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TMD disorders part 1

Terms in this set (71)

What are TMDs?
A group of unrelated disease states/disorders
What do all forms of TMD share?
A common set of symptoms (primarily pain and jaw dysfuntion.
What are the 2 major divisions of TMD?
Extracapsular (non joint-related, usually muscular) and joint related (true TMJ disorders)
Neuralgias, headaches, neurological/neuromuscular diseases, coronary artery disease are all?
not TMDs.
Causes of orofacial pain:
TMJ disorders
Masticatory musculoskeletal pain
Cervical musculoskeletal pain
neurovascular pain
neuropathic pain
sleep disorders related to orofacial pain
orofacial dystonias
headaches
intraorla, intracranial, extracranial, and systemic disorers that cause orofacial pain.
Most of patients for TMDs are
female. Many do have concomitant depression, anxiety, fibromyalgia, irritable bowels syndrome, etc. Some have very difficult problems and a few wont' ever get well.
Pain is:
an unpleasant sensory and emotional experience . It is associated with actual or potential tissue damage, or described in terms of such damage.
What pneumonic do we use to define pain clinically?
LIQORAAA
There are some more pain details that matter:
Clarify which pain you are asking about.

When you __________ (activity) which pain happens? Diffuse pain after eating or sharp pain with popping, people can have one or both.

Does it hurt first thing in the morning, as you wake?
Generally, patient will show you the primary problem, well localized to the preauricular area, one finer pointing = TMJ pain but ill defined pain, they'll move their fingers or palm across their cheek and temple which indicated ....
masticatory muscle pain.
symptom of a systemic muscle pain-producing disorders
local myalgia
myofascial pain
centrally mediated myalgia
myospasm
myositis
myofibrotic contracture
masticatory muscle neoplasia
Masticatory muscle disorders
What are the symptoms of local myalgia?
stiff, sore, cramp with chewing, opening wide, or on awakening.
What are causes of myalgia/
ischemia, bruxism, fatigue, splinting, delayed-onset muscle soreness
How do diagnose local myalgia?
regional dull ache with function, no or minimal pain at rest, local tenderness upon palpation, absence of trigger points and pain referral patterns.
Myofascial pain symptoms:
regional dull aching pain and some trigger points. May overlap with tension-type headaches.
Regional pain aggravated by function like local myalgia, but trigger point palpation causes a wider area of pain with predictable referral, reduction of pain with trigger point treatment, " soft end feel" with stretch.pain?
Myofascial pain
What are the causes of myofascial pain?
they are not well understood
What are trigger points?
sensitive, palpable nodules with the body of a muscle. They may have "taut bands" which are strands of contracted muscle extending from it. They are not histologically demonstrable but some studies find locally high levels of pain mediators.
Tigger points pressure causes pain referral in _____________ patterns
predictable patterns
What are some treatments for trigger points?
injection (local anesthetic, corticosteroid, saline)
dry needling (inject nothing)
spray and stretch (vapocoolant spray)
Describe centrally mediated myalgia?
chronic, continuous muscle pain without clinical inflammation.
What are the causes of centrally mediated myalgia?
prolonged nociceptive input, chronic autonomic upregulation, stress, other deep pain input
How do we diagnose centrally mediated myalgia?
prolonged, continuous pain by history, dull ache at rest, aggravation by function and palpation and could possibly have trigger points but when we alleviate all these problems, the pain still persists.
What is a Myospasm?
a sudden, involuntary tonic contracture, fasciculation, cramping/tight feeling
What cuases myospasm?
ischemia, neuromuscular disease, hypokalemia
How do we diagnose myospasms?
acute onset of pain in function and at rest, markedly reduce ROM, significantly increased EMG activity
What is myositis?
clinical inflammation over the entire muscle
What causes myositis?
direct trauma, spreading infection
How do we diagnose myositis?
usually the pain is continuous, diffuse tenderness, warmth, edema, moderate to severely limited ROM.
What is myofibrotic contracture:
shortened muscle, usually painless unless it is stretch, obviously.
What causes myofibrotic contracture?
long immobilization, infection or trauma cuasing fibrosis
How do we diagnose myofibrotic contracture?
limited ROM with unyielding stop (hard end feel), little or no pain involved.
What is a common cause of myofibrotic contracture?
Head and neck radiation
What is masticatory muscle neoplasia symptoms:
intramuscular swelling with or without pain, limited movement
What are causes of masticatory muscle neoplasia?
intramuscular neoplasm, benign or malignant, primary or metastatic
How do we diagnose masticatory muscle neoplasias?
Swelling, trismus, paresthesia, variable pain
What are the 4 major parts to the TMJ?
Temporal bone, mandible, fibrous capsule, lateral pterygoid muscle attachments.
What are the parts of the temporal bone that make up the TMJ?
Tympanic plate posterior, glenoid fossa, articular eminence
The interpositional fibrocartilage disk is
tightly bound to the condyle laterally and medially but there is a loose retrodiscal attachment to the posterior joint wall.
What are the 2 compartments of the TMJ?
Superior and inferior
What are the recesses of the TMJ and what are they lined with?
Synovium-lined anterior and posterior recesses.
All the fibrocartilages rely on synovial fluid for
oxygen and nutrition
The TMJ has _____ mm of rotation
20 mm
TMJ has ______ of tranlational movement
40-50
The TMJ can accomodate lateral excursions that move contralateral joint: how far?
7-10 mm
What movement translates both joints?
Protrusion
The posterior and anterior recesses are __________ spaces
potential spaces
When the disc is between the condyle and the upper bone of the joint it is referred to as:
reduced, if not, it is dispaced.
What are some orthopedic principles with the TMJ, or really any joint?
lubrication
nutrition
joint stability
loading (TMJ is loading, not weight bearing)
articular ligaments
meniscus vs. disk (meniscus has a hole, the TMJ disk does not)
What is Anterior Disc displacement?
It happens to 12-45% of all people where the disc becomes displaced infront of the condyle and is frequently asymptomatic.
Is ADD pathological or variant of normal?
Most experts agree that asymptomatic ADD is not a pathological condition.

A few authors attribute Class 2 malocclusion to ADD

All agree that ADD can become pathological in some individuals.
Normally the disc moves with the
condyle
An anteriorly displaced disc usually makes and audible pop with the condyle snapping below it but does it always pop on closing?
no
It the disc obstructs movement, pop does not occur and the joint is considered
locked
Displaced discs are not all the same, what is the classification and what is it based on?}
Wilkes Classification and is based on clinical and radiographic findings.
Later stages of Wilkes classification include ____________ changes in articular surfaces and in bone.
degenerative
What is the degeneration in articular surfaces and in bone called?
osteoarthrosis like osteoarthritis
What is the real cause of the disease?
Inflammation, disc displacement alone is frequently asymptomatic for life. The inflammatory processes are important to pathogenesis. Inflammation (the consequence of the disc displacement) that causes the problems.
Osteoarthrosis may be a final common pathway for several joint conditions:
inflammatory, endocrine, metabolic, developmental, biomechanical.
In a normal functioning TMJ, we have functional remodeling and adaptive capacity, but when something happens, we can exceed the adaptive capacity or maybe have a reduction. What can cause this?
Mechanic factors: macrotrauma, parafunctional activity, functional overloading, increased joint friction.
Dysfunctinoal remodeling leads to
abnormal cartilage that can have hypoxia, and not good circulation. Proinflammatory cytokines and a cascade of inflammation that leads to cartilage breakdown.
The etiology of arthralgia is well understood?
no it is not. Systemic factors influence disease course in several ways. Few if any have clinically useful predictive value. We understand what happens better than Why.
What are the pathological tissue changes we see?
articular tissues (articular fibrocartilage surfaces), disc, bone

Synovium

Impaired mobility (adhesions, adhesive hypomobility (suction cup effect)
What are some articular surface pathology we may see?
Softening, vascularization, fibrillation, bone exposure.
Synovial pathology:
Hypertrophy, hyperemia, capillary dilatation, microbleeding, granulation, fibrosis
What are some adhesion types:
light filmy
fibrous bands
psudowall
What are some disk pathology
neovascularization, fibrillation, perforation
Concequences of hypomobility
reduced disc movement
reduced mandibular movement
poor synovial fluid circulation (focal hypoxia, impaired nutrition, increased friction)
Declining joint health and function (inflammation, degeneration becoming self-sustaining.
Treatment option: Multiple consensus statements agree that therapy should be:
based on scientifically,-validated diagnostic evaluation, non-invasive, reversible
Common initial treatments:
Counseling
anti-inflammatory medications
occlusal orthotics (not jaw positioning or occlusion-altering)
physical therapy modalities
When non-surgical treatment fails (intracapsular diseases only)
least invasive surgical option likely to succeed.
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