Temporomandibular joint disorders-final.pptx

its a presentation about the temporomandibular joint disorders

1. department of oral medicine and radiology Temporomandibular joint disorders Presented by: Moderator: B. Priscilla Tejaswini Dr. Laxmi Kavitha IV BDS READER

2. CONTENTS INTRODUCTION ANATOMY OF TEMPOROMANDIBULAR JOINT CLASSIFICATION OF TEMPOROMANDIBULAR JOINT DISORDER MASTICATORY MUSCLE DISORDER DEGENERATIVE MUSCLE DISORDER

3. INTRODUCTION The temporomandibular joint articulation is a joint that is capable of hinge type movements and gliding movements . Hence it is also called as gliding modiarthrodial type of joint. The bony components and enclosed and connected by a fibrous capsule. The disorders of TMJ are characterized by 1. facial pain in the region of TMJs or muscles of mastication. 2.limitation or deviation in mandibular movements. 3.tmj sounds during jaw movements and function. 4.hyperalgesia of the musculoskeletal structures .

4. Anatomy of TMJ

5. Classification of Temporomandibular disorders

6. MYALGIA AND MYOFASCIAL PAIN OF THE MASTICATORY MUSCLES The diagnostic terms myalgia and myofascial pain are used for muscle pain disorders that are characterized primarily by pain, limitation, and absence of progressive disease. Local myalgia refers to pain that remains local to the provoked muscle. myofascial pain which can be associated with either spreading or radiating of the pain within the muscle or referral to a different structure when the muscle is stimulated during palpation.
Most of the research of this disorder suggests that for most individuals, symptoms are intermittent and usually do not progress to chronic pain and disability. the treatment plan for myalgia and myofascial pain of the masticatory muscles include self management therapies and clinician management therapies MASTICATORY MUSCLE DISORDER

7. . Self-management consists of patient education and a range of skills or activities that are synergistic in their effectiveness. The core activities include self-exercise, use of thermal modalities, avoidance of strain or overuse while chewing or yawning, re- establishing normal chewing patterns, self-massage, and parafunctional behavior control. . 1.Education and information Being better informed generally reduces anxiety, and that in turn decreases pain amplification and disability.. Education and information provide the patient with an understanding of the condition and the ability to perform activities and make choices that have a direct effect on the symptoms. self management

8. . 2.Self exercise therapies The most common self-exercise is simple stretching of the masticatory elevator muscles. In myofascial pain , the pain accompanying restriction in opening the mouth. Muscle stretching, should be performed 2-3 times each day; about 10 repetitions, each held for about 5 seconds. Stretching should be performed within the limits of pain threshold; that is, in a comfort zone Monitoring is best achieved by the patient using a mirror (as an inexpensive form of bio feedback) and watching the movement of the jaw. An alter- native form of this variant on stretching is to maintain the tongue in contact with the palate in order to control mouth opening in terms of both encouraging primarily rotational movement of the TMJ as well as limiting the overall opening extent;

9. . both aspects are sometimes implemented when painful popping is interfering with full stretching. A 3-month period of treatment consisting of education only or education plus a home physical therapy program are advised of which education plus home physical therapy was more effective

10. . 3.Thermal modalities Thermal agents consist of the application of moist heat to the affected areas for 15 to 20 minutes twice daily, as well as ice packs for about 10 minutes Ice is particularly effective when applied to very tender or irritable areas of muscle or joint prior to ice . 4.Self-massage patient can engage in self- massage, especially for the masseter muscle, using either cross- fiber technique or stroking the fibers along their length. Patients report nearly as much pain relief from self-massage as they do for thermal modalities. self-massage simply feels good, and that typically has motivational aspects for patients to continue with other self-care methods

11. . 5. Diet and Nutrition A common treatment recommendation for TMDs is to take only softer foods, the rationale is that avoidance of tougher or harder foods will facilitate recovery. Similarly, when extending indefinitely the restriction to only eat soft foods, muscle atrophy and occlusal changes occur, as well as increasing fatigue such as with ordinary speech. Persistent avoidance of nor mal function decreases the pain threshold and increases the tendency for the patient to believe that trying to function normally will lead to further deterioration of the jaw. In contrast, emphasizing resumption of normal function, such as via usual textured foods, facilitates recovery rather than blocks it. 6.Bilateral Chewing many patients with a TMD will start to chew on only one side, and unilateral chewing is one of the very few local factors associated with TMD.” Before resuming a normally textured diet, the patient who chews unilaterally should retrain in order to chew bilaterally, this is best facilitated by Judicious use of a mechanical soft diet for perhaps 2 weeks at most, and then gradually resuming more normally textured foods. Hard or brittle food should still be avoided until symptoms substantially improve. Normal chewing restores strength, which balances muscle tone between elevator and depressor muscles, and aids muscle relaxation

12. . 7.Yawn Control Yawning is a ballistic movement leading to rapid stretch of the masticatory elevator muscles which is painful. Patients instinctively learn to suppress the yawn by contraction of the elevator muscles which opposes the action of the jaw opening muscles under yawn reflex control. The result is that the mandible is torqued during the yawn and such suppression is not so effective. A better method is to support the jaw by providing mild counter pressure underneath the chin with the thumb and index finger or with the back of the hand.

13. . 1. Physiotherapy Appropriate goals of PT are to restore normal muscle tone and resilience, improve joint movement, reduce pain, and improve function. Both passive and active treatments are commonly included as part of therapy . Passive modalities such as ultrasound, cold laser, and transcutaneous electrical nerve stimulation (TENS) are typically used initially to reduce pain. Ultrasound : relies on high-frequency oscillations that are produced and converted to heat as they are transmitted through tissue, it is a method of producing deep heat more effectively than the patient could achieve by using surface warming. TENS : these are uses a low-voltage biphasic current of varied frequency and is designed for sensory counter stimulation for the kp control of pain. It is thought to increase the action of the modulation that occurs in pain processing at the dorsal horn of the spinal cord and (in the case of the face) the trigeminal subnucleus caudalis of the Brainstem . Clinician Management

14. . Physical therapists will commonly add more Jaw exercises such as active stretching to increase the range of jaw motion, and isotonic and isometric exercises to facilitate strength and coordinated movement.
Some physiotherapists apply mobilization techniques to increase mandibular motion 2.Intraoral appliances variously termed splints, orthotics , orthopedic appliances, bite guards, nightguards , or bruxing guards are used in TMD treatment. When carefully used, an intraoral appliance is considered to be a reversible form of therapy, however, appliances also have adverse effects as well. These appear to be more effective when TMD is the sole pain disorder, when fibromyalgia, for example, is comorbid with a painful TMD, the efficacy of the oral appliance diminishes considerably.

15. . The most common purposes advocated for appliance therapy are to provide joint stabilization, protect the teeth, redistribute forces, relax elevator muscles, and decrease or control the effects of bruxism. The appliance most commonly used for these purposes is described as a stabilization appliance or muscle relaxation splint. Full-coverage appliance therapy during sleep is a common practice to reduce the effects of brusing and is not usually associated with occlusal change. In addition, appliances seem to retain more efficacy if used for shorter periods ( eg . Only during sleep

16. . 3.Pharmacotherapy mild analgesics, non steroidal anti inflammatory analgesic drugs( NSAIDS),antianxiety agents ,tricyclic antidepressants and muscle relaxants are used for treatment of TMD pain . Because of adverse effects of all of these drugs, short term or intermittent use is preferred ,but a smaller percentage of patients who evolve into a chronic musculoskeletal pain disorder are ususally taking combinations of medications long term. NSAIDS for most TMDs should be short term to supplement the other non drug therapies that should reduce the need to for long term NSAIDStherapy . Topical NSAIDS have demonstrated significant pain reducing effecys in acute and chronic musculoskeletal injuries.

17. . NSAIDS can be incorporated in transdermal creams for application on the skin over the painful joint or muscle. Ketoprofen , felbinac , ibuprofen, diclofenac , and piroxican have significant efficiency. The long term acting benzodiazepine clonazepam was effective in a patient study of TMD treatment , 10mg cyclobenzaprine ,a muscle relaxant , taken at bedtime was found to be superior to clonazepam at managing jaw pain on awakening. These medications are used before sleep due to their sedative effects Tricyclic antidepressants , particularly antitriptyline , have proven to be effective in managing chronic orofacial pain. Opioids were previously considered appropriate for complex chronic pain disorders or briefly for acute injuries to the TMJs or muscles where moderate to severe pain is present.

18. . DEGENERATIVE JOINT DISEASES Osteoarthritis (Degenerative joint disease (DJD), is primarily a disorder of articular cartilage and subchondral bone, with secondary minimal inflammation of the synovial The articular changes are essentially a response of the joint to chronic microtrauma or pressure Microtrauma may be in the form of continuous abrasion of the articular surfaces as in natural wear associated with age or due to increased loading related to chronic parafunctional activity.

19. . Risk factors for symptomatic DJD include gender, diet, genetics, and psychological stress The possibility that a diet of excessively hard or chewy foods might cause increased loads on the joints and lead to degenerative The present disease model for DJD of the TMJ suggests that excessive mechanical loading on the joints produces a cascade of events leading to the failure of the lubrication system and destruction of the articular surfaces. These events include the generation of free radicals, the release of proinflammatory neuropeptides, signaling by cytokines, and the activation of enzymes capable of matrix degradation.”

20. . Clinical features DJD of the TMJ begins early in life and has been observed in over 20% of the TM joints in individuals older than 20 years incidence of degenerative changes increases with age Degenerative changes are found in over 40% of patients older than 40 years Many patients with mild in moderate DJD of the TMJ have no symptoms, although arthritic changes are observed on radiographs degenerative changes may be underdiagnosed by conventional radiography because the defects are confined to the articular soft tissue. These soft tissues changes are better visualized with MRI, Patients with symptomatic DJD of the TMJ experience
pain directly over the affected condyle causes limitation of mandibular opening, crepitus, and a feeling of stiffness after a period of inactivity Examination reveals tenderness and crepitus on intra-auricular and pre-auricular palpation Deviation of the mandible to the painful side is a character istic finding

21. . Radiographic findings narrowing of the joint space irregular joint space flattening of the articular surfaces osteophyte formation anterior lipping of the condyle presence of subchondral cysts

22. . Treatment physical therapy, analgesics, NSAIDS can control both pain and inflammation. In osteoarthritis, significant improvement is noted in many patients after 9 months Nonsurgical management may consist of jaw self-management, including behavior modification, hest application, soft diet. physical therapy including jaw exercises. Occlusal appliances may be helpful when sleep bruxism is an etiologic factor. Arthenscopy , Arthroplasty, and arthrotomy and joint replacement are surgical procedures are useful Only when there is significant TMJ pain or disabling limitation of mandibular movement .

23. RHEUMATOID ARTHRITIS Rheumatoid arthritis is an inflammatory , autoimmune disease primarily affecting periarticular tissues and secondarily bone. The disease process starts as a vasculitis of synovial membrane and progress to chronic inflammation . The chronic inflammation is marked by intense cellular infiltrate and subsequent formation of granulation tissue. Clinical manifestations The TMJs in Rheumatoid arthritis are usually involved bilaterally Pain is usually associated with early acute phase of disease but is not a common complaint in later stages Other symptoms often include morning stiffness ,joint sounds , tenderness ,swelling directly over the joint, limited mouth opening and crepitus

24. . Only a small percentage of patients experiences permanent clinically significant disability. Micrognathia and anterior open bite are commonly seen in patients with juvenile idiopathic arthritis. Radiographic features Narrow joint space destructive lesion of condyle and limited condylar movement are observed There is a little evidence of marginal proliferation or other reparative activity in rheumatoid arthritis in constrast to the radiographic changes often observed in DJD. High resolution CT of the TMJs in rheumatoid arthritis patients shows erosions of the condyle and glenoid fossa that are not detected on conventional radiographs.

25. . Normal tmj joint erosion of condyle condylar deformity reduction of joint space Management if RA is suspected after a history and physical examination , laboratory tests including rheumatoid factor , antinuclear antibody, ESR and c reactive protein should be ordered. Patients with positive laboratory results should be referred to a rheumatologist .

26. . REFERENCES BURKET’S ORAL MEDICINE ,Author :MICHAEL GLICK, 12 TH EDITION

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