Temporomandibular dysfunction: chiropractic rehabilitation

TMD: chiropractic rehabilitation

Temporomandibular dysfunction: chiropractic rehabilitation C. Skaggs

Orofacial disorders (OFDs) often have histories that reveal predisposing and complicating factors that contribute significantly to the patient's condition. This seemingly cumulative complexity of presentations observed with OFD may be explained by Lewit's reference to compensations often developing 'upstream' of joint dysfunction and muscle imbalance (Lewit 1991). This provides possible explanation for epidemiological studies showing a high prevalence of temporomandibular dysfunction (TMD) signs (90%) with approximately half of these presenting with symptoms (Solberg 1979). Therefore early recognition, particularly in non-cervicocranial disorders of orofacial signs, may be critical in preventing chronic problems from developing. Management versus treating all of a given patient's complicating factors is the difference between appropriate and poor care for the patient. If we unravel Louise' s history, we can scroll all the way to her childhood orthodontic history as a possible early challenge to her masticatory function. The history also mentioned her children having small dental arches, which require orthodontics. This suggests that Louise may have had small dental arches, which may have

Clayton Skaggs DC Head, Neck and Orofacial Rehab Center, Clayton Plaza, 7700 Clayton Road, Suite 109, St Louis, MO 63117, USA Correspondence to: Clayton Skaggs Tel: +I 314 781 0181; Fax: +1 314 781 0611 Received March 1997 Accepted May 1997

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benefited from palatal expansion instead of the reduction associated with extraction. Further stomatognathic analysis, such as cephalometric measurement, would assist these theories. Premolar extractions have been proposed as having specific implications in the development of TMD (Span & Witzig 1987). However, current studies refute this claim, and actually reveal in one study to lead to less TMD with extraction orthodontics (Egermark & Thilander 1992). This disparity in the literature and among dental factions supports focusing treatment on improving function and neuromuscular control versus altering structure. The next chronological step is the possible complication stemming from the skiing accident. The description of the fall reports trauma to the right side, including fracture of the right clavicle. This would typically cause compromised neck flexion, most probably also involving rotation. The sternocleidomastoids (SCMs) are probably involved in resulting dysfunction. Chronic overactivity, tightness and associated weakness stemming from a distant trauma have been proposed to occur via the central nervous system by theories such as neuroplasticity and traumatic reflex (Hanna 1988, Bonica 1989). Additionally, Lewit (1996) has observed and described overactivity and trigger points of the SCM as being a common objective indicator for orofacial and cervicocranial disorders. Louise's temporal type headache is also suggestive of a heterotopic pain (a pain occurring at a site different from that of the cause) from the SCM. Chronic overactivity of the SCM (peripheral neck flexors) will weaken and inhibit the deep neck flexors,

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providing the perfect formula for forward head posture (FHP). FHP is consistently implicated in the development and perpetuation of OFD (Gonzales & Manns 1996). This static dysfunction must be treated aggressively. Although there is little research on the deleterious effects of chewing gum (Kuwahara et al 1995), this should be considered a complicating factor. In Louise's case the likelihood is increased due to the approximation of the start of gum-chewing and the onset of head pain. Gum-chewing is a repetitive activity, which often involves poor mandibular movement patterns. The mechanics of chewing gum causes accentuation of jaw closure, thereby increasing the activity of elevator muscles against the depressors. This can result in muscular overactivity, repetitive strain and eventual functional pathology. Biopsychosocial factors continue to receive an increasing amount of attention in the analysis of orofacial disorders. In text, literature and presentations, the biopsychosocial model of care is stressed as an essential criteria for resolving chronic pain and disability associated with OFD. Often the reference is misunderstood, leading to inappropriate classification for many of these patients as malingerers or psychologically ill, when in fact it is a condition of illness behaviour and central nervous system impairment requiring modification and restoration (Dworkin 1992). There are obvious descriptions of lifestyle stressors and deficiencies with Louise. The fast pace of a 'today's mother', minimal aerobic exercise, sporadic good nutrition and excessive consumption of artificial sweeteners could affect an individual's adaptive potential and play a role in her recovery.

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Symptom presentation Palpatory tenderness to the right TMJ and pain after biting a hard object gives strong indication of specific TMJ inflammation. Biting on a hard object involves the power-stroke phase of mandibular closure (Okeson 1993), which causes potential condyle-disc instability on the side of the hard object. Because non-steroidal anti-inflammatories gave only temporary relief, one must consider the TMJ problem to be secondary to, and/or associated with, additional neuromusculoskeletal dysfunction. Louise' s presentation of right ear pain and right chronic temporal headache could have multiple and shared aetiology. Rarely is TMD an isolated condition (McNeil et al 1990). Steenks et al (1996) showed cervical dysfunction present with TMD more often than TMD alone. Yu et al (1994) showed there to be more referral from deep inputs than peripheral inputs in a study correlating jaw and neck muscles. This identifies more potential for convergent referral from the cervical spine to the jaw, rather than from the jaw to the cervical spine. Myofascial patterns of referral from the masseter, pterygoids, SCM, suboccipitals, and temporalis often coexist with articular dysfunction of the TMJ and/or cervical spine. Investigation and documentation regarding this confluence of activity continue to centre around the trigeminocervical nucleus and its ability to unite multiple regions of pain and dysfunction in the cervicocranial region. Okeson (1996), in his guidelines for orofacial pain, states 'The clinical phenomenon of sensory, motor, and autonomic effects resulting from deep pain input are important because referral from the cervical region is common and easily mistaken for masticatory pain'. Although popping and clicking are cited as symptoms, it is unspecified as to which side. Popping/clicking is certainly involved in many internal

derangement disorders (Scapano 1991). Often it involves medial displacement of the disc. In this case, the clicking seems to have been present before the onset of symptoms and was unassociated with function or pain. This type of irrelevance associated with popping or clicking of the joint is commonly reported in the literature (Davant et al 1993). Although improvement of mandibular and/or cervicocranial function may very well unload and decrease audibilization in the TMJ, reducing the clicking/popping should not be a purpose of treatment unless requested as such by the patient. The remaining subjective finding concerning mandibular function is the noted loss of jaw opening. This most often results from one of the following: internal derangement with muscle imbalance, muscle imbalance alone, or acute muscle and/or chronic myofascial tightness. Because of the associated findings of TMJ tenderness, deviation on opening, clicking of the joint and right ear pain, this aetiology is likely to be muscle imbalance with associated internal derangement and myofascial tightness. The patient in this case also cited occasional low back pain. This could be an isolated symptom with dysfunction unrelated to or affecting the orofacial pain. At the same time there could be some important kinetic links to this minor mention of pain. Lewit has made strong comments about the correlation of body statics and orofacial pain (Lewit 1991). He, as well as others, comments on pelvic torsion and sacroiliac joint dysfunction as being an important area of consideration with chronic orofacial pain or unresolving orofacial disorders (Gregory 1993). There is certainly cause to hypothesize that FHP can involve lower body mechanics and therefore pelvic and lower limb dysfunction could be associated with OFD. The question is raised as to the extent, when or if at all, these associated areas

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of pain or dysfunction (i.e. FHP, low back pain) are to be investigated or treated.

Objective findings Objective discovery is limited in this case to the report of mandibular ranges of motion. Abrupt deviation to the left might indicate internal derangement of the right TMJ with probable medial displacement. This type of derangement is often accompanied by increased overactivity of the mandibular elevators with probable dominance of overactivity being on the right. If present, this would be associated with weakness/inhibition of the mandibular depressors, which again would be more involved on the right. Resolution of the weakness and/or inhibition uncomplicates the majority of OFD (Skaggs 1996). Increased palpatory tension of the hyoid is also commonly seen on the side of TMJ dysfunction. These submandibular functional lesions can significantly compromise masticatory functions including speech, respiration, swallowing and mastication. Lateral excursion shows pain on the fight in both directions, indicating increased tension and potential inflammation of the fight TMJ complex. Mandibular range of motion of 37 mm is slightly below most accepted ranges of normal. Rocobado (1985) states maximum mandibular opening to be 50 ram, thereby taking the periarticular connective tissue to 100% stretch. He qualifies that the stretch of the periarticular connective tissue should not exceed 70-80%, thus making functional mandibular range of motion approximately 40 ram. Okeson' s recent guidelines (1996) cite normal minimum interincisal distance and active ranges of motion to be from 36 to 44 mm and less in women.

Recommendations As mentioned earlier there are often many treatable factors and clinical

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TMD: chiropractic rehabilitation

presentations in chronic OFD. Using the most current diagnostic classification, this case would fall under the categories of primary headache disorders, temporomandibular disorders and associated structures (i.e. neck). The astute practitioner must be judicious in pursuing the elements that will produce the greatest beneficial effect with the least amount of risk and insult to future health. To put it simply, primary treatment should be conservative and simple. Qualification as to what is considered appropriate conservative care is where disagreement persists within paradigms of management of OFD. It is well established in the literature that management of occlusion is not essential in treating most TMD (Carlsson et al 1984, Just 1991, McNamara 1995). It is also well established that cervical spine disorders (CSDs) are predominant when TMDs are present and that CSD has more likelihood of being the primary mechanism vs TMD (McNeil 1990, Pandamesee 1994, Steenks et al 1996). It is strongly supported clinically as well as in the literature that muscle and myofascial dysfunction are more often the mechanism and source of pain in OFD than the TMJ (Janda 1986, Friction 1988). Additionally, it is suggested that there is high prevalence of abnormal illness behaviour, including parafunctional activity (such as nail-biting, bruxism) associated with the development or perpetuation of OFDs (Okeson 1996). Therefore, the proposed conservative care for OFD of this classification should include: • manual techniques to address muscle imbalances of the masticatory system, neck and upper torso

• exercises and training to facilitate good head posture and mandibular movement • behavioural techniques to address abnormal illness and parafunctional habits. Occlusal therapy, such as splint therapy, would then become secondary treatment applied only after legitimate trial of the above. Secondary treatment would also require continuation of rehabilitation and behavioural management if still indicated. This would include moving into more aggressive stages of active rehabilitation and functional restoration. Tertiary management might consist of further diagnostic considerations such as imaging, interdisciplinary care and psychological counselling. Phase II occlusal therapy (i.e. orthodontics, prosthedontics), microsurgery of the TMJ, trigger point injections and nerve blocks are some of the treatment options at this level of management. In this case, Louise would begin at the primary level of management (Skaggs 1996). (See Box 1.) Manipulation and/or mobilization of the cervicocranial junction and other cervical segments is a very critical element and in the acute condition can have instantaneously beneficial effects. Rarely, however, is it the sole treatment for OFD. It should be diagnosed and performed by a practitioner with proper training and a high level of skill and experience. It is important to stress the proficiency in this procedure for two reasons: first, and most importantly, are the poor results that will come forth with less than skilled application of this procedure; second, there is the wellknown risk involved with thrusting and movements of the cervical spine. Mobilization of the TMJ has been

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Box 1 Treatment approach for altered mandibular function

•

Manipulate/mobilize cervicocranial junction • Mobilize, and if necessary, ilStabilizeTM joint :i! R::e' ! a x , i and if necessary, stretch ii:ii{:i;::~asseter, pterygoids, SCM, ;::::i:::g~prahy0idSand suboccipitals • ::i:;~i:~rainmotor control of mandibular iiii :i~press6rs :::'i:Correctparafunctional habits, [ ::,i:: and standing posture

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I proposed by many authors and clinicians. Manipulation has also been recommended, although I have not found this necessary or productive in case of TMD. The mobilization that will be described is utilized to decompress the condyle-disc complex and reduce tension in the associated tissues (Fig. la). If the dysfunction of the TMJ is not manageable through manual techniques, then stabilization in the form of a splint is recommended as secondary management. A fiat plane (stabilization splint) is the conservative and primary choice for most TMD (Kirk 1991). Manual techniques, especially rehabilitation, should continue through this process. Soft tissue treatment follows a progressive sequence: post-isometric relaxation (PIR), stretch (contract-relax-stretch, CRAC), myofascial stretch, active myofascial stretch. Most of the muscles of mastication can be taken through this series. Treatment of the lateral pterygoid will be described as an example. PIR success is dependent on practitioners' ability to be light in their resistance contact. PIR of the lateral pterygoid is described (Fig. 2).

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Fig. 1 TMJ mobilization: (A) Once the involved side is detelnlined, the practitioner is placed at head, on opposite side of TMJ receiving treatment. Palmar thumb contact is placed on lower molars with inferior hand and superior hand palpating joint articulation anterior to tragus. Slack is lightly removed and barrier engaged. Barrier and release is first directed inferiorly. Then medial and lateral inferior vectors are completed. Respiration can be used to assist release. Barrier should not require or receive engagement longer than 25 seconds. (B & C) Medial and lateral mobilization for the condyle~lisc complex is accomplished by holding a mandibular contact and performing supination and pronation of the hand. This movement is very similar to the screwing on and off of a lid.

Myofascial stretch

Fig. 2 LateraI pterygoid: PIR is performed with the patient supine with mouth slightly open. The practitioner places his thumbs on the mandible from above; the patient is told to press chin gently forward against practitioner's thumbs, while breathing in; the patient then exhales, letting the chin drop back. The practitioner takes up the slack only. Stretch then consists of the same contacts. The patient this time applies a forceful resistance of protrusion and after exhalation the practitioner applies mild stretch to the mandible.

Fig. 3 Myofascial stretch: Patient is supine. Practitioner is at patient's head facing caudally. Practitioner uses opposite hand of jaw receiving treatment, to apply intra-oral contact. Same side hand contacts frontal-temporal region. Intra-oral hand forms a gun-like configuration, the arm abducted to 90 ° with the elbow at 90 °, and the wrist adducts to approximate 40 °. Index finger enters along maxillary gingiva to notch-like position inferior to the zygoma and directed posteriorly towards the condyle. No force is applied once initial contact is made, The weight of the arm with gravity allows for the release. This is very important as this procedure can be very painful. The opposite hand manoeuvres the head in rotation and decompressive movement, helping relieve the tension. Active release with this contact then adds blocking the muscle at the most concentrated area of tension while the patient protrudes through your firmly held contact. This is very painful and should be the last recourse.

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Facilitation and retraining of the mandibular depressors is fundamental to the complete restoration of these disorders. This procedure has been shown in several ways, but it is essential that the patient incorporates proper loading in combination with symmetry of contraction (Figs 4 & 5). In the author's opinion if the rotational component of mandibular function is not returned to at least 50% of total mandibular movement, dysfunction will persist, returning abnormal load and tension to the masticatory system. Insults occurring on a daily basis including nail-biting, gum-chewing, sitting poorly, etc. must be removed. New useful habits may need to be initiated. Often pain avoidance habits, i.e. use of non-steroidal antiinflammatory drugs may need converting to pain confrontation habits such as exercise and stretching. Additions to this treatment plan may include treatment approaches for associated functional pathologies (altered neck flexion, abnormal scapulohumeral rhythm). If direct

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Fig. 5 Loaded mandibular depression: Patient is seated. Patient hand contact is on hyoid or just superior. (A) Patient is asked to raise hyoid and/or contract muscles just superior to hyoid. Mouth should be at quarter opening. This process loads the condyle-disc complex in rotation. Once this is learned the patient can proceed to partial and full opening (B). Peel back: Patient places tongue in roof of mouth as to make the 'N' sound. Without losing contact with the roof of the mouth, the patient performs mandibular opening and closing (C).

change is not seen within 2 weeks of initiation of treatment, whether due to genuine lack of response, noncompliance or inability to perform the home programme, the patient should be progressed to secondary management. Excellent results are achieved via self-application. Louise, and people like her, can reach a comfortable state of function within the conservative applications of primary management if they are ready to apply themselves and someone takes the time to teach them.

REFERENCES

Fig. 4 Rhythmic stabilization: Facilitation of the depressors is performed with the patient supine. The practitioner is at the patient's head facing caudal. The practitioner places his thumbs on the mandible from above. The mandible is then passively depressed by the practitioner in a down-and-back trajectory, emphasizing the rotation of the condyle disc complex, to approximately mid-opening. The patient is then asked to hold the mandible in that position. The practitioner first applies mild force to closure and eventual challenge in all directions.

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Bonica JJ 1989 The Management of Pain. Lea & Febiger, Philadelphia, PA Carlsson GE et al 1984 Dental occlusion and the health of the masticatory system. Journal of Craniomandibular Practice 2:142-147 Davant TS et al 1993 A quantitative computerassisted analysis of disc displacement in patients with intemal derangement using sagittal view and magnetic resonance imaging. Journal of Oral & Maxillofacial Surgery 51 : 974-979 Dworkin SF 1992 Perspectives on psychogenic versus biogenic factors in orofaciaI and other pain states. APS Journal 3:172-180 Egermark I, Thilander B 1992

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Craniomandibular disorders with special reference to orthodontic treatment: an evaluation from childhood to adulthood. American Journal of Orthodontics & Dentofacial Orthopedics 101: 29-34 Friction JR 1988 TMJ and Craniofacial Pain: Diagnosis and Management. Ishiyaku EuroAmerica, Inc., St Louis, MO Gonzales H, Manns A 1996 Forward Head Posture: Its Structural and Functional Influence on the Stomatognathic System - a Conceptual Study. Journal of Craniomandibular Practice 14(1) Gregory TM 1993 Temporomandibular disorder associated with sacroiliac sprain. Journal of Manipulative & PhysiotoNcal Therapeutics 16(4) Hanna T 1988 Somatics: Reawakening the Mind's Control of Movement, Flexibility and Health. Addison-Wesley Publishing Co. Janda V 1986 Some aspects of extracranial pain. Journal of Prosthetic Dentistry 56(4) Just J 1991 Treating TM disorders: a survey on diagnosis, etiology and management. Journal of the American Dental Association 122:56 60 Kirk WS 1991 Magnetic resonance imaging and tomographic evaluation of occlusal appliance treatment for advanced internal derangement of temporomandibular joint. Journal of Oral & Maxillofacial Surgery 49:9-12 Kuwahara T, Bessette RW, Maruyama T I995 Chewing pattern analysis in TMD patients with and without internal derangement: Part II. Journal of Craniomandibular Practice 13: 93-98

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Skaggs/Ryan Lewit K 1991 Manipulative Therapy in Rehabilitation of the Locomotor System, 2nd edn. Butterworth-Heinemann Ltd, London Lewit K 1996 Advanced Manual Medicine and Rehabilitation Training Course. Charles University, Prague McNamara JA 1995 Occlusion, orthodontic treatment, and temporomandibular disorders: a review. Journal of Orofacial Pain 9:73-90 McNeil C et al 1990 Craniomandibular Disorders: Guidelines for Evaluation, Diagnosis and Management. Quintessence Books, Chicago, IL Okeson JP 1996 Orofacial Pain: Guidelines for Assessment, Diagnosis and Management. Quintessence Publishing Co., Chicago, IL Okeson JP 1993 Management of Temporomandibular Disorders and

Occlusion, 3rd edn. Mosby Year Book, St Louis, MO Pandamesee M 1994 Incidence of cervical disorders in a TMD population. Journal of Dental Research If ADR: Abst 680 Rocobado M 1985 Arthrokinematics of the temporomandibular joint. In: Clinical Management of Head, Neck and TMJ Pain and Dysfunction. W.B. Saunders Co., Philadelphia, PA Scapano RP 1991 The posterior attachement: its structure, function and appearance in TMJ imaging studies. Journal of Craniomandibular Disorders & Facial & Oral Pain 5:155-166 Skaggs CD 1996 Rehabilitation Management of Orofacial Pain and Temporomandibular Disorders. LACC Diplomate Course,

Chicago, IL Solberg WK, Woo MW, Houston JB i979 Prevalence of mandibular dysfunction in young adults. Journal of the American Dental Association 98:25-33 Spahl TJ, Witzig JW 1987 The Clinical Management of Basic Maxillofacial Orthopedic Appliances. Vol. 1: Mechanics. Littleton Co. PSG Publishing. Steenks MH, Wijer A, Bosman F 1996 Orthopedic diagnostic tests for temporomandibular and cervical spine disorders. Journal of Back and Musculoskeletal Rehabilitation 6(2) Yu X-M, Hu JW, Vernon H, Sessle BJ 1994 Effects of inflammatory irritant application to the rat temporomandibular joint on jaw and neck muscle activity. Pain

Temporomandibular dysfunction: traditional Chinese medicine approach M. K. Ryan

Chinese medicine relies heavily on observation of the patient and his or her tongue and taking the pulse to arrive at a diagnosis. In the absence of these and without being able to follow up on certain interesting symptoms in the case, anything said will necessarily be somewhat speculative. What follows are suggestions as to how one might proceed in thinking about Louise's temporomandibular joint (TMJ). Chinese medicine would not ignore the structural and mechanical aspects of the problem and might well combine its own versions of bodywork with an energetic assessment, leading to herbal and Mary Kay Ryan NCCA Dipl Ac/Herbology USA Curraghcrowley West, Ballineen, County Cork,

Republic of Ireland Correspondence to: M. K. Ryan Tel/Fax: +353 23 47887 Received Apri11997 Accepted May 1997

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acupuncture treatment. Even if the mechanical, structural explanations make sense, however, for Chinese medicine there is still a question as to why these symptoms recently worsened when the mechanical 'causes' have been present for so long. A number of aspects of Louise's case are of special interest in Chinese medicine. She has undergone fairly major surgical dental work, an injury to the clavicle and a head injury. Each one of these would be seen as a trauma to the area. Any injury to an area causes a stagnation of qi and blood and possible injury to the channels, which, if unresolved, can lead to chronic pain, stiffness, restriction and immobility. The TMJ problem she has developed lately could be a cumulative result of these injuries, or the stasis could have been irritated by recent changes in Louise's overall health, to wit the onset of menopause and the use of hormone replacement therapy (HRT) to suppress the symptoms of menopause. The slightly excessive alcohol intake along with overuse of sweetener could

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also be contributing. Menopausal symptoms are complex and would need to be fully assessed in Louise's specific case. In general, menopause is accompanied by a decrease in the body's blood and yin, which leads to heat symptoms like hot flushes, irritability, insomnia, anxiety and palpitations. Heat rises and all of these symptoms occur or are experienced higher in the body. Louise may already have a weakness of the gall-bladder channel, which rules the side of the head, caused by her head injuries. Her recurrent back pain may also indicate a tendency to trouble in this channel. Other channels that might be involved are the stomach and large intestine, both of which run through the clavicle, the shoulder girdle and the face and jaw. (The routes of these three channels relate the clavicular injury to the jaw - Figs 1-3.) All three of these channels are also susceptible to rising heat symptoms. So the rising heat caused by Louise's menopausal symptoms may be exacerbating the chronic stagnation of that area.

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