20171023 Putting the Mouth into Health-the Importance on Oral Function by Prof. Chris Peck

1. The University of Sydney Page 1
Putting the mouth into health-the
importance on oral function
Challenges from the Silver Tsunami:
Mastication and Swallowing
2017 Global Health Forum in Taiwan
Professor Chris Peck
Dean, Faculty of Dentistry

2. The University of Sydney Page 2
odt.org

3. The University of Sydney Page 3
OVERVIEW
Jaw
function
impairment
Jaw function
Causes
Impact
Assessment
Management

4. The University of Sydney Page 4
ORAL HEALTH - WHO
– Oral health is essential to general health and quality of life.
It is a state of being free from mouth and facial pain, oral
and throat cancer, oral infection and sores, periodontal
(gum) disease, tooth decay, tooth loss, and other diseases
and disorders that limit an individual’s capacity in biting,
chewing, smiling, speaking, and psychosocial wellbeing.
» http://www.who.int/mediacentre/factsheets/fs318/en/

5. The University of Sydney Page 5
THE IMPORTANCE OF THE OROFACIAL SYSTEM IN HEALTH &
WELLBEING
– Social interactions
– Communication
– Emotional expression
– Mastication
– Involved in life-saving reflexes that
protect other external sensory (e.g. retina,
olfactory epithelium, taste receptors) and
internal homeostatic (e.g. respiratory and
digestive tracts) systems from damaging
environmental changes.
– Established links between dental and
systemic diseases
istock.com (2008)

6. The University of Sydney Page 6
ADAPTATION -MASTICATORY SYSTEM BIOMECHANICS
– Masticatory System
– Functionally complex
– 6 DoF movement possible: translation along & rotation
about 3 axes
– Over 16 muscle groups drive function
– Muscle co-activation is the norm resulting in complex
force interactions at the teeth
– Difficult/impossible to measure all biomechanical
variables directly
– Mechanically redundant system
GOAL: TO UNDERSTAND STRUCTURE-FUNCTION RELATIONSHIPS

7. The University of Sydney Page 7
ADAPTATION – MUSCLE STRUCTURE AND FUNCTION
– Jaw function and occlusal changes can
change muscle structure at all levels
– mitochondrial content
– cross-sectional area of the fibres,
– fibre-type composition
– Retention of teeth maintains jaw-closing
muscle size
– may enhance masticatory ability
– Grünheid T et al. Eur J Orthod
2009;31:596-612

8. The University of Sydney Page 8
ADAPTATION- THE MODERN OCCLUSION
0
5
10
15
20
25
30 ca 1600
ca 1950
Kaidonis 2008
Varella 2006
%

9. The University of Sydney Page 9
NORMAL TOOTH CONTACT
– Total tooth contact duration
~ 18 mins/day
– Occurs during mastication and
swallowing
• Each chewing stroke: tooth contact
occurs ~0.3 s
• Swallowing during meals, between
meals and during sleep
– Function and comfort satisfactory
with 20 well-distributed teeth or 10
occluding pairs

10. The University of Sydney Page 10
JAW FUNCTION IMPAIRMENT
CAUSES

11. The University of Sydney Page 11
IMPAIRED ORAL FUNCTION AND CAUSES
Eating
Speech
Opening
Clenching
Pain
Structural changes
Motor impairment

12. The University of Sydney Page 12
CARDINAL SIGNS & SYMPTOMS OF TMDs
TMDs
Pain of
muscles/
TMJs
Impaired
function
Joint
sounds
– IMPACTS
– chewing
– wide mouth opening
– speech
– These motor problems are significant
issues

13. The University of Sydney Page 13
TEMPOROMANDIBULAR DISORDERS-IS THERE INCREASED
CLENCHING?
– Female TMD subjects
– Jaw muscle pain
– Age-matched controls with
no current medical/dental
treatment
– Worked in administrative
positions or dental clinics
– No gum chewing
– Recording >7 hr
Assess non-functional muscle activity (teeth clenching, grinding)

14. The University of Sydney Page 14
TEMPOROMANDIBULAR DISORDERS-IS THERE INCREASED
CLENCHING?
Average non-functional events/hr
0
50
100
150
200
250
300
350
400
450
500
0.2s 0.3s 0.4s 0.5s 0.6s 0.7s 0.8s 0.9s 1s
No pain
Pain
No.Events
Event Duration

15. The University of Sydney Page 15
OROFACIAL PAIN - PREVALENCE IN NSW
Does this pain interfere with your ability to manage your day to day activities?
36% yes 65% moderate or more
How long have you had this pain?
71.5% > 1 year
Orofacial pain in past month
17.4% female 12.5% male
N= 20, 264 interviewed 62% female Age: 16-97 NSW Health

16. The University of Sydney Page 16
OROFACIAL PAIN - EXTRACRANIAL SYMPTOMS
Clinical population-Westmead
Hospital, NSW
– 61.3% of the OFP subjects reported
extracranial symptoms
– 20% had these symptoms for more
than six months
Peck 2003

17. The University of Sydney Page 17
OROFACIAL PAIN – THALAMOCORTICAL DYSFUNCTION
•Loss of neurons
•Reduced input to higher
brain centres
•Reduced neurotransmitter
(GABA) release
•Altered connections to
sensory cortex
•Aberrant input interpreted as
PAIN
Henderson 2017

18. The University of Sydney Page 18
PAIN AND MOTOR CORTEX CHANGES
Nash et al. J Orofacial Pain 24; 379-390, 2010
Regions within the contralateral primary motor cortex in which signal intensity increased (red)
and decreased (blue) during orofacial muscle pain. The discrete region in which signal
intensity increased is surrounded by a larger region in which signal intensity decreased.

19. The University of Sydney Page 19
– TMD group-categorised by
depression
– Individuals chewed gum
– No depression cohort (from
the DASS-42 scale)
– Depression cohort ('mild',
'moderate', 'severe' and
'extremely severe'
categories, DASS-42 scale)
– More depressed individuals
chewed faster
Depression influences chewing velocity Brandini et al 2011
MULTIDIMENSIONAL FEATURES OF PAIN INFLUENCES MOVEMENT

20. The University of Sydney Page 20
CATASTROPHISING EFFECT ON JAW MOVEMENT
Akhter 2011
– High Catastrophisers
– Increased variability
• Jaw closing velocity
• Opening amplitude
• Closing amplitude
Catatrophising increases movement variability

21. The University of Sydney Page 21
OFP – Impact Integrated Pain Adaptation Model
Pain
Sensory
Emotional
Murray GM, Peck CC. J Orofacial Pain 21; 263-278, 2007
Unique
Movement

22. The University of Sydney Page 22
THE DENTITION - BITE FORCE
Bite
force
Patient
motivation
&
cooperation
Jaw muscle
size
Jaw gape
Muscle
fibre
distribution
AgeSex
craniofacial
type
Pain
Tooth
contacts

23. The University of Sydney Page 23
THE DENTITION - BITE FORCE DISTRIBUTION
– Bite force not associated with decay or
periodontal attachment
– Miyaura, 1999; Morita 2003
– Moderate loss of posterior tooth support
results in loss of clenching force
– Gibbs 2002
– Removable prostheses replacing molar
contacts enable only 35-60% maximum bite
force
– Miyaaura 2000, Shinkai 2001
– Occlusal contacts on the posterior teeth: the
most important of the occlusal parameters in
determining bite force
Gibbs 2002

24. The University of Sydney Page 24
FUNCTIONAL DENTITION
•Impaired function with fewer than 20 uniformly distributed teeth and/or
reduced number of occluding teeth
•Changes in food selection when less than 10 pairs of occluding teeth
•The shortened dental arch - comprising anterior and premolar regions
•Good oral function, improved oral hygiene, comfort

25. The University of Sydney Page 25
OROFACIAL DEFECTS
C Wallace 2017, Westmead

26. The University of Sydney Page 26
SALIVARY FLOW
– Saliva has profound effects on the oral
cavity
– Influences oral function and food
selection
– Few dental practitioners assess
adequately
– Management is largely sub-optimal
– Needs oral disease prevention focus
– Molecular biology research may lead to
salivary function
» Doddsa et al 2005

27. The University of Sydney Page 27
AGEING – JAW MUSCLE SIZE
– Craniofacial MRI segmentation;
masticatory performance; salivary flow
– N=62
– Masticatory performance correlated
with:
– Masseter muscle volume
– Stimulated saliva flow rate
» CS Lin 2017

28. The University of Sydney Page 28
AGEING – NEURAL CHANGES
– Nerve changes in premotor cortex
associated with masticatory
performance
– Brain signatures may contribute to the
age-related decline in masticatory
performance.
– Decreased abilities in sensorimotor
integration, attentional control or
attentional monitoring
CS Lin et al 2016, 2017

29. The University of Sydney Page 29
IMPACT

30. The University of Sydney Page 30
IMPACT: DENTAL-SYSTEMIC HEALTH LINKS
Dental
Health
Diabetes
Cardiac
Arthritis
StrokeObesity
Pregnancy
Alzheimer’s
HEALTH AND WELLBEING REQUIRE GOOD ORAL FUNCTION

31. The University of Sydney Page 31
THE IMPACT OF OROFACIAL PAIN AND IMPAIRED FUNCTION
Impact
Depression
Anxiety
Stress
Jaw function
Social
activities
Daytime
Parafunction
Change in
health
SIGNIFICANT FINDINGS cf CONTROLS
Unpublished Peck 2014

32. The University of Sydney Page 32
THE IMPACT OF TOOTH LOSS
Loss of
teeth
Reduced
intake of
fruits
&vegetables
Increased
obesity
Lower
biochemical
levels
Fewer
nutrients,
dietary fibre
Joshipura 1996; Krall 1998;
Moynihan 1994; Nowjack-
Raymer 2000, 2003; Sheiham
1999, 2001, 2003

33. The University of Sydney Page 33
IMPACT ON QUALITY OF LIFE - CHEWING
Oropharyngeal cancer
– Systematic review and Meta-analysis
– N=1366
– 1 year post-treatment - problems with
– xerostomia,
– dysphagia
– chewing
» Høxbroe Michaelsen et al.,
2017

34. The University of Sydney Page 34
IMPACT ON FOOD CHOICE-A COMPLEX BEHAVIOUR
– Multiple interrelating factors influence
food choice
– Nutrition education during the course of
life may improved diet and a better
nutritional status.
– Reduce costs in the health sector due to
the prevention of nutrition related
diseases, such as obesity, coronary heart
disease and diabetes mellitus.
» Koehler & Leonhaeuser 2008

35. The University of Sydney Page 35
INABILTY TO RETURN TO HOME
Naruishi 2017

36. The University of Sydney Page 36
ASSESSMENT

37. The University of Sydney Page 37
ASSESSMENT - A BIOPSYCHOSOCIAL CONTEXT
Bio-
Psycho-Social
– Biological concepts: e.g. nociception;
tissue damage & loss
– Psychological concepts: depression,
anxiety, catastrophising
– Social concepts: impact on individual
and significant others; response of
others
The need to be a biobehavioural clinician – S Dworkin

38. The University of Sydney Page 38
DETERMINANTS OF ORAL HEALTH FOR OLDER PEOPLE
NSW Health 2014

39. The University of Sydney Page 39
ASSESSMENT - SUBJECTIVE AND OBJECTIVE
– Functional impairment is frequently
related to pain
– Psychosocial Assessment
– Preventative focus
– Need to consider consequences of ageing
– Physical and mental changes
– Co-morbidities
– Polypharmacy
– Financial status
Subjective
•Interview(s)
•Questionnaires
Objective
•Examination
•Tests

40. The University of Sydney Page 40
MAKING A DIAGNOSIS: SCREEN ALL PATIENTS
1. In the last 30 days, how long did any pain last in your jaw or temple area on
either side? No pain/ Pain comes and goes/ Pain is always present
2. In the last 30 days, have you had pain or stiffness in your jaw on awakening?
3. In the last 30 days, did the following activities change any pain (that is, make
it better or make it worse) in your jaw or temple area on either side?
•A. Chewing hard or tough food
•B. Opening your mouth or moving your jaw forward or to the side
•C. Jaw habits such as holding teeth together, clenching, grinding, or chewing gum
•D. Other jaw activities such as talking, kissing, or yawning
•Gonzalez YM et al. JADA 2011

41. The University of Sydney Page 41
JAW FUNCTIONAL LIMITATION SCALE - 20
Score from no limitation (0) to Severe limitation (10)
Chew tough food Swallow
Chew hard bread Yawn
Chew chicken (ie prepared in oven) Talk
Chew crackers Sing
Chew soft food (eg macaroni, canned or soft fruits,
purred foods)
Putting on a happy face
Eat soft food requiring no chewing Putting on an angry face
Open wide enough to bite from a whole apple Frown
Open wide enough to bite into a sandwich Kiss
Open wide enough to talk Smile
Open wide enough to drink from a cup Laugh
https://ubwp.buffalo.edu/rdc-tmdinternational/

42. The University of Sydney Page 42
PSYCHOSOCIAL ASSESSMENT
Anxiety
Feeling tense
Heart pounding
Scared for no
reason
Nervous/shaky
inside
Spells of
terror/panic
Feeling something
bad will happen
4
Depression
Feeling lonely
Poor appetite/
overeating
Everything an
effort
Restless sleep
Crying easily
Lack of
energy
Thoughts of
death, suicide
Catastrophising
Overwhelmed
Focus on pain
No
improvement
Serious
implications
Nothing helps
Afraid of
worsening
Self-efficacy
No
enjoyment
No
socialising
No House
chores
No Work
No activity
Goals
incomplete

43. The University of Sydney Page 43
Movement range-incisors –Opening: 50mm (<40)
–Lateral& protrusive:10mm (<7)
EXAMINATION

44. The University of Sydney Page 44
EXAMINATION – PALPATION

45. The University of Sydney Page 45
TEMPOROMANDIBULAR DISORDERS - CLASSIFICATION
TMD
s
TEMPOROMANDIBULAR JOINT DISORDERS
MASTICATORY MUSCLE DISORDERS
HEADACHE
ASSOCIATED STRUCTURES

46. The University of Sydney Page 46
TEMPOROMANDIBULAR DISORDERS TAXONOMY
I. TEMPOROMANDIBULAR JOINT DISORDERS
– Joint pain
– Arthralgia; Arthritis
– Joint disorders
– Disc disorders
– Hypomobility disorders other than disc disorders
• Adhesions/Adherence
• Ankylosis
– Hypermobility disorders
• Dislocations
– Joint diseases
– Degenerative joint disease
– Systemic arthritides
– Condylysis/Idiopathic condylar resorption
– Osteochondritis dissecans
– Osteonecrosis
– Neoplasm
– Synovial Chondromatosis
– Fractures
– Congenital/developmental disorders
– Aplasia, Hypoplasia, Hyperplasia
II. MASTICATORY MUSCLE DISORDERS
– Muscle pain
– Myalgia
– Tendonitis
– Myositis
– Spasm
– Contracture
– Hypertrophy
– Neoplasm
– Movement Disorders
– Orofacial dyskinesia, Oromandibular dystonia
– Masticatory muscle pain attributed to systemic/central pain disorders
– Fibromyalgia/widespread pain
III. HEADACHE
– Headache attributed to TMD
IV. ASSOCIATED STRUCTURES
– Coronoid hyperplasia

47. The University of Sydney Page 47
MANAGEMENT

48. The University of Sydney Page 48
MANAGEMENT PHILOSOPHY
Prevention Restoration

49. The University of Sydney Page 49
PREVENTION- MINIMISE DISEASE
•Common risk factor
approach
•Integrated approach
•Focus on general
health and wellbeing

50. The University of Sydney Page 50
MANAGEMENT STEPS
Better outcomes are obtained with early diagnosis & management
Explanation, Reassurance,
Motivation & Behavioural Mx
Pain/Symptom Reduction
Regain Function
Review & Future Prevention

51. The University of Sydney Page 51
MANAGEMENT - SELF-CARE
education
self-exercise
self-massage
thermal therapy
dietary advice & nutrition
parafunctional behaviour identification, monitoring, & avoidance
Durham 2016

52. The University of Sydney Page 52
MANAGEMENT - MODIFY FOOD TEXTURE

53. The University of Sydney Page 53
PHYSIOTHERAPY- E.G., ISOTONIC RESISTANCE EXERCISE
– Isotonic resistance (60% MVC)
or
– Sham exercise
– 4 weeks duration
– Repeat identical movement and assess
muscle activity at 4 weeks & 8 weeks

54. The University of Sydney Page 54
PHYSIOTHERAPY- E.G., ISOTONIC RESISTANCE EXERCISE
10
5
15
2 4 6 8 10 12 14 16 18
2
4
6
8
Displacement
(mm)
Right Lateral Jaw Movement
Time (sec)
Example
EMG Activity
(% MVC)
Onset Offset
Pre-Exercise
1s
Post-Exercise
6 s
-1 s
-2 s Duration -2 s

55. The University of Sydney Page 55
VALUE-BASED HEALTH CARE
– CHOICE & COMPETITION for patients are powerful forces to encourage continuous
improvement in value and restructuring of care.
– VALUE = PATIENT HEALTH OUTCOMES
PER DOLLAR SPENT
– POSITIVE-SUM COMPETITION on value for patients is fundamental to health care
reform in every country.
– http://www.isc.hbs.edu/health-care/vbhcd/

56. The University of Sydney Page 56
VALUE-BASED HEALTH CARE
1. System re-organization around the patient’s
needs
2. Outcomes valued by the patient need to be
measured, as well as the cost of care
3. Assessment of health care cost needs to be
overhauled from fee for service to ‘bundled
payments’ ie. one price is charged for a
complete course of the patient’s care.
4. Systems of care must become integrated, not
remain ‘silo-nated’
5. Health care needs to expand it’s geographic
reach
6. These changes need to be supported by a robust
IT platform that is patient-centric, captures all
useful data, and makes the patient record readily
accessible for those who need it