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The Diagnosis and Management of Orofacial Pain
CDS 846
Course Director: Jeffrey P Okeson, DMD Professor and Chair, Department of Oral Health Science Director, Orofacial Pain Center okeson@uky.edu
Handout for examination #
- What types of orofacial pain disorders should you treat?1. What types of orofacial pain disorders should you treat?
- Why pain is more than a mere sensation?2. Why pain is more than a mere sensation?
- How can you be sure the patient’s pain complaint is3. How can you be sure the patient’s pain complaint is related to a TM disorder?related to a TM disorder?
- How can we differentiate and classify orofacial pain4. How can we differentiate and classify orofacial pain disorders?disorders?
Some Important QuestionsSome Important Questions
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!
- General types of Orofacial PainsGeneral types of Orofacial Pains --
1. Dental Pains1. Dental Pains
a. Pulpala. Pulpal
b. Periodontalb. Periodontal
- General types of Orofacial PainsGeneral types of Orofacial Pains --
1. Dental Pains1. Dental Pains
a. Pulpala. Pulpal
b. Periodontalb. Periodontal
2. TMD Pains2. TMD Pains
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
Musculoskeletal pain disordersMusculoskeletal pain disorders
of the masticatory system.of the masticatory system.
A Muscle Disorder^ An Intracapsular Disorder
These disorders are treated quite differently.
Listen carefully to your patient.
I. Masticatory Muscle DisordersI. Masticatory Muscle Disorders
- Protective Co1. Protective Co--ContractionContraction
- Local Muscle Soreness2. Local Muscle Soreness
- Myofascial Pain3. Myofascial Pain
- Myospasm4. Myospasm
- Chronic Centrally5. Chronic Centrally Mediated MyalgiaMediated Myalgia II. Temporomandibular JointII. Temporomandibular JointDisordersDisorders
- Derangements of the1. Derangements of the CondyleCondyle--Disc ComplexDisc Complex a. Disc Displacementa. Disc Displacement with Reductionwith Reduction b. Disc Displacementb. Disc Displacement without Reductionwithout Reduction
- Structural Incompatibilities2. Structural Incompatibilities a. Adhesions / Adherencesa. Adhesions / Adherences b. Deviation in Formb. Deviation in Form c. Subluxationc. Subluxation d. Spontaneous Dislocationd. Spontaneous Dislocation
- Inflammatory Disorders3. Inflammatory Disorders a. Synovitisa. Synovitis b. Capsulitisb. Capsulitis c. Retrodiscitisc. Retrodiscitis d. Arthritidesd. Arthritides III. Chronic Mandibular HypomobilityIII. Chronic Mandibular Hypomobility
- Ankylosis1. Ankylosis
- Muscle Contracture2. Muscle Contracture
- Coronoid Impedance3. Coronoid Impedance IV.IV. Growth DisordersGrowth Disorders
- Congenital /Developmental1. Congenital /Developmental Bone DisordersBone Disorders a. Agenesisa. Agenesis b. Hypoplasiab. Hypoplasia c. Hyperplasiac. Hyperplasia d. Neoplasiad. Neoplasia
- Congenital /Developmental2. Congenital /Developmental Muscle DisordersMuscle Disorders
Classification of Temporomandibular DisordersClassification of Temporomandibular Disorders
- Okeson, 2003 - - General types of Orofacial PainsGeneral types of Orofacial Pains --
1. Dental Pains1. Dental Pains
a. Pulpala. Pulpal
b. Periodontalb. Periodontal
2. TMD Pains2. TMD Pains
3. Non3. Non--TMD PainsTMD Pains
- 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
- pain / pleasure center - (emotions, behavior, instincts and drives) - the spinal cord
The Primate Brain
the limbic structures
the medullary structures
the cortex
- motivational response - (reason, meaning, consequence)
Definition of Pain
“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.”
- Dorland’s Medical Dictionary, 1988
Definition of Pain
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”
Definition of Nociception
The mechanism that provides for the reception of noxious or potentially noxious stimuli into neural impulses that are transmitted to the CNS.
Definition of Pain
The subject’s conscious perception of modulated nociceptive impulses that generate an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Definition of Suffering
The emotional response to pain and other factors that reflects the subject’s anticipated impending and future threat to his well-being.
Definition of Pain Behavior
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
- Pressure Receptors (Pacinian Corpuscles)
- Pain Receptors (Free Nerve Endings)
-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
- Classification of Primary Afferent Neurons
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 Aristotelian Theory
- The Specificity (Sensory) Theory
- The Intensive (Summation) Theory
- The Pattern Theory
- The Pain Perception-Reaction Theory
- The Gate Control Theory
- The Concept of Pain Modulation
- The Biopsychosocial Model of Pain
- The Neuromatrix Theory
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
- Site: The location of the pain.
- Source: The origin of the 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
- Sensory (afferent) Effects a. Referred Pain b. Secondary Hyperalgesia
- Motor (efferent) Effects a. Protective Co-Contraction b. Trigger Points
- Autonomic Effects
The Clinical Characteristics of Referred Pain
- Referred pain most commonly occurs in other divisions of the same nerve that mediates the pain. a. vertical laminated pattern b. does not cross the midline (in the trigeminal)
- If another nerve is affected, it is usually cephalad to the nerve that mediates the pain.
How can you differentiate primary pain
from referred pain?
Referred pain is wholly spontaneous
and dependent upon the original
source of pain.
Diagnostic Rules for Identifying Referred Pain
- Local provocation of the site of pain does not increase the pain.
- Local provocation of the source of pain increases the pain not only at the source but also the site.
- Local anesthesia at the site of pain does not decrease the pain.
- Local anesthesia at the source of pain decreases the pain not only at the source but also at the site.
Occlusion / Orthopedic Instability
Trauma
Emotional Stress
Deep Pain Input
Muscle Hyperactivity
Etiologic Considerations of TMD
How does occlusion relate to TMD?
- Orthopedic stability/ instability
- An acute change in the occlusal position
- The condyles are in their most superior anterior position in the fossae resting against the posterior slopes of the articular eminentiae. (musculoskeletally stable)
- The discs are properly interposed between the condyles and the fossae.
- Occlusal Stability -
The optimum orthopedically stable relationship
- Even and simultaneous contact of all teeth with posterior teeth contacting slightly heavier than anterior teeth.
- Adequate tooth-guided contacts on the laterotrusive side.
- In the alert feeding position, posterior teeth contact heavier than anterior teeth.
Orthopedic Stability
Joint Stability = Occlusal Stability
Orthopedic instability
plus
loading
leads to intracapsular disorders.
Joint instability
Occlusal stability
A “stable malocclusion”
- another important concept -
A dental malocclusion
that is orthopedically stable.
Remember
These studies examine two different types of muscle activity.
- Conscious, voluntary muscle activity
- Williamson & Lundquist, 1983 -
- Sub-conscious, involuntary muscle activity
- Rugh, Barghi & Drago, 1984 -
Peripheral
Influenced Activity
CNS Influenced
Activity
- Parafunctional Activity
- (bruxing, clenching, oral habits)
- Functional Activity
- (chewing, swallowing, speaking)
Marked protective reflex activity Decreased protective reflex activity
Peripheral sensory input inhibits activity
CNS input increases activity
- Conclusions -
- How do occlusal interferences affect muscle activity?
What type of occlusal interference? (acute or chronic)
What type of muscle activity? (functional or parafunctional)
- an acute occlusal interference - - an acute occlusal interference -
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
- a chronic occlusal interference - - a chronic occlusal interference -
How do occlusal interferences affect TM Disorders
- Occlusal interferences and muscle pain 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
- Occlusal interferences and muscle pain disorders
- Occlusal interferences and intracapsular disorders
Orthopedic instability plus loading leads to intracapsular disorders Orthopedic instability
Problems with bring the teeth into occlusion are answered in the
- In summary, consider this thought -
muscles…..
….once the teeth have occluded, problems with loading are answered in the joints.
Anatomy and Biomechanics of the Temporomandibular Joint
- Function and Dysfunction -
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
Summary
- Ligaments do not actively participate in normal joint function.
- Ligaments do not stretch.
- The articular surfaces of the TMJ are always maintained in constant contact.
Types of Temporomandibular Joint Disorders
- Derangements of the Condyle-Disc Complex a. disc displacement b. disc dislocation with reduction c. disc dislocation without reduction
- Structural incompatibilities a. adhesions b. deviation in form c. subluxation d. spontaneous dislocation
“Click”
Disc displacement with reduction
“Click”
Disc dislocation with reduction
Clinical signs of acute dislocation without reduction
- A positive history
- Limited mouth opening (25-30 mm)
- Normal lateral movement to the ipsilateral side
- Restricted lateral movement to the contralateral side
- A sudden elimination of the click
1 2
(^3 )
(^5 )
- What is the etiology of disc derangement disorders?
- Accidents - Motor Vehicle Accidents Sporting Accidents Unexpected Blows
closed mouth trauma
vs.
opened mouth trauma
Intubation Procedures Third Molar Extractions Long Dental Procedures Cervical Traction
- Macrotrauma a. Gross trauma b. Iatrogenic trauma 2. Microtrauma a. Chronic muscle hyperactivity b. Orthopedic instability
- What is the etiology of disc derangement disorders?
bruxism / clenching
Orthopedic Instability plus Loading
- Are disc derangement disorders always progressive?
- Adaptation - destruction of cells = repair of cells
destruction of cells
repair of cells
