Identifying And Recovering From Tmj Injuries (Shorter Version)

TMJ is the name of the joint.

Temporomandibular Disorder– TMD– is the name of the injury

TMD, Headaches and Trauma

Evidence Based Continuing Education Recommendations

#1 When treating patients with whiplash injuries to the neck, it is essential to screen them for TMJ pain and dysfunction at their initial evaluation and at follow up evaluation for up to one year.

Source:

Journal of the American Dental AssociationJADA 2007; 138 (8): 1084-91See attached copy of article, pg 1090.

Evidence Strength:

A, consistent good quality patient oriented evidence. This is a consistent, high quality cohort study.

TMD, Headaches and Trauma Evidence Based Continuing Education Recommendations

(continued…)

#2 Because temporomandibular disorders (TMD) remain a frequent cause of visits to primary care physicians, internists and pediatricians, learning to screen for TMD is helpful in providing effective treatment strategies.

Source:

New England Journal of MedicineN Engl J Med 2008; 359: 2693-705See attached copy of article pgs 2697, 2702

Evidence Strength:

C, consensus, usual practice, expert opinion.This review focuses on the most common forms of TMD seen by the primary care physician: myofascial pain disorder, intra-articular disk derangement disorders, osteoarthritis, and rheumatoid arthritis.

Three main Three main categories:categories:

The National Institute of Health (NIH) defines TMD as disorders of the jaw joint and chewing muscles. website: http://www.nider.nih.gov/HealthInformation/DiseasesAndConditions/TMDTMJ/TmjDisorders)

Myofascial pain, the most common TMD involves discomfort or pain in the muscles that control jaw functionsInternal derangement of the joint, (a displaced disc, dislocated jaw or injury to the condyle) “jaw clicking”

Arthritis.

Main Cause of TMD Main Cause of TMD (according to the (according to the NIH website)NIH website)

Trauma. •Direct trauma to the lower jaw (ex: chin or face striking steering wheel, airbag deployment jamming lower jaw backwards)

• Striking the side of the head (ex: side window impact)

The following video is a real-life traumatic TMD captured on film. (video also available at www.tmjdoctorofmaryland.com)

Briefly, Chris Hoiles, the Oriole catcher was struck in the side of his helmet by the back swing of a batter. Mr. Hoiles commented he didn’t really know what happened to him (he was stunned). Then he explained he was hit in the side of the head and he complains of headaches and jaw pain. (The Temporalis Muscle when injured contracts, elevating the lower jaw, hence his headache and jaw pain). His wife then commented that the doctor said there was nothing wrong and he was being taken to the emergency room of a hospital for a C.A.T. Scan.

A Real Life TMD InjuryA Real Life TMD Injury

Listening closely, many victims Listening closely, many victims of trauma (ex: motor vehicle of trauma (ex: motor vehicle accidents) exhibit these exact accidents) exhibit these exact same complaints:same complaints:

Typically, this patient goes home, continues with their normal activities (yelling at children, singing in church, chewing gum, etc) and exacerbates this injury to the point where in a few days they are suffering from terrible headaches.

This is how a typical TMD occurs.

Main Cause of TMD Main Cause of TMD (according to the (according to the NIH website)NIH website)Trauma.

•Direct trauma to the lower jaw (ex: chin or face striking steering wheel, airbag deployment jamming lower jaw backwards)• Striking the side of the head (ex: side window impact)• Whiplash trauma

The Journal of the American Dental Association published a study (“Delayed Temporomandibular Joint Pain and Dysfunction Induced by Whiplash Trauma,” JADA, Vol. 138 http://jada.ada.org August 2007.) that concluded:

One in every three people who are exposed to whiplash trauma is at risk of developing delayed TMJ symptoms that may require clinical management.

Subjects reported that they had complained about TMJ symptoms to their orthopedic surgeons, physical therapists or dentists, but treatment for their posttraumatic symptoms had been focused only on their neck symptoms, regardless of the severity of the TMJ symptoms.

TMJ symptoms after whiplash trauma is common. It is crucial to be aware of the delayed onset of TMD when making adequate diagnoses, prognoses and medicolegal decisions.

The NIH indicates TMD is not caused by a bad bite or braces.The NIH indicates TMD is not caused by stress or tooth grinding. NIH estimates that there are 10 million sufferers of TMD.

Symptoms Symptoms

• Headaches (pain in temples)• Pain in the facial muscles• Pain from the jaw joint• Clicking sounds emanating from the joint• Difficulty in opening and closing the mouth• Ear pain, pressure, or ringing• Sore throat• Light-headedness or dizziness

DiagnosisDiagnosis

• History of trauma to temples, head, face, jaw, neck, or whiplash injury• Symptoms• Physical exam including palpation of head, neck, shoulders• Imaging studies

TreatmentTreatmentThe New England Journal of Medicine (NEJM) (“Temporomandibular Disorders” (NENGLJMED 359;25 WWW.NEJM.ORG DECEMBER 18, 2008) recommends that treatment be conservative and reversible.

Treatment consists of behavior management, physical therapy, jaw appliance therapy, and medication management (muscle relaxers and anti-inflammatory medications).

NEJM notes: “TMDs are classified as one subtype of secondary headache disorder by the International Headache Society in the International Classification of Headache Disorders II The Academy of Orofacial Pain has expanded on this classification…”

NEJM concluded that undiagnosed TMDs are a frequent cause for doctor visits.

NEJM reported the incidence of TMD patients seeking care to be 3:1 female to male.

Headaches are a chief symptom of TMD. The vast majority of all headaches are muscular in nature (muscle tension type headaches). Muscle induced headaches come from either the neck, face and head muscles or all three. This is why headache patients referred for CAT Scans and neurological tests report negative (normal) results the majority of the time. These tests look for blood vessel or neurological damage inside the skull, but not damage to the muscles controlling the opening and closing of the mouth on the outside of the skull.

Headaches as a Symptom of Headaches as a Symptom of TMDTMDWhen interviewing your client, you ask:

“What hurts?”

If the client indicates headaches, ask:

“Is your pain at your temples, forehead, back of head or all three?”

If the client says, “The back of their head.”, this is probably not a TMD induced headache.

If the client says, “My forehead”, this is most likely referred pain from the back of the head.

If the client say “My temples”, this may well be a TMD induced headache.

If the client says, “It feels like a rubber band is stretched around my head”, this is a headache consisting of temporalis and posterior neck muscle injuries and should be evaluated by both a physician and dentist. This may well be a TMD induced headache.

Pain on the side of the head indicates damage to the temporalis muscle, (see Figure 1) the large muscle completely covering the side of the head and which partially controls the closing of the mouth.

Patients with headaches, a negative CAT scan, and a normal neurological evaluation may well have a temporomandibular disorder

Figure 1

Use the TMD Questionnaire (see attachment in packet). Several ‘yes’ responses indicate the need for further evaluation by a dentist with extensive training in TMD evaluation and treatment.

Screening Questions for TMJ Screening Questions for TMJ InjuriesInjuries

If you have headaches, a negative C.A.T. Scan and a normal neurological evaluation, you may well have a temporomandibular disorder.

Do you experience headaches? (Especially in the morning when you wake up or in the evening when you go to bed?)YES NO

Do you have pain around the eyes, in the forehead, or at your temples?YES NO

Do you have pain in the face, neck, or shoulders?YES NO

Do you have pain, ringing, or buzzing in your ears?YES NO

Screening Questions for TMJ Screening Questions for TMJ InjuriesInjuries

Do you experience clogging, fullness, or pressure in your ears that comes and goes?YES NO

Do you experience dizziness? YES NO

Do you experience a clicking, popping, or snapping in your jaw joints when you open wide, close your mouth, or bite down?YES NO

Do you have pain when you open wide, close your mouth, or bite down?YES NO

Do you have difficulty with chewing, talking, or yawning?YES NO

**A COMBINATION OF ANY “YES” ANSWERS TO THESE QUESTIONS IS INDICATIVE FOR A TMJ EVALUATION BY A DENTIST.**

Screening Questions for TMJ Screening Questions for TMJ InjuriesInjuries

Treatment ConsiderationsTreatment Considerations Tell the client to relate his TMD symptoms to his

doctor to be included in the doctor’s initial evaluation.

Contact the client’s physician, request a TMD consult based on the patient’s history and symptoms from your interview and responses to the questionnaire. Request that the doctor includes the patient’s TMD complaints in his findings and refers the patient to a dentist competent in TMD treatment.

Refer the client directly to dentist for evaluation.

TMD’s are best treated through a combined effort of physician, physical therapist, and dentist.

Identifying and Recovering from Identifying and Recovering from TMJ InjuriesTMJ Injuries (TMD, Headaches, and (TMD, Headaches, and Trauma)Trauma)

For more information or to contact the Doctor

Dr . Stephen H. Gamerman

107 W. Saratoga St. 9811 Mallard Drive, Ste. 112

Baltimore, MD 21201 Laurel, MD 20708

410-539-1155 301-523-1470

Website: TMJdoctorofmaryland.com Email: [email protected]