The Toronto Crown and Bridge Study Club Toronto, Ontario, Canada September 25, 2020 “Management considerations for Temporomandibular Disorders Part 2” by Jeffrey P Okeson, DMD Professor and Dean Founder, Orofacial Pain Program Provost's Distinguished Service Professor University of Kentucky College of Dentistry Lexington, Kentucky 40536 - 0297 [email protected]jeffokeson.net 1 I. Masticatory Muscle Disorders 1. Protective Co - Contraction 2. Local Muscle Soreness 3. Myofascial Pain 4. Myospasm 5. Chronic Centrally Mediated Myalgia II. Temporomandibular Joint Disorders 1. Derangements of the Condyle - Disc Complex a. Disc Displacement with Reduction b. Disc Displacement without Reduction 2. Structural Incompatibilities 3. Inflammatory Disorders Classification of Temporomandibular Disorders 2 Muscle Pain Muscle pain is the most common type of pain humans experience. 3 Muscle Pain Muscle pain is the most common type of pain humans experience. Chronic muscle pain affects between 11–24% 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 Clenching Sleep Related Bruxing 6
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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
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.
Common beliefs regarding bruxism, tooth wear, EMG and pain- Facts or Fiction ? -
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
Common beliefs regarding bruxism, tooth wear, EMG and pain- Facts or Fiction ? -
12
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.4. There is a strong correlation between tooth wear and RMMA
(rhythmic masticatory muscle activity).
Lavigne, et al. Bruxism physiology and pathology: an overview for clinicians. J Oral Rehab. 35:7: 476-495, 2008.
There is no correlation between tooth wear and RMMA observed in a sleep lab.
TRUE
FALSE
FALSE
FALSE
Common beliefs regarding bruxism, tooth wear, EMG and pain- Facts or Fiction ? -
13
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.4. There is a strong correlation between tooth wear and RMMA
(rhythmic masticatory muscle activity).5. There is a strong correlation between bruxing activity and pain.
Lavigne, et al. Bruxism physiology and pathology: an overview for clinicians. J Oral Rehab. 35:7: 476-495, 2008.
There is no correlation between pain and RMMA observed in a sleep lab.
TRUE
FALSE
FALSE
FALSE
FALSE
Common beliefs regarding bruxism, tooth wear, EMG and pain- Facts or Fiction ? -
14
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.4. There is a strong correlation between tooth wear and RMMA
(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.
Common beliefs regarding bruxism, tooth wear, EMG and pain- Facts or Fiction ? -
15
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.4. There is a strong correlation between tooth wear and RMMA
(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
Common beliefs regarding bruxism, tooth wear, EMG and pain- Facts or Fiction ? -
16
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.4. There is a strong correlation between tooth wear and RMMA
(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.
Common beliefs regarding bruxism, tooth wear, EMG and pain- Facts or Fiction ? -
17
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.
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
A Masticatory Muscle Model
Okeson, 2012
Acute Time Chronic
Myospasm
CNS Effectson Muscle Pain
AnEvent
ProtectiveCo-
contraction- Myospasm -
An involuntary, CNS induced tonic contraction, often associated with local metabolic conditions.
33
NormalFunction
ResolutionLocal
MuscleSoreness
A Masticatory Muscle Model
Okeson, 2012
Regional Myalgic Disorders
Myofascial PainCentrally Mediated Myalgia
Acute Time Chronic
Myospasm
CNS Effectson Muscle Pain
AnEvent
ProtectiveCo-
contraction
34
NormalFunction
ResolutionLocal
MuscleSoreness
A Masticatory Muscle Model
Okeson, 2012
Regional Myalgic Disorders
Myofascial PainCentrally Mediated Myalgia
Acute Time Chronic
Myospasm
CNS Effectson Muscle Pain
AnEvent
ProtectiveCo-
contraction
Myofascial Pain
site
source
35
NormalFunction
ResolutionLocal
MuscleSoreness
A Masticatory Muscle Model
Okeson, 2012
Regional Myalgic Disorders
Myofascial PainCentrally Mediated Myalgia
Acute Time Chronic
Myospasm
CNS Effectson Muscle Pain
AnEvent
ProtectiveCo-
contraction
Centrally Mediated Myalgia
36
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
37
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
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
38
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
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
A Masticatory Muscle Model
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
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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 -
Local Muscle Soreness
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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 -
Local Muscle Soreness
43
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 -
Local Muscle Soreness
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 -
Local Muscle Soreness
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 -
Local Muscle Soreness
2. You have misdiagnosed the disorder.
MPD
46
Occlusal Appliance Therapy
TypeIndicationsFabricationClinical Protocol
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The Stabilization Appliance
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Occlusal Appliance Therapy
TypeIndicationsFabricationClinical Protocol
49
Local Muscle Soreness
Chronic Centrally Mediated Myalgia
Bruxism
The Stabilization Appliance
- Indications -
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Occlusal Appliance Therapy
TypeIndicationsFabricationClinical Protocol
51
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
54
Occlusal Appliance Therapy
TypeIndicationsFabricationClinical Protocol
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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
When an occlusal appliance reducesthe patient’s symptoms...
….what do you do next?
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Reasons that could explain why your occlusal appliance reduced the muscle pain.
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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
Reasons that could explain why your occlusal appliance reduced the muscle pain.
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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
Reasons that could explain why your occlusal appliance reduced the muscle pain.
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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