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5002 Case 4 Cheat Sheet by

Dental Hygienist - Chronic TMD w/ known TMJ OA

Case Hx

- 48 y.o.
- Stiff neck & upper back pain
- Painful R jaw
- 0/10 at rest
- 7/10 when chewing
- 4/10 after chewing
- Onset after tooth removal 12 years ago
- Has OA of jaw (fears this will worsen)
- RF: massaging jaw when it locks
- AF: grinding teeth & chewing
Neck & upper Tx
- 0/10 - 5/10
- 10-12 years ago
- AF: running, standing too long & neck extension

Physical Exam Findings

Upper crossed syndrome: muscle imbalance in two sets of opposing muscles
- Tight: upper traps, elevator scapulae, & pectoralis major & minor → respon­sible for elevating & protra­cting the shoulders & rounding the upper back
- Weak: lower traps, serratus anterior, & the deep Cx flexors → respon­sible for stabil­ising the shoulder blades & supporting the neck & upper back
- Can fit 2 fingers between teeth
- Palpable click-over R TMJ
- Centric relation test is painful on R
- Masseter, temporals, digastric, lateral pterygoid tight bilate­rally
- Cx PROM all directions moderately restricted + flexion caused L upper traps pain
Deep neck flexor endurance: shacking after 5 seconds
Wall angel: unable to flatten back against wall or stretch arms towards wall

Clinical tests

Wall angel:
- Purpose: assess Tx mobility
- Findings: Unable to flatten back against wall or stretch arms towards wall
Beighton score:
- Purpose: screen for hyper-mobility
- Findings: 0
TOS tests:
- Purpose: Identifies compre­ssion of neurom­uscular structures as they exit through the Tx outlet
- Findings: Didn't reproduce any pain aka. -ve
Name 4 TOS tests:
- Adson's
- Reversed Adson's
- Roo's
- Hypera­bdu­ction


Working diagnosis:
- Chronic TMD (tempo­rom­and­ibular dysfun­ction) w/ knownTMJ OA
- Chronic non-sp­ecific mechanical neck & Tx pain w/ associated upper crossed posture
Subdiv­isions of pain-r­elated TMDs:
1. Myalgia / myofascial pain
2. Arthralgia (joint pain)
3. Intra-­art­icular disorders (within joint)
4. Headache (typically confines to the temporal region)
- Some neck muscle pain has been found to be correlated with TMD, doesn't completely account for rest of pt's presentations
- Non-sp­ecific mechanical neck & thoracic spine pain is very common (∴ high probab­ility), links w/ the pt's posture & explains some of the other examin­ation findings in the Tx & upper quarter
- Poor neck flexor endurancehas been linked w/ chronic TMD & chronic neck pain & poor posture (espec­ially a forward head posture)
What's the pt trying to tell me:
- Pt has identified stress (grinding teeth, unhappy at home, use of the Headspace app) → will aggravate both the TMD & neck/upper Tx symptoms
→ Pt should try to identify sources of stress & DC can offer to help them access further support
Address the pt's expect­ations for having tech x-rays → they're not indicated, & would need to explain theist the pt

Learning outcomes

Tempor­oma­ndi­bular disorder (TMD) diagnosis & manage­ment:
Signs & symptoms:
- Jaw pain: located in jaw joint, surrou­nding muscles or both
- Jaw clicking or popping: may be duet the displa­cement of the jaw joint or the movement of the cartilage disc within the joint
- Jaw stiffness: may make it difficult to eat, speak, or jawn
- Headaches: especially in the temples or behind the eyes
- Ear pain or fullness: feeling of fullness in the ear, even though there's no infection
- Neck & shoulder pain: may become sore or painful as a result of compen­sating for the jaw
- Teeth grinding or clenching: (espec­ially during sleep), can lead to tooth damage, headaches, & jaw pain
- X-rays: help identify any bony abnorm­alities or damage to the jaw joint
- MRI: jaw joint, surrou­nding tissues, muscle, ligaments, & cartilage
- CT: Jaw joint, surrou­nding struct­ures, including bones & soft tissues
- Cone beam CT: 3D images of the jaw joint
- Lifestyle changes: soft foods, not gum chewing, stress management to reduce jaw tension
- Medica­tions
- Manual therapy
- Oral applia­nces: (e.g. splint or mouthg­uard) to relieve jaw pain & reduce teeth grinding & clenching
- Injections
- Surgery
Consider the impact of stress on the pt's prognosis:
- Can have signif­icant impact on prognosis, especially for pts w/ chronic illnesses or condit­ions; chronic stress is linked to a range of -ve health outcomes (↑ inflam­mation, impaired immune function, & heightened risk of heart disease, diabetes, etc)
- Impaired immune function: can lead to a longer recovery time & more severe symptoms for pts with chronic illnesses
- Increased inflam­mation: can exacerbate symptoms of chronic illnesses & lead to further damage to organs & tissues
- Worsening of symptoms: (e.g. pain, fatigue, & digestive issues), can impact a pt's quality of life & ability to manage their condition
- Delayed healing: can lead to longer recovery & ↑ risk of complications
- Poor treatment adherence: pts may have harder time following treatment plans, can lead to poorer outcomes & slower recovery
Indica­tions for Cx spine x-rays:
- Pt has no HIGH RSIK factors to warrant Cx x-ray immediately
- Pt has NO LOW risk factors + ROM rotation is not below 45° (PROM tested only, no AROM detailed [preff­ered])
Management of chronic non-sp­ecific neck & Tx pain:
- Chronic pain: consider referral to psych-­man­agement / pain clinic
- Home exercises to maintain movement between treatments
- Non-sp­ecific neck pain:
- Short term: Tx manipu­lation w/elec­tro­thermal therapy
- Long term: Cx manipu­lation, exercises ± manual therapies
- Encourage activity & ADLs
- Stretching & streng­thening exercises, ROM exercises, manual therapy
- Non-sp­ecific Tx pain:
- Tx manual therapy: massage, trigger point therapy (TPT), stretches, traction, manipu­lation & mobili­sation
Functional management for this pt:
- Stabil­isation exercises
Neck / upper Tx:
- Wall angel
- Prayer stretch
- Upper traps stretch
- Lev. scap. stretch
- Wall chin tucks


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