Richard R. Riggs, DDS

2. Practice Philosophy Most of our time is consumed with evaluating clinical problems and then verifying these with the patient Biopsychosocial: we should look at patients as a whole unit. This is basically getting to know your patients. Conservative: this approach will allow us not to “over-treat” patients Reversible: treatments are best applied if they can be removed or reversed. Team Approach: you will not be able to handle all of these patients yourself Manage vs Cure: patients are managed, not usually cured of their problems. Some interarticular problems are more easily managed. Escalation: approximately 80% of patients will see improvement with 20% of our protocols

3. Goals of the TMD Section of the Course Foundation of Knowledge: understand all aspects of tissues and systems. Must know function before you know dysfunction. Differentially Diagnose: be discerning in your analysis Patient Evaluation: take your time Patient expectations: Available Treatments Limitations: know that these exist Expectations: these must be on the same wavelength as what treatment the clinician will present. An example is recapturing the articular disc. Patients may expect that this will be accomplished, but the clinician must inform the patient of the low likelihood of this happening Referral Protocol: there must always be an avenue for you to send patients to a more experienced practitioner

4. Temporomandibular Disorders (TMD) Many times it is exhibited as a cluster of related disorders There can be a musculoskeletal (internal derangements) and/or rheumatologic origin The masticatory system is always directly or indirectly involved

5. TMD: Epidemiology Scandanavian study: Most problems are with joint noises and jaw deflection. Non-patient populations greater than 18 years old 40-75%: one clinical sign is evident 50% of the population will exhibit sounds and/or deviation (much more so than in patients under 18 years of age Less than 5% have limited opening 33% of the population has one symptom Approximately 10% of those greater than 18 years of age will exhibit pain

6. TMD: Epidemiology Non-patient populations that are less than 18 years of age: 17-27% will exhibit one clinical sign (usually clicking) 17.5% exhibit joint sounds Less than 5% will experience limited opening 33% will have one symptom Approximately 10% will have pain (very low percentage)

7. Prevalence Non-pain patients Utilizing the Helkimo Index: Signs and Symptoms are about 1:1 in males and females As seen individually: Females exhibit greater signs than males Headache, Joint noise, TMD & muscle pain

8. TMD Signs & Symptoms

9. Age and Sex Distribution

10. Pain Clinic Populations

11. General Population

12. Adaptation Normal Adaptation Pathology

13. Signs & Symptoms

14. Related Signs/Symptoms

15. Etiology Trauma: only item in the literature that is precipitating for development of joint problems Direct: easily identifiable because it occurred recently Only supported initiating factor 24-72 hr onset after the acute trauma Long dental appointment; 3rd molar extractions; intubation during general anesthesia Indirect Whiplash Post injection trismus: more relevant than whiplash injuries MRI’s and radiographs and non-predictive Micro Bruxism: seen in 90% of the population. Actually is common in children because of jaw development issues Less than 5% of bruxism patients develop pain

16. Adaptation Normal Injury/Pathology Adaptation + - Successful adaptation is expected in most patients over time

17. Etiology Anatomical Skeletal Retrognathia Steep eminence or even a deep vertical overlap Occlusal Non-working contacts; CR-MI slide; tooth loss; overclosed vertical dimension; occlusal guidance; deep bite; anterior open bite; excessive overjet; crossbite relationships; Occlusal slide may be a protective mechanism, according to some researchers. Not much science behind these etiologies. Treating occlusal interferences are temporary, at best. Conservation is the key.

18. Risk factors for specific occlusal findings Slide from RCP to ICP is greater than 2mm Osteoarthrosis; muscle pain Unilateral posterior crossbite Disc displacement Overjet is greater than 6mm Osteoarthrosis; muscle pain > 6 missing posterior teeth Internal derangement; Osteoarthrosis Long centric leads to osteoarthrosis and muscle pain. Anterior open bite Osteoarthrosis; muscle pain

19. Etiology Pathophysiologic Systemic Connective Tissue disease (the joint is basically connective tissue); infection; metabolic; endocrine; neurological; vascular; generalized joint laxity Co-morbidity: these are more difficult to treat because they complicate the scene These patients don’t usually develop jaw problems. Kids that exhibit mouthbreathing….they typically grind their teeth. Relationship between retrognathic issues in these kids. Local Genetic

20. Etiology Pathophysiologic Systemic Local Chewing efficiency; impairment threshold < 3 posterior teeth Cervical muscle activity (much pain) effects jaw muscles in a secondary manner Disc displacement without reduction (DDw/oR) leads to Osteoarthrosis; parallel but independent course Disc displacement with reduction (DDwR): 50% leads to OA but no histological changes Synovial fluid viscosity; loss of weeping lubrication Increased intracapsular pressure = decreased range of motion (ROM); leads to less nutrition, waste removal, growth leads to advanced TMD Early sign of joint problems No association of pain/dysfunction with disc position Genetic

21. Etiology Pathophysiologic Systemic Local Genetic: Familial trait is evident, but not well studied and no test is yet available to detect these problems. For example, skeletal relationships and sick parents generally have sick kids. It is also generally learned from parents. Although anatomical, physiological and psychosocial factors are heritable traits, research is lacking for specific markers associated with the development of TM disorders at this time

22. Etiology Psychosocial Individual, interpersonal, situational variables affect TMD patients capacity to adapt Similar traits as other pain patients (back pain) More anxiety and emotional distress Increased sympathetic activity = muscle pain Attention focused on pain = increased pain levels 20 gain External locus of control: they depend on someone else to fix the problem

23. Contributing Factors (Fricton) Behavioral sleep, posture, diet, bruxism, alcohol, smoking, exercise Social work, home, 20 gain, finances, litigation Cognitive locus of control, expectations, low self-esteem Emotional depression, anxiety, worry, fear, anger Biological hormonal, surgery, trauma, genetic Environmental weather, allergens, chemicals, water/air pollutants

24. Etiology (summary) All theories (except trauma) are primary contributing factors that exacerbate or perpetuate pre-existing conditions Occlusal findings are a result of TMD vs. causing TMD: This is why we do not have to treat clicking problems, unless the patient is having range of motion or pain. Conservative treatment always rules. Proposed findings of all theories are seen in greater percentage of non-TMD populations HEALTH IS SUCCESSFUL ADAPTATION: All of us are in some stage of adaptation. If we did not adapt, we would not be able to treat.

25. Differential DiagnosisofOrofacial Pain Richard R. Riggs, D.D.S. Diplomat: American Board of Orofacial Pain Fellow: American College of Dentists Fellow: International College of Dentists Weldon Bell’s books. Attorneys purchase these books more than dentists do.Weldon Bell’s books. Attorneys purchase these books more than dentists do.

26. Differential Diagnosis The determination of one of two or more conditions a patient is suffering from by systematically comparing and contrasting their historical and clinical findings.

27. Sources of Orofacial Pain Intracranial Pain Disorders Primary Headache Disorders Neurogenic Pain Disorders Intraoral Pain Disorders Temporomandibular Disorders (our focus in this course) Associated Structures Axis II, Mental Disorders

28. Labeling Bias A mental set that perpetuates a self-fulfilling prophecy. Rule out the diagnoses that do not fit. DO NOT rule in the diagnosis that supports your prejudices.

29. Avoiding Labeling Bias

31. DDX Right muscle splinting sub-condylar fracture Osteoarthrosis acute disc displacement with an acquired occlusal position shoulder neck Left muscle splinting (usually non-painful) condylar hyperplasia abscess Trigeminal motor lesion Parotitis Condylar subluxation Spasm of the lateral pterygoid muscle Answers to previous slide.Answers to previous slide.

32. Intracranial Pain Disorders Vascular (usually, these patients are seeing a physician for the problems listed below) TIA (speech difficulty is exhibited) Subarachnoid Hemorrhage Arteritis (in elderly populations) Nonvascular Pseudotumor cerebri (benign intracranial hypertension) Low cervical spinal fluid pressure Neoplasms Infections

33. Primary Headache Disorders Migraine Tension-type Cluster Not associated with structural lesions Trauma Vascular Non-vascular Substances or withdrawal Non-cephalic infection Metabolic disorders Disorders of cranial structures Neurogenic

34. Neurogenic Pain Disorders Paroxysmal (intermittent) Trigeminal Neuralgia Glosso-pharingyeal neuralgia Nervus Intermedius Superior Laryngeal Occipital Continuous (usually due to nerve damage or blood flow to the area that creates an ischemia) Deafferentation Post-herpetic Post-surgical Multiple Sclerosis Diabetic neuropathy Tolosa-Hunt (eye)

35. Intra-oral Pain Disorders Pulpal Visceral, threshold, poorly localized, pain > stimulus Reversible = pain duration short Irreversible = pain duration long Fracture ; pain on release > biting pain No bite changes or mobility, percussion negative Periodontal Musculoskeletal, gradient, well localized, pain = stimulus Bite changes, mobility, percussion positive Swelling, fistulas, tissue color changes

36. Intra-oral Pain Disorders Mucogingival and glossal ANUG Apthous ulcers (stomatitis) Herpetic gingivostomatitis Candidiasis Pseudomembranous Atrophic Hypertrophic/hyperplastic Angular cheilitis Trauma Cancer Burning mouth syndrome Geographic tongue Medication side effect Xerostomia Contact stomatitis; fixed-drug erruption Dermatological Erythema multiforme; lichen planus; pemphigus (oid); lupus Systemic Diabetes; uremia; crohns; leukemia; cytopenia; agranulocytosis cyclic neutropenia; sickle cell anemia

37. Temporomandibular Disorders Extra-articular (all muscle) Intra-articular (within the joint) Synovitis DDWR (disc displacement with reduction) DDWOR (disc displacement without reduction) Osteoarthrosis Rheumatoid arthritis Condylar subluxation

38. Associated Structures Eyes Tolosa-Hunt Glaucoma Ears Otitis Externa Nose Sinusitis Throat Tonsillitis Eagle’s Syndrome Lymphatics Lymphoma Lymphadenopathy Salivary Glands Infections Calculi

39. Associated Structures Cervical Spine C2-3 Trigeminal Spinal Tract Nucleus: C3 Forward Head Posture: your neck posture influences your jaw posture. We really should not be checking a patient’s occlusion lying down, because they do not eat lying down. Osteoarthritis Ankylosing Spondylitis Cervical Strain

41. Axis II, Mental Disorders Somatization Disorder (Briquet’s) Conversion Disorder Hypochondriasis Body Dysmorphic Disorder Factitious Disorders (hypochondriac) Malingering PTSD

42. Nonodontogenic Tooth Pain Sinus Salivary glands Tongue Periodontium Oral soft tissues Viral Heart TMJ Muscle Tumor Neck C2-3 Vascular Neuropathic Continuous Intermittent

43. Variables Location: Source or Site Intensity: VAS, NAS Quality: McGill Timing: Patterns Frequency: Day, x/wk, x/mo, x/yr. Duration: On and off Modifiers: Increase/decrease Pain

44. Location

45. Intensity

46. Quality (descriptor) of Pain Throbbing, pounding, pulsing Flashing, shooting, traveling Sharp, ice-pick, cutting Pressure, cramping, tight Hot, burning, searing Dull, aching, heavy Numb, cold, swollen

47. Timing

48. Frequency Day Week Month Quarter Year

49. Duration Relief continuous seconds minutes hours days weeks months years none seconds minutes hours days weeks months years

50. Pain Modifiers opening mouth yawning closing mouth eating kissing talking singing moving jaw side to side moving jaw forward clenching teeth together bending forward lying down cold inside mouth heat inside mouth cold on face heat on face exercise neck movements shoulder movements sleep tension or anxiety other - describe

51. Timeline

53. Extra-capsular Location - diffuse, muscular, uni- & bilateral Frequency - cyclical, undulates Duration - steady, minutes to days Intensity - mild to moderate Quality - dull, aching, heavy, full, swollen, moves Timing - associated with jaw function Comments - anxiety, fatigue, stress, overuse of jaw, poor sleep, bruxism, avoids muscle use

54. Intra-capsular Location - localized, unilateral, preauricular Frequency - sporadic, cyclical, constant Duration - momentary to constant Intensity - painless to severe Quality - sharp, stabbing, dull, annoying, pulling Timing - associated with jaw function Comments - a noisy joint doesn’t necessarily need treatment

55. Stages of Intracapsular Disorders Clicking with function only Reciprocal clicking Intermittent locking Open locking Acute closed lock Soft tissue remodeling Hard tissue remodeling

56. DDx of Clicking Early opening click Late opening click Late opening thud Deviation in form Partial disc displacement Disc displacement with reduction

57. History Format Chief Complaint History of Present Illness Medical History Dental History Psychosocial History

58. Chief Complaint Record in the patient’s words Interpret Separate each complaint Prioritize each complaint

59. Patient Interview Reviewing the history the patient has completed prior to their appointment. Allows you and the patient to be “on the same page”. Allows you to observe patients demeanor. Expand on areas that are “sketchy”. Formulate a timeline.

61. Time Management

62. Miscellaneous

63. The End