Management of Temporomandibular Disorders

Orofacial Musculoskeletal Pain
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What About the Role of Sleep? poor sleep interferes with______pain processingWhat About the Role of Sleep? sleep modulates ______pain and pain influences sleepWhat About the Role of Sleep? sleep disturbance is common in _____chronic pain patientsWhat About the Role of Sleep? musculoskeletal system is _____ to sleep deprivationvery vulnerableacute painOngoing nociception Mostly peripheral mechanism involvedacute pain accompanied byanxiety and fearacute pain resolves when?as soon as the healing process occurschronic painHealing has occurred Maintained by central sensitizationchronic pain accompanied byanxiety depression sleep problemschronic pain resolves when?it continues even after healing has occurredAcute vs Chronic PainAcute pain is a symptom of disease Chronic pain is a disease itself; it erodes all aspects of a patient's lifeManagement GoalsReduce pain Restore or improve function Enable the patient to resume normal, daily activities Improve quality of life Decrease dependance on health care Reduce pain, suffering & disabilityManagement of Temporomandibular DisordersPatient education and self-care Home-care instruction Pharmacotherapy Physical medicine Injection techniques Behavioral modification Occlusal appliance therapyPatient Education Ensure that the patient becomes an ______ participant in therapy Discuss problems with the patient in _______active, willing easily understandable termspatient self careActive exercise program is suggested (mild aerobics, active and passive stretching) Nutritional guidance (soft diet)Home-Care Regimen -places _____ on patient -empowers pt by giving him/her ___________ -often aids in the ______ -may prevent _____responsibility an active part in care healing process further injuryhome care regimen foodEat soft foods and take smaller bites Stop gum chewing improve nutritionhome care regimen tx for painCold for muscle pain; heat for TMJ pain Increase aerobic activity Improve head posture and sleep (more deep sleep)PharmacotherapyAnalgesics muscle relaxants antidepressants sleep medsanalgesicsNSAID's, acetaminophen Corticosteroids OpioidsNSAIDsMost commonly prescribed analgesics for mild to moderate pain - "ceiling" effect Often used in combination with other medicationsNSAIDs MOAInhibits cyclooxygenase (COX) enzymes and blocks the conversion of arachidonic acid to proinflammatory prostaglandinscorticosteroids vs NSAIDscorticosteroids: stronger anti-inflammatory effect and more rapid actioncorticosteroidsShort-term therapy for acute TMJ paincorticosteroids preparationsoral injectable topicalcorticosteroids short-term therapy for acute TMJ pain -oral preparationsMedrol Dosepakcorticosteroids short-term therapy for acute TMJ pain -injectable preparationsevere episodes of TMJ paincorticosteroids short-term therapy for acute TMJ pain - topical preparationphonophoresis (ultrasound)corticosteroids MOAPrevents formation of arachidonic acid and conversion to prostaglandins and leukotrienesSkeletal Muscle Relaxants groupscentrally acting peripherally actingSkeletal Muscle Relaxants centrally actingdon't affect muscles directly inhibits polysynaptic reflexes in CNSSkeletal Muscle Relaxants peripherally actinginhibit muscle contraction by blocking synaptic transmission at the neuromuscular junctionCyclobenzaprine (Flexeril)Short-term relief of acute myofascial painCyclobenzaprine (Flexeril) durationlong acting: 12-24 hoursCyclobenzaprine (Flexeril) symptomsdrowsiness- use mostly at nightCyclobenzaprine (Flexeril) related toamitriptyline (tricyclic antidepressant)Cyclobenzaprine (Flexeril) related to amitriptyline (TCA) -contraindicated in _____narrow angle glaucoma, prosthatic hyperthophy, recent myocardial infarctionCyclobenzaprine (Flexeril) dosage5-10 mg HS (before bed)Physical MedicineVapocoolant spray Stretch techniques Ischemic compression Myofascial release techniques Electronic modalitiesPhysical Medicine electronic modalities- Transcutaneous electrical nerve stimulation (TENS) - Electroacupuncture - Ultrasound therapyvapocoolant sprayPassive stretching of the muscles Topical vapocoolant Cooling effect reduces pain and permits the muscle to be stretchedvapocoolant spray topical vapocoolantFluorimethane Ethyl chloridevapocoolant spray commonly used formuscle spasm myofascial trigger pointsvapocoolant spray how to use1st locate trigger point (if close to sensitive organs protect with shield) apply spray over muscle surface wait 5 mins stretch affected muscle to relieve trigger pointinjection techniques objectiveTo inactivate TrP (trigger points) and relieve pain and tightness of the involved muscleinjection techniquesdry needling injection with anestheticinjection techniques injection with anestheticreduces muscle pain and post injection soreness more effective than dry needling LA without vasoconstrictor preferred (damages muscles if used on regular basis)dry needlingno local anesthetic used repeated movements of needle around trigger point to mechanically disrupt the fibrous bands keeping the muscle contractedinjection techniques steps1- locate trigger point using muscle palpation 2- mark trigger point location 3-sterilize skin 4-leave fingers over taut band (guides needle and prevents band movement) 5-insert needle (muscle twitch response) 6-move the needle rapidly back and forth around the trigger point until twitch response is gone after 5 mins, do active stretching of affected muscle to relieve trigger pointContraindication to Injection TherapyAllergy to the local anesthetic Inflammation or infection in the muscle (myositis) Acute muscle injury or trauma Prolonged bleeding tendency or use of anticoagulant medicationsmost common modality to manage symptoms of TMJintraoral appliance therapyIntraoral Appliance Therapy(Occlusal Splints or Orthotics) A biomechanical method used to manage pain/dysfunction related to the temporomandibular joint (TMJ) and its associated musculatureAppliances: Proposed MechanismsTemporarily eliminates occlusal interferences Decreases joint loading Increases stability between maxilla and mandible Increase vertical dimension Reduces bruxism Reposition TMJ condyles Protects teeth Placebo effectAppliances: Proposed Mechanisms reduces bruxism how?decreases activity in masticatory muscles via change in reflex patternsThe Ideal Splint would provide ____a therapeutic effect without any detrimental side-effectsThe Ideal Splint side effects might includeMajor/minor occlusal changes Increased parafunctional jaw activity Fractured restorations Irritation of cheeks and lips Allergic reactionsIntraoral Appliances Types coveragefull and partial coverageIntraoral Appliances Types materialhard and soft appliancesIntraoral Appliances Types MOArepositioning stabilizationIntraoral Appliances Types ideal appliancefull coverage hard appliancesMaxillary or Mandibular Both appliancescan provide virtually a perfect gnathologic occlusion have comparable efficacymandibular appliancesGenerally cause less speech interference and less visible when speaking -preferable for patient who wears appliance during the dayUpper or Lower Orthotic Appliance ? - Consider fabricating for arch that would provide the ______greater occlusal stabilityIntraoral Appliances - TypesJoint stabilization Anterior repositioning NTI appliance ProvisionalIntraoral Appliances - Types provisionalsoft vinylJoint Stabilization Appliance featuresHas a flat surface occluding with the opposing dentition Enables patients to move freely from maximum intercuspationJoint Stabilization Appliance most commonly used in patients withtooth attrition TMD symptomsIndications for Stabilization SplintTMJ capsulitis secondary to nocturnal bruxism Muscular pain secondary to nocturnal bruxism Dental pain and hypersensitivity secondary to nocturnal bruxism Dental wear by attrition Unstable occlusion Clicking or locking Tension-type headacheIndications for Stabilization Splint clicking or locking aggravated byaggressive bruxing behaviorIndications for Stabilization Splint tension type headache caused bytemporalis overactivity perpetuated by chronic night-time clenchingJoint Stabilization Appliance archmaxillary or mandibularJoint Stabilization Appliance coveragefullJoint Stabilization Appliance occlusioncentric (habitual) occlusion anterior (cuspid) guidance even occlusal and incisal contactsJoint Stabilization Appliance _____mm thick posteriorly1.5-2 mmJoint Stabilization Appliance purposeServes as a behavior-changing device to make patient aware of clenching and tooth-grinding -Modifies parafunctional behaviour -Does not change maxillomandibular relationshipJoint Stabilization Appliance best worn when?during sleep and 1-2 hours during dayAnterior Repositioning Appliance primary used in patients withdisc displacement with reductionAnterior Repositioning Appliance how does it workHolds the mandible in the anterior location where the condyle is reduced onto the disc The disc-condyle mechanical disturbance are temporarily eliminated and the forces loading the condyle are transmitted through the disc's intermediate zoneAnterior Repositioning Appliance proposed mechanismsMaintains "normal" disc relationship to prevent disc displacement on closing Decreases adverse joint loading Decreases joint clickingAnterior Repositioning Appliance indicationsAcute "closed lock" Retrodiscitis Traditionally for patients who have disc displacement with reduction Temporarily holds mandible anteriorAnterior Repositioning Appliance Temporarily holds mandible anterior how?Condyle is positioned onto disc's intermediate zone (where condyle is reduced onto disc)Anterior Repositioning Appliance WearingMay need full time for acute closed lock Maintain for two months to encourage "pseudodisc" formation After 2 months, convert to joint stabilization splintanterior repositioning appliance preferred to wear when?night timeAdjust appliance more efficiently by- Using acrylic bur's flat side rather than its pointOnce obtained desired centric contacts, ask patient how can make it ______more even One side may be hitting harder than other Certain contacts may be noticeably hitting hardercheck which contacts?non-working , working, protrusive in protrusive you shouldn't have contacts between the posterior teethocclusal splint and heavy bruxersneed to fabricate appliance every 2-3 yearsPartial Coverage ApplianceNO soft partial coverage appliances -unopposed teeth over-erupt -opposed teeth may intrude due to excessive occlusal loadingpartial coverage appliance anterior repositioning splints can lead tobilateral posterior open bitesSoft ApplianceEasily fabricated, inexpensive, and may be inserted at an initial appointmentSoft Appliance may desire to use....In emergencies where patient in acute distress As prognostic tool As an easily adjustable interim appliance TMD management of children (primary or mixed dentition) When patient's financial situation is an overwhelming concernSoft Appliance may desire to use as prognostic tool to evaluate...whether an occlusal appliance would be beneficial, e.g., for tinnitus, unsure whether patient has TMD, etc.NTI appliancenociceptive trigeminal inhibition appliance small transparent device worn over upper incisors -can cause intrusion of upper and lower anterior teeth--> open biteNociceptive Trigeminal Inhibition (NTI) Appliance marketed for ________ associated with _______TMD and headaches occlusal changesNociceptive Trigeminal Inhibition (NTI) Appliance vs stabilization applianceNot as effective as stabilization applianceNTI Appliance Hope for the Headache Sufferers tx and preventionTMD muscle pain tension type headaches migrainesNTI Appliance Hope for the Headache Sufferers MOAstops the clenching between teeth decr hyperactivity of trigeminal nerve leading to migraineWhat About the Role of Surgery?Only indicated in a few cases when TMJ has been confirmed as the primary source of painsurgical proceduresArthrocentesis Arthroscopy Open joint procedures (Arthrotomy) TMJ replacementWhile no specific therapies have been proven to be uniformly effective, many of the conservative modalities have proven to be at least as effective in providing symptomatic relief as most forms of invasive treatment. Because these modalities do not produce ______, they present much less risk of producing ____irreversible changes harm