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Differential Diagnosis of TMD,Head, & Facial Pain
Leonard B. Goldstein, D.D.S., Ph.D.
Director, Clerkship Education
New York College of Osteopathic Medicine
EROC 2009
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Diseases that mimicTemporomandibular Disorders
Differential Diagnosis
1. Comprehensive Medical History
2. Thorough Physical Examination
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Clinicians must develop a plannedsystematic approach to patients withcomplaints of TMJ pain, or risk overlookingmore serious conditions, which carry
increased morbidity, and in someinstances, mortality.
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Referred PainPain is considered referred if the origin of the
irritative lesion is some distance from the siteat which the pain is perceived. The anatomicbasis for this phenomenon is that pain isreferred from one region to another by
sensory nerves that share a commonsegment within the gray matter of the spinalcord.
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The sensory innervation of the region
surrounding the TMJ is supplied by fourcranial nerves (V, VII, IX, X), and twocervical nerves (C1, C2). Trigeminal pain isreferred to the region anterior to the tragusby way of the auriculotemporal branch ofthe third division.
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Lesions involving the floor of the mouth,
teeth, mandible, anterior 2/3 of thetongue, palate, paranasal sinuses andinfratemporal fossa can result in pain
directed to the same region by thetrigeminal nerve.
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Pain felt in the external auditory canal
and postauricular region can betransmitted by the sensory branch of thefacial nerve by way of the nervusintermedius.
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Patients with lesions involving the
geniculate ganglion (Ramsay HuntSyndrome), as well as tumors of the 7th
nerve have reported pain in the TMJregion.
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GlossopharyngealReferred pain travels from the tonsils,
eustacian tube, posterior base of thetongue and nasopharynx to the petrosalganglion and down the nerve of Jacobsonto the middle ear.
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Pain can also be referred in regions ofthe head and neck, which areinnervated by branches of the Vagusnerve (to the external auditory canal).
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Differential Diagnosis
TMJ Pain may be due to Pathology in a
contiguous site or may be referred from aremote site. The patient can onlyidentify the site where the pain is feltnot the location of its source. Therefore,a comprehensive and careful search ofthe head and neck is necessary toascertain the correct diagnosis.
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Vascular Syndromes1. Carotidynia
a) a variant of migraineb) long-lasting throbbing neck and facial pain
c) Pain is reproduced by palpation of the
carotid
d) Usually, self-limiting, and responds tosteroids and salycilates
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Temporal Arteritis
(Also Called Giant Cell and Cranial Arteritis)
1. Vascular inflammatory disease ofunknown origin
2. Predeliction for Whites over 55 yearsof age
3. Female over male predominance 2:1
4. Headache is most common complaint*
5. Painful Mastication *
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Temporal Arteritis
(Also Called Giant Cell and Cranial Arteritis)
6. Often, an elevated SED Rate (ESR)
7. Biopsy of the Temporal artery is
confirmatory
8. Prominent, Tender Temporal Artery
9. Prednisone 40-60 mg daily alleviatessymptoms and avoids ocularcomplications (blindness)
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Eagles Syndrome
Caused by inflammation of an elongated
styloid process. Pain can be elicited bypalpation of the tonsillar fossa.Treatment is by excision of the styloid
process. Symptomatic improvement hasbeen reported with Steroid and Lidocaineinjections in the Tonsillar Fossa.
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Neuralgic Pain
1. A trigger area or region where lightstimulation produces severe pain in thesensory distribution of that nerve
2.
Pain is paroxysmal in nature3. Pain does not awaken the patient at
night from sleep
4. The pain is unilateral
Most neuralgias share the following commonfeatures:
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Trigeminal Neuralgia (Tic
Douloureaux)One of the most painful conditions
known to man. A misdiagnosis of dentaldisease is commonly made and isresponsible for many unnecessaryextractions. Periods of spontaneousremission occur which may span monthsor even years. Clinical diagnosis ofTrigeminal Neuralgia can be based on:
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1. Clinically negative neurologic finding
2. Alleviation of pain and abolishment of the
trigger point by administration of a localanesthetic to block the involved trigeminalnerve division
3. The Half Inch Test in which the patient,when asked to demonstrate where the painbegins will avoid touching the trigger zoneby inch in fear of precipitating an attack
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Glossopharyngeal NeuralgiasAn uncommon condition compared to
trigeminal neuralgia.
Characterized by paroxysms of pain thatradiate from the pharynx and tonsillarfauces to the TM region, ear, and
tympanum.
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Pain occurs with swallowing, chewing,talking, or yawning.
Tonsillar and pharyngeal regions aretrigger zones.
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Sphenopalatine NeuralgiaPain radiates to the mandible, zygoma,
and ear. Attacks are associated withedema of the nasal mucosa. Thediagnosis rests on the immediatecessation of pain after cocainization of thesphenopalatine ganglia during an attack(or 4% Lidocaine).
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Herpes Zoster Oticus (Ramsay
Hunt Syndrome)An uncommon acute infectious disease
that affects the sensory and motor
branches of the facial nerve. Starts with pain and burning.
Within 2-3 days, the pain is followed by theonset of isolator facial nerve paralysis.
Within 10-14 days, vesicular eruptionsappear on the skin of the external auditorycanal.
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SinusitisAcute and chronic infections of the
maxillary sinus can refer pain to the TMJas well as the cheeks and teeth.Misdiagnosed as TMJ pain in 20% of thecases.
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Headaches Migraine (Vascular Headache)
Cluster (Vascular Headache)
Muscle Contraction Headache
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The trigeminal nerve is commonly involved
in acoustic neuromas. Facial hyperesthesiaand occasionally, periauricular pain are themost common symptoms secondary totrigeminal involvement.
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Confirmation of the presence of anacoustic neuroma is by contrast enhancedCT Scanning or Magnetic ResonanceImaging (MRI). Treatment is by surgicalexcision of the tumor.
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Ear DiseasePathologic conditions of the ear maymasquerade as TM Disorders. Patients
with TMJ pain often have symptomssimilar to those of true ear pathology.Therefore, disease within the ear must
be considered and excluded as a sourceof TMJ pain.
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1. Medical History
2. Examination of the ear
a) Inspection of the auricle and externalauditory canal, looking for erythenia, earprotrusion, tenderness, ecchymosis, orvesicular eruptions.
b) Otoscopy with insufflation.1. Perforation of the tympanic membrane
2. Otorrhea
c) Hearing status using a 512Hz tuning fork.
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1. Diffuse External Otitis usually seen duringthe summer with constant high humiditybacterial and/or fungal. Treatment involves
mechanical cleansing of the ear canal,maintenance of a dry environment,applications of topical antibiotic drops.
The following conditions represent the mostcommon ear disorders that may mimic a TMDisorder.
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2. Malignant External Otitis. Malignant ornecrotizing otitis is destructive bacterial infectionof the external auditory canal that is most often
observed in diabetic and immunocompromisedpatients. Treatment involves extensivedebridement of the ear canal with removal of allgranulation tissue and prolonged (6-10 weeks)intravenous antibiotic therapy directed againstpseudomonas aerugenosa, the primary causativepathogen. These include Ticarcillin, thirdgeneration Cephalosporins (e.g. Ceftazedrine,Cefoperazone), and Ceprofoxacin.
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3. Bullows Myringitis
4. Acute Otitis Media. Bacterial infection of the middleear that often accompanies an upper respiratory
infection. Deep-seated, throbbing pain oftenassociated with hearing loss. The conductivehearing loss is secondary to the accumulation ofpurulent fluid in the middle ear space. Otoscopyreveals a dull and erythematous tympanic
membrane that has lost its normal landmarks andhas limited mobility. Treatment includes analgesicsand oral antibiotics. The antibiotics of choice areCeclor, Septra, and Augmentin.
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*Note: The diagnosis of nasopharyngealcarcinoma must always be considered in any
adult who develops otitis media notprecipitated by a URI and is refractory tomedical treatment. Such cases of recurrent
or refractory serious otitis media requirenasopharyngoscopy and CT scanning of thenasopharynx to rule out a mass lesion.
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MalignanciesMalignancies, both regional and metastic,can manifest themselves as TMJ pain andmust always be considered in everydifferential diagnosis of TMJ pain.
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Although most malignant tumors thatinvolve the TMJ are usually secondary tocontiguous spread from the skin, parotidgland, ear, and nasopharynx, somemetastasis from the breast, lung,
prostate, and colon have been reported.
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Pre-auricular mass in a patient with
symptoms of TMJ pain should alert theclinician to consider the parotid gland asthe primary focus.
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The majority of parotid tumors (80%)are benign. The most common
presentation of a benign tumor is that ofa firm, mobile, and non-tender mass.
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Clinical features of a malignant
parotid tumor:1. Pain is often associated with a higher
incidence of malignancy. Additionally,
pain is often an indicator of poorprognosis.
2. Facial nerve paralysis.
3.
Hardness and fixation of the mass areassociated with 30% to 50% incidenceof malignancy.
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Examination and DiagnosisMedical History:
1. Baseline information
2. Alert practitioner to pertinent medicalhistory or to complications that may beencountered.
3. Help establish etiology of problem.
4. Establish and maintain a legal record.
5. Help establish a database for research.
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Organization of Medical History
1. Personal data.
2. Chief complaint.
3. History of present illness.
4. Past medical history.
5. Past dental history.
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ExaminationExamination for T.M. disorders differsfrom the examination for general
dentistry. The teeth and periodontiumreceive less attention than the state ofthe muscles and joints and the
mandibular movement.
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The examination is made up of:1. Observation.
2. Masticatory muscle examination
(palpation and resistance testing).
3. T.M. joint examination. (Palpation,range of motion, selective joint
loading, assessment of joint sounds).4. Head and neck examination.
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5. Occlusal analysis.
6. Diagnostic anesthetic blocks.
7. Cervical spine examination.
8. T.M. joint imaging.
9. Specialist consultation.
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Masticatory Muscle
Examination: This is the most important part of the
examination.
The recommended technique issimultaneous palpation of the left and
right sides using approximately 3pounds of pressure.
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1. Temporalis Muscles.
2. Zygomatic arch.
3. Masseter muscles.
4. Anterior Digastric Muscles.
5. Cervical Spine.
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6. Trapezius Muscles.
7. Sternocleidomastoid Muscles.
8. Medial Pterygoid Muscles.
9. Lateral Pterygoid Muscle Area.
10. Coronoid Process.
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Temporomandibular Joint
Examination1. Palpation of the lateral aspect of each
joint (anterior to the external Auditory
meatus).2. Palpation of the condyle through the
external Auditory Meatus.
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3. Range of motion:
a) Maximal Interincisal opening/active range ofmotion.
b) Lateral movement.
c) Protrusive movement.
d) Patterns of mandibular opening.
e) Selective Temporomandibular joint loading.1) If clenching elicits joint tenderness capsulitis or
Retrodiscitis is suspected.
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Head and Neck Exam:1. Thorough exam for palpable nodes,
Salivary gland pathology, and
Neoplastic disease.2. Evidence of habitual cheek biting or
tongue thrusting.
3. Joint sounds clicking or crepitus.
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Clicking has been shown throughCadaver Studies, arthrography, and open
joint surgery to be indicative of discdisplacement.
The later the click occurs during theopening movement, the more severe thedisc displacement.
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Crepitus is evidence of a change inosseous contour. It commonly indicatesosteoarthritis, but other Arthritides mustbe considered as well.
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Occlusal Analysis:Take notes of the patients maxillo-mandibular relationship, both skeletal
and dental.
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Cervical Spine Examination:Many patients presenting for TMJevaluations have cervical symptoms. It
is clinically evident that these problemscan act synergistically with the TMdisorders and can refer pain to the
temporal region. Motor vehicle accidentvictims, in particular, often present withboth cervical sprain and TMJ injury.
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Dental practitioners are not normallytrained to do in-depth analysis of the
upper quarter, but should evaluate thestructures generally. When indicated,(almost always), a referral should be
made to a physical therapist, physiatrist,osteopathic physician, or a neurologist.
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The Practitioner should note:1. Any shoulder asymmetry or deviation of
the neck.
2. Check for forward head or neckposture.
3. Check head rotation (about 80 degrees
in each direction).
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4. Extension and Flexion (about 60degrees in each direction).
5. Side-bending (about 45 degrees ineach direction).
During this exam, all pain and limitationof movement is noted.
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Temporomandibular JointImaging
General Screening:
Panoramic x-ray.
Lateral Transcranial Imaging.
Tomograms produce clear radiographic
slices of the condyle, which canclearly show subtle osseous changes.
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Arthrography requires injection ofradiopaque dye into both joint spaces. Itcan visualize the meniscus duringmovement (Fluroscopic record recordedon videocassette). This invasive
procedure causes tenderness and somepatients are allergic to the dye.
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CT and MRI
CT is superior for visualizing osseousstructures while MRI can visualize discposition.
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Comprehensive treatment ofTemporomandibular Joint disorders
(Craniomandibular) can be brokendown into three areas:
Modalities.
Mobilization. Patient Education.
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Physical Modalities and ManualTechniques Used in the Treatment of
Maxillofacial Pain
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1. Physical modalities are only an adjunctto therapeutic techniques.
2. Physical modalities can be used to:A. Decrease pain.
B. Increase or decrease circulation.
C. Alter nerve conduction velocity.
D. Facilitate soft tissue stretching by alteringthe elastic properties of the connectivetissue.
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E. Decrease swelling.
F. Decrease muscular spasm and trigger
points.G. Prepare the superficial tissue for electrical
modalities, mobilization, posture re-education, or exercise.
H. Speed the repair of connective tissue.
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Application of cold:
Cryotherapy:
Although cold traditionally has been used
therapeutically for acute injury, the sameeffect can be beneficial in the sub-acuteand chronic phase of dysfunction.
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Physiologically, cold will:
1. Cause vasoconstriction.
2. Decrease metabolism.
3. Reduce swelling.4. Reduce muscle spasm.
5. Reduce pain by producing a local
anesthetic effect.
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The cold impedes synaptic transmissionand slows nerve conduction velocity, thus
elevating the pain threshold.
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Cold can be applied easily andinexpensively as ice chips or cubes,
commercial ice packs, or vasocoolantspray. Ice massage can be performed bythe patient to reduce muscle spasm. The
ice cube is stroked over the muscle inspasm, parallel to the direction of themuscle fibers. Application should continueuntil the area becomes numb.
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Flouro-methane spray and stretch wasdeveloped by Dr. Janet Travell in 1985. A
thin spray of vapocoolant is directed overa trigger point zone while the practitionerpassively stretches the involved muscles.
The streams of spray should overlap andbe performed in one direction from triggerpoint toward the referral zone of pain.
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Spray and stretch techniques should onlybe applied to myogenous
craniomandibular disorders, because theeffect of over-opening of the mouth canprogress the displaced disc relationship in
intracapsular disorders.
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Application of Heat:
Heat should not be used directly over theT.M. joint. Heat can be used over the
muscles of the upper back and neck.
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Heat promotes relaxation:
1. Reduces pain.
2. Increases metabolism.3. Increases connective tissue flexibility.
4. Prepares muscles for the modalities and
exercise.
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Ultrasound is known to increase heatin the deep soft tissue. In addition,
heat:1. Increases circulation.
2. Alters nerve conduction velocity.
3. Increases pain threshold, and4. Modifies skeletal muscle contractile
properties.
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Therefore, ultrasound is used to treatjoint contractures, scar tissue, muscle
spasm, and pain. Ultrasound can also beused for phonophoresis, which propels ahydrocortisone, or dexamethasone
impregnated coupling agent into the softtissue or the T.M. joint.
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Phonophoresis can:
1. Reduce local irritation.
2. Reduce pain.
3. Reduce post-treatment irritation frommobilization and/or exercise.
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Electric High Voltage Stimulation (HVS orEGS) is a form of electric stimulation
applied to reduce pain, alter nerveconduction, increase circulation, anddecrease swelling.
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Transcutaneous Electrical NeuralStimulation, (TENS), is an effective
adjunct to physical therapy in thereduction of pain. If appropriately used,the TENS unit can bridge the gap
therapeutically between office treatmentsessions.
Mobilization Techniques
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Mobilization TechniquesJoint Liberation
After the soft tissue of the maxillofacialregion is prepared by the application of
physical modalities, the OsteopathicPhysician may elect to use mobilizationtechniques.
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Mobilization may be applied to:
1. Stretch the soft tissue of the
maxillofacial region.2. Increase the range of motion of the
temporomandibular joint.
3. Relax the muscle spasm.
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4. Restore the TM joint disc to a morenormal position on the condylar head.
5. Stabilize the joint.6. Prepare the joint for treatment.
7. Restore joint play.
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*The American Academy of Orofacial Pain(AAOP) cited physical therapy as an
important adjunctive treatment in themanagement of TMD.
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*The American Academy ofCraniomandibular Disorders (AACD)
guidelines note that Physical therapyhelps relieve musculoskeletal pain andrestore normal function by altering sensoryinput, reducing inflammation, decreasing,
coordinating, and strengthening muscleactivity, and promoting the repair andregeneration of tissues.
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Manual Therapy
Manual therapy is the application of gentle,passive, sustained and oscillating forces to
joints or soft tissues to assist in theirreadaptation. Readaptation may restore
joint mobility through lengthening of themuscle, capsule, or fascial structure. Once
the tissue is sufficiently flexible andstrengthened, the patient can regain a moreideal head-on-neck orthostatic relationship.
Soft Tissue and Joint
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Soft Tissue and JointMobilization
Soft tissue mobilization techniquesinclude deep pressure point massage,
stretching, myofascial release, strain-counterstrain, and craniosacral therapy.
The masticatory and cervical
musculature is prone to thedevelopment of trigger points whenshortening, lengthening, or loosening ofmuscles occurs.
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1. Myofascial Release is a combination of direct,indirect, and reflex neural release procedures.Abnormalities and mechanical asymmetries
found by palpation of tissue are signals ofaltered structure. The basis of this technique issensing palpable changes of various levels oftissue and manually directing gentle force toassist in releasing tissues. This alteration oftissue is thought to be mechanical andneuroreflexive. This technique can be used forthe muscles of mastication as well as the uppercervical spine.
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2. Joint Mobilization techniques aredivided into four grades:
Grade I - Small amplitude movement atthe beginning of joint range is used forextremely irritable joints(neuromodulation).
Grade II - A larger amplitude oscillationthat is partway into available joint range.
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Grade III Large-amplitude movementsthat move the joint through full availablerange.
Grade IV Small-amplitude movementsthat are performed at the end of jointrange.
The presenting state of the joint dictatesthe grade of mobilization to be performed.
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Causing pain must always be avoided,and a decision to increase mobilization isbased upon re-evaluation as therapyprogresses.
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Manipulation, or grade IV mobilizationemploys a high-velocity, low amplitude
thrust that moves a joint beyond itsrestricted range. This should only be usedby a therapist who has extensive trainingand experience in manual therapy. GradesI through IV are most often used with theTMJ. Grades I through IV are used fortreatment of the cervical spine.
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Specific Joint Mobilization: TMJ
When mandibular movements are severelylimited, severe pain and spasm due torecent trauma are present, extraoral
techniques are useful. They can helpdecrease spasm and pain when done ingrades I and II oscillations in:
1. Lateral glide.
2. Depression.
3. Protrusion.
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After the soft tissue of themaxillofacial region is prepared by theapplication of physical modalities(such as TENS), mobilization may beapplied to:
1. Stretch the soft tissue of the maxillofacial
region.2. Increase the range of motion of TM
joints.
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3. Restore the TM joint disc to a morenormal position on the mandibular head.
4. Stabilize the joint.5. Restore joint play.
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Initially, the practitioner may simply gentlydepress the mandible to take up the slack
in the joint capsule. According to Rocabado,this action will restore play in the joint. Jointplay is the passive, nonvoluntary movementin the joint, which is actually the normal jointlaxity. Although this movement is minimal, itis required for normal joint function and ispresent in all synovial joints.
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Once the joint play is restored, thepractitioner should concentrate on
restoring any motions that the patient islacking. As muscle guarding decreasesand the range of motion increases,
restricted soft-tissue structures are moreeasily assessed and allow the appropriateuse of direct intraoral techniques.
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The desired effect of mobilization techniquesis the deformation of collagen within its elastic
range. Clinicians must develop an acutetissue-sensing ability through practice. Activemandibular opening is helpful in increasingthe effectiveness of these treatment
techniques. If these techniques are used withtoo much force, increased pain and swellingand decreased mobility may result.
Specific Joint Mobilization:
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Specific Joint Mobilization:Upper Cervical Spine
Headache and facial pain can originate fromC1-3. Mobilization of the subcranial jointsshould always be preceded by a vertebralartery test. The test is designed to detectthe presence of vascular insufficiency, whichmay be exacerbated by backward bending,
side-bending, and/or, rotation of the head.Symptoms include pupillary changes,nystagmus, dizziness, visual changes, andgiddiness.
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The first cervical mobilization is transversevertebral pressure. A gentle force is applied
with the thumbs on the lateral tip of thelateral mass of C1. This technique is appliedtoward and away from the symptomatic sideof the upper cervical spine. When done
appropriately, a decrease in pain, spasm, andjoint restriction between the occiput and C1will occur.
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Posteroanterior unilateral vertebral pressure isused when symptoms are bilateral or unilateral.
This should never be done in a way thatproduces radicular symptoms. At the occiput-atlantal joint (0-C1), the primary motions areflexion and extension. When Posteroanterior
unilateral pressures are used, motion will beincreased when the force is directed to theposterior aspect of the lateral mass of the
Atlas.
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If it is used at the C1-2 segment, theprimary motion will be approximately 40
degrees of rotation. The force is applied tothe C2 articular pillar. This movement isfurther enhanced by rotating the patients
head 30 degrees before applying thistechnique, thus taking up the slack at C1-2.
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Patient Education
Education of patients is a key factorduring all phases of physical therapy. Adiscussion of the nature of the pathologyand its relationship to posture, pain, andmechanics is necessary. Patients must
understand that they are responsible forthe problem and its treatment.
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Forward head posture with resultantrounding of the shoulders can produce
dysfunction of the Craniocervical andTemporomandibular systems.
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Postural re-education starts withinstruction in relaxed sitting position.
Patients who sit in FHP over long periodsof time are placing the head in aposteriorly rotated position, leading to
pathologic changes in the soft tissue ofthe TMJ, hyoid, and cervical spine.
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Adaptive FHP strongly influencesmuscle tone and elasticity of the
masticatory system.1. The resting position of the mandible is
altered.
2. Suboccipital impingement forces areincreased.
3. Freeway space is influence.
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4. FHP alters breathing and swallowing as aresult of decreased airway potency andtongue position.
5. May lead to clenching, Bruxisim, and TMJloading.
6. FHP may lead to increased compressive
forces and intervetebral discdegeneration.
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Sitting Posture
1. Chairs with appropriate lumbar support tomaintain lumbar lordosis.
2.
Knees and hips should be in a 90-90 degreeposition with free lateral movement to turnleft and right.
3. When hips are in the 90 degree position,
proper anterior pelvic tilt is maintained,promoting a decrease in lumbar disc pressureand inducing proper cranio cervical posture.
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Sleeping Posture
1. Least easily controlled.
2. Patients should be instructed to avoid
lying in a prone position, whichstresses the cervical spine by rotatingand extending it, and places tension
on the cervical joints, muscles, andligaments. The TMJ also receivescompressive forces in this position.
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Patients with waking pain or increasedstiffness should have their sleeping
posture evaluated.
Appropriate sleeping posture is lying onthe side or back. The head and neckmust be supported by a pillow meetingthe patients Biomechanical need.
Nasal-Diaphragmatic
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Nasal DiaphragmaticBreathing
Mouth breathing (caused by allergies ornasal obstruction) increases activity on the
Scalenes and Sternocleidomastoidmuscles.
Enlargement of the adenoids may lead to
forward and downward position of thetongue.
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Shortening of the Scalenes andSternocleidomastoids leads to increasedposterior cranial rotation.
As the cranium is pulled into FHP, activity of theTemporales and Masseter muscles increasecausing the mandible to elevate and retrude.
These events may ultimately lead to change inocclusion, facial morphology and lead to cervicalspine pathology.
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Self-Mobilization Exercises
A self-mobilization program will helpmaintain joint mobility as well as muscle
strength and length, thus preventingrecurrence of pain.
A stretching program is as important as
a musculoskeletal strengtheningprogram.
Passive Stretching: Cervical
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a g aSpine
Flexibility is a key factor in preventingrepeated injury.
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Passive Stretching: TM Joint
Passive mobilization of the TMJ is done athome after application of ice or heat.
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SPLINT THERAPY
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Occlusal Splints
Removable interocclusal appliances.
Usually fabricated from hard acrylic.
Prescribed for the treatment ofBRUXISM and CRANIOMANDIBULARSYMPTOMS for almost a century.
TMD Treatment Objectives of
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jSplints
Eliminate occlusal interference.
Stabilize tooth and joint relationships.
Provide a passive stretching of themusculature to reduce abnormal muscleactivity.
Decrease parafunctional habits.
Protect against tooth abrasion.
Decrease joint loading.
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Theories of Splint Therapy
Design of Multiple Appliances
Expectations, Limitations, and
Complications of Splint Therapy
The Six Major Theories Covering the
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The Six Major Theories Covering theMechanism of the Action of Splints
Occlusal Disengagement Theory
Vertical Dimension Theory
Maxillo-mandibular Realignment Theory Oral Orthopedics Theory
TMJ Repositioning Theory
Cognitive Awareness Theory
Occlusal Disengagement
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g gTheory
Placement of an appliance with properocclusal relationships replaces
previously faulty occlusal relationships. Eliminates the stimulus causing
muscular hypertrophy.
Allows for proper joint and mandibularfunction.
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Vertical Dimension Theory
The craniomandibular system is adaptiveand can function in the presence of verticalchange.
When the change becomes excessive, andthe adaptive capacity is overcome,pathology and dysfunction may result.
Therefore, placing an appliance to restore amore normal vertical dimension of occlusionmay cause a decrease in dysfunction.
Maxillo-Mandibular
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Realignment Theory
Proposes that the mandible ismalpositioned relative to the maxilla at
the position of maximum intercuspation(centric occlusion).
If the mandible is repositioned, a more
optimum maxillo-mandibularrelationship can be evolved, and thesymptoms eliminated.
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Oral Orthopedics Theory
Malrelationship of the jaw effects the entireneuromuscular system, involving function ofthe head, neck, and shoulders.
Advocates evaluation of head and neckposture as well as jaw relationships.
Reposition the mandible with its condyles to
produce an optimum neuromuscular balanceas well as a bilateral condyle/fossae and jawrelationship.
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MORA
Developed by Dr. Harold Gelb.
Hard acrylic appliance that covers thelower posterior teeth only.
Advantages of the MORA
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ginclude:
Ease of construction.
Hygienic.
Comfortable. Inconspicuous.
Reversible.
Phonetically and aestheticallyacceptable.
The Muscle-Determined
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Position
Treatment involves low frequency TENS tostimulate the 5th and 7th cranial nerves.
Stimulation causes an automatic involuntary
closure. Accomplishes a neuromuscularly controlled
balanced muscle contraction.
Determines a functionally correct occlusalposition, compatible with a continued state ofrelaxation.
TEMPOROMANDIBULAR JOINT
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REPOSITIONING THEORY
Proposes that a change in the condylarposition within the involved TMJ will
improve joint function and relievesymptoms.
Anterior Repositioning for Treatmentof Internal Derangements
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of Internal Derangements(Variation of the Condylar Repositioning Theory)
An internal derangement is an abnormalrelationship of the disc (meniscus) to
the condyle when the teeth are in theintercuspal position.
Disc is placed anteriorly.
Condyle is placed posteriorly.
ANTERIOR REPOSITIONING
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SPLINTS
Move the mandible into an anteriorposition.
Bring the condyle forward. Re-establish the correct condyle/disc
relationship.
Eliminate clicking.
Relieve condylar pressure on the retro-discal tissues.
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Anterior Repositioning Splints
Function to keep the disc in place sothat:
Soft tissue healing can occur. The disc may recontour.
Osseous remodeling may occur.
COGNITIVE AWARENESS
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THEORY
States that the presence of any splint inthe patients mouth is a constant
reminder to alter previous behaviorpatterns.
SPLINT THERAPY
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THE CONCEPT
A treatment that functions within thecontext of other treatment measures
including: Physical therapy.
Medication.
Psychological counseling.
Other branches of dental and medical care.
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The Ideal Splint Should Be:
Comfortable.
Non-invasive.
Reversible.Aesthetic.
Retentive.
Functional.
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Proper Selection of Splint Type
Depends on an individuals needs andrequests.
Depends on an accurate diagnosis.
Muscular disorders without joint involvementhave different requirements from internalderangements.
Muscular derangements differ in extent ofmeniscus displacement, chronicity, and degreeof pathologic tissue change.
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BRUXISM
Is defined as jaw clenching with orwithout forcible excursive movement,
where the intensity of the clenchingdictates the severity of tooth grinding.
Is generally accepted to be one of the
primary contributing factors in TMD.
Traditional Inter-Occlusal
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Splint Methods
Specific design addresses lateralmovement (grinding).
Severity of symptoms is dictated by theintensity of vertical movement(clenching).
NTI
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(Nociceptive Trigeminal Inhibition)
A new method and device thatsuppresses clenching intensity by
exploiting the nociceptive trigeminalinhibition reflex and prevents canine(cuspid) and posterior tooth contact.