TMD Etiology, Epidemiology, Differential Diagnosis, Non-Dental Tooth Pain

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Orofacial Pain Temporomandibular Disorders
Richard R. Riggs, DDS
Private Practice Dallas, Texas
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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

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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

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Temporomandibular Disorders (TMD)
Histologically, mechanically and functionally,
the temporomandibular joint is different than
other joints in the body

• 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

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TMD Epidemiology
Defining and explaining the interrelationships of
factors that determine disease frequency and
distribution

• 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

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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)

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Prevalence

• Non-pain patients
• Utilizing the Helkimo Index
• Signs and Symptoms are about 11 in males and
  females
• As seen individually
• Females exhibit greater signs than males
• Headache, Joint noise, TMD muscle pain

• Pain clinic frequency of patients
• The ratio is approximately 91 female to male
  (estrogen plays a role
• Males have more acute trauma episodes

Females take care of the themselves. Males go to
a medical or dental practitioner only when they
are about to die or they are threatened with
death.
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TMD Signs Symptoms
Percentage Incidence
Number of Signs Symptoms
Mainly pain
These are the ones who really need treatment
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Age and Sex Distribution
This data is from a Seattle based HMO system with
patients from 8 years old to 80 years old. The
female bars are on the inside. Most seek
treatment between 25-40 years old. Childbearing
age in females is the most likely time. It is
NOT progressive over time.it gets better over
time, after 35.
65 69 yo
25 34 yo
10 14 yo
Only irreversible treatments will cause things to
progress.
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Pain Clinic Populations
These are relatively equal distributions,
overall. This does not take into account the
dominant treatments done by a general
practitioner. It really depends on who is
running the clinics and their clinical
reputations.
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General Population
Only 7 of the general population patients need
treatment. There may be many signs and symptoms,
but few need to be treated.
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Adaptation

• Normal
• Adaptation
• Pathology

Flattening of the condyle is exhibited. There is
no joint space. This is Dr. Riggs
mother-in-law. No asymmetries are seen, no pain,
no visible problems, there is no limitation of
movement and no deflections of the mandible.
This is a good example of adaptation. All of us
are in some state of adaptation. This is why we
dont see a progression in this disease. If
adaptation does not occur, problems will develop.
Patients should undergo treatment first, then
have their TM condition evaluated. Example
Orthodontic treatment will help, but their TMD
conditions will still be there.
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Signs Symptoms
TMD appears to be non-progressive
Joint noise will increase with time, but it can
be managed. This is looking at a cross section
of the population. This follows the
biopsychosocial syndrome.
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Related Signs/Symptoms
tension headach shoulder pain photophobia migra
ine neck pain retro-orbital pain chronic
headache poor posture tearing clogged
ears hard to swallow abnormal opening ear pain
sinusitis bad bite ear ringing nasal
drainage missing
teeth dizziness allergies mouth
breathing facial pain red eyes clenching/grind
ing
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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
• MRIs 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

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Adaptation

• Successful adaptation
• is expected in most
• patients over time

• Normal
• Injury/Pathology
• Adaptation
• -

Impairment (articular disc is out of place, but
the patient is still able to function)
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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.

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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
• gt 6 missing posterior teeth
• Internal derangement Osteoarthrosis
• Long centric leads to osteoarthrosis and muscle
  pain.
• Anterior open bite
• Osteoarthrosis muscle pain

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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 dont usually develop jaw
  problems.
• Kids that exhibit mouthbreathing.they typically
  grind their teeth. Relationship between
  retrognathic issues in these kids.
• Local
• Genetic

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Etiology

• Pathophysiologic
• Systemic
• Local
• Chewing efficiency impairment threshold lt 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

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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

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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

These can start the patient to express the
problems that were originally sub-clinical. End
up as triggers for the underlying conditions.
Use of dental assistants that can do behavioral
modifications on patients. Allows clinician to
do other things. Want patient to control these
problems by learning treatment modalities
themselves. Acute pain patients can develop into
chronic pain patients, if they have a
predilection to obsessive-compulsive disorders.
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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

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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.

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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

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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.

History gathering is the most important thing to
do.
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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

AAOP
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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.

Occlusion by itself is not the main reason
patients develop these problems. Dont prejudged
your treatments. There are a myriad of things
that can cause these problems. Everyone who has
a click does not necessarily have a TMJ problem.
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Avoiding Labeling Bias
Hx of CC Exam Yes Rule out Extracranial
Refer or Tx Rule out
Intracranial Refer Rule out
Vascular Refer Rule out
Neurogenic Refer Rule out SMP
Refer or Tx Rule out Joint / muscle
Refer or Tx Psychogenic
Refer
No
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12 differential diagnosis existing on this
patient.
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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

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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

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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

129 subcategories
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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)

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Intra-oral Pain Disorders

• Pulpal
• Visceral, threshold, poorly localized, pain gt
  stimulus
• Reversible pain duration short
• Irreversible pain duration long
• Fracture pain on release gt 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

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Intra-oral Pain Disorders

• 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

• Mucogingival and glossal
• ANUG
• Apthous ulcers (stomatitis)
• Herpetic gingivostomatitis
• Candidiasis
• Pseudomembranous
• Atrophic
• Hypertrophic/hyperplastic
• Angular cheilitis
• Trauma
• Cancer

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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

Arthrosis non-painful osseous remodelling of
tissues
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Associated Structures

• Eyes
• Tolosa-Hunt
• Glaucoma
• Ears
• Otitis Externa
• Nose
• Sinusitis

• Throat
• Tonsillitis
• Eagles Syndrome
• Lymphatics
• Lymphoma
• Lymphadenopathy
• Salivary Glands
• Infections
• Calculi

All of the above can create tooth and/or joint
problems. Influences of the maxillary posterior
teeth can create joint problems.
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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 patients occlusion lying down,
  because they do not eat lying down.
• Osteoarthritis
• Ankylosing Spondylitis
• Cervical Strain

Cervical spine issues can produce a significant
amount of facial pain. Try to reproduce the
pain, as a clinical diagnostic procedure.
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Axis II, Mental Disorders

• Somatization Disorder (Briquets)
• Conversion Disorder
• Hypochondriasis
• Body Dysmorphic Disorder
• Factitious Disorders (hypochondriac)
• Malingering
• PTSD

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Nonodontogenic Tooth Pain
All of the below can refer pain to the dentition

• Sinus
• Salivary glands
• Tongue
• Periodontium
• Oral soft tissues
• Viral
• Heart

• TMJ
• Muscle
• Tumor
• Neck C2-3
• Vascular
• Neuropathic
• Continuous
• Intermittent

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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

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Location
Watch the body language as patient describes the
site of their pain. Look at their eyes, how they
hold their head, their hands, and their posture.
Look at facial asymmetries. Discern their
demeanor and behavior Compare it to their
written description and to their pain drawing.
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Intensity
We need to ascertain where there pain level is,
at any point in time.
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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

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Timing
10
8
6
4
2
0
1
3
5
7
9
1
3
5
7
9
11
11
-2
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Frequency

• The number of times pain is noted per

• Day
• Week
• Month
• Quarter
• Year

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Duration Relief

• continuous
• seconds
• minutes
• hours
• days
• weeks
• months
• years

• none
• seconds
• minutes
• hours
• days
• weeks
• months
• years

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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

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Timeline
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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

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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 doesnt necessarily
• need treatment

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Stages of Intracapsular Disorders

• Clicking with function only
• Reciprocal clicking
• Intermittent locking
• Open locking
• Acute closed lock
• Soft tissue remodeling
• Hard tissue remodeling

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DDx of Clicking

• Early opening click
• Late opening click
• Late opening thud
• Deviation in form
• Partial disc displacement
• Disc displacement with reduction

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History Format

• Chief Complaint
• History of Present Illness
• Medical History
• Dental History
• Psychosocial History

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Chief Complaint

• Record in the patients words
• Interpret
• Separate each complaint
• Prioritize each complaint

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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.

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If you listen to the patient, they will tell you
the diagnosis
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Time Management
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Miscellaneous
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The End