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Temporomandibular Joint Disorders

Management Team

Temporomandibular Joint Disorders

Overview

Temporomandibular joint (TMJ) disorders are a result of the inflammation of the TMJ, a hinge-like joint that connects the lower jaw to the skull, resulting in severe jaw and neck pain and headaches.

The combination of a hinge-like action and sliding motions is responsible for the movement-related functions performed by the TMJ. The parts of the bones that interact within the TMJ are protected by cartilage; the articular disk, a shock-absorbing disk, which ensures smooth movement, is present between these parts. TMJ disorders, which are often quite painful, can occur due to the following causes: 

  • Erosion of the articular disk or its displacement and misalignment
  • Arthritis-induced damage to the cartilage in the TMJ
  • Damage to the joint caused by a blow or other accidents
  • Bruxism

The symptoms of TMJ disorders include the following:

  • Soreness or stiffness in the jaw muscle
  • Frequent headaches, neck pain, and migraines
  • Clicking or popping of the jaw
  • Trismus (lockjaw)
  • Pain when eating or yawning
  • A misaligned bite
  • Pain and swelling around the jaw joint
  • Tenderness of the jaw muscles

Usually, TMJ disorders are diagnosed on the basis of an oral examination. Dentists will examine the jaw when the mouth is opened and closed to check for clicking sounds and assess the range of motion of the jaw; further, they will gently press some areas in the jaw to locate any sites of pain. If any problem is suspected based on the findings of the aforementioned tests, the following procedures may be needed:

  • Dental X-ray: to examine the jaw and/or teeth and identify any bone-related problems.
  • CT scan: for a detailed analysis of the bones involved in the functioning of the TMJ.
  • MRI: to detect problems in the articular disk or surrounding soft tissues.
  • TMJ arthroscopy: insertion of a small thin tube (cannula) into the joint space and visualisation of the joint region using a small camera (arthroscope); this technique is sometimes used to diagnose TMJ disorders.

While symptoms sometimes disappear without treatment, TMJ disorders may case persistent symptoms, in which case one or more of the following treatment options (often performed simultaneously) are recommended:

  • Medications: The following medications may help alleviate TMJ disorder-induced pain (when administered along with other nonsurgical treatments):
    • Pain killers and anti-inflammatories.
    • Tricyclic antidepressants for controlling bruxism and sleeplessness and relief from pain.
    • Muscle relaxants, such as antispasmodics, may be used for a few days or weeks: these provide relief from the pain attributed to muscle spasms.
  • Nondrug therapies: TMJ disorders may also be treated using nondrug therapies:
    • Application of mouth guards or splints: These occlusal devices, which may be soft or firm depending on the nature of use, are often beneficial for people with jaw pain when inserted over the teeth. However, the mechanisms by which they provide pain relief remain unclear.
    • Physical therapy: To maintain the flexibility and strength of the jaw muscles, dentists often recommend exercises along with the administration of ice, moist heat, and ultrasound therapies.
    • Counselling: Awareness, education, and counselling can help patients identify problematic habits, i.e., those that may exacerbate pain, such as leaning on the chin, tooth clenching/grinding, or onychophagia (biting fingernails). Accordingly, patients may be trained to avoid such habits via corrective psychotherapy.
  • Surgeries and other related procedures: If other conservative approaches fail to provide relief from symptoms, surgical procedures to correct the jaw and the TMJ may be recommended.
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Transcatheter Mitral Valve Repair (TMVr)

Management Team

Transcatheter Mitral Valve Repair (TMVr)

Overview

Transcatheter mitral valve repair (or “TMVr”) is a non-surgical minimally invasive procedure to repair a leaking mitral valve (mitral regurgitation) using an implanted clip (MitraClip™).

If your team of cardiologists has determined that you would benefit from having this procedure, then in the days before your procedure, it is important that you:

  • Take all your prescribed medications
  • Tell your doctor if you are taking any other medications
  • Make sure your doctor knows of any allergies you have
  • Follow all instructions given to you by your doctor or nurse

The following steps provide a general overview of the TMVr procedure with the MitraClip™ system. Your doctor will explain the procedure to you and can provide you with specific details and answer any questions you may have.

  • Your doctor will make a small incision in your upper leg, where a Steerable Guide Catheter (a hollow, flexible tube slightly larger than the diameter of a pencil) will be inserted through a vein to reach your heart.
  • The MitraClip™ implant, which is attached to the end of a Clip Delivery System, will be guided, using imaging equipment, to your mitral valve through the catheter for placement.
  • Your doctor will implant the Clip at the appropriate position on your mitral valve. The Clip will grasp the mitral valve leaflets to close the centre of the mitral valve and reduce mitral regurgitation.
  • Your doctor will then perform tests to confirm that the Clip is working properly. In some cases, your doctor may implant a second Clip for further reduction of mitral regurgitation.
  • Once the Clip is in place and working properly, it will be disconnected from the Clip Delivery System.
  • The Clip Delivery System and the Steerable Guide Catheter will then be removed from your body and the incision in your leg will be closed.

The implanted Clip will become a permanent part of your heart, allowing your mitral valve to close more tightly and reduce the backward flow of blood.

You should experience relief from your symptoms of mitral regurgitation soon after your procedure.

  • You will need to stay in the hospital from one to five days, depending on your recovery and overall health.
  • You will undergo close monitoring during this period. Your doctor will perform several tests to understand your heart function.
  • You may need to take blood-thinning medications for some time after the procedure. This is to decrease your risk of developing a dangerous blood clot.
  • You will be given instructions about your medications by your doctor or nurse before you are discharged from your hospital.
  • You will be discharged from the hospital and kept under the care of your family doctor or cardiologist, who will conduct follow-up appointments.
  • It is critical that you report for all follow-up appointments and adhere to the instructions of your doctor.
  • Most patients will not need special assistance at home following discharge from the hospital, other than for ongoing needs for any unrelated health conditions.

  • Limit strenuous physical activity (such as jogging or activities that cause shortness of breath, grunting, or straining when lifting heavy objects) for at least 30 days, or longer, if your doctor thinks it is necessary
  • Carefully follow your doctor’s instructions regarding medications you need to take, especially if blood-thinning drugs are prescribed
  • Call your doctor if you cannot keep taking your medications because of side effects, such as rash, bleeding, or upset stomach
  • Notify your doctor before any medical or dental procedure; you may need to be prescribed antibiotics to avoid potential infection

After your procedure, you will receive an Implant Identification Card, which your doctor will fill out and which you must carry with you at all times. This card identifies you as a patient who has a MitraClip™ implant.

  • Show your Implant Identification Card if you report to an emergency room.
  • If you require a magnetic resonance imaging (MRI) scan, tell your doctor or MRI technician that you have a MitraClip™ implant. Test results indicate that patients with the MitraClip™ implant can safely undergo MRI scans under certain conditions described on the card.
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Transcatheter Aortic Valve Replacement / Implantation (TAVR / TAVI)

Management Team

Transcatheter Aortic Valve Replacement / Implantation (TAVR / TAVI)

Overview

Transcatheter aortic valve replacement (TAVR), also known as transcatheter aortic valve implantation (TAVI), is a non-surgical minimally invasive procedure to treat aortic valve stenosis, a condition in which the valve between the main artery (aorta) and the heart narrows due to thickening of the valve walls.

TAVR can provide relief for the signs and symptoms of aortic valve stenosis. It may increase survival rates for people believed to be at intermediate or high risk of surgical complications from aortic valve replacement or for those who cannot undergo open-heart surgery.

TAVR is done to replace the aortic valve in people with aortic valve stenosis.

  • Aortic valve stenosis — or aortic stenosis — occurs when the heart’s aortic valve narrows.
  • This narrowing prevents the valve from opening fully, which obstructs blood flow from your heart into your aorta and from there to the rest of your body.

  • Aortic stenosis can cause chest pain, fainting, fatigue, leg swelling and shortness of breath.
  • It may also lead to heart failure and sudden cardiac death.

TAVR may be an option if you have aortic stenosis that causes signs and symptoms.

  • People who are considered at intermediate or high risk of developing complications after aortic valve replacement surgery.
    • This includes people with lung disease or kidney disease
  • People who have an existing biological tissue replacement valve that is not functioning well anymore.

Transcatheter aortic valve replacement (TAVR) carries a risk of complications, which may include:

  • Bleeding
  • Problems with the replacement valve, such as the valve slipping out of place or leaking
  • Stroke
  • Heart rhythm abnormalities (arrhythmias)
  • Kidney disease
  • Infection
  • Death

TAVR involves replacing your damaged aortic valve or your poorly functioning existing replacement valve with one made from cow or pig heart tissue, also called a biological tissue valve.

The decision to perform TAVR is made by a multidisciplinary group of medical and surgical heart specialists. Together, they determine an individual’s best treatment options.

  • Before TAVR, you will need to undergo tests and be evaluated by a multidisciplinary team of heart valve specialists to determine if you are suitable to undergo the treatment.
  • You will undergo an evaluation to ensure there are no risk factors that may impact you during the procedure.
  • You may also be prescribed medications to decrease infection risk prior to the procedure.

  • Before the TAVR procedure, you may be administered general anaesthesia.
  • Medication will be given to you intravenously so as to avoid the formation of blood clots.
  • Your heart function and rhythm will be monitored by the TAVR team. They will also keep an eye out for any changes in heart function. These changes can be treated as required during the procedure.
  • For the TAVR procedure, the access to your heart may be provided through a blood vessel in your leg. Access can also be provided through an incision in the chest, which permits the doctors to reach the heart via a large artery or the tip of the left ventricle (the bottom left chamber of the heart).
  • If these approaches are determined to be unsuitable, doctors may access the heart through other approaches.
  • A hollow tube or catheter is passed through the access point during TAVR.
  • Advanced imaging techniques are utilized by your doctor to move the catheter along your blood vessels, into the heart, and to the aortic valve.
  • Once the catheter is positioned precisely, your doctor will expand a balloon to press the replacement valve into place inside the native aortic valve. There are some valves that can be expanded without a balloon.
  • Once the valve is securely in place, the catheter is removed from your body.

  • You may be required to stay in the intensive care unit (ICU) for a night after your TAVR procedure.
  • Typically, you will stay in the hospital for two to five days after the procedure to recover.
  • Your doctor will prescribe blood-thinning medications to you after the procedure to prevent the formation of blood clots. They will also discuss with you how long you need to continue taking these medications.
  • You may need to continue taking certain medications after your procedure.
  • Your doctor will recommend that you take medications before certain dental procedures to prevent certain infections, as you are at higher risk of certain infections with a replacement heart valve. Talk to your doctor about his or her recommendations.
  • It is important that you take your medications as prescribed.
  • You will likely need regular follow-up appointments with your doctor.
  • Let your doctor know if you have any new or worsening signs or symptoms. Your doctor may recommend that you make healthy lifestyle changes, such as eating a heart-healthy diet, exercising regularly, maintaining a healthy weight and avoiding smoking.

  • TAVR can decrease the risk of death and improve the lives of people with aortic stenosis who cannot have surgery or for whom surgery is too risky by relieving the signs and symptoms of aortic valve stenosis and improve overall health.
  • TAVR has similar mortality rates as heart valve surgery in people with aortic stenosis who have an intermediate or high risk of complications from open-heart surgery.
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Trigger Finger

Management Team

Trigger Finger

Overview

Trigger finger is a common condition affecting single or multiple fingers or the thumb. The tunnel present at the base of the finger/thumb is thickened, leading to an improper sling of the tendon. The affected finger/thumb mimics the trigger of a gun when an attempt is made to straighten it.

Most of the patients are healthy adults with no underlying cause. However, some risk factors include:

  • Female sex.
  • Diabetes and rheumatoid arthritis.
  • Gripping activities.

  • The primary complaint is clicking or stiffness at the base of the affected finger/thumb, which is more pronounced during early morning or after a period of rest.
  • The patient typically complains of pain at the base of the finger (A1 Pulley) during the initial stages, while fixed locking or even weakness of the affected finger or thumb can occur in the advanced stage of the disease.

  • Physical examination.
  • X-rays to rule out arthritis.
  • Ultrasonography to see the condition of the affected tendon pulley.
  • Magnetic resonance imaging (MRI) to assess any causes for the swelling/compression.

Non-surgical treatment

  • Splinting the finger/thumb in a straight position, especially during the nighttime can be tried in initial cases with some response.
  • Activities like gripping should be avoided in some cases.
  • Physiotherapy may be beneficial in relieving the pressure around the pulley. Additionally, anti-inflammatory medications may provide temporary relief in the initial stages.
  • Around 50%–60% of the patients respond well to local steroid injections around the A1 pulley to reduce the inflammatory process. A maximum of 2 such injections can be tried.

Surgical treatment

  • Surgery:
    • The procedure can be performed under local or regional anaesthesia depending on the medical condition, pain threshold, and disease stage.
    • Open surgery involves an incision of around 2 cm at the base of the finger/thumb and releasing the A1 pulley completely, which is usually seen as a tight constricting band.
  • After surgery:
    • A sterile dressing is applied after the surgery and the patient is asked to do the finger movements as early as possible.
    • Complete recovery can take up to 2–3 weeks.
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Tennis Elbow

Management Team

Tennis Elbow

Overview

Tennis elbow is a condition in which the tendons attached to the outer part of the elbow are inflamed. It is also known as lateral epicondylitis because the inflamed tendons are attached to the lateral epicondyle.

Although the cause for this condition is unclear, risk factors include:

  • Repeated elbow overuse and movements, such as those during screwing, typing, or knitting.
  • History of diabetes, thyroid disorders, or conditions like rheumatoid arthritis.

  • Pain on the outer aspect of the elbow, especially while doing activities like twisting and lifting heavy weights.
  • Sometimes the patients present with radiating pain down to the forearm, wrist, or weakness.

  • Physical examination through tests, such as Cozen’s test.
  • X-rays to rule out fractures, bony spurs, or even calcifications.
  • Ultrasonography to assess the integrity of the extensor origin muscles (present on the outer part of the bone).
  • Magnetic resonance imaging for additional information.

Non-surgical treatment

  • Lifestyle modifications, including avoiding activities like lifting heavy weights and twisting movements at the elbow.
  • Specific sports injury treatment
  • Applying ice packs on the affected area to reduce the inflammation (swelling) and pain to a larger extent.
  • Splints and strapping using commercially available braces help reduce the strain on the extensor compartment muscles and promote the healing process. The use of straps, especially while playing sports, can reduce pain.
  • Stretching and strengthening exercises to strengthen the whole muscle-tendon unit, including the elbow and wrist joints.
  • Local injections (such as steroids) and platelet-rich plasma can alleviate the pain and promote regeneration at the tendon site.

Surgical treatment

  • Surgery:
    • Mini-open surgery: This involves making a 3–4 cm incision over the outer aspect of the elbow joint and excising the unhealthy tissue, followed by repairing the tendons (most commonly Extensor Carpi Radialis Brevis).
    • Arthroscopy: This is a new modality that helps in addressing the pathology with 2–3 small incisions releasing the pressure on the tendons and excising the unhealthy tissue.
  • After surgery:
    • Wound care for 2 weeks and maintaining the arm in a sling.
    • Based on the type of repair/release done, the rehabilitation usually starts 2 weeks after surgery.
    • Complete recovery is expected by the end of 2–3 months.
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