okeson diff dx of tmd texas 3-17 · okeson differential dx of tmd star of the south dental meeting...

Okeson Differential DX of TMD Star of the South Dental Meeting

1

byJeffrey P Okeson, DMD

Professor and Division Chief of Orofacial Pain Department of Oral Health Science

Director, Orofacial Pain Center University of Kentucky College of Dentistry

Lexington, Kentucky [email protected]

www.jeffokeson.com

Differential Diagnosis of Temporomandibular Disorders

The Star of the South Dental MeetingMarch 3, 2017Houston, Texas

- General types of Orofacial Pains -

1. Dental Painsa. Pulpalb. Periodontal



2. TMD Pains

What is TMD?

“A collective term embracing a number of clinical problems that involve the masticatory musculature, the TMJ and associated structures or both.”*

*de Leeuw: Orofacial Pain AAOP GuidelinesQuintessence Publishers, 2013, p116.

I. Masticatory Muscle Disorders1. Protective Co-Contraction2. Local Muscle Soreness3. Myofascial Pain4. Myospasm5. Chronic Centrally

Mediated Myalgia

II. Temporomandibular Joint Disorders1. Derangements of the

Condyle-Disc Complexa. Disc Displacement

with Reductionb. Disc Displacement

without Reduction2. Structural Incompatibilities

a. Adhesions / Adherencesb. Deviation in Formc. Subluxationd. Spontaneous Dislocation

3. Inflammatory Disordersa. Synovitisb. Capsulitisc. Retrodiscitisd. Arthritides

III. Chronic Mandibular Hypomobility1. Ankylosis2. Muscle Contracture3. Coronoid Impedance

IV. Growth Disorders1. Congenital /Developmental

Bone Disordersa. Agenesisb. Hypoplasiac. Hyperplasiad. Neoplasia

2. Congenital /DevelopmentalMuscle Disorders

Classification of Temporomandibular Disorders

- Okeson, 2013



2. TMD Pains3. Non-TMD Pains


2


Temporomandibular Disorder

is only one subgroup

of Orofacial Pain Disorders.

- remember -

Classification of Facial Pains

Somatic Pain

Axis II(Psychological Conditions)

Axis I(Physical Conditions)

Axis I Axis II

Diagnosis

Superficial Pain

Mucogingival P

ain

Deep Pain

Cutaneous P

ain

Muscle P

ain

TM

J Pain

Osseous P

ain

Co

nn

ect. T

issue

Pa

in

Periodontal P

ain

Visce

ral P

ain

Mu

sculo

skele

tal P

ain

Visce

ral M

uco

sal P

ain

Gla

nd

ula

r, EN

T P

ain

Pu

lpa

l Pa

in

Va

scula

r Pa

in

Ne

uro

vascu

lar P

ain

Neuropathic Pain

Episodic Pain

Pa

roxysm

al N

eu

ralg

ia

Continuous Pain

Trig

em

ina

l Ne

ura

lgia

Pe

riph

era

l Me

dia

ted

Pa

in

Metabolic P

olyneuropathies

Ce

ntra

l Me

dia

ted

Pa

in

En

trap

me

nt N

eu

rop

ath

y

Ne

uritic P

ain

De

nto

alve

ola

r Pa

in

Occlu

sal D

ysesth

esia

Bu

rnin

g M

ou

th D

isord

er

Oth

er N

eu

ralg

ias

Myo

spa

sm (D

yston

ia)

Central M

ediated Myalgia

Myofascial P

ain

Lo

cal M

uscle

So

ren

ess

Protective C

o-Contraction

Ca

psu

lar P

ain

Arth

ritic Pa

in

Re

trod

iscal P

ain

Lig

am

en

tou

s Pa

in

Neurovascular V

ariants

Oth

er P

rima

ry He

ad

ach

e

Trigem

inal Autonom

icC

ephalalgia (TA

C)

Arte

ritis Pa

in

Po

st He

rpe

tic Ne

ura

lgia

Co

mp

lex R

eg

ion

al

Pa

in S

ynd

rom

e

Sympathetically Maintained Pain

Te

nsio

n-T

ype

Mig

rain

e

Ca

rotid

ynia

Pe

riph

era

l Ne

urits

Mood Disorders

Bip

ola

r Diso

rde

r

Mood D

isorder due to

a Medical C

ondition

De

pre

ssive D

isord

er

Anxiety Disorders

Po

sttrau

ma

tic Stre

ssD

isord

er

Anxiety D

isorder due to a M

edical Condition

Ge

ne

ralize

d A

nxie

tyD

isord

er

Somatoform Disorders

Co

nve

rsion

Diso

rde

r

Pa

in D

isord

er

Un

diffe

ren

tiate

dS

om

ato

form

Diso

rde

r

Hyp

och

on

dria

sis

Ma

lad

ap

tive H

ea

lthB

eh

avio

r

Stress-R

elatedP

hysiological Response

Pe

rson

ality T

raits

or C

op

ing

Style

Other Conditions

Psych

olo

gica

l Fa

ctors

Affe

cting

Me

d C

on

ditio

n

Oth

er C

on

ditio

ns

Ma

ling

erin

g

Centrally Mediated

Okeson: Bell’s Oral and Facial Pain, 2014

He

rpe

s Zo

ster

De

affe

renta

tion P

ain

Tra

um

atic N

eu

rom

a

1. What types of orofacial pain disorders should you treat?

Some Important Questions

2. How can you be sure the patient’s pain complaint is

related to a TM disorder?

Primary Pain

Pains in which the site and sourceare in the same location.

Heterotopic Pain

Pains in which the site and sourceare not in the same location.

Tissue injury

The normal processing ofnociception to pain

It’s notpain here.



It’s onlypain here.

PainPain

Tissue injury

The patient feels shoulder pain.

Primary pain


3

PainThe patient feels shoulder pain.

Primary pain

Continuednociceptive input

centralexcitatory

effects

Possible Central Excitatory Effects

1. Sensory (afferent) Effects

2. Motor (efferent) Effects

3. Autonomic Effects

PainNow the patient feels pain in the shoulder...

...and also in the TMJ.

Continuednociceptive input

centralexcitatory

effects

Pain

Referred Pain

The Clinical Characteristics of Referred Pain

b. does not cross the midline (in the trigeminal)

1. Referred pain most commonly occurs in other divisions of the same nerve that mediates the pain.a. vertical laminated pattern

2. If another nerve is affected, it is usually cephaladto the nerve that mediates the pain.

Pain

PainLocal provocation of the

site of pain does not increase the pain.

Pain

PainLocal provocation of the

source of pain increases the pain not only at the source but also at the site.


4

Pain

PainLocal anesthetic at the site

of pain does not decrease the pain.

Pain

PainLocal anesthetic at the

source of pain decreases the pain not only at the source but also the site.

Possible Central Excitatory Effects

1. Sensory (afferent) Effectsa. Referred Pain

2. Motor (efferent) Effectsa. Protective Co-Contraction

b. Trigger Points

Referral patterns from the trapezius muscle

The patient’s chief complaint is temporal headache.

site

source

1. What types of orofacial pain disorders should you treat?

2. How can you be sure the patient’s pain complaint is related to a TM disorder?

Some Important Questions

University of British Columbia - Hannam, Langenbach, Scott, Peck, Zhang, 1999

3. Is there a relationship between occlusal factors and TMD?Normal functioning masticatory system

Etiologic Factors

Occlusal Factors

Trauma

Emotional Stress

Deep Pain Input

Parafunction

The asymptomatic individual

Acute ChronicTime

Managing these Etiologic Factors may no longer be adequate.

Altered HPA axis functionIncreased central sensitization

Decreased descending inhibition

Chronic Pain ConditionsChronic TMD

Myofascial painFibromyalgia

Sleep disturbances

Adaptability of the individual

Adaptability

TMD

Central Mechanisms

Genetic factorsBiologic factors

Hormonal factorsPsychosocial factors

Others ?


5

Normal functioning masticatory system

Etiologic Factors

TMD

Adaptability

The asymptomatic individual

Adaptability of the individual

Occlusal Factors

Trauma

Emotional Stress

Deep Pain Input

Parafunction

Dental therapy only affects one factors.

Genetic factorsBiologic factors

Hormonal factorsPsychosocial factors

Others ?

So when is occlusionrelated to TMD?

1. How does the occlusal condition affectorthopedic stability of the mandible?

2. How does an acute change in the occlusal condition affect masticatory function?

How does occlusion relate to TMD?

Dynamic considerations

- Condylar Stability -

• The condyles are in their most superior anterior positionin the fossae resting against the posterior slopes of thearticular eminentiae. (musculoskeletally stable)

• The discs are properly interposed between thecondyles and the fossae.

- Occlusal Stability -

The optimum orthopedically stable relationship

• Even and simultaneous contact of all teeth with posteriorteeth contacting slightly heavier than anterior teeth.

• Adequate tooth-guided contacts on the laterotrusive side.• In the upright closing position, posterior teeth contact

heavier than anterior teeth. (the envelope of function)

Orthopedic Stability

Joint Stability = Occlusal Stability

Orthopedic instabilityplus loading

An intracapsular disorder

Occlusal stability

Joint instability

1. How does the occlusal condition affectorthopedic stability of the mandible?

2. How does an acute change in the occlusal condition affect masticatory function?

How does occlusion relate to TMD?

Dynamic considerations


6

Correction of theocclusal alteration.

Provide Therapy

Resolution ofmasticatory muscle

disorder.

No resolution ofmasticatory muscle

disorder.

Cyclic Muscle Pain?

A Psychiatric Condition?

If the occlusal alteration is left unchanged it results in either:

- chronic response -

a masticatory muscledisorder

Occlusal Dysesthesia?

Seventh EditionFebruary 2014

Quintessence Publishers1-800-621-0387

Seventh Edition488 pages

2013

Elsevier/Mosby Company1-800-325-4177

Okeson Texts Okeson Home Page

University of KentuckyMini-Residency Program

June 5-9, 2017Shadowing Program

1 week (40 hr)

Newly Updated Lecture Series- DVDs or streaming -www.jeffokeson.net

okeson diff dx of tmd texas 3-17 · okeson differential dx of tmd star of the south dental meeting...

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