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Dr. Tucker’s Self Help Guide to the
Diagnosis & Treatment of Temporomandibular Disorders
Jeffrey Tucker, DC, DACRB
11600 Wilshire Blvd. #412
Los Angeles, CA 90025
310-473-2911
www.DrJeffreyTucker.Metaehealth.com
1
WHAT YOU CAN LEARN IN THIS
SELF GUIDE:
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•
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To identify problems of craniomandibular
function and appropriate self care.
To determine if your jaw muscles are
overactive and learn a corrective exercise
treatment.
To screen yourself for problems related to
activity limitations with chewing, swallowing,
speaking, respiration, and emotional
expression.
Learn specific nutritional recommendations.
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2
DIAGNOSIS of Temporomandibular
Disorders (TMD)
TMD is a collective term for a broad range of
disorders displaying a variety of signs – radiating
pain in the face, neck, or shoulders; limited
movement or locking of the jaw; painful clicking
or grating when opening or closing the mouth;
and a significant change in the way the upper
and lower teeth fit together. Other common
symptoms include headaches, earaches,
dizziness, hearing problems, and difficulty
swallowing.
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The Jaw Symptom Questionnaire consists of
the following questions:
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Does it hurt when you open wide to yawn?
Does it hurt when you chew or use the jaws?
Does it hurt when you’re not chewing or using the jaws?
Is your pain worse upon waking?
Do you have pain in front of the ear, or earaches?
Do you have jaw muscle or cheek pain?
Do you have pain in the temples?
Do you have pain or soreness in the teeth?
Do your jaws make noise so that it bothers you or others?
Do you find it difficult to open your mouth wide?
Does your jaw ever get stuck/lock as you open it?
Does your jaw ever lock open so that you cannot close it?
Is your bite uncomfortable?
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Jaw Symptom Questionnaire
• In my experience if a patient answers
more than three of the above questions
they will benefit by education, an antiinflammatory home care program including
dietary changes, nutritional supplements,
heat or ice applications, avoidance of
mechanically stressful activities, and
resting the jaw (practice the “lips apart and
jaws relaxed” procedure).
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“Do I have a disorder of the mouth, face or
Temporomandibular joints manifesting as neck
pain or headache?”
Your Dentist can evaluate if you have the
following:
• Disorders of the teeth
Atypical Odontalgia
Silent draining abscess
• Oral lesions
Carcinomas of the oral cavity
• Vascular lesions (see specific nutrition
recommendations next slide)
Temporal arteritis
Facial migraine
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General Nutrition for TM Disorders
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•
•
•
EC Matrixx™ is a mechanism-specific formula designed to support healthy
connective tissues by supporting the extracellular matrix, a key structural
component of connective tissues such as tendons, ligaments, and cartilage.
Features berberine and tetrahydro iso-alpha acids (THIAA), which have
been shown in laboratory research to influence MMP-13, an enzyme
involved in the maintenance of connective tissue structure.
THIAA has also been shown to beneficially influence multiple cellular
signaling processes related to connective tissue health.
Supports biochemical processes that influence the health of the
extracellular matrix.
Chondro-Relief Intensive Care — 3-6 capsules daily with food. Joint &
soft tissue support with MSM, Green Lipped Mussel, Hyaluronic Acid and
ASU.
Inflavonoid Intensive Care — 3-9 tablets daily with meals. For relief of
minor pain.
E-Complex 1:1 — 2-4 softgels daily. 1:1 ratio of alpha and gamma
tocopheryls.
www.DrJeffreyTucker.Metaehealth.com
7
“Do I have a disorder of the mouth, face or Temporomandibular joints manifesting as neck pain or headache?”
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Your Dentist can evaluate if you have the following:
Disorders of the teeth
Atypical Odontalgia
Silent draining abscess
Oral lesions
Carcinomas of the oral cavity
Vascular lesions (see specific nutrition
recommendations next slide)
• Temporal arteritis
• Facial migraine
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Headache: Vascular / Migraine
Nutrition
• In conjunction with UltraInflamX
• NOTE: in all forms of headaches,
sensitivities to certain food or
environmental factors can be a significant
entity to address. If determined to be, add
to the outlined protocols Perimine.
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Headache: Vascular / Migraine requires nutrition for
Inflammation Management: Cleanse, Repair& Put Out
the Fire
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•
A natural strategy should attempt to support the production of substances in the body that
protect tissue integrity and relieve pain and inflammation. This goal can be achieved by
targeted nutritional support:
Key anti-inflammatory nutrients, such as:
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Potent antioxidant nutrients, such as:
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Magnesium, zinc, and vitamins C, B3 & B6 to support healthy essential fatty acid and eicosanoid
metabolism
Citrus bioflavonoids, such as:
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L-glutamine to protect the integrity of the gastrointestinal mucosa barrier
Vitamin B5 (along with zinc and quercetin) to promote GI healing
Rice bran fiber to promote the growth of beneficial GI bacteria; decrease betaglucuronidase, mucinase, and
nitroreductase activities; and increase bile excretion
Eicosanoid-balancing nutrients, such as:
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Mixed carotenoids, zinc, manganese, selenium, rutin, rosemary, and vitamins A, C & E to reduce free
radical generation
GI-supportive nutrients, such as:
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Ginger to inhibit pro-inflammatory prostaglandin and leukotriene production
Turmeric to scavenge nitric oxide production and inhibit pro-inflammatory prostaglandin production
Quercetin to inhibit lipoxygenase, tumor necrosis factor alpha, and nitric oxide
Hesperidin to inhibit arachidonic acid metabolism and histamine release, thus resulting in analgesic and
anti-inflammatory activities
Detoxifying nutrients, such as:
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N-acetylcysteine and sodium sulfate to promote sulfation in phase II detoxification activities (often
compromised in inflammatory conditions)
Limonene to induce glutathione conjugation and glucuronidation
– 2 scoops of UltraInflamX includes all of the above.
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Headache: Vascular / Migraine Nutrition
• In conjunction with UltraInflamX
• NOTE: in all forms of headaches,
sensitivities to certain food or
environmental factors can be a significant
entity to address. If determined to be, add
to the outlined protocols Perimine.
www.DrJeffreyTucker.Metaehealth.com
11
Migraine Headache: Preventive
Maintenance supplements
• Trancor — 4 capsules daily. Helps balance between the
calming influence of GABA and the excitatory effects of
glutamate.
• Somnolin — 4 capsules daily (2 in the AM and 2 in the PM).
After headaches are under control for 4-6 weeks decrease by
1 pill per week until lowest dose is found that maintains the
patient symptoms. Features a complementary blend of 5-HTP,
theanine,and targeted B vitamins.
• EPA-DHA Extra Strength — 2 softgels 2-3 times daily with
meals. Essential fatty acids from cold water fish. Natural antiinflammatory documented to benefit migraine sufferers.
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Migraine Headache
At Onset:
• Trancor™ - 4 capsules daily.Trancor is formulated to
support a sense of tranquility in those who may feel
worried or nervous by beneficially modulating the
balance between the calming influence of GABA and the
excitatory effects of glutamate.
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“Do I have a disorder of the mouth, face or
Temporomandibular joints manifesting as neck
pain or headache?”
Your Dentist or Chiropractor can evaluate you
for the following:
• Neurological lesions
Atypical facial pain
Typical trigeminal neuralgia
Atypical trigeminal neuralgia
Pre-trigeminal neuralgia
Tic douloureux
See specific nutritional recommendations next
slide
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Specific nutritional recommendations: Atypical facial
pain, Typical trigeminal neuralgia, Atypical trigeminal
neuralgia, Pre-trigeminal neuralgia, Tic douloureux
• Ceralin Forte® — Three capsules daily.
Ceralin Forte is formulated to provide wellrounded support for brain and nerve
protection, addressing multiple pathways
involved in neurological health.
• Wellness Essentials™ For Men/Women
formula — 2 packets daily. Key Vitamins &
Minerals, Essential Fatty Acids, PLUS
gender specific nutrition.
www.DrJeffreyTucker.Metaehealth.com
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“Do I have a disorder of the mouth, face or
Temporomandibular joints manifesting as neck
pain or headache?”
Your Physician can evaluate you for the
following:
• Disorders of the eyes
Eye strain
Acute glaucoma
• Disorders of the ears
Ear pain (otalgia) (specific nutrition
recommendation)
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Ear pain of unknown origin.
General Treatment Strategies:
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Assume problem has a dietary component until proven otherwise.
Eliminate all dairy products for at least three weeks.
Eliminate refined sugars and “junk food.”
Address food intolerance (begin with most simple and inexpensive).
eliminate foods that are on the “common offenders” list, or
perform elimination/provocation (E/P) testing
if E/P is unsuccessful you may wish to proceed to serum IgG, IgE or
IgM—invasive and costly but very useful.
Eliminate trans fatty acids from diet.
Decrease omega-6 intake while increasing omega-3 intake.
Reduce intake of meat and eggs unless person is malnourished.
Address biomechanical problems with Chiropractor i.e. TM
dysfunction.
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“Do I have a disorder of the mouth, face or
Temporomandibular joints manifesting as a
disorder of the nose and throat?”
 Chronic nasal airway obstruction (CNAO) or
 Sinusitis - Signs and Symptoms
 Tenderness to palpation, swelling, redness, and opaque transillumination of involved sinuses
 Fever, chills: suggest expansion of the infection beyond the sinuses
 Nasal congestion and serous or mucopurulent discharge (usually
yellow or green)
 Malaise
 Headache and/or dizziness that changes with position and is worse
lying down or bending over
 History of upper respiratory infections, dental problems, nasal
allergies, or injury to the area
 Nasal mucosa is red and swollen, and the exudate may be seen in
the turbinates corresponding to the infected sinus(es)
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Sinusitis Acute Nutrition
Management
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Sinuplex - Features a unique, ephedra-free blend of vitamin C, quercetin, nettle root
extract, bromelain, and N-acetylcysteine. Supports healthy sinus, nasal, lung, and
respiratory function. May help support healthy eicosanoid synthesis.
Ingredients are carefully selected and manufactured with advanced processing
technologies to preserve the potency and stability of delicate components such as
bromelain.
NOTE: If patient has a history of antibiotic use, add UltraFlora Plus to the protocol.
Advanced Probiotic Nutrition with Immunoglobulins
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Chronic Sinus Condition
Management
• Perimine — 1-2 tablets twice daily with food. Patented, FlavonoidRich Perilla Seed Extract. Perimine features a patented extract of
Perilla seed (Perilla frutescens), a unique herb that supports a
healthy immune response in individuals who may be sensitive to
certain food or environment factors. Dried Perilla seed and leaves
have both historical and modern applications in Traditional Chinese
Medicine to alleviate chest fullness, support healthy mucus
secretion, and promote healthy breathing.
• Sinuplex — 2-4 tablets daily as needed. Healthy sinus and lung
support.
• Nazanol—1-2 tablets 2-3 times daily (based on severity of
condition) on empty stomach. Natural, stimulant-free herbal support
for healthy sinus, nasal and lung function.
www.DrJeffreyTucker.Metaehealth.com
20
“Do I have a disorder of the cervical spine (neck)
or headache manifesting as pain in the orofacial
or TM apparatus area?”
Ask your Doctor to rule out:
• Vascular lesion
Carotidynia
Thomboangiitis obliterans (Buerger’s disease)
• Neurological lesions
Neck-tongue syndrome
• Arthritic Disease
RA, SLE, AS, Psoriatic arthritis (see nutritional
recommendations)
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Core Nutritional Support Protocol
for RA, SLE, AS, Psoriatic arthritis
•
UltraInflamX® Plus 360 — 2 scoops twice daily. Multi-mechanistic support
with key nutrients, phytonutrients, and selective kinase response
modulators (SKRMs) to address underlying inflammation.
• Follow either the Modified Elimination Diet or the Anti-Inflammatory Diet
• LactoFlamX™ — 1 capsule daily LactoFlamX features L. plantarum 299V
— a strain-identified probiotic that has been specifically shown to support
the integrity and healthy function of the muscosal lining.
• EPA-DHA 6:1™ Enteric Coated — 2 softgels three times daily. EPA-DHA
6:1 Enteric Coated omega 3 fatty acids providing a ratio appropriate for
patients with chronic inflammatory conditions.
• Iso D3™ — 1 tablet three times daily. Vitamin D3 with Isoflavones. Iso D3 is
designed to support optimal metabolism of vitamin D to its active
form.
If there is a soy sensitivity use:
• D3 1000™ — 2 microtablets three times daily. High potency vitamin D3 —
the most bioactive form of supplemental vitamin D.
www.DrJeffreyTucker.Metaehealth.com
22
“I have been diagnosed with a
Temporal muscle tendinitis”
•
•
Perform corrective exercise stretches in this presentation.
Nutrition: EC Matrixx™ is a mechanism-specific formula designed
to support healthy connective tissues by supporting the
extracellular matrix, a key structural component of connective
tissues such as tendons, ligaments, and cartilage.
Features berberine and tetrahydro iso-alpha acids (THIAA), which
have been shown in laboratory research to influence MMP-13, an
enzyme involved in the maintenance of connective tissue
structure.
THIAA has also been shown to beneficially influence multiple cellular
signaling processes related to connective tissue health.
Supports biochemical processes that influence the health of the
extracellular matrix.
www.DrJeffreyTucker.Metaehealth.com
23
SELF TEST: MANDIBULAR
FUNCTION MOVEMENT
PATTERN
• Seated or standing in front of a mirror.
1. Slowly open & close mandible.
2. Qualification: Pass/fail
You fail if your mandible (lower jaw)
protrudes on initial phase of opening.
Follow the exercises in this presentation.
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Normal Opening
Three fingers width
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General Signs & Symptoms of TMD
 Pain on opening
 Trismus (limitation of mouth opening) or deviated jaw mobility
 Joint noises (clicking, popping, grinding)
 Pain on chewing
 Tenderness or pain felt in the jaw joint or muscles, or both
 Pain felt in the area of the ear, temples, or cheeks
 General Signs & Symptoms of TMD, con’t
 Ear “fullness”
 Subjective hearing loss
 Change in occlusion
 Abnormal wear of the teeth
 Headache (most common presentation are frontotemporal & suboccipital)
 Muscle hypertonicity
 Hypertrophy of the jaw muscles
 Tinnitis
 Dizziness
 Neck pain
 Upper trapezial pain
 Upper extremity pain & paresthesia
 Difficulty swallowing
Steigerwald, D.P., Whiplash and Temporomandibular Disorders: An Interdisiplinary Approach to Case
Management. Keiser Publishing, San Diego, CA., 1992
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Major Categories of TMDS
• Muscle Disorders (treat with corrective exercises &
nutrition)
Muscle pain
Protective muscle splinting (trismus, bracing, guarding)
Myospasm
Myositis
Myofascial pain (trigger point activity)
Contracture
Hypertrophy
Dyskinesia (muscle incoordination)
Dstonia
Bruxism
These disorders are treated by a Rehabilitation
Chiropractor or physical therapist. Warm laser, as used
by Dr. Tucker is an excellent pain-less non-surgical
www.DrJeffreyTucker.Meta29
treatment for the above
symptoms.
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Nutrition for Muscle Disorders
•
•
•
•
•
•
EC Matrixx™ is a mechanism-specific formula designed to support healthy
connective tissues by supporting the extracellular matrix, a key structural
component of connective tissues such as tendons, ligaments, and cartilage.
Features berberine and tetrahydro iso-alpha acids (THIAA), which have been
shown in laboratory research to influence MMP-13, an enzyme involved in the
maintenance of connective tissue structure.
THIAA has also been shown to beneficially influence multiple cellular
signaling processes related to connective tissue health.
Supports biochemical processes that influence the health of the extracellular
matrix
Muscle Spasm Remedy is a high quality, handmade homeopathic remedy
designed to relieve muscle aches, spasms, or pain.
Chondro Relief Intensive Care — 3-6 capsules daily with meals.
Comprehensive joint & soft tissue support, with MSM, Green Lipped Mussel,
Hyaluronic Acid, and ASU.
E-Complex 1:1 — 1 softgel 2 times daily with food. E Complex-1:1 is a unique,
natural vitamin E supplement that features a 1:1 ratio of alpha- to gammatocopherol; this ratio more closely resembles the tocopherol profile found
naturally in vitamin E-rich plants.
Avoid caffeine, menthols.
Dietary Suggestions: Anti-Inflammatory Diet
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30
Major Categories of TMDS
• Ask your Doctor which Temporomandibular joint
disorders do you have:
 Disc displacement or internal derangement
 Arthralgia
 Capsulitis or synovitis
 Arthritis disease (systemic)
 Degenerative disease (osteoarthritis)
 Traumatic articular disease (sprain or strain, fracture)
 Disc displacement without reduction (closed lock)
 Disc displacement with reduction
 Subluxation of the condyle
 Dislocation of the condyle
These disorders are treated by a Rehabilitation Chiropractor or
physical therapist. Warm laser, as used by Dr. Tucker is an
excellent pain-less non-surgical treatment for the above
symptoms.
www.DrJeffreyTucker.Metaehealth.com
31
General Nutrition for TM Disorders
•
•
•
•
EC Matrixx™ is a mechanism-specific formula designed to support
healthy connective tissues by supporting the extracellular matrix, a key
structural component of connective tissues such as tendons, ligaments,
and cartilage. Features berberine and tetrahydro iso-alpha acids
(THIAA), which have been shown in laboratory research to influence
MMP-13, an enzyme involved in the maintenance of connective tissue
structure.
THIAA has also been shown to beneficially influence multiple cellular
signaling processes related to connective tissue health.
Supports biochemical processes that influence the health of the
extracellular matrix.
Chondro-Relief Intensive Care — 3-6 capsules daily with food. Joint &
soft tissue support with MSM, Green Lipped Mussel, Hyaluronic Acid
and ASU.
Inflavonoid Intensive Care — 3-9 tablets daily with meals. For relief of
minor pain.
E-Complex 1:1 — 2-4 softgels daily. 1:1 ratio of alpha and gamma
tocopheryls.
www.DrJeffreyTucker.Metaehealth.com
32
Major Categories of TMDS:
Inflammatory disorders
Continuous pain that is increased with
function
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Core Nutritional Support Protocol
UltraInflamX® Plus 360 — 2 scoops twice daily. Multi-mechanistic support with key
nutrients, phytonutrients, and selective kinase response modulators (SKRMs) to
address underlying inflammation.
Follow either the Modified Elimination Diet or the Anti-Inflammatory Diet
Kaprex® — 2 tablets twice daily. Non-responders by day 5 move to 3 tablets 2-3 times
daily.
Time to benefit: Immediate to 10 days.
Kaprex is a clinically tested herbal dietary supplement that provides natural joint relief that is
easy on the gastrointestinal (GI) tract. It works by interfering with signals in the body that
initiate the production of damaging compounds that cause minor pain and negatively
impact cartilage and other joint tissues
EPA-DHA 6:1™ Enteric Coated — 2 softgels three times daily. EPA-DHA 6:1 Enteric
Coated omega 3 fatty acids providing a ratio appropriate for patients with chronic
inflammatory conditions.
Iso D3™ — 1 tablet three times daily. Vitamin D3 with Isoflavones. Iso D3 is
designed to support optimal metabolism of vitamin D to its active form.
If there is a soy sensitivity use:
D3 1000™ — 2 microtablets three times daily. High potency vitamin D3 — the most
bioactive form of supplemental vitamin D.
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33
Anti-Inflammatory Diet
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34
Major Categories of TMDS
• Disorders of mandibular mobility (hyper- or
hypo-mobility)
Hypermobility
Adhesion
Ankylosis
Coronoid process elongation
Fibrosis of muscle (contracture)
These disorders are treated by a Rehabilitation
Chiropractor or physical therapist. Warm laser, as
used by Dr. Tucker is an excellent pain-less nonsurgical treatment for the above symptoms.
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35
Major Categories of TMDS
• Growth disorders
Hypoplasias
Hyperplasias
Neoplasias
These conditions require co-management of
multiple doctors.
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OROFACIAL DISORDERS
FUNCTIONAL ANATOMY
Primary Functions of the Masticatory
System:
Mastication
Swallowing
Speech
Secondary Functions:
Respiration
Emotional expression
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MANDIBULAR POSTURAL REST
POSITION (MPRP)
The normal MPRP is in equilibrium between
the downward pull of gravity and the
myotatic reflex contraction of the
mandibular elevators. MPRP depends on
muscle tonus of the anterior and posterior
cervical muscles, head posture, and the
inherent elasticity of muscles.
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MANDIBULAR POSTURAL REST
POSITION (MPRP)
• Normally there is no occlusal (tooth-to-tooth) contact
during MPRP. This interoccclusal space is termed
freeway space and is usually 3-5 mm when measured
from MPRP to full occlusal contact. This dimension is
increased in mouth breathers and is decreased in people
who brux or clench.
• Significance of MPRP is that, under normal conditions, it
is a time for rest and repair of the TMJ system.
• Head posture is probably the single most important
factor governing MPRP. A Chiropractor is the most
skilled practitioner to evaluate your head posture.
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MANDIBULAR POSTURAL REST
POSITION (MPRP)
• Significance of MPRP is that, under
normal conditions, it is a time for rest and
repair of the TMJ system.
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MUSCLES OF MASTICATION
•
Elevators (jaw closing) of the mandible:
(these are commonly overactive)
1. Masseter
2. Medial pterygoid
3. Temporalis muscles
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MUSCLES OF MASTICATION
• The posterior fibers of the temporalis can
retract the mandible and maintain the
condyles posteriorly. The superficial fibers
of the masseter protrude the jaw. The
deep fibers act as a retruder. The medial
pterygoid can protrude and lateral deviate
it to the opposite side.
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MUSCLES OF MASTICATION
• Depressors (jaw opening) of the mandible:
Digastrics
• Protrusion (jaw jutting forward) of the
mandible:
Inferior lateral pterygoid
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MASSETER MUSCLE
• Actions: Elevate the
mandible and close the
jaw. Deep fibers also
retrude the mandible.
• Synergist: Temporalis,
medial pterygoid
• Antagonist: Digastric,
inferior lateral pterygoid
• It is frequently overactive
and can become tight.
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Masseter muscle nutrition
• Fibroplex® Plus provides targeted nutritional support
for soft tissues in those with muscle tenderness and
discomfort. Featuring a blend of specific vitamins,
minerals, and amino acids in an easy-to-use delivery
form, this specialized formula works by supporting
cellular energy production and muscular and nervous
system function.
• Provides targeted nutrition for soft tissue in those with
muscle tenderness and discomfort.
• Provides targeted support for energy metabolism and
neuromuscular function.
• Supports cellular energy production and mitochondrial
function.
www.DrJeffreyTucker.Meta• Provides magnesium
in the form of an amino acid
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chelate designed to be easily
absorbed
45
Tinnitis caused by the Masseter
Muscle
• Unilateral tinnitus may be associated with
trigger points in the upper posterior portion
of the deep layer of the masseter muscle.
Unilateral tinnitus also may arise from TMJ
intracapsular disease. If the tinnitus is
bilateral, one should suspect a systemic,
rather than a myofascial cause (Travell).
• Vitamin-deficiency of niacinamide and
thiamine may be related to tinnitus. (see
next slide for nutrition)
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•
•
•
•
•
•
Tinnitis:
Nutrition
Appropriate Wellness Essentials™ formula — 1-2 packets daily. Key
Vitamins & Minerals, Essential Fatty Acids, PLUS gender specific nutrition.
CoQ10 ST 100 — 1 softgel three times daily. Stabilized, Highly Absorbable
Coenzyme Q10 with Natural Vitamin E. According to a German study
published in Otolaryngol Head Neck Surg. 2007 Jan; 136(1):72-7, “For a
Subgroup of people CoQ10 may provide relief from the symptoms of
tinnitus.” The test group was administered 100mg. of CoQ10 three times
daily for 12 weeks.
If a history of antibiotic use:
Ultra Flora IB — 1 capsule daily with food. (minimum of 2 bottles). Ultra
Flora IB is an enhanced potency probiotic formula designed to help relieve
bowel irritation and related functional discomforts by promoting a healthy
balance of intestinal microflora.
If on prescription diuretics:
MG/K Aspartate — 2 tablets daily with food. Magnesium and Potassium
combination designed to optimally replace lost potassium levels.
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MASSETER MUSCLE
Exercise
1) Passive Mandibular Self-stretch
2) Three-step resistive exercise: 1. resistance held
for 10 sec as the patient actively, gently tries to
close the mouth while it is held wide open. 1a.
Relax. 2. patient tries to open the mouth as wide
as possible with gentle assistance from the
hand, slightly increasing the range of motion. 3.
active opening effort of the patient is resisted by
the hand. Repeat 3X. The patient then opens
and closes the mouth through the maximal
active range of motion several times without
resistance.
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TEMPORALIS MUSCLE
• Actions: Elevation (closure) of
the mandible. The posterior
fibers, in addition, are
important for retrusion and
lateral deviation of the
mandible to the same side.
• Synergists: ipsilateral:
masseter, superior lateral
pterygoid, medial pterygoid.
contralaterally:
same plus temporalis.
• Antagonist: inferior lateral
pterygoid, anterior digastric,
omohyoid, mylohyoid.
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TEMPORALIS MUSCLE
• Trigger points may be activated: by
bruxism & clenching; direct trauma i.e. fall
on the head, impact from a ball, auto
accident; prolonged jaw immobilization;
cervical traction; excessive gum chewing.
• Self Treatment: Massage the muscle and
rub out the tender points found.
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TEMPORALIS MUSCLE
• Usually, about 2 ½ knuckles of jaw
opening is reached if the temporalis, but
not the masseter, muscle is involved.
Masseter tension restricts opening more
severely.
• Giant Cell Arteritis (Temporal arteritis):
headache, fever, consequent blindness,
respond to corticosteroid therapy.
• Exercise: Mandibular Self-stretch
The patient is encouraged to induce a widewww.DrJeffreyTucker.Meta51
open yawn as a regular
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MEDIAL (INTERNAL) PTERYGOID
• Actions: Bilaterally, elevates the mandible:
Unilaterally, deviates the mandible to the
opposite side; it also can assist protrusion.
• Symptoms caused by active trigger points
are difficulty in swallowing & painful,
moderately restricted, jaw opening.
Stuffiness of the ear may be a symptom of
trigger points.
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MEDIAL (INTERNAL) PTERYGOID
• Patient examination usually reveals
contralateral deviation of the incisal path
as the jaws are opened and closed, with
restriction of opening.
• Activation: sucking of thumb, excessive
gum chewing, occlusal interference,
bruxism (lateral grinding of the teeth),
clenching, anxiety and emotional tension.
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INFERIOR LATERAL PTERYGOID
• Attaches, in front, to the lateral pterygoid
plate and, behind, to the neck of the
mandible.
• Action: Bilateral=its primary role is
protrusion (jaw jutting forward)
Unilateral=lateral movement to opposite
side
With depressors=pulls the condylar head
forward and down so that the condyle can
translate over the posterior surface of the
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eminence, (essential
for full opening)
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INFERIOR LATERAL PTERYGOID
• Examination: Slight decrease in jaw
opening; lateral excursion of the mandible
is reduced toward the opposite side, away
from the involved muscle; midline incisal
path deviates, usually away from the
affected side.
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INFERIOR LATERAL PTERYGOID
• Lateral pterygoid function is practically
eliminated by having the patient slide the tip of
the tongue backward along the roof of the mouth
to the posterior border of the hard palate, which
stops translation of the condyles across the
eminentia. If the incisal path straightens out
when the mouth is opened in this way, it is
chiefly lateral pterygoid dysfunction that is
causing the muscular imbalance; if the incisal
path still zigzags, other muscles and/or a TMJ
derangement are responsible (Travell p.264)
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INFERIOR LATERAL PTERYGOID
Exercise #1
• Both divisions are passively stretched by
maximal retrusion of the mandible. Patient
supine. Practitioner places his thumbs on the
mandible from above; the patient is told to press
chin gently forward against his thumbs, while
breathing in; the patient then exhales, the Dr.
pushes the mandible backwards with the teeth
separated by only a few millimeters. Follow this
up with full active ROM by maximally protruding
& retruding the mandible, without manual
resistance.
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INFERIOR LATERAL PTERYGOID
Exercise #2
• Rhythmic stabilization self stretch: patient
grasping the mandible by the fingers &
thumb, inside & outside the mouth, then
slowly & smoothly, but firmly, pulling it
forward until the muscles feel tight.
Alternate, rhythmic protrusion and
retrusion efforts by the hand.
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INFERIOR LATERAL PTERYGOID
Exercise #3
• Active resistive exercise (strength): patient
protrudes the mandible against resistance,
and then moves the mandible to each side
also against resistance.
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SUPERIOR LATERAL
PTERYGOID
• Originates from the infratemporal surface
of the greater wing of the sphenoid bone
and, attaches to the disc and capsule (40
percent) and condyle (60 percent).
• Action: Pulls the articular disc forward &
checkreins its backward movement, thus
assisting mandibular elevation.
Overactivity or TrP shortening, displaces
the articular disc forward & impedes its
return to its normal position on closure of
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the jaws.
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SUPERIOIR LATERAL
PTERYGOID
• Patient examination: slight restriction of
jaw opening, a distorted incisal path, and
often occlusal abnormality.
• Travell “Trigger point’s in this muscle are
the chief myofascial source of referred
pain felt in the TMJ area.” P.260
• Activation of trigger points: Satellites from
the SCM (short leg), malocclusion,
bruxism, gum chewing, playing an
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instrument. www.DrJeffreyTucker.Metaehealth.com
DIGASTRIC causes difficulty
swallowing
• Referred pain and tenderness from trigger
points in the posterior belly are projected
to the upper part of the
sternocleidomastoid muscle.
• Symptoms include difficulty swallowing.
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DIGASTRIC
• Action: Assist depression & retrusion (pulls
the mandible back & down).
• When the hyoid is fixed by the suprahyoid
& infrahyoid muscles, the digastics (left &
right) can depress the mandible & bring
the teeth apart.
• When the mandible is stabilized, the
digastric muscles, with the suprahyoid &
infrahyoid muscles, elevate the hyoid
bone, which is a necessary function for
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swallowing. www.DrJeffreyTucker.Metaehealth.com
DIGASTRIC
• Omohyoid & sternothyroid are both muscles
involved in proximal stabilization for speaking
and swallowing function of the mandible.
Zang, B.A. The effect of the occlusal splint on the
biomechanics of the cranium, cervical spine,
mandible and the hyoid region. Orthodontic Review,
Jan/Feb., 1988.
• Synergist: Inferior lateral pterygoid
• Exercise: patient should do a self-stretch, jaw
protruding passive exercise, lying supine.
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DIGASTRIC
SKILL TECHNIQUE
• Hyoid restriction is most often associated
with unilateral increased tension of the
digastrics. This is evaluated by softly
shifting the hyoid from side to side.
Deviation of the cartilage can usually be
seen on the side of increased tension.
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DIGASTRIC
SKILL TECHNIQUE
• Post-isometric Release (PIR) is performed with
the patient supine; one hand of the practitioner
resists the opening of the mouth while the thumb
or finger of the other hand exerts minimal force
on the hyoid on the side of increased tension or
deviation. The patient is instructed to open their
mouth gently, and breath in; to hold their breath,
and then to breath out and relax. During
relaxation, resistance in the digastrics will give
under the practitioner’s thumb.
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A PROPER TM CLINICAL
EXAMINATION INCLUDES
1.
2.
3.
4.
5.
6.
History
ROM
Mandibular tracking
Auscultation
Palpation
Provocations (joint/muscle challenges)
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Motor Vehicle Accidents & TMD
History Questions
1. Have you noticed any clicking, popping or other noise in the temporomandibular (jaw) joints occurring with mouth
movement which have arisen (or have increased) following the accident?
Yes___ No___
2. Since the accident have you noticed any inability to fully open or fully close the mouth without strain/pain?
Yes___ No___.
3. Since the accident have you noticed any sense of an altered bite or altered jaw posture or altered jaw function
during chewing, speech or other mouth movements?
Yes___ No___
4. Have you noticed any symptoms associated with your ears since the accident, specifically:
A sense of diminished hearing
Ringing in the ears
A sense of pressure in the ears
Pain in the ears
5. Since the accident have you experienced headaches, neck or shoulder pain?
Yes___ No___
6. Have you noticed any tendency to clench your teeth since the accident?
Yes___ No___
7. Have you experienced any of these symptoms before the accident?
Yes___ No___
If yes, which ones?
If yes, when was the last time you had this/these symptom(s) before the accident?
If yes, describe the difference, if any, between the symptom before and after the accident?
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TM Diagnostic Aides
• Typical arthrogenous (joint) pain improves
as the day progresses, especially if the
jaw is active.
• Masticatory myofascial pain is typically
worse upon awakening if bruxism
(grinding) is present. However, inflamed
joints can be aggravated by bruxism as
well and hurt upon awakening as well.
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Whiplash/TMD Unique Factors
1. The onset of local signs and symptoms of
TMD may be delayed by weeks to
months.
2. Peripheral symptoms of TMJ
inflammation such as headaches and
neck pain will surface within hours to
days. These symptoms may continue to
be the dominant complaint indefinitely.
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•
•
•
•
•
•
•
•
Causes of pain in the Region of the
Temporomandibular Joint Differential
Diagnosis
Inflammation of the preauricular lymph nodes
Otitis media or extrena
Referred pain from a trigger point
Tenosynovitis of the temporalis tendon as it
passes behind the zygomatic arch
Trigeminal neuralgia
Dental caries
Bony tumors, both benign & malignant (primary
& metastatic)
Inflammatory arthritides (i.e., ankylosing
spondylitis, rheumatoid arthritis, juvenile arthrits,
psoriatic arthritis, etc.)
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DR. TUCKER’S INITIAL
MANAGEMENT & TREATMENT
• I want to reassure you that you can get better
and have many treatment options.
• Continue to become educated:
a) Anti-inflammatory diet is very valuable.
b) Self care includes the use of heat or ice.
c) Avoid mechanically stressful activities, soft diet,
avoid exhaustive chewing (chewing gum, eating
caramels, biting a pen or pencil, chewing tough
meat, bagels, pizza, cracking nuts or ice with
teeth), avoid sleeping on stomach.
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INITIAL MANAGEMENT &
TREATMENT
• Rest the jaw. That means minimal talking
& chewing.
• Maintain good posture. Get evaluated by a
Chiropractor and learn how to enhance
your posture.
• Avoid clenching.
• Practice the “lips apart & jaws relaxed”
procedure.
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INITIAL MANAGEMENT &
TREATMENT
• Approximately 10 to 30 days are usually
required for chiropractic & home therapy to
exert some effect.
• Pain Control: Meditation, vitamins/herbs,
NSAID’s, muscle relaxant,
antidepressants.
• Physiotherapy: Laser, Stretch-and-spray,
ice packs, heat packs, diathermy, EMS,
US, anesthetic injections, soft tissue
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mobilization & www.DrJeffreyTucker.Metamanipulation.
ehealth.com
THANK YOU!
• I appreciate that we could spend time
together.
• My email is [email protected]
• To order vitamins/minerals please go to
my website www.DrJeffreyTucker.com
and click on the Metagenics link.
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