tmd/orofacial pain diagnosis and goals of comprehensive...

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TMD/Orofacial Pain Diagnosis and Management: Clarifying the Issues

Henry A. Gremillion, DDS, MAGDLouisiana State University School of Dentistry

Goals of Comprehensive Dentistry

• Optimum oral health

• Anatomic harmony

• Functional harmonyFunctional harmony‐ TM joints‐ musculature‐ occlusion

• Orthopedic stability

–An unpleasant sensory and emotional

experienceexperience.

–Associated with actual or potential tissue

damage.

–Described in terms of such damage.

Chronic Pain in the United States

57% suffered from chronic or recurrent pain in last year

Small variation between age groups

4 of 10 chronic pain sufferers reported significant life4 of 10 chronic pain sufferers reported significant life adjustments

76% impacted by pain

Research America! September 4, 2003

UNC Pain Center UNC Pain Center –– Primary Pain ComplaintsPrimary Pain Complaints

Head face and neckHead face and neck 43%43%

Body Region

Head, face, and neckHead, face, and neck 43%43%

Back, lower extremitiesBack, lower extremities 23%23%

OtherOther 34%34%

Chief concern‐bitemporal headache ‐pain TM joint clicking

‐sore teeth upon waking ‐neck pain

Should I treat this patient?Should I treat this patient?

What is the diagnosis?What is the diagnosis?

How should I treat this patient?How should I treat this patient?

What factors are important in this case?What factors are important in this case?

22

What We See

The Many Faces of Pain

What We Don’t See/Know!!!

Pain

Individualization of care:Investigate all possible facets to include

-etiology-perpetuation-recurrence

bid di i-co-morbid conditions

Prevalence Rate of Facial Pain

Per 100,000

Toothache 12,361

45,711 Households Interviewed

Oral Ulcer 8,392

TM Joint 5,289

Face Pain 1,415

Burning Mouth 707

Lipton, Ship, Larach-Robinson JADA 124:115, 1993

22% of population suffered from

Orofacial Pain

orofacial pain more than once in the

previous 6 months.

Lipton, Shipp, Larach-Robinson JADA 124:115, 1993

6% of the population suffer from TM joint

f 6

Orofacial Pain

and or face pain in a 6 month period

Lipton, Shipp, Larach-Robinson JADA 124:115, 1993

Temporomandibular DisordersTemporomandibular Disorders

Defining temporomandibular disorders

Epidemiology

A t f th ti t t tAnatomy of the masticatory structures

Etiology of TMD

Diagnostic classifications

Management

33

Temporomandibular Disorder

A collective term referring to a number of clinical problems involving the masticatory musculature, the temporomandibular joint(s) and associated structures

or bothor both.

• Pain in the:– Temporomandibular joints

Masticatory muscles

Cardinal Signs/Symptoms


– Masticatory muscles– Cervical region

• Limitation or disturbance of

mandibular movements• Temporomandibular joint sounds

TooMuchDisagreement

TMD Epidemiology

clickingNATURAL COURSE??

catching

locking

degeneration

TMD Epidemiology

No evidence that TM joint clicking must progress to locking and degeneration

No evidence that arthritic reactions must develop

NATURAL COURSE

No evidence that arthritic reactions must develop in joints that lock

Most degenerating joints tend to become non-painful with time (1-3 years)

As many as 16% may have long term pain

TMD: Complex Interactions

PsychologicAssociated

Anatomic

Physiologic

Neurologic

Psychologic

Teeth

Musculature(cervical

and masticatory)

TM Joint

Associatedstructures

44

PATHOGENESIS

The cellular events and reactions and otherThe cellular events and reactions and other pathologic mechanisms occurring in the

development of disease.


Many things can light the fuse…many things can keep it burning!

Anatomy Stress Nutrition Parafunction Trauma Gender l D d P D

TMD: Etiologic VariablesTMD: Etiologic VariablesTMD: Etiologic VariablesTMD: Etiologic Variables

HomeostaticBalance

HomeostaticBalance

Pathofunction

Sleep Disorders Pain Depression Occlusion Coping Posture

Pathofunction

TMD: Prevalence of Signs and Symptoms

75% of the general population have at least one sign of TMJ dysfunction. (joint noise, joint t d t )tenderness, etc.)

33% have at least one symptom (face pain, joint pain, etc.)

• Age and sex distribution of 3,428 TMD patients presenting at a Seattle based HMO of 360,000 enrollees.enrollees.

• The mean ages of the women and men were 34.2 years and 33.8 years, respectively

• Of those seeking treatment, 85.4% were women.

TMD Etiology

• Theories– Behavioral

• Stoic nature of males

Gender Differences

• Stoic nature of males• Social conditioning (cultural factors)• Care seeking trends

– Physiologic• Structural• Hormonal

55

TMD Etiology

Effects of Anxiety (F>M)-Decreased pain threshold

Gender Differences

Decreased pain threshold

-Decreased pain tolerance

-Disrupted self-control strategies

-Increased EMG

-Increased pain behavior

Rollman, GB, Harris G. Percept. Psychophys. 42: 268 1989

Links have been identified betweenguilt, grief, emotional and depressive

TMD: Anxiety/Stress

stress syndromes and immunologicstatus.

Lesse S. Am J Psychia 1968;124:25-40Lipsitt DR. Int J Psych Med 1970;1:15-25

Pain Sensitivity

Gender Differences

CNS Processing

• Hormonal Influences on pain modulation

Fillingim RB, Maixner W. Pain Forum 4(4):209-221,1995

vs

TMD Etiology

Gender Differences

Greater pain sensitivityGreater pain sensitivity

• During menstrual cycle

• At ovulation

• Following menses

TMD EtiologyTMD Etiology

Functional estrogen receptors have been identified in the female TM joint.

Hormonal influences

Abubaker AO, et al. Oral Maxillofac Surg 51:1096-1100, 1993, g ,Aufdemorte TB, et al. OM, OS, OP 61:307-314, 1986

Functional estrogen receptors have

not been found in the male TM joint.

Milam SB. OM,OS,OP 64:527-532, 1987

TMD EtiologyTMD Etiology

It is likely that sex hormones profoundly influence l ll d h d l

Gender differences

several cell activities associated with remodeling or degenerative processes in the temporomandibular

joint.

Milam SB. IASP Press 4:89-112, 1995

66

Are occlusal factors related to TMD?

Proper occlusion of the dentition occurs in a dynamicrelationship with the oral and facial musculature, periodontium, supporting osseous framework, temporomandibular joints, and the enveloping

neuromuscular system.

TM joints

Teeth

Periodontium

Musculature

TM joints

Hannam 1983

Orthopedic Stability

Key Questions

• Are occlusal factors related to TMD symptoms in this case?

• What is the optimum occlusal contact relationship for this patient?

TMD Etiology: Occlusion

Found an association between open

Tanne, et al. J Orofac Pain 7:156-162, 1993

bite, posterior crossbite, and deepbite and the occurrence of TMD.


Occlusal Variable

• Anterior open bite

• Overjet > 6mm

TMD Subgroup

• Arthrosis and myalgia

• Arthrosis

• CR/IP slide > 4mm

• Unilateral lingual

crossbite

• 5 or more missing

posterior teeth

• Arthrosis

• Disk displacement and

arthrosis

• Arthrosis

Pullinger A et al. J Dent Res 72:968.1993


Epidemiologic studies show thatEpidemiologic studies show that60-65% of the U.S. population have

some degree of malocclusion.

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“How teeth fit

TMD & Occlusion: Orthopedic Stability

How teeth fitis important…”

“What people do with

TMD & Occlusion:Orthopedic Stability

their teeth may bemore important!!”

Maladaptive Occlusion

• Variable directions of muscular loading forces

• Selective action of multiple dental

Factors affecting adaptability

• Selective action of multiple dental and articular constraints

– direction of load

– duration of load

– degree of load

– individual host resistance

What do you see?

There There exists a functional homeostatica functional homeostaticbalance between balance between thethe dental occlusion,dental occlusion,

the neuromuscular system, the the neuromuscular system, the TM joints, and the relationshipTM joints, and the relationship

of the head and neck.of the head and neck.

Trigeminocervical/vertebral

artery compression

Alteration in proprioceptive input

Greater tension on suprahyoid

musculature

Trigeminocervical/vertebral

artery compression

Alteration in proprioceptive input

Greater tension on suprahyoid

musculatureHannam 1983

musculature

Abnormal tongue posture/tongue

thrust/ anterior open bite

Hyperactivity of mandibular musculature

musculature

Abnormal tongue posture/tongue


Hyperactivity of mandibular musculature

88

Masticatory and Cervical MyalgiaPostural Relationship

• 164 patients– Poor sitting/standing posture 96.0%

– Forward head posture 84.7%

– Rounded shoulders 82.3%

– Lower tongue posture 67.7%

Fricton JR, Kroening R. OS,OM,OP 1982;54(6):628-634.

The co-existence of neck pain and TMD occurs in approximately 70% of cases.

Padamsee M, et al J Dent Res 1994;186.

Cervicogenic headache accountsfor 15-35% of all chronic and

recurrent headaches.

Nilson AN. Spine 1995;20:1884-1888.Pf ff th V K b H F t N l 1990 5 157 164Pfaffenrath V, Kuabe H. Funct Neurol 1990;5:157-164.

Data supports the concept ofinterdependence between the cervical

and trigeminal sensory-motor systems.

Disease in one system may inducepain and/or dysfunction in

the other system.Browne PA, Clark GT, et al. OS, OM, OP, OR, Endo 1998;86:633-40.

Forward Head Posture

• Trigeminocervical/vertebral

artery compression

• Alteration in proprioceptive input

Associated symptoms

p p p p

• Greater tension on suprahyoid

musculature

• Abnormal tongue posture/tongue


• Hyperactivity of mandibular musculature

Is there a relationship?

• Sleep

• Depression• Depression

• Anxiety

• Pain

Sleep Disturbances

A Simple Review of Sleep History

IIs

Standard of Care in a Comprehensive

Evaluation

99

There There exists a functional, homeostatica functional, homeostaticbalance between the dental occlusion,balance between the dental occlusion,

the neuromuscular system, the the neuromuscular system, the

Sleep Posture

y ,y ,TM joints, and the relationshipTM joints, and the relationship


Hannam 1983

How long does it take you to fall asleep?

How many times do you awaken at night?

How long does it take to fall back asleep?

How many hours of sleep do you get?

Do you awaken feeling rested?

Depressed Mood

Anxiety

Norepinephrine (NE)Serotonin (5-HT)

Functional domains of Serotonin and Norepinephrine

Sex

Appetite

Aggression

Concentration

Interest

Motivation

y

Irritability

Thought process

Vague Aches and pains

What Wive’s Like Least About Sleeping With Their Husbands

• Snoring

• Hogging the bed

USA Today August 1994

Hogging the bed

• Stealing the covers

• Kicking

• Grinding their teeth

Dental considerations

Sleep Disorders: Bruxism

• Temporalis headache

• Jaw muscle stiffness

• Jaw muscle fatigue

• TM joint clicking/locking

• Hypersensitive dentition

• Masseter hypertrophy

Erosion / Gastroesphogeal RefluxErosion / Gastroesphogeal Reflux

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Sleep DisturbancesSleep Disturbances

•• Awakened by heartburn and sour tasteAwakened by heartburn and sour taste

Enamel erosionEnamel erosion

SleepSleep--related GERDrelated GERD

•• Enamel erosionEnamel erosion

•• Hypersensitive teethHypersensitive teeth

•• Failed composite restorationsFailed composite restorations

•• Faulty amalgam margins (elevated)Faulty amalgam margins (elevated)

Sleep DisturbancesSleep Disturbances

SleepSleep--related GERDrelated GERD

Hallmarked by regurgitation of stomachHallmarked by regurgitation of stomachHallmarked by regurgitation of stomachHallmarked by regurgitation of stomachcontents which are extremely caustic (pH < 4).contents which are extremely caustic (pH < 4).

Normal oral pH is 6.75 (average).Normal oral pH is 6.75 (average).

TMD: Current Concepts

• Major cause of non‐dental orofacial pain

• Subclassification of musculoskeletal disorders

• Cluster of disorders expressed in the masticatory system

• Share common sign and symptoms

• Recurrent

• Associated with a multitude of contributing factors

TMD Diagnosis

Finding all the components of TMD is

f tnecessary for a correct diagnosis and appropriate treatment !

DIAGNOSIS IS THE KEY!DIAGNOSIS IS THE KEY!

Must Consisider:Must Consisider:anatomyanatomy

Must Consisider:Must Consisider:anatomyanatomy-- anatomyanatomy

-- physiologyphysiology-- neurologyneurology-- psychologypsychology

-- anatomyanatomy-- physiologyphysiology-- neurologyneurology-- psychologypsychology

Masticatory System: Unique Features

• Right and left function as one unit

• Articulating surfaces are u a g u a afibrocartilaginous

• Articular disc separates the joint into two compartments

• Ginglymoarthrodial joint (hinge-gliding)

P L WestessonP L Westesson

1111

Masticatory System: Unique Features

• Right and left function as one unit• Articulating surfaces are

fibrocartilaginousA ti l di t th j i t• Articular disc separates the joint into two compartments

• Ginglymoarthrodial joint (hinge-gliding)

• Articulation has a rigid end point on closure of the teeth

Patient Evaluation

Chief concern(s)

History of chief concern(s)

Data collectionData collection

Past medical/dental history

Review of systems

Physical examination

Additional studies if indicated

Differential diagnosis

Paradigms in PainDiagnosis and Management

Enhanced understanding of pain mechanisms and pathways has p yprovided for targeting pathology on a case specific basis.

TMD – McGill Pain Questionnaire

TMJ 100%

Neck 75%

J. Gen. And Int. Med., July 1994

Other Areas of Head 72%

Back 72%

Shoulder 66%

Arms 44%

I th it f i

TMD/Orofacial Pain: Diagnosis

Key QuestionsKey Questions

Is the site of pain (area perceived by the patient) the

source of the pain?

Pain Pathways

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ORIGINS OF PAIN

Vascular‐ throbbing, pounding

Migraine

Temporal arteritis

Inflammation

Hypertension

ORIGINS OF PAIN

Neuropathic‐ sharp, burning, tingling, numb

Neuralgia

Neuropathy

Entrapment

Vascular compromise

ORIGINS OF PAIN

Musculoskeletal‐ dull, aching stiff, sore

Myofascial pain

M l iMyalgia

Tension‐type headache

Arthrosis/arthritis

ORIGINS OF PAIN

Psychogenic‐ bizarre, vague, migrating

Rare

Somatoform disorder

Must consider:

fibromyalgia

systemic disease

Acute Pain Characteristics

• Protective mechanism

• Sudden onset

• Limited duration

• Patients usually show• Patients usually show anxiety

• No persisting psychologic reactions

• Responds well to traditional therapy

Chronic Pain Characteristics

• Has no useful purpose

• Occurs after acute phase

• Not self-limiting; appears permanentp

• Invariably accompanied by psychologic changes in behavior

• May be refractory to traditional forms of therapy

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Principles of ManagementThe 3 “P’s”

Psychology

Pharmacology Physical Medicine

The integration of multiple modalitiesand disciplines in conjunction with

an enhanced understanding of

TMD: Management

an enhanced understanding ofpain mechanisms and pathways

have been the most important advances in the care of the patient who

suffers from recurrent / chronic pain.

Principles of Management

1. Is intervention necessary?

‐Is condition acute or chronic?

I diti i ?

Key Questions

‐Is condition progressive?

2. To what degree do we intervene?

‐Reversible versus irreversible treatment?

‐Monodisciplinary versus multidisciplinary

approach?

Principles of Management

1. Diagnosis specific management plan2 Reversible approaches2. Reversible approaches3. Escalation of care only when needed

Management Considerations

Patient education and self-care

1. Rest

2 H bit d difi ti2. Habit awareness and modification

-repeat timer

-visual cues

Management Considerations

3. Home physiotherapeutic regimen-moist heat-iceice-thermal contrast therapy-massage-gentle range of motion exercises

1414

Management ConsiderationsManagement Considerations

Nutritional Supplementation

Glucosamine1500mg/day

Chondroitin Sulfate1200 mg/day

NUTRITION

Abnormal calcium handling (hypocalcemia)Enhanced inflammatory responseElevated trigeminovascular irritability

Magnesium deficit: effects

Elevated trigeminovascular irritabilityNeuromuscular hyperexcitabilityMovement disordersAssociated with myofascial pain



C l i M iCalcium1200 mg/day

Magnesium600 mg/day



Vitamin CB t C tVit i E

Vitamin C1000 mg/day

Sustained-release

Beta Carotene25,000 IU/day

Vitamin E400-800 IU/day



B-100 Complex

Cognitive-Behavioral Intervention

1. Behavior modification

2. Life-style counseling3. Progressive relaxation4. Guided imagery5. Hypnosis6. Biofeedback

1515

Physical Self Regulation

for the Management of

Trigeminal Pain

Department of Psychology and Orofacial Pain CenterUniversity of Kentucky

Charles R. Carlson, Ph.D.

Physical Self Regulation(PSR) What is it??

• a “management platform” used to address the disturbed physiology diagnosed in Orofacial Pain patients

• make the physiology behind conditions sensible to patient• manage parafunction and postural problemsi f i d i l diff i• improve perfusion and synovial diffusion‐ glucose and endogenous opioids‐ only negative feedback for NE

Guidelines for Restful Sleep

– Pillow– Position ‐ on back unless painful and use Postural Relaxation– Covert ModelingPicture self sleeping in relaxed positionSelf‐talk: “I will not clench or grind”

– Use diaphragmatic breathing’ f– Don’t worry if you move

Follow a Plan for Eating, Drinking and Exercising

• EatingNutritional needs and Timing of intake

• DrinkingRole of waterRegular intake ‐ 6‐8 8 oz. GlassesCaffeine ‐ stimulant and dehydrant

• ExercisingPh i i lPhysician approvalExample: Walking program (pace, duration, goal)Reward self afterwards

Musculoskeletal painMusculoskeletal pain

Pharmacotherapy and physical medicinePharmacotherapy and physical medicineare the cornerstones of management ofare the cornerstones of management of

l k l t l il k l t l imusculoskeletal pain.musculoskeletal pain.

Nonsteroidal antiNonsteroidal anti--inflammatory drugsinflammatory drugsand skeletal muscle relaxants are keyand skeletal muscle relaxants are key

aspects of pharmacotherapeutic strategiesaspects of pharmacotherapeutic strategiesfor musculoskeletal pain.for musculoskeletal pain.

TargetTarget‐‐specific pharmacotherapyspecific pharmacotherapy

– NSAIDs

– Muscle relaxants

– Tricyclic antidepressants

– Sleep aid medications

– Local anesthetics (trigger point injections)

– Transdermal preparations

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1. Anti‐inflammatory agentsa. Nonsteroidal anti‐inflammatory drugs

i. Indications

‐reduction of inflammation

l f i

Pharmacotherapy

‐control of pain

ii. Side effects

‐gastric disturbance

‐inhibit platelet aggregation

‐tinnitus/dizziness

‐renal, liver toxicity

Centrally Acting Muscle RelaxantsCentrally Acting Muscle Relaxants

• Diverse group of drugs

• Similar pharmacologically to sedative-h ti d ti i t thypnotics and antianxiety agents

• Diminish output of nerve impulses to voluntary muscles

PharmacologyPharmacology

2. Muscle Relaxants

a. Indications

i. Muscle relaxation

b Side Effectsb. Side Effects

i. Excessive sedation

ii. Lightheadedness, dizziness

Muscle RelaxantsMuscle Relaxants

Generic Brand Dose (mg)

Carisoprodol Soma 350 mg tid

Methocarbinol Robaxin 750 mg tidMethocarbinol Robaxin 750 mg tid

Cyclobenzaprine Flexeril 10 mg bid

Diazepam Valium 2‐5 mg tid

• Muscle relaxants- most evidence for use of:– Cyclobenzaprine

Myogenous Pain

Management considerations Management considerations

Brown BR, Womble J. JAMA 1978;240:1151-1152.

– Benzodiazepines (diazepam, alprozolam, clonazepam)

– Tizanidine

Singer EJ, Dionne RA. J Orofac Pain 1997;11:139-147.Harkins S, et al. J Craniomandib Disord 1991;5:179-186.

Russell IJ, et al. Arhtiritis Rheum 1991;34:552-560.

Gerard A, et al. Pain Physician 2002;5(4):422-432.

• Secondary amines• Secondary amines

Tricyclic antidepressantsTricyclic antidepressants

Myogenous Pain


– nortriptyline (Pamelor)

– desipramine (Norpramin)

• Tertiary amines– amitriptyline (Elavil)

– imipramine (Tofranil)

– nortriptyline (Pamelor)

– desipramine (Norpramin)

• Tertiary amines– amitriptyline (Elavil)

– imipramine (Tofranil)

1717

• Dosage regimen i iti l d 10 25 t b dti

• Dosage regimen i iti l d 10 25 t b dti


Myogenous Pain


– initial dose 10-25 mg at bedtime

– weekly increases of 10-25 mg as required and tolerated

– usual effective daily dose 10-75 mg

– Associated with improved sleep

– initial dose 10-25 mg at bedtime

– weekly increases of 10-25 mg as required and tolerated

– usual effective daily dose 10-75 mg

– Associated with improved sleep

McQuay HJ, et al Anesthesia 1993;48:281-285.Zitman FG, et al. Pain 1990;42:35-42.

Orofacial PainOrofacial PainOrofacial PainOrofacial Pain


PharmacotherapyPharmacotherapy

Th l i ti f TCATh l i ti f TCAThe analgesic properties of TCAsThe analgesic properties of TCAshave been shown to be independenthave been shown to be independent

of their antidepressant properties.of their antidepressant properties.

Mangi G. Durgs;42:730-748.Onhenga P, Van Houdenhove B. Pain 1992;49:205-220.


S d i i t dS d i i t d

Myogenous Pain


Secondary amines are associatedSecondary amines are associatedwith less sedative and anticholinergic with less sedative and anticholinergic side effects compared with the tertiaryside effects compared with the tertiary

amines.amines.

• indications • usual time/action

PharmacotherapyPharmacotherapyPharmacotherapyPharmacotherapyKnow the pharmacologyKnow the pharmacology

Must consider:

• off-label accepted uses

• spectrum of side effects

• drug interactions

relationships

• pharmacokinetics

• specific dosing guidelines

By choosing drug therapy and route of administration for each patient individually, we can best solve that patient’s problem and

provide the best therapeutic t f th t ti toutcome for that patient.

Transdermal Delivery:A reasonable option???

1818

Keto-Lido-Flex Gel-Ketoprofen 10%-Lidocaine 5%-Cyclobenzaprine 1%-Pleurionic lecithin organogelPleurionic lecithin organogel

-30 grams

-Apply to affected area 4 times daily

Advantages of Transdermal over Oral dosing

• Delivery of high concentration of drug to the site where it is needed.

• Multiple drugs administered as 1 doseMultiple drugs administered as 1 dose.

• Significant reduction in systemic toxicity.

• Depot effect at site of application.

Drugs that can be administered via transdermal gels

• NSAIDS

• Corticosteroids

X thi d i iti

• Skeletal muscle relaxants

• Antihistamines• Xanthine derivitives

• Benzodiazepines

• Anticonvulsants

• Antidepressants

• Narcotics

• Antihistamines

• Sex hormones

• Antipsycotics

• Vasoconstrictors

• Anesthetics

There There exists a functional homeostatica functional homeostaticbalance between the dental occlusion,balance between the dental occlusion,

the neuromuscular system, the the neuromuscular system, the TM joints, and the relationshipTM joints, and the relationship


Hannam 1983

Physical Therapy / MedicinePhysical Therapy / Medicine

1. Posture training

2. Exercise

5. Physical agents/modalitiesa. ice and stretchb. TENS

Management ConsiderationsManagement ConsiderationsManagement ConsiderationsManagement Considerations

3. Mobilization

4. Stabilization

Sc. ultrasoundd. iontophoresis

Physical Therapy / MedicinePhysical Therapy / Medicine

1. Posture training

2. Exercise

3. Mobilization

4. Stabilization

5. Physical agents/modalitiesa. ice and stretchb. TENSc. ultrasoundd. iontophoresis4. Stabilization d. o top o es s

1919


Occlusal appliance therapy

1. Anterior deprogrammer

2. Non‐directive anterior guidance appliance

3. Anterior repositioning appliance

Effects of Occlusal Orthosis TherapyEffects of Occlusal Orthosis Therapy

Alteration in occlusal vertical dimension

Protection of dentition / supporting structures

Alteration of sensory input Alteration of sensory input

Cognitive awareness

Change in mandibular position

Compensatory

Placebo

Yet to be determined


Occlusal appliance therapy

1. Anterior deprogrammer‐ Rationale

By separating the posterior teeth this appliance immediately removes interferences to centric relation and excursive movements.

Muscle relaxation can be obtained rapidly.

Anterior DeprogrammerAnterior Deprogrammer

When manipulation can not be accomplished due to muscle splinting.

Indications

2020


Confirmation of an occlusal‐muscle diagnosis.

Indications


Treatment of painful masticatory musculature on an emergency basis.

Indications

Child Adult


When limited opening prevents other forms of treatment.

Indications

Beware of pitfalls of treatmentBeware of pitfalls of treatment

2121

A i D‐ decreases muscle hyper‐activity‐ decreases sustained joint loading‐ decreases noxious tooth contacts‐ increases neuromuscular harmony

Anterior Deprogrammer

Stabilization Occlusal ApplianceStabilization Occlusal Appliance

•• bruxismbruxism

•• myofascial painmyofascial pain

•• noxious occlusionnoxious occlusion

•• postpost surgerysurgery

Indications

•• myofascial painmyofascial pain

•• muscle splintingmuscle splinting

•• capsulitiscapsulitis

•• postpost‐‐surgerysurgery

•• diagnosticdiagnostic

•• adjunct periodontal adjunct periodontal therapytherapy

2222

Occlusal Appliance DeliveryOcclusal Appliance Delivery

•• stabilized appliancestabilized appliance•• shallow guidance in all excursive movementsshallow guidance in all excursive movements•• limit cuspid tracking in laterallimit cuspid tracking in lateral

Refinement

p gp g•• smooth crosssmooth cross--over transitionover transition•• hormonious excursive guidancehormonious excursive guidance•• bilateral equal intensity centric relation bilateral equal intensity centric relation

contactscontacts•• no distalizing contactsno distalizing contacts

Class I CaseClass I Case Class II Division 1 CaseClass II Division 1 Case

Class II Division 2 CaseClass II Division 2 Case

2323

Class III CaseClass III Case

Do splints work?

What are their effects?

2424

Differential Diagnosis

The systematic consideration of the ti t’ i d t ipatient’s signs and symptoms in

order to distinguish one disease from another.

Diagnosis: goals/purpose

• Identify and classify the disorder

• Characterize the mechanism(s) of pathofunction

• Localize the source(s) of painLocalize the source(s) of pain

• Determine the etiology (if possible)

• Delineate contributing/perpetuating factors

Welden E. Bell

TM Joint: Normal BiomechanicsTM Joint: Normal BiomechanicsTM Joint: Normal BiomechanicsTM Joint: Normal Biomechanics

T1 Closed Open

Normal Joint

TM Joint Inflammatory Conditions

2525

Capsulitis, Synovitis, Retrodiscitis

an inflammation of the synovial lining, capsular, or retrodiscal tissues of the p ,

temporomandibular joint that can be due to infection, an immunologic condition secondary to

articular surface degeneration, or trauma.

Capsulitis, Synovitis, Retrodiscitis

• Patient education• Restrict mandibular function

Management Considerations:

Restrict mandibular function• Control parafunctional activity• Pharmacotherapy

– Analgesic/anti‐inflammatory– Muscle relaxant (?)

• Stabilization orthotic• Physical therapy

TM Joint HypermobilityHypermobility

• Patient education

• Limit mouth opening



• Avoidance training

• Physical therapy

• Isometric exercises (elevator muscles)

2626

Temporomandibular JointDislocation (Open Lock)

A condition in which the condyle is positioned anterior to the articular eminence and is unable toanterior to the articular eminence and is unable to return to a closed position. May be momentary or

prolonged.

Dislocation (Open Lock)


Limit mo th opening



• Avoidance training


• Isometric exercises (elevator muscles)

• Surgery

Disc Displacement With ReductionDisc Displacement With ReductionDisc Displacement With ReductionDisc Displacement With Reduction

Superior and Inferior Bellies of the Lateral Pterygoid Muscle EMG Activity at Basic Jaw

Positions

Mahan, P.E., et al. J. Prosthet. Dent. 50:710, 1983

2727

*SLP

ILP

Partial Disc Displacement with Reduction

From Piper

Articular Disc Displacement

Retrodiscal tissue

Articulardisc

Displaced Disc

Articular Disc DisplacementWith Reduction

2828

Disc Displacement with Reduction(Painful)

Internal Derangement

Disturbed arrangement of the temporomandibular joint components resulting in interference with

smooth joint movement.

May relate to elongation, tear, or rupture of the capsule or ligaments causing altered disc position or

morphology.

Disc Displacement With Reduction

An abrupt alteration or interference of the disc‐condyle structural relationship during mandibularcondyle structural relationship during mandibular

translation with mouth opening or closing.

Disc Displacement With ReductionDisc Displacement With ReductionDisc Displacement With ReductionDisc Displacement With Reduction

Articular Disc Displacement

Retrodiscal tissue

Articulardisc

Articular Disc DisplacementWith Reduction

2929

Disc DisplacementWith Reduction (Painful)


• Restrict mandibular function



• Pharmacotherapy

– Analgesic/anti‐inflammatory

– Muscle relaxant (?)

• Stabilization orthotic

TM Joint:Affects of Reduced Loading

• Improved mesenchymal cell reprogramming

• Facilitation of pseudodisc formation

• Facilitation of condylar remodeling

• Reduction in amount of cellular debris

• Decreased synovial irritation

Moses

Pseudodisc Hypothesis

When subjected to constant repetitive compressive forces and loading, the retrodiscal tissue may transform

into a disc‐like tissueinto a disc‐like tissue.

Scapino. OS,OM,OP 1983 (April):382-97Baustein, Scapino. Plas Recon Surg 1986 (December):756-64

3030

Pseudodisc Hypothesis

Many TM joints display an adaptive capacity to remodel themselves and continue to function without ideal discthemselves and continue to function without ideal disc

position.

Solberg, Hansson. J Oral Rehab 1985, 12:303-321Westesson, Rohlin. OS,OM,OP 1984;4:17-22

Disc Displacement with Reduction(Painless)

Disc Displacement Without Reduction

An altered or misaligned disc‐condyle structural relation that is maintained during mandibular

translation.

Closed Open

Displaced Disc Without Reduction

3131

Disc DisplacementWithout Reduction (Acute)

• Pain precipitated by forced mouth opening• History of clicking that ceased with the occurrence of

“locking”???g• Pain with palpation of the affected side (during acute

stage)• Ipsilateral occlusal changes during the acute stage

Articular Disc DisplacementWithout Reduction

Articular Disc DisplacementWithout Reduction

Disc DisplacementWithout Reduction (Painful)





• Pharmacotherapy

– Analgesic/anti‐inflammatory

– Muscle relaxant (?)


Temporomandibular Joint Arthrocentesis

Sudden Onset Closed Lock with no prior history of clickingSudden Onset Closed Lock with no prior history of clicking

Anchored‐disc phenomenonversusAcute Closed Lock(Disk displacement without reduction)

Anchored‐disc phenomenonversusAcute Closed Lock(Disk displacement without reduction)

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TM Joint DistractionTM Joint Distraction Arthrosimplicity‐Outpatient Arthroscopy

1.1mm scope

Normal Anatomy

Arthroscopy: Diagnostic findings

a. Normal findings

b Synovitis

TMJ ARTHROSCOPY Procedures

b. Synovitis

c. Disk displacement

d. Fibrillation

e. Adhesions

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Adhesions AdhesionsAdhesions

1. Aggressive ROM exercises

2. NSAIDs

3. Reduce joint loading

TMJ ARTHROSCOPY

Post-op Management

3. Reduce joint loading

a. Medications

b. Occlusal orthosis

Disc DisplacementWithout Reduction (Chronic)

• Sudden onset of limited mouth opening that occurred at some time in the past

• History of clicking that ceased with sudden onset of y glocking

• Soft tissue imaging reveals displaced disc without reduction

• Condylar remodeling• May be painful or painless• Gradual resolution of limited mouth opening

Disc Displacement Without Reduction (Chronic)Degenerative Joint Disease

A chronic inflammatory or non-inflammatory disease resulting in joint deformity caused by degenerative

changes in the articular cartilage fibrous connectivechanges in the articular cartilage, fibrous connective tissue, and/or the articular disc within the

temporomandibular joint.

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Degenerative temporomandibular jointdisease is the result of maladaptation

to increased joint loading.

Westesson, Rohlin 1984Axelson, et al. 1992, 1993

Stegenga, et al. 1992deBont, Stegenga 1993

3535

52 year old female

Chief concern: bilateral pre-auricular pain (severe) with swelling

Clinical Findings

• TM joint– Severe pain at lateral and posterolateral aspects on palpation bilaterally

– Severe pain on loading bilaterally

– Maximum painless opening 15mm

– Course crepitus

• Masticatory musculature– Generalized moderate pain on palpation

3636

TM Joint Degenerative Joint Disease


• Restricted function

Management considerationsManagement considerations

• Pharmacotherapy– analgesic/anti-inflammatory

– muscle relaxant ???

• Control parafunctional activities

• Occlusal orthosis therapy


Pharmacotherapya. NSAIDs

b. Muscle relaxants

S i

Degenerative Joint Disease Treatment

4) Antioxidants

Vitamin C (sustained release)

1000 mg/d

Vitamin E

200‐400 I.U./d

Betacarotene

2500 I.U./d (am)

c. Supportive1) Glucosamine

1200‐1500 mg/d

1) Chondroitin Sulfate

1500 mg/d

3) MSM


• Disk displacement with reduction (at b li )

EpidemiologyEpidemiology-- natural course?natural course?

30 year follow30 year follow--up (n=99)up (n=99)

baseline)– 75% clicking ceased

– 13% reported crepitus

• Disk displacement without reduction

(at baseline)– 7% reported crepitus


• Masticatory function

EpidemiologyEpidemiology-- natural course?natural course?

30 year follow30 year follow--up (n=99)up (n=99)

– patients=controls

• Clicking and pain– decreased

• Most common complaint– fatigue of masticatory muscles

DeLeeuw R, et al. J Orofac Pain 1994;8:18-24

Most TMD discomfort arisesfrom muscle‐based pathology

Wright E. J Craniomandib Pract 1986; 4:149

3737

TMD:

Masticatory and CervicalMuscle Pathology

Patient: M.M.

Primary concerns:

-bi-temporal headaches-facial swelling-jaw pain when awakenjaw pain when awaken-sore/sensitive teeth-non-restorative sleep-fatigue

Myositis

Inflammation of a muscle, usually due to local causes such as infection or injury.

• Increased pain with mandibular movement

• Onset following prolonged or unaccustomed use

• May be localized or generalized

• Limited range of motion due to pain and swelling

Myositis


• Eliminate / minimize cause


– Avoid exercise, stretching, muscle injections

• Restrict masticatory function

• Pharmacotherapy– Analgesic / anti‐inflammatory

– Antibiotic(?)


• Control parafunctional behavior(s)

Patient: D. B.

Chief concerns:-painful limited opening of sudden onset-left side pre-auricular swelling

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Protective Muscle Splinting

Restricted or guarded mandibular movement due to a co-contraction of muscles as a means of avoiding pain caused

by movement.

• Severe pain with function, but not at rest

• Marked limited range of motion without significant increase on passive stretch

Protective Muscle Splinting

• Patient education• Eliminate / reduce etiologic factor(s)


• Stabilization orthotic• Pharmacotherapy

– Analgesic / anti‐inflammatory– Muscle relaxant

• Control parafunctional behavior(s)• Physical therapy

Myospasm(Acute Trismus, Cramp)

An involuntary, sudden tonic contraction of a muscle.

• Acute pain

• Continuous muscle contraction (fasciculation)

• Increased EMG activity even at rest

Myospasm(Acute Trismus, Cramp)


• Eliminate cause


• Restrict function to within painless limits

• Pharmacotherapy– Muscle relaxant

– Analgesic

• Behavior modification



3939

Patient: Marcus

• 28 year old Caucasian male

• Medical history:– non-contributory

Patient: MarcusChief pain concern:

“I have a toothache in my lower right molar area”

Radiographic and clinical findings (intraoral assessment)were non-contributory to determination of a diagnosis.

Patient: Marcus

• Aggravating factors:– chewing

– clenching

• Alleviating/relieving factors:– analgesics (NSAIDs, opioids)

Patient: MarcusChief pain concern:

“constant toothache, even where I don’t have teeth any more”

4040

• Regional dull, aching pain

P f t i i t i l t d

Myofascial Pain

Diagnostic criteria Diagnostic criteria

• Presence of trigger points in muscles, tendons, or fascia

• Pain reduction with abolishment of trigger point

• Constant dull ache

Myofascial Pain

Clinical characteristics Clinical characteristics

Zone of referenceZone of reference

• Fluctuates with intensity

• Consistent referral pattern

• Local or distant trigger point

• Alleviation with trigger point abolishment

• Rope-like band of muscle

Myofascial Pain

Clinical characteristics Clinical characteristics

Trigger pointsTrigger points

• Tenderness on palpation

• Palpation alters pain

• Consistent location

Myofascial Pain

The muscle containing the active trigger point is frequently found by recognizing the patient’s pain pattern.

TrP

Perceived PainFrequently coldParaesthesiaNumbness

Myofascial Trigger Point Identification

Palpation is the Key!Exquisite Spot Tenderness‘Palpable Muscle Band’Local TwitchJump SignPatient Recognition

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• Nutritional

Sl di t b

• Physical disorders

P f ti l h bit

Myofascial Pain

Contributing factors Contributing factors

• Sleep disturbance

• Stress/anxiety

• Endocrinological

• Parafunctional habits

• Postural strains

• Disuse

• Nutritional– Calcium 1200 mg/day

M i 600 /d

Myofascial Pain


– Magnesium 600 mg/day

– B-100 complex

• Sleep disturbance– Sleep hygiene

– pharmacotherapy

• Avoid increased bed rest

• Maintain range of motion/mobility

Myofascial Pain

Management considerationsManagement considerations

• Palliative care techniques– ice massage

– heat

– ethyl chloride spray

– gentle stretching

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• Pharmacotherapy– NSAIDs

Myofascial Pain


– Muscle relaxants

– Tricyclic antidepressants

– Sleep aid medications

– Local anesthetics (trigger point injections)

– Transdermal preparations

Local anesthetics as a diagnostic and therapeutic tool: trigger point injections

Contraindications:

•Bleeding disorders•Local infection

Trigger Point Injections

Local infection•Anti-coagulant therapy•Psychological dependence (poor compliance)

•Inability to rest the injected muscle


Myotoxicity (increasing)

Procaine

Carbocaine

Xylocaine

Marcaine

Tetracaine

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Post injection care:

Control bleedingCross-frictional massageCross frictional massageStretch and iceAvoid overuseMoist heat (after 24 hours)Physical therapy

Should I treat this patient?Should I treat this patient?

What is/are the diagnosis(es)?What is/are the diagnosis(es)?

What factors are important in this case?What factors are important in this case?

How should I treat this case?How should I treat this case?

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• Greater awareness does not come in a single blinding flash of enlightenment.

The Future

• It comes slowly piece by piece, and each piece must be worked for by the patient effort of study and observation of everything, including ourselves.

Scott PeckRoad Less Traveled 285

tmd/orofacial pain diagnosis and goals of comprehensive...

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