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 [email protected]@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.
