Basics about TMJ ( development fuction movement etc ) with classification of tmj disorders and stress on tmj examination.
Also covers muscles of masstication
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The applied anatomy of temporomandibular joint has many significant applications in maxillofacial surgery. Understanding these important anatomic relations- variations enables surgeons to perform the surgical procedures safely. Knowledge of these concepts helps us to recognize the problems and complications as and when they occur and manage them accordingly.
Presentation describing the anatomy of muscles of mastication along with actions, functions, applied anatomy and conditions encountered in dental scenario along with treatment modalities
Basics about TMJ ( development fuction movement etc ) with classification of tmj disorders and stress on tmj examination.
Also covers muscles of masstication
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The applied anatomy of temporomandibular joint has many significant applications in maxillofacial surgery. Understanding these important anatomic relations- variations enables surgeons to perform the surgical procedures safely. Knowledge of these concepts helps us to recognize the problems and complications as and when they occur and manage them accordingly.
Presentation describing the anatomy of muscles of mastication along with actions, functions, applied anatomy and conditions encountered in dental scenario along with treatment modalities
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
It contains following subheadings:
-maxilla and mandible anatomy
-TMJ(Temporo mandibular joint)
-Muscles of mastication
By:
Dr. Syed Irfan Qadeer
Prof. and HOD Department of Anatomy
SPIDMS,Lucknow
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
this presentation describes the detail anatomy of Temporo-mandibular joint with respect to its articulating surfaces, ligaments, muscles and blood and nerve supply.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
NASM Integrated Flexibility Continuum
Corrective Flexibility: This phase is designed to correct common postural dysfunctions, muscle imbalances, and joint dysfunction. It includes: SMR and static stretching (and neuromuscular stretching if trained in technique). ... This includes SMR and dynamic stretching.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
It contains following subheadings:
-maxilla and mandible anatomy
-TMJ(Temporo mandibular joint)
-Muscles of mastication
By:
Dr. Syed Irfan Qadeer
Prof. and HOD Department of Anatomy
SPIDMS,Lucknow
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
this presentation describes the detail anatomy of Temporo-mandibular joint with respect to its articulating surfaces, ligaments, muscles and blood and nerve supply.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
NASM Integrated Flexibility Continuum
Corrective Flexibility: This phase is designed to correct common postural dysfunctions, muscle imbalances, and joint dysfunction. It includes: SMR and static stretching (and neuromuscular stretching if trained in technique). ... This includes SMR and dynamic stretching.
-MET is a type of osteopathic manipulative treatement used in osteopathic therapy, physical therapy, massage therapy and occupational therapy.
- A form of diagnosis and treatment in which the patient's muscles are actively used on request, from a precisely controlled position, in a specific direction, and against a distinctly executed physician counterforce. 1.Dr. TJ Ruddy:
first osteopathic doctor to use muscle energy in the
1940’s and 1950’s, he referred to it as resistive duction,
which he defined as a series of muscle contractions against
resistance; used techniques mainly in the C‐spine.2.Dr. Fred Mitchell, Sr.: has been titled the Father of
muscle energy.
-He took Dr. Ruddy’s principles and incorporated them into manual medicine to any body region/ articulation.
-He believed that pelvis was the key to musculoskeletal system.
Muscles,
Faculty of Medicine,
Alexandria University,
Medical Student: Mohammed Yasir Taha Alkhammas,
Under Supervision: Professor Dr. Nancy Mohamed El Sekily
Controlled use of sensory stimulus.
Specific Motor response
Normalization of muscle tone
Use of Developmental sequences.
Sensorimotor development = from lower to higher level.
Use of activity to demand a purposeful response.
Practice of sensory motor response is necessary for motor learning.
CP-Care curriculum, training course and assessment mechanism (ECVET based)
Website: http://cpcare.eu/en/
This project (CP-CARE - 2016-1-TR01-KA202-035094) has been funded with support from the European Commission. This communication reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein.
Muscle energy technique, a manual therapy technique with a long term history and 8 variations which can be used in various condition to treat muscle as well as joints. This slide show consists of detailed history, variations/types and summary of MET in detail.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. Introduction
Masticatory system:
Nerves
Muscles
Three sections:
Neuro-anatomy and function
Physiologic activities
Oro-facial pain
1/5/2018
2
3. Anatomy And Function Of
Neuromuscular System
Neurologic structures
Neuron
Sensory receptor
Brain and brainstem
Muscles
Motor unit
The muscle
Muscle sensory receptor
1/5/2018
3
4. Anatomy And Function Of
Neuromuscular System
Neuro-muscular function
Function of sensory receptors
Reflex action
Reciprocal innervation
Regulation of muscle activity
Influence from higher centers
1/5/2018
4
7. Sensory Receptors
Neurologic structures or organs located in all body
Various types
Exteroceptors
Nociceptors
Proprioceptors
Interoceptors
1/5/2018
7
11. Reticular Formation
Concentrations of cell or nuclei
Pathway towards higher centers
Monitoring impulses that enter brainstem
Controls the overall activity of the brain
important influence on pain and other sensory input
1/5/2018
11
12. Thalamus
Located in the very center of the brain
Made up of numerous nuclei
Interrupt impulses
1/5/2018
12
13. Hypothalamus
Small structure in the middle of the base of the brain
Major center of the brain for controlling internal body
functions
Stimulation excites the sympathetic nervous system
increased level of emotional stress can stimulate the
hypothalamus to up regulate the sympathetic nervous system
and greatly influence nociceptive impulses entering the brain
1/5/2018
13
14. Limbic Structures
limbic => “border”
Border structures of the cerebrum and the diencephalon
Control our emotional and behavioral activities
Responsible for specific behaviors such as anger, rage, and
docility
Control emotions such as depression, anxiety, fear, and
paranoia
pain/pleasure center
1/5/2018
14
15. Cortex
Made up predominantly of gray matter
Associated with the thinking process and memory storage
Acquisition of skills
Different regions have different functions
1/5/2018
15
18. Motor Unit
Variation in innervation
Fewer muscle fibers per motor neuron => more precise
movement
Inferior lateral pterygoid muscle has a relatively low muscle
fiber– motor neuron ratio
Masseter has greater number of motor fibers per motor
neuron
1/5/2018
18
21. Muscle Function
Three potential functions
Isotonic Contraction: When a large number of motor units in the
muscle are stimulated, contraction or an overall shortening of the
muscle occurs
Isometric Contraction: When a proper number of motor units
contract in opposition to a given force, the resultant function of the
muscle is to hold or stabilize the jaw
Controlled relaxation: When stimulation of the motor unit is
discontinued, the fibers of the motor unit relax and return to their
normal length. By control of this decrease in motor unit stimulation,
precise muscle lengthening can occur that allows smooth and
deliberate movement
1/5/2018
21
22. Muscle Function
Eccentric contraction
Often injurious
Forced lengthening of a muscle at the same time that it is
contracting
1/5/2018
22
25. Muscle Spindles
Monitor tension within the skeletal muscles
Fibers parallel
Within each spindle, the nuclei of the intrafusal
fibers are arranged in two distinct fashions:
Chainlike (nuclear-chain type)
Clumped (nuclear-bag type)
1/5/2018
25
33. Function Of Sensory Receptors
Passive stretching of muscle => spindles inform the CNS of
activity
Active muscle contraction monitored by both the Golgi
tendon organs and the muscle spindles
Movement of the joints and tendons stimulates pacinian
corpuscles
1/5/2018
33
34. Reflex Action
A reflex action is the response resulting from a stimulus that
passes as an impulse along an afferent neuron to a posterior
nerve root or its cranial equivalent, from which it is then
transmitted to an efferent neuron leading back to the skeletal
muscle
Reflex action may be monosynaptic or polysynaptic
Two general reflex actions are important in the masticatory
system
myotatic reflex
nociceptive reflex
1/5/2018
34
37. Myotatic (Stretch) Reflex
Occurs without a specific response from cortex
Important in determining the resting position of the jaw
Principal determinant of muscle tonus in elevator muscles
Protects masticatory system from sudden stretching of a
muscle
Maintains stability of the musculoskeletal system with muscle
tonicity
1/5/2018
37
39. Nociceptive (Flexor) Reflex
Protects the teeth and supportive structures from potential
damage due to sudden and unusually heavy functional forces
1/5/2018
39
40. Reciprocal Innervation
Control of antagonistic muscles is of vital importance in reflex
activity
Antagonism in muscle activity
Jaw opening
The neurologic controlling mechanism for these antagonistic
groups is known as reciprocal innervation
Enables smooth and exact control
1/5/2018
40
41. Influence From Higher Centers
Within the brainstem is a pool of neurons that control
rhythmic muscle activities known as the central pattern
generator (CPG)
Example:
During the process of chewing the CPG initiates contraction of
the supra- and infrahyoid muscles at the precise time the
elevator muscles are told to relax. This allows the mouth to open
and accept food. Next, the CPG initiates contraction of the
elevator muscles while relaxing the supra- and infrahyoid
muscles, producing closure of the mouth onto the food.
1/5/2018
41
42. Influence From Higher Centers
Increased emotional stress => the limbic structures and
hypothalamic/pituitary/adrenal axis (HPA) => gamma efferent
system => contraction of the intrafusal fibers
Increase in muscle tonus
More sensitive to external stimuli
Greater risk of muscle fatigue
Increase in interarticular pressure of the TMJ
1/5/2018
42
43. Influence From Higher Centers
Increased gamma efferent activity may also increase the
amount of irrelevant muscle activity
Reticular formation involved in the HPA pathway
Often these activities assume the role of nervous habits, such
as biting on the fingernails or on pencils, clenching the teeth,
or bruxism
1/5/2018
43
51. Anterior Movement
Early stages
Incising of food
Forward movement
Alignment and position of opposing incisors
Later stages
Crushing of bolus
Concentrated on posterior teeth
Little anterior movement
1/5/2018
51
58. Lateral Movement
Relates to the stage of mastication
Food introduced in mouth: lateral movement is great
Varies according to the consistency
Hardness of food also has an effect on the number of
chewing strokes
1/5/2018
58
59. Lateral Movement
Although mastication can occur bilaterally, about 78% of
observed subjects have a preferred side where the majority
of chewing occurs
Side with the greatest number of tooth contacts during
lateral glide
People who seem to have no side preference simply
alternate their chewing from one side to the other
1/5/2018
59
60. Tooth Contacts During Chewing
When food introduced
Increases when bolus is broken down
Minimal force
Two types:
Gliding
Single
Average contact time during mastication 194ms
1/5/2018
60
61. Tooth Contacts During Chewing
influence or even dictate the initial opening and final
grinding phase
tall cusps and deep fossae promote a predominantly
vertical chewing stroke
Flattened or worn teeth encourage a broader chewing
stroke
1/5/2018
61
63. Tooth Contacts During Chewing
Effect of TMJ
Normal individuals masticate with chewing strokes that are
well rounded, more repeated, and with definite borders
Person with TMJ pain, less repeated pattern, strokes are
much shorter and slower and have an irregular pathway
Relate to the altered functional movement of the condyle
around which the pain is centered
1/5/2018
63
64. Forces Of Mastication
Maximal biting force varies
Males can bite with more force than can females
Greatest maximal biting force reported is 975 lb. (443 kg)
More on molar than that of incisor
Increase with age up to adolescence
Study by Gibbs and colleagues reports that grinding phase of
closure stroke averaged 58.7 lb. on posterior teeth
With tougher foods, chewing occurs predominantly on first molar
and second premolar areas
1/5/2018
64
65. Role Of Soft Tissues In Mastication
Mastication could not be performed without the aid of
adjacent soft tissue
Role of lips
Guide and control intake
Sealing off the oral cavity
Tongue
Maneuvering of food
initiates the breaking up process by pressing it against the hard
palate
Push food onto the occlusal surfaces of teeth
After eating, tongue sweeps the teeth to remove any food residue
that has been trapped in the oral cavity
1/5/2018
65
67. Swallowing
Series of coordinated muscular contractions
Food from oral cavity through the esophagus to the
stomach
Consists of voluntary, involuntary, and reflex muscular
activity
decision to swallow depends
degree of fineness of food
intensity of taste extracted
degree of lubrication of bolus
1/5/2018
67
68. Stabilization Of Mandible
Mandible must be fixed so that contraction of suprahyoid and
infrahyoid muscles can control proper movement of hyoid
bone needed for swallowing
Adult swallow => teeth for mandibular stability (somatic
swallow)
Absence of teeth => mandible is braced by placing tongue
forward and between the dental arches or gum pads (infantile
or visceral swallow)
1/5/2018
68
69. Infantile Swallow
Normal transition from infantile swallow to adult swallow does
not occur
lack of tooth support because of poor tooth position or arch
relationship
Discomfort occurs during tooth contact because of caries or tooth
sensitivity
Over retention => labial displacement of anterior teeth by
tongue muscle => anterior open bite
1/5/2018
69
70. Adult Swallow
Average tooth contact => about 683 ms
Three times longer than during mastication
Force applied to teeth => approximately 66.5 lb. which is 7.8
lb. more than force applied during mastication
1/5/2018
70
76. Frequency of Swallowing
Swallowing cycle occurs 590 times during a 24-hour
period:
146 cycles during eating,
394 cycles between meals while awake, and
50 cycles during sleep
Lower levels of salivary flow during sleep result in less
need to swallow
1/5/2018
76
78. Speech
3rd major function
occurs when a volume of air is forced from lungs by
diaphragm through larynx and oral cavity
Controlled contraction and relaxation of the vocal cords
precise form assumed by the mouth determines the
resonance
and exact articulation of sound
Inspiration of air is relatively quick and taken at the end of a
sentence or pause
Expiration is prolonged, allowing a series of syllables, words,
or phrases to be uttered
1/5/2018
78
79. Articulation of Sound
Varying relationships of lips and tongue to the palate and
teeth
Sounds formed by lips are the letters “M,” “B,” and “P.”
Teeth are important in saying the “S” sound
Tongue and palate are especially important in forming “D”
sound
Many sounds can also be formed by using a combination of
anatomic structures. Example, the tongue touches the
maxillary incisors to form the “Th” sound
1/5/2018
79
80. Articulation of Sound
Lower lip touches incisal edges of the maxillary
teeth to form the “F” and “V”
posterior portion of the tongue rises to touch the
soft palate for “K” and “G”
1/5/2018
80
82. Considerations of Orofacial Pain
Types
Acute
Chronic
Dull achy that can significantly decrease the individual’s
ability to function
Affects quality of life
1/5/2018
82
84. Pain Modulation
Degree of pain relates more closely to the patient’s perceived
threat of the injury and the amount of attention given to the
injury
Pain modulation means that impulses arising from a noxious
stimulus can be altered before they reach the cortex for
recognition
Occur as the primary neuron synapses with the interneuron or
as the input ascends to complex brainstem and cortex
May have excitatory or inhibitory effect
1/5/2018
84
85. Pain Modulation
Mechanisms by which pain can be modulated
Non-painful cutaneous stimulation system
Intermittent painful stimulation system
psychological modulating system
1/5/2018
85
86. Non-painful Cutaneous Stimulation
System
It has been postulated that if the larger fibers are stimulated
at the same time as the smaller ones, the larger fibers will
have precedence and mask the input to the CNS from the
smaller ones, described as the gate control theory
For the effect to be great, the stimulation of the large fibers
must be constant and below a painful level
The effect is immediate and usually vanishes after the large-
fiber stimulus is removed
1/5/2018
86
87. Non-painful Cutaneous Stimulation
System
Noxious input that reaches the spinal cord can also be altered at
virtually every synapse in the ascending pathway to the cortex
Descending inhibitory system = modulate this input so as not to
be perceived by the cortex as pain
Transcutaneous electrical nerve stimulation (TENS) = Constant
sub threshold impulses in larger nerves near the site of an injury
or other lesion block the input from smaller nerves, preventing
painful stimuli from reaching the brain
1/5/2018
87
88. Intermittent painful stimulation system
Stimulation of areas of the body that have high concentrations of
nociceptors and low electrical impedance
Reduce pain felt at a distant site due to the release of endorphins
Two basic types
Enkephalins
Beta-endorphins
Enkephalins appear to be released in the cerebrospinal fluid and
therefore act quickly and locally to reduce pain
Beta-endorphins are released into the bloodstream like hormones
by the hypophysis cerebri are slower-acting but their effect lasts
longer
1/5/2018
88
89. Psychological Modulating System
Not well understood
Certain psychological states affect pain
Emotional stress can be strongly correlated with levels of
pain
Patients who devote a great amount of attention to their
pain are likely to suffer more
Prior conditioning and experience also affect the degree of
pain felt
1/5/2018
89
90. Types Of Pain
When a patient describes a pain whose site and source
are in the same location, is it is referred to as a primary
pain
When patient feels the pain is not where the pain is
coming from. These are called heterotopic pains.
There are generally three types of heterotopic pains
Central pain
Projected pain
Referred pain
1/5/2018
90
91. Types Of Pain
Referred pain clinical rules
The most frequent occurrence of referred pain is within a single
nerve root, passing from one branch to another (e.g., a
mandibular molar referring pain to a maxillary molar)
Sometimes referred pain can be felt outside the nerve responsible
for it. When this occurs, it generally moves cephalad (upward,
toward the head) and not caudal
In the trigeminal area, referred pain rarely crosses the midline
unless it originates at the midline. For example, pain in the right
TMJ will not cross over to the left side of the face
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92. The Central Excitatory Effect
Certain input into the CNS, such as deep pain, can create an
excitatory effect on other unassociated interneurons. This
phenomenon is called central excitatory effect
Neurons carrying nociceptive input into the CNS can excite
other interneurons in one of two possible ways
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93. The Central Excitatory Effect
Afferent input is constant and prolonged, it continuously
bombards the interneuron, resulting in an accumulation of
neurotransmitter substance at the synapses. If this accumulation
becomes great, the neurotransmitter substance can spill over to
an adjacent interneuron, causing it also to become excited.
From there, the impulses go to the brain centrally, and the brain
perceives nociception as being transmitted by both neurons.
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94. The Central Excitatory Effect
Single interneuron may itself be one of many neurons that
converge to synapse with the next ascending interneuron. As
this convergence nears the brainstem and cortex, it can become
increasingly difficult for the cortex to evaluate the precise
location of the input.
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95. Clinical Manifestations Of The Central
Excitatory Effect
When afferent interneurons are involved, referred pain is
often reported
Wholly dependent on the original source of pain
Local provocation of the source increases the pain both at
the source and often also at the site
A local anesthetic blockade of the site does not affect the
pain felt, since this is not the origin of the pain
A local anesthetic blockade of the source reduces both the
source and the site of referred pain
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96. Clinical Manifestations Of The Central
Excitatory Effect
Another type of pain sensation that can be experienced when
afferent interneurons are stimulated is secondary hyperalgesia
Secondary hyperalgesia/allodynia is present when there is
increased sensitivity of tissues without a local cause.
A common location for secondary hyperalgesia/allodynia is the
scalp. Patients who experience constant deep pain will commonly
report that their “hair hurts.”
local anesthetic blocking at the source may not immediately arrest
the symptoms. Instead, may linger for some time(12 to 24 hours)
after the blockade is administered
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This chapter is divided into three sections
basic neuroanatomy and function of the neuromuscular system
basic physiologic activities of mastication, swallowing, and speech
concepts and mechanisms that are necessary to understand orofacial pain
The neuron: basic structural unit. composed of a mass of protoplasm n protoplasmic processes. cell bodies located in the spinal cord are found in the gray substance. Cell bodies found outside the CNS are grouped together in ganglia. capable of transferring electrical and chemical impulses. May b afferent or efferent or interneurons
Sensory receptors r neurologic structures or organs located in all body tissues dat provide information to CNS by way of afferent neurons.
receptors in peripheral tissues such as the skin n oral mucosa r exteroceptors
receptors specific for discomfort and pain r nociceptors. located throughout the body
Proprioceptors provide information regarding the position n movement
first-order neurons (primary afferents) carry input into dorsal horn to synapse with second-order neurons.
The second-order neuron then crosses over and ascends on to higher centers.
Small interneurons connect the primary afferent neuron with primary motor (efferent) neuron, allowing reflex arc activity.
dorsal root ganglion contains the cell bodies of the primary afferent neurons
second-order neurons, these neurons carry them to the higher centers for interpretation and evaluation
numerous centers in the brainstem and brain
Through out body 1st order neuron synapse in dorsal horn but afferent fibers from face and oral cavity donot enter through spinal nerves. trigeminal nerve entering the brainstem at the level of the pons.
primary afferent neuron enters the brainstem to synapse with a second-order neuron in trigeminal spinal tract nucleus (STN of V).
spinal tract nucleus is divided into three regions; subnucleus oralis (sno), subnucleus interpolaris (sni), and subnucleus caudalis (snc).
also composed of the motor nucleus of V (MN of V) and the main sensory nucleus of V (SN of V).
cell bodies of the trigeminal nerve are located in the gasserian ganglion (GG).
Once of second-order neuron receives the input, it is carried on to the thalamus (Th) for interpretation.
The reticular formation plays an extremely important role in monitoring impulses that enter the brainstem.
Controls the overall activity of the brain by either enhancing the impulses to the brain or inhibiting the impulses
major center of the brain for controlling internal body functions, such as body temperature, hunger, and thirst
Stimulation of the hypothalamus excites the sympathetic nervous system throughout the body, increasing the overall level of activity of many internal parts of the body
basic component of the neuromuscular system which consists of a number of muscle fibers innervated by one motor neuron
Each neuron joins with the muscle fiber at a motor endplate.
When the neuron is activated, the motor endplate is stimulated to release small amounts of acetylcholine, which initiates depolarization of the muscle fibers
The number of muscle fibers innervated by one motor neuron varies greatly according to the function of the motor unit
may innervate only 2 or 3 muscle fibers, as in the ciliary muscles (which precisely control lens of the eye)
Inferior lateral pterygoid muscle has a relatively low muscle fiber– motor neuron ratio and therefore is capable of the fine adjustments in length needed to adapt to horizontal changes in the mandibular position
Masseter has greater number of motor fibers per motor neuron, which corresponds to its more gross functions of providing the force necessary during mastication
To understand effect muscles have on each other and their bony attachments, basic skeletal relationships of the head and neck must be observed.
skull is supported in position by the cervical spine. It is not centrally located or balanced over the cervical spine.
it is overbalanced to the anterior and quickly fall forward
Muscles are needed to overcome this imbalance muscles that attach the posterior aspect of the skull to the cervical spine and shoulder region must contract
Some of the muscles that serve this function are the trapezius, sternocleidomastoid, splenius capitis, and longus capitis
antagonistic group of muscles exists in the anterior region of the head: the masseter (joining the mandible to the skull), the suprahyoids (joining the mandible to the hyoid bone), and the infrahyoids (joining the hyoid bone to the sternum and clavicle).
Isotonic Contraction: occurs in the masseter when the mandible is elevated, forcing the teeth through a bolus of food
Isometric Contraction: occurs in the masseter when an object is held between the teeth
Controlled relaxation: This type of controlled relaxation is observed in the masseter when the mouth opens to accept a new bolus of food during mastication.
An example of eccentric contraction occurs with the tissue damage associated during an extension-flexion injury (whiplash injury)
muscle spindles, which are specialized receptor organs found in the muscle tissues;
Golgi tendon organs, located in the tendons;
Pacinian corpuscles, located in tendons, joints, periosteum, fascia, and subcutaneous tissues;
nociceptors, found throughout all the tissues of the masticatory system
Skeletal muscles consist of two types of muscle fibers. The first is extrafusal fiber, which is contractile and makes up the bulk of the muscle; the other is intrafusal fiber, which is only minutely contractile. A bundle of intrafusal muscle
fibers bound by a connective tissue sheath is called a muscle spindle
Two types of afferent nerves, larger fibers conduct impulses at a higher speed and have lower thresholds (central region) and end in the poles of the spindle (away from the central region) are the smaller group (II, A-beta)
Fiber stretch is monitored at the nuclear-chain and nuclear-bag regions
Afferent of muscles of mastication go to CNS trigeminal nucleus
intrafusal fibers receive efferent innervation by way of fusimotor nerve fibers, originate in the CNS; when stimulated, they cause contraction of the intrafusal fibers. When the intrafusal fibers contract, the nuclear chain and nuclear-bag areas are stretched, which is registered as if the entire muscle were stretched, and afferent activity is initiated
Thus there are two manners in which the afferent fibers of the muscle spindles can be stimulated: generalized stretching of the entire muscle (extrafusal fibers) and contraction of the intrafusal fibers by way of the gamma efferents. The muscle spindles can register only the stretch; they cannot differentiate between these two activities.
extrafusal muscle fibers receive innervation by way of the alpha efferent motor neurons, cell bodies in the trigeminal motor nucleus. Stimulation of these neurons therefore causes the group of extrafusal muscle fibers (the motor unit) to contract
Located in the muscle tendon
they are more sensitive and active in reflex regulation during normal function.
They primarily monitor tension
occur in series with the extrafusal muscle fibers
Afferent fibers enter near the middle of the organ and spread out over the extent of the fibers. Tension on the tendon stimulates the receptors in the Golgi tendon organ. Therefore contraction of the muscle also stimulates the organ
large oval organs made up of concentric lamellae of connective tissue
perception of movement and firm pressure
At the center of each corpuscle is a core containing the termination of a nerve fiber. These corpuscles are found in the tendons, joints, periosteum, tendinous insertions, fascia, and subcutaneous tissue. Pressure applied to such tissues deforms the organ and stimulates the nerve fiber
Several general types exist: some respond exclusively to noxious mechanical and thermal stimuli; others respond to a wide range of stimuli, from tactile sensations to noxious injury; still others are low-threshold receptors specific for light touch, pressure, or facial hair movement. The last type is sometimes called a mechanoreceptor.
only monosynaptic jaw reflex.
The myotatic reflex is activated by a sudden application of downward force to the chin with a small rubber hammer. This results in contraction of the elevator muscles (masseter), preventing further stretching and often causing elevation of the mandible into occlusion.
Sudden stretching of the muscle spindle increases the afferent output from the spindle. The afferent impulses pass into the brainstem by way of the trigeminal mesencephalic nucleus. There the afferent fibers synapse in the trigeminal motor nucleus with the alpha efferent motor neurons, leading directly back to the extrafusal fibers of the elevator muscle, which was stretched. The reflex information sent to the extrafusal fibers is to contract. Note the presence of the gamma efferent fibers. Stimulation of these can cause contraction of the intrafusal fibers of the spindle and thus sensitize the spindle to a sudden stretch
To prevent dislocation, the elevator muscles (and other muscles) are maintained in a mild state of contraction called muscle tonus. This property of the elevator muscles counteracts the effect of gravity on the mandible and maintains the articular surfaces of the joint in constant contact
polysynaptic reflex to noxious stimuli and is therefore considered to be protective
The nociceptive reflex is activated by unexpectedly biting on a hard object. The noxious stimulus is initiated when the tooth and periodontal ligament is stressed. Afferent nerve fibers carry the impulse to the trigeminal spinal tract nucleus. The afferent neurons stimulate both excitatory and inhibitory interneurons. The interneurons synapse with the efferent neurons in the trigeminal motor nucleus. Inhibitory interneurons synapse with efferent fibers leading to the elevator muscles. The message carried is to discontinue contraction. The excitatory interneurons synapse with the efferent neurons that innervate the jaw, depressing muscles. The message sent is to contract, which brings the teeth away from the noxious stimulus
For the mandible to be elevated by the temporal, medial pterygoid, or masseter muscles, the suprahyoid muscles must relax and lengthen.
Likewise for the mandible to be depressed, the suprahyoids must contract while the elevators relax and lengthen.
Helps in regulation of muscle activity
For the CPG to be most efficient, it must receive constant sensory input from the masticatory structures. Therefore, the tongue, lips, teeth, and periodontal ligaments are constantly feeding back information that allows the CPG to determine the most appropriate and efficient chewing stroke. Once an efficient chewing pattern that minimizes damage to any structure is found, it is learned and repeated. This learned pattern is called a muscle engram
In the absence of any significant emotional state, the action is usually predictable and accomplishes the task efficiently. However, when the individual is experiencing higher levels of emotion, such as fear, anxiety, frustration, or anger, the following major modifications of muscle activity can occur:
Mastication is defined as the act of chewing food.
It represents the initial stage of digestion, when the food is broken down into small particles for ease of swallowing
It is a functional activity that is generally automatic and practically involuntary; yet when desired, it can be readily brought under voluntary control
Mastication is made up of rhythmic and well-controlled separation and closure of the maxillary and mandibular teeth
(mandible is traced in frontal plane) complete chewing stroke has a movement pattern described as tear-shaped. It can be divided into an opening phase and a closing phase.
incisal edges of the teeth are about 16 to 18 mm apart. It then moves laterally 5 to 6 mm from the midline as the closing movement begins
closing movement has been further subdivided into crushing phase (trap food) n grinding phase (mandible is guided by the occlusal surfaces of teeth back to intercuspal position, which causes cuspal inclines of teeth to pass across each other, permitting shearing and grinding of bolus of food)
As teeth approach each other, lateral displacement is lessened, when teeth are only 3 mm apart, jaw occupies position only 3 to 4 mm lateral to starting position of the chewing stroke.
At this point the teeth are so positioned that buccal cusps of mandibular teeth are almost directly under buccal cusps of the maxillary teeth on the side to which the mandible has been shifted
In the early stages, incising of food is often necessary.
During incising, the mandible moves forward a significant distance, depending on the alignment and position of the opposing incisors
sagittal plane (working side)
During opening phase mandible moves slightly anteriorly
During the closing phase, it follows a slightly posterior pathway, ending in an anterior movement back to the maximum intercuspal position
amount of anterior movement depends on contact pattern of anterior teeth and stage of mastication
The movement of the mandibular first molar in the sagittal plane during a typical chewing stroke varies according to the side on which the person is chewing
Working side: first molar moves in a pathway similar to that of the incisor
In other words, the molar moves slightly forward during the opening phase and closes on a slightly posterior pathway, moving anteriorly during the final closure as the tooth intercuspates
The condyle on the right side also follows this pathway, closing in a slightly posterior position with a final anterior movement into intercuspation
left mandibular first molar drops almost vertically, with little anterior or posterior movement until the complete opening phase has occurred. Upon closure, the mandible moves slightly anteriorly and the tooth returns almost directly to intercuspation
The condyle on the left side also follows a pathway similar to that of the molar. There is no final anterior movement into the intercuspal position in the pathway of either the molar or the condyle
The harder the food, the more chewing strokes needed. It is interesting, that in some subjects the number of chewing strokes does not change with varying textures of food. This might suggest that for some subjects the CPG is less influenced by sensory input and more by muscle engrams.
Chewing on one side leads to unequal loading of the temporomandibular joints. Under normal conditions, this does not create any problem owing to the stabilizing effect of the superior lateral pterygoids on the discs.
In the final stages of mastication, just prior to swallowing, contact occurs during every stroke but forces to the teeth are minimal.
Two types of contacts have been identified:
gliding, which occurs as the cuspal inclines pass by each other during the opening and grinding phases of mastication, and
single, which occurs in the maximum intercuspal position
When the posterior teeth contact in undesirable lateral movement, the malocclusion produces an irregular and less repeatable chewing stroke
These slower, irregular but repeatable pathways appear to relate to the altered functional movement of the condyle around which the pain is centered
Mastication could not be performed without the aid of adjacent soft tissue structures.
As food is introduced into the mouth, the lips guide and control intake while also sealing off the oral cavity. The lips are especially necessary when liquid is being introduced.
decision to swallow depends on several factors:
the degree of fineness of the food, the intensity of thetaste extracted, and the degree of lubrication of the bolus.
During swallowing the lips are closed, sealing the oral cavity. The teeth are brought up into their maximum intercuspal position, thus stabilizing the mandible.
Stabilization of the mandible is an important part of swallowing.
The normal adult swallow utilizing the teeth for mandibular stability has been called the somatic swallow.
When teeth are not present, as in the infant, the mandible must be braced by other means.
In the infantile swallow,or visceral swallow, mandible is braced by placing tongue forward and between the dental arches or gum pads. This type of swallow occurs until the posterior teeth erupt
On occasion, the normal transition from infantile swallow to adult swallow does not occur. This may be due to:….
Over retention of infantile swallow can result in labial displacement of the anterior teeth by the powerful tongue muscle. This may present clinically as an anterior open bite
is voluntary and begins with selective parting of masticated food.
separation is performed mostly by tongue.
bolus is placed on the dorsum of the tongue and pressed lightly against the hard palate. The tip of the tongue rests on the hard palate just behind the incisors. The lips are sealed and the teeth are brought together. The presence of the bolus on the mucosa of the palate initiates a reflex wave of contraction in the tongue that presses the bolus backward. As the bolus reaches the back of the tongue, it is transferred to the pharynx.
Once the bolus has reached the pharynx, a peristaltic wave caused by contraction of the pharyngeal constrictor muscles carries it down to the esophagus. The soft palate rises to touch the posterior pharyngeal wall, sealing off the nasal passages. The epiglottis blocks the pharyngeal airway to the trachea and keeps the food in the esophagus. During this stage of swallowing, the pharyngeal muscular activity opens the pharyngeal orifices of the Eustachian tubes, which are normally closed. It is estimated that these first two stages of swallowing together last about 1 second.
The third stage of swallowing consists of passing the bolus through the length of the esophagus and into the stomach. Peristaltic waves take 6 to 7 s to carry the bolus through the esophagus.
As the bolus approaches the cardiac sphincter, the sphincter relaxes and lets it enter the stomach. In the upper section of the esophagus, the muscles are mainly voluntary and can be used to return food to the mouth when necessary for more complete mastication. In the lower section, the muscles are entirely involuntary.
Acute pain provides protection from environment challenges (the nociceptive reflex)
Some pains last far longer than normal healing time and therefore no longer have protective value termed chronic
approximately 45% of human sensory cortex is dedicated to the face, mouth, and oral structures This degree of sensory dedication suggests that these structures have significant meaning to the individual.
degree of pain and suffering does not correlate well with the amount of tissue damage. Instead, the degree of pain relates more closely to the patient’s perceived threat of the injury and amount of attention given to the injury
Pain modulation means that impulses arising from a noxious stimulus, which are primarily carried by afferent neurons from the nociceptors, can be altered before they reach the cortex for recognition
Transcutaneous electrical nerve stimulation (TENS) is an example of the non painful cutaneous stimulation system masking a painful sensation
pain-modulation system can be evoked by the stimulation of areas of the body that have high concentrations of nociceptors and low electrical impedance
The first is central pain. When a tumor or other disturbance is present in the CNS, the pain is often felt not in the CNS but in peripheral structures
projected pain: neurologic disturbances cause painful sensations to shoot down the peripheral distributions of the same nerve root that is involved in the disturbance
referred pain. sensations are felt not in the involved nerve but in other branches of that nerve or even in an entirely different nerve
Diagnostic blocking of the painful areas can be extremely valuable in providing information that can help to differentiate the site of pain from the source of pain.