Evaluation & Treatment of Evaluation & Treatment of TMDTMD

Presented by:Presented by:Christy Dauner, OTRChristy Dauner, OTRLaurie Applebee, PTLaurie Applebee, PT

Susan Vaughn, MS, OTRSusan Vaughn, MS, OTR

Learning ObjectivesLearning Objectives

Identify TMD risk factors and related Identify TMD risk factors and related diagnosesdiagnoses

Differentiate joint and muscle disordersDifferentiate joint and muscle disorders Understand goals of Occupational Therapy Understand goals of Occupational Therapy

for TMDfor TMD Understand OT treatments for TMD and Understand OT treatments for TMD and

muscle disordersmuscle disorders Perform assessment and treatment Perform assessment and treatment

approaches for TMDapproaches for TMD

Disorders of the TMJDisorders of the TMJ

Myofascial DysfunctionMyofascial Dysfunction Internal DerangementInternal Derangement CapsulitisCapsulitis SubluxationSubluxation ArthritisArthritis

Risk Factors for TMDRisk Factors for TMD

Trauma such as blow to the jaw, whiplash injuries, MVA, Trauma such as blow to the jaw, whiplash injuries, MVA, dental work, opening the mouth too wide or for too long, dental work, opening the mouth too wide or for too long, prolonged chewingprolonged chewing

Oral parafunctional habits such as clenching and bruxism Oral parafunctional habits such as clenching and bruxism that place continued strain on the masticatory systemthat place continued strain on the masticatory system

Malocclusion causes bite instability or functional Malocclusion causes bite instability or functional interference during chewing that places postural strain on interference during chewing that places postural strain on the masticatory systemthe masticatory system

Stressful life events can trigger parafunctional habits and Stressful life events can trigger parafunctional habits and muscle guarding/tensionmuscle guarding/tension

Emotional factors such as depression or anxiety decreases Emotional factors such as depression or anxiety decreases the ability to cope with pain and can increase the ability to cope with pain and can increase parafunctional habits.parafunctional habits.

TMJ EvaluationTMJ Evaluation

History & Symptoms (referred pain)History & Symptoms (referred pain) Functional LimitationsFunctional Limitations Tests, Measures & PalpationTests, Measures & Palpation

AROM (active/passive incisal opening, AROM (active/passive incisal opening, lateral excursion, and protrusion)lateral excursion, and protrusion)

PROM – scissor stretchPROM – scissor stretch TMJ NoiseTMJ Noise Muscle Palpation Muscle Palpation

Differential DiagnosisDifferential Diagnosis

Scissor stretch test: if opens further Scissor stretch test: if opens further - muscular, if not - internal - muscular, if not - internal derangementderangement

Clench test: bite down on tongue Clench test: bite down on tongue depressor for 10 – 15 seconds. Pain depressor for 10 – 15 seconds. Pain on same side – muscle, opposite side on same side – muscle, opposite side – joint– joint

““S” vs. “C” curve with openingS” vs. “C” curve with opening

Occupational Therapy Occupational Therapy Goals for TMDGoals for TMD

Increase ROM to >40mmIncrease ROM to >40mm Decrease painDecrease pain Teach joint protection (decrease Teach joint protection (decrease

parafunctional habits, limited opening)parafunctional habits, limited opening) Improve function (eating, yawning, DDS Improve function (eating, yawning, DDS

visit tolerance, oral hygiene, talking, sleep, visit tolerance, oral hygiene, talking, sleep, work)work)

HEP independenceHEP independence Neutral posture (head on neck, jaw, Neutral posture (head on neck, jaw,

scapular position, TUTA)scapular position, TUTA)

Myofascial Pain DysfunctionMyofascial Pain Dysfunction

Most common disorder Most common disorder Referred muscle painReferred muscle pain Muscle pain aggravated by jaw Muscle pain aggravated by jaw

function or parafunctionfunction or parafunction HA’sHA’s Tenderness of muscles w/o Tenderness of muscles w/o

mechanical symptomsmechanical symptoms Loss of motion or painful motionLoss of motion or painful motion

Myofascial Pain DysfunctionMyofascial Pain Dysfunction

Caused by an underlying related Caused by an underlying related disorder – malocclusion, arthritis, disorder – malocclusion, arthritis, internal internal

derangement, poor posturederangement, poor posture Education is key! – posture, Education is key! – posture,

parafunction, stress managementparafunction, stress management Often chronic and cyclicalOften chronic and cyclical Often a myofascial component with all Often a myofascial component with all

diagnosesdiagnoses

Myofascial DysfunctionMyofascial Dysfunction

Myofascial contributors may include:Myofascial contributors may include: * Lateral pterygoid* Lateral pterygoid

* Medial pterygoid* Medial pterygoid

* Temporalis* Temporalis

* Masseter* Masseter

* Digastrics* Digastrics

* Muscles of the cervical spine * Muscles of the cervical spine

Lateral PterygoidLateral PterygoidOrigin: Lateral Pterygoid Plate of Sphenoid Origin: Lateral Pterygoid Plate of Sphenoid

Insertion: Condylar Neck, Ramus of Mandible and Insertion: Condylar Neck, Ramus of Mandible and DiscDisc

TMJ Muscles – Lateral TMJ Muscles – Lateral PterygoidPterygoid

#1 myofascial source of pain#1 myofascial source of pain Due to attachment to disc it can Due to attachment to disc it can

cause disc and jaw to be unable to cause disc and jaw to be unable to return to normal resting position and return to normal resting position and cause clicking or popping. cause clicking or popping.

Malocclusion of teeth/missing teethMalocclusion of teeth/missing teeth

Referral pattern – zygomatic Referral pattern – zygomatic arch, TMJarch, TMJ

Medial PterygoidMedial PterygoidOrigin: Inner Surface of Lateral Pterygoid Plate Origin: Inner Surface of Lateral Pterygoid Plate

Insertion: Ramus of Mandible by the Angle Insertion: Ramus of Mandible by the Angle

TMJ Muscles – Medial TMJ Muscles – Medial PterygoidPterygoid

Stuffiness in earStuffiness in ear Swallowing difficulty as restriction in Swallowing difficulty as restriction in

protrusion of jawprotrusion of jaw

Referral pattern – posterior mandible, Referral pattern – posterior mandible, mouth, below and behind TMJ including mouth, below and behind TMJ including

internal ear – not teethinternal ear – not teeth

TemporalisTemporalisOrigin: Temporal Fascia, Superior to Zygomatic Origin: Temporal Fascia, Superior to Zygomatic

ArchArchInsertion: Coronoid Process of MandibleInsertion: Coronoid Process of Mandible

TMJ Muscles - TemporalisTMJ Muscles - Temporalis

Significant postural muscle (the only Significant postural muscle (the only time it isn’t working is when you’re time it isn’t working is when you’re lying supine) lying supine)

Perpetual clenchingPerpetual clenching

Referral pattern – lower jaw, molar teeth and Referral pattern – lower jaw, molar teeth and gum, maxilla, lower portion of mandible, gum, maxilla, lower portion of mandible,

temple eyebrow and external eartemple eyebrow and external ear

Masseter Masseter Origin: Zygomatic ArchOrigin: Zygomatic Arch

Insertion: Mandibular Angle and RamusInsertion: Mandibular Angle and Ramus

TMJ Muscles - MasseterTMJ Muscles - Masseter

““Sinusitis”Sinusitis”

Referral pattern - temple, Referral pattern - temple, alongalong

eyebrow, behind eye or eyebrow, behind eye or upper teethupper teeth

DigastricsDigastricsOrigin: Mastoid Notch (posterior), Symphysis of Origin: Mastoid Notch (posterior), Symphysis of

Mandible (anterior)Mandible (anterior)Insertion: Join by a Common Tendon to the Hyoid Insertion: Join by a Common Tendon to the Hyoid

BoneBone

TMJ Muscles - DigastricsTMJ Muscles - Digastrics

Rarely in spasm due to forward head Rarely in spasm due to forward head posture (stretch weakness)posture (stretch weakness)

Referral pattern – behind Referral pattern – behind mandible toward back of ear, mandible toward back of ear,

lower incisorslower incisors

Cervical Spine MusclesCervical Spine Muscles

Form stable base for TMJ on which to Form stable base for TMJ on which to work work

Poor posture – condyle rotates Poor posture – condyle rotates backward – change of biomechanicsbackward – change of biomechanics

Referral pattern from the cervical Referral pattern from the cervical spine-Temporal Headaches, SCMspine-Temporal Headaches, SCM

Assess for tension in upper traps, Assess for tension in upper traps, scalenes, and SCMscalenes, and SCM

Parafunctional BehaviorsParafunctional Behaviors

Gum/candy chewing (chewing limited to 15 – 20 Gum/candy chewing (chewing limited to 15 – 20 minutes/day!) – including chewing on one sideminutes/day!) – including chewing on one side

Clenching/bruxing/grindingClenching/bruxing/grinding Leaning on chin/jawLeaning on chin/jaw Biting nails, pencils, cheeksBiting nails, pencils, cheeks Sleep positionSleep position Caffeine useCaffeine use Musical instrumentsMusical instruments Mouth breathingMouth breathing Phone cradlingPhone cradling

Treatment – Myofascial Pain Treatment – Myofascial Pain DysfunctionDysfunction

Modalities: US - 1.0 – 1.2 w/cm2, 3 MHz, x5 Modalities: US - 1.0 – 1.2 w/cm2, 3 MHz, x5 minutes to joint or muscle, heat, electrical minutes to joint or muscle, heat, electrical stimulation stimulation

Manual Therapy – joint mobs/distraction, MFR – Manual Therapy – joint mobs/distraction, MFR – including upper cervical regionincluding upper cervical region

HEP/Lifestyle changesHEP/Lifestyle changes Tongue positioning (TUTA)Tongue positioning (TUTA) Self-joint distraction &/or MFRSelf-joint distraction &/or MFR Eliminating parafunctional behaviorsEliminating parafunctional behaviors Postural instructionPostural instruction

Conjunction with splint therapy &/or counseling Conjunction with splint therapy &/or counseling (Referral to psychology for CBT as needed for (Referral to psychology for CBT as needed for stress and anxiety management)stress and anxiety management)

Resting Joint PositionResting Joint PositionCapsule – anterior/posterior onlyCapsule – anterior/posterior only

Normal Joint MotionNormal Joint Motion

Internal DerangementInternal Derangement

Disc DisorderDisc DisorderInternal DerangementInternal Derangement

Disc held in place by collateral ligaments Disc held in place by collateral ligaments and posterior ligament, w/ movement and posterior ligament, w/ movement dictated by lateral pterygoiddictated by lateral pterygoid

Click, pop, lockClick, pop, lock Pain at jointPain at joint ““S” shaped opening/closing to reposition S” shaped opening/closing to reposition

jawjaw Eye painEye pain History of traumaHistory of trauma

Treatment – Internal Treatment – Internal DerangementDerangement

Modalities: Iontophoresis, electrical stimulation, Modalities: Iontophoresis, electrical stimulation, cold – ice massagecold – ice massage

Manual therapy – Joint distractionManual therapy – Joint distraction Joint protection techniques: Limit motion to no Joint protection techniques: Limit motion to no

noise, soft food diet or chewing behaviorsnoise, soft food diet or chewing behaviors Home exercise instructionHome exercise instruction

Change parafunctional behaviorsChange parafunctional behaviors Self joint distraction techniquesSelf joint distraction techniques Tongue positioning for relaxation (TUTA)Tongue positioning for relaxation (TUTA)

Postural instruction and controlled Postural instruction and controlled opening/neuromuscular re-educationopening/neuromuscular re-education

Treatment - OtherTreatment - Other

Capsulitis Capsulitis Usually a result of another disorder unless Usually a result of another disorder unless

post surgerypost surgery Modalities, MT and HEPModalities, MT and HEP

Subluxation Subluxation Excess opening (>40 mm)Excess opening (>40 mm) Usually a component of myofascial pain Usually a component of myofascial pain

dysfunction, and treated as this, with dysfunction, and treated as this, with addition of stab exercises and controlled addition of stab exercises and controlled openingopening

Treatment - OtherTreatment - Other

ArthritisArthritis Generalized joint pain and inflammationGeneralized joint pain and inflammation Usually seen in conjunction w/ other Dx Usually seen in conjunction w/ other Dx Joint protection, restJoint protection, rest Stretching, therapeutic exerciseStretching, therapeutic exercise Modalities (cold vs. heat, pulsed US, Modalities (cold vs. heat, pulsed US,

phono/iontophoresis, E-stim)phono/iontophoresis, E-stim)

Intervention: DentistIntervention: Dentist

Assess occlusionAssess occlusion Parafunctions of clenching/bruxingParafunctions of clenching/bruxing MalocclusionsMalocclusions Pressure on back teeth activate Pressure on back teeth activate

temporalis an superior head of lateral temporalis an superior head of lateral pterygoid, anterior teeth activatepterygoid, anterior teeth activate massetersmasseters

Lab - EvaluationLab - Evaluation

AROM (Therabite)AROM (Therabite) Active Incisal Opening (Normal 40-60 Active Incisal Opening (Normal 40-60

mm)mm) Passive Incisal Opening (Normal 42-62 Passive Incisal Opening (Normal 42-62

mm) mm) Lateral Excursion (Normal Lateral Excursion (Normal >>7 mm)7 mm) Protrusion (Normal Protrusion (Normal >> 7 mm) 7 mm)

Lab - EvaluationLab - Evaluation

TMJ Palpation/ObservationTMJ Palpation/Observation Quality of Motion: Quality of Motion:

Smooth/Rigid/Jerky/Guarded/Fasciculation/ Smooth/Rigid/Jerky/Guarded/Fasciculation/ ThrustingThrusting

TMJ Noise: Opening Click, Closing Click, TMJ Noise: Opening Click, Closing Click, ReproducibleReproducible

Visually Assess Opening (S or C Shaped Visually Assess Opening (S or C Shaped Curve)Curve)

LabLab Muscle Palpation Muscle Palpation

Medial Pterygoid (elevation, protrusion, and Medial Pterygoid (elevation, protrusion, and lateral deviation to opposite side)lateral deviation to opposite side)

Place index finer on muscle at inside of bottom teeth Place index finer on muscle at inside of bottom teeth in mouth. Place opposite thumb under jaw line below in mouth. Place opposite thumb under jaw line below ear. Apply pressure to muscle as if to touch finger ear. Apply pressure to muscle as if to touch finger and thumb. Move along gum line until reach incisors and thumb. Move along gum line until reach incisors in front. Hold until relaxes 1-2X/dayin front. Hold until relaxes 1-2X/day

Lateral Pterygoid (elevation, protrusion, and Lateral Pterygoid (elevation, protrusion, and lateral deviation to opposite side)lateral deviation to opposite side)

Place index finger inside mouth, under cheek bone. Place index finger inside mouth, under cheek bone. Point finger up and towards opposite eye. Apply Point finger up and towards opposite eye. Apply pressure to muscle until it relaxes. To check pressure to muscle until it relaxes. To check positioning of finger, actively move jaw in opposite positioning of finger, actively move jaw in opposite direction and muscle will contract under finger. Hold direction and muscle will contract under finger. Hold until relaxes 1-2X/dayuntil relaxes 1-2X/day

LabLab

Manual TherapyManual Therapy Trigger point releaseTrigger point release Joint distraction Joint distraction

Place thumb on back, bottom molar and Place thumb on back, bottom molar and wrap fingers under jawwrap fingers under jaw

Press down as you lift on jaw in scooping Press down as you lift on jaw in scooping motion motion

Do NOT pull jaw forwardDo NOT pull jaw forward

Thank YouThank You Feel free to contact Christy at 952-908-Feel free to contact Christy at 952-908-

2567 or at 2567 or at Christyd@pdrclinics.comChristyd@pdrclinics.com with with questions.questions.

PDR Clinic Locations: Edina, Burnsville, PDR Clinic Locations: Edina, Burnsville, Maplewood, Burnsville, ChanhassenMaplewood, Burnsville, Chanhassen

Specializing in the treatment of chronic Specializing in the treatment of chronic neck, back and TMJ pain.neck, back and TMJ pain.