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TMJ Pain and Neuropathic Pain in Patients with Temporomandibular Joint Disorders. Dr. Gaetano Meli. Symptoms and signs of TMJ disorders. Lateral deviation of the jaw during the mandibular range of motion Bruxism Presence of sounds or clicks during the jaw movement TMJ pain - PowerPoint PPT Presentation
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TMJ Pain and Neuropathic Painin Patients with
Temporomandibular Joint Disorders
Dr. Gaetano Meli
Symptoms and signs of TMJ disorders
• Lateral deviation of the jaw during the mandibular range of motion
• Bruxism• Presence of sounds or clicks during the jaw
movement • TMJ pain• Neuropathic pain (facial numbness and
dysesthesia, headache, toothache and earache)• Reduction of the mandibular opening• Sleep and Psychological disorders• Spine disorders
Okeson JP, Management of Temporomandibular Disorders and Occlusion, 2006
Different types of Pain
TMJ PAIN• When pain is located in the proximity of the
temporomandibular joint
NEUROPATHIC PAIN• Involving greater portion of the orofacial region
and it is associated with the onset of sensory deficits of the head (facial paresthesia,headaches, toothache, and ear sounds)
Okeson JP, Management of Temporomandibular Disorders and Occlusion, 2006
Neuropathic pain prevalence
Dupont JS, Cranio, 2003
Bell classification OF TMDMasticatory muscle
disordersTemporomandibular joint
disordersChronic mandibular
hypomobilityGrowth disorders
Protective co-contraction Disc displacement with or
without reduction Ankylosis Congenital or
developmental bone disorders
Local muscle soreness
Structural incompatibility of the articular surfaces
Muscle contracture Congenital or developmental
muscle disorders
Myofascial pain Inflammatory conditions
Coronoid impedance
Myospasm
Centrally mediated myalgia
Okeson- Bell; American academy of orofacial pain, 1996
Relationship among pain and MRI findings
Emshoff, 2001-2003
“Not all patients have the same reaction to a given
stimulus.They exhibit a differing
grade of individual physiological tolerance
(Okeson)
Temporomandibular joint disorders
Click
Temporomandibular joint disorders
Lock
Temporomandibular joint disorders
Osteoarthrosis Subchondral Cyst
Which are the causes of the onset of neuropathic pain?
The first mention of a possible clinical relationship among atypical trigeminalgia and temporomandibular disorders was proposed by Costen and dates back to 1934.
He hypothesized that in those patients the disc and/or condyle may directly damage the mandibular nerve and/or its branches by exerting intermittent compression, traction or friction during the jaw opening
AnatomyMRINetter plates
Prospective case-control analysis
Study Group A
Control Group B
Control Group C
16 TMJs with TMJ-D and neuropathic pain
16 TMJs with TMJ-D without neuropathic pain
16 healthy TMJs
Selection criteria
No significant sex or age differences among the three groups
Clinical diagnosis of TMJ-D achieved by “Clinical diagnostic criteria for TMD” (Truelove)
Presence of neuropathic pain assesed bythe “neuropathic pain diagnostic questionnaire” (Bouhassira)
DN4 Neuropathic Pain Diagnostic Questionnaire. Interview of the patient Question 1 : Does the pain have one or more of the following characteristics? 1.Burning yes no 2.Painful cold yes no 3.Electric shocks yes no Question 2: Is the pain associated with one or more of the following symptoms in the same area? 4.Tingling yes no 5.Pins and needles yes no 6.Numbness yes no 7. Itching yes no Examination of the patient
Question 3: Is the pain located in an area where the physical examination may reveal one or more of the following characteristics ?
8.Hypoesthesia to touch yes no 9.Hypoesthesia to prick yes no
Question 4: In the painful area, can the pain be caused or increased by? 10.Brushing yes no
Disc – mandibular nerve distance
ControlCase
Pedullà, Meli, Garufi et al ; AJNR Am J Neuroradiol. Aug. 2009
Healthy subjects Patients with TMJ-D without neuropathic pain
Pedullà, Meli, Garufi et al ; AJNR Am J Neuroradiol. Aug. 2009
Distance of the TMJ disc to the mandibular nerve at the maximum jaw opening in the study group A and in the two control groups B and C
TMJ Study Group A Control Group B Control Group C
1 10 10 102 6 8 113 4 9 124 9 10 95 8 9 86 5 9 107 9 10 108 3 5 119 7 7 810 6 9 711 7 6 712 5 7 813 5 11 1314 4 9 1115 5 5 816 7 7 8
Mean Value 6,25 8,18 9,43Standard Deviation
2,01 1,83 1,82
•TMJ PAIN could be correlated to the presence of internal derangement, effusion, osteoarthrosis, and bone marrow edema within the TMJ
• TMJ NEUROPATHIC PAIN could be associated to the presence of a mechanical impingement of the TMJ disc on the mandibular nerve fibers
Conclusion
Thanks for your time
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