Temporomandibular joint disorders iii

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Oral & Maxillofacial Surgery
Fifth Year

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Temporomandibular joint disorders iii

  1. 1. Myofascial Pain Dysfunction Syndrome Dr. Wael M. Talaat Assistant Professor of Oral & Maxillofacial Surgery University of Dammam
  2. 2. Myogenous TMD (muscle-related)   Usually caused by overwork, fatigue or tension of the jaw and other muscles in the head and neck. This type of TMD commonly causes jaw ache, toothache, headache and/or an ache in the back of the neck.
  3. 3. Myofascial pain disorders Six categories 1. Myositis Acute inflammation with pain, edema and decreased ROM. Usually secondary to overuse, but no infection or trauma seen TX: rest, NSAIDs 2. Muscle Spasm Acute contraction from overuse, overstreching Tx: rest, NSAIDs, massage, heat, relaxants 
  4. 4. 3. Contracture - End stage of untreated muscle spasm - Due to fibrosis of muscle and connective tissue - Tx: NSAIDs, massage, vigorous physical therapy, occasional surgical release of scar tissue 4.Hysterical trismus - Decreased ROM - Psychosocial etiology - More common in females 
  5. 5. 5. Fibromyalgia Diffuse, systemic process with firm, painful bands (trigger points) Usually seen in weight bearing muscles Often associated sleep disturbance More common in females  Diagnostic criteria - trigger points - known path of pain for trigger points 
  6. 6. 6. Collagen vascular disorders -- Sjogren’s Syndrome autoimmune xerostomia, xeropthalmia with keratitis sometimes muscle and joint pain , including the TMJ diagnose with minor salivary gland biopsy  -- SLE autoimmune, butterfly rash, fever, rheumatoid arthritis -- Scleroderma autoimmune characterized with gradual muscle and joint pain, tightening of skin limited jaw expansion with pain may be initial presentation
  7. 7. Etiology    The ETIOLOGY of MPDS is multifactorial. Commonly accepted cause is BRUXISM resulting from stress & occlusion being an aggravating factor. MPDS can also result from internal joint problems, such as disc displacement disorders, or degenerative joint disorders.
  8. 8.  When the pain source is purely in the muscles it has been termed: „Myofascial pain dysfunction‟ ( MPDS ) by Laskin.  However, when the TMJ itself is also involved, it is called „TMJ pain dysfunction syndrome‟ by Schwartz
  9. 9. Myofascial Pain Dysfunction Syndrome ( MPDS ) The MPD syndrome is : • • • Common cause of TMJ pain Psycho-physiologic disease involving muscles of mastication. Stress-related disorder. There is an increase in mandibular muscle tension in tandem with teeth grinding and/or clenching resulting in spasm, pain, and dysfunction.
  10. 10. The condition is characterized by:   - PAIN - unilateral, dull, aching pain, which increases with muscular activity, and progressively worsens towards the end of the day. - Patients experience limitation of mouth opening. - Complaints associated with referred pain include * headache * earache, tinnitus * burning tongue * sometimes decreased hearing. 
  11. 11. Increased stress levels result in poor habits, like : - bruxism, - clenching of teeth, and even - excessive gum chewing. leading to muscular overuse, fatigue and spasm, and subsequently pain.
  12. 12. Many symptoms may not appear related to TMJ itself. They are: • Headache: Pain becomes worse while opening and closing the jaw. Exposure to cold weather or air-conditioned air may increase muscle contraction and facial pain.
  13. 13. • Ear pain: • Pts with TMJ disorder notice ear pain but there are no signs of infection. • The ear pain is usually described as being in front of or below the ear. • Because of this -many a times, patients are treated for a presumed ear infection, which can often be distinguished from TMJ by an associated hearing loss or ear drainage. Because ear pain occurs so commonly, ENT specialists are frequently called on to make the diagnosis of a TMJ disorder. •
  14. 14. • Sounds: Grinding, crunching, clicking, or popping sounds are common in patients with a TMJ disorder. These sounds may or may not be accompanied by increased pain.
  15. 15. • Dizziness: A majority of patients with a TMJ disorder report a vague dizziness or imbalance (vertigo). The cause of this type of dizziness is not well understood.
  16. 16. • Ringing in the ear (Tinnitus): For unknown reasons, patients with a TMJ disorder experience noise or ringing in the ear (tinnitus). More than half of those patients, will have resolution of their tinnitus after successful treatment of their TMJ.
  17. 17. Diagnosis  Clinical exam:       Compare both sides of the jaw, face and head for symmetry Feel the TMJs, jaw bones and head and neck muscles to find painful areas Inspect the gums, mouth tissue and teeth for disease and excessive tooth wear facets from bruxism Look for jaw deviation on opening Listen for joint noises Measure mouth opening and check side-to-side movements
  18. 18. PHYSICAL EXAMINATION Systemic evaluation of muscles of mastication 1. Symmetry 2. Muscular hypertrophy 3. Palpation for presence of tenderness ,spasm or trigger point 
  19. 19. PHYSICAL EXAMINATION Evaluation of TMJ tenderness and noise 1.point of tenderness 2.form of joint noise : clicking or crepitus 
  20. 20. PHYSICAL EXAMINATION Measurement of range of jaw motion 3.5 cm in vertical 1 cm in protusively and laterally 
  21. 21.  Clinical signs on examination of myofacial dysfunction include: 1. Limitation of jaw opening (normal range is at least 35 mm as measured from lower to upper anterior teeth) 2. Palpable spasm of facial muscles 3. Clicking or popping sound in the TMJ 4. Tenderness on palpation of the TMJ via the external auditory meatus 5. Crepitus over the joint 6. Lateral deviation of the mandible.
  22. 22. Management The aim of management should be:      Control the factors that worsen TMD Decrease harmful pressure or “loading” on the joints Restore jaw function Help resume regular daily activities Pain reduction techniques
  23. 23. The treatment of myofascial pain dysfunction syndrome is divided into four phases.  - Phase I treatment is initiated upon diagnosis, and consists of : educating the patient on muscle fatigue and spasm as the cause of pain and dysfunction. It helps to explain referred pain. - the avoidance of clenching and grinding is emphasized - a soft diet is instituted.
  24. 24. • NSAIDs are prescribed, with or without a muscle relaxant. The most commonly used agents are Diazepam (2-5 mg twice a day) and Ibuprofen (400 mg thrice a day). Naproxen (500 mg twice daily) and Celecoxib (100 mg twice daily) • • Moist Heat therapy + stretch massage helps to relieve the pain & relax the joint and muscles. 50% of patients will obtain significant relief in 2-4 weeks.
  25. 25. Phase II therapy is initiated if Phase one treatment fails. • Medications are continued, but a custom made oral orthopaedic acrylic appliance (splint) is added. • These include occlusal splints, bite guards and night guards. • These appliances helps prevent muscle overuse, including bruxism. • Some of the common occlusal splints used in clinical practice are: 1. Centric relation splint. 2. Anterior repositioning splint. 3. Soft or resilient splint. 4. Anterior bite plane. 5. Posterior bite plane.
  26. 26. • The appliance is usually worn at night, but can also be worn during the day, if necessary. • Care should be taken to instruct the patient not to wear the appliance at all times, as the posterior teeth may become displaced. • If the patient remains asymptomatic, the appliance is discontinued. If symptoms return, the appliance may be resumed at night, and its use continued as long as necessary. •
  27. 27. Phase III Therapy Phase III includes • • • Physiotherapy of the muscle groups, including Ultrasonic therapy, Electro galvanic stimulation, TENS. Recently, it has been reported that pulsed radio frequency energy therapy (PRFE) in patients with TMJ arthralgia is safe and effective and also increases mandibular motion. These therapies focus beams of heat, sound or radio waves into the TMJ to increase blood flow and relieve pain.
  28. 28. Phase IV Therapy • Phase IV involves • Psychological counseling to identify stress factor and referral to a TMJ center. The TMJ center employs psychological counseling and trigger-point injections, for treatment. • Biofeedback helps patients to recognize times of increased muscle activity and spasm, and provides methods to help control them. • In preliminary studies, Botulinum toxin has been used successfully to treat various pain syndromes, including TMDs.
  29. 29. Thank You

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