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in: How to Practice at Today’s Standard of Care
OROFACIAL PAIN: Standard of Care
Charles McNeill, DDS, FACD, FICD
Professor Emeritus & Director
Patricia A. Rudd, PT, DPT CCTT
Associate Clinical Professor
UCSF Center for Orofacial Pain
3.
Monday, August 31, 15
Articular Disc Disorders
ACUTE TMD DIAGNOSES
Acute TMD Mgt
(Localized Musculoskeletal Disorders)
Monday, August 31, 15
TM Joint Pain
v Masticatory Muscle Pain
v
AAOP TMD Dx Classification:
Localized Disorders
Monday, August 31, 15
AAOP TMD Dx Classification:
Localized Disorders
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•
•
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Monday, August 31, 15
ARTICULAR
Devel./ Acquired Disord.
Disc Disorders
Inflammatory Disorders
Degenerative Disorders
TMJ Dislocation
Ankylosis
AAOP TMD Dx Classification:
Localized Disorders
•
•
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ARTICULAR
Devel./ Acquired Disord.
Disc Disorders
Inflammatory Disorders
Degenerative Disorders
TMJ Dislocation
Ankylosis
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
Monday, August 31, 15
DISC DISORDERS
Monday, August 31, 15
DISC DISORDERS
v
Disc Displace. w Reduction
v Asymptomatic
(Biologic Variation)
Monday, August 31, 15
DISC DISORDERS
v
Disc Displace. w Reduction
v Asymptomatic
(Biologic Variation)
Monday, August 31, 15
DISC DISORDERS
Disc Displace. w Reduction
v Asymptomatic
(Biologic Variation)
v Disc Displace. w Reduction
❖Symptomatic
(Impingement Disorder)
v
Monday, August 31, 15
DISC DISORDERS
Disc Displace. w Reduction
v Asymptomatic
(Biologic Variation)
v Disc Displace. w Reduction
❖Symptomatic
(Impingement Disorder)
v
Monday, August 31, 15
DISC DISORDERS
Disc Displace. w Reduction
v Asymptomatic
(Biologic Variation)
v Disc Displace. w Reduction
❖Symptomatic
(Impingement Disorder)
v
v
Disc Displace. w/o Reduction
v Acute “Closed Lock”
Monday, August 31, 15
DISC DISORDERS
Disc Displace. w Reduction
v Asymptomatic
(Biologic Variation)
v Disc Displace. w Reduction
❖Symptomatic
(Impingement Disorder)
v
v
Disc Displace. w/o Reduction
v Acute “Closed Lock”
Monday, August 31, 15
DISC DISORDERS
Disc Displace. w Reduction
v Asymptomatic
(Biologic Variation)
v Disc Displace. w Reduction
❖Symptomatic
(Impingement Disorder)
v
v
Disc Displace. w/o Reduction
v Acute “Closed Lock”
v
Disc Displace. w/o Reduction
v Chronic “Closed Lock”
Monday, August 31, 15
DISC DISORDERS
Disc Displace. w Reduction
v Asymptomatic
(Biologic Variation)
v Disc Displace. w Reduction
❖Symptomatic
(Impingement Disorder)
v
v
Disc Displace. w/o Reduction
v Acute “Closed Lock”
v
Disc Displace. w/o Reduction
v Chronic “Closed Lock”
Monday, August 31, 15
ASYMPTOMATIC DISC DISPL. w RED.
(Biologic Variation - Clicking)
Ribeiro RF et al: J Orofacial Pain 1997;11:37-47
Westesson P-L et al: OOO 1989; 68:551-554
Monday, August 31, 15
ASYMPTOMATIC DISC DISPL. w RED.
(Biologic Variation - Clicking)
v
DEFINITION: Condyle Re-establishes a Normal
Anat. Relat. w Disc During Condylar Translation
Ribeiro RF et al: J Orofacial Pain 1997;11:37-47
Westesson P-L et al: OOO 1989; 68:551-554
Monday, August 31, 15
ASYMPTOMATIC DISC DISPL. w RED.
(Biologic Variation - Clicking)
v
DEFINITION: Condyle Re-establishes a Normal
Anat. Relat. w Disc During Condylar Translation
v
Common In Asymptomatic Volunteers
(34% of 56 controls)
v
v
v
v
TMJ Clicking w Mand. Mvt.
Normal Mand. Mobility (ROM)
Ipsalateral Deviation on Opening
Pain-free Mandibular Function
Ribeiro RF et al: J Orofacial Pain 1997;11:37-47
Westesson P-L et al: OOO 1989; 68:551-554
Monday, August 31, 15
ETIOLOGY:
Disc Displacement w Reduction (Clicking)
GENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS
§
§
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§
§
Monday, August 31, 15
Developmental Biologic Variation
Previous History Macrotrauma
Microtrauma Related to Bruxism??
Pathophysiologic, e.g.,
Synovial Fluid Degradation
Hormonal, e.g., Jt. Laxity
Contrib. Fx. May Be
á Muscle Activity
(2° to Overuse, Stress)
Goal Oriented Plan:
Non-Painful Disc Displacement w Reduction
GOALS
¤ Reassure
Patient of Insignificance of
Clinical Sign in Adult
¤ Inform Parents of Possible Decreased
Mandibular Growth in Children
PLAN
¤ Patient
Monday, August 31, 15
Education
Goal Oriented Plan:
Non-Painful Disc Displacement w Reduction
GOALS
¤ Reassure
Patient of Insignificance of
Clinical Sign in Adult
¤ Inform Parents of Possible Decreased
Mandibular Growth in Children
PLAN
¤ Patient
Monday, August 31, 15
Education
SYMPTOMATIC DISC DISPL. w REDEDUCTION
(Impingement Disorder -Clicking with Hesitation,
Catching & Possible Pain)
Ribeiro RF et al: J Orofacial Pain 1997;11:37-47
Westesson P-L et al: OOO 1989; 68:551-554
Monday, August 31, 15
SYMPTOMATIC DISC DISPL. w REDEDUCTION
(Impingement Disorder -Clicking with Hesitation,
Catching & Possible Pain)
v
DEFINITION: Condyle Re-establishes a Normal
Anat. Relat. w Disc but w Episodic Difficulty/Pain
(Possible disc, synovium or capsule Impingement)
Ribeiro RF et al: J Orofacial Pain 1997;11:37-47
Westesson P-L et al: OOO 1989; 68:551-554
Monday, August 31, 15
SYMPTOMATIC DISC DISPL. w REDEDUCTION
(Impingement Disorder -Clicking with Hesitation,
Catching & Possible Pain)
v
DEFINITION: Condyle Re-establishes a Normal
Anat. Relat. w Disc but w Episodic Difficulty/Pain
(Possible disc, synovium or capsule Impingement)
v
CLINICAL PRESENTATION:
v
v
v
v
TMJ Clicking w Mand. Mvt.
Dev. & Pos. Hesitency w Red.
Normal ROM unless Jaw “Catches”
Pain at Time Condyle Re-establishes
Normal Anat. Relat. w Disc
Ribeiro RF et al: J Orofacial Pain 1997;11:37-47
Westesson P-L et al: OOO 1989; 68:551-554
Monday, August 31, 15
Goal Oriented Plan:
Symptomatic DD w Reduction (Impingement)
Clicking with Hesitation, Catching & Possible Pain
Monday, August 31, 15
Goal Oriented Plan:
Symptomatic DD w Reduction (Impingement)
Clicking with Hesitation, Catching & Possible Pain
Monday, August 31, 15
Goal Oriented Plan:
Symptomatic DD w Reduction (Impingement)
Clicking with Hesitation, Catching & Possible Pain
¤ PAIN
CONTROL:
• Self-Management (Rest, Jaw Relax.)
• Meds (NSAIDS, Muscle Relaxants)
• Physical Therapy (ES, US)
Monday, August 31, 15
Goal Oriented Plan:
Symptomatic DD w Reduction (Impingement)
Clicking with Hesitation, Catching & Possible Pain
¤ PAIN
CONTROL:
• Self-Management (Rest, Jaw Relax.)
• Meds (NSAIDS, Muscle Relaxants)
• Physical Therapy (ES, US)
¤ IMPROVE
QUALITY of MOBILITY:
• Physical Therapy
(Jt. Mob./Self Reduction)
• Home Exercise Program
(Gentle Stabilization Exercises;
Muscle Contract. w/o Jt. Move.)
Monday, August 31, 15
Goal Oriented Plan:
Symptomatic DD w Reduction (Impingement)
Clicking with Hesitation, Catching & Possible Pain
¤ PAIN
CONTROL:
• Self-Management (Rest, Jaw Relax.)
• Meds (NSAIDS, Muscle Relaxants)
• Physical Therapy (ES, US)
¤ IMPROVE
QUALITY of MOBILITY:
• Physical Therapy
(Jt. Mob./Self Reduction)
• Home Exercise Program
(Gentle Stabilization Exercises;
Muscle Contract. w/o Jt. Move.)
Monday, August 31, 15
STRUCTURED SELF-CARE PROGRAM
§
Rest the Masticatory System
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Soft Diet (Chew Slowly)
Chew on the Affected Side
Avoid Biting on Anteriors
Avoid Chewing Gum
Habit Awareness & Modification
Relaxation / Coping Strategies
Lifestyle Changes
Bite Force
Monday, August 31, 15
STABILIZATION EXERCISES
Gentle Isometric Exercises:
Muscle Contraction w/o Joint Movement
§ Resist Opening, Closing,
§
§
Monday, August 31, 15
Laterotrusion & Protrusion
Hold for 5 secs
Repeat 5 Times, 3-5 times/d
Acute Musculoskeletal TMD/OFP
Management Model
Patient Education
APPLIANCE INDICATIONS
When Symptoms Are
at Their Worst on Waking
(Short Term / Not 24/7)
Symptomatic Care
Behavior Modification
Bite Force
Pharmacotherapy
Physical Rehabilitation
Oral Appliance Therapy
Monday, August 31, 15
Acute Musculoskeletal TMD/OFP
Management Model
Patient Education
APPLIANCE INDICATIONS
When Symptoms Are
at Their Worst on Waking
(Short Term / Not 24/7)
Symptomatic Care
Behavior Modification
Bite Force
Pharmacotherapy
Physical Rehabilitation
Oral Appliance Therapy
Monday, August 31, 15
Acute Musculoskeletal TMD/OFP
Management Model
Patient Education
APPLIANCE INDICATIONS
When Symptoms Are
at Their Worst on Waking
(Short Term / Not 24/7)
Symptomatic Care
Behavior Modification
Bite Force
Pharmacotherapy
Physical Rehabilitation
Oral Appliance Therapy
Monday, August 31, 15
Acute Musculoskeletal TMD/OFP
Management Model
Patient Education
APPLIANCE INDICATIONS
When Symptoms Are
at Their Worst on Waking
(Short Term / Not 24/7)
Symptomatic Care
Behavior Modification
Bite Force
Pharmacotherapy
Physical Rehabilitation
Oral Appliance Therapy
Monday, August 31, 15
Studies Comparing Stabil. Splint & NTI
Monday, August 31, 15
Studies Comparing Stabil. Splint & NTI
๏
๏
๏
Monday, August 31, 15
Nociceptive Trigeminal Inhibition Suppression System Not
Supported By Bruxism Studies
Clenching & Grinding Unchanged w Both Appliances
No Relevent Differences in Signs & Symptoms
Studies Comparing Stabil. Splint & NTI
๏
๏
๏
Nociceptive Trigeminal Inhibition Suppression System Not
Supported By Bruxism Studies
Clenching & Grinding Unchanged w Both Appliances
No Relevent Differences in Signs & Symptoms
Magnusson T et. al., Swed Dent J 2004;28:11-20
Monday, August 31, 15
Studies Comparing Stabil. Splint & NTI
๏
๏
๏
Nociceptive Trigeminal Inhibition Suppression System Not
Supported By Bruxism Studies
Clenching & Grinding Unchanged w Both Appliances
No Relevent Differences in Signs & Symptoms
Magnusson T et. al., Swed Dent J 2004;28:11-20
๏
Monday, August 31, 15
Decrease in Postural EMG Activity was Short Lasting w Both Appliances;
But EMG Not Related to Clin. Outcome
Studies Comparing Stabil. Splint & NTI
๏
๏
๏
Nociceptive Trigeminal Inhibition Suppression System Not
Supported By Bruxism Studies
Clenching & Grinding Unchanged w Both Appliances
No Relevent Differences in Signs & Symptoms
Magnusson T et. al., Swed Dent J 2004;28:11-20
๏
Decrease in Postural EMG Activity was Short Lasting w Both Appliances;
But EMG Not Related to Clin. Outcome
Bodere C, Woda A, Int J Prosthodont 2008;21:253-258
Bad-Hansen L et al,, Jr Oral Rehabil 2007;34:105-111
Monday, August 31, 15
Studies Comparing Stabil. Splint & NTI
๏
๏
๏
Nociceptive Trigeminal Inhibition Suppression System Not
Supported By Bruxism Studies
Clenching & Grinding Unchanged w Both Appliances
No Relevent Differences in Signs & Symptoms
Magnusson T et. al., Swed Dent J 2004;28:11-20
๏
Decrease in Postural EMG Activity was Short Lasting w Both Appliances;
But EMG Not Related to Clin. Outcome
Bodere C, Woda A, Int J Prosthodont 2008;21:253-258
Bad-Hansen L et al,, Jr Oral Rehabil 2007;34:105-111
๏
Monday, August 31, 15
RCT of 40 Pts Comparing Stabilization Splints w NTI
No Statistically Significant Difference over 3 mos.
Studies Comparing Stabil. Splint & NTI
๏
๏
๏
Nociceptive Trigeminal Inhibition Suppression System Not
Supported By Bruxism Studies
Clenching & Grinding Unchanged w Both Appliances
No Relevent Differences in Signs & Symptoms
Magnusson T et. al., Swed Dent J 2004;28:11-20
๏
Decrease in Postural EMG Activity was Short Lasting w Both Appliances;
But EMG Not Related to Clin. Outcome
Bodere C, Woda A, Int J Prosthodont 2008;21:253-258
Bad-Hansen L et al,, Jr Oral Rehabil 2007;34:105-111
๏
RCT of 40 Pts Comparing Stabilization Splints w NTI
No Statistically Significant Difference over 3 mos.
Jousted A et al: Acta Odont Scandinavia 2005;63;218-226
Monday, August 31, 15
Studies Comparing Stabil. Splint & NTI
๏
๏
๏
Nociceptive Trigeminal Inhibition Suppression System Not
Supported By Bruxism Studies
Clenching & Grinding Unchanged w Both Appliances
No Relevent Differences in Signs & Symptoms
Magnusson T et. al., Swed Dent J 2004;28:11-20
๏
Decrease in Postural EMG Activity was Short Lasting w Both Appliances;
But EMG Not Related to Clin. Outcome
Bodere C, Woda A, Int J Prosthodont 2008;21:253-258
Bad-Hansen L et al,, Jr Oral Rehabil 2007;34:105-111
๏
RCT of 40 Pts Comparing Stabilization Splints w NTI
No Statistically Significant Difference over 3 mos.
Jousted A et al: Acta Odont Scandinavia 2005;63;218-226
•
•
•
•
Monday, August 31, 15
NTI RISKS:
Super-eruption of Teeth
Intrusion of Ant. Teeth
Increased Mobility/Sensitivity
of Ant. Teeth
Irreversible Alteration of
Condylar Position
Studies Comparing Stabil. Splint & NTI
๏
๏
๏
Nociceptive Trigeminal Inhibition Suppression System Not
Supported By Bruxism Studies
Clenching & Grinding Unchanged w Both Appliances
No Relevent Differences in Signs & Symptoms
Magnusson T et. al., Swed Dent J 2004;28:11-20
๏
Decrease in Postural EMG Activity was Short Lasting w Both Appliances;
But EMG Not Related to Clin. Outcome
Bodere C, Woda A, Int J Prosthodont 2008;21:253-258
Bad-Hansen L et al,, Jr Oral Rehabil 2007;34:105-111
๏
RCT of 40 Pts Comparing Stabilization Splints w NTI
No Statistically Significant Difference over 3 mos.
Jousted A et al: Acta Odont Scandinavia 2005;63;218-226
•
•
•
•
NTI RISKS:
Super-eruption of Teeth
Intrusion of Ant. Teeth
Increased Mobility/Sensitivity
of Ant. Teeth
Irreversible Alteration of
Condylar Position
Greene CS & Obrez A
OOOO 2015;119:489-498
Monday, August 31, 15
NORMAL CONDYLE / DISC POSITION
DISC DISPLACEMENT w REDUCTION
Monday, August 31, 15
NORMAL CONDYLE / DISC POSITION
DISC DISPLACEMENT w REDUCTION
Monday, August 31, 15
NORMAL CONDYLE / DISC POSITION
DISC DISPLACEMENT w REDUCTION
Monday, August 31, 15
ACUTE DISC DISPL. w/o REDUCTION
(Clicking Converts to Abrupt Loss of Clicking & Movement)
Monday, August 31, 15
ACUTE DISC DISPL. w/o REDUCTION
(Clicking Converts to Abrupt Loss of Clicking & Movement)
v
Monday, August 31, 15
DEFINITION: Condyle Fails to Re-establish a
Normal Anat. Rel. w Disc During Condylar
Translation or Rotation; < 3mo.
ACUTE DISC DISPL. w/o REDUCTION
(Clicking Converts to Abrupt Loss of Clicking & Movement)
v
Monday, August 31, 15
DEFINITION: Condyle Fails to Re-establish a
Normal Anat. Rel. w Disc During Condylar
Translation or Rotation; < 3mo.
ACUTE DISC DISPL. w/o REDUCTION
(Clicking Converts to Abrupt Loss of Clicking & Movement)
v
Monday, August 31, 15
DEFINITION: Condyle Fails to Re-establish a
Normal Anat. Rel. w Disc During Condylar
Translation or Rotation; < 3mo.
ACUTE DISC DISPL. w/o REDUCTION
(Clicking Converts to Abrupt Loss of Clicking & Movement)
v
DEFINITION: Condyle Fails to Re-establish a
Normal Anat. Rel. w Disc During Condylar
Translation or Rotation; < 3mo.
v
CLINICAL PRESENTATION:
1. Joint Pain Provoked by Fx.
2. Marked Limited Mand. Mvt.
w Hard End-feel
3. Straight Line Deflection
to Affected Side
4. Marked Ltd. Laterotrusion
to Contralat. Side
Monday, August 31, 15
ETIOLOGY:
Disc Displacement w/o Reduction
§
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§
PREDISPOSING FX: DD w Reduction
Macrotrauma
Pathophysiologic
i.e., áSynovial Fluid Degradation
Sustained á in Overuse of Jaw
Abrupt Change in Oral Function
Abrupt Change in Occl. / Appl.Therapy
Contrib. Fx May Be áá Muscle Activity
(2° to Overuse, Stress)
Monday, August 31, 15
Goal Oriented Plan:
Acute Disc Displ. w/o Reduction
with Possible Co-morbid Synovitis
Monday, August 31, 15
Goal Oriented Plan:
Acute Disc Displ. w/o Reduction
with Possible Co-morbid Synovitis
Monday, August 31, 15
Goal Oriented Plan:
Acute Disc Displ. w/o Reduction
with Possible Co-morbid Synovitis
๏ INCREASE
MOBILITY:
• Restore Joint Biomechanics
• Physical Therapy
(Joint Mobilization, S&S, STM )
• Home Exercise Program
Monday, August 31, 15
Goal Oriented Plan:
Acute Disc Displ. w/o Reduction
with Possible Co-morbid Synovitis
๏ INCREASE
MOBILITY:
• Restore Joint Biomechanics
• Physical Therapy
(Joint Mobilization, S&S, STM )
• Home Exercise Program
Monday, August 31, 15
Goal Oriented Plan:
Acute Disc Displ. w/o Reduction
with Possible Co-morbid Synovitis
๏ INCREASE
MOBILITY:
• Restore Joint Biomechanics
• Physical Therapy
(Joint Mobilization, S&S, STM )
• Home Exercise Program
¤
PAIN CONTROL:
• Self-Management (Ice, Rest)
• Meds: (Analgesics, Local Anes.
Injections, NSAIDs, Muscle Relaxants)
• Physical Therapy (Cold, Utrasound)
Monday, August 31, 15
ICE APPLICATION (15mins.)
(When Co-morbid Joint Synovitis)
v For
Severe Pain
v New Injuries (<72 hrs)
v Re-Injury
• Decreases Inflammation
• Reduces Acute Edema
• Reduces Acute Muscle
Tightness & Assoc. Pain
Monday, August 31, 15
ANTI-INFLAMMATORY MEDS
(When Co-morbid Joint Synovitis)
§
§
§
§
§
§
§
§
§
Naproxen (Naprosyn) 500mg. bid *
Sulindac (Clinoril) 150-200mg. bid
Nabumetone (Relafen) 500-750mg. bid
Meloxicam (Mobic) 7.5-15mg d
Celecoxib (Celebrex) 100-200mg. bid
Diclofenac (Voltaren) 1.3% Flector Patch bid
Voltaren Gel 1% 2 Grams qid
Compounded Topicals 90ml 2 drops tid-qid
Methyprednisolone (Medrol Dosepak) 24-32mg d/1wk
followed by 1wk 4mg 6 day Tapering Dose
Misoprostol (Cytotec) 200 µg qid
Omeprazole (Prilosec) 20mg bid
*Least Cardic Risk - Medical Research Council of the U.K.
Monday, August 31, 15
Skeletal Muscle Relaxants
(When Masticatory Muscles Are Involved)
§
Cyclobenzaprine (Flexeril) 5-10mg 2hrs before hs
§
Cyclobenzaprine ER (Amrix) 15-30mg 2hrs before hs
• Local effect at brain stem
• Potentiates Norepinephrine & Seratonin
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§
§
§
Metaxolone (Skelaxin) * 2/400mg tid
Tizanidine (Zanaflex) *1mg > 8mg hs
Clonazepam (Klonopin) 0.5-1mg tid
Baclofen 5-10mg tid
*(Act Centrally on Alpha 2 Receptors:
CNS Depressant)
Monday, August 31, 15
?
ANXIOLYTICS: Short-term Only
(When Patient is Very Anxious)
§
§
§
Alprazolam (Xanax) 0.25-.5mg tid
Lorazepam (Ativan) 2-6mg tid
Diazepam (Valium) 2-10mg tid
GABA Receptor Agonists; Promote
Inhibitory Activity at Neural Junction
Indications: Anxiety; Fast-acting Muscle Relaxation
Monday, August 31, 15
PHYSICAL THERAPY
§
§
§
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§
Patient Education
Therapeutic Exercises
Joint Mobilization / Manipulation
Soft-tissue Mobilization
Modalities
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§
§
§
Monday, August 31, 15
Heat & Ice
Spray & Stretch
Elect Stim. / Iontophoresis
Ultrasound / Phonophoresis
LONG-TERM GOAL ORIENTED
PLAN: Acute DD w/o Reduction
RESTORE NORMAL FUNCTION:
(S/P Reduction of Disc)
§
Jaw Stabilization
Stabilization Exercises
§ Sleep Posture
§ Habit Control
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§
§
Self-reduction Instruction
Taper / Discontinue Meds
Self-reduction
Monday, August 31, 15
SLEEP POSTURE
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§
§
Side-Lying Position with
Pillow Support Between Neck
& Shoulders
Supine Position with Pillow
Support for Lordotic Curve of
Neck
Avoid Prone (Stomach)
Position
Monday, August 31, 15
CHRONIC DISC DISPL. w/o RED.
(Prolonged Non-clicking >3 mos.)
Monday, August 31, 15
CHRONIC DISC DISPL. w/o RED.
(Prolonged Non-clicking >3 mos.)
v
DESCRIPTION: Condyle Fails to Reestablish a Normal Anat. Relat. w Disc
During Condylar Translation; > 3 mos.
Monday, August 31, 15
CHRONIC DISC DISPL. w/o RED.
(Prolonged Non-clicking >3 mos.)
v
DESCRIPTION: Condyle Fails to Reestablish a Normal Anat. Relat. w Disc
During Condylar Translation; > 3 mos.
Monday, August 31, 15
CHRONIC DISC DISPL. w/o RED.
(Prolonged Non-clicking >3 mos.)
v
DESCRIPTION: Condyle Fails to Reestablish a Normal Anat. Relat. w Disc
During Condylar Translation; > 3 mos.
Monday, August 31, 15
CHRONIC DISC DISPL. w/o RED.
(Prolonged Non-clicking >3 mos.)
v
DESCRIPTION: Condyle Fails to Reestablish a Normal Anat. Relat. w Disc
During Condylar Translation; > 3 mos.
v
CLINICAL PRESENTATION:
1. Possible Sl.- Mod. Jt. Pain w Fx.
2. Possible Ltd Mand. Mvt.
3. Sl. to Mod. Defl. to Affected Side
4. Ltd. Lat. to Contralateral Side
Monday, August 31, 15
Goal Oriented Plan:
Chron. Disc Displac. w/o Reduction
(Prolonged Non-clicking >3 mos.)
Monday, August 31, 15
Goal Oriented Plan:
Chron. Disc Displac. w/o Reduction
(Prolonged Non-clicking >3 mos.)
Monday, August 31, 15
Goal Oriented Plan:
Chron. Disc Displac. w/o Reduction
(Prolonged Non-clicking >3 mos.)
¤ INCREASE
MOBILITY:
• Physical Therapy (Jt. Mobilization)
• Home Exercise Program (Opening &
Translatory Exercises)
Monday, August 31, 15
Goal Oriented Plan:
Chron. Disc Displac. w/o Reduction
(Prolonged Non-clicking >3 mos.)
¤ INCREASE
MOBILITY:
• Physical Therapy (Jt. Mobilization)
• Home Exercise Program (Opening &
Translatory Exercises)
Monday, August 31, 15
Goal Oriented Plan:
Chron. Disc Displac. w/o Reduction
(Prolonged Non-clicking >3 mos.)
¤ INCREASE
MOBILITY:
• Physical Therapy (Jt. Mobilization)
• Home Exercise Program (Opening &
Translatory Exercises)
Monday, August 31, 15
Goal Oriented Plan:
Chron. Disc Displac. w/o Reduction
(Prolonged Non-clicking >3 mos.)
¤ INCREASE
MOBILITY:
• Physical Therapy (Jt. Mobilization)
• Home Exercise Program (Opening &
Translatory Exercises)
¤ PAIN
CONTROL: Usually Not Painful
• Self-Management (Avoid Overuse)
• Physical Therapy (ES, US, Heat)
• Meds (NSAIDs, Ms Relax., prn)
Monday, August 31, 15
Goal Oriented Plan:
Chron. Disc Displac. w/o Reduction
(Prolonged Non-clicking >3 mos.)
¤ INCREASE
MOBILITY:
• Physical Therapy (Jt. Mobilization)
• Home Exercise Program (Opening &
Translatory Exercises)
¤ PAIN
CONTROL: Usually Not Painful
• Self-Management (Avoid Overuse)
• Physical Therapy (ES, US, Heat)
• Meds (NSAIDs, Ms Relax., prn)
Monday, August 31, 15
RESTORING TRANSLATION
Active & Active-Assisted
Active ROM Ex.
Monday, August 31, 15
Active-assisted ROM Ex.
RESTORING TRANSLATION
Active & Active-Assisted
Active ROM Ex.
Monday, August 31, 15
Active-assisted ROM Ex.
RESTORING TRANSLATION
Active & Active-Assisted
Active ROM Ex.
Monday, August 31, 15
Active-assisted ROM Ex.
CHRONIC DD w/o REDUCTION
(Long-term Goals)
RESTORE NORMAL
FUNCTION:
§
§
Discontinue Meds
Progressive Self-Management
Program
Advance Diet, Manual
Resisted Exercises
(Stabilization) for
Strength & Endurance
Monday, August 31, 15
Long-term Outcome
Treatment Outcome
Chronic Displ. w/o Red.
Monday, August 31, 15
Treatment Outcome
Chronic Displ. w/o Red.
Monday, August 31, 15
Treatment Outcome
Chronic Displ. w/o Red.
Monday, August 31, 15
ARTICULAR DISC DISORDERS
REDUCTION
w/o REDUCTION
Asymptomatic
Symptomaic
Acute
Chronic
TMJ Clicking
Normal ROM
Jaw Deviation
Pain-free
TMJ Clicking/
Catching?
Altered ROM
Jaw Deviation
Painful?
No Clicking/
Catching
Limited ROM
Jaw Deflection
Painful
No Clicking/
Catching
Slight Ltd ROM
Jaw Deflection
Pain-free
Monday, August 31, 15
Summary of Disc Studies
๏ Disc
position is highly variable
(50+% of pop./ 78% of Pts./ 33% of subjects)
๏ Not
essential to “recapture disc”
๏ Interoccl. appliances rarely improve
disc-condyle relationship
๏ Occlusal tx, especially equilibration, rarely indicated
๏ Successful mgt based on
physical rehab, not surgery
Flores-Mir C et al: Am J Orthod Dentofac Orthop 2006;130:324-330
Tasaki MM et al: Am J Orthod Dentofac Orthop 1996;109:249-262
Ribeiro RF et al: J Orofacial Pain 1997;11:37-47
Monday, August 31, 15
Acute Musculoskeletal TMD/OFP
Management Model NIDCR Policy Statement 2013
Patient Education
Symptomatic Care
Behavior Modification
Pharmacotherapy
Physical
Rehabilitation
(Oral Appliance Therapy)
Monday, August 31, 15
Acute Musculoskeletal TMD/OFP
Management Model NIDCR Policy Statement 2013
Patient Education
MANAGEMENT
PHILOSOPHY
Symptomatic Care
Diagnostically Driven
Problem-Based
Goal Oriented
Behavior Modification
Pharmacotherapy
Physical
Rehabilitation
(Oral Appliance Therapy)
Monday, August 31, 15
Acute Musculoskeletal TMD/OFP
Management Model NIDCR Policy Statement 2013
Patient Education
MANAGEMENT
PHILOSOPHY
Symptomatic Care
Diagnostically Driven
Problem-Based
Goal Oriented
Behavior Modification
MANAGEMENT GOALS
Pharmacotherapy
Physical
Rehabilitation
(Oral Appliance Therapy)
Monday, August 31, 15
Relieve Pain
Promote Healing
Restore Functional ROM
Optimize Masticatory Function
Return to Previous Level of ADL
Acute Musculoskeletal TMD/OFP
Management Model NIDCR Policy Statement 2013
Patient Education
Symptomatic Care
Behavior Modification
MANAGEMENT GOALS
Pharmacotherapy
Physical
Rehabilitation
(Oral Appliance Therapy)
Monday, August 31, 15
Relieve Pain
Promote Healing
Restore Functional ROM
Optimize Masticatory Function
Return to Previous Level of ADL
Acute Musculoskeletal TMD/OFP
Management Model NIDCR Policy Statement 2013
Patient Education
Symptomatic Care
Behavior Modification
Pharmacotherapy
Physical
Rehabilitation
(Oral Appliance Therapy)
Monday, August 31, 15
Acute Musculoskeletal TMD/OFP
Management Model NIDCR Policy Statement 2013
Patient Education
Symptomatic Care
Behavior Modification
Pharmacotherapy
Physical
Rehabilitation
(Oral Appliance Therapy)
Monday, August 31, 15
NO SURGERY or
TREATMENT
of the
OCCLUSION
Acute Musculoskeletal TMD/OFP
Management Model NIDCR Policy Statement 2013
Patient Education
Symptomatic Care
Behavior Modification
Pharmacotherapy
Physical
Rehabilitation
(Oral Appliance Therapy)
Monday, August 31, 15
NO SURGERY or
TREATMENT
of the
OCCLUSION
“The art of medicine is in
amusing the patient
while nature cures the
disease”
VOLTAIRE
Monday, August 31, 15