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[Physio Explained] Talking TMJ: Optimising your assessment & treatment with Dr Alana Dinsdale

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In this episode with Dr Alana Dinsdale we explore assessment of the temporomandibular joint (TMJ). We explore:

  • The anatomy of the TMJ
  • Symptoms of TMJ disorder
  • Hypothesis categories in treatment of the TMJ
  • Motor control in the TMJ
  • Role of screening the Cervical spine

This episode is closely tied to Alana’s Practical she did with us. With Practicals you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster.

👉🏻 Watch Alana’s Practical here with our 7-day free trial: https://physio.network/practicals-dinsdale

Dr Alana Dinsdale is a physiotherapist, researcher, and lecturer at The University of Queensland, specialising in the management of temporomandibular disorders (TMDs). She completed her PhD at UQ in 2023, focusing on disability and management strategies for individuals with persistent intra-articular TMDs. With a strong clinical background in private practice physiotherapy, Alana is dedicated to advancing TMD management through research, education, and collaboration. 

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Our host is @sarah.yule from Physio Network

SPEAKER_02:

With the diagnostic criteria, pain-related TMD is one of the key clinical things that we're looking for. within the physical examination is reproduction of similar or familiar symptoms when we're palpating certain structures. So for example, if we palpate the masseter and they report, that's the pain that I get when I'm chewing or when I wake up in the morning, or that maybe even brings on the headache that they get, that's one of the most helpful diagnostic tools that we can use within a clinical setting to rule in and pain-related TMDs.

SPEAKER_01:

What is a temporomandibular dysfunction and how do the different types impact treatment? Alana Dinsdale is an experienced physiotherapist, researcher and lecturer at the University of Queensland. Alana has done a TMD assessment and management practical with Physio Network where you can sink your teeth even further into the topic. So be sure to click the link in the show notes to watch Alana's practical for free with our seven day trial. I think you're going to enjoy today's podcast. I'm Sarah Yule and this is Physio Explained. Well, welcome Alana to the podcast. Thank you and thank you for having me. I'm really excited to be here. Thanks for joining us to discuss our favourite condylar hinge joint known as the temporomandibular joint. Before we get into it, I'm curious, what does your working week look like?

SPEAKER_02:

Yeah, so my... Primary, I guess, job is that I'm a lecturer at the University of Queensland. So that includes a balance of both teaching undergraduate and graduate entry master's students. So those that are training to be physiotherapists. And then I also do a few hours a week in clinical settings. So that's kind of in private practicing general musculoskeletal conditions. But my primary focus is on yoga. jaw pain or jaw disorder

SPEAKER_01:

patients, so TMD patients. I'd be lost. Well, let's sink our teeth into it, shall we? I promise that's the only time I'll use a pun, but I couldn't help it. So what is a TMD?

SPEAKER_02:

Yeah, so TMD, it's a great question. And I think it's something that If you're seeing TMDs clinically, it's really important to have an understanding of, I guess, where they start and where they end. TMDs, the term refers to temporomandibular disorders. which is a group of musculoskeletal conditions that are affecting the jaw joint complex. So that includes, you know, the bones, the discs, retrodiscal tissue, things like that around the jaw, as well as the surrounding structures. So things like ligaments, capsules and muscles. So things like masseter and temporalis. So I think It's really important to recognize that it's a group of conditions. So it's not just kind of a sole entity. And there's a few different things that fall under this, I guess, term TMD. Clinically, TMDs are characterized by a variety of symptoms, depending on what's going on with the jaw and the jaw condition. So these symptoms include things like jaw or orofacial pain, clicking, coming from the jaw joint, locking, like people are having difficulty. Often it's with opening, but it can also be that their mouth gets stuck open and they struggle to shut. Joint crepitus, so they're reporting kind of fine clicks or crackles within the joint when they're moving. And then it might also be accompanied by other symptoms that we less commonly relate to the jaw, like headaches and tinnitus as well.

SPEAKER_01:

So would those all be the different types of TMDs or do you classify them even further?

SPEAKER_02:

There's two main subgroups of TMD according to the most recent diagnostic criteria. So that's the DC slash TMD. The recent diagnostic criteria for temporomandibular disorders recognizes two main subgroups. So that's pain-related TMDs. And as you can imagine, they're characterized clinically by PAVE. And that can be pain in the jaw joints, pain in the muscles like masseter temporalis. And it can also be headaches that are attributed to TMD. So all of those conditions fall under pain-related TMDs. Then there's also intra-articular TMDs. So those are the types of TMDs that are characterized more by mechanical symptoms. like jaw locking clicking crepitus and then the most common presentation is that we have a combination of both of these going on so that's kind of our mixed tmd presentations and to keep things i guess interesting from a clinical perspective you might have pain related on one side and intra-articular on the other or you might have them occurring concurrently on the same side so I guess even though there's different types of TMDs, they can overlap clinically. So what's your typical

SPEAKER_01:

approach when looking at those in practice?

SPEAKER_02:

With the diagnostic criteria, pain-related TMDs, one of the key clinical things that we're looking for within the physical examination is reproduction of similar or familiar symptoms when we're palpating certain structures. So, for example, if we palpate the masseter and they report, that's the pain that I get when I'm chewing or when I wake up in the morning or, you know, that maybe even brings on the headache that they get. That's one of the most helpful diagnostic tools that we can use within a clinical setting to rule in pain-related TMDs. Intra-articular TMDs are a little bit trickier. A lot of them, the sensitivity and specificity of tests clinically aren't excellent, I guess, without the use of imaging. But certainly, we can be getting suggestions that there's something going on intra-articular-wise with that joint. If we're noticing reduced range of motion, like they can't open their mouth, and especially if it's severely reduced, like they're opening you know, less than 20 millimeters, we're suspecting they've got a lock, which is more suggestive of intra-articular pathologies than solely from, you know, muscle tightness or something like that. The other thing is that when we look clinically is we definitely want to be palpating the TMJs, both of them, when people are running through their range of motion so that we can be feeling for things like clicks and crepitus that you might not be able to hear necessarily. Sometimes you

SPEAKER_01:

can, but not always. So it's sounding like, as with a lot of our musculoskeletal presentations, we're sifting through and getting a really thorough subjective and hopefully getting those clues as to what we might be hunting further into, which then leads us into our objective examination where we are starting to build that hypothesis of what structures might be sensitive or tender or tight or moving a bit more based on the subjective description that we've been given.

SPEAKER_02:

Absolutely. I think the patient interview, as with other musculoskeletal conditions, a good patient interview is so integral and in directing the physical examination especially that initial physical examination where we're wanting to by the end of that we want to have a hypothesis or should i say diagnosis even without imaging we should be having an idea of what's going on with that joint complex and what might be contributing to this person's problem and then we also want to have enough information to know what impairments we might be wanting to investigate or limitations or restrictions these people are presenting with that we kind of need to be looking at and making sure that we're assessing within that initial physical examination so that we're not just treating half the picture.

SPEAKER_00:

Want an easier way to improve your assessment and treatment skills? Introducing Practicals. We'll see you next time.

SPEAKER_01:

And so I suppose the next question might be, what might the care of a patient with temporomandibular disorder look like?

SPEAKER_02:

Yeah, I think it obviously depends on what we find within the initial patient interview and physical examination. But there are, I guess, a number of things physiotherapists are able to kind of do to from a management perspective for people that are presenting for care for temporomandibular disorders. So there's a number of tools in the toolkit that we can use to address some of the things that we're finding within the physical examination. Like if somebody's presenting with pain and they're having issues, for example, opening their mouth, we might be using manual therapy techniques like whether it's massage trigger point or massage through those muscles. We can be using joint mobilizations as well to try and, I guess, reduce some of that pain and improve that range of motion in the short term. There's also, I guess, a number of tools that we can be using as well from a self-management and exercise perspective that can be really, really helpful in order to help these changes or these improvements that we're getting within the session last a lot longer and kind of get that patient a lot more actively involved in our management, which we obviously know is so important across all areas of musculoskeletal care. So I guess kind of even just brainstorming and thinking about some of those different types of TMDs and how they might present, if somebody was presenting with, I guess, a very dare I say, common presentation of a pain-related TMD. So they might kind of be coming in reporting bilateral orofacial pain through kind of the cheeks, the jaw, maybe a bilateral or unilateral headache with it as well. They might report that that pain is much worse first thing in the morning. And we find out through our physical examination and also our patient interview that they, I guess, may be quite an anxious or stressed person, or they're going through a really stressful period of their life. They're getting a lot of clenching and grinding at night. And sometimes people know that's happening. Sometimes they don't. Or during the day, if they're in a stressful job, they might be getting day clenching as well. So one of the initial goals of management might be to educate the patient about how these kind of patterns or habits can relate into what they're experiencing and teach them how that jaw should be sitting without being clenched, I guess, or without the teeth kind of clenching together in those periods of stress. So teaching that relaxed jaw position is really, really important for people that are presenting with clenching and grinding patterns or pain that's exacerbated by those kinds of parafunctional activities. Equally, I guess kind of sending those patients home with we might be doing within the physiotherapy session, we might be doing some manual therapy to try and, you know, reduce pain through some of those structures in the early stages. And then we might be teaching that patient as well exercises, stretches that they can be doing to combine with that relaxed jaw position that might help improve long term the symptoms that they're experiencing. Another example is if somebody's presenting with more intra-articular presentation. So maybe they'd have got a recurrent locking jaw. So they're getting a recurrent episodes of locking. And then in between those episodes of locking, they're getting clicking with the jaw. That might be suggestive to us that potentially this person's having an issue intra-articular wise with their jaw joint. And maybe we need to look at how that joint is moving, what kind of impairments we might be finding within the physical examination. Are there any strength impairments and are there any proprioceptive impairments or motor control impairments that are accompanying range of motion impairments? I think very commonly we focus heavily on range of motion as the only thing that we're working on or the only thing that we're kind of capturing as an outcome measure. But I guess the research definitely shows us that with people with intra-articular conditions, there are so many different activity limitations, participation restrictions, impairments that they're presenting with that we kind of need to make sure we're getting the whole picture. And the same applies for pain-related.

SPEAKER_01:

I think that's a really nice way of structuring it as well because it's easy to get overwhelmed by sometimes the air of mystery around the TMJ. But when we look at those hypothesis categories and sort of zoom out, we know that there are features that we can have that pragmatic approach for and take that biopsychosocial view and then look at joint structure and function and how it translates in. What sorts of issues do you typically see around motor control and proprioception?

SPEAKER_02:

Yeah, so a really common one with motor control proprioception is with mouth opening. We might see, for example, on the physical assessment, they might be opening their mouth and one time they swing to the right or they deviate to the right. So they swing to the right and then come back to midline. The next time we see they deflect or deviate to the left, so they either swing out to the left and come back or they swing out and stay out. And then the third time they might move straight. And so when we're kind of seeing, I guess, this mixed bag of, you know, we see them do the same movement three times or four times and they're doing it different each time, already I'm starting to think perhaps it's not something, you know, mechanical. With the joint that's causing this movement problem with opening, often it might be accompanied by a click or a clunk or a lock that they're reporting as a problem for them. Maybe it's that they don't know where their jaw is in space and that's why it's giving us this really inconsistent pattern. And often patients that have those issues, if we put them in front of a mirror or something like that, where they're able to visually see what's happening, often they're they can move a lot straighter or at least a lot more consistently and we should see their symptoms lessen with that increase in visual feedback. The other thing that we can do is get them to put their hands or their fingertips on their TMJs, so both sides just lightly touching the TMJs as they're opening and just paying attention to try and, I guess, keep that moving symmetrically or moving as straight as possible. It's You know, it's never perfect and we're not necessarily kind of getting fixed up on that. But if that's a cue that works for the patient and by palpating both sides, it improves their symptoms and improves that quality of movement, it's definitely something that we can consider within exercise management.

SPEAKER_01:

And at what point do you bring the cervical spine into it?

SPEAKER_02:

I would always, in my first session, I'm always thinking about Is the cervical spine contributing for this patient? And if it is, to what degree? So there are definitely some people that come in that present very clearly with jaw dysfunctions or jaw problems. That's very characteristic of TMD. But as soon as we start addressing cervical problems, they spontaneously resolve. Equally, I think there's people that come in that even if they're experiencing cervical symptoms, we really, their jaw symptoms are not getting better unless we're targeting the jaw specifically. So I think part of the patient interview, we need to be capturing any maybe pre-existing or underlying cervical issues that that patient might be experiencing or have experienced in the past. We also want to be within a physical examination, I guess, getting those early ideas of is there something going on with the cervical spine that's kind of matching in with what we're seeing? And often a treatment directed test or a treatment direction test, should I say, can really help determine is the cervical spine playing a role in jaw movement. So a really simple one that I would do really commonly is if I see somebody and Within the physical assessment, we're assessing cervical range of motion. We're getting an idea of that overall positioning of that head on neck posture and how that fits into kind of how they're sitting or standing at rest. I don't change anything to do with the posture until I've had a look at cervical range of motion. and jaw range of motion and got some outcome measures and got an idea of what movements are affected. And then something as simple as changing that head or neck posture, getting that person to sit up a lot taller, adopt what I guess we refer to in inverted commas as a neutral or an upright posture where things are, I guess, less of that forward head posture position. And then I will just reassess the problematic movements. And if that person notices a significant improvement in their symptoms, just by changing their head on neck posture and their overall posture, I'm definitely going to be digging in a lot more in that initial session into cervical spine and cervical spine

SPEAKER_01:

treatment. I think those are some fantastic clinical pearls and highlights the importance of us just having that pragmatic assessment approach that then leads into a really nice treatment and management. So thank you so much for all your wisdom today. You're very welcome. Be sure to click the link in the show notes to access Alana's practice for free or practical rather for free with the seven-day trial. Thanks so much, Alana. No worries. Thank you very much Thanks.