, diagnosed in
2014.
- Bladder infection.
 Vital signs:
- BP 130/83, Pulse 70
 No pain history in TMJ

Medications:
-Prednisone 40 mg per day.
-Hydroxychloroquine 200 mg twice a day.
-Vitamin D and Calcium.
 Systemic lupus erythematosus (SLE)
is an autoimmune disease. It can affect
the skin, joints, kidneys, brain, and
other organs.
 SLE is much more common in women
than men. It may occur at any age but
appears most often in people between
the ages of 10 to 50.
 African Americans and Asians are
affected more often than people from
other races.
 Mild forms of the disease may be treated with:
 NSAIDs for joint symptoms and pleurisy, after
talking with your doctor
 Corticosteroid creams for skin rashes
 A drug also used to treat malaria
(hydroxychloroquine) and low-dose
corticosteroids for skin and arthritis symptoms
 Treatments for more severe SLE may include:
 High-dose corticosteroids
 Cytotoxic drugs
 PFMs on # 18, 19 and 30
 Pt complained that when crowns were placed
on #18 & 19 they were contacting heavily
 Crowns were re-done and new bite
registrations taken but problem persisted
 TMD consult was scheduled with Dr. Roche
 ROM
- Comfortable opening: 48 + 1 OB= 49 mm
- Maximum opening (unassisted) 49+1 OB
=50 mm
- Maximum opening (assisted) 50+1 OB
=51 mm
- Protrusion 5+3 OJ= 8 mm
- R. Lateral excursion = 9 mm
- L. Lateral excursion = 12 mm
 Path of Opening
- opening pattern is straight.
TMJ Noises:
-Coarse crepitus (right and left TMJ)
during opening/closing.
 Excursion

-Crepitus (right).
 Right Left
 Masseter:
Moderate pain No pain
 Lateral Pterygoid:
No pain No pain
 Medial Pterygoid:
No pain No pain
 Temporalis:
No pain No pain
 SCM :
No pain No pain
 Tongue ridging(scalloping): negative
 Cheek ridging: negative
 Attrition: # 6, 11, 15, 22 – 26
 #27 fractured facially.
• Intact cortices of the
temporal fossa and
condylar head, with
physiologic thickness.
• Trabecular pattern
within physiologic
limit.
• Steep slope of
temporal eminence.
• Mild flattening of the
condylar articular
surface.
• Condylar process is
centered in temporal
fossa.
• Condylar process
translates to the crest
of the articular
eminence. (Good
range of condylar
translation).
• Intact cortices of the
temporal fossa and
condylar head, with
thickening along the
lateral aspect of the
fossa.
• Reduced height of
condylar process.
• Flattening of the
articular surface.
• Bone spurring is
noted along the
anterior aspect of the
articular surface
(osteophyte).
• Bone-on-bone contact
of the condylar
process with the
articular process.
• The condylar
process translation
remains posterior to
the eminence,
(limitation of
condylar
translation).
 R.joint: early signs of remodeling
associated with degenerative joint
disease.
 L. joint: moderate to advanced
degenerative joint disease.
1. Myalgia.
2. Osteoarthritis causing left
malocclusion/trauma to teeth
3. Systemic Lupus erythematosus
4. Nocturnal bruxism.
1. TMJ is often missed joint by rheumatologist
during examination, but commonly affected in
several diseases, including SLE.
2. It is important for clinician and rheumatologist
to be able to recognize symptoms of TMD.
3. TMD involvement may be secondary to
systemic inflammation and arthritis or clinical
manifestation of an independent pathology such
as infection, degeneration and osteonecrosis.
4. Early diagnosis as well as timely and
appropriate management is warranted.
1. The most frequent findings in
rheumatoid arthritis were
temporomandibular sounds and pain.
Pain was found in significantly higher
proportion in patients with SLE.
2. This study supports the notion that
TMJ examinations should be
encouraged in the rheumatology
setting and clinician should be able to
provide pain management and patient
support.
1. It was found that 22% patients with SLE
have locking or dislocation, tenderness
to palpation, and pain in mandibular
movement.
2. Radiographic changes of condyles
including flattening, erosions,
osteophytes and sclerosis were seen in
30% of patients
 Patient referred to Faculty Dental Office
for treatment with Dr. Susan Roche.
 Recommended Tx:
- Rest, soft/ liquid diet for 2 wks.
- Heat/ Ice packs 10 mins 3x /day.
- Occlusal splint monitored 1x/month for 6
months to see if occlusion is still
changing
 Restorative tx to be done by prosthodontist
 Andre L F Costa and Simone Appenzeller.
Autoimmune diseases: symptoms, diagnosis and
treatment ISBN : 978 . Chapter 11.
 Aliko A, Ciancaglini R,Alushi A, Tafaj A, Ruci D.”
Temporomandibular joint involvement in
rheumatoid arthritis, systemic lupus
erythematosus and systemic sclerosis. Int J Oral
Maxillofac Surg. 2011 Jul;40(7):704-9. doi:
10.1016/j.ijom.2011.02.026. Epub 2011 Apr 3
 Jonsson R, Lindvall AM, Nyberg G.
“temporomandibular joint involvement in
systemic lupus erythematosus”. Arthritis Rheum.
1983 Dec;26(12):1506-10
REQUIRED READING
 Ammar Rasheed Haider Fakhri Batool Obeidat

 Haitham Shasha Tara khamo Sukhman panag

 Farheen Pasha Geetha shankarnarayan Bassel Al-Khalil

 Thaer Alqadoumi Omran Bishbish Reema Younan

 Mostafa Al-adami