[MUSIC] Welcome. We will begin our discussion of specific orofacial pain conditions with Temporomandibular Disorders or TMDs. If you are a health care provider, it is more than likely you have already encountered a patient a TMD, as it is prevalent in the general population. TMDs are considered to be a musculoskeletal disorder. At this point, it is important to understand the terms TMJ and TMD. Many patients who have pain, clicking sounds, and dysfunction associated with their jaw joint will say they have TMJ or have been diagnosed with TMJ. In these scenarios, the term TMJ is used inappropriately as it is identifying an anatomical structure, much like saying I have an ankle, knee, or elbow. The more appropriate term used to describe these conditions is TMD, which is reflective of a disorder affecting any or all components of the the TMJ complex and its associated structures. This is an excellent opportunity to educate your patient regarding appropriate use of these terms. In our discussion of TMDs, we will focus on disorders that are frequently encountered in clinical practice. These include Articular disc disorders, Arthritic conditions, and Muscular disorders. Patients may present with a wide variety of symptoms that may be indicative of a single disorder, or a combination of disorders. At this time, I would like to review some basic information regarding TMDs. In the United States, 40 to 75% of adults demonstrate one sign of TMD. For example, many people complain of jaw clicking that does not cause pain or dysfunction and has little to no impact on their quality of life. This would be considered a sign of a TMD. Up to 33% of the adult population in the US will experience at least one symptom of TMD. This is most commonly reported as pain in the TMJ area, or jaw muscles, and may cause referred pain to other structures of the head and neck. Fortunately, the majority of patients with TMD will not require active treatment, because most TMD's will eventually resolve without any interventions. However, up to 10% of patients with TMD require active treatment for their condition, and many of these patients require multi-modal therapy and inter-disciplinary care. The onset of TMDs typically occurs between the ages of 20 to 50 years, but that does not exclude individuals younger than 20 or older than 50 from developing TMDs. In my practice, I have seen individuals in their adolescent years complaining of new onset TMD symptoms, as well as elderly patients well into their 90s suffering from initial episodes of TMD pain. Treatment of TMDs must be tailored towards individual needs. Age and physical capability should be taken into account when formulating appropriate management strategies. Females have higher rates of TMD compared to males. Studies have reported female to male ratios ranging from three to one, to as high as nine to one. Many theories have been offered as to why females present more frequently with TMD's than males, but most of these theories are speculative. Some experts consider being female a risk factor for TMD. Patients with TMD can report a wide range of symptoms that not only affect the TMJ complex and its associated structures, but other structures of the head and neck. The information presented here represents common patient reported symptoms of TMD that affect other head and neck structures. Patients with TMD typically complain of facial, jaw, and mouth pain. General dentists and dental specialists typically rule out local causes of pain that may originate in the oral cavity, such as caries or periodontal infection. When all local factors have been ruled out, these patients are often referred for a TMD evaluation. Common complaints related to TMD's include earache, ear congestion, and ear pain. Due to the proximity of the TMJ complex to the structures of the ear, it is understandable why some patients may initially consult their general physician and/or an ear, nose, and throat specialist for evaluation of TMD related ear pain. Patients may also complain of throat pain, secondary to TMD, and will often be initially evaluated by these same health care providers. When all local factors have been ruled out, these patients are often referred for a TMD evaluation. TMD patients often complain of persistent headache, or head pain, which is usually attributed to tension type headache. Patients often consult with their general physician and or neurologist for headache evaluation. When all local factors have been ruled out, these patients are often referred for a TMD evaluation. Another important point to consider is if neck and or shoulder pain is identified in patients with TMD, it is recommended to have the appropriate health care provider evaluate and manage these conditions, as it is often affects TMD treatment outcomes. From these examples, it is understandable why patients are often evaluated by multiple health care providers without evidence of site-specific pathology. Ultimately, many of these patients will be referred to a healthcare provider trained to diagnose and manage TMD. At this time, it is appropriate to review basic anatomy related to TMD's. In this diagram, we can view the anatomical positions of the mascatory muscles. The Temporalis muscle is a large muscle that occupies the lateral portion of the skull. Many patients with headache that were diagnosed with migraines suffer from myalgia or muscle pain associated with the Temporalis muscle, which may be the true source of their headache pain. The Masseter muscle originates from the zygoma, or cheekbone, and inserts into the mandible. Patients with TMD often complain of ache and or fatigue of this muscle as it is commonly affected in patients with this disorder. Accessory muscles of mastication can also be seen in this diagram. If you draw your attention to the insert photos we can appreciate the anatomical locations of the other Masticatory muscles commonly affected in TMD. Such as the Lateral and Medial pterygoid muscles. An important anatomical relationship to appreciate is the Lateral pterygoid muscle inserts directly into the TMJ complex. Patients with Lateral pterygoid muscle pain often have TMJ pain for this reason. We will now review basic anatomy of the TMJ complex. We can appreciate the close proximity of the Mandibular condyle. Which is the portion of the mandible that is part of the TMJ complex and is capable of rotational and translational movement to the external auditory meatus which is the entrance to the ear canal. Note the relative round smooth structure of the condylar head. The Glenoid fossa is part of the temporal bone of the skull that constitutes part of the TMJ complex. The Articular eminence is a bony structure that serves as the ram for condylar dismovement. The bowtie shaped structure between the Articular eminence and the condyle is the articular disc which has a major role in TMJ function. Lastly, we can see the Lateral pterygoid muscle inserting directly into the TMJ complex as mentioned previously. We will now focus our attention on the questions that are relevant to ask a patient if they are complaining of pain with a suspected TMD origin. By asking these questions the clinician can gain a better understanding of the patient’s complaints. And determine if the pain the patient is experiencing is due to TMD or another type of oral facial pain. When performing a TMD focused history, the clinician should ask questions in an efficient but empathetic manner. It is important to consider the emotional state of the patient as their pain may alter their typical demeanor or exacerbate a psychological condition. The patient should be asked about the onset of pain symptoms. Has the problem developed during the past few days to weeks? Or has this been occurring for several months to years? The patient's response to this question will help to determine if this is an acute or chronic condition. The patient should be asked about history of trauma. Common traumatic events that may precipitate TMDs are direct injuries to the face or jaw, or having the jaw opened for an extended period of time for dental treatment. The response to this question will help to determine if further evaluation for bone fractures, or soft tissue trauma is warranted. The patient should be asked about the type and quality of their pain. Many TMD patients complain of a dull throbbing ache or fatigue sensation in the face or jaw. Others complain of sharp pain in the ear area. These types of pain often present in combination, and understanding the type and quality of oral facial pain the patient is experiencing will help guide the clinician towards the appropriate diagnosis. The patient should be asked about timing of the pain. TMD patients typically complain of increasing pain in the evening after using their jaw throughout the day. Alternatively, some TMD patients will complain of pain upon waking which is usually attributed to sleep para functions such as tooth grinding. The patient should be asked about pain with jaw function and eating certain types of food. TMD patient's often report increased jaw pain with increased jaw function, as well as eating chewy or hard textured foods. If the patient with suspected TMD tells you their jaw pain is not effected by jaw movement or does not get worse with eating chewy foods, the clinician should consider oral facial pain conditions other than TMD in their differential diagnosis. It is important to ask the patient if they are aware of any joint noises such as clicking, popping or crunching. If the patient does report any of these sounds, it may be indicative of a TMJ articular disc disorder or arthritic condition affecting the TMJ. Also, if the patient reports they have previously experienced joint clicking and it is no longer present, it may alert the clinician to a possible TMJ disc disorder that was physiologic that has now become pathologic. Obtaining a history of parafunctional habit is often challenging. As many TMD patients perform this activity while sleeping. So they are unaware of the habit. You can ask the patient if they wake up with joint or facial pain. As this is highly suggestive of sleep parafunction. Also you may ask the patient if a bed partner has ever told them they observed jaw movement, or have heard teeth grinding sounds while the patient is asleep. Some patients continuously clench their teeth during the daytime, which is also considered a parafunctional habit. If the patient reports a history of jaw locking, you should ascertain the frequency of this occurrence and associated symptomatology. Clinicians may consider different therapeutic approaches in patients who report infrequent episodes of locking that are non-painful. Compared to that patient who experiences jaw locking multiple times per day, accompanied by severe pain. Clinicians who treat patients with TMD understand that certain Comorbid conditions may impact the patient's symptoms and prognosis. This information is typically obtained when reviewing the patient's medical history. But is important to query the patient regarding Comorbid conditions in the context of TMD. We will discuss Comorbid conditions that impact TMD in the next slide. Finally, it is critical for clinicians to understand what types of TMD evaluations the patient has already completed, if any specific diagnosis has been rendered, and what treatments has the patient already received for management. The patient with an acute history of TMD symptoms that has not had extensive clinical investigations or many types of therapeutic recommendations often requires management strategies vastly different than the patient with a 20 year history of TMD who has seen multiple health care providers, completed extensive diagnostic testing, and has been treated unsuccessfully with multiple types of therapy. The latter scenario is common in orofacial pain practices and managing patients who report these types of experiences is often challenging for the clinician. As mentioned previously, there are Comorbid conditions that have an impact on TMD. It is important to determine if patients with TMD have any of these conditions as it may influence management of the condition and treatment outcomes. These Comorbid conditions can be divided into centrally acting and peripherally acting categories. Fibromylagia, widespread pain disorders, Complex Regional Pain Syndrome, headaches, anxiety, depression, and sleep disturbance are all considered centrally acting conditions. You should recognize a few of these conditions as access two factors. Those conditions considered periphally acting include parafunctional habit, postural tension, and trauma. What are the implications of these comorbid conditions on TMD? As previously mentioned, they can have a major impact on evaluation, diagnosis, and management. They increase the risk of TMD progressing from an acute to chronic condition. They have been implicated in delayed or incomplete recovery of TMD with standard treatments. They can affect central pain mechanisms and or regulation. They act peripherally to cause direct muscle and or TMD injury. I've stressed throughout this entire segment, these comorbid conditions should be addressed appropriately and given consideration when formulating a TMD treatment plan to promote and improve outcomes. In the next segment, we will discuss clinical examination techniques and specific types of TMDs.
