Making a diagnosis is obtained by carefully evaluating the information derived from the history and examination procedures. But remember that a patient can have more than one disorder at a time. TMJ disorders can be broken down into two general problems: A disc derangement disorder, and/or A masticatory muscle disorder.

Patient is female, 56 yoa, 150 pounds. Accountant that retired about 2 years

ago, selling her accountant firm.

Pt. presents with mild, unilateral pain in her right temporomandibular joint. She states that moving her jaw (opening & clenching) accentuates the pain. She also complains of stiffness. Although mild, the pain is constant but is worse by late afternoon/evening. However, no popping/clicking is heard. Pt. reports that symptoms began about three years ago. Pt. has also noticed some stiffness in her fingers, especially after rest.

Pt. had braces from age 13-16, and wore her retainer until age 24.

Pt. had jaw surgery at age 26 to correct her underbite.

When she was working, she chewed more gum than usual (about 2 packs/day) during March & April, due to higher stress levels.

Pt. was placed in a night guard by her dentist at age 34, due to night bruxism.

Her diet is a standard American diet. Father has history of gout. Mother has

history of diabetes.

Open mouth: ↓, 3 cm (about a knuckle & a ½) w/ pn & lateral deviation to left and return to midline.

Lateral movement to L: ↓, 1 cm w/ pn. Lateral movement to R: WNL, 2 cm no pn. Protrusion/Retraction: NAD, no pn. Muscle testing Temporalis & Massester: weak/not

able to produce full resistance on right; pn upon clenching (pn produced w/ normal loading of joints).

Auscultation: crepitus noted. Palpation: no popping/clicking. Intraoral palpation of temporal tendon: no pn. Stiffness in fingers is isolated to PIP’s.

1. Gouta. M/C in big toe but can affect TMJ; typically in older individuals; pn

may or may not be increased with movement; symptoms are typically bilateral; dietary changes increase symptoms.

2. Rheumatoid Arthritisa. M/C in hands but can affect TMJ; typically bilateral; 50% of pts w/ RA have TMJ complaints; pt will present with multiple joint complaints.

3. Temporal Tendonitisa. d/t constant & prolonged activity of the temporalis muscle; muscle hyperactivity can be 2 B to bruxism, increased emotional stress, etc.; typically unilateral aggravated by jaw function (chewing, yawning); limited jaw opening.

4. Osteoarthritis/DJDa. Occurs when joint is overloaded or disc dislocation; typically unilateral; aggravated by mandibular movement.

Gold Standard : CT MRI is also useful to confirm disc

displacement, but under diagnosis of osseous changes.

Noted: Flattening/Lipping of condyle Erosions Osteophytic formation ↓ joint space

Figure 1. Bilateral closed-mouth–related magnetic resonance images, or MRIs, in a patient with right side–related temporomandibular joint, or TMJ, pain. A–B. Left TMJ that does not have internal derangement or osteoarthrosis, or OA. A. Sagittal MRI shows posterior band of the disk (arrows) superior to condyle. B. Coronal MRI shows disk superior to condyle (arrows). C–D. Right TMJ with OA and anterolateral disk displacement without reduction. C. Sagittal MRI shows disk (arrows) anterior to condyle, which is flattened and deformed. D. Coronal MRI showing lateral disk displacement (arrows) associated with condylar shape abnormalities.

LOOK AT JOINT SPACEASSESS CONDYLAR MOBILITY

Uric Acid Serum Test (Gout) WNL

Rheumatoid Factor (RA) WNL

ESR (Erythrocyte Sedimentation Rate) (inflammation) (RA) WNL

Gout R/O: Uric Acid levels WNL

Rheumatoid Arthritis R/O: RF & ESR WNL

Temporal Tendonitis R/O: no pn w/ palpation of temporal tendon,

no pn noted in the temple region or behind the eye.

Osteoarthritis/DJD R/I: Diagnostic Imaging & classic symptoms.

Fair, due to the degenerative osseous changes of theTMJ; with co-treatment of dental and chiropractic care.

Focused on: Pain control Reducing overloading of TMJ

Since the TMJ might easily be irritated, try to avoid unnecessary mechanical stresses on the joint: not chewing gum, smaller bites of food, etc.

Co-treat with dentist to use splint therapy. This will not have a direct effect on the inflammatory process, but will prevent overloading of the TMJ by reducing muscle hyperactivity.

TENS Ultrasound Massage Exercises to maintain normal muscle/joint

function, improve ROM, & stabilize TMJ

Naturally occurs in cartilage Sources: shrimp shells, lobster, crab Recommended dosage: 1500-2000

mg/day

H/A, dizziness, earache w/ posterior neck pain

27yoa, male, 5’9”, 175lbs Patient presents with chronic neck pain and

one sided mild headaches. He notices the H/A during midterms and finals and when he’s working on big cases. He estimated 2-3x every other month. He describes neck pain as tight sore muscles. The combination of the two are an on going condition during and after Law School (at 25yoa). Light dizziness and ringing in the ear occasionally occurs after a long dinner gathering (i.e. business dinner or family gatherings). He also notices ear popping at times when he swallow. These occurred after he accepted the position at the Law Firm (26yoa).

As kid, he used to wear braces for his overbite but did not follow up by wearing retainers after the braces was taking off. Did not play sports and do not recall any other childhood trauma at this time. (Dentist prescribed occlusal splint (night guard) for bruxisim at 22yoa)

MVA at the age of 16. A car rammed into him 20mph while stopped at a red light. Did not visit PCP, Chiropractor, or any other physician after MVA. No other recollection of any other trauma since (present day).

Mother is diagnosed with HBP and Father is not diagnosed with any health conditions. 1 brother and 2 younger sister are currently healthy and not diagnosed with any health conditions as well

On a note, He’s been married for 1 ½ years.

Admits to no history of taking any drugs Drinks beer (only) occasionally with

coworkers and at family functions. Drinks 3x’s/week and up to 2-3 bottles when drinking. Do not go out to clubs/concerts. Usually a restaurant for drinks. Likes to play golf and bowling.

Take Advil for headaches and posterior neck pains.

Palpation: Cervical- C2 RP, C6 RP TMJ- Right Popping, no clicking, no crepitus,

no tenderness Soft Tissue- TrP RU Traps, Bilat TrP,

SCM/Scalenes, Bilat TrP Levator Scapulae, Right TrP Temporlais, Bilat Masseter, and Right Lat/Med Pterygoid

Myotomes 5/5 to all muscles mention in palpation

findings

ROM: TMJ Active Passive WNL

Open R-popping(0) DNP yes Closed Minor overbit (1) DNP yes Jut Jaw 0 DNP yes Left 0 DNP yes Right 0 DNP yes

No pain Excruciating Pain 0 1 2 3 4 5

Foraminal Compression (-) Radicular px Jackson’s Compression (-) Radicular px Extension Compression (-)Radicular disc

px & ill-defined px apophyseal jts Flexion Compression (-)Radicular disc px

& ill-define px apophyseal jts

2 knuckles in mouth w/out difficulty (AROM)

Compressive Test- Pressure S-P increase px = retrodiscal involvment d/t synovitis

Chvostek (Weiss Sign)Test-CN VII, Tap area of nerve and view for twitching (-) (+) hypocalcaemia= tetany

Inspect for creptius, fluid, infections, and inflammation Slight crepitus, NO signs of fluid, infections or

inflammation Temperature

98.9° Friction Rub (-)

Hear sounds even on both sides Weber (-)

512Hz, equal on both sides Rinne (+)

AC>BC Romberg (-) Tandem Gait (-) H Eye movements

NAD, no nystagmus

X-Ray (plain film) Not useful d/t the size of the disc and joint space

CT= No osseous changes to mandibular condyles from the Dentist imaging More of an accurate view for osseous changes,

evaluating condyle position and disc space. MRI= Only under diagnosis of osseous

changes can MRI be useful in confirming disc displacement. Also recommend if necessary b/c view of disc (T2

weighted) and pathological changes of soft tissues i.e. masseter, temporalis, lat/med pterygoid muscles.

None

Otitis Media is an infection or inflammation of the middle ear. This

inflammation often begins when infections that cause sore throats, colds, or other respiratory or breathing problems spread to the middle ear. These can be viral or bacterial infections.

unusual irritability difficulty sleeping tugging or pulling at one or both ears fever fluid draining from the ear loss of balance unresponsiveness to quiet sounds or other signs of

hearing difficulty such as sitting too close to the television or being inattentive

http://www.nidcd.nih.gov/health/hearing/otitism.html

Tension Headaches They may occur at any age, but are most common in adults and

adolescents. If a headache occurs two or more times a week for several

months or longer, the condition is considered chronic. Chronic daily headaches can result from the under- or over-treatment of a primary headache. For example, patients who take pain medication more than 3 days a week on an regular basis can develop rebound headaches.

Tension headaches occur when neck and scalp muscles become tense, or contract. The muscle contractions can be a response to stress, depression, a head injury, or anxiety.

Any activity that causes the head to be held in one position for a long time without moving can cause a headache. Such activities include typing or other computer work, fine work with the hands, and using a microscope. Sleeping in a cold room or sleeping with the neck in an abnormal position may also trigger a tension headache.

http://www.nlm.nih.gov/medlineplus/ency/article/000797.htm

Meniere’s Disease is an abnormality of the inner ear of the canal causing a host of

symptoms, including vertigo or severe dizziness, tinnitus or a roaring sound in the ears, fluctuating hearing loss, and the sensation of pressure or pain in the affected ear. The disorder usually affects only one ear and is a common cause of hearing loss. Named after French physician Prosper Ménière who first described the syndrome in 1861.

The symptoms of Ménière’s disease are associated with a change in fluid volume within the byrinth. The labyrinth has two parts: the bony labyrinth and the membranous labyrinth. The membranous labyrinth, which is encased by bone, is necessary for hearing and balance and is filled with a fluid called endolymph. When your head moves, endolymph moves, causing nerve receptors in the membranous labyrinth to send signals to the brain about the body’s motion. An increase in endolymph, however, can cause the membranous labyrinth to balloon or dilate, a condition known as endolymphatic hydrops.

Many experts on Ménière’s disease think that a rupture of the membranous labyrinth allows the endolymph to mix with perilymph, another inner ear fluid that occupies the space between the membranous labyrinth and the bony inner ear. https://www.nidcd.nih.gov/health/balance/meniere.html

Myofascial TMJ Myofascial pain disorders are the most common cause of

pain in the head and neck, and those involved in the temporomandibular joint are no exception. The complex symptomatology and frequent psychosocial factors often make these disorders difficult to treat. The muscles of mastication are primarily involved, and the condition is characterized by a unilateral dull, aching pain which increases with muscular use. Common complaints associated with referred pain include headache, otalgia, tinnitus, burning tongue and sometimes decreased hearing.

There is believed to be a large psychosocial component of this disease. Increased stress levels are believed to result in poor habits, including bruxism, clenching and even excessive gum chewing. These lead to muscular overuse, fatigue and spasm, and subsequently, pain.

http://www2.utmb.edu/otoref/Grnds/tmj-1998/tmj.htm

Myofascial TMJ Rule In: Trigger Points, Unilateral H/A, No signs of

infection/inflammation, tinnitus, vertigo, bruxism, and stress

Otitis Media (382.9) Rule In: Loss of balance (vertigo) Rule Out: NO infection

Tension Headaches (723.1) Rule In: Tight muscles in back of head and neck, mild-

moderate band like pain Rule Out: not episodic, not severe, bilateral pain

Meniere’s Disease (386.00) Rule In: Dizziness, Ringing in the ear (tinnitus), neck

pain, and fullness (pressure) in ear Rule Out: Romberg Test, Tandem Gait, no vomiting,

no spinning, no fluid in ear, no nystagmus

Myofascial TMJ

Good, due to myofascial release of the muscles and no current osseous degenerative or disc dislocation.

Cryotherapy Heat Muscle goading Massage Stretching TENS Medications CMT Refer Out to Dentist

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www.austindental.com/DJD/DJD.shtml www.canadianpainsociety.ca/congres/

edmonton2006/Presentations/Thursday_Session102_Thie.pdf

Management of Temporomandibular Disorders & Occlusion by Jeffrey P. Okeson

Mosby’s Physical Examination Handbook, 6th ed.

Differential Diagnosis & Management for the Chiropractor by Thomas A. Souza