TMJ Dysfunciton

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TMJ Dysfunciton
  INFORMATION FOR CANDIDATE  Your next patient in general practice is a 33 year old Mr. James Thornton who has been complaining about recurrent pains on the right side of his face, especially when talking or chewing. Sometimes he feels some clicking / crepitus over the joint where his lower and upper jaw Meet. The pain radiates sometimes towards the ear, other times down into the lower jaw or forwards into his cheek or even back into his neck. YOUR TASK IS TO:      Take a focused history    Examine the patient    Arrange for appropriate investigations    Discuss the most likely diagnosis and management with the patient  HOPC:  For a number of years James has experienced now increasing episodes of pains in his right side of the face. It started on chewing with a dull pain but now it also happens when he talks and sometimes he can feel a clicking sensation or a crepitus in the joint where the upper and lower jaw meet. The pain radiates in all sort of directions, towards the ear, down to the angle of the lower jaw, forward to his cheek or back into his neck and even the shoulder. He also noticed that his bite feels uncomfortable and different from usual. His wife has commented that he seems to be clenching and grinding (bruxism) his teeth in his sleep a lot. PHx.:  unremarkable, especially no trauma to his jaw! FHx.:  normal SHx:  married high school teacher with two children, no problems, non smoker, non drinker, NKA, no medication. EXAMINATION:  normal general appearance and vital signs.    restricted jaw opening (normal range is at least 40 mm as measured from lower to upper anterior teeth)     palpable spasm of facial muscles (masseter and internal pterygoid muscles)    Unilateral facial swelling    Clicking or popping in the TMJ    Tenderness to palpation of the TMJ via the external auditory meatus (the tips of the fingers placed behind the tragi at each external acoustic meatus and pulled forward while the patient opens the jaw)    Crepitus over joint    Lateral deviation of mandible INVESTIGATIONS: 1.   Laboratory Studies:  No laboratory studies are specifically indicated to rule in temporomandibular joint (TMJ) syndrome; however, appropriate laboratory samples may be drawn to help rule out other disorders. o   Complete blood count (CBC), if infection is suspected o   Calcium, phosphate, or alkaline phosphatase, for possible bone disease o   Uric acid if gout is suspected o   Serum creatine and creatine phosphokinase, indicators of muscle disease o   Erythrocyte sedimentation rate if temporal arteritis is suspected and rheumatoid factor if rheumatoid arthritis is suspected 2.   Imaging Studies   o   An orthopantamogram may show a fracture, evidence of osteoarthritis, or displacement of the articular disk. o   Plain radiographs may demonstrate resting and hinge movement of the TMJ. o   CT scan may reveal greater detail of bones than radiographs alone. o   MRI is the test of choice when looking for disk displacement or pathology.  DIAGNOSIS: TEMPORO MADIBULAR JOINT (TMJ) DYSFUNCTION   The temporal mandibular joint (TMJ) is the synovial joint that connects the jaw to the skull. Each joint is composed of the condyle of the mandible, an articulating disk, and the articular tubercle of the temporal bone. The movements allowed are side to side, up and down, as well as protrusion and retrusion. This complicated joint along with its attached muscles, allows movements needed for speaking, chewing, and making facial expressions. There are 3 distinct causes of pain at the TMJ, which collectively fall under the broader term of TMJ syndrome:      Myofascial pain dysfunction (MPD) syndrome, pain at the TMJ due to various   causes of increased muscle tension and spasm. It is believed that MPD syndrome is a physical manifestation of psychological stress. No primary disorder of the  joint itself is present. Pain is secondary to events such as nocturnal jaw clenching and teeth grinding. Treatment is focused on behavioral modification as opposed to  joint repair.    Internal derangement (ID), where the problem lies within the joint itself, most commonly with the position of the articulating disc    Degenerative joint disease, where arthritic changes result in degeneration of the articulating surfaces Pathophysiology The pathophysiology of temporomandibular joint syndrome is not entirely understood. It is believed that the etiology of TMJ dysfunction syndrome is likely multifactorial and arises from both local insults and systemic disorders. Local problems frequently arise from articular disc displacement and hereditary conditions affecting the structures of the  joint itself, such as hypoplastic mandibular condyles. The TMJs can also be affected by conditions such as rheumatoid arthritis, osteoarthritis,  and diseases of the articular disks. In addition, hypermobile TMJs, nocturnal jaw clenching, nocturnal bruxism, jaw clenching due to psychosocial stresses, and local trauma also play a significant role. The trigeminal nerve innervates the TMJ and surrounding structures explaining the pain and referred pain patterns of TMJ disorders.   Irritation of the mandibular branch (V3) of the trigeminal nerve results in pain locally at the TMJ and also to other areas of V3 sensory innervation, which include the ipsilateral skin, teeth, side of the head, and scalp. Female-to-male ratio is roughly 4:1, greatest incidence of temporomandibular joint (TMJ) syndrome is in adults aged 20-40 years. DIFFERENTIAL DIAGNOSES:  Dental, Infections, Myopathies,  Dislocations, MandibleOtitis MediaFractures, Mandible   Sinusitis   Gout and Pseudogout   Temporal ArteritisHeadache, Cluster Tick-Borne Diseases, Lyme   Headache, Migraine   Trigeminal Neuralgia   Headache, Tension   MANAGEMENT:  Signs and symptoms of temporomandibular joint (TMJ) disorders improve over time with or without treatment for most patients. As many as 50% of the  patients have symptomatic improvement in 1 year and 85% in 3 years. Conservative management should be attempted before invasive therapies, such as orthodontics or surgery, are recommended. If organic disease such as rheumatoid arthritis and obvious dental malocclusion is excluded, a special set of instructions or exercises can alleviate the annoying problem of TMJ arthralgia in about 3 weeks (John Murtagh). Method 1 'Chewing' the piece of soft wood       Obtain a rod of soft wood approximately 15 cm long and 1.5 cm wide. An ideal object is a large carpenter's pencil.    Instruct the patient to position this at the back of the mouth so that the molars grasp the object with the mandible thrust forward.    The patient then rhythmically bites on the object with a grinding movement for 2-3 minutes at least 3 times a day. Method 2 The 'six by six' program  This is a specific program recommended by some dental surgeons. The six exercises should be carried out six times on each occasion, six times a day, taking about 1-2 minutes. Instruct the patient as follows: 1.   Hold the front one-third of your tongue to the roof of your mouth and take six deep breaths. 2.   Hold the tongue to the roof of your mouth and open your mouth six times. Your  jaw should not click. 3.   Hold your chin with both hands keeping the chin still. Without letting your chin move, push up, down and to each side. Remember, do not let your chin move. 4.   Hold both hands behind your neck and pull chin in. 5.   Push on upper lip so as to push head straight back. 6.   Pull shoulders back as if to touch shoulder blades together. These exercises should be pain-free. If they hurt, do not push them to the limit until pain eases. Method 3 The TMJ 'rest' program  This program is reserved for an acutely painful TMJ condition.    For eating avoid opening your mouth wider than the thickness of your thumb and cut all food into small pieces.    Do not bite any food with your front teeth  —   use small bite-size pieces.    Avoid eating food requiring prolonged chewing, e.g. hard crusts of bread, tough meat, raw vegetables.
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