Unit 6 - Craniomandibular

Pathoanatomy: Temporomandibular Joint Pain with Mobility Deficits

What is the proposed underlying cause of the condition?

• Arthralgia (capsulitis/synovitis)

• Capsular fibrosis

• Osteoarthritis

• Disk displacement without reduction

Pathoanatomy: TMJ Pain with Mobility Deficits

What is the proposed underlying cause of the condition?

Arthralgia (capsulitis/synovitis)

Inflammatory condition of the capsule and extracapsular articular soft tissue

Pathoanatomy: TMJ Pain with Mobility Deficits

What is the proposed underlying cause of the condition?

Capsular fibrosis

Loss of capsular mobility

Pathoanatomy: TMJ Pain with Mobility Deficits

What is the proposed underlying cause of the condition?

Osteoarthritis

Progressive degeneration of the articular cartilage

Pathoanatomy: TMJ Pain with Mobility Deficits

What is the proposed underlying cause of the condition?

Disk displacement without reduction

• Displacement of the articular disk anterior to the condyle blocking further anterior translation

• Progressed from disk displacement with reduction and hypermobility

Medical Screening: TMJ Pain with Mobility Deficits

What other conditions should be considered with this patient presentation?

Viscerogenic

• Neoplastic conditions

• Inflammatory or systemic disease

• Cardiopulmonary conditions

• Cervical vascular pathology

Medical Screening: TMJ Pain with Mobility Deficits

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Spinal fracture

• Cervical myelopathy

• Upper cervical ligamentous instability

Medical Screening: TMJ Pain with Mobility Deficits

What other conditions should be considered with this patient presentation?

Psychological

• Anxiety

• Depression

Differential Diagnosis: TMJ Pain with Mobility Deficits

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Neck pain with headache

• Trigeminal neuralgia

Trigeminal neuralgia

condition that leads to neuropathic symptoms in the face, in the distribution of the trigeminal nerve, and should be considered

Differential Diagnosis: TMJ Pain with Mobility Deficits

What other conditions should be considered with this patient presentation?

Primary headache

• Migraine

• Tension-type

Differential Diagnosis: TMJ Pain with Mobility Deficits

What other conditions should be considered with this patient presentation?

Dental conditions

might require outside referral

Subjective Examination: TMJ Pain with Mobility Deficits

What system, structure, pain mechanism, and phases of healing are unique to this patient presentation?

• System

  • Neuromusculoskeletal

• Structure

  • Temporomandibular joint and periarticular soft tissue

• Pain mechanism

  • Nociceptive, nociplastic

• Phase of healing

  • Muscle strain 2-4 weeks, capsule sprain and cartilage injuries 10-12 weeks

Subjective Examination: TMJ Pain with Mobility Deficits

What are common subjective reports for patients with mobility deficits?

Arthralgia

• Recent history of parafunctional oral habits or trauma

• May be gradual or immediate onset

• May report tenderness to palpation

• Symptom reproduction with biting on the contralateral side

• No current joint sounds if in isolation

Subjective Examination: TMJ Pain with Mobility Deficits

What are common subjective reports for patients with mobility deficits?

Capsular fibrosis

• History of trauma, disk displacement without reduction, or immobilization

• Gradual onset

• Will report limited mouth opening

• No current joints sounds, may have a previous history of end rage or mid range clicks

• May be pain-free

Subjective Examination: TMJ Pain with Mobility Deficits

What are common subjective reports for patients with mobility deficits?

Osteoarthritis

• History of trauma, disc displacement without reduction

• Older age with gradual onset

• Crepitus currently, may have a previous history of end rage or mid range joint sounds

• May report tenderness to palpation and limited mouth opening

• Radiographic evidence of osteoarthritis

Subjective Examination: TMJ Pain with Mobility Deficits

What are common subjective reports for patients with mobility deficits?

Disk displacement without reduction

• History of disc displacement with reduction and hypermobility

• Previous history of reciprocal mid range and end range joint sounds

• No current joint sounds

• History of joint locking or catching

• Acutely will have a sudden loss of range of motion

• Chronically range of motion may be normal

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Systems Review: Cardiopulmonary

• Vitals – BP, HR, auscultate

• Assess for mechanical reproduction of symptoms and/or adverse response to movement

• AROM, PIVM, compression/distraction

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Systems Review: Neuromusculoskeletal

• Cranial nerves

• Reflexes/pathological reflexes

• Dermatomes/myotomes

• Upper cervical ligamentous testing

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Structural examination

Dental occlusion

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Palpation examination

• Tenderness to palpation of the lateral condyle and/or posterior compartment

• Point tenderness may include myofascial trigger points if concurrent myalgia

• Increases resting tone of superficial cervical muscles and muscles of mastication

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Specific Tests and Measures: Movement and provocation examination

• Cervical clearing examination

• TMJ active range of motion

• TMJ passive accessory testing

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Cervical clearing examination

• Active range of motion

• Passive intervertebral motion

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

TMJ active range of motion

• May see limited range of motion due to pain and/or joint hypomobility

• Deviation towards ipsilateral side with opening and protrusion

• Limited contralateral lateral excursion

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

TMJ passive accessory testing

Possible reproduction of symptoms and joint hypomobility

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Specific Tests and Measures: Orthopaedic examination tests

• Forced retrusion (compression) TMJ provocation test

• Forced biting provocation test (dental stick test)

• Auscultation of the TMJ

• Muscles of mastication isometric resistive provocation test

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Forced retrusion (compression) TMJ provocation test

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Forced biting provocation test (dental stick test)

• Arthralgia, osteoarthritis

• Reproduction of symptoms – contralateral side

• Sn 0.71, Sp 0.77; +LR 3.09

  

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Auscultation of the TMJ

• Osteoarthritis

• Sn 0.70, Sp 0.43; +LR 1.23 –LR 0.70

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Muscles of mastication isometric resistive provocation test

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Specific Tests and Measures: Muscle performance examination

• Muscle recruitment and endurance

• Muscle length testing

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Muscle recruitment and endurance

• Deep neck flexors and extensors

• Parascapular muscles

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Muscle length testing

Cervicoscapulothoracic muscles

Objective Examination: TMJ Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Test-item cluster (Disk displacement without reduction)

• Dental stick test

• Isometric test

• Joint provocation test

• Joint sound test (crepitus)

• Deviation with mandibular opening

• Limited contralateral lateral excursion

• Limited anterior glide accessory test

• 5/7 positives Sn 0.71, Sp 0.91; +LR 7.89

Prognosis: TMJ Pain with Mobility Deficits

What is the prognosis of the condition?

Clinical course and prognosis

• Minimal evidence to project clinical course and prognosis for conservative management

• Intraoral devices demonstrate inferior effectiveness to manual therapy

• Only 50% of patients after TMJ arthroplasty report a favorable outcome

Interventions: TMJ Pain with Mobility Deficits

What are interventions recommended for mobility deficits?

• Education

• Exercise

• Manual therapy

Interventions: TMJ Pain with Mobility Deficits

What are interventions recommended for mobility deficits?

Education

• Cessation of parafunctional oral habits

• Mouth resting position

• Limit positions that load the joint

• Soft diet and small bites

Interventions: TMJ Pain with Mobility Deficits

What are interventions recommended for mobility deficits?

Exercise

• Exercises that promote range of motion and mobility of the TMJ

• Impairment-based approach to address cervicoscapulothoracic mobility, flexibility, endurance, neuromuscular control, and strength

• Rocabado 6x6

Rocabado 6x6

a common set of exercises that ask the patient to perform six cervical spine and timber temporomandibular joint exercises, six times per day for six repetitions

Interventions: TMJ Pain with Mobility Deficits

What are interventions recommended for mobility deficits?

Manual therapy

• Mobilization of the TMJ

• Mobilization and manipulation of the cervicothoracic spine

Interventions: TMJ Pain with Mobility Deficits

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

• Imaging

• Medical Intervention

• Psychological

Interventions: TMJ Pain with Mobility Deficits

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

Imaging

• Radiograph necessary to confirm osteoarthritis

• Indicated only when a non-musculoskeletal condition is suspected to failure of conservative management where imaging may change the course of care

Interventions: TMJ Pain with Mobility Deficits

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

Medical Intervention

• Medications

• Injections

• Intra-oral appliances

• Arthroplasty

Interventions: TMJ Pain with Mobility Deficits

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

Psychological

• Counseling

• Meditation

• Biofeedback

Pathoanatomy: TMJ with Movement Coordination Impairments

What is the proposed underlying cause of the condition?

• Hypermobility

• Disk displacement with reduction

• Mylagia

Pathoanatomy: TMJ with Movement Coordination Impairments

What is the proposed underlying cause of the condition?

Hypermobility

• Increased extensibility and laxity of the passive stabilizing elements of the joint

• May be congenital or acquired through repetitive strain to the capsule and posterior and collateral ligaments

Pathoanatomy: TMJ with Movement Coordination Impairments

What is the proposed underlying cause of the condition?

Disk displacement with reduction

• Displacement of the articular disk anteriorly that reduces

• Progression from hypermobility

Pathoanatomy: TMJ with Movement Coordination Impairments

What is the proposed underlying cause of the condition?

Mylagia

• Painful guarded muscles of mastication (masseter, temporalis, lateral pterygoid) with taut bands and myofascial trigger points

• Parafunctional habits, joints conditions, stress and anxiety, nociplastic pain

Medical Screening: TMJ with Movement Coordination Impairments

What other conditions should be considered with this patient presentation?

Viscerogenic

• Neoplastic conditions

• Inflammatory or systemic disease

• Cardiopulmonary conditions

• Cervical vascular pathology

Medical Screening: TMJ with Movement Coordination Impairments

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Spinal fracture

• Cervical myelopathy

• Upper cervical ligamentous instability

Medical Screening: TMJ with Movement Coordination Impairments

What other conditions should be considered with this patient presentation?

Dental conditions

• need to be screened

• might mimic temporomandibular dysfunction

Medical Screening: TMJ with Movement Coordination Impairments

What other conditions should be considered with this patient presentation?

Psychological

• Anxiety

• Depression

Differential Diagnosis: TMJ with Movement Coordination Impairments

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Neck pain with headache

• Trigeminal neuralgia

Differential Diagnosis: TMJ with Movement Coordination Impairments

What other conditions should be considered with this patient presentation?

Primary headache

• Migraine

• Tension-type

Subjective Examination: TMJ with Movement Coordination Impairments

What system, structure, pain mechanism, and phases of healing are unique to this patient presentation?

• System

  • Neuromusculoskeletal

• Structure

  • Temporomandibular joint and periarticular soft tissue

• Pain mechanism

  • Nociceptive, nociplastic

• Phase of healing

  • Muscle strain 2-4 weeks, capsule sprain and cartilage injuries 10-12 weeks

Subjective Examination: TMJ with Movement Coordination Impairments

What are common subjective reports for patients with movement coordination impairments?

Hypermobility

• May have history of parafunctional oral habits

• During end range opening may report a click

• Generally asymptomatic unless combined with a myalgia or arthralgia

• Can report pain with end range opening activities like eating or yawning

Subjective Examination: TMJ with Movement Coordination Impairments

What are common subjective reports for patients with movement coordination impairments?

Disk displacement with reduction

• History of joint hypermobility

• Presence of reciprocal mid range click

• Previous history of reciprocal end range joint sounds

• No report of range of motion loss unless combined with myalgia or arthralgia

Subjective Examination: TMJ with Movement Coordination Impairments

What are common subjective reports for patients with movement coordination impairments?

Mylagia

• May have a history of parafunctional oral habits, stress and anxiety, or nocipalstic pain conditions

• May have history of other temporomandibular joint conditions with associated symptoms

• No joints sound if occurring in isolation

• Pain with palpation of the involved muscles or eating and chewing

• May have painful, limited opening if masseter and temporalis are involved

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Systems Review: Cardiopulmonary

• Vitals – BP, HR, auscultate

• Assess for mechanical reproduction of symptoms and/or adverse response to movement

  • AROM, PIVM, compression/distraction

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Systems Review: Neuromusculoskeletal

• Cranial nerves

• Reflexes/pathological reflexes

• Dermatomes/myotomes

• Upper cervical ligamentous testing

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Structural examination

Dental occlusion

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Palpation examination

• Tenderness to palpation of the lateral condyle and/or posterior compartment

• Point tenderness may include myofascial trigger points if concurrent myalgia

• Increases resting tone of superficial cervical muscles and muscles of mastication

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Movement and provocation examination

• Cervical clearing examination

• TMJ active range of motion

• TMJ passive accessory testing

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Cervical clearing examination

• Active range of motion

• Passive intervertebral motion

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

TMJ active range of motion

• End range or reciprocal click possible

• Aberrant motions common

• May see limited range of motion due to pain or could be full to hypermobile

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

TMJ passive accessory testing

Possible reproduction of symptoms and joint hypermobility

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Orthopaedic examination tests

• Forced retrusion (compression) TMJ provocation test

• Forced biting provocation test (dental stick test)

• Auscultation of the TMJ

• Muscles of mastication isometric resistive provocation test

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Forced retrusion (compression) TMJ provocation test

Reproduction of symptoms – Joint

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Forced biting provocation test (dental stick test)

• Pain on opposite side – Joint

• Pain on same side or bilateral – Muscle

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Auscultation of the TMJ

Joint sounds during midrange or end range active range of motion

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Muscles of mastication isometric resistive provocation test

• Masseter and temporalis

  • Limited, painful opening and pain with power stroke

  • Pain-free resisted lateral excursion and protrusion

• Lateral pterygoid

  • Full, pain free opening

  • Pain with resisted protrusion and power stroke

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Muscle performance examination

• Muscle recruitment and endurance

• Muscle length testing

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Muscle recruitment and endurance

• Deep neck flexors and extensors

• Parascapular muscles

Objective Examination: TMJ with Movement Coordination Impairments

What are the key examination procedures for patients with movement coordination impairments?

Muscle length testing

Cervicoscapulothoracic muscles

Prognosis: TMJ with Movement Coordination Impairments

What is the prognosis of the condition?

Clinical course and prognosis

• Minimal evidence to project clinical course and prognosis for conservative management

• Intraoral devices demonstrate inferior effectiveness to manual therapy

• Only 50% of patients after TMJ arthroplasty report a favorable outcome

Interventions: TMJ with Movement Coordination Impairments

What are interventions recommended for movement coordination impairments?

• Education

• Exercise

• Manual therapy

Interventions: TMJ with Movement Coordination Impairments

What are interventions recommended for movement coordination impairments?

Education

• Cessation of parafunctional oral habits

• Mouth resting position

• Limit positions that load the joint

• Soft diet and small bites

Interventions: TMJ with Movement Coordination Impairments

What are interventions recommended for movement coordination impairments?

Exercise

• Exercises that promote proprioception and neuromuscular control

• Impairment-based approach to address cervicoscapulothoracic mobility, flexibility, endurance, neuromuscular control, and strength

• Rocabado 6x6

Interventions: TMJ with Movement Coordination Impairments

What are interventions recommended for movement coordination impairments?

Manual therapy

• Soft tissue manipulation and dry needling

• Joint mobilization and manipulation of the TMJ and cervicothoracic spine

Interventions: TMJ with Movement Coordination Impairments

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

• Imaging

• Medical Interventions

• Psychological

Interventions: TMJ with Movement Coordination Impairments

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

Imaging

• Radiograph necessary to confirm osteoarthritis

• Indicated only when a non-musculoskeletal condition is suspected to failure of conservative management where imaging may change the course of care

Interventions: TMJ with Movement Coordination Impairments

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

Medical Intervention

• Medications

• Injections

• Intra-oral appliances

• Arthroplasty

Interventions: TMJ with Movement Coordination Impairments

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

Psychological

• Counseling

• Meditation

• Biofeedback