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HO5

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
5. Masticatory Muscle Disorders
Monday, August 31, 15
ACUTE TMD DIAGNOSES
Acute TMD Mgt
(Localized Musculoskeletal Disorders)
TM Joint Pain
v Masticatory Muscle Pain
v
AAOP TMD Dx Classification:
Localized Disorders
•
•
•
•
•
•
•
ARTICULAR
Devel./ Acquired Disord.
Disc Disorders
Inflammatory Disorders
Degenerative Disorders
TMJ Dislocation
Ankylosis
Fracture
Localized Disorders
•
•
•
•
•
•
•
ARTICULAR
Disc Disorders
TMJ Dislocation
Ankylosis
Fracture
•
•
•
•
•
•
MUSCULAR
Myalgia
Myofascial Pain
Tendinitis
Myospasm
(Trismus)
Myositis
Myofibrotic
Localized Disorders
•
•
•
•
•
•
•
ARTICULAR
Disc Disorders
TMJ Dislocation
Ankylosis
Fracture
•
•
•
•
•
•
MUSCULAR
Myalgia
Myofascial Pain
Tendinitis
Myospasm
(Trismus)
Myositis
Myofibrotic
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
CURRENT CONCEPTS Re: Etiology of TMD
GENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS
๏
MUSCULAR
Peripheral Sensitization
•
•
Ischemia w Prolonged Contract.
Tissue Injury Inflammation (Delayed Onset)
NGF, SP, Glutamate, Histamine, CGRP
๏ Central Sensitization
•
•
Sympath. Hemodynamic (Stress)
Descending Modulatory NT
Seratonin, NA, Endogen. Opiates
Alstergren P et al, J Orofac Pain 2010;24:172-180
CURRENT CONCEPTS Re: Etiology of TMD
GENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS
๏
MUSCULAR
Peripheral Sensitization
•
•
Ischemia w Prolonged Contract.
Tissue Injury Inflammation (Delayed Onset)
NGF, SP, Glutamate, Histamine, CGRP
๏ Central Sensitization
•
•
Sympath. Hemodynamic (Stress)
Descending Modulatory NT
Seratonin, NA, Endogen. Opiates
Systematic Reviews: (Medline, Cochrane)
Low Level Evidence to Support Occlusal Factors Cause TMD
Alstergren P et al, J Orofac Pain 2010;24:172-180
LOCAL MYALGIA: w/o Referred Symptoms
MYOFASCIAL PAIN: w Referred Symptoms
v
DEFINITION: Pain of Muscle Origin Affected by Affected by
v
PRESENTATION:
Jaw Function with Replication by Provocation Testing
•
•
•
•
•
•
Regional Dull Ache w Localized
Tender Areas & Taut Bands
Pain Aggravated by Function
Possible Ms. Stiffness/Tightness
Possible ò Opening that ñ w Assisted Stretch
Pain ò w Local Anes. / Spray & Stretch
Refer pain to four
mandibular incisors &
alveolar ridge below
LOCAL MYALGIA: w/o Referred Symptoms
MYOFASCIAL PAIN: w Referred Symptoms
v
DEFINITION: Pain of Muscle Origin Affected by Affected by
v
PRESENTATION:
Jaw Function with Replication by Provocation Testing
•
•
•
•
•
•
Regional Dull Ache w Localized
Tender Areas & Taut Bands
Pain Aggravated by Function
Possible Ms. Stiffness/Tightness
Possible ò Opening that ñ w Assisted Stretch
Pain ò w Local Anes. / Spray & Stretch
Refer pain to four
mandibular incisors &
alveolar ridge below
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
MYOFASCIAL TRIGGER POINTS
Hyperirritable areas within taut bands of skeletal muscle or fascia, that give rise to characteristic
referred pain, tenderness & autonomic phenomena.
Crtical Evaluation QuinterJL et.al., Rheumatology .Oxford 2014
A site of secondary allodynia reflecting altered central nociceptive
Latremolier A, Woolf CJ; 2009 - Travell JG, Simons DG; 1983
Common
manifestations of
chronic pain states
w assoc.
allodynia/
hyperalgesia
Underlying
mechanisms
include
peripheral and
central
sensitization
Common
manifestations of
chronic pain states
w assoc.
allodynia/
hyperalgesia
PTERYGOID MUSCLES
v
Refer pain diffusely to mouth,
below & behind the TMJ & ear
v
May be associated with stuffiness
in ear?
MEDIAL
v
Refer pain deeply into TMJ &
maxillary sinus
LATERAL
NOT to
TEETH
MYOFASCIAL TRIGGER POINTS:
Referred Pain (Dermatome Pain)
Rostral-Caudal
Facial Dermatomes
Subnucleus
Caudalis
Lamina 3
Sessle BJ et al: Convergence of Afferents… Pain 1986;27:219-235
R de Leeuw, GD Glasser, OFP Guidelines, 5th ed. p1-23, Quintessence, Chicago, 2013
GOAL ORIENTED PLAN:
Myalgia/Myofascial Pain
v
PAIN CONTROL:
v
v
v
v
v
v
v
INCREASE MOBILITY:
❖
Patient Education
Self-Mgt. (Heat, Contrast Heat & Ice, Massage, Soft Diet)
Behavior Mod. (Emphasize Jaw Relaxation,
Sleep Posture & Ergonomics)
Meds (Muscle Relaxants or TCAs)
Physical Therapy (Heat, STM, US & ES)
Trigger Point Injections / Acupuncture
Physical Therapy (ROM Ex’s)
GOAL ORIENTED PLAN:
Myalgia/Myofascial Pain
v
PAIN CONTROL:
v
v
v
v
v
v
v
INCREASE MOBILITY:
❖
Patient Education
Self-Mgt. (Heat, Contrast Heat & Ice, Massage, Soft Diet)
Behavior Mod. (Emphasize Jaw Relaxation,
Sleep Posture & Ergonomics)
Meds (Muscle Relaxants or TCAs)
Physical Therapy (Heat, STM, US & ES)
Trigger Point Injections / Acupuncture
Physical Therapy (ROM Ex’s)
PATIENT EDUCATION
v
Reassure Patient Re. ↓ Morbidity of Sn & Sx
v
Thoroughly Explain the Dx & It’s Significance
Explain Risk-Benefit Ratios of Each Management Option
Including No Tx
Emphasize the Need to Comply w
an Individualized Self-Mgt Program
Timely Management of Early Symptoms
v
v
v
SYMPTOMATIC MANAGEMENT
v
v
v
v
v
Moist Heat
Contrast Heat & Ice
v Relaxes Muscles
v Reduces Referred
Muscle Pain
Spray & Stretch
Massage/Acupuncture
Ergonomic Issues
v Work Related Posture
v Computer / Study Posture
SYMPTOMATIC MANAGEMENT
v
v
v
v
v
Moist Heat
Contrast Heat & Ice
v Reduces Referred
Muscle Pain
Spray & Stretch
Massage/Acupuncture
Ergonomic Issues
v Work Related Posture
v Computer / Study Posture
HEAT APPLICATION (20 mins.)
v
v
Reduce Mild to Mod. Pain
Decrease Muscle Tension
v Improves
Local Blood Flow
v Promotes Healing
v Increases Patient’s Comfort
v Prepares Tissues for Movement
PHARMACOTHERAPY
ACUTE
Muscle Relaxs.
v Anxiolytics
v
CHRONIC
Muscle Relaxants
v Tricyclics (Pain
Mgt. Dosing)
v
SKELETAL MUSCLE RELAXANTS
v
v
v
v
v
Cyclobenzaprine (Flexeril) 5-10mg 2hrs before hs
v Local effect at brain stem
v Potentiates Norepinephrine & Seratonin
Metaxolone (Skelaxin) *
2/400mg tid/qid
Tizanidine (Zanaflex) *
1mg > 8mg hs
Clonazepam (Klonopin)
?
0.5-1mg tid
Baclofen 5-10mg tid
* (Act centrally on Alpha 2 Receptors; CNS Depressant)
ANXIOLYTICS: Short Term
§
§
§
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
TRICYCLIC ANTIDEPRESSANTS
(Pain Dosing if Sleep Disturbance)
v
v
v
v
Amitryptyline (Elavil)
Nortriptyline (Pamelar)
Doxepin (Sinequan)
Desipramine (Norpramin)
Titrate Dosage 10mg q 2 wks (up to 50-75mg) until âSx
Inhibits NT Reuptake (Serotonin & Norepinephrine)
Indications: Chron./Neuropath. Pain; Poor Sleep: Bruxism
TRICYCLIC ANTIDEPRESSANTS
v
CONTRAINDICATIONS:
•
•
•
•
v
ADVERSE EFFECTS:
•
•
Anticholinergic:
BPH, Glaucoma, Tachycardia/Fibrillation
Cardiac Disease (AV block, MI)
Bipolar Disorder, Psychosis, Dementia
Cognitive Impairment
CNS: dizziness, drowsiness, tremor
Other: Wt. gain, sweating, vivid dreams
ANESTHETIC TRIGGER POINT INJECTIONS, DRY
NEEDLING, BOTULINUM TOXIN-A or B (BOTOX):
Limited Anesthesia at Site of Injection or Paralysis of
Targeted Motor Units By Acting on Acetylcholine Receptors
Nicol A Ferrante FM Clin Pain Med 2013:11
Royal Ma The Use of Botulinum Toxin in Mgt of MFP www.pain.com
PHYSICAL THERAPY
§
§
§
§
§
Patient Education
Therapeutic Exercises
Joint Mobilization / Manipulation
Soft-tissue Mobilization
Modalities
§
§
§
§
Heat & Ice
Spray & Stretch
Elect Stim. / Iontophoresis
Ultrasound / Phonophoresis
Myofascial Pain (Long-term Goals)
v
v
PAIN CONTROL p.r.n.:
v Self-Management (Heat, Contrast Heat & Ice, Massage)
v Behavior Mod. (Emphasize Jaw Relaxation)
v Oral Appliance (If Parafx. is a Sustaining Factor)
IMPROVE FUNCTION:
v â Meds (Flexeril p.r.n.)
v Progressive Self-Mgt &
Cond. Programs
v Proper Head Neck Posture
and Ergonomics
BEHAVIOR MODIFICATION
§
Cognitive Behavioral Intervention
§
Habit Awareness
§
§
§
§
§
§
Relax Face & Jaw
Teeth Apart
Relaxation Strategies
Lifestyle Changes
Coping Mechanisms
Ergonomic Strategies
PHYSICAL REHABILITATION
v
Exercises
v
v
v
v
v
v
Postural Training
v
v
v
v
Proprioceptive
Range of Motion (ROM)
Isometric (Stabilization)
Strengthening / Conditioning
Cardiovascular
Jaw / Tongue
Head / Neck
Sleep Posture
Ergonomics
Acute Musculoskeletal TMD/OFP
Management Model
Patient Education
Symptomatic Care
Behavior
Modification
Pharmacotherapy
Physical
Rehabilitation
Oral Appliance Therapy
ORAL APPLIANCE
INDICATIONS
When Symptoms Are
Are Worse on Waking
Systematic Reviews: Stab Splint Therapy Compared to
Other Appliances & Treatments (All TMD DX Including MFP)
๏
๏
Occlusal Splints for Treatment of Bruxism
Comparison of Various Splints: Hard, Soft & Non-Occl Splints;
Equal Efficacy for All 3 Appliances
๏
๏
Marecdo CR et al Cochrane Database Syst Rev 2007 17:CD005514
๏
๏

Systematic Review of Electronic Data Search, 1966-2006
๏ 10 RCTs in 2 Meta Analyses Comparing Hard Stabl. Appl. to Other Appl. & to


Non-occl. Appl & No Tx
Similiar Efficacy: to Other Appliances: Soft, Ant. Repositioning, & Ant. Bite
Appl.: But Less Risk
Modest Efficacy w Stab. Splint to Non-occl. Splint & No Tx
๏
๏



Fricton J et. al., J Orofac Pain 2010;24:237-254
๏
๏



Fricton J et. al., J Orofac Pain 2010;24:237-254



Electronic Data Search1966-2003:
12 Relevant RCTs Comparing Stabilization Splints w AP ,BFB, Jaw Exer., Relax.
Strateg., Non-occl. Appl., & No Tx
No Statistically Signif. Diff. Compared to Other Active Txs;
(Exercise Better for Disc Displacement)
Al-Ani MZ et al. Cochrane Collaboration Cochrane Reviews 2007
List T,, Axelsson S J Oral Rehabil 2010:37:430-451
SLEEP- RELATED MOVEMENT DISORDERS
(Rhythmic Masticatory Muscle Activity)
An Exaggerated Form of Oromotor
Activity Assoc. with Sleep Microarousal which occurs 6-14 X hr
(Stages 1 & 2)
10%
50%
20%
v
20%
❖
❖
Total Time Clench/Grinding 50
seconds (1% Sleep Time)
Extreme Bruxism: TMD Pts = Subjects
Rhythmic Mast. Ms., TMD Pts =
Subjects
3-5 Non-REM to REM Cycles q 90 (70-110) min
No Statistically Significant Difference of Stabilizing Appliance (Splint) Compared to Other
Active Treatments;PT Exercises Better for DD
Lavigne GL et.al., J Oral Rehabil 2008;35:476-494
Raphael KG et.al., JADA 2012;143:1223-1231
Al-Ani MZ et al. Cochrane Collaboration Cochrane Reviews 2007
SLEEP BRUXISM:
Polysomnographic (PSG) Studies
‣ Related to Autonomic & Other Brain Functions Rather than
‣
‣
‣
‣
‣
‣
Peripheral Occlusal Sensory Mech.
Brief
activity in the brainstem & reticular system
Stages I & II Sleep: Arousal Response
Related to Periodic: Limb Move., Leg Cramps, OSA
SB Higher in Children & Adolescents than Adults
Tooth wear Does Not Predict SB Severity
Extreme Bruxism: TMD Pts = Subjects
Lavigne GL et.al., J Oral Rehabil 2008;35:476-494
Raphael KG et.al., JADA 2012;143:1223-1231
Klasser GD J Can Dent Assoc 2015;81:12
Diurnal (Awake) Bruxism



Prolonged (Up to 30+ min), Low-level
Awake Tensing /Clenching of Jaw
Causes Delayed Pain Than Brief
Sleep Bruxism Events
EMG Levels Specific Areas
Depending on Jaw Position
Management: Aware Oral Habits,
Relaxation & Coping Strategies
Palla S. 5th International Conference OFP &TMD Brazil 2009
Sleep Bruxism Management
•
•
•
•
•
•
•
•
•
•
Behavioral: Stress Management, Relaxation Strategies &
Sleep Hygiene
Pharmacological:
Benzodiazepine (Clonazepam, Valium, Xanax, Ativan)
Muscle Relaxants (Flexeril)
Tricyclic Antidepressants (Pamelar, Doxepin)
Anticonvulsants (Gabapentin)
Botulinum Toxin
Occlusal Splints/Nightguards??
Only if Symptoms worse on waking
Protects excessive tooth wear
Lobbezoo F., Orofacial Pain: From Basic Science to Clinical Management, Quintessence 2008
TENDONITIS


DEFINITION: Tendinous Inflammation 2° to
Repetitive Strain, Direct Trauma or Injury
CLINICAL PRESENTATION:
• Acute Pain Initially
• Extreme Tend. w Palpation
• Increased Pain w Mand. Mvt.
• Possible Limited ROM
• Prolonged Recovery Typical
GOAL ORIENTED PLAN: Tendinitis
v
PAIN CONTROL: Immediate Goal
v
v
v
v
DECREASED MOBILITY:
v
Self-Management (Rest, Relax. Jaw, Ice)
Meds (NSAIDs, Analgesics, Ms Relax.?)
PT (Cold, ES, STM & US)
Physical Therapy (Home Exercise
Progressive Self-Mgt Program)
Myospasm (Trismus)


DEFINITION: Acute, Sudden, Involuntary, Tonic
Contraction of a Muscle
CLINICAL PRESENTATION:
• Acute Onset of Pain
•
•
•
•
•
Pain at Rest & w Function
Continuous Involuntary Muscle Contraction
Significant Decrease in Jaw Mobility & Fx.
Increased EMG Activity at Rest
May Be Assoc. w Myositis o
Local Infection
GOAL ORIENTED PLAN:
Myospasm (Trismus)
v
PAIN CONTROL:
v
v
v
v
Self-Management (Rest, Ice)
Meds (Analgesics, Anxiolytics,
Ms. Relax., Antiobiotics)
Physical Therapy (ES, US, STM, Cold)
INCREASE MOBILITY:
v
v
Physical Therapy (STM & Jt. Mob.)
Home Ex. Prog. (A/A ROM & AROM Ex.)
GOAL ORIENTED PLAN
v
v
v
Restore Normal Function:
(Passive & Active – Assisted
Exs.)
Taper Meds
Progressive Self-Mgt Program
GOAL ORIENTED PLAN
v
v
v
Restore Normal Function:
(Passive & Active – Assisted
Exs.)
Taper Meds
Progressive Self-Mgt Program
Management Model
NIDCR Policy Statement 2013
Patient Education
Symptomatic Care
Behavior Modification
Pharmacotherapy
Physical Rehabilitation
(Orthoses/Splints)
Management Model
Patient Education
Symptomatic Care
Pharmacotherapy
(Orthoses/Splints)
MANAGEMENT
PHILOSOPHY
Diagnostically Driven
Problem-Based
Goal Oriented
Management Model
Patient Education
Symptomatic Care
MANAGEMENT
PHILOSOPHY
Diagnostically Driven
Problem-Based
Goal Oriented
MANAGEMENT GOALS
Pharmacotherapy
(Orthoses/Splints)
Relieve Pain
Promote Healing
Restore Functional ROM
Optimize Masticatory Function
Return to Previous Level of ADL
Management Model
Patient Education
Symptomatic Care
MANAGEMENT GOALS
Pharmacotherapy
(Orthoses/Splints)
Relieve Pain
Promote Healing
Restore Functional ROM
Optimize Masticatory Function
Return to Previous Level of ADL
Management Model
Patient Education
Symptomatic Care
Pharmacotherapy
(Orthoses/Splints)
Management Model
Patient Education
Symptomatic Care
Pharmacotherapy
(Orthoses/Splints)
NO SURGERY or
TREATMENT
of the
OCCLUSION
Management Model
Patient Education
Symptomatic Care
Pharmacotherapy
(Orthoses/Splints)
NO SURGERY or
TREATMENT
of the
OCCLUSION
The thing about science is, even if
you don’t believe in it, it’s still true.
Neil deGrasse Tyson

HO5

Transcription

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