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Material Type: Notes; Professor: Okeson; Class: DIAGNOSIS/MANAGEMENT OF OROFACIAL PAIN; Subject: Conjoint Dental Sciences; University: University of Kentucky; Term: Unknown 2009;
Typology: Study notes
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The Diagnosis and Management of Orofacial Pain
Course Director: Jeffrey P Okeson, DMD Professor and Chair, Department of Oral Health Science Director, Orofacial Pain Center okeson@uky.edu
Handout for examination #
Muscle?Muscle?
Joint?Joint?
Cervical?Cervical?
Sinus?Sinus?
Dental?Dental?
Periodontal?Periodontal?
Otological?Otological?
Neuropathic?Neuropathic?
Neurovascular?Neurovascular?
Mucogingival?Mucogingival?
All pains felt in theAll pains felt in the face areface are notnot TMD!TMD!
What is TMD?What is TMD?
“A collective term embracing a number of clinical“A collective term embracing a number of clinical problems that involve the masticatory musculature,problems that involve the masticatory musculature, the TMJ and associated structures or both.”the TMJ and associated structures or both.”**
de Leeuw: Orofacial Pain AAOP Guidelinesde Leeuw: Orofacial Pain AAOP Guidelines Quintessence Publishers, 2008, p116.Quintessence Publishers, 2008, p116.
Temporomandibular DisordersTemporomandibular Disorders
A Muscle Disorder^ An Intracapsular Disorder
These disorders are treated quite differently.
Listen carefully to your patient.
I. Masticatory Muscle DisordersI. Masticatory Muscle Disorders
Classification of Temporomandibular DisordersClassification of Temporomandibular Disorders
- Okeson, 2003 - - General types of Orofacial PainsGeneral types of Orofacial Pains --
Temporomandibular DisorderTemporomandibular Disorder is only one subgroupis only one subgroup of Orofacial Pain Disorders.of Orofacial Pain Disorders.
Classification of Orofacial Pains Somatic Pain Superficial Pain Mucogingival Pain
Deep Pain Cutaneous Pain
Muscle Pain
Central Mediated Myalgia Myospasm Myofascial Pain Local Muscle Soreness Protective Co-Contraction
TMJ Pain^ Osseous Pain Connect. Tissue Pain Periodontal Pain
Musculoskeletal Pain Visceral Pain
Glandular, ENT Pain Visceral Mucosal Pain Pulpal Pain^ Vascular Pain^ Neurovascular Pain
Arthritic Pain^ Capsular Pain^ Retrodiscal Pain^ Ligamentous Pain
Neuropathic Pain Episodic Pain Paroxysmal Neuralgia
Continuous Pain
Trigeminal Neuralgia
Metabolic Polyneuropathies^ Peripheral Mediated Pain Central Mediated Pain
Entrapment Neuropathy Deafferentation Pain Neuritic Pain Burning Mouth Disorder(Phantom Pain) Atypical Odontalgia
Neurovascular Variants Other Primary Headache Cluster and other TCA Arteritis Pain^ Peripheral Neurits^ Herpes Zoster Post Herpetic Neuralgia
Mood Disorders a Medical Condition^ Mood Disorder due to^ Bipolar Disorder^ Depressive Disorder
Anxiety Disorders Posttraumatic Stress Disorder a Medical Condition^ Anxiety Disorder due to^ Generalized Anxiety Disorder
Somatoform Disorders Pain Disorder^ Conversion DisorderSomatoform Disorder Undifferentiated
Other Conditions Other ConditionsAffecting Med Condition^ Psychological Factors Hypochondriasis Malingering
(Physical Conditions)^ Axis I (Psychological Conditions)^ Axis II
Other Neuralgias
Okeson, 2005
Pain Syndrome^ Chronic Regional
Sympathetically Maintained Pain
Carotidynia^ Tension-Type Migraine^ Traumatic Neuroma Physiological Response^ Stress-RelatedBehavior^ Maladaptive Healthor Coping Style^ Personality Traits Axis I Axis II Diagnosis TMD
The Mammalian Brain
the limbic structures
the medullary structures
The Primate Brain
the limbic structures
the medullary structures
the cortex
“A more or less localized sensation of discomfort, distress, or agony, resulting from the stimulation of specialized nerve endings. It serves as a protective mechanism insofar as it induces the sufferer to remove or withdraw from the source.”
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”
The mechanism that provides for the reception of noxious or potentially noxious stimuli into neural impulses that are transmitted to the CNS.
The subject’s conscious perception of modulated nociceptive impulses that generate an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
The emotional response to pain and other factors that reflects the subject’s anticipated impending and future threat to his well-being.
The subject’s audible and visible actions that communicate his suffering to others.
The Human Being is:
a musculoskeletal system, (muscles & bones) with an envelope, (skin & mucosa) and a supply system, (digestive & vascular) with a coordination system. (peripheral & central nervous systems)
Superficial Somatic Structures (the envelope)
Cutaneous Tissues Mucogingival Tissues
Musculoskelatal System
Muscles Bones Joints Tendons Ligaments Related Connective Tissues
Visceral Structures (the supply system)
Cardio-Vascular Structures Digestive Structures Glandular Structures Ocular Structures Auricular Structures Mucosal Structures Pulmonary Structures
Sensory Input from the Supply System
-Interoceptors-
Sensory Input from the Supply System
Provides information needed to maintain function of the supply system.
Sensed below a conscious level.
Pain generally inhibits action of the individual.
fiber function diameter velocity
A beta cutaneous touch 8 microns 100 m/sec pressure
A delta nociception <3 microns 15 m/sec mechanoreceptors thermoreceptors
c polymodal nociception 1 micron 1 m/sec mechanoreceptors thermoreceptors chemoreceptors
Subnucleus oralis Subnucleus interpolaris Subnucleus caudalis
Trigeminal entry zone Motor Nucleus of V Sensory Nucleus of V Spinal Tract Nucleus of V
Types of Second Order Neurons
Low Threshold Mechanoreceptive Neurons (LTM)
Nociceptive Specific Neurons (NS)
Wide Dynamic Range Neurons (WDR)
The Evolution of Pain Theories
Melzack R and Wall, PD: Pain mechanisms: A new theory. Science, 150:975-979, 1965
The Gate Control Theory
inhibitory interneuron
A beta
c fiber
The body and the mind are separate. When something is wrong with the body, the clinician directs therapy towards the effected part and the patient recovers.
Mechanistic Model of Disease
The body and the mind function together as a unit. The clinician must consider both the body and the mind for optimum treatment results.
Biopsychosocial Model of Disease
Biopsychosocial Model of Disease
Bio (^) Somatosensory nociceptive input
Psychosocial
Limbic Structures Thalamus Reticular System Cortex
Site and Source of Pain
Primary Pain
Pains in which the site and source are in the same location.
Pain
Now the patient feels pain in the shoulder... ...and also in the TMJ....and also in the TMJ.
Continued nociceptive input
central excitatory effects
Pain
Referred PainReferred Pain
Possible Central Excitatory Effects
The Clinical Characteristics of Referred Pain
Diagnostic Rules for Identifying Referred Pain
Occlusion / Orthopedic Instability
Trauma
Emotional Stress
Deep Pain Input
Muscle Hyperactivity
Etiologic Considerations of TMD
How does occlusion relate to TMD?
The optimum orthopedically stable relationship
Orthopedic Stability
Joint Stability = Occlusal Stability
Orthopedic instability
Joint instability
Occlusal stability
A “stable malocclusion”
Remember
These studies examine two different types of muscle activity.
Marked protective reflex activity Decreased protective reflex activity
Peripheral sensory input inhibits activity
CNS input increases activity
What type of occlusal interference? (acute or chronic)
What type of muscle activity? (functional or parafunctional)
Parafunctional Activity (bruxing, clenching, oral habits)
Functional Activity (chewing, swallowing, speaking)
protective co-contraction (muscle splinting) decreases activity
altered muscle engrams or a masticatory muscle disorder little to no effect
How do occlusal interferences affect TM Disorders
a masticatory muscle disorder
or
altered muscle engrams (adaptation)
An acute change in the occlusal condition leads to
How do occlusal interferences affect TM Disorders
Orthopedic instability plus loading leads to intracapsular disorders Orthopedic instability
Problems with bring the teeth into occlusion are answered in the
muscles…..
….once the teeth have occluded, problems with loading are answered in the joints.
Anatomy and Biomechanics of the Temporomandibular Joint
articular discarticular disc the superior lateralthe superior lateral pterygoidpterygoid
the inferior lateralthe inferior lateral pterygoidpterygoid
retrodiscal tissuesretrodiscal tissues
Some general orthopedicSome general orthopedic principlesprinciples
1.1. Every synovial joint is held together byEvery synovial joint is held together by the muscles that pull across the joint.the muscles that pull across the joint. 2.2. The articular surfaces of the joints areThe articular surfaces of the joints are always in constant contact.always in constant contact. 3.3. The amount of interThe amount of inter--articular pressurearticular pressure is determined by the muscle that pullis determined by the muscle that pull across the joint.across the joint.
IntermediateIntermediate zone of thezone of the articular discarticular disc
the directional forcesthe directional forces of loadingof loading
How is the TMJ loaded?How is the TMJ loaded?
1.1. Collagenous structures thatCollagenous structures that attach bone to bone.attach bone to bone. 2.2. The purposes of ligaments are toThe purposes of ligaments are to limit joint movement.limit joint movement. 3.3. Ligaments have specific lengths.Ligaments have specific lengths. 4.4. Ligaments do not stretch.Ligaments do not stretch. 5.5. Ligaments do not activelyLigaments do not actively participate in normal function.participate in normal function.
Characteristics of LigamentsCharacteristics of Ligaments
Types of Temporomandibular Joint Disorders
“Click”
Disc displacement with reduction
“Click”
Disc dislocation with reduction
Clinical signs of acute dislocation without reduction
1 2
(^3 )
(^5 )
closed mouth trauma
vs.
opened mouth trauma
Intubation Procedures Third Molar Extractions Long Dental Procedures Cervical Traction
bruxism / clenching
Orthopedic Instability plus Loading
destruction of cells
repair of cells