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Diagnosis and Management of Orofacial Pain - Lecture Slides | CDS 846, Study notes of Dental Radiology

Material Type: Notes; Professor: Okeson; Class: DIAGNOSIS/MANAGEMENT OF OROFACIAL PAIN; Subject: Conjoint Dental Sciences; University: University of Kentucky; Term: Unknown 2009;

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CDS 846 Okeson, notes for test #1
1
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 #1
1. What types of orofacial pain disorders should you treat?1. What types of orofacial pain disorders should you treat?
2. Why pain is more than a mere sensation?2. Why pain is more than a mere sensation?
3. How can you be sure the patient’s pain complaint is 3. How can you be sure the patient’s pain complaint is
related to a TM disorder?related to a TM disorder?
4. How can we differentiate and classify orofacial pain 4. 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?
-- important important --
All pains felt in the All pains felt in the
face are face are notnot TMD!TMD!
-- General types of Orofacial Pains General types of Orofacial Pains --
1. Dental Pains1. Dental Pains
a. Pulpala. Pulpal
b. Periodontalb. Periodontal
-- General types of Orofacial Pains General 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 Guidelines*de Leeuw: Orofacial Pain AAOP Guidelines
Quintessence Publishers, 2008, p116.Quintessence Publisher s, 2008, p116.
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Download Diagnosis and Management of Orofacial Pain - Lecture Slides | CDS 846 and more Study notes Dental Radiology in PDF only on Docsity!

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 #

  1. What types of orofacial pain disorders should you treat?1. What types of orofacial pain disorders should you treat?
  2. Why pain is more than a mere sensation?2. Why pain is more than a mere sensation?
  3. 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?
  4. 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?

    • importantimportant --

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.

  • An important concept -

Listen carefully to your patient.

I. Masticatory Muscle DisordersI. Masticatory Muscle Disorders

  1. Protective Co1. Protective Co--ContractionContraction
  2. Local Muscle Soreness2. Local Muscle Soreness
  3. Myofascial Pain3. Myofascial Pain
  4. Myospasm4. Myospasm
  5. Chronic Centrally5. Chronic Centrally Mediated MyalgiaMediated Myalgia II. Temporomandibular JointII. Temporomandibular JointDisordersDisorders
  6. 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
  7. Structural Incompatibilities2. Structural Incompatibilities a. Adhesions / Adherencesa. Adhesions / Adherences b. Deviation in Formb. Deviation in Form c. Subluxationc. Subluxation d. Spontaneous Dislocationd. Spontaneous Dislocation
  8. Inflammatory Disorders3. Inflammatory Disorders a. Synovitisa. Synovitis b. Capsulitisb. Capsulitis c. Retrodiscitisc. Retrodiscitis d. Arthritidesd. Arthritides III. Chronic Mandibular HypomobilityIII. Chronic Mandibular Hypomobility
  9. Ankylosis1. Ankylosis
  10. Muscle Contracture2. Muscle Contracture
  11. Coronoid Impedance3. Coronoid Impedance IV.IV. Growth DisordersGrowth Disorders
  12. Congenital /Developmental1. Congenital /Developmental Bone DisordersBone Disorders a. Agenesisa. Agenesis b. Hypoplasiab. Hypoplasia c. Hyperplasiac. Hyperplasia d. Neoplasiad. Neoplasia
  13. 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.

    • rememberremember --

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 spinal cord

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.”

  • Bonica, 1990

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

  1. Pressure Receptors (Pacinian Corpuscles)
  2. 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

  1. Sensory (afferent) Effects a. Referred Pain b. Secondary Hyperalgesia
  2. Motor (efferent) Effects a. Protective Co-Contraction b. Trigger Points
  3. Autonomic Effects
    1. Autonomic (sympathetic)

The Clinical Characteristics of Referred Pain

  1. 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)
  2. 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?

  • remember -

Referred pain is wholly spontaneous

and dependent upon the original

source of pain.

Diagnostic Rules for Identifying Referred Pain

  1. Local provocation of the site of pain does not increase the pain.
  2. Local provocation of the source of pain increases the pain not only at the source but also the site.
  3. Local anesthesia at the site of pain does not decrease the pain.
  4. 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?

  1. Orthopedic stability/ instability
  2. An acute change in the occlusal position
    • Condylar Stability -
  • 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.

  1. Conscious, voluntary muscle activity
    • Williamson & Lundquist, 1983 -
  2. 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

  • Summary -
  1. 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

  • Summary -
  1. Occlusal interferences and muscle pain disorders
  2. 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

  1. Ligaments do not actively participate in normal joint function.
  2. Ligaments do not stretch.
  3. The articular surfaces of the TMJ are always maintained in constant contact.

Types of Temporomandibular Joint Disorders

  1. Derangements of the Condyle-Disc Complex a. disc displacement b. disc dislocation with reduction c. disc dislocation without reduction
  2. 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

  1. A positive history
  2. Limited mouth opening (25-30 mm)
  3. Normal lateral movement to the ipsilateral side
  4. Restricted lateral movement to the contralateral side
  5. A sudden elimination of the click

1 2

(^3 )

(^5 )

  1. What is the etiology of disc derangement disorders?
    • Accidents - Motor Vehicle Accidents Sporting Accidents Unexpected Blows

closed mouth trauma

vs.

opened mouth trauma

  • Iatrogenic Trauma -

Intubation Procedures Third Molar Extractions Long Dental Procedures Cervical Traction

  1. Macrotrauma a. Gross trauma b. Iatrogenic trauma 2. Microtrauma a. Chronic muscle hyperactivity b. Orthopedic instability
  2. What is the etiology of disc derangement disorders?

bruxism / clenching

  • parafunctional habits -

Orthopedic Instability plus Loading

  1. Are disc derangement disorders always progressive?
    • Adaptation - destruction of cells = repair of cells

destruction of cells

repair of cells