| Diagnosis
Once the presence of a craniomandibular functional disorder has been
ascertained clinically in a patient (joint noise, pain, deviation or limitation
of movement), one needs to continue with further diagnostic and instrumental
procedures directed towards confirming the diagnostic hypothesis. This should be
formulated first, i.e. a dysfunctional temperomandibular arthropathy, for
epidemological reasons. To this end, it is particularly useful to use imaging of
the temperomandibular joints and if possible, electrical verifications
(phonoarthrometry and electromyography). The differential diagnoses that in
these cases should be considered therefore, include:
-
Degenerative dysfunctional arthropathy (arthrosis);
- Arthritis
(immunopathologic, infective, post-traumatic, etc.);
- Condylomandibular
malformations;
- CA. of the TMJ (primary or metastatic).
Taking down a meticulous case-history, a
rational use of radiographic modalities (tomograms, CAT scan, NMR, and
radionuclide imaging) and of blood tests (haematological, immunological), should
clarify the diagnosis in cases where interpretative doubts
exist.
Diagnostic criteria
Structural/biological/ functional
- Imaging of the
TMJ (CAT scan, NMR, Radionuclide imaging)
- Arthrokinematics of TMJ
movements
Clinical
- Case-history
- Clinical
examination
- Instrumental examinations
(documented)
Pathological
- Pathological, histological
examinations
- Arthroscopy with, or without, biopsy
Rehabilitation of mandibular function
In the treatment of
temperomandibular dysfunctional arthropathies, one should bear in mind that the
possibility of effectively overcoming the symptom (joint noise, pain,
limitation), is generally proportional to the gravity of the specific symptom.
Consequently, the greatest expectation of success is limited to those serious
acute cases (open or closed lock of the mouth, acutization of joint pain and
noises). Minor symptoms that are not disabling, should not usually be taken
seriously as indications for treatment (less significant sounds in absence of
pain and structural changes).
Recent
results regarding long-term instrumental studies done before and after treatment
with occlusal splints, suggest that great care should be taken in the use of
these instrumental modalities, even if only occasional, because of the risk of
iatrogenic lesion induced in the contralateral joint to the one affected, that
will not be picked up from just a clinical examination.
Though a first acute
onset of such a pathological condition in a young person may respond positively
to a timely and appropriate intervention, it is nevertheless advisable to refer
all infants and young patients still in the growth stage, for examination by a
specialist. This should be done even if they present with only one of the
symptoms characterizing this pathology.
The treatment of dysfunctional
arthropathies of the TMJ should be divided into:
- Treatment of emergencies
(hypomobility, acute pain)
- Treatment of subacute or chronic cases (chronic
pain, joint noise, deviation of movement)
Treatment of
dysfunctional emergencies
Mandibular hypomobility
(open and closed lock)
mandibular movement (hypomobility) can present
with a more or less serious reduction in the degree of opening of the mouth
(closed lock), or with the impossibility of closing the mouth and bringing the
teeth into occlusion (open lock).
The closed lock happens usually in a
patient with a more or less long-standing history of joint sounds associated
with, or without, pain, and on rare occasions, in one-sided dysfunctional cases,
leads to the impossibility of carrying out normal functional activities
(mastication, phonation).
In cases of hypermobility and
incoordination between the condylar, meniscal and temporal components of the
joint, locking is usually caused by an acute dislocation that undermines the
positioning of the intracapsular structures as a result of an anteromedial shift
of the disc and a posterolateral displacement of the condyle.
The patient
presents with:
- A more or less marked reduction in the
aperture of the mouth;
- A marked laterodeviation of the affected side (with
maximal opening);
- Eventual pain in the joint affected.
The diagnosis is confirmed by radiographic
findings of condylar hypomobility. The resolution of the lock is often
spontaneous, or provoked by automatic movements that the subject performs to
overcome the resistence to complete opening of the mouth.
In those cases that
present to the dental clinician, the treatment suggested is the
following:
- Progressive mobilisation of the dislocated joint by teaching the
patient mediotrusion movements while opening the mouth (autoassisted movement,
active physiotherapy)
- The application of a temporary repositioning splint
in a position of mediotrusion of the dislocated
condyle.
In cases that are not
resolved within 1- 2 weeks with the above treatment, it is advisable to refer
the patient to a specialist centre for a manipulation under anaesthetic, so as
to avoid iatrogenic damage to the affected TMJ through laceration of the intra-
or pericapsular ligamentous structure. The same manoevre can be cause of damage
to the contralateral TMJ, if there is a marked resistence to manipulation from
contracture.
By open lock is meant the sudden inability to close
the mouth completely and the impossibility of maximally clenching the teeth
(partial block). Usually, it is the consequence of the anterior overriding of
the eminence and the disc by the condyle (hypermobility/ anterior dislocation of
the condyle, and posteriorly, of the disc.) During forced and repeated attempts
to close the mouth, the subject can bring the arches together to maximal
clenching position of the teeth, replacing the condylar head in the centre of
the fossa (x ray findings), without however, being able to grit his
teeth.
When the phenomenon of dislocation involves both joints, the
patient may present to the dentist or the doctor in quite an alarming state of
open lock of the mouth (bilateral subluxation).
The treatment
for a complete lock requires the reduction of the bilateral subluxation under
bilateral, mandibular nerve block (Gaw Gates technique). This is done by
manipulation in traction and retrusion using a bimanual
technique.
Treatment of a partial block (subluxation and unilateral
dislocation), should be limited to one or more of the following procedures:
-
A mandibular nerve block (Gaw Gates technique);
- A gentle manipulation in
retrusion of the mandible;
- The application, if appropriate, of a modified
Hawley occlusal splint (with only anterior bite) to be reset daily, for 1 - 2
weeks.
Joint and Muscle Pain
In dysfunctional TMJ
arthropathy, pain can be episodic, often during acute attacks or complications
(e.g. locking), or more or less continuous or chronic.
In the first case,
treatment is palliative as it is preferable to resolve the cause that has given
rise to the pathology.
In the case of subacute or chronic pain, therapy is
aimed at resolving the inflammatory process of a rheumatic, arthrotic nature. We
suggest some of the following drug therapies for use with children according to
their age/body weight (see Table 1).
| Table 1 |
|
Drug |
Dosage |
Side
effects |
|
Salicylates: Aspirin
|
50 - 100mg/kg/die, 50 -
100mg/kg/die, 200mg/kg/die |
Respiratory alkalosis,
metabolic acidosis, alterations in coagulation, gastrointestinal
disturbances |
|
p.Aminophenol:
Acetaminophen |
125 - 250mg/kg/die, 8 -
15mg/kg/die |
Nausea, vomiting,
diarrhoea, cutaneous rashes, haematurea |
|
Indol: Indomethacin
|
3 - 5mg/kg/die, 20 -
30mg/kg/die |
Anorexia, nausea,
abdominal pain, diarrhoea, frontal headache, neutropenias,
thrombocytopenias |
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