Download TREATMENT

MANAGEMENT OF TMD
Clinical A/P Chua Ee Kiam
PRINCIPLES OF TREATMENT
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Treatment should be based on specific diagnosis
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Treatment should address the cause of symptoms
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Treatment should reflect relative urgency of the
symptoms
TREATMENT
GENERAL PRINCIPLES
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Reduce pain
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Reduce functional overload
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Provide stabilization
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Improve function
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Prevent progression of problem
TREATMENT
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EMERGENCY TREATMENT
PATIENT EDUCATION
MEDICATION
APPLIANCE THERAPY
JAW MANIPULATION
ARTHROCENTESIS
ARTHROSCOPY
PHYSIOTHERAPY
COUNSELLING
JAW SURGERY
OCCLUSAL REHABILITATION
OTHERS (INCLUDING RE-TREATMENTS)
TREATMENT
EMERGENCY TREATMENT (following acute trauma)
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Ice pack
moist heat
reduce function
anterior appliance
anti-inflammatory medication
TREATMENT
EMERGENCY TREATMENT (following acute trauma)
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Ice pack
moist heat
reduce function
anterior appliance
anti-inflammatory
medication
ACUTE PAINS & PROBLEMS
1. First episode of pain & difficulty of mouth opening
2. Traumatic trismus
3. Locked
4. Chronic problem becoming acute
5. Trauma
6. Problems with appliance
7. Worried parents, friends and lovers
8. Emotional crisis
9. Dislocation
10.Flare-up of rheumatoid arthritis or systemic problems
11. Effects from unconventional treatments
12. Flare-up from disc surgery
TREATMENT
PATIENT EDUCATION
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Limited function protocol
Reduce trauma
Exercises
TREATMENT
MEDICATION
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NSAIDS
Muscle relaxants (x)
Low dose antidepressants (x)
Steroids (x)
TREATMENT
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The arachidonic acid pathway constitutes one of the main mechanisms for the
production of pain and inflammation, as well as controlling homeostatic
function.
The pathway produces prostaglandins (from cyclooxygenase metabolism)
leukotrienes ( from lipoxygenase metabolism)
PROSTAGLANDIN PATHWAY
Stimulus
Phospholipids
Phospholipase A2
Arachidonic Acid
Enzyme - Lipoxgensaes
( Leukotrienes )
.
Enzyme- Cyclooxygenases (COX 1 & 2)
(Prostaglandins)
important mediators of inflammation
TREATMENT
The COX-1 is related to the toxicity and COX 2 is specific to
inflammation.
Traditional NSAIDs are considered "nonselective" because
they inhibit both COX-1 and COX-2. The inhibition of COX-2
by traditional NSAIDs accounts for the anti-inflammatory effect
of the drugs while the inhibition of COX-1 can lead to NSAID
toxicity and associated side effects (ulcers, prolonged bleeding
time, kidney problems).
COX-2 is usually specific to inflamed tissue, there is much less
gastric irritation associated with COX-2 inhibitors
Inhibition of COX-1 undesirable while inhibition of COX-2 is
considered desirable.
MEDICATION
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Muscle relaxants
behavioural addiction effects high
for significant acute pain
never in chronic pain
eg. Valium 5mg 1 nightly
MEDICATION
NSAIDS
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weaker anti-inflammatory than steroids
inhibits the metabolism of arachinodic acid to
prostaglandin
require 5 days to reach peak blood levels
eg
Ponstan 250mg
Naprosyn 375mg tid
Ibuprofen 600mg tid
Feldene 10mg bid
MEDICATION
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Ultracet (1 tab = tramadol 37.5mg + 325mg paracetamol)
1-2 tab qds x 5/7
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Arcoxia (etoricoxib 120mg)
I tab a day x 5/7
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Celebrex (celecoxib 200mg)
I tab a day x 5/7
MEDICATION
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Tri-cyclic antidepressants (TCAD)
prevent re-uptake of (NA & 5HT) into
presynaptic nerve endings
increases post synaptic receptor sensitivity
in low dose - useful in pain management
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Amitriptyline
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MEDICATION
Steroids
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used to suppress inflammation
Kopp & Wenneberg, 1981 reported significant benefits
Poswillo, 1970 found erosions of condyles of monkeys after
multiple intra-articular injections
MEDICATION
b) Steroids
eg.
Celestone (bethamethasone 3mg/ml
Kenacort (triamcinolone acetonide)
Indication: Acute synovitis
MEDICATION
c) Local anaesthetics
temporal tendonitis
d) Botulin toxin
SYSTEMATIC REVIEWS ON TMDS - MEDICATION
11 studies fulfilled the criteria
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2.
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11.
Rossi et al, 1983
Roldan et al, 1990
Harkins et al, 1991
Ekberg et al, 1996
Winocur et al, 2000
Nguyen et al, 2001
Herman et al, 2002
Lobo et al, 2004
Ta & Dionne 2004
Kimos et al, 2007
Tchivileva et al, 2010
N- 496
83% females
SYSTEMATIC
REVIEWS ON
TMDS -
MEDICATION
1.
Naproxen sodium 500mg 2x daily x 6/52 had most
significant
pain
reduction
(Ta
&
Dionne)
2.
Topical application of methyl salicylate (Theraflex –
TMJ cream) over the masseter 2x daily x 2/52 significant efficacy over placebo (Lobo et al)
3.
Gabapentin (anticonvulsant) 300mg - 4200mg daily
x 3/12 - significant pain reduction over placebo
(Kimos et al)
TREATMENT
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APPLIANCE THERAPY
WHY DO APPLIANCES WORK (THEORIES)
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Occlusal disengagement
Vertical Dimension compensation
Maxillary - mandibular re-alignment
TMJ reposition
Cognitive Awareness
APPLIANCE THERAPY
REQUIREMENTS OF AN APPLIANCE
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UNOBSTRUSIVE
ADEQUATE STRENGTH & RIGIDITY
MAINTAINS TEETH STABILITY
APPLIANCE THERAPY
INDICATIONS
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BRUXISM (NOCTURNAL & DIURNAL)
ARTHRALGIA
MYALGIA
LOCKED (DD WITHOUT REDUCTION)
ATTRITTED DENTITION
UNSTABLE OCCLUSION
ANTERIOR OPEN BITE
ASSESSMENT OF PERMISSIBLE THERAPEUTIC
CONDYLAR POSITION
OCCLUSAL REHABILITATION
OBSTRUCTIVE SLEEP APNEA
TYPES OF APPLIANCES (CLASSIFICATION)
1.
2.
3.
4.
5.
6.
7.
LOCATION
TYPE OF COVERAGE
TEXTURE
MANNER OF FABRICATION
MATERIAL USED
JAW POSITION
PERSONALITY INVOLVED
TYPES OF APPLIANCES
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ANTERIOR, UPPER, LOWER
FULL OR PARTIAL COVERAGE
SOFT OR HARD, BOTH
SUCK-DOWN, PREFORMED, HEAT CURED
CLEAR, PINK OR TOOTH COLOURED
STABILISATION, REPOSITION, ONLAY
MICHIGAN, GELB, NTI
APPLIANCE THERAPY
LABORATORY STAGES
 extension
 thickness
 retention
 finish
APPLIANCE THERAPY
POST INSERTION INSTRUCTIONS
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difficulty talking and eating
difficulty sleeping
increased salivation
tightness around teeth
unable to close jaw
perception of increased grinding or clenching
possibility of sore throat
ADJUSTMENTS
 anterior regions
 clasps
 balanced occlusion
REPOSITION THERAPY
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Appliance is placed in anterior position
24 hour wear for 3-6 months
Rehabilitation with prostheses or orthodontics
Costly
SYSTEMATIC
REVIEWS ON
TMDS - TREATMENT
OCCLUSAL APPLIANCE
1.
2.
3.
4.
Stabilization appliance worn at night
likely
to
lead
to
short-term
improvement when compared to no Tx
Equally effective in reducing pain
compared
with
other
Tx
(PT,
behavioural medicine, etc)
Few SRs reported adverse events
related to use of partial non-occluding
appliances (NTI* – can contribute to
tooth pain & occlusal changes
Occlusal adjustment less effective
than placebos
May 15th, 2006
I was wondering if anybody has used the NTI device for
their tmj problems. I recently got one and it seems to be
making things worse. The muscles in my eyes/ face have
totally seized up and it feels like the same with my jaw
(even though I am not able to clench anymore). I'm totally
upset, this cost me $850 and it's making it worse. I wear it
all day/ night and only take it out to eat. When I eat it feels
like my mouth and bite is all out of wack. Is it common to
get worse before better????
*NTI-tss (Nociceptive Trigeminal Inhibition-tension
suppression system)
TREATMENT
JAW MANIPULATION
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determine site
stabilize the patient
guide condyle medially and anteriorly
engage the disc
maintain open position
ultrasound therapy
TREATMENT
PHYSIOTHERAPY
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CRYOTHERAPY
MOIST HEAT
ULTRASOUND
INTERFERENTIAL THERAPY
TENS
JAW EXERCISES
STRETCHING EXERCISES
TREATMENT
PHYSIOTHERAPY
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CRYOTHERAPY
CRYOGEL PACKS
(POLYVINYL ALCOHOL GEL IN POLYTHELENE-VINYL
ACETATE BAG)
TREATMENT
PHYSIOTHERAPY
CRYOTHERAPY
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Cold impulses negate pain impulses; breaking the cycle of
pain metabolites - muscle spasms - pain
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At lower temperature muscle activity is sustained for
longer periods without fatigue
PHYSIOTHERAPY
MOIST HEAT
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silica gel in canvas
heated to 65-82 deg C for 1/2 hour
used to increase blood flow and relax muscles
PHYSIOTHERAPY
ULTRASOUND (0.75 -3 mHz)
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acoustic vibrations propagated in the form of longitudinal
mechanical waves
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these cause alternate compressions and rarefactions
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depolymerizes proteins (decreasing viscosity of hyaluronic acid
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higher the frequency, shorter the wavelength, greater the
absorption
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has thermal and mechanical effects
ULTRASOUND
CONTRAINDICATIONS
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Brain, Spinal Cord, Eyes, Reproductive organs
Acute Infections
DXT
Haemophiliacs
Deep Vein Thrombosis
PHYSIOTHERAPY
TENS
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sensory pathways are affected
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large fibres are stimulated
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blocks small activity and stop pain
signals being transmitted
PHYSIOTHERAPY
INTERFERENTIAL CURRENT THERAPY
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The high frequency carrier waveform penetrates the skin more deeply than
a regular TENS unit, with less user discomfort for a given level of
stimulation.
Stimulation is characterized by the crossing of two electrical medium,
independent frequencies that work together to effectively stimulate large
impulse fibers.
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When two differing unmodulated medium frequency (around 4000 Hz)
alternating currents are applied to tissues, a vibration (interference currents
between 1 & 100 Hz) is generated
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Facilitating ionic movement of cells (increased cellular activity & active
hyperaemia)
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Useful for pain relief swelling control
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Relaxes muscle spasm
PHYSIOTHERAPY
JAW EXERCISES
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Keeping teeth apart in clenching
Limiting jaw opening in hyper-mobile joints
Jaw strengthening exercises
To encourage active movement of “sticky”
displaced disc
PHYSIOTHERAPY
STRETCHING EXERCISES
SYSTEMATIC
REVIEWS ON
TMDS - TREATMENT
PHYSICAL THERAPY
1.
Acupuncture comparable to
other forms of conservative tx
Very
few
side-effects
or
adverse effects of acupuncture
2. 1 SR found active jaw exercise
and postural training to be
effective but none for various
electrical modaliities
TREATMENT
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COUNSELLING & STRESS MANAGEMENT
TREATMENT
COUNSELLING
Counselling is a helping relationship where a
repertoire of interventions or helping
strategies are addressed in the psychological
process.
TREATMENT
COUNSELLING & STRESS MANAGEMENT
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PATIENT AT RISK
INDICATIONS
SUPPORT STRUCTURE
COPING SKILLS
PSYCHOTHERAPY
PSYCHIATRIC CARE
COUNSELLING
GOALS
 Manage current problems
 manage crises
 make decisions
 develop specific life skills
 heal past emotional deprivations
SYSTEMATIC
REVIEWS ON
TMDS - TREATMENT
BEHAVIOURAL TY & MULTIMODAL TX
1. BT just as effective as Multimodal Tx
(biofeedback, relaxation training,
stress management & CBT – usually
used in combination – so difficult to
know what works best
2. Reviews emphasized the need for
behavioural assessment in clinical
examination
3. Use of dual axis recommended as in
RDC/TMD classification system
TREATMENT
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PATIENT EDUCATION
MEDICATION
APPLIANCE THERAPY
JAW MANIPULATION
PHYSIOTHERAPY
COUNSELLING & STRESS MANAGEMENT
ARTHROSCOPY/ ARTHROCENTESIS
TREATMENT
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ARTHROSCOPY
TREATMENT
ARTHROCENTESIS
 Pumping procedure
 Introduction of fluid into joint space
 Manipulate joint
 Joint lavage
 Steroid injections
ARTHROSCOPY
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indicated for persistent lock & fibrous ankylosis
developed by Omnishi, 1975
investigated by Murakami, 1983
first success, 1987
Sanders, 1986 - 84% excellent results (n=138
Tarro, 1988
JAW SURGERY
MENISECTOMY
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earlier reports showed reduced pain; most
probably due to sensory denervation
Yaillen et al (1970) showed degenerative disease,
fibrous ankylosis, condylar resorption, osteophyte
formation, etc in monkeys
TREATMENT
JAW SURGERY
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MENISECTOMY & IMPLANTS
JAW SURGERY
MENISECTOMY & IMPLANTS
(Silastic or Proplast)
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Chronic reaction (Christie & co, 1977; Vistnes & co,
1978; Rosenthal, 1983)
Severe reaction - osteoclastic activity, foreign body
giant cell reaction (Timmis et al, 1986)
Lymph node involvement (Dolwick et al, 1985)
JAW SURGERY
DISC REPAIR
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reposition & reshape
TREATMENT
JAW SURGERY
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MENISECTOMY
MENISECTOMY & IMPLANTS
DISC REPAIR
ARTHROSCOPIC SURGERY
CORONOIDECTOMY
SYSTEMATIC
REVIEWS ON
TMDS - TREATMENT
SURGERY
1. Arthroscopic surgery,
arthro-centesis & PT
affected mandibular
movement, reduction in
pain intensity and
mandibular functioning
2. Most studies inconclusive
TREATMENT
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PATIENT EDUCATION
MEDICATION
APPLIANCE THERAPY
JAW MANIPULATION
PHYSIOTHERAPY
COUNSELLING & STRESS MANAGEMENT
ARTHROSCOPY/ ARTHROCENTESIS
JAW SURGERY
OCCLUSAL REHABILITATION
TREATMENT
OCCLUSAL REHABILITATION
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OCCLUSAL ONLAYS
FIXED PROSTHODONTICS
ORTHODONTICS
TREATMENT
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OCCLUSAL REHABILITATION
TREATMENT
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EMERGENCY TREATMENT
PATIENT EDUCATION
MEDICATION
APPLIANCE THERAPY
JAW MANIPULATION
ARTHROCENTESIS
ARTHROSCOPY
PHYSIOTHERAPY
COUNSELLING
JAW SURGERY
OCCLUSAL REHABILITATION
OTHERS (INCLUDING RE-TREATMENTS)
CONCLUSION
When you have a hammer, everything starts looking like a nail.
Pullinger, 1987