Diagnosis and co-management of temporomandibular joint disorders: a case study

40

lntmduction Temporomandibular Joint Disorders (TJDs) can arise from a diverse range of astiologies. This provides a challenge to the clinician both in terms of diagnosis and management. Often, input can be required from multiple areas of speciality within the health professions and such input can often improve the patients prognosis. Traditionally, inter- disciplinary co-operation has been lacking. This is due, in pan, to poor inter-professional communication, but also to the traditional compartmentalisation of medicine and the fear of individual practitioners of stepping outside their province. Nevertheless, it is necessary to develop a stronger exchange of thought on an inter- professional basis since there is no one profession with the expertise to treat all the conditions which can cause disturbance in the stomatognathic system [I].

This case report presents an alternative approach bo a patient with chronic temporomandibular joint (TMJ) problems, emphasising inter-professional co-operation in patient management with successful outcome.

Case Report A48-year-old housewife presented with a five year history of severe continuous, frontal headaches. She also suffered from pain in the tight zygomatic arch; right shoulder (pectoralis musdes and scapula); face (right temporal and frontal regions) and decreasing vision in the right eye. The patient also reported suffering kom “migraine headaches” all of her adult life. She had no aura prior to the onset of symptoms and so was diagnosed by her General Practitioner (GP) as having Common Migraines. These headaches occurred approximately once a month. Aggravating factors induded dietary intake of dairy products or ckrus tiuits.

The onset of symptoms had been insidious with gradual progression to constant pain. More recent symptoms included ‘tingling and fizzing” sensations down the posterior aspect of the right arm as far as the dorsal surface of the hand. Symptoms were exacerbated by ironing, eating and helping her disabled husband (weighing approximately 90 kg) in and oti of his wheelchair. Previous treatment had cornmenu& three years previously with osteopathy, mainly consisting of sofl tissue work for the neck and shoulder pain and providing temporary relief. The patient m-presented to her GP a year afier seeing the osteopath for ongoing face, neck and shoulder pains.

He referred her for routine cervical spine x-rays which were reported as normal. Neurological referral followed but once magnetic resonance imaging had proved unremarkable, the patient was discharged without treatment.

Five months prior to presentation, the patients face pain became more severe and she consulted an Acupuncturist. She received approximately eight sessions of acupuncture which, she claimed, relieved the facial pain but worsened that in the jaw. At approximately the same time, the patient consulted her GP for a migraine that had persisted for two weeks. The GP referred the patient for a computed tomographic (CT) scan and lumbar puncture, the results of both showing no abnormality. She was also referred to an Ophthalmic Consultant for her diminishing sight. The Consultant felt that symptoms were due to restricted circulation to the eyes and again no treatment was given.

Previous medical history included a total hysterectomy one year prior to presentation. Her GP regarded the migraines as a contra-indication to Honnone Replacement Therapy (HRT). For the previous five years the patient had taken Losec (Omeprazol) irregularly for “excess stomach add”. Family history included a sister and father with Adult Onset Diabetes Mellitus, the former being insulin- dependent. Five years before presenting, the patient had four teeth extracted from the lower jaw (three adjacent molars on the right and one molar on the lefl). A plate had been tit&d but was too uncomfortable to wear and hence remained unused.

Physical examination revealed marked postural abnormalities. The patient held her head in right lateral flexion and slight forward flexion with her right shoulder and iliac crest positioned higher than her let?. She exhibited pronounced anterior head carriage. The right side of her mouth drooped and, due to the oblique positioning of her right zygomatic arch and right ear lobe (both inferior to the lefl), her glasses did not tit well on the right side. The right orbii was noticeably smaller than the letI. There was pronounced hypertonic@ and localised tenderness around the tight internal and external pterygoid muscles, right temporalis, masseters bilaterally, upper and middle kapezius musdes and subocdpital musdes bilaterally.

There was restricted cervical range of motion with all movements producing right TMJ pain in the condylar region and pain in the right stemocleidomastoid (SCM) musde. The TMJ demonstrated deviation of the mandible to the

The British Journal of Chiropractic, 1999, Vol 3 NO. 2

CASE STUDIES

right during the swing phase of motion and more pronounced deviation to the right during the glide phase of motion. Joint motion palpation revealed restriction of the upper cervical, upper thoracic and lumbosacral motion segments. Foraminal compression tests for the cervical spine produced pain in the suboccipital muscles and frontal region on the right. Compression tests for the sacro-iliac region revealed joint restriction on the left and pronounced tenderness over the right sacro-iliac joint. Prone and supine analysis showed the lek leg to be approximately 1 cm shorter than the right.

The patient was found to have an elevated blood pressure (160/96 mmHg). She was also mildly myopic. Neurological examination of the cranial nerves, upper and lower extremities was unremarkable, as was cardiovascular, respiratory and abdominal examination and urinalysis.

Copies of cervical spine x-rays taken two years prior to presentation at the chiropractic clinic were obtained. The lateral cervical view gave the overall appearance of hypolordosis, however, cervical lordosis measurement gave a hypedordotic angle of 50° [2]. The exaggerated angulation of the occipitoatlantal joint in extension appeared to contribute to the hypedordosis recorded. There was a Grade I anterolisthesis of C3; osteophytosis, facet arthrosis and decreased intervertebral disc height, seen at the levels of C4 to C6, consistent with moderate osteoarthritis of the cervical spine. Although the possibiiii of upper cervical instability could not be ruled out, it was decided not to x-ray this patient until orthodontic assessment had been made.

The working diagnosis was of a chronic, iatrogenically-induced, severe instability of the right TMJ with concomitant hypertonicity of supportive musculature, producing hypomobilii of the upper cervical and upper thoracic spine.

It was explained to the patient prior to treatment that whilst chiropractic care for her cervical spine and jaw would help to alleviate some of her symptoms, more stability of her jaw was required to make further progress in the reduction of symptoms and prevention of their return. with the patients agreement she was referred to her Dental Surgeon (with a covering letter). He supported a primary diagnosis of TMJ disorder and it was agreed to embark on a simultaneous programme of orthodontic and chiropractic treatment. This consisted of thoracic manipulation, supine pelvic blocking and soft tissue work using muscular stretching, exercises and, for the SCM, scalenes and sub-occipital muscles, dry needling techniques. The TMJ was treated using intra- and extra-oral techniques. This involved massage and stretching predominantly for pterygoid and masseter muscles and dry needling around the temporomandibular condyles. Significant improvement was made following orthodontic and chiropractic treatment. The patient noticed a reduction in jaw pain, shoulder and arm symptoms after the second treatment and her blood pressure had decreased to 160/90. The patient continued to progress well and between the sixth and seventh treatment visits the patient had a new lower jaw denture fitted. She was advised by the Dental Surgeon to wear her denture at all times

The British Journal of Chiropractic, 1999, Vol 3 No. 2

with minimal deaning time. She noted an immediate change in the symmetry of her face and the frame of her glasses had to be altered in order to fit her re- aligned right side.

Twenty-four hours after the denture was fitted, the patient reported a further reduction in pain symptoms ‘Yrom head to toe”, but espedally in her neck and face. She returned to the Chiropractic dinic with her head posture corrected, no longer held in forward and lateral flexion. Due to increased stability of the TMJ and cervical spine, cervical manipulation was used for the first time on the eighth treatment visit with the positiie effect of reducing pain and muscle tension around the right eye. Twelve to twenty four hours after treatment the patient noticed vision in her right eye was no longer blurred.

The pafJent was treated 12 times in a period of two months. Following the tenth treatment, she remained symptom free except for occasional tightness across the frontal region when she was anxious or tired. Her blood pressure settled at around 132/85 mmHg. Rehabilitation consisted of gentle daily neck stretches. To date, she remains asymptomatic

An additional element to this case was a psychological aspect that emerged in the course of treatment. The patient divulged that during her first marriage she had been sexually abused. Her tension levels were compounded by caring for her current husband, who had been wheelchair-bound for 12 years. She had been receiving counselling to help deal with the emotional trauma for three years and felt that this had been effective in helping her to “gain control of her lie again”. She also felt that chiropractic treatment helped to release psychological as well as physical tension.

Discussion The most difficult diagnostic challenge facing the practitioner in a case of TJD is determining the primary cause of the patients widespread symptoms. In this case a detailed history indicated that the onset appeared to be be linked to specific dental extractions. Further indicators towards a primary diagnosis of TJD came from the physical examination of the TMJ following specific guidelines [3]. This revealed the localised tenderness to palpation of the TMJ and musdes of mastication and altered condylar movement with lateral translation of the jaw on swing and glide phases.

TJD can be defined as a pain dysfunction phenomenon characterised by severe pain in the TMJ, cranial, facial, cervical, pre-auricular and post- autiurlar areas. In addition, it may involve the mandibular, temporal, frontal and zygomatic bone areas [4]. Several authors emphasise the absence of any dear cut line that differentiates between disorders of the cervical spine and TMJ, although history, signs and symptoms may lead a practitioner to believe one is more likely or predominant than the other, the two are so closely interrelated that components of both disorders are likely to co-exist [1,5,61.

The correlation of TJD with the surrounding structures is demonstrated by the wide range of tenderness found when an individual is examined for jaw pain. The TMJ is tender generally and the

musdes of mastication are also tender. There is also a high percentage of patients with pain in the posterior cervical, upper trapezius and stemodeidomastoid muscles [I].

There are a number of good dinical indicators as to the presence of TJD (See Table 1) [I $1.

De Steno (1977) advocates the use of a ‘TMJ Triad” in the diagnosis of TJD. The triad contains components that when present in certain relations to each other cause precipitation of pain and dysfunction. The triad is composed as follows: * The patient must be predisposed to TJD. * The tissues (neuromuscular, skeletal and dental) must be in some degree of pathologic alteration. . There must exist a degree of stress sufficient to cause excessive muscle tension e.g. clenching or brudng of the teeth. He further states that the triad is potentially present in all individuals although not until all three components become involved is there any dinical manifestation of TJD (see Figure 1). r/l.

Abramson (1994) states that the tensions of the muscles of the head and neck work through a dynamic interplay that creates a balanced and stable support when in health and leads to irritating and destructive forces when in a dysfunctional state. The pull of the anterior cervical musdes induding the suprahyoids and intiahyoids are balanced against the pull of the posterior cervical muscles. This balanced relationship must be, and is, maintained during mandibular and cervical movements and postural changes. Alteration in the function of one group of musdes will change this relationship (Figure

41

CASESTUDIES

Figure 1: The TMJ triad showing componenets that, when present in certain relations,

lead to joint dysfunction.

Forward movement of the TMJ is achieved by keeping the neck flexed at its base, while a correction of the head posture is accomplished by an extension of the occipkoatlantal articulation. Unfortunately, this change in the relationship between the head and neck actually reverses the effect of the downcast head on the TMJ, i.e. the forces directed posterior are increased. The strain of forward head posture substantially increases the work of the cervical extensors, thus promoting trigger point development via postural strain [5,9].

2) PI. There are two components of the condylar

movement: rotation and translation of the condylar head in the fossa. Lateral movements occur when the non-working side condyle translates anteriorly while the other condyle on the working side pivots around a vertical axis that remains relatively tixed in the fossa [I ,3,7]. In this patients case, lateral translation was seen to occur to the right side.

The function of teeth in chewing and speech is obvious, but there are other functions that are critical, such as orthopedic support. In a healthy orthopsedic support system, the teeth absorb nearly all the forces the muscles generate (1.7-2.0 MP) whereas the condyles absorb a minor loading force. If the dental support system is not adequate at the point of maximum closure, the forces of muscular contraction will excessively load the joint as they are directed through the condyle, causing posterior displacement of the condyle which, in turn, impinges on the retrodiscal tissue (loose connedive tissue, highty vascularised and innervated). The retrodiscal tissue is rich in propnoceptive nerve endings that send et&rent nerve impulses to the central nervous system, the net response is reflexive and is designed to relieve pressure on the posterior joint [5].

De Wijer et al. (1996) investigated whether patjents with Cervical Spine Disorders (CSDs) and subgroups of patients with TJD differed regarding specific and accompanying signs and symptoms of these disorders [6]. It was found that both sufferers of CSD and TJD reported symptoms of head and shoulder pain (CSD sufferers reported symptoms more frequently). Spinal pain is often projected multisegmentally because of the innervation pattern of the spine [lO,ll]. These patterns of somatic referred pain do not necessarily indicate which structure

There is a dynamic relationship between the mandibular position in space and that of the head-neck posture. When the head flexes, the mandible is shied down and forward and the teeth will contact more anteriorly. Conversely, the mandible is moved posteriorly when the head is extended. Lateral side bending of the head creates great contact on the side toward which the head is bent [8]. On a chronic basis, this tendency to protect the posterior structures of the TMJ creates a head that is looking toward the ground. This position is not compatible with either the vestibular or the ocular system. To correct this incompatibility, the trigeminal system uses the tonic neck reflexes and the vestibular and

acts as the primary source of pain but suggest the segmental level mediating nociception. Pain from nockaption of cervical tissue may radiate to the head, shoulder, arm, interscapular and/or thoracic region.

The eye muscles are skeletal in nature and respond to the stress of compensation as. If the head position remains altered there will be compensatory postural stress and/or strain in the ocular musculature. Abnormal postural position of the head and shoulder girdle can facilitate ocular compensation through the stemocletiomastoid (SCM) and upper trapezius muscles, as well as the vestibular system. Excitation tiom trigger points in these muscles may cause blurred or double vision [9].

Figure 2: Interplay between muscles of the jaw and neck.

ocular centres to bring the head anterior and superior [I ,8].

Figure 3: The body resembles three stacked, inverted pyramids. Although unstable, this wnfigura- tion is ideal for mobility. static sta- bility in this configuration is best

when the three pyramids are ver- tically aligned.

Cailliit (1991) likens the body to a stack of three inverted pyramids (see Figure 3) [12]. The shoulder girdle is the base of the second or middle inverted pyramid. This position leaves it susceptible to influence from the pyramid above and below. From below, the shoulder girdle is atfected by leg length discrepancies, pelvic malalignment, and concomitant compensatory spinal curvatures. Likewise, from above, the shoulder girdle will be affected, because head position dictates the position of the neck, shoulder and even dental occlusion [13]. Walther (1983) states that a short leg or pelvic disturbance can create secondary

imbalances in the stomatognathic system [I]. He and Gregory (1993) illustrate this point by quoting research by Geib (1985) which found that marked changes occurred in electromyographic (EMG) firing patterns during chewing when a 10 mm heel lift was removed from the short leg side, with the EMG returning to normal when the heel lit? was replaced [I ,14,15]. He went on to report that a 6 mm difference in leg length could result in pain throughout the skeletal system, with a shoulder consequently depressing one inch and concluded that overall body posture is an important factor in both TMJ occlusion and TJD [I% On drawing conclusions from a case report that describes the relief of TJD by the use of pelvic blocking to reduce sacroiliac sprain, Gregory (1993) states that the case indicates that sacro-iliac joint sprain may cause TJD, or conversely that temporomandibular factors associated with malocclusion can

result in sacro-iliacdyskrnction [14]. He warns that before titting dental splints or equilibrating the occlusion, the sacro-iliac joints should be re- examined for proper function and any sprain should be reduced. After occlusion-altering dental procedures, the sacroiliac joints should be examined for proper function to determine if they show ongoing functional stability.

De Steno (1997) states that the onset of TJD could be precipitated by such psychological events as manta1 difficulties or bereavement [A. Stress builds within the individual, and, in societies where outward expression of emotions is repressed, br-uxism or clenching develops, which is an oral manifestation resulting kom inhibition of open expression.

Patients experiencing facial pain are cautious and slow to seek medical care for their problem. According to Rocabado and lglarsh (1991) the often “invisible” symptom of facial pain is frequently concealed or ignored by its victim because rejection by the medical practitioner is feared [16].

In this light, the personality picture which the patient presents appears to be reactive to the condition rather than the cause of the condition. These reactions, however, may be selected unconsciously by the patient on the basis of pre- existing life style as well as on a situational level. Thus, for example, the person with the life style of a victim may seize upon this disorder to reinforce and reconfirm his conviction that life is out to vkztimise him [I 7]. Many factors can be responsible for persistent muscle pain, and the most effective management strategies will be directed at elimination of those most important. In one case, permanent

42 The British Journal of Chiropractic, 1999, Vol 3 No. 2

ocdusal change may be required, whereas in another, stress management might be needed the most [I 81.

Given the interdependence between the TMJ and cervical spine, Chinappi and Getzoff (1994 & 1995) propose a model of Dental-Chiropractic co- management [19,20] In their management model for treating strudural-based disorders, they observe that dental occlusion as well as the spine, peivis and cranium, are detemining factors in the overall functional health of the body [14].

Co-management relies on chiropractic manipulation to facilitate the ability of the neck and cranium to accommodate mandibular and dental changes. A more balanced posture of the mandible, slightly downward and forward, diminishes loading in the TMJ. Correction of bite creates better function of the TMJ and allows significant changes in the function of the cervical spine and shoulder girdle [I 51.

Treatment of patients with forward head posture traditionally is focused on the cervical region to regain alignment of the head. In many instances postural changes will occur only if orthopredic support of the mandible is achieved and the compressive forces that cause nociceptive stimulation of the joint receptors are resolved. The generally accepted approach to TJD treatment is aimed at relieving muscle or joint strain and to bestow structural stability, care should start with conservative and reversible procedures [5,14,15]. Approaches that tit this scheme include manipulation of the spine, muscle therapy, craniosacral manipulation, spray and stretch, transcutaneous electdcal nerve stimulation, stress management, counselling, acupuncture and acupressure. The use of an orthotic designed specifically for the upper or lower dental arches can balance the bite in a muscularly neutral position or may be used to anteriorise the mandible according to need.

To support the interaction between orthodontist and chiropractor, Chinappi and Getzoff (1994 & 1995) propose a three-phase model of care [14,15]. In the initial phase of treatment, therapy is aimed at correcting neuromusculoskeletal dysfunction and relieving stress on the worst affected structures. Concerns of how far to go in dental correction otten can be modulated against how the body is functioning as compared with its functional state at the beginning of treatment. Progress at this stage is monitored through the analysis of findings not symptoms [21].

In the sub-acute or intermediate phase of care, significant structural change occurs. Ongoing chiropractic care is vital in order to support the work of the dental surgeon. Adjustments should be continued until the findings stabilise i.e. there is no significant deterioration or improvement from the previous visits. In the final stage of care, more traditional dental procedures are performed, e.g. the placement of crowns, bridges and braces. These procedures create the final occlusion that ultimately will hold the jaw in an aligned position. The chiropractic goal is to maintain function with occasional adjustments and good lifestyle counselling. [19].

Conclusion Cases with a multiplicity of symptoms can present a diagnostic dilemma. To establish the primary cause of symptoms requires careful and sometimes persistent detective work. Accurate recollection by the patient of the case history will provide pertinent dues and careful physical examination will eliminate or reduce

differential diagnoses. Without this fundamental approach to diagnosis correct patient management cannot be determined.

The fact that there is a functional and anatomical

relationship between the jaw, head and cervical spine

would indicate the need for cotreatment in many cases.

This case illustrates that orthodontic outcomes can be

dependent on chiropractic intervention and gives support

to the concept of integrated cans as outlined by Chinappi

and Getzoff [14,15]. It is hoped it will further influence the

developing dialogue between other practitioners that will

advance the concept of integrated care.

Acknowledgements Printed with kind permission of the Vocational Training Scheme sub-committee and Research

Division of the College of Chiropractors.

The British Journal of Chiropractic, 1999, Vol 3 No. 2