Okeson Handout Hinman TX tmd 3-22-18 · University of Kentucky College of Dentistry Lexington, Kentucky 40536-0297 ... c. promote emotional stress awareness / reduction. d. encourage

byJeffrey P Okeson, DMD

Director, Orofacial Pain ProgramChief, Division of Orofacial Pain

Provost's Distinguished Service Professor University of Kentucky College of Dentistry

Lexington, Kentucky [email protected]

jeffokeson.net

“Management considerations for Temporomandibular Disorders”

The Hinman Dental MeetingAtlanta, GeorgiaMarch 23, 2018

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

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 Complex

a. Disc Displacement with Reductionb. Disc Displacement without Reduction

2. Structural Incompatibilities3. Inflammatory Disorders

Classification of Temporomandibular Disorders

Muscle PainMuscle pain is the most common type of pain

humans experience.

Muscle PainMuscle pain is the most common type of pain

humans experience.

Chronic muscle pain affects between11–24% 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

We dentists have been trained to think of muscle pain as a consequence of an anatomic variation.

Muscle Pain

Malocclusion Incorrect joint position

Or ....we think about muscle pain as it relates to parafunction (bruxism, clenching, tooth wear).

Muscle Pain

Awake Time ClenchingSleep Related Bruxing

Or ....we think about muscle pain as it relates to parafunction (bruxism, clenching, tooth wear).

Muscle Pain

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.

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.

Common beliefs regarding bruxism, tooth wear, EMG and pain- Facts or Fiction ? -

What are some common beliefs?

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


1. TMD patients report more bruxing activity than controls.2. TMD patients actually brux more than controls.


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

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



bruxing activity.4. There is a strong correlation between tooth wear and RMMA

(rhythmic masticatory muscle activity).


There is no correlation between tooth wear and RMMA observed in a sleep lab.

TRUE

FALSE

FALSE

FALSE




(rhythmic masticatory muscle activity).5. There is a strong correlation between bruxing activity and pain.


There is no correlation between pain and RMMA observed in a sleep lab.

TRUE

FALSE

FALSE

FALSE

FALSE




(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.

Yemm 1985Majewski 1984 Carlson, 1993Maillou, 1997Sevensson, 2004

TRUE

FALSE

FALSE

FALSE

FALSEFALSE




(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




(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.


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

Masticatory Muscle Pain

What is it?What causes it?

SpasmAn involuntary, CNS induced tonic

contraction, often associated with local metabolic conditions.

Cramp

Masticatory Muscle Pain

What is it?What causes it?

Spasm

Yet studies demonstrate that there are no differences in EMG activity

between masticatory muscle pain patients and controls.

Yemm 1985Majewski 1984 Carlson, 1993Maillou, 1997Sevensson, 2004

AClinicalMasticatoryMuscleModel

Okeson 2012

NormalFunction

ResolutionLocal

MuscleSoreness

AMasticatoryMuscleModel

Okeson, 2012

Regional Myalgic Disorders

Myofascial PainCentrally Mediated Myalgia

Systemic MyalgicDisorder

Fibromyalgia

Acute Time Chronic

Myospasm

CNS Effectson Muscle Pain

AnEvent

ProtectiveCo-

contraction

NormalFunction

ResolutionLocal

MuscleSoreness


Okeson, 2012




Fibromyalgia

Acute Time Chronic

Myospasm


AnEvent

ManagingMuscleDisorderstakessomethinking.

ProtectiveCo-

contraction

ProtectiveCo-

contraction

1Local

MuscleSoreness

2

Myospasm

3

Myofascial Pain4

Fibromyalgia6

Important:Theyareallmanageddifferently.

5 Centrally Mediated Myalgia

NormalFunction

Resolution





Fibromyalgia

Acute Time Chronic

Myospasm


AnEvent

ProtectiveCo-

contraction

Becauseofourlimitedtime,wecanonlydiscussthemostcommondisorder.

LocalMuscle

Soreness

LocalMuscle

Soreness

NormalFunction

Resolution


Acute Time Chronic

AnEvent

ProtectiveCo-

contraction

Becauseofourlimitedtime,wecanonlydiscussthemostcommondisorder.

LocalMuscleSoreness1.Description2.Etiology3.History4.Examinationfindings5.Treatment

LocalMuscle

Soreness

Aprimary,non-inflammatory,myogenouspaincondition.

- description-

LocalMuscleSoreness

(musclefatigue/overuse)

1. Protractedco-contractionproduceschangesinthemuscletissue,suchasfatigue,ischemia,resultingintheproductionofalgogenicsubstances.

2. Deeppaininput(mayleadto“cyclicmusclepain”)3.Localtissuetrauma

a.localinjury(e.g.injections,strain)b.unaccustomedmuscleuse(e.g.bruxism,chewing

gum)(Delayedonsetlocalmusclesoreness)4.Increasedlevelsofemotionalstress

- etiology-

LocalMuscleSoreness

1.Thepainbeganseveralhoursordaysfollowinganeventassociatedwithprotectiveco-contraction.(e.g.alteredsensoryinput,highcrown)

2.Tissueinjury(injections,openingwide,orunaccustomedmuscleuse- painmaybedelayed).

3.Secondarytoanothersourceofthepain.4.Associatedwithanincreasedleveloftheemotional

stress.

- history-

LocalMuscleSoreness

1.Structuraldysfunction:adecreaseinthevelocityandrangeofmandibularmovement.Thefullrangeofmovementcannotbeachievedbythepatient.Passivestretchingbytheexaminercanoftenachieveamorenormalrangeofmovement(softendfeel).

- clinicalcharacteristics-

LocalMuscleSoreness

2.Minimalpainatrest.3.Increasedpainwithfunction.4.Localtendernesstopalpation.

Thegeneralgoaloftherapyistoreducesensoryinputthatcanleadtocyclicmusclepainby:

1.Eliminateanyongoingalteredsensoryorproprioceptiveinput.2.Educationpatientandencouragephysicalselfregulation.

a.decreasejawusetowithinpainlesslimits.b.stimulateproprioceptorswithnormalmuscleuse.c.promoteemotionalstressawareness/reduction.d.encouragereductionofnon-functionaltoothcontacts

(cognitiveawareness).3.Occlusalappliancetherapy.4.Consideredtheuseofmildanalgesics.(ibuprofen400mgtid)

- treatment-

LocalMuscleSoreness

Expectresultsin1-3weeks.Ifthetherapyisnotsuccessful,considerthateither:

1.Theetiologicfactorsarenotbeingcontrolledor

- treatment-

LocalMuscleSoreness

2.Youhavemisdiagnosedthedisorder.

MPD

Occlusal Appliance Therapy

TypeIndicationsFabricationClinical Protocol

The Stabilization Appliance Occlusal Appliance Therapy


Local Muscle Soreness

Chronic Centrally Mediated Myalgia

Bruxism

The Stabilization Appliance

- Indications -



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

Right lateral movement Left lateral movement

The Final Stabilization Appliance

What about mandibular appliances?

The final mandibular stabilization appliance

Right lateral movement Left lateral movement



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

1 3/10 reinforce physical self regulationreevaluate the stabilization appliance, adjust PRN



4 0/10 What do you do next?

Managing the patient with Local Muscle Soreness

When an occlusal appliance reducesthe patient’s symptoms...

….what do you do next?

Reasons that could explain why your occlusal appliance reduced the muscle pain.

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


So why did the patient respond?

DentalEtiologies

Non-Dental

Etiologies


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


DentalEtiologies


1. A change in the occlusal condition2. A change in the condylar position3. A change in the vertical dimension


DentalEtiologies


1. A change in the occlusal condition2. A change in the condylar position

OrthopedicInstability

Develop a dental treatment plan

selective grindingfixed prosthodontic therapy

removable prosthodontic therapyorthodontic therapyorthognathic surgerycombined therapies

occlusal appliance maintenance

TX possibilities


Time to change our discussionto a different disorder.

Seventh EditionFebruary 2014

Quintessence Publishers1-800-621-0387

Seventh Edition488 pages

2013

Elsevier/Mosby Company1-800-325-4177

Newly Updated Lecture Series- DVDs or streaming -www.jeffokeson.net

Okeson Texts Okeson Home Page

University of KentuckyMini-Residency Program

June 4-8 2018Shadowing Program

1 week (40 hr)

[email protected]

Occlusion Meds

PTPain

Referral

Stress

Muscledisorders

DiscDisorders

Splints

MuscleDisorders

Occlusion Meds

PTPain

Referral

Stress

Muscledisorders

Splints

DiscDisordersDisc

Disorders

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

2. Structural Incompatibilities3. Inflammatory Disorders

I. Masticatory Muscle Disorders1. Protective Co-Contraction2. Local Muscle Soreness3. Myofascial Pain4. Myospasm5. Chronic Centrally Mediated Myalgia

Management of TM joint disorders

What about the use of an“Anterior Positioning Appliance” ?

A painful disc displacement

- Think orthopedically - - Think orthopedically -

Anterior therapeutic position, pain reduction

The anteriorpositioning appliance

The anteriorpositioning appliance

- an interesting question -

When an “Anterior Positioning Appliance”reduces the patient symptoms…..

.....what do you do next ?

The problem was there were no data.

Which philosophy is correct?

The Re-builders

MS position

The Re-capturers

MS position

The Repairers

MS position

What is the short-term successof anterior positioning appliances?

Short-term Treatment of Disc Displacement With Reduction (phase I)

author # of pat type of tx duration reported success

Anderson et al 10 APA - 24 hrs/day 3 months sign. improvement1985 10 SA -24 hrs/day 3 months no change

Lundh et al 24 APA - 24 hrs/day 6 weeks much better1985 23 SA - 24 hrs/day 6 weeks slightly better

23 Control 6 weeks no change

Okeson 40 APA - 24 hrs/day 2 months 80%1986

Simmons et al 7 APA - 24 hrs/day 9 months 95%1995

Davies et al 40 APA - 24 hrs/day 2 months 88%1997 25 APA - only HS 2 months 65%

20 APA - only day 2 months 52%average 75-80%

What is the long-term successof anterior positioning appliances

for pain and dysfunction?

author # of pat type of tx duration success/pain & dysfunction

Moloney & 241 no occlusal changes 3 yrs 36%Howard,1986 APA & orthodontics 3 yrs 50%

APA & Cr / Bridge 3 yrs 43%

Okeson 40 no occlusal changes 2.5 yrs 25%1988

Butterworth 151 APA & orthodontics 1.75 yrs 51%et al, 1992

Davies et al 48 no occlusal changes 3 yrs 70%1997

Vichaichalerm- 17 no occlusal changes 4.2 yrs 35% vong et al,1993

Summers et al 75 APA & Cr / Bridge 1-6 yrs 52%1997

Tallents et al 68 APA & Cr / Bridge 1-3 yrs 44%1990

Long-term Treatment of Disc Displacement With Reduction (phase II)

average 45%

What is the long-term successof anterior positioning appliances

when pain and dysfunctionare evaluated separately?

author # of pat type of tx duration success/pain success/click

Moloney & 241 no occlusal changes 3 yrs not reported 36%Howard,1986 APA & orthodontics 3 yrs not reported 50%

APA & Cr / Bridge 3 yrs not reported 43%

Okeson 40 no occlusal changes 2.5 yrs 75% 33%1988

Butterworth 151 APA & orthodontics 1.75 yrs 86% 51%et al, 1992

Davies et al 48 no occlusal changes 3 yrs 87-92% 70%1997

Vichaichalerm- 17 no occlusal changes 4.2 yrs 77% 35% vong et al,1993

Summers et al 75 APA & Cr / Bridge 1-6 yrs 86% 52%1997

Tallents et al 68 APA & Cr / Bridge 1-3 yrs _ 44% 1990

Long-term Treatment of Disc Displacement with reduction (phase II)

average 83% average 45%

What is the long-term successfor Joint Sounds?

author # of pat type of tx duration success

Moloney & Howard 34 APA & orthodontics 3 yrs 50% click returned1986 14 APA & Cr / Bridge 3 yrs 43% click returned

Butterworth et al, 1992 151 APA & orthodontics 1.75 yrs 49% click returned

Summers et al, 1997 75 APA & Cr / Bridge 1-6 yrs 48% click returned

Tallents et al, 1990 68 APA & Cr / Bridge 1-3 yrs 56% click returned

Okeson, 1988 40 no occlusal changes 2.5 yrs 67 % click returned

Vichaichalermvong et al, 1993 17 no occlusal changes 4.2 yrs 65% click returned

Dolwick et al, 1987 33 TMJ surgery 4.2 yrs 58% click returned

de Leeuw , 1994 99 Nonsurgical 30 yrs 56% click returned

Long-term Success for Joint Sounds

average 55% return

Summary of Studies on Anterior Positioning Appliance Therapy

Long-term effects

Pain Clicking

Yes YesShort-term effects

Yes No

Treatment Considerations

Has the Disc been “recaptured” ?

MS position

Painful loading of the retrodiscal tissues. Position the mandible forward off the retrodiscal tissues.(pain reduction)

MS position

The retrodiscal tissues adapt.

The condyle can now function in the musculoskeletally stable position painlessly.

(there may still be clicking)

MS position

Studies that support the fibrotic adaptation of the retrodiscal tissues.

Scapino RP, 1983Hall MB, et al,1984

Solberg WK et al, 1985Arkerman S, et al, 1986

Blaustein DI & Scapino RP, 1986Isberg A, et al, 1986

Solberg WK, et al, 1986Baldioceda F, et al, 1989

Salo L, et al, 1989Luder HU, et al, 1993Pereira FJ, et al, 1996aPereira FJ, et al, 1996b

Long-term Outcome of Disc Displacement with reduction

- conclusions from results of long-term studies -

Anterior positioning appliances may be helpful but only on a part time basis.

1. Educating the patient to the problem2. Reduce heavy chewing3. Reduce non-functional tooth contacts4. Appliance therapy

Our goal should be to help the patient adaptthe retrodiscal tissues by reducing loading forces.

With time the muscle develops

a myostatic contracture.

A painless shorteningof the functional length

of the muscle.

The result is a posterior open bite

Final Anterior Positioning Appliance Final Anterior Positioning Appliance

A temporary therapeutic position

nota final treatment position.

How should anterior positioning appliances be used in patients with anterior disc

displacement with reduction?

Clinicalevaluation

Stabilization Appliance(always at night and

when needed during the day)

No pain

Continuedpain

Time,re-evaluate

Reduce use of theappliance and assess

for orthopedic stability

Anterior Positioning Appliance(always at night and

when needed during day)

Reduces pain Time,re-evaluate

Decrease useof the appliance

Returnof pain

Management of disc displacement with reduction

Patient

No changein pain

No pain

No further treatment indicated(consider bruxism)

Return tothe APA

Pain reduction, allow more time

Convert the APAto a SA

Orthopedic stability

Pain returns

No pain

Assess fororthopedic stability

Orthopedic instability

Evaluate for appropriate

dental therapy

No dental therapy

indicated


Clinicalevaluation

Stabilization Appliance(always at night and

when needed during the day)

No pain

Continuedpain

Time,re-evaluate

Reduce use of theappliance and assess

for orthopedic stability

Anterior Positioning Appliance(always at night and

when needed during day)

Reduces pain

No changein pain

Time,re-evaluate

Decrease useof the appliance

No pain,no further treatment indicated

(consider bruxism)

Returnof pain

Patient

Begin24 hour use

Reduction of pain

No reduction of pain Re-evaluate pain, consider surgical

evaluation


Long-term Outcome of Disc Displacement with reduction

- conclusions from results of long-term studies -

Anterior positioning appliances may be helpful but only on a part time basis.

Permanent occlusal changes are seldom indicated.

1. Educating the patient to the problem2. Reduce heavy chewing3. Reduce non-functional tooth contacts4. Appliance therapy

Our goal should be to help the patient adaptthe retrodiscal tissues by reducing loading forces.

Do not ever lose sight of the fact that we are healthcare providers.We have been granted the privilege of treating our fellow men/women.

- A closing philosophical thought -

When you do this, you will have a happy and grateful patient.Treatment plan your patients as if they were family members.

Seventh EditionFebruary 2014

Quintessence Publishers1-800-621-0387

Seventh Edition488 pages

2013

Elsevier/Mosby Company1-800-325-4177

Newly Updated Lecture Series- DVDs or streaming -www.jeffokeson.net

Okeson Texts Okeson Home Page

University of KentuckyMini-Residency Program

June 4-8, 2018 Shadowing Program

1 week (40 hr)

[email protected]

Documents

Okeson Handout Hinman TX tmd 3-22-18 · University of Kentucky College of Dentistry Lexington, Kentucky 40536-0297 ... c. promote emotional stress awareness / reduction. d. encourage