Download References Masticatory System • Psychosocial function

Steve Kraus PT OCS MTC CCTT CODN
5/17/14
The Triangles of Treatment
of the Masticatory System
Steve Kraus PT
Biopsychosocial
Approach
Movement
System
Impairments
Manual
Therapy
References
Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders:
Review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;
6:301-355.
Kraus SL. Temporomandibular disorders. In: Saunders HD, Saunders Ryan R, editors.
Evaluation, treatment and prevention of musculoskeletal disorders, vol. 1 - Spine. 4th edition.
Chaska (MN): The Saunders Group, Inc.; 2004. p. 173–210.
Kraus SL. Head and Orofacial Pain; Cervical Spine Implications Editor, H Gremillion Dental
Clinics of North America 2007; 51(1):161- 93
Methodological quality of a systematic review on physical therapy for temporomandibular
disorders: influence of hand search and quality scales Craane B, Dijkstra P, Stappaerts K & De
Laat A Clin Oral Invest Dec 2010
American Academy of Orofacial Pain: Guidelines for Assessment Diagnosis, and Management,
ed 5. De Leeuw R and Klasser GD (eds). Chicago: 2013.
Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for clinical and Research
Applications. Schiffman E, Ohrbach R, Truelove E. et al J Oral Facial Pain Headache 2014;
28: 6-27
Masticatory System
Masticatory system is important to an
individual’s general health and quality of life.
• Orofacial function
chew
swallow
yawn
brushing of teeth
• Psychosocial function
talk
smile
www.TMDstevekraus.com
laugh
kiss
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Steve Kraus PT OCS MTC CCTT CODN
5/17/14
Movement
System
Impairments
Masticatory System
Impairment of the masticatory system may result from;
Malocclusion
Imperfect positioning of the teeth when the jaws are closed.
If the malocclusion is effecting the patient’s oral function
and psychosocial function then necessary dental treatment
is needed, i.e. orthognathic surgery, orthodontics, full
mouth reconstruction and equilibration.
There is an absence of evidence, from RCTs, that treatment of
the malocclusion treats or prevents TMD.
In only select cases should irreversible procedures to the
occlusion be done for the treatment of TMD.
The Cochrane Library, Issue 2, 2005.
Masticatory System
Temporomandibular Disorder Temporomandibular Joint
Muscles of mastication
Conservative, reversible, and cost-effective treatments are
recommended for the vast majority of patients suffering from
acute or chronic TMD pain and dysfunction.
Conservative treatments includes;
oral appliance therapy
pharmacologic management
physical therapy
Why physical therapy for the treatment of TMD?
TMD is a musculoskeletal problem
TMD ranks only second to low back pain in the US
Physical therapy is conservative
Physical therapy is cost effective
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Steve Kraus PT OCS MTC CCTT CODN
•
Myalgia 728.85
local myalgia
myofascial pain
myofascial pain with referral
lateral pterygoid spasm
trismus
•
•
5/17/14
Arthralgia 524.62
Subluxation 830.1
Disc Displacements 524.63
Disc displacement with reduction
Disc displacement with reduction
with intermittent locking
Disc displacement without reduction with
limited opening
Disc displacement without reduction
without limited opening
•
Degenerative Joint Disease 715.18
RDC/TMD is a landmark paper providing operational definitions to distinguish TMD
patients from controls and to diagnose the most common subtypes of TMD using
reasonable reliable and valid tests and measurements
Myalgia
Opening and Closing Muscles
Supra hyoid /
infra muscles
Temporalis
Medial
Pterygoid
Masseter
Lateral
pterygoid
Myalgia
History
.90 sensitivity and .99 specificity
In the past 30 days patient reports having;
1. Pain in the jaw, temple, in the ear or in front of the ear that;
a. Is modified with jaw movement, function or parafunction and / or
b. awakens them at night and / or is present in the AM upon awakening
Exam
Positive for both of the following
1.
2.
Confirmation of pain location(s) in the temporalis and/or masseter muscle(s)
Report of familiar pain in the temporalis or masseter muscle(s) with at least
one of the following provocation tests;
a. Palpation of the temporalis or masseter muscle(s)
b. Maximum unassisted or assisted opening movement(s)
Baseline measurements; measure interincisal opening (IO)
a. without pain
b. with max unassisted opening
c. with assisted opening
Functional mouth opening;
> 30mm interincisal opening (IO)
www.TMDstevekraus.com
a
b
c
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Steve Kraus PT OCS MTC CCTT CODN
5/17/14
Biopsychosocial
Approach
Pain
Biopsychosocial issues
Pain, is much more than a physical entity.
A patient's pain experience and reaction to pain is driven
by the individual’s biopsychosocial makeup (depression /
fear / anxiety)
A bidirectional relationship between pain and emotions
(D/F/A)
Depression / anxiety / fear can develop as a result of pain
or if patient is predisposed to depression, anxiety and fear,
such emotions can be magnified because of pain.
Giesecke, T., Gracely, R.H., Williams, D.A., et al 2005. The relationship between depression,
clinical pain, and experimental pain in a chronic pain cohort. Arthritis Rheum. 2005; 52, 1577–
1584.
Patient Health Questionnaire (PHQ)
Is short, reliable and valid screening instrument for
detecting “psychological distress” due to anxiety and/or
depression in patients in any clinical setting
Graded Chronic Pain Scale 2.0
Is short, reliable and valid screening instrument for
measureing pain intensity and disability
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Steve Kraus PT OCS MTC CCTT CODN
Pain
5/17/14
Biopsychosocial issues
Biopsychosocial issues are enhanced by the
patient’s journey to find relief in their pain.
Patients with TMD often consult with multiple healthcare
providers, or consulted with family members, friends and
the internet.
Each source is telling the patient something different as to
what it is they have and what treatments are needed.
Patients become confused enhancing the feelings of
hopelessness, fear, anxiety and depression.
Pain
Biopsychosocial issues
Patient Education
Patient Education to reduce unnecessary fear and anxiety.
Fear and anxiety may contribute to bruxism
Educate the patient on your diagnostic findings.
Provide time for the patient to ask any questions about
your diagnosis and expectations of treatment.
ask the patient if they have any questions regarding
what previous healthcare professionals have said about
their condition.
ask what their primary stresses and concerns are
Manual
Therapy
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Steve Kraus PT OCS MTC CCTT CODN
5/17/14
Treatments for Myalgia
Patient Education to reduce fear / anxiety. Fear and anxiety may
contribute to bruxism.
Bruxism is one of several oral parafunctional activities
Parafunctional activity include habitual use of the mouth
unrelated to eating, drinking, yawning or talking.
Behavioral Modification
Decrease or eliminate oral parafunctional activity
–
–
nocturnal bruxism
– diurnal bruxism
biting finger nails, chewing gum, ice, pencil, etc.
Modalities Electric stimulation
(pre mod interferential)
Ultrasound
Iontophoresis
Cervical Spine Disorder
Substantial evidence has shown cervical spine
mobility and positioning influences the
kinematics of the human mandible.
Cervical Spinal Pain in Chronic Craniomandibular Pain
Patients. Visscher CM. Printed by; Thela Thesis,
Amsterdam; 2000
Satellite trigger points in the masticatory muscles may prove
resilient to treatment until the primary trigger points in cervical
spine muscles have been treated first.
Reduction of pain and EMG activity in the masseter region by trapezius
trigger point injection Carlson C, Okeson J, Falace D, et al. Pain, 55 (1993)
397-400
Summary
Treatments for Myalgia
Patient Education to reduce fear / anxiety. Fear
and anxiety may contribute to bruxism.
Behavioral Modification
Modalities
Cervical Spine Disorder
Dry Needling
Intraoral Massage
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Steve Kraus PT OCS MTC CCTT CODN
5/17/14
Massage the muscles of mastication to treat Myalgia
Massaging jaw muscles will help;
reduce pain
reduce pain with chew, talk and yawn
increase mouth opening (if closing muscles are tight)
to get back teeth together (if opening muscle is tight)
Temporalis
Medial
Pterygoid
Masseter
Lateral
pterygoid
Massage
Masseter
Masseter
Origin:
Superficial portion – anterior 2/3 of lower
border of zygomatic arch
Deep portion – medial surface of zygomatic
arch
Insertion:
Lateral surface of ramus and angle of
mandible
Function:
Elevates the mandible
Massage
Indication for massaging the
lateral pterygoid muscle;
Lower head
lateral pterygoid
Facial pain not responding to other treatments
for myalgia
Pterygoid muscle spasm
www.TMDstevekraus.com
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Steve Kraus PT OCS MTC CCTT CODN
Lateral Pterygoid
Lower head
lateral pterygoid
5/17/14
Massage
Origin:
lateral surface of the lateral pterygoid plate
Insertion:
neck of condyle of the mandible
Function:
Depresses mandible, protrude mandible, side to
side movement of mandible
Pterygoid spasm may occur when;
• blow to chin
• unexpected resistance when
chewing
• yawning
Patient unable to bring back teeth together on the side of the spasm.
Masseter massage
Lower head lateral pterygoid massage (area)
Location of finger tip
Brace finger against patient's upper gum line
Ask patient to open & close mouth
Opening will bring pterygoid muscle into
palpation finger
www.TMDstevekraus.com
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Steve Kraus PT OCS MTC CCTT CODN
5/17/14
The Triangles of Treatment
of the Masticatory System
Steve Kraus PT
Patient Education
Biopsychosocial
Approach
Movement
System
Impairments
Manual
Therapy
Myalgia;
Intraoral Massage
pain and limited oral functions
may or may not have limited mouth opening
may or may not be able to bring back teeth together
Thank You
www.TMDstevekraus.com
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