Post on 25-Jan-2020
transcript
20/01/2014
1
Ambra Michelotti
michelot@unina.it
University of Naples Federico II
Limiting your risk when
treating patients with TMD
American Association of OrthodontistsTMD diagnosis
Condylar position and TMD risk
Occlusal interference and TMD risk
Red Flags and TMD risk
Outline
Temporomandibular disorders (TMDs) encompass a group of
musculoskeletal and neuromuscular conditions that involve thetemporomandibular joints (TMJs), the masticatory muscles and all
associated tissues.
The signs and symptoms associated with these disorders are diverse, and
may include difficulties with chewing, speaking and other orofacial
functions.
They also are frequently associated with acute or persistent pain, and the
patients often suffer from other painful disorders (comorbidities).
The chronic forms of TMD pain may lead to absence from or impairment
of work or social interactions, resulting in an overall reduction in thequality of life.
AMERICAN ASSOCIATION FOR DENTAL RESEARCH TMD POLICY STATEMENT REVISION, MARCH 3, 2010
Temporomandibular Disorders
TMD
Modified by Diatchenko et al, 2006
Modified by Benoliel et al, 2011
Environment
Occlusion
Orthodontics
Na+, K+-
ATPase
Serotonin
transporter
BDNF
12q11.2
Cannabinoid
receptorsMAO
11q23
Adrenergic
receptorsNMDA POMC
COMT
Interleukins
5q31-32 22q11.21
Opioid
receptors ProdynorphinDREAM NGF
IKKNET
CREB1
Serotonin
receptor GR
Dopamine
receptors
GAD65 CACNA1A
6q24-q25 1p13.1 5q31-q32 9q34.3 Xp11.23
Fatigue, stiffness or pain of the jaw muscles
Jaw movementsimpairment
TMJ
Pain Sounds
Click Crepitus
Deviation Deflection
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Main complaints
Preauricular pain, right and left TMJs clicking sounds,
headache, malocclusion, missing posterior teeth
XX
Sharp pain, at the left and right
preauricular regions; during clicksound, during chewing and opening
movements
Headache
- localization: temporal region, bilaterally
- frequency: often (2-3 times/week)
- intensity: moderate-high (5-7 VAS)
- decreases with rest and increases with jaw
movements
X
X
X
X
Vertical range of motionUnassisted opening
without pain41 mm
Maximum assisted
opening49 mm
Maximum unassisted
opening46 mm
Vertical incisor overlap
3 mm
FAMILIAR PAINFAMILIAR PAIN
Jaw excursionsRight lateral
Excursion5 mm
Left lateral
excursion2 mm
Protrusion
3 mm
FAMILIAR PAINFAMILIAR PAIN
FAMILIAR HEADACHEFAMILIAR HEADACHE
FAMILIAR PAINFAMILIAR PAIN
Joint Palpation
Joint SoundsRight joint Left joint
LR LL P C O O C P LL LR
Click
Crepitus
X X X X X X X X
Click sound at right and left TMJs during chewing,
opening, closing and lateral movements
FAMILIAR PAINFAMILIAR PAIN
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Not necessary
TMD diagnosis
Condylar position and TMD risk
Occlusal interference and TMD risk
Red Flags and TMD risk
Outline
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11 cases in which disturbance of mandibular joint
function was considered the chief etiologic factor of abnormal ear and head conditions
Left
Reduction of posterior vertical dimension
Ronald H. RothSan Mateo, California
The condyles should be seated superior and anterior in thefossae against the articular disks and the distal slope of thearticular eminence, and centered transversely.
Angle Orthod. 1973
7 patients
2 controls
The centricity of the condyles in the glenoid fossa involves a range, and eccentricity does
not necessarily indicate TMD. Therefore, the analysis of articulated casts will not be
diagnostic of TMD per se.
Mounting dental casts on an articulator helps in measuring the centric relation-centricocclusion discrepancy in 3 planes of space. This is important information when the goal is
to treat to a musculoskeletal stable position.Objective: to evaluate the reliability and validity of 3 bite registrations in relation tocondylar position in the glenoid fossae using magnetic resonance imaging in a
symptom-free population.
(Am J Orthod Dentofacial Orthop 2013;144:512-7)
Centric Occlusion Centric RelationRoth Power Centric
Relation
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• The differences between the 3 bite positions were small and, more
importantly, highly variable.
• Variability in the findings between the bite registrations appear to reflect
the lack of accuracy and predictability.
• Based on the findings that we are not positioning the condyles in specific
positions in the fossae with various bite registrations, the clinicalsignificance followed by the routine practice of condylar positioning
must be questioned.
No association between condylar position
and signs and symptoms of TMD was found
OOOO, 2009
Interestingly…
normal joints
normal joints
Angle Orthod, 2010
Pu
llin
ge
rA
, JO
R 2
01
3
Great overlap
Wide distribution
Condyle position per se is not diagnostic and
would fail any useful prediction values
CONCLUSION…
Left
Deep bite / Class II 2
Mandibular dysfunction and incisor relationship. A theoretical explanation for the clicking joint. Berry DC, Waltkinson AC Br Dent J, 1978
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The extraction – non extraction dilemma as it relates to TMDRP McLaughlin, JC Bennett. Angle Orthod, 1995
Excessive anterior interferences resulting in possible posterior
condyle displacement are the result of treatment mechanics
…however
There is no evidence that asymptomatic TM
joints with posterior positioned condyles are
at risk for disc displacement derangements.
CONCLUSION
There is no evidence that centric condylar
position means “healthy” TM joint.
There is no evidence that centric condylar
position limits risk when treating patients with
TMD.
TMD diagnosis
Condylar position and TMD risk
Occlusal interference and TMD risk
Red Flags and TMD risk
Outline
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Long term mechanisticnociception is related not onlyto peripheral sensitization ofnociceptive neurons but alsoto central sensitization
Xie
et a
l, J
OR
20
13
In animal models, artificial occlusal alterations can result in disorders
or damage of TMJs, masticatory muscles, and the nervous system.
However…
Results from animal studies cannot be
directly extrapolated to humans
Xie
et a
l, J
OR
20
13
10 % MVC
Gallo LM, Palla S. J Oral Rehabil 1995; 22: 455-462
Decrease of contractionintensity
Decrease in number of activity periods
No changes in PPT
None of the subjects developed signs
and symptoms of TMD
…however sometimes
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Artificial interferences seem to play a different role in responses in subjects with an earlier TMD history
compared to those without
Differentadaptation
…why? Effects of occlusal interference in patients with muscle pain
Michelotti et al., in preparation
No differences in number of activityperiods during active interference
Different adaptation to occlusal changes 0
10
20
30
40
50
60
70
80
90
IFCbefore DIC AIC IFCafter
N/h
r
Session
CTR
TMD
0
1
2
3
4
5
6
IFCbefore DIC AIC IFCafter
Du
r (s
)
Session
CTR
TMD
0
5
10
15
20
25
IFCbefore DIC AIC IFCafter
A m
ean
(%
MV
C)
Session
CTR
TMD
**
TMD subjects showed
higher number of events with higher
intensity compared to
healthy subjects
Avignon Palais de PopesHans Christian Andersen
The Princess and the
Pea
250 subjects filled the
Oral Behavior Checklist (OBC)
10 without
parafunctions (nPAR)
10 with
parafunctions (PAR)
80%
10th 90th
(6 f,4 m; mean age ± SD
22.3±1.8)
(9 f,1 m; mean age ±SD 20.4±1.17)
Oral Behaviour Checklist
Dental prostheses
Orthodontic treatment
One or more missing teeth with the exception of third molars
Neurological disorders
Assumptions of drugs affecting the Central Nervous System.
Exclusion criteria
Markiewicz et al, 2006
Aim
Michelotti et al. JOP 2012
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- occlusal discomfort- spontaneous pain
- headache
Visual Analogue Scale (VAS)
☺ �
p<0.01
State Anxiety Trait Anxiety
Higher values of trait anxiety in Parafunctional subjects
During AIC occlusal discomfort, headacheand spontaneous pain were higher in
Parafunctional Subjects
Perceived the occlusal
interference as cause of discomfort
They did not report pain
or signs of dysfunctions
Perceived the occlusal
interference as cause of high discomfort
High trait anxiety
individualsLow trait anxiety
individuals
They reported pain or
signs of dysfunctions
Conclusion
Michelotti and Iodice, JOR 2010
Take Home Message
Occlus
alchange
yAdaptabilit
ytolerance
Physiological
tolerance
Occlusalhypovigilance
Occlusalhypervigilanc
e
Occlusalhypervigilanc
e
Somatosensoryamplification
Somatosensoryamplification
Increased parafunctiona
l activities
Increased parafunctiona
l activities
Physiological tolerance exceeded
Physiological tolerance exceeded
TMD SYMPTOMSTMD SYMPTOMS
Decreased parafunctional
activities
NORMAL
FUNCTION
NORMAL
FUNCTIONTMD diagnosis
Condylar position and TMD risk
Occlusal interference and TMD risk
Red Flags and TMD risk
Outline
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P. A. 45 ys
Main complaints
• Facial pain
• Limited jaw movement
• Headache
P. A. 45 ys
• Facial Pain from 1 years (24h/24h; 7days/7days). The tongue is
affected too. Started after the prosthodontic rehabilitation. She changed many prosthetic manufactory but the pain is always present.
• Headache (bilateral)
• Cervical and back pain
Axis I
1°°°° Myofacial Pain with referrals
2°°°° Headache attributed to TMD
3°°°° Cervical Pain
FAMILIAR PAINFAMILIAR PAIN
FAMILIAR HEADACHEFAMILIAR HEADACHE
RDC/TMD Psychological Evaluation Axis II
Graded Chronic
Pain Scale
20
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Psychological Evaluation Axis II
Depressionand non specificphysical
symptoms
Treatment protocol
1°°°° Counseling
3°°°° Prosthetic
rehabilitation
2°°°° Physiotherapy
4°°°° Psychiatric
Consultation
• Chronicity
• Functional limitation
• Discrepancy in findings
• Overuse of medication
• Inappropriate behaviour
• Inappropriate expectations
• Inappropriate responsiveness to prior treatment
• Identify red-flags from self-report screener
Flag areas that might be associated
with history taking
Recommendations on rehabilitation of TMDs
Cairns B, List T, Michelotti A, Ohrbach R, Svensson P
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Orthodontic treatment
Range of motion WNL
Surgery
Bilateral facial pain. Severe pain on both
sides in the masseter and temporal regions.
Pain increases during mandibular
movements, chewing and yawning, so that
he could eat only soft meals
Headache, bilateral, localized at temples.
Present everyday, worse in the evening.
Stress increases headache.
M.S. 25 ysTwo months later…
Main complaint
Myofascial pain
Headache attributed to TMD
1) Counseling
2) Physiotherapy3) Drugs
For 3 weeks
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M.S. 25 ys
• Preauricular pain on right
• Limited jaw movement
• Pain during jaw movement
During class II elastics • Suspend class II elastics• Distraction of the right TMJ
• Coordination exercise of the jaw opening• Home regimen physiotherapy
Symptom free Take Home Message
Michelotti and Iodice, JOR 2010
Differential
diagnosis
Patient information
and counseling
+Suspend
temporarily active orthodontic
treatment
orthodontic treatment
Patient develops TMD
signs and symptoms
during
orthodontic treatment TMJ
disease
Conservativ
e treatment
Myofascial
pain
Conservativ
e treatment
No pain
Revaluate the orthodontic
treatment plan
No pain
Continue the
orthodontic treatment