Initial Management of TMJ Disorders

Studies shows…

• Affects more than 25% of the general population.

• 20 out of 100 Headaches are due to TMJ Disorders.
 Definition …

A group of pathologies affecting

» The masticatory muscles
» The TMJ
» Related structures

Qualyle and Gray – 1990 , Reik & Hale - 1981

 Classification…

Masticatory muscle Disorders Result from extrinsic trauma

• Protective muscle splinting 1. Traumatic arthritis
• Muscle hyperactivity or spasm 2. Dislocations
• Myositis (muscle inflammation) 3. Fractures
4. Disk derangements
5. Myositis
6. Myospasm
7. Tendonitis
Inflammatory joint disorders
• Rheumatoid arthritis
• Infectious arthritis Degenerative joint disease
• Metabolic arthritis • Arthrosis (noninflammatory phase)
• Osteoarthritis (inflammatory phase)

Derangement of the temporomandibular joint

• Incordination
• Clicking
• Partial disk derangement
• Anterior disk displacement with reduction(clicking)
• Anterior disk displacement without reduction(closed lock)

ADA-based upon the classification developed by Weldon Bell.

 ETIOLOGY…

• Macrotrauma
• Microtrauma
• Stress
• Occlusal deficiencies
• Parafunctional habits like bruxism, nail biting etc.
 Symptoms…
3 cardinal Features
Orofacial pain, joint noise, & restricted jaw function

• TMJ Clicking.
• TMJ locking
• Change in occlusion
• Ringing (tinnitus) in the ears
• Headache
• Sensitive teeth
 Diagnosis…

History
• Pain-
– Onset,
– Nature,
– Intensity,
– Site,
– Duration,
– Aggravating factor
– Location
– Behaviour
– Quality
• Underlying influences - Stress, Anxiety, Depression
Clinical examination…

• Masticatory muscles examination

• Evaluate for tenderness
• Joint sounds and their location
during opening, closing
• Mandibular function may be
evaluated
• Dental Examination
 Investigations…
• OPG
• CT
• MRI
• Arthrography

CT MRI

Arthrography
MANAGEMENT…

1. Conservative treatment
 Counselling
 Drug therapy
 Physical therapy
 Others

2. Surgical Treatment
Management…COUNSELLING

• Reassurance
STRESS MANAGEMENT
RELAXATION…
Management…DRUG THERAPY

• Drug therapy(effective for 70% of pts)

 Analgesics
 Anti inflammatory agents
 Muscle Relaxants
 Antidepressants
 Local Anesthetics
Physical therapy…

• Manual techniques
Massage therapy:
Patient is encouraged to apply
gentle massage to the painful
areas regularly. It stimulates
the cutaneous sensory nerves.
Physical therapy…

• Joint mobilization:
The thumb is placed in the
patients mouth over the
mandibular second molar
area, while the cranium is
stabilized with the other
hand, then the thumb exerts
downward force on the
second molar area.
• PASSIVE EXERCISES.
• STRETCHING
EXERCISES
Vapocoolant sprays…
• Encourages the
relaxation of muscles
• Applied to the painful
areas for 5 seconds
and then the muscle is
gently stretched.
• Agents used are ethyl
chloride and
fluoromethane.

Schwartz et al…
 Coolant therapy…

An ice pack is placed to painful areas for 2 to 4 mins.

THERMOGRAPHY

Moist heat reduces the levels

of pain and discomfort.
 TENS…
(Trans Cutaneous Electrical Nerve Stimulation)

Portable TENS unit is placed over the painful areas. The

electrical activity decreases the pain perception.
 Ultrasound…

Increases the temperature of the interface of the tissues

Provides a deep heat which increases the blood flow
Improves the flexibility and extensibility of connective tissues
Acupuncture…

• Needles placed in the face

helps to reduce pain in
these areas.
• Needles are maintained in
place for 30 mins. During
which they are twirled
every 5 to 10 mins
 SURGERY

Surgery is reserved for those cases which fail to

satisfactorily respond to the above mentioned
methods.

Surgery is usually indicated if non-surgical

treatments have failed and clinical and diagnostic
findings indicate a derangement inside .
 CONCLUSION…

TMD are one of the most misdiagnosed

disorders and show variety of misleading
symptoms. So, proper diagnosis and treatment
is a must for relief of the patient.
 Referrences
1. American Academy of Orofacial Pain . In: Orofacial Pain: Guidelines for Assessment, Diagnosis
and Management, 4th ed. de Leeuw R, editor. Chicago: Quintessence; 2008.
2. Wright EF. Manual of Temporomandibular Disorders. Ames, IA: Blackwell; 2005.
3. Okeson JP. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis, MO:
CV Mosby; 2008.
4. Fricton J. Myogenous temporomandibular disorders: Diagnostic and management
considerations. Dent Clin North Am. 2007;51:61–83.
5. Murphy E. Managing Orofacial Pain in Practice. Chicago: Quintessence; 2008.
6. Ribeiro RF, Tallents RH, Katzberg RW, et al. The prevalence of disc displacement in
symptomatic and asymptomatic volunteers aged 6 to 25 years. J Orofac Pain. 1997;11:37–47.
7. Egermark I, Carlsson GE, Magnusson T. A 20-year longitudinal study of subjective symptoms of
temporomandibular disorders from childhood to adulthood. Acta Odontol Scand. 2001;59:40–48.
8. Magnusson T, Egermark I, Carlsson GE. A longitudinal epidemiologic study of signs and
symptoms of temporomandibular disorders from 15 to 35 years of age. J Orofac
Pain. 2000;14:310–319.
9. Wassell RW, Adams N, Kelly PJ. The treatment of temporomandibular disorders with stabilizing
splints in general dental practice: One-year follow-up. J Am Dent Assoc. 2006;137:1089–1098.
10. Fricton JR, Schiffman EL. Management of masticatory myalgia and arthralgia. In: Sessle BJ,
Lavigne GJ, Lund JP, Dubner R, editors. Orofacial Pain: From Basic Science to Clinical
Management. Chicago: Quintessence; 2008.