Temporomandibular Joint Disorders Question And Answers

Temporomandibular Joint Disorders Essay Questions

Question 1. Define myofascial pain dysfunction syndrome. Describe the clinical features, diagnostic, criteria, and management in detail.
Answer:

• Myofascial pain dysfunction syndrome is a noninflammatory, musculoskeletal disorder that involves the muscles of mastication. The symptoms include pain, restriction of jaw movements, joint sounds, deviation of the mouth on closing and opening movements, and pain on palpating the affected masticator muscles or their tendons.
• The pain is associated with characteristic myofascial trigger points. The motor and sensory disturbances may be local to the trigger points or may be distant with a referred pain pattern. It often involves the neck and back.
• Myofascial pain dysfunction syndrome is classified as a craniomandibular disorder by the American Academy of Craniomandibular Disorders.

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Myofascial pain dysfunction syndrome Etiopathogenesis:

• Chronic muscle stress leads to trigger points. People undergoing stress and anxiety are more prone for developing myofascial pain dysfunction syndrome (MPDS).
• This is based on the concept of teeth clenching, in consequence, to stress causes repeated strain on muscles which leads to the development of trigger points.

Myofascial pain dysfunction syndrome Predisposing Factors: Psychological disorders, metabolic disorders, sleep disorders, and personality status that are prone to parafunctional habits like clenching of teeth predispose to MPDS.

Triggering (or) Precipitating Factors: Trauma to masticator muscles, occlusal disturbance, infection, and iatrogenic causes may trigger MPDS.

Perpetuating Factors or Maintaining Factors: Predisposing and precipitating factors either alone or in combination lead to a myospasm- pain-myospasm cycle.

Myofascial pain dysfunction syndrome Pathophysiology: The masticator muscle spasm is pathogenetic for the clinical features of this syn¬drome. Muscle spasm is caused by:

1. 1. Overextension of the muscle
   2. Overcontraction of the muscle
   3. Muscle fatigue.

• The myofascial pain dysfunction syndrome (MPDS) so produced causes pain, limitation of movement, changes in jaw position, and occlusal disharmony. Irregularities in occlu¬sion appear to be the precipitating factor in the pathogenesis of myofascial pain dysfunction syndrome.
• Occlusal interferences, posterior bite collapse, deep overbite, overjet, and many other factors tend to restrict movement and predispose the patients to increased parafunctional activity resulting in overuse, and thus fatigue of muscles and pain.
• The pain may cause muscle spasms and contractions leading to parafunctional habits and forming a cycle of events.

Myofascial pain dysfunction syndrome Clinical Features: Myofascial pain is characterized by a deep, diffused, dull quality in contrast to well-defined dental pain. Trigger points, a rigid and tender muscle, and referred pain are the pathognomonic features associated with MPDS.

Four cardinal signs of this syndrome:

1. 1. Tenderness with referred pain to the joints and other muscles.
   2. Movements are restricted and limited to relax or fully lengthen the muscle.
   3. Persistent muscle pain, weakness, and stiffness.
   4. Clicking or crepitus sounds during jaw movements.

• It also causes degenerative changes in the joint and muscle contraction as a feature of long-standing spasms.
• Females are affected more. This is due to their less tolerance for pain and tendency for undergoing stressful situations.

Myofascial pain dysfunction syndrome Diagnostic Criteria:

• A diagnosis of myofascial pain syndrome (MPS) depends on the clinical examination and palpation.
• There is no standardized diagnostic tool like lab investigations or radiographic views to make an evidence-based determination.

Laskin’s criteria: Four cardinal signs:

1. Unilateral pain
2. Muscle tenderness
3. Audible clicking
4. Restricted jaw movements

Negative characteristics:

• No radiographic evidence.
• No tenderness in the TMJ area on palpation.

Myofascial pain dysfunction syndrome Management:

• Trigger point injection: Injection of the local anesthetic solution, procaine to the trigger point.
• Spray and stretch: It is beneficial to cool the skin over the trigger points and referred sites using an ice stick or refrigerant spray. The application should be rapid and for a short duration so that the cooling will not affect the underlying muscle which otherwise will reduce the stretch instead of stimulating it.
• The cooling act should be followed by a hot pack application to warm up the skin.
• Posture retraining: Training for maintaining the correct posture and biomechanics will relieve muscle stress and tension.
• Electrical stimulation: Transcutaneous electrical nerve stimulation (TENS) therapy is useful in the management of trigger points and pain control, as they exhibit low resistance to electrical energy.
• Medical management.
  • Muscle relaxants and analgesics can be used.
  • Benzodiazepines 2-5 mg — 3 times/day with acetaminophen 650 mg —3 times/ day.
  • For patients suffering from chronic myofascial pain with proven depression, tricyclic antidepressants (25-75 mg at bedtime) can be administered.

Question 2. Enumerate the various causes of trismus with pathophysiology and treatment.
Answer:

• Trismus is described by a reduced mouth opening due to long-lasting spasms of the muscles.
• The restriction may range from simple and nonprogressive to highly morbid.

1. Trismus Classification: The mean maximal mouth opening for males is 51.3 mm and for females is 44.3 mm.

1. Interincisal distance of greater than 30 mm and less than 35 mm is referred as mild trismus.
2. Interincisal distance of 15-30 mm is noted as moderate trismus.
3. Interincisal distance of less than 15 mm is noted as severe trismus.

Trismus Etiopathogenesis:

• Infection
• Trauma
• Iatrogenic (Dental treatment like high point restorations)
• TM joint disorders
• Tumors
• Oral submucous fibrosis
• Drug-related
• Radiotherapy and chemotherapy
• Congenital or developmental growth disorders
• Miscellaneous conditions like hysteria.

Trismus Infection:

• The typical finding in space infections is trismus. Both odontogenic and non-odontogenic infections can lead to the spreading of space infection and trismus.
• Periapical, periodontal, and pericoronal abscesses, dentoalveolar abscesses, and cellulitis are the odontogenic cause of trismus. Among these, peri coronal infections associated with 3rd molar eruption is the most frequent cause of trismus.
• Nonodontogenic infection includes tonsillitis, tetanus, meningitis, and parotid abscess.

2. Trauma: The fracture of the mandible, zygoma, or zygomatic arch can limit coronoid movement and cause trismus.

Trauma Dental Procedures:

• Surgical extraction of mandibular 3rd molars.
• Inaccurate needle positioning during mandibular block administration results in trismus, 2-5 days later the process.
• The needle may penetrate and injure the medial pterygoid muscle or damage the blood vessel. The resulting bleeding and hematoma in the muscle are organized to fibrosis. This type of trismus causes severe symptoms.
• Application of thermal packs and stretching exercises using wooden spatulas are the needful management. The patient should be reassured about the reversible nature of the condition.

Temporomandibular Joint Disorders:

• Fibrosis or unilateral condylar hyperplasia.
• Temporomandibular joint trauma or dislocation.
• Displacement of meniscus anteromedial to the condyle.

3. Tumors:

• Tumors in the pharynx, parotid, mandible or TMJ may lead to trismus. Nasopharyngeal tumors and tumors involving the infratemporal fossa may also cause trismus.
• Radiotherapy for oral cancer involving masticator muscles in the field of radiation leads to trismus as a later complication.
• Oral Submucous Fibrosis: Oral submucous fibrosis is characterized by chronic inflammation and fibrosis of the submucosal tissues leading to muscle stiffness and difficulty in mouth opening.
• Tumors Drug-induced: Drugs that cause trismus as a side effect include: Succinylcholine, phenothiazines, tricyclic antidepressants, metoclopramide, and phenothiazines.
• Tumors Congenital Disorders: Hypertrophy of the coronoid process interferes with the anteromedial border of the zygomatic arch and causes trismus.

Management of Trismus:

• Treatment depends on the etiological factor:
  • For mild pain and dysfunction, heat therapy is indicated by placing moist hot towels on the affected area for 15-20 minutes every hour. Administration of NSAIDs is usually adequate. After the acute inflammation subsides, physiotherapy should be started with opening and closing exercises and lateral excursions of the mandible for 5 minutes every 3-4 hours.
  • In case of any dental infection, appropriate endodontic management or extraction should be carried out with antibiotics and analgesic support.
  • For oral submucous fibrosis, intralesional corticosteroid injections are the choice of management, but in a severe case of trismus, reconstruction of the buccal pad of fat followed by vigorous physiotherapy is indicated.
  • In severe cases, diazepam 2.5-5 mg—3 times/day can be administered as muscle relaxants.
  • Treatment should be continued until the patient becomes asymptomatic.

Temporomandibular Joint Disorders Multiple Choice Questions

Question 1. Deviation of the jaw towards the affected side occurs in

1. Unilateral fracture of the mandible
2. Unilateral condylar hyperplasia
3. Unilateral dislocation of the mandible
4. Unilateral condylar hypoplasia
   (Note: Deviation of the jaw towards the affected side occurs in unilateral condylar agenesis, unilateral condylar hypoplasia, unilateral condylar fracture, and ankylosis).

Answer: 4. Unilateral condylar hypoplasia

Question 2. Bilateral condylar fracture results in

1. Inability to open the mouth
2. Inability to close the mouth
3. Anterior open bite
4. Posterior open bite

Answer: 3. Anterior open bite

Question 3. In dislocation of the mandible, the usual complaint will be

1. Inability to open the mouth
2. Inability to close the mouth
3. Anterior open bite
4. Posterior open bite

Answer: 2. Inability to close the mouth

Question 4. Ely’s cysts are radiographic findings in TMJ osteoarthritis.

1. TMJ gouty arthritis
2. TMJ osteoarthritis
3. Costen’s syndrome
4. TMJ osteosarcoma

Answer: 2. TMJ osteoarthritis

Temporomandibular Joint Disorders Viva Voce

Question 1. What is subluxation?
Answer: The condyle moves ahead of the articular emi¬nence during the wide opening but returns to the original position without any manipulation.

Question 2. What is gouty arthritis?
Answer: The accumulation of urate crystals in a joint that leads to inflammation and pain is known as gouty arthritis. This is due to the long-term elevation of serum urate levels.

Question 3. What is the internal derangement of TMJ?
Answer: Internal derangement of the joint comprises conditions like disk displacement, disk dislocation or condylar injury.

Question 4. What is Costen’s syndrome
(or)
Mandibular joint neuralgia?
Answer: It is complex features of impaired hearing, a stuffy sensation in the ears, tinnitus; mild dizziness, and burning sensation in the nose, throat, and sides of the tongue. The pathology is either malocclusion from any cause or adverse changes of one or both mandibular joints.

Temporomandibular Joint Disorders Highlights

• The temporomandibular joint (TMJ) is both hinging and sliding type of joint and is hence known as ginglymoarthrodial joint. It is a bilateral joint fused in the midline and hence, influences the movements of each other.
• Also, the teeth and muscles of mastication also affect the function of the joint. It has two structural components—the temporal above and the mandibular below.
• A fibrous capsule surrounds TMJ. It has selective sliding movements between the bony joints in addition to hinge movement.