Temporomandibular Joint Disorders

exp date isn't null, but text field is

  • These are varied, of special concern is dislocation.

DISLOCATED MANDIBLE

CLINICAL DESCRIPTION

The condylar head moves forward and out of the socket.

CLINICAL FEATURES

  • The mouth remains open and cannot close spontaneously. Sometimes pain is present. Diagnosis is mainly clinical. If the mandibular midline deviates to one side, the dislocation is unilateral.

INVESTIGATIONS

  • CT Scan, MRI
  • Skull views (PA, TL, OPG, Arthrography of TMJ)

TREATMENT

Reduction of dislocated mandible 

  • Advise the patient on prevention and that there may be permanent changes in opening.
  • Injection of Local anesthesia 2 % Lignocaine (2−5 mls) into the joint or adjacent area of insertion of lateral pterygoid muscle may allow spontaneous reduction.

MANUAL REDUCTION

  • Pre−medicate with a benzodiazepine (e.g., Diazepam 5−10 mg IV). The patient's head is stabilized.
  • The operator places his thumbs on the external oblique line of the mandible (lateral to the third molars) with fingers placed under the chin.
  • A rotatory motion is performed by the thumbs pressing downwards and forwards, and the fingers pressing upwards until the mandible is reseated.
  • Stabilize the jaw to maintain mandible in position using Barton's bandage for at least six (6) weeks.
  • If conservative management fails, surgical intervention becomes inevitable

 

POST EXTRACTION BLEEDING (PEB)

CLINICAL DESCRIPTION

  • Commonly due to disturbing the blood clot by the patient through rinsing or inadequate
    • Compression on the gauze, though at times may be due to bony/tooth remnants.
  • Bleeding socket can be primary (occurring within first 24 hours post extraction) or secondary
    • Occurring beyond 24 hours post extraction.

CLINICAL FEATURES

  • Prolonged bleeding 8-12 hours after extraction
  • No blood clot on the socket

INVESTIGATIONS

  • FBC
  • LFT
  • Bleeding time, PTT, TT

TREATMENTNON-PHARMACOLOGICAL

  • Instruct a patient to avoid spitting and rinsing

PHARMACOLOGICAL 

  • Stop any treatment with aspirin
  • Personally press adrenaline pack for 15−30 minutes
  • If persistent − give Vitamin K 10 mg IM STAT and maintain the pack or consider the following:
  • Suturing, bone wax, gelatin sponge

Note: give antibiotics as a prophylaxis preferably Metronidazole

 

INFECTED SOCKETS

CLINICAL DESCRIPTION

A post extraction complication due to infection of the clot due to contamination (infected socket). The condition is painful and if not managed well could lead to osteomyelitis.

CLINICAL FEATURESSIGNS AND SYMPTOMS

  • Severe painful socket 2-4 days after tooth extraction
  • Fever
  • Necrotic blood clot in the socket
  • Swollen gingiva around the socket
  • Sometimes there may be lymphadenopathy and trismus (Inability to open the mouth)

INVESTIGATIONS

  • Intraoral X-rays

TREATMENT

  • Under local anesthesia with Lignocaine 2% socket debridement and irrigation with 3% Hydrogen peroxide. The procedure of irrigation is repeated the 2nd and 3rd day and where necessary can be extended to 4th day if pain persists. On follow-up visits local anesthesia is avoided unless necessary.
  • Patient is instructed to rinse with warm saline (5ml spoonful salt in 200 mls cup of warm water) or 3% hydrogen peroxide 8 hourly or 6 hourly in a day.
  • Antibiotics prescribed to prevent progression to osteomyelitis: Amoxicillin 500 mg PO 6 hourly for 5 days.

PLUS

  • Metronidazole 400 mg 8 hourly for 5 days.
  • X-Ray: Periapical X-ray of the socket may be necessary when there is poor progression apart from the above treatment, aim is to check whether there is no root remnant, foreign body or any local bone pathology

 

DRY SOCKETS

CLINICAL DESCRIPTION

It is a post extraction complication due to failure to form clot (dry socket). The condition is very painful and it defers from infected socket by lack of clot and its severity of pain.

CLINICAL FEATURESSIGNS AND SYMPTOMS

  • Severe pain 2-4 days post-extraction
  • Pain exacerbated by entry of air on the site
  • Socket devoid of clot
  • It is surrounded by inflamed gingiva

INVESTIGATIONS

  • Intraoral X-rays

TREATMENT

  • Treatment is under local anesthesia with Lignocaine 2% socket debridement and irrigation of 3% hydrogen peroxide. The procedure of irrigation is repeated the 2nd and 3rd day and where necessary can be extended to 4th day if pain persists. On follow-up visits local anesthesia is avoided unless necessary.