TMD all day handout part 2 for 9-25-20

The Toronto Crown and Bridge Study ClubToronto, Ontario, Canada

September 25, 2020

“Management considerations for Temporomandibular Disorders Part 2”

byJeffrey P Okeson, DMD

Professor and DeanFounder, Orofacial Pain Program

Provost's Distinguished Service Professor University of Kentucky College of Dentistry

Lexington, Kentucky [email protected]

jeffokeson.net

1

I. Masticatory Muscle Disorders1. Protective Co-Contraction2. Local Muscle Soreness3. Myofascial Pain4. Myospasm5. Chronic Centrally Mediated Myalgia

II. Temporomandibular Joint Disorders1. Derangements of the Condyle-Disc Complex

a. Disc Displacement with Reductionb. Disc Displacement without Reduction

2. Structural Incompatibilities3. Inflammatory Disorders

Classification of Temporomandibular Disorders

2

Muscle PainMuscle pain is the most common type of pain

humans experience.

3

Muscle PainMuscle pain is the most common type of pain

humans experience.

Chronic muscle pain affects between11–24% of the world’s population

Cimmino et al. 2011

In the U.S. chronic pain are estimated to incur an economic burden of $500 billion dollars annually.

Miranda et al. 2010

4

We dentists have been trained to think of muscle pain as a consequence of an anatomic variation.

Muscle Pain

Malocclusion Incorrect joint position

5

Or ....we think about muscle pain as it relates to parafunction (bruxism, clenching, tooth wear).

Muscle Pain

Awake Time ClenchingSleep Related Bruxing

6

mailto:[email protected]

Or ....we think about muscle pain as it relates to parafunction (bruxism, clenching, tooth wear).

Muscle Pain

7

We dentists have developed many concepts regarding the etiology of muscle pain.

How valid are the data?

The data have been classically based on patient report and clinical observations.

8

We dentists have developed many concepts regarding the etiology of muscle pain.

How valid are the data?

The data have been classically based on patient report and clinical observations.

Current data is based on real time activity in a sleep lab.

9

1. TMD patients report more bruxing activity than controls.

Self-report of bruxism:55% of TMD patients report they bruxonly 15% of controls report they brux

Raphel et al. Sleep bruxism and myofascial pain TMD. JADA:143(11):1223-1231.2012

TRUE

Common beliefs regarding bruxism, tooth wear, EMG and pain- Facts or Fiction ? -

10

1. TMD patients report more bruxing activity than controls.2. TMD patients actually brux more than controls.


Results of 2 nights in sleep studies:9.7 % of TMD patients showed bruxism10.9% of the controls showed bruxism (RMMA index of 1.7 events per 1.5 hours)

- no statically significant difference -

Raphel et al. Sleep bruxism and myofascial pain TMD. JADA:143(11):1223-1231.2012

TRUE

FALSE

11

1. TMD patients report more bruxing activity than controls.2. TMD patients actually brux more than controls.3. There is a correlation between the magnitude of tooth wear and

bruxing activity.

Lavigne, et al. Bruxism physiology and pathology: an overview for clinicians. J Oral Rehab. 35:7: 476-495, 2008.

There is no difference in the magnitude of tooth wear and the amount of bruxing activity observed in a sleep lab.

TRUE

FALSE

FALSE


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bruxing activity.4. There is a strong correlation between tooth wear and RMMA

(rhythmic masticatory muscle activity).


There is no correlation between tooth wear and RMMA observed in a sleep lab.

TRUE

FALSE

FALSE

FALSE


13



(rhythmic masticatory muscle activity).5. There is a strong correlation between bruxing activity and pain.


There is no correlation between pain and RMMA observed in a sleep lab.

TRUE

FALSE

FALSE

FALSE

FALSE


14



(rhythmic masticatory muscle activity).5. There is a strong correlation between bruxing activity and pain.6. Patients who have pain have higher resting EGM activity.

Studies demonstrate that there are no differences in EMG activity between masticatory muscle pain patients and controls.

Yemm 1985Majewski 1984 Carlson, 1993Maillou, 1997Sevensson, 2004

TRUE

FALSE

FALSE

FALSE

FALSEFALSE


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(rhythmic masticatory muscle activity).5. There is a strong correlation between bruxing activity and pain.6. Patients who have pain have higher resting EGM activity.7. Patients who brux more, have more pain.

Self-reported bruxers (cut off 4 episodes of RMMA an hour)Low frequency bruxers had more pain than the high frequency bruxers.

- Rompre et al, J of Dent Res, 2007

TRUE

FALSE

FALSE

FALSE

FALSEFALSEFALSE


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(rhythmic masticatory muscle activity).5. There is a strong correlation between bruxing activity and pain.6. Patients who have pain have higher resting EGM activity.7. Patients who brux more, have more pain.

TRUE

FALSE

FALSE

FALSE

FALSEFALSEFALSE

Perhaps we need to begin to rethink muscle pain.


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In order to successfully treat muscle pain we need to understand normal muscle function and what factors lead to pain.

Muscle Pain

We need to think physiologically….….not dentally

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Masticatory Muscle PainWhat is it?

What causes it?

SpasmAn involuntary, CNS induced tonic

contraction, often associated with local metabolic conditions.

Cramp

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Masticatory Muscle Pain

Cramp

spasm in a calf muscle

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Masticatory Muscle PainWhat is it?

What causes it?

Spasm

Yet studies demonstrate that there are no differences in EMG activity

between masticatory muscle pain patients and controls.

Yemm 1985Majewski 1984 Carlson, 1993Maillou, 1997Sevensson, 2004

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A Clinical Masticatory Muscle Model

Okeson 2012

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NormalFunction

ResolutionLocal

MuscleSoreness

A Masticatory Muscle Model

Okeson, 2012

Regional Myalgic Disorders

Myofascial PainCentrally Mediated Myalgia

Systemic MyalgicDisorder

Fibromyalgia

Acute Time Chronic

Myospasm

CNS Effectson Muscle Pain

AnEvent

ProtectiveCo-

contraction

23

NormalFunction


Okeson, 2012

AnEvent

An event can alter normal masticatory muscle function.

The eventmay be local

or The eventmay be central

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1. Sudden or unusual alteration in sensory input.2. Deep pain input.

a. associated with local structuresb. idiopathic pain input

3. Trauma.a. local injuryb. excessive or unaccustomed usec. muscle, tendon, or ligament strain

Local Factors:

An Event

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NormalFunction


Okeson, 2012

AnEvent

An event can alter normal masticatory muscle function.

The eventmay be local

or The eventmay be central

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Central Factors:

An Event

1. Increased levels of emotional stress.(an up regulation of the autonomic nervous system)

2. A down regulation of the descending inhibitory system.(systemic disorders, illness, fatigue, diet, etc.)

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NormalFunction


Okeson, 2012

AnEvent

ProtectiveCo-

contraction

If the event does not resolve, or is of significant consequence, the muscles respond with protective co-contraction.

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PainProtective muscle co-contraction(muscle splinting)

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NormalFunction

Resolution


Okeson, 2012

AnEvent

ProtectiveCo-

contraction

If the event is eliminated or isof little consequence,

the protective co-contraction resolves.

Normal humanexperiences.

30

NormalFunction

ResolutionLocal

MuscleSoreness


Okeson, 2012

AnEvent

ProtectiveCo-

contraction

If the event is not eliminated, or is of significant consequence, protective

co-contraction continues resulting inlocal muscle soreness.

The most common acute muscle disorder

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NormalFunction

ResolutionLocal

MuscleSoreness


Okeson, 2012

Acute Time Chronic


AnEvent

ProtectiveCo-

contraction

Activity within the central nervous system can either influence or actually be the origin of the muscle pain. When this occurs the disorder needs to be managed by addressing both peripheral and central factors.

32

NormalFunction

ResolutionLocal

MuscleSoreness


Okeson, 2012

Acute Time Chronic

Myospasm


AnEvent

ProtectiveCo-

contraction- Myospasm -

An involuntary, CNS induced tonic contraction, often associated with local metabolic conditions.

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NormalFunction

ResolutionLocal

MuscleSoreness


Okeson, 2012



Acute Time Chronic

Myospasm


AnEvent

ProtectiveCo-

contraction

34

NormalFunction

ResolutionLocal

MuscleSoreness


Okeson, 2012



Acute Time Chronic

Myospasm


AnEvent

ProtectiveCo-

contraction

Myofascial Pain

site

source

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NormalFunction

ResolutionLocal

MuscleSoreness


Okeson, 2012



Acute Time Chronic

Myospasm


AnEvent

ProtectiveCo-

contraction

Centrally Mediated Myalgia

36

NormalFunction

ResolutionLocal

MuscleSoreness


Okeson, 2012




Fibromyalgia

Acute Time Chronic

Myospasm


AnEvent

ProtectiveCo-

contraction

37

NormalFunction

ResolutionLocal

MuscleSoreness


Okeson, 2012




Fibromyalgia

Acute Time Chronic

Myospasm


AnEvent

ProtectiveCo-

contraction

Fibromyalgia• Widespread muscular and joint pain.• The Wide Spread Pain Index (WPI).• The Symptom Severity Scale (SS).

• WPI of > 7 and SS of > 5• WPI of 3-6 and SS of > 9

• Lasting longer than three months.• There is no other explanation for the pain.

- Important Concept -This is not

a dental problem

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NormalFunction

ResolutionLocal

MuscleSoreness


Okeson, 2012




Fibromyalgia

Acute Time Chronic

Myospasm


AnEvent

Managing Muscle Disorders takes some thinking.

ProtectiveCo-

contraction

ProtectiveCo-

contraction

1Local

MuscleSoreness

2

Myospasm

3

Myofascial Pain4

Fibromyalgia6

Important: They are all managed differently.

5 Centrally Mediated Myalgia

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NormalFunction

Resolution


Acute Time Chronic

AnEvent

ProtectiveCo-

contraction

Because of our limited time, we can only discuss the most common disorder.

Local Muscle Soreness1. Description2. Etiology3. History4. Examination findings5. Treatment

LocalMuscle

Soreness

40

A primary, non-inflammatory, myogenous pain condition.

- description -

Local Muscle Soreness

(muscle fatigue / over use)

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1. Protracted co-contraction produces changes in the muscle tissue, such as fatigue, ischemia, resulting in the production of algogenic substances.

2. Deep pain input (may lead to “cyclic muscle pain”)3. Local tissue trauma

a. local injury (e.g. injections, strain)b. unaccustomed muscle use (e.g. bruxism, chewing

gum) (Delayed onset local muscle soreness)4. Increased levels of emotional stress

- etiology -


42

1. The pain began several hours or days following an event associated with protective co-contraction. (e.g. altered sensory input, high crown)

2. Tissue injury (injections, opening wide, or unaccustomed muscle use - pain may be delayed).

3. Secondary to another source of the pain.4. Associated with an increased level of the emotional

stress.

- history -


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1. Structural dysfunction: a decrease in the velocity and range of mandibular movement. The full range of movement cannot be achieved by the patient. Passive stretching by the examiner can often achieve a more normal range of movement (soft end feel).

- clinical characteristics -


2. Minimal pain at rest.3. Increased pain with function.4. Local tenderness to palpation.

44

The general goal of therapy is to reduce sensory input that can lead to cyclic muscle pain by:

1. Eliminate any ongoing altered sensory or proprioceptive input.2. Education patient and encourage physical self regulation.

a. decrease jaw use to within painless limits.b. stimulate proprioceptors with normal muscle use.c. promote emotional stress awareness / reduction.d. encourage reduction of non-functional tooth contacts

(cognitive awareness).3. Occlusal appliance therapy.4. Considered the use of mild analgesics. (ibuprofen 400mg tid)

- treatment -


45

Expect results in 1-3 weeks.If the therapy is not successful, consider that either:

1. The etiologic factors are not being controlledor

- treatment -


2. You have misdiagnosed the disorder.

MPD

46

Occlusal Appliance Therapy

TypeIndicationsFabricationClinical Protocol

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The Stabilization Appliance

48



49


Chronic Centrally Mediated Myalgia

Bruxism

The Stabilization Appliance

- Indications -

50



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1. The appliance is stable and retentive.2. All the teeth contact evenly on flat surfaces in the

musculoskeletally stable position.3. Eccentric contacts are on the anterior teeth4. In the upright position, posterior teeth contact heavier

than the anterior teeth.5. The appliances smooth and polished.

Final Criteria for the Stabilization Appliance

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Right lateral movement Left lateral movement

The Final Stabilization Appliance

53

The final mandibular stabilization appliance

Right lateral movement Left lateral movement

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Managing the patient with Local Muscle Soreness

Week VAS Treatment

0 6/10 education, physical self regulation reduce use to painless limitsreduce non functional tooth contactsintroduce the stabilization appliance, night time use

1 3/10 reinforce physical self regulationreevaluate the stabilization appliance, adjust PRN



4 0/10 What do you do next?

Managing the patient with Local Muscle Soreness

56

When an occlusal appliance reducesthe patient’s symptoms...

….what do you do next?

57

Reasons that could explain why your occlusal appliance reduced the muscle pain.

58

1. A change in the occlusal condition2. A change in the condylar position3. A change in the vertical dimension4. A change in cognitive awareness5. Altered sensory input to the CNS (bruxism)6. Natural musculoskeletal recovery 7. Placebo effect8. Regression to the mean


59

DentalEtiologies

Non-Dental

Etiologies

So why did the patient respond?

1. A change in the occlusal condition2. A change in the condylar position3. A change in the vertical dimension4. A change in cognitive awareness5. Altered sensory input to the CNS (bruxism)6. Natural musculoskeletal recovery 7. Placebo effect8. Regression to the mean


60

Management of Temporomandibular Disorders

II. Temporomandibular Joint Disorders1. Derangements of the Condyle-Disc Complex

a. Disc Displacement with Reductionb. Disc Dislocation with Reductionc. Disc Displacement without Reduction

2. Structural Incompatibilities3. Inflammatory Disorders

I. Masticatory Muscle Disorders1. Protective Co-Contraction2. Local Muscle Soreness3. Myofascial Pain4. Myospasm5. Chronic Centrally Mediated Myalgia

61

Management of TM joint disorders

What about the use of an“Anterior Positioning Appliance” ?

62

A painful disc displacement

- Think orthopedically -

63

- Think orthopedically -

Anterior therapeutic position, pain reduction

64

The anteriorpositioning appliance

65

The anteriorpositioning appliance

66

- an interesting question -

When an “Anterior Positioning Appliance”reduces the patient symptoms…..

.....what do you do next ?

The problem was there were no data.

67

Which philosophy is correct?

The Re-builders

MS position

The Re-capturers

MS position

The Repairers

MS position

68

What is the short-term successof anterior positioning appliances?

69

Short-term Treatment of Disc Displacement With Reduction (phase I)

author # of pat type of tx duration reported success

Anderson et al 10 APA - 24 hrs/day 3 months sign. improvement1985 10 SA -24 hrs/day 3 months no change

Lundh et al 24 APA - 24 hrs/day 6 weeks much better1985 23 SA - 24 hrs/day 6 weeks slightly better

23 Control 6 weeks no change

Okeson 40 APA - 24 hrs/day 2 months 80%1986

Simmons et al 7 APA - 24 hrs/day 9 months 95%1995

Davies et al 40 APA - 24 hrs/day 2 months 88%1997 25 APA - only HS 2 months 65%

20 APA - only day 2 months 52%average 75-80%

70

What is the long-term successof anterior positioning appliances

for pain and dysfunction?

71

author # of pat type of tx duration success/pain & dysfunction

Moloney & 241 no occlusal changes 3 yrs 36%Howard,1986 APA & orthodontics 3 yrs 50%

APA & Cr / Bridge 3 yrs 43%

Okeson 40 no occlusal changes 2.5 yrs 25%1988

Butterworth 151 APA & orthodontics 1.75 yrs 51%et al, 1992

Davies et al 48 no occlusal changes 3 yrs 70%1997

Vichaichalerm- 17 no occlusal changes 4.2 yrs 35% vong et al,1993

Summers et al 75 APA & Cr / Bridge 1-6 yrs 52%1997

Tallents et al 68 APA & Cr / Bridge 1-3 yrs 44%1990

Long-term Treatment of Disc Displacement With Reduction (phase II)

average 45%

72

What is the long-term successof anterior positioning appliances

when pain and dysfunctionare evaluated separately?

73

author # of pat type of tx duration success/pain success/click

Moloney & 241 no occlusal changes 3 yrs not reported 36%Howard,1986 APA & orthodontics 3 yrs not reported 50%

APA & Cr / Bridge 3 yrs not reported 43%

Okeson 40 no occlusal changes 2.5 yrs 75% 33%1988

Butterworth 151 APA & orthodontics 1.75 yrs 86% 51%et al, 1992

Davies et al 48 no occlusal changes 3 yrs 87-92% 70%1997

Vichaichalerm- 17 no occlusal changes 4.2 yrs 77% 35% vong et al,1993

Summers et al 75 APA & Cr / Bridge 1-6 yrs 86% 52%1997

Tallents et al 68 APA & Cr / Bridge 1-3 yrs _ 44% 1990

Long-term Treatment of Disc Displacement with reduction (phase II)

average 83% average 45%

74

What is the long-term successfor Joint Sounds?

75

author # of pat type of tx duration success

Moloney & Howard 34 APA & orthodontics 3 yrs 50% click returned1986 14 APA & Cr / Bridge 3 yrs 43% click returned

Butterworth et al, 1992 151 APA & orthodontics 1.75 yrs 49% click returned

Summers et al, 1997 75 APA & Cr / Bridge 1-6 yrs 48% click returned

Tallents et al, 1990 68 APA & Cr / Bridge 1-3 yrs 56% click returned

Okeson, 1988 40 no occlusal changes 2.5 yrs 67 % click returned

Vichaichalermvong et al, 1993 17 no occlusal changes 4.2 yrs 65% click returned

Dolwick et al, 1987 33 TMJ surgery 4.2 yrs 58% click returned

de Leeuw , 1994 99 Nonsurgical 30 yrs 56% click returned

Long-term Success for Joint Sounds

average 55% return

76

Summary of Studies on Anterior Positioning Appliance Therapy

Long-term effects

Pain Clicking

Yes YesShort-term effects

Yes No

77

Treatment Considerations

Has the Disc been “recaptured” ?

78

MS position

Painful loading of the retrodiscal tissues.

79

Position the mandible forward off the retrodiscal tissues.(pain reduction)

MS position

The retrodiscal tissues adapt.

80

The condyle can now function in the musculoskeletally stable position painlessly.

(there may still be clicking)

MS position

81

Long-term Outcome of Disc Displacement with reduction

- conclusions from results of long-term studies -

Anterior positioning appliances may be helpful but only on a part time basis.

1. Educating the patient to the problem2. Reduce heavy chewing3. Reduce non-functional tooth contacts4. Appliance therapy

Our goal should be to help the patient adaptthe retrodiscal tissues by reducing loading forces.

82

Protrude the mandible

Contraction of the inferior lateral pterygoid.

83

With time the muscle develops

a myostatic contracture.

A painless shorteningof the functional length

of the muscle.

The result is a posterior open bite

84

Final Anterior Positioning Appliance

85

A temporary therapeutic position

nota final treatment position.

86

Clinicalevaluation

Stabilization Appliance(always at night and

when needed during the day)

No pain

Continuedpain

Time,re-evaluate

Reduce use of theappliance and assess

for orthopedic stability

Anterior Positioning Appliance(always at night and

when needed during day)

Reduces pain Time,re-evaluate

Decrease useof the appliance

Returnof pain

Management of disc displacement with reduction

Patient

No changein pain

No pain

No further treatment indicated(consider bruxism)

87

Return tothe APA

Pain reduction, allow more time

Convert the APAto a SA

Orthopedic stability

Pain returns

No pain

Assess fororthopedic stability

Orthopedic instability

Evaluate for appropriate

dental therapy

No dental therapy

indicated


88

Clinicalevaluation

Stabilization Appliance(always at night and

when needed during the day)

No pain

Continuedpain

Time,re-evaluate

Reduce use of theappliance and assess

for orthopedic stability

Anterior Positioning Appliance(always at night and

when needed during day)

Reduces pain

No changein pain

Time,re-evaluate

Decrease useof the appliance

No pain,no further treatment indicated

(consider bruxism)

Returnof pain

Patient

Begin24 hour use

Reduction of pain

No reduction of pain Re-evaluate pain, consider surgical

evaluation


89

Long-term Outcome of Disc Displacement with reduction

- conclusions from results of long-term studies -

Anterior positioning appliances may be helpful but only on a part time basis.

Permanent occlusal changes are seldom indicated.

1. Educating the patient to the problem2. Reduce heavy chewing3. Reduce non-functional tooth contacts4. Appliance therapy

Our goal should be to help the patient adaptthe retrodiscal tissues by reducing loading forces.

90

- Some closing thoughts -

A few closing thoughts.

91

Remember the importance of establishing the proper diagnosis.

92

Some Important Questions

Who should you treat?

Success begins with selecting the patients you can help.

Cervical Pain

TMJ Pain

Neuropathic Pain

Muscle Pain

93


Effective management of orofacial painis achieved more by thinking than doing.

Use your brain it isyour most powerful tool.

94


Thinking provides the proper diagnosis,making treatment predictable and reliable.

95


It’s what you think you know...

96


It’s what you think you know...

...that keeps you from learning.

97


“It’s not what you don’t know that gets you in trouble…..

...its what you do knowthat just ain’t so.”

Mark Twain

98


“It’s what you learn after you know it allthat really counts.”

Coach John Wooden

99


Confidence is what you feel…

100


Confidence is what you feel…

...before you know all the details.

101

Don’t jump too soon.


102


This isn’t rocket science, but it does take some thinking.

103


“The greatest problem in communicationis the illusion that

it has been accomplished.”

- George Bernard Shaw

104

Remember……next Monday morning, you are going to have a

28 year old female will come to your office.

Chief Complaint: facial pain with limited mouth opening

What will you do? How will youtreat her?

105

Do not ever lose sight of the fact that we are healthcare providers.We have been granted the privilege of treating our fellow men/women.

- A closing philosophical thought -

When you do this, you will have a happy and grateful patient.Treatment plan your patients as if they were family members.

106

Seventh EditionFebruary 2014

Quintessence Publishers1-800-621-0387

Eighth Edition488 pages

2019

Elsevier/Mosby Company1-800-325-4177

Newly Updated Lecture Series- DVDs or streaming -www.jeffokeson.net

Okeson Texts Okeson Home Page

University of KentuckyMini-Residency Program

June 7-11-2021 Shadowing Program

1 week (40 hr)

[email protected]

107

Documents

TMD all day handout part 2 for 9-25-20