Case Study of TMJ Arthritis

A 66 y.o. Female presents with neck pain, myofascial pain, TMJ pain, limited chew, talk and yawn, inflammation left TM Joint. TMJ range 28mm w/o pain, 33mm with pain, with stethoscope significant crepitus and clicking left greater than right, Lateral excursion left decreased to 6mm, right 9mm, protrusion 8mm pain end range. Airway assessment mallampati 4, scalloping of the tongue, mucosal ridging bilaterally. Brief tooth assessment no pain with an assessment of cold to teeth, Lateral pole tenderness and posteriorly along synovial tissues, increase pain with loading of left TMJ and consistent with the Rocabado Pain Map. Negative bite test initially, but the more we did it, symptoms did come on, also with tongue blade positioned more under second maxillary premolar with load increased left TMJ symptoms. Several of the usual suspects with regards to the muscle of mastication, along with neck-related pain, tenderness, limited upper cervical spine mobility, particularly Atlas (C1), in addition to C4-5, and CT junction.

As we know and have discussed in the past, you have to include manual treatment of the cervical spine and upper Thoracic spine. After our initial evaluation and treatment patient agreed to get a cone beam scan to confirm objective findings on exam of fairly severe DJD, but also concerns of potential active inflammatory component and based on palpation and neck related symptoms it appeared patient might also have eagle syndrome and calcification of the stylohyoid ligament on both sides. The cone beam helped confirm these things. In addition, it helped rule out any active inflammatory component, and a piece of additional information was the loose body or joint mouse in the right TM joint. And as in so many cases while we might expect the right TM joint to be painful, etc all her sx where on the left, but both joint capsules were also very tight on both sides and required the usually prep work by treating the soft tissues with manual work extra and intraorally, along with joint mobs to both TM joints to improve mobility, reduce intra joint compression, improve capsular mobility and ultimately translation within the joints. In conjunction was doing cervical and thoracic work, appropriate TMJ related exercises, as well as cervical and postural correction exercises. I also referred her back to her dentist to assist in making a hard acrylic mandibular appliance as thin as possible with guidance and even contacts to reduce compression in the joint and help offload the sensitized and inflamed posterior tissues. We just completed visit 6, the patient can now open to 39mm without pain and 44mm with pain, lateral excursion bilaterally is 9mm, protrusion is 9mm, obviously given the significant joint deterioration on both sides, the 4:1 ratio we discuss in class will not match up perfectly in a case like this. She has no lateral pole tenderness at this point, so my assumption based on DC/TMD is we have helped alleviate some joint swelling, she can functionally chew, talk and yawn with significantly less pain at this point and time. I share this case, and I realize I am not providing all the details and intricacies of the evaluation and treatment because, as I stress in my course and teach, even patients that have such severe degeneration can function very well with minimal to no pain when PTs and Dentists team up to provide a nice, comprehensive collaboration along with a very compliant patient. She is diligent with her exercises, followed my advice to help reduce her joint inflammation and, more importantly, joint protection, and following up with her primary for additional blood work to make sure there is no underlying systemic inflammatory condition. Again I stress all this because, as I also share in my course, there is so much fear and anxiety that a patient can present with. If they have seen other practitioners that scare them on how bad their case is just based on their images, this is proof, granted only an N of 1. Still, I see numerous cases like this year after year after year. These patients can get relief and do very well with good, comprehensive conservative care between PT and Dentistry and other health care providers, massage therapists, chiropractors, ENTs, etc.

TMJs, coronal, axial, and sagittal views, teeth clenched. Bilateral degenerative joint disease. Loose body/joint mouse in the right joint and signified by the white arrow.

TMJs, coronal, axial, and sagittal views, teeth clenched on mandibular appliance made by the dentist, condylar position altered just enough to allow a reduction in compression posteriorly, medially, and slightly superiorly in the joint. We tend to go with the thinnest appliance necessary to achieve the required relief.

TMJs, sagittal view, mouth open. The loose body (white arrow) has changed position with respect to condyle and articular eminence.

calcified stylohyoid process on both sides

When at all possible I reach out to the primary dentist to at least get a copy of their most recent panorex view after my evaluation, while not as detailed as a cone beam scan, in this patient’s case you can see the calcified stylohyoid process on both sides circled in red, the joint mouse on the right circled in white and noted bilateral DJD with alterations to the condyle and temporal bone.