PAIN

1. DR DAVIS NADAKKAVUKARAN M.D.S
READER
MALABAR DENTAL COLLEGE EDAPPAL

2. CONTENTS
 Introduction
 History
 Definition
 Pathophysiology
 Symptoms
 Examination
 Treatment
o medication
o physiotherapeutic modalities
o stress management
o occlusal splints
o TMJ arthrocentesis
o TMJ arthroscopy
o surgical treatment

3. INTRODUCTION
 TMJ disorders are among the most misdiagnosed and
mistreated maladies in medicine
 It has got multifactorial origin or etiology and as a part of
misunderstanding stems from the inability to point at exact
etiological factors

4. HISTORY
Costen[1934]-occlusal etiology in TMJ pain
Schwartz[1956]-term TMJ pain dysfunction
syndrome
Laskin[1969]-provocative paper on MPDS
Mackenzie and Banks and Toller and
Poswillo[1975]-diagnosis & treatment of intrinsic
joint disorders

5. DEFINITION
 The MPDS is a pain disorder, in which unilateral pain is
referred from the trigger points in myofascial structures ,to
the muscles of head and neck. Pain is contrast to the
sudden sharp ,shooting ,intermittent pain of neuralgias.
But the pain may range from mild to intolerable

6. PATHOPHYSIOLOGY[ETIOLOGY ]
Extrinsic factors
-Trauma
-Occlusal
disharmony
-Habits
-Psychological
Intrinsic factors
-Internal
derangement of
TMJ
-Anterior locking of
disc
-Meniscal
displacement due to
trauma

7. DIAGNOSIS
1. Unilateral preauricular pain
2. Dull constant pain
3. Muscle tenderness
4. Clicking noise
5. Altered jaw function
Negative criteria
- no radiographic changes
- no tenderness in external auditory meatus

8. SYMPTOMS
 Cardinal symptoms of MPDS
 pain or discomfort, anywhere about the head or neck
 limitation of motion of the jaw
 joint noise – grating ,clicking ,snapping etc
 tenderness to palpation of the muscles of mastication

9. Neurologic
Gastrointest
inal tract
Musculoskel
etal
otologic
oTingling
oNumbness
oTwitches
oTrembling
olacrimation
oNausea
oVomiting
oDiarrhea
oConstipation
oDry mouth
oFatigue
oTension
oWeakness
oTiredness
oShift joint
pain
oTinnitus
oEar pain
oVertigo
oDizziness
oDiminished
hearing
Associated symptoms of MPDS

10. EXAMINATION
 HISTORY OF THE PATIENT
Physical
component
Psychologic
component
Dental
component
General
health
Nutrition
Age
Occupation
Lifestyle
Ethnic
background
Behavior
Social custom
Emotional
health
Parafunctional
habits
Supracontacts
Incorrect
dynamics
Improper
vertical
dimensions

11. PHYSICAL EXAMINATION
 Consists of an evaluation of entire masticatory system
along with head and neck region
AURICULAR
MUSCULAR
DENTAL
CERVICAL

12. ARTICULAR OR TMJ FUNCTION
 Amount of oral opening and excursion
 Palpitation for tenderness
 Grading of click or crepitus – noise evaluation
 Auscultation
 Extent of movement
ROM range of motion
AROM active range of motion
PROM passive range of motion
Normal vertical range of motion in adult – 40-50 mm
The AROM and PROM test should be carried out to delineate
the source of restrictions .whether articular or muscular
or both

13. MUSCULAR EXAMINATION
 Systemic palpitation of the muscle and tendon is the
best way to ascertain both subclinical and clinical
existing levels of dysfunction
 Areas responsive to palpitation TRIGGER POINTS
 Muscle palpitation helps in
1.location of muscle pathology
2.evaluation of muscle tone
3.location of trigger points
4.location of swelling
5.identification of anatomical landmarks

15. DENTAL /OCCLUSAL EVALUATION
1.Gross occlusal discrepancies ,prematurities or interference
2.Anterior openbite, collapsed bite ,cross bite ,reduced
vertical dimension
3.Attrision ,wear facets ,mobility of teeth ,missing teeth
4.Type of malocclusion ,skeletal or dentofacial deformities

16. CERVICAL EXAMINATION
 TMJ is in close proximity to the upper part of the cervical
spine
 Functionally ,the cervical spine and the TMJ occlusion are
interrelated
 Any change in one of these can affect the function or the
position of the other
 Shoulder and neck muscles are palpated incline the
patient’s head forward for shoulder and neck examination.
Look for tender points

18. RADIOGRAPHIC EVALUATION
 Helpful in diagnosing intra- articular pathologies , soft
tissue pathologies ,osseous pathologies
1.Panoramic radiography
2.Tomograms
3.Transcranial radiography
4.TMJ arthrography
5.Computed radiography
6.CT scan and MRI

20. AURICULOTEMPORAL NERVE BLOCK
 Usually 27 or 26 gauge needle is inserted through the skin
just anterior to the junction of tragus and ear lobe
 The needle is then advanced behind the posterior aspect of
the condyle in an anteromedial direction to a depth of 1 cm
where 1.5 ml of anesthetic solution is deposited after
aspiration
 If the true source of pain is the joint ,then the pain should
be eliminated or decreased within 5 min

22. MEDICATION
DRUG DOSAGE
Aspirin 2 tabs 0.3 – 0.6 gm/4 hourly
piroxicam 10-20 mg/3-4 times a day
ibuprofen 200-600 mg/3 times a day
pentazocine 50 mg/2-3 times a day
Valium/librium 5-10 mg/2-3 times a day
methocarbamol 500 mg/2-3 times a day
amitriptyline 10-25 mg/3 times a day or at
bedtime

23. NSAIDS
• To reduce inflammation and to provide pain relief
• 14 -21 days
MUSCLE
RELAXANT
• Recommended only for short duration
• Diazepam[2-5mg] ,cyclobenzapine 10mg at bedtime
[10 days ]
ETHYL
CHLORIDE
SPRAY
• or intramuscular injection
• 2% lignocaine or 0.05 % bupivacaine can be used

24. PHYSIOTHERAPEUTIC MODALITIES
 Heat application
 Ultrasound
 Cryotherapy
 Massage with counter –irritants and vibrators
 Use of vapocoolent spray
 Tetanizing and sinusoidal currents
 Electrogalvanic stimulation
 Active stretch exercises
 Transcutaneous electronic nerve stimulator

25. STRESS MANAGEMENT
• Biofeedback technique teaches how to relax
• Acupuncture
• Acupressure
• Yoga
• Hypnosis deep breathing relaxation
• Biofeedback instrument provides audio as well as visual
output allowing patient to hear and see increased muscle
activity and then relax

26. OCCLUSAL SPLINTS
 They are used
 To temporarily disengage the teeth
 To improve /restore the vertical dimension
 To serve as safety or protective appliance
 To reduce spams, contracture and hyperactivity of
musculature
 To create a balanced joint –tooth stabilization of the
mandible
• Two types mainly used
stabilization splint
relaxation splint

27.  STABILIZATION SPLINT
 Reduces the load on the retrodiskal area and thereby
reduce the pain
 Used to eliminate occlusal interference with bruxism
 12-18 hours use is advocated up to 4-6 months
 Follow up is done until the occlusion is stabilized and
muscles are free of tenderness
• RELAXATION SPLINT
 Used for disengagement of teeth and only for short periods
[up to 4 weeks ]
 Fabricated over the maxillary teeth and a platform is added
to disengage mandibular anterior

28. TMJ ARTHROCENTESIS
 Simple treatment for limited mouth opening accompanied by
severe pain
 OBJECTIVE
 Improve the disk mobility
 Eliminate joint inflammation
 Eliminate pain
 Early physiotherapy
 Remove the resistance to condyle translation .return to
normal function
• INDICATION
 All patients who had proved refractory to conservative
treatment [medication ,bite appliances ,physiotherapy and
manipulation of joint ]

29.  ADVANTAGE
 Simple technique
 Minimum armamentarium
 Less invasive
 Therapeutic benefit
 Highly effective
• TECHNIQUE
 Patient is made to lie supine position with the head turned
 With palpating index finger on the affected side ,TMJ
movement are palpitated
 2 points are marked – articular fossa and eminence
 Auriculotempral nerve block given
 19 or 18 gauge needle of 1.5 inch long needle
 1st needle - into the superior joint compartment
corresponding to the posterior mark

30.  2nd needle –into the articular eminence
 A 10 cc syringe is filled with Ringer lactate solution and
connected to the 1st needle
 Solution is pushed to distend the joint space
 Initially ,the solution which will flow out of 2nd needle
will be blood tinged or turbid ,but as more solution is
pushed through the 1st needle ,the flow of clear
solution will be noticed
 Atlast 1 ml of hydrocortisone is injected into the joint
space followed by removal of needle

31. TMJ ARTHROSCOPY
 Consists of the insertion of a specially designed fiberoptic
endoscope into a joint compartment for diagnosis and
therapeutic purpose
 TECHNIQUE
 basic single puncture diagnostic technique
 double puncture technique for therapeutic as well as
surgical purpose
• INDICATION
 disk dysfunction
 Osteoarthrosis
 Synovial disease
 Hypermobility associated with severe pain

32.  CONTRAINDICATIONS
 Regional infection
 Presence of tumor
 Usual medical contraindications to surgery
• USES OF ARTHROSCOPIC TECHNIQUE
 Lavage –arthrocenesis
 Lysis of adhesion
 Disk mobility improvement
 Biopsy
 Retrodiskal cauterization
• COMPLICATIONS
 Inadequate finding
 Costly equipment
 Facial paralysis
 Instrument breakage

33.  ARTHROSCOPIC EXAMINATION
 Anterior zone comprises the synovial tissue ,anterior
slope of the eminence with its fibrocartilage and anterior
portion of the disk
 Intermediate zone comprised of articular cartilage
covering the articular eminence and meniscus
 Posterior zone comprised of synovial tissue and glenoid
fossa.examination always begin in the posterior zone with
condyle in the forward position . Operator can detect
synovial inflammation ,adhesion ,edema ,perforation or
prolapse of the disk

34. SURGICAL TREATMENT
1.Condylar shave and arthroplasty
2.Condylectomy
3.Eminectomy
4.Disk surgery

35.  Condylar shave and arthroplasty- consists of removing several
millimeters of articular surface. Recontouring should be done
 Condylectomy – excision of the condyle.this procedure has
mixes results and multiple complications ,particularly an open
bite,malocclusion and deviation of mandible on opening
 Eminectomy –performed to increase an access to the joint
space for reconstruction of the disc,as well as to diminish the
obstacles in the path of translocation
 Disk surgery –autogenous grafts like dermis ,temporalis fascia
,myofascial flaps etc have been used after removal of the
disk.alloplastic materials like silastic, proplast, teflon also been
used after diskectomy

36. REFERENCE
 Textbook of oral and maxillofacial surgery –Neelima Anil
Malik[3rd edition ]
 Textbook of oral and maxillofacial surgery –
Chitra Chakravarthy (2nd edition )