Temporomandibular Joint Disorder Syndrome (�TMJ�) by 6wH3vvWt

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									 Temporomandibular Joint
Disorder Syndrome (“TMJ”)
        MLK Med-Peds
      Laura Hanson, MS2
          Definition of TMJ
 Chronic or acute musculoskeletal pain with
  dysfunction of the masticatory system
 Distinct from dental disease
 Due in part to persistent, unconscious,
  repetitive use of masticatory muscles
Why is it hard to recognize TMJ?
   Difficult to classify
    – Many overlapping syndromes, all based on
      symptomatology rather than etiology
   Difficult to study a natural course or
    – Large percent of general population has
      classic symptoms. (75% in one study)
    – Disease vs non-disease.
   Physicians aren’t taught it- dentists are.
    Why is it important to recognize
 Pain is the most common reason people
  seek medical attention
 $80 billion each year in lost workdays,
  worker’s comp/disability, and healthcare
 The prevalence of TMJ-related pain in
  2000 was 12% (~2% will seek treatment),
  and 10 million Americans will suffer TMJ
  related complaints each year.
                Types of TMJ
   Intracapsular
    – Rheumatoid Arthritis
    – Articular disk displacement
   Extracapsular
    – Myofascial/myogenic
    – More common
Classification of Synovial Joint
   Stress              Cervical traction
   Malocclusion        Dental manipulation
   Bruxism             Trauma
   Clenching           Internal joint
   DJD                  derangement
   Female Gender
          Jaw Malocclusion
 Very common
 May be inherited or acquired
 Braces, crowed teeth, extra teeth, missing
 May be a cause OR result of chronic
  masticatory muscle tension
 Grinding
 Control: 360 tooth contacts a night
 TMJ: 1325 tooth contacts a night
           Disk Displacement
 Displacement may be anterior, lateral, or
  medial, and is NOT diagnostic
 Study using MRIs
    – 84% of subjects with TMJ
    – 33% of asymptomatic subjects
   Cadaver study
    – 40-60% incidence of displacement
   No convincing evidence of progression to
    locking or joint degeneration.
Anterior Disk Displacement
         Presenting Symptoms
 Pain in muscles of mastication
 Pain in ipsilateral ear, jaw, neck
 Dull headache worsened with chewing
    – Sometimes only symptom is headache
 Symptoms relate to stress
 Audible clicking, crepitus, or locking
  (usually a sign of disc displacement)
   International Headache Society
    – http://www.i-h-s.org  Guidelines  ICHD-II
      Classification (pdf)
   Primary Headaches
    – Migraine
    – Tension-Type Headache
    – Cluster Headache
              Headaches cont’d
   Secondary Headaches- Headache due to:
    – Head/Neck trauma
    – Vascular disorders
    – Non-vascular intracranial disorders
    – Substance use or withdrawal
    – Infection
    – Disorders of homeostasis
    – Disorders of cranium, neck, eyes, ears, nose, sinuses,
      teeth, mouth, or other facial/cranial structures
    – Psychiatric disorders
     Headache attributed to TMJ
A.   Recurrent pain in one or more regions of the head
     and/or face, + C and D
B.   Xray, MRI, and/or bone scintigraphy demonstrate TMJ
C.   Evidence that pain is related to TMJ: (at least 1)
       1.   Movement and/or chewing
       2.   Decreased range of motion or irregular jaw opening
       3.   Noise from one or both joints during movement
       4.   Tenderness of one or both joint capsules
D.   Headache resolves within 3 months, and doesn’t recur,
     after successful treatment of TMJ
               Physical Exam
   Inspection:
    – Body or facial asymmetry
    – Deviated jaw motion
    – Restricted or guarded jaw motion
    – Should NOT see swelling
    – Also observe for crepitus/clicking
                Physical Exam
   Palpation
    – Palpate the joint intra/extraorally with mouth
      open and closed to find tenderness
    – Palpate the masseter over the angle of the
      jaw bilaterally
    – Palpate the temporalis over a wide area, both
      clenched and relaxed
    – Palpate the pterygoid inside the mouth
    – Note any clicking/crepitus
Internal pterygoid
 Limited yield
 Panorex, Periapical radiographs, CT -
  evaluate bony structures for DJD or disc
  displacement (no change in outcome)
 MRI will show the disc
 Consider imaging when dental problems
  are suspected or if conservative
  management fails (evaluating for surgery).
   Rule of thirds: 235 patients studied with
    – 33% resolved
    – 31% ongoing pain
    – 36% relapsing course
     What should you do?
A 37 year old female in law school
presents to your office with the chief
complaint of headache. It is frontal and
bitemporal, and is associated with
photophobia, but no nausea. You
prescribe migraine medication, but she
returns in one week with persistent
headache. What now?
       Not a migraine, huh…
 What symptoms do you want to ask
 What will you look for on physical exam?
 Support
 Education
 Exercise, massage
 Acrylic appliance
 Pain Relief (NSAIDs, TCAs,muscle
  relaxants, narcotics)
 Injections
 Surgery
 Sheon, Robert P. “Temporomandibular Joint
  Dysfunction Syndrome”. UpToDate, June 2005.
 Gremillion, Henry A. “The Prevalence and
  Etiology of Temporomandibular Disorders and
  Orofacial Pain”. Texas Dental Journal, July 2000.
 DeBont, Lambert GM., et al. “Epidemiology and
  natural progression of articular
  temporomandibular disorders”. Oral Surg Oral
  Med Oral Pathol Oral Radiol Endod, 1997.

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