1
Q
Most common cause of orofacial pain and headache
A
TMD
includes disorders involving the masticatory muscles and/or TMJ
2
Q
Conditions that can mimic TMJ pain requiring referral
A
- tooth
- ear
- sinus
- gland
- Cancer
- fracture
- trigeminal neuralgia
- giant cell arteritis (>50yo)
- eagle’s syndrome
3
Q
Trigeminal Neuralgia
A
- shock like pain (milliseconds to 2 mins)
- Trigger points or spontaneous pain
- strong intensity
- absence of pain between crises
- pain often associated with involuntary contraction of the facial muscles at the same facial side of the pain
4
Q
What can trigger Trigeminal Neuralgia pain?
A
- ordinary activities such as speaking, swallowing, chewing and brushing teeth as well as by non-noxious facial stimuli such as touch or a puff of air
- a simple change in the position of the head may trigger the pain, as well as lying down on the facial side pain
- TMD can be secondary to TN or coexisting to it
5
Q
Trigeminal Neuralgia can precede what?
A
diagnosis of MS
especially <40 yo
should add full cranial nerve screen, full balance eval, etc
6
Q
Diagnosis of Probably Trigeminal Neuralgia
A
- Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes, affecting one or more division of the trigeminal nerve
- pain has at least one of these characteristics: intense, sharp, superficial or stabbing OR precipitating from trigger zones or by trigger factors
- attacks are stereotyped in the individual patient
- no clinically evident neurologic deficit
- not attributed to another disorder
7
Q
Red/Yellow flags for Probably Trigeminal Neuralgia
A
- non-contiguous trigemina system distribution
- bilateral symptoms
- visual changes
- age < 40 yo
8
Q
Treatment for Trigeminal Neuralgia
A
- pharmacological treatment management is the gold standard
- surgical options exist particularly in cases of nerve compression
- PT can be appropriate in conjunction with medial management if there are cervical and masticatory triggers to address
9
Q
What is Giant Cell (aka Temporal) Arteritis
A
- involves the major branches of the aorta, usually extrocranial branches of the carotid artery
- typical age > 50 years with incidence increasing with age
10
Q
Signs and symptoms of GCA are classified into subsets:
A
- cranial arteritis
- extracranial arteritis
- systemic symptoms
- polymyalgia rheumatic
**type of secondary headache disorder
11
Q
Giant Cell Arteritis sxs
A
- complaints of persistent pain/HA; temporal; often bilateral; jaw claudication
12
Q
giant cell arteritis treatment
A
- PT is not appropriate
- referral for medical management
- red flag for immediate referral could be new, severe HA > 50, especially in temporal region
13
Q
What is Eagle’s Syndrome
A
- elongation of the styloid process or calcification of the stylohyoid ligament
14
Q
Eagle’s Syndrome Sxs
A
- dull and throbbing ache in the neck/jaw worsens with head rotation, can become shooting/stabbing with movement
- swallowing problems, may include a feeling that something is stuck in the throat
- pain at the base of the tongue, painful tongue movements
- tinnitus
- change in voice
15
Q
Eagle’s Syndrome Treatment
A
Referral Required
16
Q
Other conditions that can cause TMD like symptoms
A
Trauma
WAD
Cervicalgia
17
Q
Myogenous TMD diagnostic criteria
A
- local myalgia
- myofascial pain
- myofascial pain with referral
18
Q
Arthrogeneous TMD Diagnostic Criteria
A
- arthralgia
- subluxation
- disc displacements
- degenerative joint disease
19
Q
Individuals with painful TMD have more what?
A
pain conditions and a greater number of medical comorbidies, particularly neurral/sensory and respiratory conditions than controls
20
Q
There is a strong relationship between what and what?
A
- neck disability and jaw disability and patients with TMD report worse self-reported neck disability compared to individuals without TMD
21
Q
Subjects with TMD show reduced what?
A
cervical flexor and extensor muscle endurance
22
Q
TMD treatment guidelines
A
- conservative, reversible, and evidence based therapeutic modalities
- behavior modification
- physical therapy
23
Q
General TMD Invention Strategies
A
(if a patient has pain related to ANY form of TMD)
- Address symptom reduction (pt ed and parafunctional habits)
- Address joint mobility issues
- Consider cervical spine and postural issues
- Address neuromuscular control
24
Q
Symptom Management
A
- Biobehavioral strategies including education to decrease fear, anxiety, anger, and depression
- Rest relief positions and postural education
- decrease nocturnal and diurnal parafunctional habits and oral behaviors
- reduce joint loading and modifying ADLs
- STM
- Modalities
25
STM for TMD
External
Intraoral
MTrP release
Dry needling
26
Joint Mobility
- Increase: AROM, AAROM, Joint mobs
- Decrease: stabilization, biofeedback
- Maintain functional neutral ROM
27
Cervical Spine Intervention
- postural education
- mobilization/manipulation
- stretching
- strengthening/stabilization (deep cervical flexors)
28
Neuromuscular Re-education
- strengthening?
- mirror movements (controlled, uncontrolled)
- biofeedback
- tactile cuing
- joint loading
29
TMD: Myalgia
- Myofascial pain with/without referral
| - trismus (aka lockjaw; tonic contraction of the muscles of mastication often following radiation)
30
Myofascial Pain with and Without Referral
- education
- STM
- Manual Therapy
- Ther Exs
- Neuromuscular Re-Ed
- Postural Training
- Physical agents for pain relief or muscle relaxation
- MTrP dry needling
Why are they over using the muscles?
31
Common Causes of TMD: Arthralgia
- Osteoarthritis (DJD)
- Disc Displacement Disorder: DDWR, DDWoR WLO, DDWoRWoLo
- Synovitis/ Capsulitis/ Retrodiscitis
32
Goal of treatment for DDWR
- goal is to increase condyle/disc translation along the eminence without popping
- pt ed
- symptom control
- controlled motion
- joint loading with opening
- open/close with estim
33
Goal of Treatment for DDWoR WLO
get full opening
34
Capsulitis/Retrodiscitis treatment
- Protected rest
- Protected mobility
- patient education
- modalities to reduce inflammation and pain
35
Headache Attributed to TMD
- painful TMD demonstrated by clinically based diagnostic criteria
- evidence of causation shown by the following:
history of headache in temples that is changed with jaw movement, function and/or parafunction AND report of familiar headache in the temple area with palpation of temporals OR ROM of jaw
- headache should not be better accounted for by another headache diagnosis
36
Surgical intervention for TMD
- arthrocentesis
- arthroscopy
- open joint surgery
- joint replacement
37
Acute post op phase of TMJ arthroplasty
- 0-72 hrs
- symptom relief
- controlled motion of opening
- postural education
- patient education
38
Repair Phase s/p TMJ arthroplasty
- 3 days - 6 weeks
- increasing controlled motion to WNL opening and begin LD
- continued symptom relief
- gradual progression o isometric strengthening
- increasing return to thick foods
39
Oral appliance therapy
- occlusal guard often used for bruxism and sx's associated with myogeneous pain, usually which sleeping
- full coverage, hard acrylic stabilization appliance
- covers all maxillary or mandibular teeth
40
Are open bites reversible?
no
41
Anterior repositioning appliance
- not routinely recommended for bruxism/pain
- is sometimes used for disc displacement disorders with varying evidential support, and is increasingly being used in obstructive sleep apnea management
42
Indications for dental referral for an oral appliance
- waking up at night or in the morning with head, face, or jaw pain due to masticatory muscle pain or arthralgia as a result of bruxism
- waking up in the morning with locking of the jaw as a result of bruxism
- severe attrition of the teeth as a result of bruxism
