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OROFACIAL PAIN

VIEWS: 219 PAGES: 89

									       OROFACIAL PAIN:
MANAGEMENT OR MISMANAGEMENT??
          OROFACIAL PAIN

 Twenty-Seven Percent of American Adults
  Suffer From Dental Pain In Any Given Year (47
  Million People).
 Thirty Percent of American Adults Suffer From
  Some Form Of Facial Pain In Any Given Year
  (52 Million People)
 Orofacial Pain Affects 57% Of Americans Each
  Year (99 Million People)
  SOCIOECONOMIC IMPACT OF
       OROFACIAL PAIN
 In one year, 44% of patients with dental
  pain will miss one or more days of work
  (20 million work days)
 In one year, 17% of patients with facial
  pain will miss one or more days of work (9
  million work days)
 In one year, 61% of patients with orofacial
  pain will miss one or more work day (29
  million work days)
 IT IS CLEAR FROM THESE
DATA THAT OROFACIAL PAIN
IS A MAJOR PUBLIC HEALTH
         PROBLEM!!!
COMMON FORMS OF OROFACIAL PAIN

       HEADACHE
       TOOTHACHE
       SINUS PAIN
       EYE PAIN
       SALIVARY GLAND PAIN
       JAW MUSCLE PAIN
       JAW JOINT PAIN
“TMJ”
       WHAT IS “TMJ” ???


 The term “TMJ” actually means
 Temporomandibular Joint, which is the jaw
 joint.
         WHAT IS “TMJ” ???
 The term has been used inappropriately to
  describe a series of signs and symptoms that
  include facial pain, limitation of mouth opening,
  pain on chewing, clicking sounds in the jaw joint,
  headache and earache.
 The problem is that there are many conditions
  that can produce these same signs and
  symptoms and this has lead to considerable
  misdiagnosis and mistreatment of patients!!
WHAT IS “TMJ”???
 The correct term for what has
  been referred to as “TMJ” is
 temporomandibular disorders
(“TMDs”), which includes those
 conditions that involve the jaw
joint and those that involve the
    muscles of mastication
HOW COMMON ARE THESE
    CONDITIONS???
 MORE THAN TEN MILLION
AMERICANS SUFFER FROM
  TEMPOROMANDIBULAR
   DISORDERS (TMDs)!!!
 TEMPOROMANDIBULAR
DISORDERS ARE A MAJOR
   HEALTH PROBLEM!!!
         PAINFUL
    TEMPORMANDIBULAR
       DISORDERS
 ARTHRITIS OF THE TMJ (Degenerative
  Joint Disease, Rheumatoid Arthritis)
 INTERNAL DERANGEMENTS OF THE
  TMJ
 MYOFASCIAL PAIN AND DYSFUNCTION
  (MPD, MASTICATORY MYALGIA)
INTERNAL DERANGEMENTS
      OF THE TMJ
INTERNAL DERANGEMENT OF THE TMJ
CLASSIFICATION OF INTERNAL
     DERANGEMENTS

 ANTERIORLY DISPLACED DISC THAT
  RETURNS TO NORMAL POSITION DURING
  MOUTH OPENING (CLICKING!!)
 ANTERIORLY DISPLACED DISC THAT DOES
  NOT RETURN TO NORMAL POSITION
  DURING MOUTH OPENING (LOCKING!!)
 ADHESION OF THE DISC TO THE JOINT
  SOCKET (LOCKING!!)
TMJ CLICKING
TMJ LOCKING
DISC ADHESION
     CAUSES OF INTERNAL
       DERANGEMENTS
 TRAUMATIC INJURIES
 CHRONIC JOINT COMPRESSION (TOOTH
 CLENCHING AND GRINDING)
WHIPLASH INJURY AND THE
  TEMPORMANDIBULAR
       JOINT???
TREATMENT OF TMJ
    CLICKING
SHOULD TMJ CLICKING BE
     TREATED???
 ONLY IF IT IS PAINFUL OR
SOCIALLY UNACCEPTABLE!!!
   MEDICAL MANAGEMENT OF
    PAINFUL TMJ CLICKING


 MEDICATIONS FOR RELIEF OF PAIN
 SOFT, NONCHEWY DIET
 USE OF A BITE APPLIANCE TO PREVENT
 CHRONIC TOOTH CLENCHING AND
 GRINDING
SURGICAL TREATMENT OF
 PAINFUL TMJ CLICKING


 ARTHROSCOPIC SURGERY
 DISCOPLASTY (Surgical
 repositioning of the disc)
    TMJ ARTHROSCOPY


    TMJ
ARTHROSCOPY
(PERMITS DIRECT
VISUALIZATION AND
     BIOPSY)
TREATMENT OF TMJ
    LOCKING
All Patients With Limited Mouth
     Opening Due To Disc
Displacement Or Disc Adhesion
Require Surgical Intervention!!!
SURGICAL TREATMENT OF TMJ
         LOCKING



   ARTHROCENTESIS
TMJ ARTHROCENTESIS
TMJ ARTHROCENTESIS
JOINT MOBILITY IS MORE
 IMPORTANT THAN DISC
      POSITION!!!
  LONG-TERM EVALUATION OF ARTHROCENTESIS
       FOR THE TREATMENT OF INTERNAL
  DERANGEMENTS OF THE TEMPOROMANDIBULAR
                   JOINT
                     Carvajal WA, Laskin DM
                J Oral Maxillofac Surg 58:852,2000

 32 Joints with Anterior Disc Displacement Without

  Reduction (Locking)

 Ave. Follow-Up 48.7 Mo (Range 10-96 Mo)

 91% Success Rate In Eliminating Pain and Increasing

  Range Of Motion
SURGICAL TREATMENT OF TMJ
         LOCKING

 ARTHROSCOPIC SURGERY
 DISCOPLASTY (Surgical
  Repositioning of the disc)
 DISCECTOMY (Surgical
  removal of the disc)
MYOFASCIAL PAIN AND
 DYSFUNCTION (MPD)

  MPD SYNDROME
MASTICATORY MYALGIA
    DIAGNOSTIC FEATURES OF THE
           MPD PATIENT

 UNILATERAL, DULL, ACHING FACIAL
    PAIN THAT IS POORLY LOCALIZED
   MODERATE TO SEVERE LIMITATION
    OF MOUTH OPENING
   NO TMJ TENDERNESS
   MUSCLE TENDERNESS (Masticatory and
    Cervical)
   NO RADIOGRAPHIC TMJ CHANGES
LOCALIZATION OF THE PAIN
GENERAL CHARACTERISTICS OF
      MPD PATIENTS

 PREDOMINATELY FEMALES
 20–40 YEAR AGE GROUP
 FREQUENT HISTORY OF OTHER
  PSYCHOPHYSIOLOGIC DISEASES
 OFTEN SUFFER FROM CHRONIC
  DEPRESSION
 SEEK MULTIPLE CARE PROVIDERS
 HAVE DIFFICULTY ACCEPTING A
  PSYCHOPHYSIOLOGIC ETIOLOGY FOR
  THEIR PROBLEM
PSYCHOPHYSIOLOGIC THEORY
        OF MPD
      PSYCHOLOGICAL STRESS

      MUSCLE HYPERACTIVITY

        MUSCLE FATIGUE

          MYOSPASM

              MPD
MPD IS A STRESS-RELATED
  PSYCHOPHYSIOLOGIC
         DISEASE
MISMANAGEMENT OF MPD
      PATIENTS
UNORTHODOX DIAGNOSTIC
     PROCEDURES
JAW TRACKING DEVICES
ELECTROMYOGRAPHY
UNORTHODOX TREATMENTS
   FOR MPD PATIENTS
APPLIED KINESIOLOGY
NUTRITIONAL SUPPLEMENTATION
CRANIAL BONE MANIPULATION
PAIN SUPPRESSORS
SOFT LASER
     “TMJ”


The Money Joint!!!
 WHY ARE SOME PATIENTS
    HELPED BY SUCH
UNORTHODOX METHODS OF
     TREATMENT???
THE PLACEBO EFFECT AND
   THE IMPACT OF THE
    DOCTOR-PATIENT
     RELATIONSHIP!!!
EFFECTS OF PLACEBO
     THERAPY

 PLACEBO DRUGS
 PLACEBO BITE APPLIANCE
 PLACEBO EQUILIBRATION
PLACEBO DRUG THERAPY
  IMPROVEMENT OF MPD
PATIENTS ON DRUG THERAPY

   MEPROBAMATE     58%
   PLACEBO          31%
   MYOLAX          57%

            JADA 82:587,1971
PLACEBO BITE APPLIANCE
      THERAPY
EFFECT OF PLACEBO BITE
  APPLIANCE THERAPY

FORTY PERCENT (40%) OF MPD
PATIENTS SHOWED COMPLETE OR
     MAJOR IMPROVEMENT

              JADA 84: 624, 1972
PLACEBO EQUILIBRATION
      THERAPY
 RESPONSE OF MPD
PATIENTS TO PLACEBO
   EQUILIBRATION

 TOTAL OR MAJOR IMPROVEMENT –
  16 (64%)
 NO CHANGE – 9 (36%)


                    JADA 92:755,1976
IMPACT OF THE DOCTOR-
 PATIENT RELATIONSHIP
“WITH MPD PATIENTS IT IS
 NOT ALWAYS WHAT YOU
 DO FOR THEM, BUT HOW
    YOU DO IT THAT IS
      IMPORTANT.”
TREATMENT OF MPD
    PATIENTS
    TREATMENT OF THE MPD PATIENT

   ACCURATE DIAGNOSIS
   USE OF HOME THERAPY
   MEDICATIONS FOR PAIN AND ANXIETY
   BITE APPLIANCES
   PHYSICAL THERAPY
   RELAXATION THERAPY
   POSSIBLE PSYCHOLOGICAL
    COUNSELING
     HOME THERAPY

 CHECK FOR CLENCHING HABITS
 LIMITATION OF JAW MOVEMENT
 SOFT NON-CHEWY DIET
 MOIST HEAT AND MASSAGE OF THE
 JAW MUSCLES
  MEDICATIONS FOR MPD
       PATIENTS

 MILD ANALGESICS FOR PAIN
  (NSAID’s)
 “MUSCLE RELAXANTS” FOR ANXIETY
  (DIAZAPAM or FLEXERIL)
 HYPNOTIC FOR SLEEP (DIAZAPAM or
  AMITRIPTYLENE)
BITE APPLIANCE
BITE APPLIANCE
   The Purpose Of A Bite
Appliance In MPD Patients Is
 To Eliminate Chronic Tooth
  Grinding and Clenching
          Habits!!!
BITE APPLIANCE FOR PATIENTS WHO
   GRIND THEIR TEETH (BRUXISM)
WORN ON THE
MAXILLA
COVERS ALL THE
TEETH
HAS A FLAT,
NONGUIDING
SURFACE
ALLOWS FREE
MOVEMENT IN ALL
DIRECTIONS
BITE APPLIANCE FOR PATIENTS
  WHO CLENCH THEIR TEETH
WORN ON MAXILLA
HAS A FLAT,
NONGUIDING
ANTERIOR PLATFORM
SEPARATES THE BACK
TEETH
ALLOWS FREE
MOVEMENT IN ALL
DIRECTIONS
    TREATMENT OF THE MPD PATIENT

   ACCURATE DIAGNOSIS
   USE OF HOME THERAPY
   MEDICATIONS FOR PAIN AND ANXIETY
   BITE APPLIANCES
   PHYSICAL THERAPY
   RELAXATION THERAPY
   POSSIBLE PSYCHOLOGICAL
    COUNSELING
LONG-TERM STATUS OF 175 SUCCESSFULLY
 TREATED MPD PATIENTS (8 mo – 11 yrs : X=
               5.5 yrs)


    ASYMPTOMATIC                  53%
    OCCASIONAL SYMPTOMS           37%
    SINGLE RELAPSE                 8%
    CURRENTLY SYMPTOMATIC          2%

                    JADA 89:1365,1974
                    JADA 107: 235, 1983

								
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