Performing basic clinical observation on patients with temporomandibular joint arthritis is critical to determining whether their disease has improved, worsened or remained the same, according to the Rheumatology Nurses Society president.
“The first thing I do when I walk into the room is observe the patient,” Cathy Patty-Resk, MSN, RN-BC, CPNP-BC, told attendees at the 2020 Rheumatology Nurses Society Annual Conference. While the patient may think that the first few minutes of “chit-chat” are just that, Patty-Resk said she is actually looking at the patient’s mouth to see how much it is opening and closing, whether there is symmetry in the jaw or lateral deviation.
But an important component of diagnosing temporomandibular joint (TMJ) arthritis can come even before the patient walks into the room, according to Patty-Resk. “A patient with rheumatoid arthritis is more likely than a patient with psoriatic arthritis to have TMJ,” she said. In fact, she noted, as many as 90% of patients with rheumatoid arthritis are likely to have some form of temporomandibular joint arthritis.
“In addition, historical data on the patient may be very important in putting together the picture of this rheumatic disorder,” Patty-Resk said.
The next component pertains to understanding the biomechanics of TMJ. Clinicians should look for micrognathia, which is a condition in which the chin erodes backwards. In addition, checking to see how wide a patient can open their mouth can be useful in diagnosing TMJ. “Seeing if they can fit three fingers into their mouth is a very good objective measure of knowing if their TMJ is improving, worsening or staying the same,” Patty-Resk said.
Jaw grinding may signify bone-on-bone movement, while jaw popping may signal dislocation and clicking could be early stages of displacement. Clinicians should note lateral deviation, meaning that the mandible moves from side to side as the patient opens their mouth. “Also, look and see if the anterior teeth line up,” Patty-Resk said.
But clinical observation only gets a clinician so far in managing TMJ. Patty-Resk stressed that there is a strong movement away from X-ray toward MRI in assessing this condition.
“You can never tell from an X-ray if the arthritis is actually active,” she said. She suggested that evidence on an X-ray may be of current or past damage from TMJ arthritis.
Regarding treatment, mouth guards and splints can have utility in mitigating the severity and damage caused by TMJ arthritis. For patients with a more severe condition, surgical intervention is an option.
As for interventions that nurses can recommend, instructing patients to avoid certain foods — tough meats, hard or chewy candy, and certain types of bread, among others — can go a long way. In addition, massaging the muscles of the mandible can provide relief, as can heat or ice.
“I also tell my patients not to rest their head on their chin or chew their fingernails,” Patty-Resk said.
“I hope you understand the importance of TMJ arthritis in our patients, and I hope this has been helpful,” Patty-Resk concluded. “When you have a better understanding of what is going on, the patient can have a better understanding of what is going on, and compliance with recommended interventions will go up.”