Temporomandibular Disorders -Muscular Disorders

orofacial pain
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Terms in this set (99)
orofacial pain
not about a toothache

represents non odontogenic pain
Chronic Orofacial Pain

If dental causes of pain are ruled out consider _______as the next likely source
the musculoskeletal system
largest tissue in the body
muscle tissue
most common tissue involved in chronic pain
muscle tissue
muscle tissue
largest tissue in the body: _____% of body weight
45
muscle pain types
acute
chronic
acute muscle pain
follows trauma/specific event

(if resolved, everything goes back to normal)
chronic muscle pain
difficult diagnosis and management
masticatory muscle pain model
model begins with the assumption that all muscles of mastication are healthy and functioning normally

normal muscle function can be interrupted by local or systemic events

if event is significant--> protective co-contraction/splinting will occur
(usually minor consequences and muscle function will return to normal quickly)

if prolonged co-contraction--> local muscle soreness

in some instances the CNS will respond, inducing an involuntary muscle contraction (myospasm)

CNS could mediate other conditions referred to as myofascial pain

these usually are acute and muscle function returns to normal

however, if these acute disorders are not properly managed --> chronic myalgia disorder
Image: masticatory muscle pain model
Musculoskeletal Pain
Etiological Factors
local
regional
systemic
local etiological factorsrepetitive strain oral habitslocal etiological factors any event that acutely alters the sensory proprioceptive input in _______ examples;the muscles of mastication -tooth fracture -restoration in supraocclusion -tissue damage by dental injection -excessive use of musclesregional etiological factorspoor posture malocclusionsystemic etiological factorssleep stress depression neuroendocrine (acute illness, viral infections, age, gender, genetics)these musculoskeletal conditions can be induced bymacrotrauma (car accident, sudden movements of head and neck back and forth) microtrauma (repetitive--> clenching, bruxism)musculoskeletal pain isdeepmusculoskeletal pain locationdiffusemusculoskeletal pain qualitydull aching occasionally sharpmusculoskeletal pain frequencyconstantmusculoskeletal pain intensitymoderate to severemusculoskeletal pain durationminutes, hoursmusculoskeletal pain aggravating factorsfunctional activity -physical palpation -incr by functional demands (mastication, yawning, mandibular movements)musculoskeletal pain alleviating factorsavoid functionsmusculoskeletal pain differential diagnosisTMDTMD often begins asacute musculoskeletal painTMD clinical problems involvingTMJ masticatory muscles bothmost common musculoskeletal disorder causing orofacial painTMDmuscle disorders typesmuscle splinting localized muscle soreness myospasm myositis myofascial pain fibromyalgiaMuscle Splinting Muscle Co-contractionReflexive, protective response Involves a CNS mechanismMuscle Splinting Muscle Co-contraction results inmuscle tightening and pain protects an injured part (muscle) from further traumaMuscle Splinting Muscle Co-contraction symptomslocal muscle soreness restricted range of motion pain increased with movement subjective feeling of weaknessMuscle Splinting Muscle Co-contraction managementremoval of cause rest/moist heat NSAIDLocal Muscle Soreness Delayed Onset Muscle Soreness (DOMS)post-exercise muscle pain results from heavy chewing prolonged co-contraction nocturnal bruxersLocal Muscle Soreness Delayed Onset Muscle Soreness (DOMS) nocturnal bruxerspain on awakeningLocal Muscle Soreness Delayed Onset Muscle Soreness (DOMS) nocturnal bruxers-pain on awakening caused by_______ associated with ________-muscle hyperactivity -release algogenic substancesLocal Muscle Soreness Delayed Onset Muscle Soreness (DOMS) nocturnal bruxers- release algogenic substances:ie: bradykinin and substance Palgogenic substanceschemicals released at the site of the injury causes painLocal Muscle Soreness Delayed Onset Muscle Soreness (DOMS) diagnostic criteria- Regional dull, aching pain during function - No pain / minimal pain at rest - Local muscle tenderness to palpation - Absence of trigger pointsmyospasminvoluntary sudden/continuous contractionmyospasm results inshortened muscle reduced range of motion acute malocclusionmyospasm occurs fromacute overuse strain overstretching (a previously weakened muscle)myospasm diagnostic criteria- Acute onset of pain at rest / function - Markedly reduced range of motion - Pain aggravated by function - Sensation of muscle tightnessmyospasm management- Restriction of jaw use - Heat and gentle massage - Cold spray application - Occlusal appliance - Analgesic blocking w/o vasoconstrictorMyositisInflammation of muscle from local cause - Infection following third molar extractionmyositis symptomscontinuous painful muscle diffuse tenderness swelling redness incr temp limited openingmyositis therapyanalgesics anti-inflammatories antibioticsmyositis therapy contraindicationsmuscle injectionMyofascial Pain (MFP) A _______ muscle pain disorder arising from one or more ________ sites in the _______regional local hyperirritable tender sites (trigger point) muscle, tendon, or fasciaMFP most common cause of ______persistent pain in the head, face, and neckMFP a trigger point can causereferred pain in a different anatomic distribution when stimulatedMFP prevalence: 1989 ___% of 172 consecutive patients in a university based general internal medicine practice had a chief complaint of pain31%MFP prevalence: 1989 ___% had MFP due to TrPs (trigger points) as the primary diagnosis30%MFP prevalence: 2000 In a restrospective analysis of data collected on 493 consecutive patients referred to a university orofacial pain clinic ____% had myofascial pain due to trigger point54.2%myofascial trigger pointtender point localized deep tenderness Can refer pain to another regionmyofascial trigger point located inTaut band of skeletal muscle Tendon or ligamentmyofascial trigger point diameter2-5 mmmyofascial trigger point Can refer pain to another regionzone of reference -distant from the involved muscle (may not be same dermatome)myofascial trigger point Can refer pain to another region: pattern of pain referral isreproducible & consistent therefore serves as guide to locate trigger pointsReferred PainSite and source of pain are different Diffuse and poorly localized Provoked or aggravatedreferred pain Provoked or aggravatedphysical palpation functional demandsexamples of trigger pointson trapezius muscle on masseter muscle on SCM on temporalis muscletrigger points: trapezius muscle zones of reference?temple area, behind eye, or angle of mandibletrigger points: masseter muscle zones of reference?upper or lower posterior teethtrigger points: SCM zones of reference?around the eye, cheek, tip of chin, in necktrigger points: temporalis muscle zones of reference?pain from upper teethMFP pathophysiology underlying pathologyunclear -local muscle injury or abuseMFP pathophysiology associated with local muscle injury or abuse due totrauma, overuse, abnormal posturemotor unita functional entity of skeletal muscle consisting of a group of muscle fibers and the motor neuron innervating these fibers (aka motor neural end plate)innervation of skeletal muscles is provided by a group of _________ fibers subdivided based on ________ into different subgroupsmyelinated diameter and conduction velocitya delta fibers conductpain, pressure, temperaturea beta fibers conductlight mechanical touchfibers that provide main sensory innervation of skeletal muscles and jointsa beta fibers and C fibersa beta fibers -sizeIntermediate sizea beta fibers -typesmotor and sensory fibersClinical Characteristic of Myofascial PainLocalized involving one or more TrPs Generalized due to muscle injury Comorbid with other conditionsClinical Characteristic of Myofascial Pain comorbid with other conditionscervical injuries TMD bruxism clenchingmyofascial pain characterized byincr muscle fatigue stiffness mildly restricted range of motion pain when muscle is stretched subjective feeling of weaknessFirm palpation of a trigger point will cause ajump signjump signSpontaneous reaction to palpation can manifest itself as a verbal response or withdrawal of the patient's headtwitch responseRapid, contractile motor effect (vibration)twitch response elicited by"snapping palpation" taut bandfibromyalgiasystemic disorderfibromyalgia painglobal (widespread aching or pain throughout body-most notably in weight bearing muscles)fibromyalgia etiologymultifactorial may be comorbid with other illnesses may be present with myofascial painfibromyalgia is often lumped together with myofascial pain becauseboth involve pain but lack demonstrable tissue pathologyIn order to be included in the diagnosis of fibromyalgia these pains should belocated in at least ¾ quadrants of the body or along the entire spine (widespread) must be present for a minimum of 3 months presence of 11/18 specifically defined tender pointsfibromyalgia tender pointsdifferent from myofascial trigger points -tender points don't refer pain to distant sitesChronic Pain Syndromes of Musclefibromyalgia myofascial painfibromyalgia (vs myofascial pain)global pain multifactorial etiology tender points (don't refer to different dermatomes)myofascial pain (vs fibromyalgia)regional pain source in muscle localized trigger point (may cause pain in different dermatome)management of fibromyalgiapharmacological non pharmacologicalpharmacological management of fibromyalgiatricyclic antidepressants cyclobenzaprine (muscle relaxant) pregabalin (anticonvulsant)tricyclic antidepressantsamitriptyline nortriptylinenon pharmacological management of fibromyalgiacardiovascular fitness biofeedback trainingMusculoskeletal Examination evaluation ofmuscles of mastication TMJ cervical muscles cervical screening evalulationMusculoskeletal Examination evaluation of muscles of masticationpalpationMusculoskeletal Examination evaluation of TMJpalpation range of motion auscultationhealthy muscle isNOT TENDER a painful response is abnormalpalpation of should bebilateral the entire length of the muscle