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Nyeri TMJ TMJ Pain
Yuliati Departemen Biology Oral
FKG UNAIR
Sistem Sensoris Somatik
• Sensasi sensoris somatik
rasa raba, vibrasi, 2-point discrimination, rasa tekan, propiosepsi → serat Aβ → medulla spinalis
rasa nyeri, panas & dingin ( nosisepsi ) → serat Aδ atau tipe C medulla spinalis
• Sinyal nyeri melewati 2 jaras otak
traktus neospinotalamikus → nyeri cepat
traktus paleospinotalamikus → nyeri lambat, kronis
Chapter 46 Sensory Receptors, Neuronal Circuits for Processing Information 573
transmit only impulses. Therefore, how is it that different nerve fibers transmit different modalities ofsensation?
The answer is that each nerve tract terminates at aspecific point in the central nervous system, and the type of sensation felt when a nerve fiber is stimu-lated is determined by the point in the nervous systemto which the fiber leads. For instance, if a pain fiber is stimulated, the person perceives pain regardless of what type of stimulus excites the fiber. The stimuluscan be electricity, overheating of the fiber, crushing of the fiber, or stimulation of the pain nerve ending by damage to the tissue cells. In all these instances,the person perceives pain. Likewise, if a touch fiber isstimulated by electrical excitation of a touch receptoror in any other way, the person perceives touchbecause touch fibers lead to specific touch areas in the brain. Similarly, fibers from the retina of the eyeterminate in the vision areas of the brain, fibers fromthe ear terminate in the auditory areas of the brain,and temperature fibers terminate in the temperatureareas.
This specificity of nerve fibers for transmitting onlyone modality of sensation is called the labeled lineprinciple.
Transduction of SensoryStimuli into Nerve Impulses
Local Electrical Currents at NerveEndings—Receptor Potentials
All sensory receptors have one feature in common.Whatever the type of stimulus that excites the recep-tor, its immediate effect is to change the membrane
Free nerveendings
Expanded tipreceptor
Tactile hair
Paciniancorpuscle
Meissner’scorpuscle
Krause’scorpuscle
Ruffini’send-organ
Golgi tendonapparatus
Musclespindle
Figure 46–1
Several types of somatic sensory nerve endings.
Table 46–1
Classification of Sensory Receptors
I. MechanoreceptorsSkin tactile sensibilities (epidermis and dermis)
Free nerve endingsExpanded tip endings
Merkel’s discsPlus several other variants
Spray endingsRuffini’s endingsEncapsulated endings
Meissner’s corpusclesKrause’s corpuscles
Hair end-organsDeep tissue sensibilities
Free nerve endingsExpanded tip endingsSpray endings
Ruffini’s endingsEncapsulated endings
Pacinian corpusclesPlus a few other variants
Muscle endingsMuscle spindlesGolgi tendon receptors
HearingSound receptors of cochlea
EquilibriumVestibular receptors
Arterial pressureBaroreceptors of carotid sinuses and aorta
II. ThermoreceptorsCold
Cold receptorsWarmth
Warm receptorsIII. Nociceptors
PainFree nerve endings
IV. Electromagnetic receptorsVision
RodsCones
V. ChemoreceptorsTaste
Receptors of taste budsSmell
Receptors of olfactory epitheliumArterial oxygen
Receptors of aortic and carotid bodiesOsmolality
Neurons in or near supraoptic nucleiBlood CO2
Receptors in or on surface of medulla and in aortic and carotid bodies
Blood glucose, amino acids, fatty acidsReceptors in hypothalamus
Chapter 46 Sensory Receptors, Neuronal Circuits for Processing Information 573
transmit only impulses. Therefore, how is it that different nerve fibers transmit different modalities ofsensation?
The answer is that each nerve tract terminates at aspecific point in the central nervous system, and the type of sensation felt when a nerve fiber is stimu-lated is determined by the point in the nervous systemto which the fiber leads. For instance, if a pain fiber is stimulated, the person perceives pain regardless of what type of stimulus excites the fiber. The stimuluscan be electricity, overheating of the fiber, crushing of the fiber, or stimulation of the pain nerve ending by damage to the tissue cells. In all these instances,the person perceives pain. Likewise, if a touch fiber isstimulated by electrical excitation of a touch receptoror in any other way, the person perceives touchbecause touch fibers lead to specific touch areas in the brain. Similarly, fibers from the retina of the eyeterminate in the vision areas of the brain, fibers fromthe ear terminate in the auditory areas of the brain,and temperature fibers terminate in the temperatureareas.
This specificity of nerve fibers for transmitting onlyone modality of sensation is called the labeled lineprinciple.
Transduction of SensoryStimuli into Nerve Impulses
Local Electrical Currents at NerveEndings—Receptor Potentials
All sensory receptors have one feature in common.Whatever the type of stimulus that excites the recep-tor, its immediate effect is to change the membrane
Free nerveendings
Expanded tipreceptor
Tactile hair
Paciniancorpuscle
Meissner’scorpuscle
Krause’scorpuscle
Ruffini’send-organ
Golgi tendonapparatus
Musclespindle
Figure 46–1
Several types of somatic sensory nerve endings.
Table 46–1
Classification of Sensory Receptors
I. MechanoreceptorsSkin tactile sensibilities (epidermis and dermis)
Free nerve endingsExpanded tip endings
Merkel’s discsPlus several other variants
Spray endingsRuffini’s endingsEncapsulated endings
Meissner’s corpusclesKrause’s corpuscles
Hair end-organsDeep tissue sensibilities
Free nerve endingsExpanded tip endingsSpray endings
Ruffini’s endingsEncapsulated endings
Pacinian corpusclesPlus a few other variants
Muscle endingsMuscle spindlesGolgi tendon receptors
HearingSound receptors of cochlea
EquilibriumVestibular receptors
Arterial pressureBaroreceptors of carotid sinuses and aorta
II. ThermoreceptorsCold
Cold receptorsWarmth
Warm receptorsIII. Nociceptors
PainFree nerve endings
IV. Electromagnetic receptorsVision
RodsCones
V. ChemoreceptorsTaste
Receptors of taste budsSmell
Receptors of olfactory epitheliumArterial oxygen
Receptors of aortic and carotid bodiesOsmolality
Neurons in or near supraoptic nucleiBlood CO2
Receptors in or on surface of medulla and in aortic and carotid bodies
Blood glucose, amino acids, fatty acidsReceptors in hypothalamus
Chapter 46 Sensory Receptors, Neuronal Circuits for Processing Information 573
transmit only impulses. Therefore, how is it that different nerve fibers transmit different modalities ofsensation?
The answer is that each nerve tract terminates at aspecific point in the central nervous system, and the type of sensation felt when a nerve fiber is stimu-lated is determined by the point in the nervous systemto which the fiber leads. For instance, if a pain fiber is stimulated, the person perceives pain regardless of what type of stimulus excites the fiber. The stimuluscan be electricity, overheating of the fiber, crushing of the fiber, or stimulation of the pain nerve ending by damage to the tissue cells. In all these instances,the person perceives pain. Likewise, if a touch fiber isstimulated by electrical excitation of a touch receptoror in any other way, the person perceives touchbecause touch fibers lead to specific touch areas in the brain. Similarly, fibers from the retina of the eyeterminate in the vision areas of the brain, fibers fromthe ear terminate in the auditory areas of the brain,and temperature fibers terminate in the temperatureareas.
This specificity of nerve fibers for transmitting onlyone modality of sensation is called the labeled lineprinciple.
Transduction of SensoryStimuli into Nerve Impulses
Local Electrical Currents at NerveEndings—Receptor Potentials
All sensory receptors have one feature in common.Whatever the type of stimulus that excites the recep-tor, its immediate effect is to change the membrane
Free nerveendings
Expanded tipreceptor
Tactile hair
Paciniancorpuscle
Meissner’scorpuscle
Krause’scorpuscle
Ruffini’send-organ
Golgi tendonapparatus
Musclespindle
Figure 46–1
Several types of somatic sensory nerve endings.
Table 46–1
Classification of Sensory Receptors
I. MechanoreceptorsSkin tactile sensibilities (epidermis and dermis)
Free nerve endingsExpanded tip endings
Merkel’s discsPlus several other variants
Spray endingsRuffini’s endingsEncapsulated endings
Meissner’s corpusclesKrause’s corpuscles
Hair end-organsDeep tissue sensibilities
Free nerve endingsExpanded tip endingsSpray endings
Ruffini’s endingsEncapsulated endings
Pacinian corpusclesPlus a few other variants
Muscle endingsMuscle spindlesGolgi tendon receptors
HearingSound receptors of cochlea
EquilibriumVestibular receptors
Arterial pressureBaroreceptors of carotid sinuses and aorta
II. ThermoreceptorsCold
Cold receptorsWarmth
Warm receptorsIII. Nociceptors
PainFree nerve endings
IV. Electromagnetic receptorsVision
RodsCones
V. ChemoreceptorsTaste
Receptors of taste budsSmell
Receptors of olfactory epitheliumArterial oxygen
Receptors of aortic and carotid bodiesOsmolality
Neurons in or near supraoptic nucleiBlood CO2
Receptors in or on surface of medulla and in aortic and carotid bodies
Blood glucose, amino acids, fatty acidsReceptors in hypothalamus
Penjalaran Sinyal
• ‘Fast-pain’ ( nyeri cepat, tajam ) Rangsangan mekanik atau suhu → serat Aδ ( 6-30 m/dtk ) Lokalisasi pada bagian tubuh lebih pasti Melibatkan reseptor raba Jaras melewati Traktus Neospinotalamikus → brainstem & talamus
Neurotransmiter : Glutamat • ‘Slow-pain’ ( nyeri lambat, kronik )
Rangsangan kimiawi, mekanis/suhu persisten → serat C ( 0,5-2 m/dtk )
Jaras Traktus Paleospinotalamikus
→ juga menjalarkan sinyal serabut serat Aδ Neurotransmiter : Substan P
Glutamat Neurotransmiter serat Aδ
Disekresi : medulla spinalis pada ujung2 serabut nyeri saraf AδSifat : eksitasi
Mula kerja : segera
Durasi kerja : beberapa milidetik
Substan PNeurotransmiter serat C
Mula kerja : lebih lambat drpd Glutamat ( bbrp detik sd menit )
Disekresi : medulla spinalis pada ujung2 serabut nyeri saraf C
Jalur Somatosensoris pada Sistem Saraf
556 Unit IX The Nervous System: A. General Principles and Sensory Physiology
Motor Part of the Nervous System—Effectors
The most important eventual role of the nervoussystem is to control the various bodily activities. Thisis achieved by controlling (1) contraction of appropri-ate skeletal muscles throughout the body, (2) contrac-tion of smooth muscle in the internal organs, and (3) secretion of active chemical substances by bothexocrine and endocrine glands in many parts of thebody. These activities are collectively called motorfunctions of the nervous system, and the muscles andglands are called effectors because they are the actualanatomical structures that perform the functions dic-tated by the nerve signals.
Figure 45–3 shows the “skeletal” motor nerve axis ofthe nervous system for controlling skeletal muscle con-traction. Operating parallel to this axis is anothersystem, called the autonomic nervous system, for con-
trolling smooth muscles, glands, and other internalbodily systems; this is discussed in Chapter 60.
Note in Figure 45–3 that the skeletal muscles can becontrolled from many levels of the central nervoussystem, including (1) the spinal cord; (2) the reticularsubstance of the medulla, pons, and mesencephalon;(3) the basal ganglia; (4) the cerebellum; and (5) themotor cortex. Each of these areas plays its own spe-cific role, the lower regions concerned primarily withautomatic, instantaneous muscle responses to sensorystimuli, and the higher regions with deliberatecomplex muscle movements controlled by the thoughtprocesses of the brain.
Processing of Information—“Integrative” Function of the Nervous System
One of the most important functions of the nervoussystem is to process incoming information in such away that appropriate mental and motor responses willoccur. More than 99 per cent of all sensory informa-tion is discarded by the brain as irrelevant and unim-portant. For instance, one is ordinarily unaware of the
Brain
Spinal cordSecond-orderneurons
Axon
Synapses
Cell body
Dendrites
Figure 45–1
Structure of a large neuron in the brain, showing its important func-tional parts. (Redrawn from Guyton AC: Basic Neuroscience:Anatomy and Physiology. Philadelphia: WB Saunders Co, 1987.)
Golgi tendonapparatus
Cerebellum
Motor cortex
Thalamus
BulboreticularformationPons
Somesthetic areas
Medulla
Spinal cord
Skin
Pain, cold,warmth (Freenerve ending)
Pressure(Pacinian corpuscle)(Expanded tipreceptor)
Touch(Meissner's corpuscle)
Muscle spindle
Kinesthetic receptor
Joint
Muscle
Figure 45–2
Somatosensory axis of the nervous system.
• Termasuk sensasi sensoris somatik
• Dapat dirasakan oleh hewan tingkat rendah → human
• Sensasi yg phemomenal : sesuatu yg dibutuhkan tetap ada tapi harus dieliminasi
• Respons nyeri :• intensitas ( ringan, sedang, berat )• sifat rangsangan• memori
Rasa Nyer i
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Cortex Cerebri sisi kiri ( hemispher kiri )
Cortex cerebri adalah lapisan paling luar otak , merupakan lapisan paling tebal – serta mencerminkan intelegensia
Pusatintelegensi
Pusatvisual
Pusat kontraksi otot
Pusat bicara
Cortex cerebri
1. Pusat persepsi dan interpretasi sistem sensoris somatik.
2. Pusat pengendalian sistem motorik somatik ( gerakan anggota tubuh ).
3. Pusat intelegensia.
4. Pusat penglihatan, pendengaran, bicara, taste / pengecapan.
Reseptor
• Reseptor nyeri ( nosiseptor ) - free nerve endings - axon saraf sensoris : Aδ ( fast pain ) → mekanis, termal tipe C ( slow pain ) → kimiawi, mekanis & termal (persisten) tersebar hampir di seluruh tubuh → termasuk daerah muka ( facial ) dan dental
• Reseptor somatosensorik daerah kepala dilayani n. trigeminus divisi somatosensoris
Rangsangan yg dapat menimbulkan nyeri: mekanik, kimiawi, termal, elektrik, tissue ischemia, skeletal muscle spasm
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• Beberapa bahan yang dapat menimbulkan nyeri๏ Bradikinin๏ Serotonin๏ Histamin๏ Prostaglandin๏ Leukotrien๏ Substance P๏ Enzim proteolitik๏ ion K yg berlebihan๏ asam atau basa yang berlebihan
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permeabilitas membran nosiseptor ↑
influks ion Na+
potensial aksi (impuls) membran neuron
medulla spinalis
Trauma/kerusakan jaringan
pengeluaran ion K+, sintesa prostaglandin
& bradikinin
Keradangan Jaringan Infeksi - Non infeksi
sekresi peptida (substan P)
merangsang mast cell, platelet, kapiler
inflammatory agents( Histamin, bradikinin, serotonin,
platelets factors )
Input sensoris: - kulit fasial - mukosa oral - geligi - pembuluh darah kranial - otot - TMJ
Impuls Nyeri S.S.A I : Gyrus Postcentralis
Thalamus
Tr.Spinothalamicus
Medulla SpinalisFree nerve endings
Aδ / C
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Klasifikasi Nyeri ( berdasarkan etiologi )
A. Nyeri Fisiologik• Nyeri tjd krn rangsangan, singkat dan tidak merusak jaringan
• Korelasi positif antara stimuli dan persepsi nyeri
B. Nyeri Inflamasi / Nosiseptif• Terjadi akibat keluarnya mediator inflamasi yg mengaktivasi nosiseptor
C. Nyeri Neuropatik• Nyeri yang didahului/disebabkan oleh lesi (trauma, toksin, gangguan
metabolik) atau disfungsi primer sistem saraf
• Tidak berhubungan dg aktivasi nosiseptor
D. Nyeri Psikogenik• Nyeri yg tidak berhubungan dg nyeri nosiseptif maupun nyeri neuropatik
• Didapatkan simptom psikologisCopyright©yuliati
The discovery that norepinephrine can block pain transmissionled to studies directed at the combined administration of opi-oids and clonidine, a central-acting !-adrenergic agonist forsome types of pain relief.
Serotonin also has been identified as a neuromodulator inthe NRM medullary nuclei that project to the spinal cord. It hasbeen shown that tricyclic antidepressant compounds, such asamitriptyline, have analgesic properties independent of theirantidepressant effects. These drugs, which enhance the effectsof serotonin by blocking its presynaptic uptake, have beenfound to be effective in the management of certain types ofchronic pain.11
Endogenous Analgesic Mechanisms. There is evidence that theendogenous opioid peptides, morphine-like substances syn-thesized in many regions of the CNS including the spinal cordand PAG, modulate pain in the CNS. Three families of opioidpeptides have been identified—the enkephalins, endorphins,and dynorphins. Although the endogenous opioid peptides ap-pear to function as neurotransmitters, their full significance inpain control and other physiologic functions is not completelyunderstood. Probably of greater importance in understandingmechanisms of pain control has been the characterization ofreceptors that bind the endogenous opioid peptides. The iden-tification of these receptors has facilitated a more thorough un-derstanding of the actions of available opioid drugs, such asmorphine, and it also has facilitated ongoing research into thedevelopment of newer preparations that are more effective inrelieving pain and have fewer side effects.
Pain Threshold and TolerancePain threshold and tolerance affect an individual’s response toa painful stimulus. Although the terms often are used inter-changeably, pain threshold and pain tolerance have distinctmeanings. Pain threshold is closely associated with tissue dam-age and the point at which a stimulus is perceived as painful.Pain tolerance relates more to the total pain experience; it is de-fined as the maximum intensity or duration of pain that a per-son is willing to endure before the person wants somethingdone about the pain. Psychological, familial, cultural, and en-vironmental factors significantly influence the amount of paina person is willing to tolerate. The threshold to pain is fairlyuniform from one person to another, whereas pain tolerance isextremely variable.12 Separation and identification of the roleof each of these two aspects of pain continue to pose funda-mental problems for the pain management team and for painresearchers.
Types of PainThe most widely accepted classifications of pain are accordingto source or location, referral, and duration (acute or chronic).Classification based on associated medical diagnosis (e.g., sur-gery, trauma, cancer, sickle cell disease, fibromyalgia) is usefulin planning appropriate interventions.
Cutaneous and Deep Somatic PainCutaneous pain arises from superficial structures, such as theskin and subcutaneous tissues. A paper cut on the finger is anexample of easily localized superficial, or cutaneous, pain. It is
a sharp, bright pain with a burning quality and may be abruptor slow in onset. It can be localized accurately and may be dis-tributed along the dermatomes. Because there is an overlap ofnerve fiber distribution between the dermatomes, the bound-aries of pain frequently are not as clear-cut as the dermatomaldiagrams indicate.
Deep somatic pain originates in deep body structures, suchas the periosteum, muscles, tendons, joints, and blood vessels.This pain is more diffuse than cutaneous pain. Various stimuli,such as strong pressure exerted on bone, ischemia to a muscle,and tissue damage, can produce deep somatic pain. This isthe type of pain a person experiences from a sprained ankle.Radiation of pain from the original site of injury can occur. Forexample, damage to a nerve root can cause a person to experi-ence pain radiating along its fiber distribution.
Visceral PainVisceral, or splanchnic, pain has its origin in the visceral organs.Common examples of visceral pain are renal colic, pain causedby cholecystitis, pain associated with acute appendicitis, andpeptic ulcer pain. Although the viscera are diffusely and richlyinnervated, cutting or burning of viscera, as opposed to similarnoxious stimuli applied to cutaneous or superficial structures,is unlikely to cause pain. Instead, strong abnormal contractionsof the gastrointestinal system, distention, or ischemia affectingthe walls of the viscera can induce severe visceral pain. Anyonewho has had severe gastrointestinal distress or ureteral colic canreadily attest to the misery involved.
735Chapter 39: Pain
KEY CONCEPTS
TYPES OF PAIN
! Pain can be classified according to location, site ofreferral, and duration.
! Cutaneous pain is a sharp, burning pain that has itsorigin in the skin or subcutaneous tissues.
! Deep pain is a more diffuse and throbbing pain thatoriginates in structures such as the muscles, bones,and tendons and radiates to the surrounding tissues.
! Visceral pain is a diffuse and poorly defined pain thatresults from stretching, distention, or ischemia oftissues in a body organ.
! Referred pain is pain that originates at a visceral sitebut is perceived as originating in part of the bodywall that is innervated by neurons entering the samesegment of the nervous system.
! Acute pain usually results from tissue damage and is characterized by autonomic nervous systemresponses.
! Chronic pain is persistent pain that is accompaniedby loss of appetite, sleep disturbances, depression,and other debilitating responses.
Beberapa Tipe Nyeri
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• Orofacial pain merupakan istilah umum nyeri daerah oral & fasial
• Meliputi sejumlah kelainan klinis termasuk pada otot mastikasi atau temporomandibular joint.
• Tipe nyeri orofasial : nyeri inflamasi dan neuropatik
• Etiologi akut : terutama dental pain ( pulpa, jar.periodontal ) kronis : sebag.besar dari otot, tendon TMJ
What is Orofacial Pain ?
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TMJ Dysfunction
• Merupakan salah satu penyebab facial pain
• Terjadi saat hubungan sendi rahang keluar ligamen,
menyebabkan RA dan RB pada posisi tidak seimbang
• Patogenesis : distal displacement
mandibulare overclosure
• TMJ pain terjadi akibat ketidakseimbangan aktivitas otot rahang
& spasme otot
• Struktur yg diperiksa:
otot, sendi Temporomandibular, geligi
• Simptom
1. Jaringan keras
a. Rahang : clicking, nyeri otot daerah pipi,
gerakan rahang / lidah tak terkontrol
b. Geligi : clenching, grinding at night,
ke-ausan gigi belakang
2. Jaringan lunak
a. Mulut : discomfort, gangguan membuka mulut,
hilangnya kemampuan membuka mulut dg pelan ( smothly )
deviasi rahang pada satu sisi saat buka mulut, tidak dapat menggigit ( open bite )
b. Tenggorokan : gangguan menelan, laringitis,
perubahan suara, sering batuk merasa ada benda asing di tenggorokan
c. Masalah pada leher : penurunan gerak leher, nyeri
• Etiologi
1. Teeth grinding & teeth clenching kebiasaan tidak disadari, nyeri saat bangun tidur
2. Kebiasaan mengunyah permen karet / menghisap ibu jari
3. Maloklusi restorasi
4. Mengunyah satu sisi
5. Trauma rahang riwayat kecelakaan ( patah tulang rahang atau fasial )
6. Stres memicu sistem saraf
7. Pekerjaan misal : kebiasaan memegang gagang telepon antara
bahu & kepala
Gejala lain
a. Sakit kepala keluhan sakit saat membuka rahang
b. Nyeri telinga bagian depan/dalam telinga, tidak ada infeksi
c. Pusing ( belum jelas )
d. Rasa penuh pada telinga terutama saat take off & landing pesawat diduga disfungsi Eustachian tube
e. Tinnitus ( suara bising dlm telinga )
1. Mengukur pembukaan inter-insisal ( mm )
2. Mengukur gerak lateral & protusif ( mm )
3. Memperhatikan koordinasi & simetri saat membuka & menutup mulut
4. Memperhatikan ada tidaknya suara TMJ ( mis : clicking )
5. Palpasi TMJ dari arah lateral & posterior ( dari eksternal auditory meatus )
Prosedur Pemeriksaan Klinis
6. Palpasi otot elevator & depressor
7. Evaluasi ada tidaknya prematur kontak
8. Memperhatikan pola oklusal
9. Evaluasi skeletal symmetries dari kranial / fasial
10. Mencatat overjet, overbite & garis median ( mm )
Penjalaran Impuls TMJ Pain
S.S.A I : Gyrus Postcentralis
Thalamus
Tr.Spinothalamicus
Medulla Spinalis Free nerve endings pada disk parenkim TMJ
Aδ / C
Persepsi Nyeri TMJ
• Spasme otot → Iskemia
• Hambatan suplai darah jaringan
• Peningkatan metabolisme
• Timbunan asam laktat → aktivitas metabolisme anaerob
• Bahan metabolit - bradikinin, enzim proteolitik → kerusakan jaringan
Spasme Otot - Iskemia Jaringan
Terdiri atas 2 Fase
Prinsip :
1. Dimulai setelah diagnosis
2. Diutamakan terapi konservatif
3. Didahului dengan terapi yang bersifat reversibel,
terapi iireversibel hanya bila diperlukan
Terapi / Tata laksana TMJ Pain
Fase Pertama
Tujuan : a. mengatasi keluhan utama, b. mengembalikan Range of Motion ( ROM ) mandibula, c. mengembalikan kondili pada posisi normal, d. rehabilitasi otot yg fatique & cedera , e. membangkitkan semangat penderita memecahkan masalahnya ( faktor psikogenik ), f. memperbaiki postur tubuh.
Fase Kedua Merupakan lanjutan fase pertama, jika diperlukan terapi lanjutan untuk menstabilkan kondisi perawatan fase 1.
1. Istirahat menggurangi aktivitas rahang ( menghindari mkn-an dg konsistensi keras/kenyal, tidak membuka mulut lebar )
2. Stress reduction & management program
3. Biofeedback penderita mengatur tonus ototnya sendiri ( mengatur kontraksi - relaksasi otot )
4. Physical therapy antara lain : perubahan postural ( koreksi posisi mandibula ) pemijatan
terapi panas ( melancarkan sirkulasi ) muscle exercise dll
Fase Pertama
Fase Kedua
1. Equilibration grinding oklusal yg berkontak berat efektif pada penderita tanpa spasme otot & tidak banyak gigi hilang
2. Orthodonsi mengharmoniskan hubungan sendi dg mengkoreksi geligi
3. Overlays
4. Rekonstruksi ( Restorasi, Replacing ) gigi belakang aus akibat pengunaan atau akibat karies
5. Pembedahan
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