okeson diff dx of tmd texas 3-17 · okeson differential dx of tmd star of the south dental meeting...
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Okeson Differential DX of TMD Star of the South Dental Meeting
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byJeffrey P Okeson, DMD
Professor and Division Chief of Orofacial Pain Department of Oral Health Science
Director, Orofacial Pain Center University of Kentucky College of Dentistry
Lexington, Kentucky [email protected]
www.jeffokeson.com
Differential Diagnosis of Temporomandibular Disorders
The Star of the South Dental MeetingMarch 3, 2017Houston, Texas
- General types of Orofacial Pains -
1. Dental Painsa. Pulpalb. Periodontal
- General types of Orofacial Pains -
1. Dental Painsa. Pulpalb. Periodontal
2. TMD Pains
What is TMD?
“A collective term embracing a number of clinical problems that involve the masticatory musculature, the TMJ and associated structures or both.”*
*de Leeuw: Orofacial Pain AAOP GuidelinesQuintessence Publishers, 2013, p116.
I. Masticatory Muscle Disorders1. Protective Co-Contraction2. Local Muscle Soreness3. Myofascial Pain4. Myospasm5. Chronic Centrally
Mediated Myalgia
II. Temporomandibular Joint Disorders1. Derangements of the
Condyle-Disc Complexa. Disc Displacement
with Reductionb. Disc Displacement
without Reduction2. Structural Incompatibilities
a. Adhesions / Adherencesb. Deviation in Formc. Subluxationd. Spontaneous Dislocation
3. Inflammatory Disordersa. Synovitisb. Capsulitisc. Retrodiscitisd. Arthritides
III. Chronic Mandibular Hypomobility1. Ankylosis2. Muscle Contracture3. Coronoid Impedance
IV. Growth Disorders1. Congenital /Developmental
Bone Disordersa. Agenesisb. Hypoplasiac. Hyperplasiad. Neoplasia
2. Congenital /DevelopmentalMuscle Disorders
Classification of Temporomandibular Disorders
- Okeson, 2013
- General types of Orofacial Pains -
1. Dental Painsa. Pulpalb. Periodontal
2. TMD Pains3. Non-TMD Pains
Okeson Differential DX of TMD Star of the South Dental Meeting
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- General types of Orofacial Pains -
Temporomandibular Disorder
is only one subgroup
of Orofacial Pain Disorders.
- remember -
Classification of Facial Pains
Somatic Pain
Axis II(Psychological Conditions)
Axis I(Physical Conditions)
Axis I Axis II
Diagnosis
Superficial Pain
Mucogingival P
ain
Deep Pain
Cutaneous P
ain
Muscle P
ain
TM
J Pain
Osseous P
ain
Co
nn
ect. T
issue
Pa
in
Periodontal P
ain
Visce
ral P
ain
Mu
sculo
skele
tal P
ain
Visce
ral M
uco
sal P
ain
Gla
nd
ula
r, EN
T P
ain
Pu
lpa
l Pa
in
Va
scula
r Pa
in
Ne
uro
vascu
lar P
ain
Neuropathic Pain
Episodic Pain
Pa
roxysm
al N
eu
ralg
ia
Continuous Pain
Trig
em
ina
l Ne
ura
lgia
Pe
riph
era
l Me
dia
ted
Pa
in
Metabolic P
olyneuropathies
Ce
ntra
l Me
dia
ted
Pa
in
En
trap
me
nt N
eu
rop
ath
y
Ne
uritic P
ain
De
nto
alve
ola
r Pa
in
Occlu
sal D
ysesth
esia
Bu
rnin
g M
ou
th D
isord
er
Oth
er N
eu
ralg
ias
Myo
spa
sm (D
yston
ia)
Central M
ediated Myalgia
Myofascial P
ain
Lo
cal M
uscle
So
ren
ess
Protective C
o-Contraction
Ca
psu
lar P
ain
Arth
ritic Pa
in
Re
trod
iscal P
ain
Lig
am
en
tou
s Pa
in
Neurovascular V
ariants
Oth
er P
rima
ry He
ad
ach
e
Trigem
inal Autonom
icC
ephalalgia (TA
C)
Arte
ritis Pa
in
Po
st He
rpe
tic Ne
ura
lgia
Co
mp
lex R
eg
ion
al
Pa
in S
ynd
rom
e
Sympathetically Maintained Pain
Te
nsio
n-T
ype
Mig
rain
e
Ca
rotid
ynia
Pe
riph
era
l Ne
urits
Mood Disorders
Bip
ola
r Diso
rde
r
Mood D
isorder due to
a Medical C
ondition
De
pre
ssive D
isord
er
Anxiety Disorders
Po
sttrau
ma
tic Stre
ssD
isord
er
Anxiety D
isorder due to a M
edical Condition
Ge
ne
ralize
d A
nxie
tyD
isord
er
Somatoform Disorders
Co
nve
rsion
Diso
rde
r
Pa
in D
isord
er
Un
diffe
ren
tiate
dS
om
ato
form
Diso
rde
r
Hyp
och
on
dria
sis
Ma
lad
ap
tive H
ea
lthB
eh
avio
r
Stress-R
elatedP
hysiological Response
Pe
rson
ality T
raits
or C
op
ing
Style
Other Conditions
Psych
olo
gica
l Fa
ctors
Affe
cting
Me
d C
on
ditio
n
Oth
er C
on
ditio
ns
Ma
ling
erin
g
Centrally Mediated
Okeson: Bell’s Oral and Facial Pain, 2014
He
rpe
s Zo
ster
De
affe
renta
tion P
ain
Tra
um
atic N
eu
rom
a
1. What types of orofacial pain disorders should you treat?
Some Important Questions
2. How can you be sure the patient’s pain complaint is
related to a TM disorder?
Primary Pain
Pains in which the site and sourceare in the same location.
Heterotopic Pain
Pains in which the site and sourceare not in the same location.
Tissue injury
The normal processing ofnociception to pain
It’s notpain here.
It’s notpain here.
It’s notpain here.
It’s onlypain here.
PainPain
Tissue injury
The patient feels shoulder pain.
Primary pain
Okeson Differential DX of TMD Star of the South Dental Meeting
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PainThe patient feels shoulder pain.
Primary pain
Continuednociceptive input
centralexcitatory
effects
Possible Central Excitatory Effects
1. Sensory (afferent) Effects
2. Motor (efferent) Effects
3. Autonomic Effects
PainNow the patient feels pain in the shoulder...
...and also in the TMJ.
Continuednociceptive input
centralexcitatory
effects
Pain
Referred Pain
The Clinical Characteristics of Referred Pain
b. does not cross the midline (in the trigeminal)
1. Referred pain most commonly occurs in other divisions of the same nerve that mediates the pain.a. vertical laminated pattern
2. If another nerve is affected, it is usually cephaladto the nerve that mediates the pain.
Pain
PainLocal provocation of the
site of pain does not increase the pain.
Pain
PainLocal provocation of the
source of pain increases the pain not only at the source but also at the site.
Okeson Differential DX of TMD Star of the South Dental Meeting
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Pain
PainLocal anesthetic at the site
of pain does not decrease the pain.
Pain
PainLocal anesthetic at the
source of pain decreases the pain not only at the source but also the site.
Possible Central Excitatory Effects
1. Sensory (afferent) Effectsa. Referred Pain
2. Motor (efferent) Effectsa. Protective Co-Contraction
b. Trigger Points
Referral patterns from the trapezius muscle
The patient’s chief complaint is temporal headache.
site
source
1. What types of orofacial pain disorders should you treat?
2. How can you be sure the patient’s pain complaint is related to a TM disorder?
Some Important Questions
University of British Columbia - Hannam, Langenbach, Scott, Peck, Zhang, 1999
3. Is there a relationship between occlusal factors and TMD?Normal functioning masticatory system
Etiologic Factors
Occlusal Factors
Trauma
Emotional Stress
Deep Pain Input
Parafunction
The asymptomatic individual
Acute ChronicTime
Managing these Etiologic Factors may no longer be adequate.
Altered HPA axis functionIncreased central sensitization
Decreased descending inhibition
Chronic Pain ConditionsChronic TMD
Myofascial painFibromyalgia
Sleep disturbances
Adaptability of the individual
Adaptability
TMD
Central Mechanisms
Genetic factorsBiologic factors
Hormonal factorsPsychosocial factors
Others ?
Okeson Differential DX of TMD Star of the South Dental Meeting
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Normal functioning masticatory system
Etiologic Factors
TMD
Adaptability
The asymptomatic individual
Adaptability of the individual
Occlusal Factors
Trauma
Emotional Stress
Deep Pain Input
Parafunction
Dental therapy only affects one factors.
Genetic factorsBiologic factors
Hormonal factorsPsychosocial factors
Others ?
So when is occlusionrelated to TMD?
1. How does the occlusal condition affectorthopedic stability of the mandible?
2. How does an acute change in the occlusal condition affect masticatory function?
How does occlusion relate to TMD?
Dynamic considerations
- Condylar Stability -
• The condyles are in their most superior anterior positionin the fossae resting against the posterior slopes of thearticular eminentiae. (musculoskeletally stable)
• The discs are properly interposed between thecondyles and the fossae.
- Occlusal Stability -
The optimum orthopedically stable relationship
• Even and simultaneous contact of all teeth with posteriorteeth contacting slightly heavier than anterior teeth.
• Adequate tooth-guided contacts on the laterotrusive side.• In the upright closing position, posterior teeth contact
heavier than anterior teeth. (the envelope of function)
Orthopedic Stability
Joint Stability = Occlusal Stability
Orthopedic instabilityplus loading
An intracapsular disorder
Occlusal stability
Joint instability
1. How does the occlusal condition affectorthopedic stability of the mandible?
2. How does an acute change in the occlusal condition affect masticatory function?
How does occlusion relate to TMD?
Dynamic considerations
Okeson Differential DX of TMD Star of the South Dental Meeting
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Correction of theocclusal alteration.
Provide Therapy
Resolution ofmasticatory muscle
disorder.
No resolution ofmasticatory muscle
disorder.
Cyclic Muscle Pain?
A Psychiatric Condition?
If the occlusal alteration is left unchanged it results in either:
- chronic response -
a masticatory muscledisorder
Occlusal Dysesthesia?
Seventh EditionFebruary 2014
Quintessence Publishers1-800-621-0387
Seventh Edition488 pages
2013
Elsevier/Mosby Company1-800-325-4177
Okeson Texts Okeson Home Page
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