an overview of muscle pain disorder which regularly create some discomfort for patient to live a normal life as well as to the doctor regarding diagnosis of the problem.
One of the most painful but easy-to-treat dental emergencies is a dry socket.
• Dry socket symptoms are experienced after a tooth extraction.
• This condition requires follow-up care by the doctor who performed the surgery, an oral surgeon or a dentist who is familiar with how to treat it.
For more information, contact :-
Dr Sachdeva's Dental Aesthetic And Implant Institute,
I 101, Ashok Vihar Phase 1, Delhi- 110052
Contact us at
• Phone : +919818894041,01142464041
• Our Websites:
• www.sachdevadentalcare.com
• www.dentalclinicindelhi.com
• www.dentalimplantindia.co.in
• www.dentalcoursesdelhi.com
• www.facialaestheticsdelhi.com
#drysocket #management #thirdmolarextraction #extractioncomplications
One of the most painful but easy-to-treat dental emergencies is a dry socket.
• Dry socket symptoms are experienced after a tooth extraction.
• This condition requires follow-up care by the doctor who performed the surgery, an oral surgeon or a dentist who is familiar with how to treat it.
For more information, contact :-
Dr Sachdeva's Dental Aesthetic And Implant Institute,
I 101, Ashok Vihar Phase 1, Delhi- 110052
Contact us at
• Phone : +919818894041,01142464041
• Our Websites:
• www.sachdevadentalcare.com
• www.dentalclinicindelhi.com
• www.dentalimplantindia.co.in
• www.dentalcoursesdelhi.com
• www.facialaestheticsdelhi.com
#drysocket #management #thirdmolarextraction #extractioncomplications
TMJ is a ginglymo-diarthroidal joint that is freely mobile with superior and inferior joint spaces separated by articular disc.
The type of imaging technique depends upon the clinical problems associated, so either imaging of hard tissue (OSSEOUS) or soft tissue is desired.
Certain protocols are to be taken care before the imaging procedure:
the amount of diagnostic information available from particular imaging modality.
The cost of examination
The radiation dose
Odontogenic keratocyst (OKC) is the cyst arising from the cell rests of dental lamina. It can occur anywhere in the jaw, but commonly seen in the posterior part of the mandible. Radiographically, most OKCs are unilocular when presented at the periapex and can be mistaken for radicular or lateral periodontal cyst.
In this presentation, it describes about the periapical diseases, for dental students.
very useful for endodontic purpose.
remember it does not include the pulpal diseases.
INTRODUCTION
DEFINITION
TYPES OF TRAUMA FROM OCCLUSION
GLICKMAN CONCEPT
WAERHAUG CONCEPT
STAGES OF TISSUE RESPONSE TO INJURY
CLINICAL AND RADIOGRAPHIC FEATURES OF TFO
CLINICAL DIAGNOSIS OF TFO
TFO AND IMPLANTS
TREATMENT OF TFO
CONCLUSION
REFRENCES
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.
TMJ is a ginglymo-diarthroidal joint that is freely mobile with superior and inferior joint spaces separated by articular disc.
The type of imaging technique depends upon the clinical problems associated, so either imaging of hard tissue (OSSEOUS) or soft tissue is desired.
Certain protocols are to be taken care before the imaging procedure:
the amount of diagnostic information available from particular imaging modality.
The cost of examination
The radiation dose
Odontogenic keratocyst (OKC) is the cyst arising from the cell rests of dental lamina. It can occur anywhere in the jaw, but commonly seen in the posterior part of the mandible. Radiographically, most OKCs are unilocular when presented at the periapex and can be mistaken for radicular or lateral periodontal cyst.
In this presentation, it describes about the periapical diseases, for dental students.
very useful for endodontic purpose.
remember it does not include the pulpal diseases.
INTRODUCTION
DEFINITION
TYPES OF TRAUMA FROM OCCLUSION
GLICKMAN CONCEPT
WAERHAUG CONCEPT
STAGES OF TISSUE RESPONSE TO INJURY
CLINICAL AND RADIOGRAPHIC FEATURES OF TFO
CLINICAL DIAGNOSIS OF TFO
TFO AND IMPLANTS
TREATMENT OF TFO
CONCLUSION
REFRENCES
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.
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.
satoshi kajiyama laudner presentation athletic training manual therapy kinesiology myofacial release and trigger point therapy illinois state university boston red sox orthopedic and sports enhancement center
A valuable presentation on myofasical release and muscle energy techniques for sport's and massage therapist's. This presentation is from our workshop event at the St John Street clinic on the 27th February 2016.
Physiology of Pain, Characteristic of pain, Basic consideration of nervous system, Pain receptor, Mechanism of pain causation, Theories of pain, Pathways of pain, Pain Receptors
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.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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!
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.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
3. Introduction
It is a muscular pain disorder – most common diagnosis causing
chronic pain but one of the most least understood.
Complex symptomatology, concomitant disorders and frequent
behavioral & psychosocial contributing factors make the disorder
difficult to recognize
As the name suggest it has three part
Myofascial – muscular & connective tissue origin
Pain – an unpleasant sensational & emotional experience
Dysfunction – deviated from normal function
Syndrome – collection of various symptoms
4. History
Costen – 1934 – indicate TMJ pain due to occlusal etiology
Schwartz – 1956 – coined term TMJ pain dysfunction syndrome – blamed the
spasm of masticatory and perimasticatory musculature.
Laskin – 1969 – termed as MYOFASCIAL PAIN DYSFUNTION SYNDROME –
implicated Psychophysiological theory for such incident.
5. Definition
A pain disorder, in which unilateral pain is reffered from the trigger points
in myofascial structures, to the muscles of the head and neck. Pain is
constant, dull in nature, in contrast to the sudden sharp, shooting,
intermittent pain of neuralgias.
Pain may range from mild to intolerable
6. Prevalence
Common persistent pain in head & neck region
50% of chronic head & neck pain
20-50% of people has this type of pain
7. Types of myofascial pain
disorder
6 distinct group
Myositis
Muscle spasm
Myofascial pain dysfunction (Trigger Point Pain)
Fibromyalgia
Muscle contracture
Muscle pain secondary to connective tissue disorder
8. Functional Neuroanatomy and Physiology of the
Masticatory System
Two major components:
(1) neurologic structures
(2) muscles.
9. MUSCULAR COMPONENT
MOTOR UNIT
consists of a number of muscle fibers that are innervated by one motor neuron.
Each neuron joins with the muscle fiber at a motor endplate.
Depolarization causes the muscle fibers to shorten or contract.
fewer the muscle fibers per motor neuron, the more precise the movement.
MUSCLE
Hundreds to thousands of motor units along with blood vessels and nerves are
bundled together by connective tissue and fascia to make up a muscle.
Muscles are necessary to overcome this weight and mass imbalance.
MUSCLE FUNCTION
3 potential functions
isotonic contraction
Isometric contraction
Controlled relaxation
eccentric contraction
lengthening of a muscle at the same time that it is contracting
12. Precise and complex balance of the head and neck muscles must exist to maintain
proper head position and function. A, Muscle system. B, Each of the major muscles acts
like an elastic band. The tension provided must precisely contribute to the balance that
maintains the desired head position. If one elastic band breaks, the balance of the entire
system is disrupted and the head position altered.
14. Neuromuscular Function
Function of the Sensory Receptors
Reflex Action
Reciprocal Innervation
Regulation of Muscle Activity
Influence from the Higher Centers
18. Pain modulation in trigeminal nerve
The degree of suffering 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 the impulses arising from a noxious stimulus, which
are primarily carried by the afferent neurons from the nociceptors, can be altered
before they reach the cortex for recognition.
This alteration or modulation of sensory input can occur while the primary neuron
synapses with the interneuron when it initially enters the CNS or while the input
ascends to the brainstem and cortex.
it is important to distinguish the differences among four terms:
nociception, pain, suffering, and pain behavior
19. Mechanism of pain modulation
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 mask the input to the CNS of the
smaller ones
The descending inhibitory system assists the
brainstem in actively suppressing input to the
cortex.
In order for an individual to sleep, the brainstem and
descending inhibitory system must completely
inhibit sensory input (e.g., sound, sight, touch) to
the cortex. Without a well-functioning descending
inhibitory system, sleep would be impossible.
Transcutaneous electrical nerve stimulation (TENS)
is an example of the nonpainful cutaneous
stimulation system masking a painful sensation.
Constant subthreshold impulses in larger nerves
near the site of an injury or other lesion block the
smaller nerves’ input, preventing painful stimuli
from reaching the brain.
20. Intermittent painful stimulation system
the stimulation of areas of the body that have high concentrations of
nociceptors and low electrical impedance. Stimulation of these areas may
reduce pain felt at a distant site.
Two basic types of endorphins have been identified:
(1) the enkephalins and (2) the betaendorphins.
This is the basis for acupuncture:
A needle placed in a specific area of the body having high concentrations of
nociceptors and low electrical impedance is twisted approximately two times a second
to create intermittent low levels of pain.
The stimulation causes the release of certain enkephalins in the cerebrospinal fluid,
and this reduces the pain felt in tissues innervated by that area.
Runner’s High – by Beta-endorphin
Psychologic modulating system
conditions that seem to intensify the pain experience are anxiety, fear,
depression, and despair.
Certainly the amount of attention drawn to an injury, as well as the
consequence of the injury, can greatly influence suffering.
21. CENTRAL EXCITATORY EFFECT
First explanation suggests that if the 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, neurotransmitter substance can spill over
to an adjacent interneuron, causing it also to
become excited.
second explanation of the central excitatory
effect is that of convergence. 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.
22. ETIOLOGY OF MPDS
TISSUE INJURY
Major trauma
Exposure to extreme temperature
PHYSICAL STRESSES
Extreme fatigue
Repetitive micro trauma (Clenching & Bruxism)
Other disease processes
23. Psychological factors
- Pipe smoking
- Sleeping on stomach with mandible supported by forearm.
- Teeth clenching or grinding
- Jaw thrusting, tip sucking, tongue thrusting.
- Nail, pen / pencil biting
- Constant chewing of tobacco or gum
Occlusal factor
Developmental occlusal disharmony
Acquired occlusal disharmony
Iatrogenic occlusal disharmony
24. THEORIES OF MPDS
Neurophysiological hypothesis
Repetitive strain theory
Central hypothesis
Central biasing mechanism
26. PATHOPHYSIOLOGY OF MUSCLE PAIN
Muscular shortening
(Calcium excess shortening)
Prolonged sustained and muscular contraction
Disruption of delicate sarcoplasmic reticulum
Release of free calcium ions that are stored within SR
Act on sarcomeres containing
actin-myosin complex
27. Shortened muscles experience increase in metabolic
demands due to more actin and myosin
Depletion of ATP
(Muscular fatigue)
Actin myosin binding intensified
(ATP depletion shortening)
Mechanical interruption of blood flow through
this area of biochemical derangement
Vasoconstriction decrease of oxygen in the affected
muscular fibres (shift to anaerobic metabolism)
28. Anaerobic metabolism causes propagation of decreased
pH & accumulation of Nocigenic and Spasmogenic
by-products called the “BIOGENIC AMINES” like serotonin,
histamines, kinins & prostaglandins
Activation of group III and group IV
muscle nociceptive fibres
PAIN
Pain and further exaggerated central response (reflex
response phenomenon) creates increased accumulation of
biogenic amines & intensified vasoconstriction
Local twitch response & jump signs of myofascial trigger
points
29. CLINICAL FEATURES
Trigger point are present
Presence of zone of reference
Generally present at the end of tiresome day
Limitation of motion of the jaw
Chronic, focal or regional muscle Pain as discomfort (unexplained nature)
Continuous, dull to sharp ache in region of TMJ, preauricular or post auricular
areas and at the angle of mandible
Joint noises – grating, clicking, snapping etc.
Tenderness to palpation of the muscles of mastication.
31. TRIGGER POINTS
Manifestations of abnormal muscles spindles
Nodes of degenerated tissues
Hyperirritable, localized point of tenderness in muscles
**Stimulation of trigger points produces local and referred pain
**Pathophysiology unknown although many theories proposed
32. MUSCLES INVOLVED REFERRED PAIN
1. Masseter
2. Temporalis
3. Medial pterygoid
4. Lateral pterygoid
5.Sternocleidomastoid
Preauricular, post auricular
region and mandibular body
Side of the head, masseter
origin, orbit maxillary teeth
Retromandibular region
Ear and TMJ
Ear, mastoid and anterior
cervical region
33. TEETH source
1. MAXILLARY INCISORS
2. MAXILLARY CANINES
3. MAXILLARY
PREMOLARS
4. MAXILLARY MOLARS &
MANDIBULAR MOLARS
ANTERIOR TEMPORAL MUSCLE
ANTERIOR TEMPORAL MUSCLE
INTERMEDIATE TEMPORAL
MUSCLE,SUPERFICIAL MASSETER
MUSCLE,
POSTERIOR TEMPORAL MUSCLE,
TRAPEZIUS MUSCLE AND
STERNO-CLEIDOMASTOID
MUSCLE
MUSCULAR SOURCES OF REFERRED PAIN TO THE TEETH
34. PAIN REFERENCE POINTS FOR MASSETER
MUSCLES (TRIGGER POINTS)
SUPERFICIAL LAYER MIDDLE LAYER
LOWER DEEP
41. KEYS IN MAKING A DIFFERENTIAL
DIAGNOSIS
History
Examination
Mandibular restriction
Mandibular interference
Acute malocclusion
Loading of the joint
Functional manipulation
Diagnostic anesthetic blockade
Diagnostic imaging & Investigations
42. GENERAL HISTORY: which includes medical, surgical, psychological,
occupational and social background
SPECIFIC HISTORY: related to present complaint i.e. onset and type of
pain, aggrevating and relieving, severity of symptoms, associated
symptoms and medicines taken for the problem.
HISTORY TAKING
44. EYE EXAMINATION
Testing gross vision
Diplopia or blurriness of vision is noted
Reddening of the conjunctivae should be recorded
Any tearing or swelling of the eyelids
EAR EXAMINATION:
46. MUSCLE EXAMINTION
Location of muscle pathology
Evaluation of muscle tone
Location of trigger point
Evaluation of temperature change
Location of swelling
Muscles are palpated bilaterally and simultaneously with firm but gentle pressure for 1-2min. Main
pressure is exerted with the middle finger of each hand
During palpation subjective pain should be noted.
Patient is asked question regarding unilateral / bilateral pain, tenderness is mild / moderate or severe.
Reference zone of the pain should be noted
55. Dental / occlusal examination
Occlusal discrepancies, prematurities, or interference should be noted.
Anterior open bite, collapsed bite, cross bite, reduced vertical dimensions,
wear facets, mobility of teeth missing and teeth should be checked.
Type of occlusion, skeletal, dentofacial should be checked
56. Examination of Articular joint
JOINT SOUND
either clicks or crepitation
click is a sound of short duration. If it is relatively loud, it
is sometimes referred to as a “POP”
Crepitation is a multiple gravel-like sound described as
grating
JOINT RESTRICTION
The dynamic movements of the mandible are observed
for any irregularities or restrictions.
57. Diagnostic Blocking
INDICATIONS:
It is essential when differentiating primary from secondary pains
useful to identify the pathways that mediate peripheral pain and to localize pain sources
when the source of pain is difficult to identify, local anesthetic blocking of related tissues is the key to
making the proper diagnosis
educate the patient to the source of his or her pain problem
GENERAL RULE
purpose of an injection is to isolate the particular structure that is to be blocked
clinician should have a sound knowledge of the pharmacology of all solutions that will be used
clinician should avoid injecting into inflamed or diseased tissues
clinician should maintain strict asepsis at all times.
TYPES
Muscle block
Nerve block
Intra capsular
62. Other Investigations
Electromyogram
Sonography
Sonography is the technique of recording and
graphically demonstrating joint sounds.
Many healthy joints can produce sounds during
certain movements
Presently sonography does not provide the clinician
with any additional diagnostic information over
manual palpation or stethoscopic evaluation.
Vibration analysis
Vibration analysis has been suggested to help in
diagnosing intracapsular TMD, and internal
derangements in particular
Measures the minute vibrations made by the condyle
as it translates and has been shown to be reliable.
the technique diagnoses up to 25% of normal joints
as derangements and misclassifies many deranged
joints as normal, especially if the joint sounds are not
audible or if the derangement has advanced to a
nonreducing stage
63. Thermography
Thermography is a technique that records and graphically
illustrates surface skin temperatures.
Various temperatures are recorded by different colors,
producing a map that depicts the surface being studied.
Recent studies shows Infrared imaging measurements can
provide a useful, non-invasive and nonionizing examination for
diagnosis of MTPs in masticatory muscles.
Mandibular tracking device
If a jaw-tracking device is used, the exact movement of the
mandible can be recorded
Unfortunately, many intracapsular and extracapsular disorders
create deviations and deflections in mandibular movement
pathways.
A particular deviation may not be specific for a particular
disorder, this information should only be used in conjunction
with history and examination findings.
67. Heat application
Superficial:
Hot packs, paraffin and radiants (Infra Red) Hot
moist application of towels for 15-20 min for 4
times.
Hydrocollator:
pad filled with clay and heated in water both for
70°-80°, wrapped in a protected towel and placed
over the affected area for 15-20 mins
Deep Heat application:
delivered by diathermy, ultrasound or
phonophorosis
DIATHERMY
ULTRASOUND
PHONOPHORESIS
68. DIATHERMY
Short Wave Diathermy
In chronic conditions, there will be increase in blood flow.
Increase in oxygenation on application for 10 mins
Mega Pulse
Rest period between pulse raise allows dissipation of heat by
blood flow.
Time of application – 10 mins
60 micro second pulse
100 pulse / sec.
Regime: 3 times / week for 4 weeks
69. Ultrasound:
Heat is placed on the skin which has to be coated with an acoustic coupling gel
and moved in parallel or circular over lapping sweeps 0.7 to 1 volts / cm2 for 10
mins.
Regime: 3 times / week for 4 weeks.
Uses:
Altered cell membrane permeability
Intracellular fluid absorption.
Decreased collagen viscosity.
Vasodilation
Relax muscles and analgesia.
Phonophorosis:
Application of ultrasound instead of acoustic coupling gel. It uses a pad filled with an anesthetic
or steroid cream is placed over the treatment kit
70. LASER THERAPY
Cold laser therapy
cold or soft laser has been investigated for wound healing and pain relief
A cold laser is thought to accelerate collagen synthesis, increase vascularity of
healing tissues, decrease the number of microorganisms, and decrease pain.
increases capillary permeability
Time of application: 3min
Output: 4 joules / cm2
71. Cryotherapy / Cold therapy :
Ice packs application to the painful area 4 times a day for 20
min.
Ice should not be placed over skin not more than 5 to 7 min
It lowers thermal gradient in skin, interrupting massive
concentration of Histamines, thus lowering pain threshold in the
skin.
Acupuncture:
It is based on a complex relationship between energy through
channels or natural elements (wood, earth and water) and
positive and negative elements.
Energy flow is done merely by placing a needle into a specific
site and adding either electric or heat to the needle.
It has minimal effect on reducing pain therefore not
recommended as primary therapy. Its used as an alternative
therapy.
72. Use of vasocoolent sprays:
Cold encourages the relaxation of muscles that are
in spasm and thus relieves the associated pain.
Most commonly used – ethyle chloride and
fluromethen
Fluromethane or ethylchloride spray is applied to
painful area for 5 min. Muscles are then gently
stretched after that.
Electrogalvanic stimulations:
Delivers a wide range of intensity to activate the
injured muscles.
It stimulate local circulation, achieves excitability and
conductivity without painful heating.
Pulse at 80 cycles / sec for 10 min followed by
excessive for 5 min.
73. TENS (Transcutaneous Electrical Nerve
Stimulation)
Produced by a continuous stimulation of cutaneous
nerve fibers at a sub-painful level
When a TENS unit is placed over the tissues of a
painful area, the electrical activity decreases pain
perception
TENS uses a low-voltage, low-amperage, biphasic
current of varied frequency and is designed primarily
for sensory counter-stimulation in painful disorders.
It stimulate local circulation, achieves excitability and
conductivity without painful heating.
Pulse at 80 cycles / sec for 10 min followed by
excessive for 5 min.
74. PENS (Percutaneous Electrical
Nerve Stimulation)
A new therapy for chronic pain sufferers that uses a low voltage
electrical current delivered to the subcutaneous tissue or peripheral
nerves to relieve chronic refractory neuropathic pain
It is a form of neurostimulation or neuromodultation that damping
down overactive (sensitized) nerves that are causing pain
Does not destroy any nerves. It just makes them less sensitive to
pain. A low voltage electrical current is delivered via a specially
designed needle to a layer of tissue just below the surface of the
skin close to the specific nerve, or to the nerve endings situated in
an area that is painful
Some patients will have total pain relief, others experience
prolonged pain relief for 3 months or more and others get relief for
shorter periods of time
76. PHARMACOTHERAPY
Anti inflammatory drugs:
NSAIDS: Reduces inflammation and provide pain relief both in the muscles and joints
for 14-21 days.
Aspirin 2 tab 0.3 to 0.6gm / 4th hourly
Piroxican 10-20 mg / 3-4 times /day
Ibiprofen 200-600mg / 3-4 times / day
Opoids: Pertazacine 50mg / 2-3 times /day.
Muscle relaxants:
It is used for short duration as they produce addiction.
Meprobamate 400mg TDS for 1 days.
Vallium 5-10mg 2-3 times /day.
It can be used as centrally acting eg Datrium, Succinyl colin, cusara, baclofin, and
peripherally acting.
77. ANTI ANXIETY MEDICATION:
Propylalcohol derivatives – Meprobamate 1200-1600 mg / day is divided doses.
Diphexyl methansis – Antilistamines are used in patients where benzyl diazapines are
contra indicated.
BENZODIAZEPIENES:
Alprazalam – 0.5mg 1-3 times / day
Diazepam – 2-5mg 1-4 times / day for 10 days
ANTI DEPRESSANT:
Amitriptyline 10-25 mg/day for 3 times
Fluoxitin 5mg / day
LOCAL ANAESTHETICS:
Procaine – 0.5%
Lidocain – 1%, 2%
Ethyl chloride spray or i.m.
Local anaesthetic at affected part give relief.
78. PCA (Patient Controlled
Analgesia) for MPDS
It is an effective method for administrating opiates to patient
for pain relief.
It gives patients a sense of control over pain
79. USE OF BOTOX
Botulinum toxin injections are currently the mainstay of treatment for
most focal dystonias.
Neurotoxin botulinum toxin A, when injected into a muscle, causes a
presynaptic blockade of the release of acetylcholine at the motor end
plates.
End result is a muscle that can no longer contract (paralysis).
Normally takes 1 to 2 weeks for the effect to be clinically noticeable.
Normally, activity of the motor end plate is totally restored in 3 to 4
months
Approximately 25 U of botulinum toxin A is normally appropriate for
each of these muscles.
The greatest number of motor end plates is found in the midbody of the
muscle (halfway between the insertion and origin).
80. OCCLUSAL SPLINT
Purpose:
To create a balance joint tooth stabilization the mandible.
To reduce spasm, contracture and hyperactivity of musculature.
To restore vertical dimension
Types:
Stabilization splint
Relaxation splint
81. Stabilization Splint
12-18 hrs / 4-6 months
Fabricated over the maxillary teeth covering occlusal and incisal surface made up of acrylic
A flat platform perpendicular to mandibular incisors so the splint will disengage the teeth and
release the muscles
If patient doesn’t have relief at the end of 3 month re-evaluation should be done.
Splint reduces the load on the retrodistal area and therapy relieve pain.
Pre fabricated rediant splint are also available.
82. Relaxation splint
It is used for disengagement of teeth and for only short period (upto 4 wks)
They are fabricated over the maxillary incisor teeth
A platform is added to disengage mandibular anterior
83. Differential diagnosis
Type Cause History C/F Treatment
Muscle splinting 1. Altered sensory input
2. Constant deep pain
3. Increased stress
1. Recent alteration in
local structure
2. Source of deep pain
3. Recent increase in
emotional stress
1. Decrease ROM
2. But may achieve
normal ROM on
request
3. No pain at rest
4. Pain with function
5. Muscle weakness
1. Correction of local
causes
2. Removal of source of
deep pain
3. Psychological
regulation
4. Soft diet
5. Analgesic
Local muscle
soreness
1. h/o previous muscle splinting
2. Local tissue trauma
3. Emotional stress
1. Pain begun after
several hr/day of an
event
2. Pain started by-
injection, long
standing mouth
opening
3. Increased emotional
stress
1. Decrease ROM &
velocity but normal
range not achieve on
request
2. Minimum pain at rest
3. Pain increase with
function
4. Muscle fatigue
1. Elimination of
constant deep sensory
input
2. Patient motivation and
emotional stress
management
3. Supportive therapy to
control algesia
4. Stabilization
appliance
Myospasm 1. Continue deep pain
2. Local metabolic factors
within muscle tissues
3. Idiopathic myospasm
mechanism
1. Sudden onset of
restricted jaw
movement
1. Marked restriction of
jaw movement
2. Acute malocclusion
3. Pain at rest
4. Pain increase with
function
5. Affected muscle firm
and painful
6. Generalized muscle
tightness
1. Passive lightening/
stretching by manual
massage
2. 2% lidocaine without
vasopressor to stop
persistent spasm
3. Muscle rest
4. Reestablishment of
electrolyte balance
84. Type Cause History C/F Treatment
Myofascial pain 1. Continue deep pain
2. Increased emotional stress
3. Sleep disturbance
4. Local factors – habit, posture,
muscle strain, chilling
5. Systemic factors – nutritional
imbalance, fatigue, viral
infection
6. Idiopathic trigger point
1. c/o heterotropic pain
2. c/o headache or
muscle splinting
1. Slight decrease in
velocity and range of
motion of jaw
2. Presence of trigger
point
3. Presence of reference
zone
4. Heterotropic pain at
rest
5. Pain increase with
function
6. On provocation pain at
refer zone
1. Eleminate source of
deep pain
2. Soft diet
3. Life style modification
4. Analgesic, antianxyti,
muscle relaxant
5. Spray and stretch
6. Massage
7. Injection/ theraputic
blocking
Chronic myositis 1. Mediated by CNS not by
masticatory system
2. While CNS exposed to
prolonged pain – brain
pathway of pain deranged –
antidromic effect of afferent
nerve
1. Constant, primary,
myogenous pain
2. Associated with
prolonged history of
muscle complain
1. Significant decrease in
velocity and range of
movement
2. Significant pain at rest
3. Pain increase with rest
4. Generalized muscle
tightness
5. Significant pain on
muscle palpation
6. May induce muscle
atrophy
1. Restricted muscle use
2. Soft diet
3. Slower chewing and
smaller bite
4. Avoid exercise or
injection – may
increase pain – due to
neurogenic
inflammation
5. Disengage the teeth by
relaxation splint
6. Prescribe NSAIDs
Fibromyalgia 1. Still not cleared
2. Alteration in musculoskeletal
input by CNS
1. Chronic & generalized
musculoskeletal pain
in ¾ quadrant of body
since 3 month or more
2. Presence of sleep
disturbances
3. Clinical depression
1. Generalized
myogenous pain
2. Decreased ROM
3. Presence of numerous
myofascial trigger
point
4. Generalized muscle
fatigue & weakness
1. Definitive therapy to
treat underling causes
2. NSAIDs helpful to
some extent
3. If sleep problem –
antidepressant can be
given
Editor's Notes
MASSAGE THERAPY. When muscle pain is the major complaint, massage can be helpful. The patient is encouraged to apply gentle massage to the painful
areas regularly throughout the day. This can stimulate cutaneous sensory nerves to exert an inhibitory influence on the pain. If it increases the pain, it should be stopped.
JOINT DISTRACTION OF THE TEMPOROMANDIBULAR JOINT. This can be accomplished by placing the thumb in the patient’s mouth over the mandibular second molar area on the side to be distracted. While the cranium is stabilized with the other hand, the thumb exerts downward force on the molar
PASSIVE EXERCISES. Patients with dysfunctional jaw movements can often be trained to avoid these movements by simply watching themselves in a mirror. The patient is encouraged to open on a straight opening pathway. In many instances, if this can be accomplished following a more rotational path with less translation, disc derangement disorders will be avoided.