temporomandibular!dysfunktion! tmd! - ato.dk · dkte&opgave!2013!...
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DKTE&opgave!2013!
Temporomandibular!Dysfunktion!
TMD!Discus&displacering,!diagnostik!og!håndtering!
Vejledning!til!brug!i!den!kommunale!tandpleje!
Tandlæge!Charlotte!Skou!
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TMD$
Diskus)displacering,$diagnostik$og$håndtering$
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Indholdsfortegnelse$!
Side!3!!!!Indledning!
Side!5!!!!Kæbeleddets!anatomi!
Side!7!!!!Anterior!diskus9displacering!
Side!8!!!!Epidemiologi!
Side!8!!!!Ætiologi!
Side!10!!Diagnostik!
Side!13!!Behandling/håndtering!
Side!17!!Henvisningsmuligheder!!!!!!
Side!18!!Referencer!
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Bilag!1!!DC/TMD,!Examination!Form(Akse!1),!Patient!Questionnaire(Akse!2)!og!
Decision9tree.!
Bilag!2!!!DC/TMD,!Akse!2!!Screening!og!Short!Form!Patient!Questionnaire.!
Bilag!3!!!VAS,!fra!Dansk!selskab!for!oral!fysiologi!
Bilag!4!!!Fysiurgiske!øvelser,!Århus!Tandlægeskole.!
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Vejleder'Lektor,'PhD'Nuno'Hermann,'Afd.'for'Pædodonti'og'Klinisk'Genetik,'Sektion'5,'
Tandlægeskolen,'Sundhedsvidenskabeligt'Fakultet,'Københavns'Universitet.'
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Denne! DKTE! rapport! er! udformet! som! et! udkast! til! vejledning! omkring! børn/unge!
patienter! med! Temporomandibulær! dysfunktion! (TMD)! p.g.a.! anterior! diskusA!
displacering!til!brug!i!klinikken!i!Den!Kommunale!Tandpleje.!!
Vejledningen!indeholder!en!oversigt!over!!ætiologiske!faktorer,!samt!forhold!omkring!
diagnostik!og!psykologisk,!fysiologisk!og!medicinsk!håndtering.!!!!
Skemaer! til! brug! for! anamnese! og! klinisk! undersøgelse! samt! fysiologiske! øvelser! ses!
som!bilag.!
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Temporomandibulær!dysfunktion!(TMD)!er!en!gruppe!af!tilstande!karakteriseret!ved!
smerter!i!kæbeled!og/eller!tyggemuskler,!knæk!eller!krepitation!i!kæbeleddet!og/eller!
nedsat!bevægelighed!af!kæben.!
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Vejledningen! omhandler! anterior! discusAdisplacering,! da! vi! af! og! til! støder! på! denne!
tilstand!hos!vores!unge!patienter,!som!henvender!sig! !akut!på!klinikken,!og!er!urolige!
over!tilstanden,!der!ofte!kan!være!ledsaget!af!smerte.!Derfor!er!der!brug!for,!at!vi!som!
behandlere! diagnosticerer! og! håndterer! tilstanden! korrekt! og! er! istand! til! at! give!
fyldestgørende!information!til!den!unge!og!forældre.!
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Der! er! taget! udgangspunkt! i! nyere! faglitteratur,! i! CochraneAreviews! og! i! relevante!
artikler!søgt!i!Pubmed.!
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Indledningsvist!gennemgås!kort!kæbeleddets!anatomi!og!fysiologi.!!!
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Ætiologien! for! TMD! er! multifaktoriel! med! forskellige! kendte! risikofaktorer! og!
disponerende! faktorer,! der! vil! blive! gennemgået.! Screening! for! TMD! indgår! i! den!
almindelige! undersøgelse,! og! ! vejledningen! vil! indeholde! forslag! til! indhold! af!
screening.!!Det!internationale!klassifikationssystem!DC/TMD!med!undersøgelsesskema!
vil! kort!blive!gennemgået!og! skemaerne!er! vedhæftet! som!bilag.!Da!der! ikke! ! findes!
evidensbaserede!tiltag,!som!umiddelbart!helbreder!kæbeleddet!efter!anterior!discus&
displacering,!bygger!håndteringen!alene!på!klinisk!erfaring.!Vejledningen!vil!gennemgå!
forslag!til!håndtering,!med!det!udgangspunkt,!at!de!mest!enkle!behandlinger!forsøges!
først.! ! Alternativ! behandling! som! fx! akupunktur! og! hypnose! samt! mere! avanceret!
fysiurgisk,!medicinsk!og!kirurgisk!behandling!er!udeladt,!da!det! ikke!skønnes!at!være!
relevant!i!almindelig!daglig!praksis.!!Enkelte!svære!tilfælde!af!TMD,!og!tilfælde!der!ikke!
responderer! på! indledende! håndtering,! kan! kræve! henvisning! til! specialiseret!
undersøgelse/behandling,!og!de!relevante!henvisningsmuligheder!!vil!blive!foreslået.!
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Kæbeleddets!anatomi!
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1. Musculus!pterygoideus!lateralis!øvre!hoved!(tilhæftning!på!discus!og!kondyl)!2. Musculus!pterygoideus!lateralis!nedre!hoved!(tilhæftning!på!collum)!3. Fossa!mandibularis!(ledskål)!4. Ledbrusk!i!fossa!5. Discus,!intermediære!zone!6. Discus,!posteriore!bånd!7. Discus,!posteriore!bånd!8. Ledbrusk!på!kondyl!9. Kondyl!(ledhoved)!10. Retrodiscale!zone!11. Ledkapsel,!posteriore!del!12. +!!13.!!Ledkapsel,!anteriore!del!
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Kæbeleddet!!er!et!synovialled.!Det!adskiller!sig!fra!de!fleste!andre!led!i!kroppen!ved,!at!
den!såkaldte!ledbrusk!på!artikulationsfladerne!i!fossa!og!på!kaput!yderst!har!et!fibrøst!
bindevævslag! med! tykke! strøg! af! kollagene! fibre.! ! Det! betyder! stor! kapacitet! til!
regeneration.! ! Skader! som! følge! af! konstante! små!belastninger,! småtraumer,! slid! og!
aldring!kan!i!stor!udstrækning!udbedres,!og!leddet!kan!tilpasse!sig!påvirkningerne(1)!!
Endvidere! aflastes! leddet! af! en! discus(ledskive),! som!består! af! tykt! fibrøst! colllagent!
bindevæv,! der! har! et! tyndt! ! centralt! område! omgivet! af! ! tykkere! anteriore! og!
posteriore!områder.!Discus!er!set!!anteriort!fra!tykkere!medialt!end!lateralt.!Discus!er!
anteriort!og!posteriort!forbundet!til!ledkapslen!med!ligamenter.!Medialt!og!lateralt!er!
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discus! forbundet! med! ligamenter! til! kondylen.! ! Ligamenterne! består! af! kollagent!
bindevæv,! er! ikke! elastiske! og! holder! discus! på! plads! omkring! kondylen.! ! Den!
retrodiscale! zone! posteriort! for! discus! består! af! løst! elastisk! bindevæv! ,! der! er! rigt!
innerveret!og!vaskulariseret!.!!Det!retrodiscale!væv!forbinder!discus!med!både!fossa!og!
kondyl.! ! Discus! deler! kæbeleddet! op! i! et! øvre! og! nedre! ledkammer,! der! indeholder!
synovialvæske.!Ledkamrenes!overflader!er!dækket!af!synovialmembranen(1).!!!
Musculus!pterygoideus! lateralis!øvre!hoved!hæfter!på! !den!mediale!del!af!kondyl!og!
discus,! og! trækker! dermed! discus! og! kondyl! fremad&indad.! Musklen! er! en! del! af!
tyggemuskulatur&komplekset!og!stabiliserer!discus/kondyl!ved!f.eks.!unilateral!tygning,!
men!er!under!normale!forhold!passiv!i!åbnebevægelsen(1).!
Kæbeleddet!har!som!andre! led!et!system!af!stabiliserende! ! ligamenter,!der!består!af!
bindevævsfibre(1).!
Ledkapsel,! synovialmembran,! muskler! og! ligamenter! er! tæt! innerveret! med!
nociceptorer,!der!er!knyttet!til!smertesansning.!Ledbrusk!og!discus!har! ikke!har!disse!
nervetråde(1).!!!
I! hvile! er! kondylen! placeret! i! fossa! på! centrale! del! af! discus.! Første! del! af!
åbnebevægelsen!(ca.!25&30!mm!mundåbning)!er!en!rotationsbevægelse.!!Ved!maximal!
mundåbning! (ca.40&50! mm! mundåbning)! translaterer! kondylen! ud! af! fossa! over!
tuberkulum.!Samtidig! roterer!discus!posteriort!på!kondylen.!De! retrodiscale!elastiske!
fibre!aktiveres!under!translationsbevægelsen!og!trækker!discus!posteriort,!så!kondylen!
nu! har! kontakt! på! den! forreste! del! af! discus.! I! lukkebevægelsen! er! det!modsat.! De!
elastiske! fibre!afslappes!og!øget! tonus! i!M.pterygoideus! lateralis!øvre!hoved!trækker!
discus! fremad! og! tilbage! til! udgangsposition,! hvor! kondylen! er! placeret! på! discus!
centrale!område(1).!Mundåbningen/gabeevnen!mindskes!med!alderen(1).!!
Ved! funktion,! fx.! tygning,! ! bevæger! kondylerne! sig! varierende! i! rotations&! og!
translationsbevægelse! samt! sideudslag.! ! discus! og! kondyl! bevarer! stort! set! det!
oprindelige!forhold!med!kondyl!placeret!på!discus!centrale!del(1).!
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Anterior!discus&displacering!Discus!kan!forskydes!anteriort!på!kondylen,!hvis!discus!morfologi!ændres,!hvis!de!ikke&
elastiske! ligamenter! strækkes! og! hvis! de! elastiske! retrodiscale! fibres! funktion!
kompromitteres,! så! M.pterygoideus! lateralis! kan! trække! discus! fremad! og/eller!
medialt.!Tilstanden!kan!forekomme!i!det!ene!eller!begge!kæbeled(1).!
I!første!meget!tidlige!stadie!vil!åbnebevægelsen!opleves!som!en!ujævn!bevægelse,!!og!
der!vil!ofte!være!et!klik!i!begyndelsen!af!åbnebevægelsen,!svarende!til!at!kondyl!glider!
over!discus!posteriore!fortykkelse!til!det!centrale!område.!Resten!af!åbnebevægelsen!
samt! lukkebevægelsen! vil! forløbe! normalt.! Hvis! kondylen! til! sidst! i! lukkebevægelsen!
igen!glider!op!på!discus!posteriore!del,!fremkalder!det!et!andet!knæk!(reciprokt).!Der!
vil!ofte!ikke!være!smerte,!og!den!største!gene!vil!være!selve!kæbeledsknækket(1).!!!
Hvis!discus!permanent!forskydes!anteriort,!kan!der!være!smerte!i!varierende!grad!fra!
fibre!og! ligamenter,!og!der!vil!være!en!følelse!af! låsning!af!kæbeledddet(1).!Sålænge!
tilstanden!er!periodisk!og!kæbeleddet!kan!lirkes!på!plads!ved!egen!hjælp!klassificeres!
tilstanden! ! som!discus&displacering!med! reduktion.! !Der! vil! oftest! kun! være!brug! for!
information!om!tilstanden(1).!
Der!er!tale!om!discus&displacering!uden!reduktion!med!nedsat!gabning!i!den!situation,!
hvor!discus!permanent!er!placeret!anteriort,!og!hvor!gabeevnen!stort!set!er!nedsat!til!
det! rotationsbevægelsen! tillader(1).! Der! vil! ! være! nedsat! bevægelighed! til!!
kontralaterale! side! og! deviation! af! underkæben! til! afficerede! side.! Da! discus! er!
placeret! permanent! anteriort! vil! der! ikke! forekomme! knæk.! Tilstanden! forekommer!
akut! og! er! ofte! ledsaget! af! smerte,! da! kondyl! artikulerer! på! det! højt! ! innerverede!
retrodiscale!område.!!Smerterne!kan!persistere!i!flere!uger,!så!der!vil!være!behov!for!
håndtering(1,2).!
Når! gabeevnen!og! bevægeligheden! efterhånden!normaliseres! klassificeres! tilstanden!
som!discus&displacering!uden!reduktion!uden!nedsat!gabning(1).!!Der!kan!forekomme!
let! krepitation,! som! tegn! på! erosion! af! kaput.! Der! er! oftest! ingen! eller! ubetydelige!
gener,! og! ! kæbeleddets! strukturer! adapterer! sig! til! tilstanden! !med! den! permanent!
displacerede!discus(1).!
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TMD!epidemiologi!TMD!er!den!hyppigste!årsag!til!kronisk!ansigtssmerte(1,2).!
Hyppigheden! af! symptomer! på! TMD,! herunder! diskus&displaceringer! forekommer!
sjældent! hos! børn! før! puberteten,! stiger! igennem! teenageårene,! er! højest! i!
aldersgruppen!ca.25&45!år,!for!herefter!at!aftage!med!alderen(1,3,4,5,6,7).!!
Ca.!7!%!af!unge! i!alderen!12&19!år!har! smerte! fra!muskler/kæbeled! ,!og!heraf!vil! ca.!
halvdelen!have!brug!for!håndtering!af!tilstanden.!Unge!med!disse!smerter!har!påvirket!
livskvalitet! med! større! forbrug! af! smertestillende! medicin! og! hyppigere! fravær! fra!
skole!end!raske!unge!i!samme!aldersguppe(3,4,10).!
TMD&symptomer! findes! oftest! hos! piger/kvinder(9,10,11).! De! subjektive! symptomer!
klinger!oftest!af!efter!uger/måneder!og!kun!få!har!symptomer,!der!persisterer!ud!over!
1!år(1).!
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Ætiologi!Ætiologien! for! TMD! er! multifaktoriel.! Der! er! forskellige! risikofaktorer! og!
prædisponerende! faktorer! der! har! betydning! for,! om! personen! udvikler! TMD,!
herunder!anterior!discus&displacering(1,2,12,13,14,15,16,17,18,19).!!Nedenfor!er!listet!
de!faktorer,!der!er!relevante!for!teenage&gruppen.!
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Risikofaktorer:,
Traume,!direkte!(slag!på!kæben)!
Traume,!indirekte!(fx!piskesmæld)!
Muskelhyperaktivitet/overbelastning! (fx! tyggegummi,! neglebidning,! tandpres,!
tungepres,!bidning!i!blyant,!holde!mobiltlf.!øre!mod!skulder)!
Bruksisme!
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Malokklusion!
Kropsholdning/hovedholdning!
Psykologiske!faktorer!(stress,!depression,!angst,!somatisering)!
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Kvindekøn/kvindelige!kønshormoner!
Genetiske!!
Alder!
Hypermobilitet!
Anatomiske! faktorer! (stejl! tuberkulum! artikulare,! kondyl&! og! fossamorfologi,!!!!!!!!!!!!!!!!!!
tilhæftning!af!Musculus!pterygoideus!lateralis)!
Adherencer!(kondyl&discus,!!fossa&discus)!
Andre!smertetilstande!!
Kroniske!lidelser!(f.eks.!generelle!ledsygdomme,!eks.!juvenil!idiopatisk!arthritis)!
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Det! er! veldokumenteret! at! kvindekøn/kvindelige! kønshormoner! samt! psykologiske!
faktorer!er!væsentlige!risikofaktorer(1,13,15,16,17).!!I!teenage&gruppen!skal!man!være!
opmærksom! på! forskellige! vaner,! som! særligt! kan! prædisponere! for! TMD:! f.eks.!
langvarig! tygning! af! tyggegummi,! hyppig! tygning! i! fx! bolsjer! eller! isterninger! eller!
habituel! bidning! i! fremmedlegmer.! Støtte! mobiltelefon! øre/skulder! eller! støtte! på!
kæben!med! hånd! kan! ligeledes! være! en! faktor! i! denne! gruppe,! hvis! der! er! tale! om!
daglig!langvarig!uvane(20,21,22).!
Ortodonti!i!sig!selv!øger!ikke!risikoen!for!udvikling!af!TMD.!Okklusionsforhold!forklarer!
kun!ca.!5&25%!af!TMD&tilfælde(23,24).!
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Diagnostik!TMD&screening! indgår! i! den! almindelige! undersøgelse,! og! ved! positive! fund!
anamnestisk! og/eller! klinisk! foretages! en! fuldstændig! TMD&undersøgelse! for!
udredning,!diagnostik!og!behandlingsplan.!
Diagnostic! Criteria! for! Temporomandibular! Disorders! (DC/TMD)! er! et! internationalt!
diagnose&klassifikationssystem! med! nøje! beskrevede! undersøgelsesprocedurer.!
DC/TMD!er!den!nye!udgave!af!RDC/TMD&systemet!fra!1992(25).!Det!består!af!to!dele:!
Akse!I!som!beskriver!den!fysiske!status!og!Akse!II!som!beskriver!den!smerterelaterede!
funktionsnedsættelse!og!psykologiske!status(bilag1).!
Akse!I&undersøgelsesskemaet(Examination!Form)! !er!systematisk!opbygget!med!plads!
til! egne! kommentarer.! Akse! II(Patient! History! Questionnaire)! er! udformet! som! et!
spørgeskema! samt! en! skitse! til! visuel! gengivelse! af! afficerede! områder.! Skemaet! er!
opdelt! i!4!afsnit:!Chronic!Pain!scale(GCP),!PHQ&15,!PHQ&9!og!GAD!7.!Akse! II&skemaet!
findes!også!i!en!udgave!til!brug!ved!TMD&screening!og!i!en!kort!form(bilag2).!I!systemet!
indgår! et! ”Diagnostic! Decision! Tree”! der! refererer! til! både! anamnestiske! og! kliniske!
fund!(markeret!med!rødt!f.eks.!E4,!PHQ3).!!DC/TMD&skemaerne!er!!endnu!ikke!oversat!
til! dansk.! Systemet! med! specifikationer! kan! ses! online! på! www.rdc&
tmdinternational.org.! Der! er! en! meget! udførlig! og! detaljeret! vejledning! med!
illustrationer! i! anbefalede! undersøgelsesprocedurer,! og! der! vil! blive! oploadet!
videomateriale! til! brug! for! den! kliniske! undersøgelse.! DC/TMD&systemet! vil! løbende!
blive!opdateret!på!websitet.!En!Akse!III!med!biomarkører!er!under!udarbejdelse.!
Som! supplement! til! TMD&screening! og! DC/TMD&skemaerne! kan! bruges! et!
smerteregistreringsskema,!som!f.eks.!VAS!(Visual!Analog!Scale),!som!er!et!velkendt!og!
nemt!anamnestisk!hjælpemiddel(bilag3).!!
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Diagnoser,Discus2displacering:,
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Discus&displacering!med!reduction!
”Subluxatio!Disci!Articulationis!Temporomandibularis”!
Knæk,!enkelt!eller!reciprokt!
Dicus&displacering!uden!reduction!med!nedsat!gabeevne!
“Dislocatio!Acuta!Disci!Articulatonis!Temporomandibularis”!
Ingen!ledlyd.!Låsning.!Nedsat!gabeevne!og!sideudslag.!Deviation!ved!mundåbning.!
Dicus&displacering!uden!reduction!med!nedsat!gabeevne!
”Dislocatio!Disci!Articulationis!Temporomandibularis”!
Let!krepitation,!intet!knæk.!!Oplysning!om!tidligere!nedsat!gabeevne!og!knæk.!!
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Differentialdiagnostiske,overvejelser:,
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Osteoarthritis:! Inflammatorisk! tilstand! i! kæbeleddet.! Oftest! bilateralt.! Kendetegnet!
ved! smerte,! også! i! hvile! og! grov! krepitation! som! tegn! på! degeneration! af!
ledkomponenter(1).!
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Juvenil0 Idiopatisk0 Arthritis0 (JIA):! 20&30%! får! affektion! I! kæbeled.! ! Sjælden! sygdom!
(ca.1!barn!ud!af!1000).!Debuterer!før!16&årsalderen.!Smerte!forekommer!i!varierende!
grad! afhængig! af! type,! ligesom!der! kan! være! systemisk! påvirkning.! Flere! led! er! ofte!
afficerede(26).! Ved! akut! JIA! i! kæbeleddet! er! der! typisk! kraftig! indskrænket!
bevægelighed!og!smerter!ved!funktion!og!palpation(26,27).!
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TMD&screening!!!
Anamnese, +/&!!!!!
Hovedpine! En!gang!om!ugen!eller!mere!
Ansigtssmerter! En!gang!om!ugen!eller!mere!
Gabebesvær! Hvor!ofte!?!
Tyggebesvær! Hvor!ofte!?!
Kæbeledslyd! Hvor!ofte!?!
Tandslid! Følsomhed,!kosmetisk!skæmmende!?!
Klinisk,ekstraoral,og,intraoral,undersøgelse,
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Beskrives!
Hævelser!Asymmetrier!
Afvigelser!?!
Kæbeled:!Bevægelighed!(gabning,!sideudslag)!!!!!!!!!Lyd!Smerte!
Bevægelighed!i!kæben!måles!ved!maksimal!gabeevne!og! maksimal! sideudslag,! samt! ved! at! inspicere! evt.!deviationer,! og! om! bevægelsen! er! ujævn! eller!hoppende.!!Bevægeligheden! betragtes! normalt! som! indskrænket!ved! maksimal! gabning! under! 40! mm! (inklusiv! det!incisale!vertikale!overbid),!og!ved!sideudslag!under!8!mm.! Begge! dele! måles! fra! Incisale! hjørner! på!fortænder.!Der!kan!være!naturlig!individuel!variation!i!bevægelighed,!der!også!ændrer!sig!med!alderen.!Lydfænomener!(knæk,!krepitation)!noteres.!Kapselømhed! bestemmes! ved! ! palpation! af! kæbeled!lateralt! og! posteriort! lige! foran! øret! ved!mundåbning/lukning!
Tyggemuskler!(M.masseter,!M.temporalis)!
Palpationsømhed.! Tyggemusklerne! palperes!med! 2&3!fingre,!med!et! tryk! svarende! til!1kg! (kan!afprøves!på!køkkenvægt).! ! Moderat! til! stærk! ømhed/smerte!registreres!(synlig!reaktion!ved!palpation)!
Tandslid! Grad!1&4!!
Tungeuvaner!!
Tungeimpressioner,! tegn! på! kind&! og/eller!læbebidning!
Okklusion/artikulation! Afvigelser!?!!
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13!!
Behandling/håndtering!
En!stor!gruppe!af!unge!med!subjektive!og!objektive!symptomer(f.eks.!knæk)!på!TMD,!
har!ikke!brug!for!anden!håntering!end!grundig!information!om!tilstanden,!hvis!der!ikke!
samtidig!er!smerte,!f.eks!!discus&displacering!med!reduktion.!
Hvis! der! er! smerte,! er! der! behov! for! håndtering,! da! smerte! kan! påvirke! den! unges!
livskvalitet! i! form! af! problemer! med! fødeindtag,! tale,! tandbørstning,! og! f.eks! være!
årsag!til!fravær!fra!skole/uddannelse(28,29).!
Der! findes! ingen! evidensbaseret! behandling! af! TMD,! så! håndtering! er!
traditionsbaseret,! idet! der! tages! hensyn! til! invasitet,! irreversibilitet! og!
bivirkninger(1,26,29).! ! Det! betyder! i! praksis,! at! det! mest! enkle! behandlingstiltag!
forsøges!først,!effekten!kontrolleres!og!behandlingen!justeres!og!suppleres!evt.!!Det!er!
vigtigt,!at!tage!udgangspunkt! i!den! individuelle!patient,!da!de!ætiologiske!faktorer!er!
multiple,! ligesom! symptomernes! sværhedsgrad! kan! variere.! Behandlingsmålet! er!
smertelindring! og! restitution! af! kæbeledsfunktion.! Patientens! motivation! og!
compliance!er!en!væsentlig!faktor!i!håndteringen!af!TMD(1,26,30).!!!
Når!en!behandling!er!iværksat!kontrolleres!effekten!efter!en!uge,!for!at!være!sikker!på,!
at! informationer! er! forstået,! og! at! anbefalede! tiltag! følges.! ! Herefter! kontrolleres!
tilstanden! som! udgangspunkt! efter! henholdsvis! fire! og! otte! uger! efter!
behandlingsstart.!Der!vil!kunne!forventes!bedring!af!tilstanden!efter!fire!uger!eller!før,!
men!man!bør! forberede!patienten!på,!at!der!kan!gå! længere!tid.!Hvis! tilstanden! i!de!
første!måndeder!forværres!betydeligt!eller,!hvis!der!ved!otte&ugers&kontrollen!ikke!er!
effekt! af! valgte! behandlingstiltag! eller! forværring! af! tilstanden,! skal!
henvisningsmuligheder!overvejes(29).!Hvis!der!ved!otte&ugers&kontrollen!er!god!effekt!
af! behandlingstiltag! og! bedring! af! tilstanden,! vuderes! det,! om! der! skal! ske! en!
justering/aftrapning,! idet!man!skal!være!opmærksom!på,!at!der!kan!ske! !recidiv,!hvis!
kæbeleddet! ikke! er! tilstrækkeligt! restitueret(29).! Tilfælde!med! persisterende! kronisk!
smerte!kan!kræve!henvisning!til!supplerende!undersøgelser!og!relevant!udredning!hos!
f.eks.!egen!læge.!Se!senere!for!henvisningsmuligheder.!
14!!
Ved!mistanke!om!f.eks.!JIA!henvises!straks!til!Tandlægeskolens!Lansdelscenter!for!børn!
med!JIA,!idet!nedbrydningen!af!kæbeleddet!sker!meget!hurtigt.!
Der! er! ikke! evidens! for,! at! forskellige! typer! ortodontisk! apparatur! kan! afhjælpe!
TMD(31).!
!
I!praksis!er!følgende!håndteringsmuligheder!aktuelle,!og!der!vil!oftest!være!brug!for!en!
kombination!af!tiltag:!
!
Psykologisk:,
Omfatter!information!og!rådgivning!til!patient!og!forældre!om!tilstanden!og!mulige!
årsager!til!symptomer.!Der!rådgives!om!orale!uvaner,!stresshåndtering!og!
søvn/afspænding/afslapning(32).!God!dialog!om!de!anamnestiske!fund!er!vigtig,!så!
patienten!kan!erkende!egne!muligheder!for!håndtering!af!smerteoplevelsen.!Patienten!
instrueres!i!at!skåne!kæbeled!ved!at!undgå!hård!kost!og!ekstrem!belastning!og!
bevægelse.!Der!orienteres!om!kontrolbesøg!og!!forventet!prognose.!
!
Fysiurgisk:,
Forskellige!stræk&!og!muskeløvelser!og!massage!af!evt.!ømme!muskler!medvirker!til!at!
bevare!eller!øge!mobiliteten!i!kæbeled!og!tyggemuskler(1,26).!Holdningstræning,!
stræk&!og!afspændingsøvelser!for!hals&,!nakke!og!skuldre!kan!forebygge!overbelastning!
af!muskler!i!hoved,!nakke!og!skulder!og!er!relevant!at!være!opmærksom!på!i!
teenagegruppen(21,28).!!I!de!fleste!tilfælde!kan!patienten!selv!udføre!et!
øvelsesprogram!hjemme!efter!instruktion,!men!henvisning!til!afspænding,!massage,!
fysioterapi!eller!lignende!kan!være!nødvendigt!for!nogle!unge.!I!tilfælde!af!kraftig!
smerte!ved!kæbevægelse,!må!!smertelindring!!ved!hjælp!af!farmaka!afventes.!
Varme!lindrer!symptomer!ved!at!stimulere!muskelafslapning!og!blodgennemstrømning!
superficielt.!Der!kan!f.eks.!benyttes!varmepude!eller!ris&!eller!kirsebærstenspude!
(opvarmes!i!mikrobølgeovn!i!2&3!min.!eller!i!ovn!100!grader!i!10!min.).!!
Varme!skal!ikke!bruges!i!en!akut!fase!(under!72!timer)!eller!i!tilfælde!af!inflammation!
eller!infektion(26).!!
15!!
!
Kulde!/ispakning!virker!analgetisk!og!anti&inflammatorisk,!er!godt!i!den!akutte!fase,!
men!skal!ikke!bruges!til!patienter!med!dårlig!blodcirkulation(26).!En!kuldepakning!kan!
laves!ved!lægge!en!ris&!eller!kirsebærstenspude!i!fryseren,!!pakke!en!sports&ispose,!en!
pose!isterninger!eller!frosne!ærter!ind!i!viskestykke.!Patienten!instrueres!i,!at!fjerne!
ispakning!ved!ubehag/forfrysning.!
Bidskinner,!uanset!udformning,!kan!have!en!positiv!effekt!på!symptomer!i!forbindelse!
med!discus&displacering,!og!der!er!svag!evidens!for,!at!en!plan!stabiliseringsskinne!
(hård!akrylskinne)!kan!lindre!symptomer!ved!natlig!brug(2,33,34).!!Bidskinnen!bør!altid!
dække!hele!okklusaIfladen,!da!partielle!skinner!kan!medføre!elongation!og!åbent!
bid(33,34).!Inden!beslutning!om!fremstilling!af!bidskinne!afventes!!effekt!af!
psykologiske,!farmakologiske!og!andre!fysiurgiske!tiltag.!!I!tilfælde!af!bruksisme!vil!en!
hård!eller!blød!bidskinne!kunne!forebygge!attrition(35).!!
,
Farmakologisk:,
Paracetamol!!bruges!som!første!valg!ved!svage!eller!moderate!smerter!hos!
unge(36,37).Ved!utilstrækkelig!effekt!eller!stærke!smerter!vælges!NSAID!i!lavest!
mulige!dosering!og!i!kortest!mulig!periode(36,37).!Til!børn/unge!over!12!år!doseres!
som!til!voksne,!idet!der!dog!evt.!justeres!for!fysisk!størrelse.!For!begge!præparaters!
vedkommende!gælder,!at!der,!alt!efter!smerteintensitet!og!individuel!vurdering,!kan!
doseres!efter!behov!eller!i!en!fast!dosering,!evt.!i!form!af!depottabletter.!Af!hensyn!til!
mulighed!for!observation!af!bivirkninger,!bør!NSAID!ikke!fra!begyndelsen!doseres!som!
depottabletter.!Patient!og!forældre!oplyses!om!mulige!bivirkninger!og!
maksimaldosis(36).!!
!
!
!
!
!
!
16!!
Håndtering!af!TMD!!Psykologisk) Information,!motivation,!vejledning,!rådgivning.!
Fysiurgisk*) !
Øvelser!hals,!nakke,!skuldre!!!Gentages!4!gange!2!!gange!dagligt!
1.Placer!venstre!hånd!på!højre!side!af!hovedet!og!lav!et!sejt!stræk!mod!venstre.!Hold!hagen!inde.!Stræk!i!ca.!5!sek.!Dernæst!modsatte!side.!2.!Tab!hovedet!forover!og!hold!i!ca.5!sek.!3.Løft!skuldrene!”mod!ørene”.!Hold!i!ca.!5!sek.!Sænk!og!slap!af.!!4.Løft!skuldrene!og!rul!først!skuldrene!den!ene!vej,!og!dernæst!den!anden!vej.!
Øvelser!tyggemuskler!og!kæbeled.!!!Gentages!10!gange!!2!!gange!dagligt.!!!
1.Lav!små!afslappende!jogge&bevægelser!op!og!ned!og!fra!side!til!side!uden!tandkontakt.!Underkæben!er!afslappet.!Slap!af!og!”tab”!underkæben!i!5!sek.!2.!Placer!pege&!og!langefinger!foran!øret!i!højre!og!venstre!side.!Gab!op!uden!der!føles!et!knæk.!Derefter!gentages!øvelsen!med!underkæben!protruderet.!!3. Gab!op.!Placer!tommelfingre!på!overkæbetænder!og!pegefingre!underkæbetænder!i!begge!sider!og!pres!kæberne!fra!hinanden!i!ca.!5!sek.!
Diatermisk!behandling! 1.Varme!15!min.!2!gange!dagligt!eller!mere!efter!behov.!2.Kulde!5!min.!2!gange!dagligt.!!
Massage! Massér!de!ømme!områder!med!fast!tryk!i!cirkulære!bevægelser!i!5!min.!!2!gange!dagligt!eller!efter!behov.!!Tag!evt.!creme!på!huden.!!
Bidskinne! Flad!Stabiliseringsskinne.!Bruges!nat!og!evt.!nogle!timer!eftermiddag/aften.!!!
Farmakologisk) !
Paracetamol!!tabl.!500!mg!Paracetamol!!retard!tabl.!500mg!
Voksne:!0,5&1!g!3&4!gange!dgl.,!højst!4!g!i!døgnet.!!!Børn!op!til!14!år:!1&2!tabletter!morgen!og!aften.!Voksne!>15!år:!2&4!tabletter!morgen!og!aften.!Bemærk:!Skal!synkes!hele!
NSAID!tabl.!200&600mg.!NSAID!retard!tabl.!200&600mg!
Voksne:!200&600!mg,!3!gange!dgl.!!!Voksne:!400&1200!mg!dgl.!morgen!og!aften.!!Bemærk:!Depottabletterne!kan!deles!eller!opslæmmes!i!kold!væske!umiddelbart!før!anvendelsen,!men!ikke!tygges!eller!knuses.!!
*Hæfte!med!illustreret!øvelsesprogram!(bilag4)!!kan!hentes!på!!!http://www.au.dk/fileadmin/tandlaegeskolen/Fysio&oevelser2009.pdf!!
17!!
Henvisningsmuligheder0
0I!tilfælde!med!svær!smerte!og!ingen!respons!på!pykologiske,!fysiologiske!og/eller!
farmakologiske!tiltag,!bør!patienten!henvises!til!nærmere!udredning.!Alt!efter!
omstændighederne!kan!henvises!til!følgende!instanser:!
!
Egen,læge:!Ved!mistanke!om!generel!ledlidelse,!vækstforstyrrelse,!migræne,!
dybereliggende!psykologisk!problematik,!behov!for!henvisning!til!fysioterapi!eller!
generel/specialiceret!udredning.!
!
Kæbekirurgisk,afdeling:!!Ved!mistanke!om!traume!eller!tumor!i!kæbeleddet.!
!
Tandlægeskolernes,landsdelscentre,for,børn,med,juvenil,idiopatisk,arthritis:!Ved!
mistanke!om!juvenil!idiopatisk!arthritis.!
!
Tandlægeskolernes,børneafdelinger,eller,kollegaer,i,primærsektoren,med,speciel,viden,
om,TMD:!!Ved!behov!for!nærmere!udredning!og!evt.!behandling!af!tilstanden!uden!
specifik!mistanke!om!juvenil!idiopatisk!arthritis.!
!
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!
!
18!!
Referencer!!
1.Okeson!JP.!Management!of!Temporomandibular!Disorders!and!Okklusion.!Mosby.!Elsevir!Inc.!7th!Ed.!2013.!!2.Svensson!P.!Nordisk!Odontologisk!Årbog!Odontologi.!Bidfunktionsbehandling!i!et!nyt!lys.!Munksgaard!Danmark.!2003.!3.Wahlund!K.!Temporomandibular!disorders!in!adolescents.!Epidemiological!and!methodological!studies!and!a!randomized!controlled!trial.!Swed.!Dent.!J!Suppl.!2003;(164).!2&64.!4.List!T,!Wahlund!K,!Wenneberg!B,!Dworkin!SF.!TMD!in!children!and!adolescents:!prevalence!of!pain,!gender!differences,!and!perceived!treatment!need.!J!Orofac.!Pain.!1999;13(1):9&20.!5.Tecco!S,!Crincoli!V,!Di!Bisceglie!B,!Saccucci!M,!Macrĺ!M,!Polimeni!A,!Festa!F.!Signs!and!symptoms!of!temporomandibular!joint!disorders!in!Caucasian!children!and!adolescents.!Cranio.!2011;29(1):71&9.!6.Nilsson!IM,!List!T,!Drangsholt!M.!Incidence!and!temporal!patterns!of!temporomandibular!disorder!pain!among!Swedish!adolescents.!J!Orofac.!Pain.!2007;!21(2):127&32.!7.Guarda&Nardini!L,!Piccotti!F,!Mogno!G,!Favero!L,!Manfredini!D.!Age&related!differences!in!temporomandibular!disorder!diagnoses.!Cranio.!2012;30(2):103&9.!8.Tallents!Ross!H,!Stein!S,!Macher!D!J,!Katzberg!W,!Murphy!W.!Predisposing!and!Precipitating!Factors!in!Temporomandibular!Disorders.!Seminars!in!Orthodontics,!Vol!18.!2012;10&29.!9.Schmid&Schwap!M,!Bristela!M,!Kundi!M,!Piehslinger!E.!Sex&specific!differences!in!patients!with!temporomandibular!disorders.!J!Orofac.!Pain.!2013;27(1):42&50.!doi:!10.11607/jop.970.!10.Hirsch!C,!Hoffmann!J,!Türp!JC.!Are!temporomandibular!disorder!symptoms!and!diagnoses!associated!with!pubertal!development!in!adolescents?!An!epidemiological!study.!J!Orofac.!Orthop.!2012;73(1):6&8,!10&8.!doi:!10.1007/s00056&011&0056&x.!Epub!2012!Jan!12.!11.Karibe!H,!Goddard!G,!Aoyagi!K,!Kawakami!T,!Warita!S,!Shimazu!K,!Rudd!PA,!McNeill!C.Comparison!of!subjective!symptoms!of!temporomandibular!disorders!in!young!patients!by!age!and!gender.!Cranio.!2012;30(2):114&20.!12.Sharma!S,!Gupta!DS,!Pal!US,!Jurel!SK.!Etiological!factors!of!temporomandibular!joint!disorders.!Natl!J!Maxillofac.!Surg.!2011;2(2):116&9.!doi:!10.4103/0975&5950.94463.!13.Warren!MP,!Fried!JL.!Temporomandibular!disorders!and!hormones!in!women.!Cells!Tissues!Organs.!2001;169(3):187&92.!14.Nekora&Azak!A.!Temporomandibular!disorders!in!relation!to!female!reproductive!hormones:!a!literature!review.!J!Prosthet.!Dent.!2004;91(5):491&3.!
19!!
15.Manfredini!D,!Landi!N,!Bandettini!Di!Poggio!A,!Dell'Osso!L,!Bosco!M.!A!critical!review!on!the!importance!of!psychological!factors!in!temporomandibular!disorders.!Minerva!Stomatol.!2003;52(6):321&6,!327&30!16.Slade!GD,!Diatchenko!L,!Bhalang!K,!Sigurdsson!A,!Fillingim!RB,!Belfer!I,!Max!MB,!Goldman!D,!Maixner!W.!Influence!of!psychological!factors!on!risk!of!temporomandibular!disorders.!J!Dent.!Res.!2007;86(11):1120&5.!17.Pereira!LJ,!Pereira&Cenci!T,!Pereira!SM,!Cury!AA,!Ambrosano!GM,!Pereira!AC,!Gavião!MB.!!Psychological!factors!and!the!incidence!of!temporomandibular!disorders!in!early!adolescence.!Braz!Oral!Res.!2009;23(2):155&60.!18.Kasch!H,!Hjorth!T,!Svensson!P,!Nyhuus!L,!Jensen!TS.!Temporomandibular!disorder!after!whiplash!injuri:!a!controlled,!prospective!study.!J!Orofac.!Pain.!2002;16(2):118&28.!19.Brooke!RI,!Merskey!H.!Re:!Kasch!et!al.!Temporomandibular!disorders!after!whiplash!injury:!a!controlled!prospective!study!2002;16:118&128.!J!Orofac.!Pain.!2002;!16(4):255;!author!reply!255.!20.Barbosa!Tde!S,!Miyakoda!LS,!Pocztaruk!Rde!L,!Rocha!CP,!Gavião!MB.!Temporomandibular!disorders!and!bruxism!in!childhood!and!adolescence:!review!of!the!litterature.!Int!J!Pediatr.!Otorhinolaryngol.!2008;72(3):299&314.!doi:!10.1016/j.ijporl.2007.11.006.!Epub!2008!Jan!3.!21.Gavish!A,!Halachmi!M,!Winocur!E,!Gazit!E.!!Oral!habits!and!their!association!with!signs!and!symptoms!of!temporomandibular!disorders!in!adolescent!girls.!J!Oral!Rehabil.!2000;27(1):22&32.!22.!Sanders!AE,!Maixner!W,!Nackley!AG,!Diatchenko!L,!By!K,!Miller!VE,!Slade!GD.!Excess!risk!of!temporomandibular!disorder!associated!with!cigarette!smoking!in!young!adults.!J!Pain.!2012;13(1):21&31.!doi:!10.1016/j.jpain.2011.08.003.!Epub!2011!Oct!26.!23.Gebeile&Chauty!S,!Robin!O,!Messaoudi!Y,!Aknin!JJ.!Can!orthodontic!treatment!generate!temporomandibular!disorders!and!pain?!A!review.!!2010;81(1):85&93.!doi:!10.1051/orthodfr/2010009.!Epub!2010!Apr!1.!24.Michelotti!A,!Iodice!G.!The!role!of!orthodontics!in!temporomandibular!disorders.!J!Oral!Rehabil.!2010;37(6):411&29.!doi:!10.1111/j.1365&2842.2010.02087.x.!Epub!2010!Apr!9.!25.www.rdc&tmdinternational.org!26.Okeson!J!P.!Bells!Orofacial!Pains.!The!Clinical!Management!of!Orofacial!Pain.!Quintessence!Publishing!Co.!Inc.!!6th.!Ed.!2005.!!27.www.sundhed.dk/sundhedsfaglig/laegehaandbogen/paediatri!28.Wahlund!K,!List!T,!Larsson!B.!Treatment!of!temporomandibular!disorders!among!adolescents:!a!comparison!between!occlusal!appliance,!relaxation!training,!and!brief!information.!Acta!Odontol.!Scand.!2003;61(4):203&11.!29.Bakke!M.!Temporomandibulær!dysfunktion(TMD)&smerter!fra!kæbeled!og!tyggemuskler.!Tandlægebladet!2010!nr.4.!
20!!
30.Carlson!CR,!Bertrand!PM,!Ehrlich!AD,!Maxwell!AW,!Burton!RG.!Physical!self®ulation!training!for!the!management!of!temporomandibular!disorders.!J!Orofac.!Pain.!2001;15(1):47&55.!31.Luther!F,!Layton!S,!McDonald!F.!Orthodontics!for!treating!temporomandibular!joint!(TMJ)!disorders.!Cochrane!Database!Syst!Rev.!2010.!(7):CD006541.!doi:!10.1002/14651858.CD006541.pub2.!32.Vishal!R!Aggarwal,!Karina!Lovell,!Sarah!Peters,!Hanieh!Javidi,!Amy!Joughin,!Joanna!Goldthorpe.!Psychosocial!interventions!for!the!management!of!chronic!orofacial!pain.!Cochrane!Database!Syst!Rev.!2011.!DOI:!10.1002/14651858.CD008456.pub2!33.M!Ziad!Al&Ani,!Stephen!J!Davies,!Robin!JM!Gray,!Philip!Sloan,!Anne&Marie!Glenny.!Stabilisation!splint!therapy!for!temporomandibular!pain!dysfunction!syndrome.!Cochrane!Database!Syst!Rev.!2009.!21.!DOI:!10.1002/14651858.CD002778.pub2!34.Pettengill!CA,!Growney!MR!Jr,!Schoff!R,!Kenworthy!CR.!!A!pilot!study!comparing!the!efficacy!of!hard!and!soft!stabilizing!appliances!in!treating!patients!with!temporomandibular!disorders.!J!Prosthet.!Dent.!1998;79(2):165&8.!35.Faramarz!J.!Dreyer&Nielsen!P.!Dagsdottir!L.!Abrahamsen!R.!Castrillon!E.!Baad&Hansen!l.!Svensson!P.!Nordisk!Odontologisk!Årbog!Odondologi!2013.!Bruksisme!hos!voksne!og!børn&en!oversigt.!Munksgaard!Danmark.!36.www.promedicin.dk!37.Helen!R!Mujakperuo,!Margaret!Watson,!Roderick!Morrison,!Tatiana!V!Macfarlane.!Pharmacological!interventions!for!pain!in!patients!with!temporomandibular!disorders.!Cochrane!Database!Syst!Rev.!2010.!DOI:!10.1002/14651858.CD004715.pub2!!!!!!!
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DC/TMD�Examination�Form
Patient�_____________________�Examiner�____________________
Date filled out (mm-dd-yyyy)
1a. Location�of�Pain:�Last�30�days�(Select�all�that�apply)
_ _
RIGHT�PAIN LEFT�PAIN2 None 2 Temporalis 2 Other�m�muscles 2 NonͲmast�
2Masseter 2 TMJ structures2 None 2 Temporalis 2 Other�m�muscles 2 NonͲmast
2Masseter 2 TMJ structures
2. Incisal Relationships Reference�tooth 2 FDI�#112 FDI�#212 Other
3. Opening�Pattern�(Supplemental;�Select�all�that�apply) Uncorrected�Deviation2 Straight 2 Corrected�deviation 2 Right��������������2 Left�
4. Opening�Movements
5. Lateral�and�Protrusive�Movements
mm
mm
mm
A.�Pain�Free�Opening
B.�Maximum�Unassisted�Opening
C.�Maximum�Assisted�Opening
D.�Terminated?
RIGHT�SIDE LEFT�SIDE
Pain FamiliarPain
Familiar�Headache Pain Familiar
PainFamiliar�Headache
Temporalis ࿓ ࿓ ࿓ Temporalis ࿓ ࿓ ࿓Masseter ࿓ ࿓ Masseter ࿓ ࿓TMJ ࿓ ࿓ TMJ ࿓ ࿓Other�M�Musc ࿓ ࿓ Other�M�Musc ࿓ ࿓NonͲmast ࿓ ࿓ NonͲmast ࿓ ࿓
Temporalis ࿓ ࿓ ࿓ Temporalis ࿓ ࿓ ࿓Masseter ࿓ ࿓ Masseter ࿓ ࿓TMJ ࿓ ࿓ TMJ ࿓ ࿓Other�M�Musc ࿓ ࿓ Other�M�Musc ࿓ ࿓NonͲmast ࿓ ࿓ NonͲmast ࿓ ࿓࿓
mm
mm
mm
B.�Left�Lateral
C.�Protrusion
A.�Right�Lateral
Vertical��Incisal Overlap 2 If�negative mm
Midline�Deviation
Right
2Left
2N/A
2 mmHorizontal�Incisal Overjet 2 If�negative mm
RIGHT�SIDE LEFT�SIDE
Pain FamiliarPain
Familiar�Headache Pain Familiar
PainFamiliar�Headache
Temporalis ࿓ ࿓ ࿓ Temporalis ࿓ ࿓ ࿓Masseter ࿓ ࿓ Masseter ࿓ ࿓TMJ ࿓ ࿓ TMJ ࿓ ࿓Other�M�Musc ࿓ ࿓ Other�M�Musc ࿓ ࿓NonͲmast ࿓ ࿓ NonͲmast ࿓ ࿓
Temporalis ࿓ ࿓ ࿓ Temporalis ࿓ ࿓ ࿓Masseter ࿓ ࿓ Masseter ࿓ ࿓TMJ ࿓ ࿓ TMJ ࿓ ࿓Other�M�Musc ࿓ ࿓ Other�M�Musc ࿓ ࿓NonͲmast ࿓ ࿓ NonͲmast ࿓ ࿓
Temporalis ࿓ ࿓ ࿓ Temporalis ࿓ ࿓ ࿓Masseter ࿓ ࿓ Masseter ࿓ ࿓TMJ ࿓ ࿓ TMJ ࿓ ࿓Other�M�Musc ࿓ ࿓ Other�M�Musc ࿓ ࿓NonͲmast ࿓ ࿓ NonͲmast ࿓ ࿓
1b. Location�of�Headache:�Last�30�days�(Select�all�that�apply)
2 None 2 Temporal� 2 Other 2 None 2 Temporal 2 Other
2 If�negative
6. TMJ��Noises�During�Open�&�Close�Movements
7. TMJ��Noises�During�Lateral�&�Protrusive�Movements
9. Muscle�&�TMJ�Pain�with�Palpation
TMJ
RIGHT�SIDE LEFT�SIDE
PainFamiliar�Pain
Familiar�Headache
ReferredPain Pain
Familiar�Pain
Familiar�Headache
ReferredPain
Temporalis ࿓ ࿓ ࿓ ࿓ Temporalis ࿓ ࿓ ࿓ ࿓Masseter ࿓ ࿓ ࿓ Masseter ࿓ ࿓ ࿓
PainFamiliar�Pain
ReferredPain Pain
Familiar�Pain
ReferredPain
Lateral�pole�(0.5�kg) ࿓ ࿓ ࿓ Lateral�pole�(0.5�kg) ࿓ ࿓ ࿓Around�lateral�pole�(1�kg) ࿓ ࿓ ࿓ Around�lateral�pole�(1�kg) ࿓ ࿓ ࿓
PainFamiliar�Pain
ReferredPain Pain
FamiliarPain
ReferredPain
Posterior�mandibular�region ࿓ ࿓ ࿓ Posterior�mandibular�region ࿓ ࿓ ࿓Submandibular�region ࿓ ࿓ ࿓ Submandibular�region ࿓ ࿓ ࿓Lateral�pterygoid�area ࿓ ࿓ ࿓ Lateral�pterygoid area ࿓ ࿓ ࿓
(1�kg)
(0.5�kg)
(1�kg)
(0.5�kg)
8. Joint�Locking
11. Comments
RIGHT�TMJ LEFT�TMJ
Examiner Patient Examiner PatientClick ࿓ ࿓ Click ࿓ ࿓Crepitus ࿓ ࿓ Crepitus ࿓ ࿓
Pain�w/Click
FamiliarPain
࿓ ࿓
Pain�w/Click
FamiliarPain
࿓ ࿓
RIGHT�TMJ LEFT�TMJExaminer Patient Pain�w/
ClickFamiliarPain
Examiner PatientOpen Close Open CloseClick ࿓ ࿓ ࿓ ࿓ ࿓ Click ࿓ ࿓ ࿓Crepitus ࿓ ࿓ ࿓ Crepitus ࿓ ࿓ ࿓
Pain�w/Click
FamiliarPain
࿓ ࿓
Temporalis�tendon ࿓ ࿓ ࿓ Temporalis�tendon ࿓ ࿓ ࿓
LockingReduction
Patient ExaminerWhile�Opening ࿓ ࿓ ࿓Wide�Open�Position ࿓ ࿓ ࿓
LockingReduction
Patient ExaminerWhile�Opening ࿓ ࿓ ࿓Wide�Open�Position ࿓ ࿓ ࿓
RIGHT�TMJ LEFT�TMJ
10. Supplemental�Muscle�Pain�with�Palpation
RIGHT�SIDE LEFT�SIDE
PAIN DRAWING
Right face
Left face
Indicate the location of ALL of your different pains by shading in the area, using the diagrams that are most relevant. If there is an exact spot where the pain is located, indicate with a solid dot (Ɣ). If your pain moves from one location to another, use arrows to show the path.
L R L R
Mouth and teeth
Graded Chronic Pain Scale Version 2.0 1. On how many days in the last 6 months have you had facial pain? _______ Days
2. How would you rate your facial pain RIGHT NOW? Use a scale from 0 to 10, where 0 is "no pain" and 10
is "pain as bad as could be".
No pain Pain as bad
as could be
0 1 2 3 4 5 6 7 8 9 10
3. In the LAST 30 DAYS, how would you rate your WORST facial pain? Use the same scale, where 0 is "no pain" and 10 is "pain as bad as could be".
No pain
Pain as bad as could be
0 1 2 3 4 5 6 7 8 9 10
4. In the LAST 30 DAYS, ON AVERAGE, how would you rate your facial pain? Use the same scale, where 0 is "no pain" and 10 is "pain as bad as could be". [That is, your usual pain at times you were in pain.]
No pain
Pain as bad as could be
0 1 2 3 4 5 6 7 8 9 10
5.
In the LAST 30 DAYS, how many days did your facial pain keep you from doing your USUAL ACTIVITIES like work, school, or housework?
ർ ർ ർ ർ ർ ർ ർ ർ ർ ർ ർ
Days None 1 2 3 4 5 6 7 8-20 21-25 26-30
(Score) (0) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
6. In the LAST 30 DAYS, how much has facial pain interfered with your DAILY ACTIVITIES? Use a 0-10
scale, where 0 is “no interference: and 10 is “unable to carry on any activities”.
No interference Unable to carry
on any activities
0 1 2 3 4 5 6 7 8 9 10
7. In the LAST 30 DAYS, how much has facial pain interfered with your RECREATIONAL, SOCIAL AND
FAMILY ACTIVITIES? Use the same scale, where 0 is “no interference: and 10 is “unable to carry on any activities”.
No interference
Unable to carry on any activities
0 1 2 3 4 5 6 7 8 9 10
8. In the LAST 30 DAYS, how much has facial pain interfered with your ABILITY TO WORK, including
housework? Use the same scale, where 0 is “no interference: and 10 is “unable to carry on any activities”.
No interference
Unable to carry on any activities
0 1 2 3 4 5 6 7 8 9 10
Jaw Functional Limitation Scale For each of the items below, please indicate the level of limitation during the last month. If the activity has been completely avoided because it is too difficult, then circle ‘10'. If you avoid an activity for reasons other than pain or difficulty, leave the item blank.
No limitation
Severe limitation
1. Chew tough food 0 1 2 3 4 5 6 7 8 9 10
2. Chew hard bread 0 1 2 3 4 5 6 7 8 9 10
3. Chew chicken (e.g., prepared in oven) 0 1 2 3 4 5 6 7 8 9 10
4. Chew crackers 0 1 2 3 4 5 6 7 8 9 10
5. Chew soft food (e.g., macaroni, canned or soft fruits, cooked vegetables, fish)
0 1 2 3 4 5 6 7 8 9 10
6. Eat soft food requiring no chewing (e.g., mashed potatoes, apple sauce, pudding, pureed food)
0 1 2 3 4 5 6 7 8 9 10
7. Open wide enough to bite from a whole apple
0 1 2 3 4 5 6 7 8 9 10
8. Open wide enough to bite into a sandwich
0 1 2 3 4 5 6 7 8 9 10
9. Open wide enough to talk 0 1 2 3 4 5 6 7 8 9 10
10. Open wide enough to drink from a cup 0 1 2 3 4 5 6 7 8 9 10
11. Swallow 0 1 2 3 4 5 6 7 8 9 10
12. Yawn 0 1 2 3 4 5 6 7 8 9 10
13. Talk 0 1 2 3 4 5 6 7 8 9 10
14. Sing 0 1 2 3 4 5 6 7 8 9 10
15. Putting on a happy face 0 1 2 3 4 5 6 7 8 9 10
16. Putting on an angry face 0 1 2 3 4 5 6 7 8 9 10
17. Frown 0 1 2 3 4 5 6 7 8 9 10
18. Kiss 0 1 2 3 4 5 6 7 8 9 10
19. Smile 0 1 2 3 4 5 6 7 8 9 10
20. Laugh 0 1 2 3 4 5 6 7 8 9 10
Patient Health Questionnaire-15: Physical Symptoms During the last 4 weeks, how much have you have been bothered by any of the following problems? Please place a check mark in the box to indicate your answer. Not
bothered Bothered
a little Bothered
a lot
0 1 2
1. Stomach pain ܆ ܆ ܆
2. Back pain ܆ ܆ ܆
3. Pain in your arms, legs, or joints (knees, hips, etc) ܆ ܆ ܆
4. Menstrual cramps or other problems with your periods [women only] ܆ ܆ ܆
5. Headaches ܆ ܆ ܆
6. Chest pain ܆ ܆ ܆
7.
Dizziness ܆ ܆ ܆
8. Fainting spells ܆ ܆ ܆
9. Feeling your heart pound or race ܆ ܆ ܆
10. Shortness of breath ܆ ܆ ܆
11. Pain or problems during sexual intercourse ܆ ܆ ܆
12. Constipation, loose bowels, or diarrhea ܆ ܆ ܆
13. Nausea, gas, or indigestion ܆ ܆ ܆
14. Feeling tired or having low energy ܆ ܆ ܆
15. Trouble sleeping ܆ ܆ ܆
TOTAL SCORE =
Copyright Pfizer Inc. No permission required to reproduce, translate, display, or distribute.
Patient Health Questionnaire - 9 Patient name _____________________________ Date ___________________ Over the last 2 weeks, how often have you been bothered by the following problems? Please place a check mark in the box to indicate your answer.
Not at all Several days
More than half the
days
Nearly every day
0 1 2 3
1. Little interest or pleasure in doing things ܆ ܆ ܆ ܆
2. Feeling down, depressed, or hopeless ܆ ܆ ܆ ܆
3. Trouble falling or staying asleep, or sleeping too much ܆ ܆ ܆ ܆
4. Feeling tired or having little energy ܆ ܆ ܆ ܆
5. Poor appetite or overeating ܆ ܆ ܆ ܆
6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down
܆ ܆ ܆ ܆
7.
Trouble concentrating on things, such as reading the newspaper or watching television
܆ ܆ ܆ ܆
8. Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual
܆ ܆ ܆ ܆
9. Thinking that you would be better off dead or of hurting yourself in some way ܆ ܆ ܆ ܆
TOTAL SCORE =
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
܆
Somewhat difficult
܆
Very difficult
܆
Extremely difficult
܆
Copyright Pfizer Inc. No permission required to reproduce, translate, display, or distribute.
GAD - 7
Patient name __________________________________ Date ___________________ Over the last 2 weeks, how often have you been bothered by the following problems? Place a check mark in the box to indicate your answer.
Not at all Several
days
More than half the
days
Nearly every day
0 1 2 3
1. Feeling nervous, anxious or on edge ܆ ܆ ܆ ܆
2. Not being able to stop or control worrying ܆ ܆ ܆ ܆
3. Worrying too much about different things ܆ ܆ ܆ ܆
4. Trouble relaxing ܆ ܆ ܆ ܆
5. Being so restless that it is hard to sit still ܆ ܆ ܆ ܆
6. Becoming easily annoyed or irritable ܆ ܆ ܆ ܆
7. Feeling afraid as if something awful might happen ܆ ܆ ܆ ܆
TOTAL SCORE =
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
܆
Somewhat difficult
܆
Very difficult
܆
Extremely difficult
܆
Copyright Pfizer Inc. No permission required to reproduce, translate, display, or distribute.
The Oral Behavior Checklist How often do you do each of the following activities, based on the last month? If the frequency of the activity
varies, choose the higher option. Please place a (¥) response for each item and do not skip any items.
Activities During Sleep None of the time
< 1 Night /Month
1-3 Nights /Month
1-3 Nights /Week
4-7 Nights/ Week
1 Clench or grind teeth when asleep, based on any information you may have. ܆ ܆ ܆ ܆ ܆
2 Sleep in a position that puts pressure on the jaw (for example, on stomach, on the side). ܆ ܆ ܆ ܆ ܆
Activities During Waking Hours None of the time
A little of the time
Some of the time
Most of the time
All of the time
3 Grind teeth together during waking hours. ܆ ܆ ܆ ܆ ܆ 4 Clench teeth together during waking hours. ܆ ܆ ܆ ܆ ܆
5 Press, touch, or hold teeth together other than while eating (that is, contact between upper and lower teeth). ܆ ܆ ܆ ܆ ܆
6 Hold, tighten, or tense muscles without clenching or bringing teeth together. ܆ ܆ ܆ ܆ ܆
7 Hold or jut jaw forward or to the side. ܆ ܆ ܆ ܆ ܆ 8 Press tongue forcibly against teeth. ܆ ܆ ܆ ܆ ܆ 9 Place tongue between teeth. ܆ ܆ ܆ ܆ ܆ 10 Bite, chew, or play with your tongue, cheeks or lips. ܆ ܆ ܆ ܆ ܆
11 Hold jaw in rigid or tense position, such as to brace or protect the jaw. ܆ ܆ ܆ ܆ ܆
12 Hold between the teeth or bite objects such as hair, pipe, pencil, pens, fingers, fingernails, etc ܆ ܆ ܆ ܆ ܆
13 Use chewing gum. ܆ ܆ ܆ ܆ ܆
14 Play musical instrument that involves use of mouth or jaw (for example, woodwind, brass, string instruments). ܆ ܆ ܆ ܆ ܆
15 Lean with your hand on the jaw, such as cupping or resting the chin in the hand. ܆ ܆ ܆ ܆ ܆
16 Chew food on one side only. ܆ ܆ ܆ ܆ ܆ 17 Eating between meals (that is, food that requires chewing). ܆ ܆ ܆ ܆ ܆
18 Sustained talking (for example, teaching, sales, customer service). ܆ ܆ ܆ ܆ ܆
19 Singing. ܆ ܆ ܆ ܆ ܆ 20 Yawning. ܆ ܆ ܆ ܆ ܆ 21 Hold telephone between your head and shoulders. ܆ ܆ ܆ ܆ ܆
Diagnostic Criteria for Temporomandibular Disorders (DC/TMD): Diagnostic Decision Tree
Pain-Related TMD and Headache
Regional pain [PHQ3] AND
Pain modified by jaw movement, function, or parafunction [PHQ4]
Referred pain from palpation [muscle, E9]
Examiner confirmation of masticatory muscles or joints location for pain [E1a]
Myalgia Myofascial pain
with referral Headache attributed to TMD
Headache of any type in temporal region [PHQ5] AND
Headache modified by jaw movement, function, or parafunction [PHQ7]
Familiar headache from jaw opening OR excursive movement, OR temporalis muscle palpation [temporalis, from E4, E5, OR E9]
Yes
Yes [Mast muscles]
Yes
HIS
TOR
Y
Sta
rt at
eith
er b
lue
box
EXA
MIN
ATIO
N
DIA
GN
OS
IS
Familiar pain from: jaw opening [joint, E4] OR
jaw horizontal movement [joint, E5 ] OR TMJ palpation [joint, E9];
Confirm location [E1a]
Arthralgia
Yes Yes
Yes
Yes
Investigate other pain diagnoses
No
No
No
No
No
No
No No Headache not better accounted for by another headache diagnosis
[Symptom review]
Familiar pain from: jaw opening [muscle, E4] OR
masticatory muscle palpation [muscle, E9]; Confirm location [E1a]
Yes Investigate other pain diagnoses
Diagnosis of Myalgia, Myofascial pain with referral, or Arthralgia
Yes
Examiner confirmation of headache in
temporalis area [E1b] Yes
No
Yes [TMJ]
Diagnostic Criteria for Temporomandibular Disorders (DC/TMD): Diagnostic Decision Tree
Intra-articular Joint Disorders C
LIN
ICA
L D
IAG
NO
SIS
Investigate other
diagnoses
No
Degenerative joint disease
Crepitus detected by examiner OR
Crepitus detected by patient during jaw movement
[E6 OR E7]
Yes
No
Yes
No Current TMJ noises [PHQ8]
Current intermittent locking with limited opening
[PHQ11=yes; PHQ12=no]
No
Yes
Disc displacement with reduction
Disc displacement with reduction,
with intermittent locking
Prior jaw locking in closed position [PHQ9]
AND Interference in
mastication [PHQ10]
0$2�����PP�(including overbite)
[E4C]
Disc displacement without reduction,
with limited opening
Disc displacement without reduction
Yes
No
Yes
If present in clinic: Maneuver required to
open mouth [E8]
Opening & closing click [E6] OR
[ Opening or closing click [E6] AND
Excursive or protrusive click [E7] ]
No Yes
Yes
IMA
GIN
G
Confirm by MRI when indicated
Confirm by CT when indicated
Investigate other
diagnoses
HIS
TOR
Y &
EXA
MIN
ATIO
N
Sta
rt at
eith
er b
lue
box
PAIN DRAWING
Right face
Left face
Indicate the location of ALL of your different pains by shading in the area, using the diagrams that are most relevant. If there is an exact spot where the pain is located, indicate with a solid dot (Ɣ). If your pain moves from one location to another, use arrows to show the path.
L R L R
Mouth and teeth
Graded Chronic Pain Scale Version 2.0 1. On how many days in the last 6 months have you had facial pain? _______ Days
2. How would you rate your facial pain RIGHT NOW? Use a scale from 0 to 10, where 0 is "no pain" and 10
is "pain as bad as could be".
No pain Pain as bad
as could be
0 1 2 3 4 5 6 7 8 9 10
3. In the LAST 30 DAYS, how would you rate your WORST facial pain? Use the same scale, where 0 is "no pain" and 10 is "pain as bad as could be".
No pain
Pain as bad as could be
0 1 2 3 4 5 6 7 8 9 10
4. In the LAST 30 DAYS, ON AVERAGE, how would you rate your facial pain? Use the same scale, where 0 is "no pain" and 10 is "pain as bad as could be". [That is, your usual pain at times you were in pain.]
No pain
Pain as bad as could be
0 1 2 3 4 5 6 7 8 9 10
5.
In the LAST 30 DAYS, how many days did your facial pain keep you from doing your USUAL ACTIVITIES like work, school, or housework?
ർ ർ ർ ർ ർ ർ ർ ർ ർ ർ ർ
Days None 1 2 3 4 5 6 7 8-20 21-25 26-30
(Score) (0) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
6. In the LAST 30 DAYS, how much has facial pain interfered with your DAILY ACTIVITIES? Use a 0-10
scale, where 0 is “no interference: and 10 is “unable to carry on any activities”.
No interference Unable to carry
on any activities
0 1 2 3 4 5 6 7 8 9 10
7. In the LAST 30 DAYS, how much has facial pain interfered with your RECREATIONAL, SOCIAL AND
FAMILY ACTIVITIES? Use the same scale, where 0 is “no interference: and 10 is “unable to carry on any activities”.
No interference
Unable to carry on any activities
0 1 2 3 4 5 6 7 8 9 10
8. In the LAST 30 DAYS, how much has facial pain interfered with your ABILITY TO WORK, including
housework? Use the same scale, where 0 is “no interference: and 10 is “unable to carry on any activities”.
No interference
Unable to carry on any activities
0 1 2 3 4 5 6 7 8 9 10
Jaw Functional Limitation Scale For each of the items below, please indicate the level of limitation during the last month. If the activity has been completely avoided because it is too difficult, then circle ‘10'. If you avoid an activity for reasons other than pain or difficulty, leave the item blank.
No limitation
Severe Limitation
1. Chew tough food 0 1 2 3 4 5 6 7 8 9 10
2. Chew chicken (e.g., prepared in oven) 0 1 2 3 4 5 6 7 8 9 10
3. Eat soft food requiring no chewing (e.g., mashed potatoes, apple sauce, pudding, pureed food)
0 1 2 3 4 5 6 7 8 9 10
4. Open wide enough to drink from a cup 0 1 2 3 4 5 6 7 8 9 10
5. Swallow 0 1 2 3 4 5 6 7 8 9 10
6. Yawn 0 1 2 3 4 5 6 7 8 9 10
7. Talk 0 1 2 3 4 5 6 7 8 9 10
8. Smile 0 1 2 3 4 5 6 7 8 9 10
Patient Health Questionnaire - 4
Patient name ___________________________Date ___________________ Over the last 2 weeks, how often have you been bothered by the following problems? Please place a check mark in the box to indicate your answer.
Not at all Several days
More than half the
days
Nearly every day
0 1 2 3
1. Feeling nervous, anxious or on edge ܆ ܆ ܆ ܆
2. Not being able to stop or control worrying ܆ ܆ ܆ ܆
3. Little interest or pleasure in doing things ܆ ܆ ܆ ܆
4. Feeling down, depressed, or hopeless ܆ ܆ ܆ ܆
TOTAL SCORE =
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
܆
Somewhat difficult
܆
Very difficult
܆
Extremely difficult
܆
Copyright Pfizer Inc. No permission required to reproduce, translate, display, or distribute.
Diagnostic Criteria for Temporomandibular Disorders Patient History Questionnaire
PAIN
1. Have you ever had pain in your jaw, temple, in the ear, or in front of the ear on either side?
No 侊
Yes侊
If you answered NO, then skip to Question 5.
2. How many years or months ago did your pain in the jaw, temple, in the ear, or in front of the ear first begin?
_______years ______months
3.
In the last 30 days, which of the following best describes any pain in your jaw, temple, in the ear, or in front of the ear on either side? Select ONE response.
侊 No pain
侊 Pain comes and goes
侊 Pain is always present
If you answered NO to Question 3, then skip to Question 5.
4.
In the last 30 days, did the following activities change any pain (that is, make it better or make it worse) in your jaw, temple, in the ear, or in front of the ear on either side?
No Yes
A. Chewing hard or tough food 侊 侊 B. Opening your mouth, or moving your jaw forward or to the side 侊 侊 C. Jaw habits such as holding teeth together, clenching/grinding teeth, or chewing
gum 侊 侊
D. Other jaw activities such as talking, kissing, or yawning 侊 侊 HEADACHE
5. In the last 30 days, have you had any headaches that included the temple areas of your head? If you answered NO to Question 5, then skip to Question 8.
No 侊
Yes 侊
6. How many years or months ago did your temple headache first begin? _______years
______months
7. In the last 30 days, did the following activities change any headache (that is, make it better or make it worse) in your temple area on either side?
No Yes A. Chewing hard or tough food 侊 侊 B. Opening your mouth, or moving your jaw forward or to the side 侊 侊 C. Jaw habits such as holding teeth together, clenching/grinding, or chewing gum 侊 侊 D. Other jaw activities such as talking, kissing, or yawning 侊 侊
JAW JOINT NOISES Office use
8. In the last 30 days, have you had any jaw joint noise(s) when you moved or used your jaw?
No 侊
Yes 侊
R L ܆ ܆
CLOSED LOCKING OF THE JAW
9. Have you ever had your jaw lock or catch, even for a moment, so that it would not open ALL THE WAY?
侊 侊 ܆�� ܆
If you answered NO to Question 9 then skip to Question 13.
10. Was your jaw lock or catch severe enough to limit your jaw opening and interfere with your ability to eat?
侊 侊 ܆ ܆
11. In the last 30 days, did your jaw lock so you could not open ALL THE WAY, even for a moment, and then unlock so you could open ALL THE WAY? If you answered NO to Question 11 then skip to Question 13.
侊 侊 ܆ ܆
12. Is your jaw currently locked or limited so that your jaw will not open ALL THE WAY? 侊 侊 ܆ ܆
OPEN LOCKING OF THE JAW
13. In the last 30 days, when you opened your mouth wide, did your jaw lock or catch even for a moment such that you could not close it from this wide open position?
侊 侊 ܆ ܆
If you answered NO to Question 13 then you are finished.
14. In the last 30 days, when you jaw locked or caught wide open, did you have to do something to get it to close including resting, moving, pushing, or maneuvering it?
侊 侊 ܆ ܆
Visual'Analog'Scale''(subjektiv'smertevurdring)'
VAS'(100mm)'
'
Dato:'
Navn:'
Cpr.nr.:'
'
Smerter/hovedpine'
''''''''''''''''''''''[DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD]''''''''''''''''''
''''''''Jeg'har'slet''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''Jeg'kan'slet'ikke'forestille'mig'''''''''''''''''''ingen'smerter'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''at'have'flere'smerter''''''''Almentilstand'''''''''''''''''''''''''[DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD]'''''''''''Jeg'kan'ikke''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''Jeg'kan'ikke'forestille'mig'''''''''''''''''have'det'bedre''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''at'have'det'værre'''''''Humør'''''''''''''''''''''''''''''''''''''''''''''''''''[DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD]'''''''''''''Jeg'kan'ikke'forstille'mig'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''jeg'kan'ikke'forestille'mig'''''''''''''At'være'i'bedre'humør''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''at'være'i'dårligere'humør'
Afd
. Klin
isk
Ora
l Fys
iolo
giFy
siot
erap
i
Øve
lser
spec
ielt
for
tygg
emus
kler
og
kæbe
led
1. J
oggi
ng m
ed u
nder
kæbe
n
Med
afs
lapp
et u
nder
kæbe
lave
s sm
åbe
væge
lser
op
og n
ed o
g fr
a si
de ti
l si
de u
den
tand
kont
akt.
Udf
ør k
un d
e øv
else
r, de
r er a
fkry
dset
og
genn
emgå
et i
forb
inde
lse
med
beh
andl
inge
n. Ø
vels
erne
gen
tage
s 10
gang
e 2g
ange
dag
ligt.
2. A
fspæ
ndin
g af
und
erkæ
ben
Slap
af o
g la
d un
derk
æbe
n hæ
nge.
Sæ
t tu
ngen
bag
fortæ
nder
ne i
unde
rkæ
ben.
Si
g en
”A
h”-ly
d og
træ
k ve
jret d
ybt n
ed
i mav
en.
3. M
odst
ands
øvel
se
Gab
men
s du
pres
ser o
pad
med
kny
ttet
hånd
på
hage
n i 5
seku
nder
og
tæl
lang
som
t til
5. S
lap
af.
Hjæ
lp d
ig se
lv.
KO
F-Å
T 20
09¤
Opv
arm
ning
Styr
ketr
æni
ng
4. M
odst
ands
øvel
seG
ab o
p, lu
k sa
mm
en, m
ens d
u ho
lder
igen
med
fing
rene
i 5
seku
nder
. Sla
p af
.
Læ
r af
slap
ning
Øv
dig
i at t
rækk
e ve
jret d
ybt n
ed i
mav
en, l
ad k
æbe
n hæ
nge
og
slap
af i
mus
kler
ne.
Gå
evt.
til a
fspæ
ndin
g, m
assa
ge, f
ysio
tera
pi, a
kupu
nktu
r, yo
ga
elle
r lig
nend
e
Bry
d uv
aner
Erke
nd o
g bl
iv b
evid
st o
m i
hvilk
e si
tuat
ione
r, du
pre
sser
elle
rsk
ære
r tæ
nder
. Sør
g i s
tede
t for
, at d
er e
r luf
t mel
lem
tænd
erne
.
Erk
end
dine
stre
sspå
virk
ning
erEr
kend
arb
ejds
betin
get o
g fø
lels
esm
æss
ig st
ress
-ly
t til
din
krop
Kos
tSp
is h
vad
du k
an u
den
at d
et g
ør o
ndt.
Und
gåov
erbe
last
ning
U
ndgå
over
anst
reng
else
af m
uskl
er o
g kæ
bele
d, f.
eks
. at p
ress
e un
derk
æbe
n ud
i yd
erst
illin
ger.
Tænk
på
din
hove
dhol
dnin
g og
ret
dig
op. P
as p
ådi
ne a
rbej
dsst
illin
ger.
Pas d
in sø
vn -
dårl
ig sø
vn fo
rvæ
rrer
smer
ter
Sørg
for a
t få
tilst
rækk
elig
søvn
sådu
føle
r dig
udh
vile
t.V
ær o
pmæ
rkso
m p
å, a
t ove
rdre
ven
indt
agel
se a
f kaf
fe, t
obak
ell
alm
inde
lige
hånd
købs
hov
edpi
nepi
ller k
an v
irke
søvn
fors
tyrr
ende
og
udl
øse
hove
dpin
e.
er
11. K
oord
inat
ions
øvel
se
Plac
er e
n ta
ndst
ikke
r mel
lem
fortæ
nder
ne i
unde
rkæ
ben.
Teg
n en
stre
g på
spej
let.
Gab
op
og
luk
sam
men
men
s tan
dstik
kere
n fø
lger
st
rege
n. S
kyd
und
erkæ
ben
frem
og
tilba
ge
uden
at t
ands
tikke
ren
går t
il en
af s
ider
ne.
12. B
egræ
nset
åbn
ing
Plac
er tu
nges
pids
en i
gane
n. Å
ben
og
luk
mun
den
men
s tun
gesp
idse
n he
le
tiden
er i
kon
takt
med
gan
en.
13. G
abeø
vels
e fo
r kæ
bele
d
Plac
er p
ege-
og la
ngef
inge
rud
for
kæbe
ledd
et i
begg
e si
der.
Gab
op
og
luk
sam
men
ude
n kn
æk.
14. G
abeø
vels
e fo
r kæ
bele
d
Plac
er p
ege-
og la
ngef
inge
rud
for
kæbe
ledd
et i
begg
e si
der.
Skyd
un
derk
æbe
n lig
e fr
em o
g ga
b op
og
luk
sam
men
i de
nne
still
ing
uden
knæ
k.
5. M
odst
ands
øvel
se
Skub
und
erkæ
ben
til si
den
men
s du
hold
er ig
en m
ed e
n hå
nd. H
old
5
seku
nder
. Sla
p af
. Gen
tage
s i m
odsa
tte
side
.
6. M
odst
ands
øvel
se
Skub
und
erkæ
ben
frem
men
s du
hold
er ig
en m
ed h
ånde
n i
5 se
kund
er. S
lap
af.
10. M
assé
r de
ømm
e om
råde
r på
kæbe
r og
tindi
ng m
ed e
t fas
t try
k i
cirk
ulæ
re b
evæ
gels
er i
5 m
in. B
rug
gern
e cr
eme.
8. B
rug
varm
epud
e el
ler o
pvar
met
hå
ndkl
æde
på
de ø
mm
e om
råde
r i 1
5 m
in.
Uds
pænd
ing
7. P
lace
r peg
efin
gere
n på
unde
rkæ
ben
og
tom
mel
finge
ren
påov
erkæ
ben
og p
res
kæbe
rne
fra
hina
nden
i 5
seku
nder
. Bru
g ev
t. be
gge
hænd
er.
Mas
sage
Var
me
beha
ndlin
g
9. B
rug
en k
ulde
pakn
ing
om
vikl
et a
f hå
ndkl
æde
på
de ø
mm
e om
råde
r i 5
m
in.
Kul
de-b
ehan
dlin
g
Øve
lser
for
kæbe
led
Træ
ning
af k
æbe
led
for
at u
ndgå
knæ
k