Bijan Movahedian Attar - PowerPoint Presentation

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Bijan Movahedian Attar

DDS, OMFS

Associate professor

Department of Oral and Maxillofacial Surgery,

Isfahan University of Medical Sciences

Headaches attributed to Temporomandibular Disorders

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HEADACHE

or

TMD mimicking a HEADACHE

?

A CHALENGING DISTINCTION TO MAKE

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Sever

headache

usually found in majority of

TMD

patients

“Almost 80%”

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70 % of

headache

patients had also a clinical confirmation of

TMD

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Association between TMD & headache

International Headache Society recognizes that secondary headache can be attributed to TMD

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Headache and TMD are comorbid disease

Presence of one increases the frequency of the other at a rate above the expected one

Association between TMD & headache

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The treatment of TMD associated with headache facilitates the treatment of headache in varying percentage

Association between TMD & headache

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The larger the number of sign/symptoms of TMD, the higher the frequency of migraines

Association between TMD & headache

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The higher the frequency of headaches, the more frequent the muscular and articular sign/symptoms of TMD

Association between TMD & headache

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When patient report a severe headache

A clinical assessment of TMJ and masticatory muscles should be performed in order to exclude TMDs

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TMD should considered in all patients who complain of chronic “

sinus headache “and do not demonstrate objective evidence of sinus, neurologic, neoplastic or vascular abnormalities

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Temporomandibular

Disorders:

An often overlooked cause of chronic headache

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TEMPOROMANDIBULAR DISORDERS

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A clinical problem involving TM joint, masticatory muscles and related structures

Temporomandibular Disorders

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EPIDEMIOLOGY

About 60-70% of the population have features of TMDs

About 20-30% report symptoms of TMDs

About 5% of people with TMD symptoms actually seek treatment

The

female:male

ranges from 3:1 to 9:1

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Etiology of TMD

Exact Cause is Unknown

Many factors work together to initiate or aggravate the condition

Occlusal Disharmony

Psychological Distress

Parafunctional Habits

Acute Truma to Jaw

Trauma from Hyperextension

(after dental visit!)

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Condyles

Articular surface of the temporal bone

Capsule

Articular disc

Ligaments

Lateral pterygoid

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Functional Anatomy

(Shock absorber)

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Functional Anatomy

Synovial joint

Two movements:

Hinge type

Gliding type

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Temporalis

Muscle

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Masseter Muscle

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Medial

Pterygoid Muscle

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Inferior

Lateral Pterygoid Muscle

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Superior

Lateral Pterygoid Muscle

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TMD classification

Type 1

Muscular disorders

Type 2

intra articular , disk disorders

Type 3

arthritic disorders

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MPD is the most common cause of masticatory pain and limited function for which patients seek dental consultation and treatment.

The cause of MPD is multifactorial.one of the most commonly accepted causes of MPD is

bruxism

and

clenching

resulting from stress and anxiety, with occlusion being a modifying or aggravating factor.

myofasial

pain

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The etiology of the most common TMDs is unknown.

Two hypotheses,

occlusal

disharmony and psychological distress have dominated the literature

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ETIOLOGY

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Lateral occlusal interfere

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Anterior teeth lingual tipping deep overbite

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INTERNAL DERANGEMENT

Abnormal relationship of the articular disc to the mandibular condyle, fossa

, and

articular eminence, interfering with the smooth action of the

joint

Is a localized mechanical fault within the

joint

Synonymous with disc displacement

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DISC POSITION

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Complete anterior disc displacement

medial section

Autopsy

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TMPDS

Signs & Symptoms

Pre-auricular pain that may radiate to other sites

Tenderness of the joint on palpation

Limited mouth movement (due to pain)

Deviation of mandible on opening & closing

Tenderness of muscles of mastication

Joint sounds

Headache

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Internal derangement

Disc displacement with reduction

Disc displaced

(usually anteriorly)

during opening & reduced

(return back to normal)

upon closing

Reproducible clicking

No limitation of mouth opening

Deviation of jaw might be present

Pain might be present

Intermittent locking

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TMJ sounds

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Internal derangement

Disc displacement without reduction

Disc is displaced during opening & closing

Disc does not reduce (does not return back to normal)

Persistent limitation of mouth opening

Pain

No clicking

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Diagnosis of TMDs

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History

Pain

Joint Sounds

Restriction of Opening

Swelling

Over the maxilla

In the area of parotid gland

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The joint

Lateral aspect

Examiner should be in front of the patient

A single finger is placed over each condyler head

Jaw movement

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Clinical examination of

TMD

Mouth opening

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Opening patterns

Straight

Deviation (right & left)

Corrected deviation

Others

Clinical examination of TMD

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Lateral deviation

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CONTRALATERAL PAIN SUGGESTS ARTICULAR DISEASE

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Muscular tenderness

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Tenderness of Lateral

pterygoid

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Radiographic Evaluation

Panoramic radiography

Lateral

transcranial

radiography

CT scan

TMJ arthrography

MRI

Nuclear Imaging

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DEGENERATIVE CHANGES IN CONDYLE

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Bruxism (clenching) and TMD

Significant association between TMD and clenching

Prevalent in near 70% of patient with

myofacial

pain

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Management of TMDs

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C

onservative

therapy

P

atient

education

Splint therapy

Pharmacotherapy

Occlusal

management

Physical

therapy

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Types of

o

cclusal Splints Used in

TMJ Disorders

Stabilization splints

Repositioning splints

Pivot splints

Soft splints

Bite plane splints

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SPLINT THERAPY

Stabilization splints

:

Stabilization splints are

the most

commonly used splints to treat myofascial

pain

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Stabilization splint

Treatment of TMD

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Repositioning splint

Treatment of TMD

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Categories of Medications used to treat TMJ Disorders

NSAIDs

Corticosteroids

Analgesics

Muscle relaxants

Antidepressants

Anxiolytics

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TMD BoNT-A* Injections

Botulinum

toxin injections are placed throughout the temporalis (5-25U) and masseter (25-50U) musculature.

Medial (5-25U) and Lateral (5-10)

pterygoid

muscles may also be injected through an intra-oral approach.

*Allergan, Botox®, USA

Reprinted from

Freund B, Schwartz M, Symington JM

.

Br J Oral Maxillofac Surg

2000;38(5):466-471, with permission from The British Association of Oral and Maxillofacial Surgeons.

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SURGERIES OF THE JOINT

Discectomy

Disc repositioning

Condylotomy

Arthrocentesis

Arthroscopy

Partial and total joint replacement

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Lavage &

Arthrocentesis

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HOLMLUND-HELMSING LINE

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ARTHROSCOPY

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There should be no dividing line between the knowledge of both

orofacial pain specialist and headache physicians

Conclusion

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Let us having

“Team work” to treat our patient with headache

Conclusion

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A dynamic relationship

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MYOFASCIAL PAIN AND DYSFUNCTION

Refers to a group of poorly defined muscle disorders (eg, fibromyalgia) characterized by diffuse facial pain and episodic limited jaw opening

May result from parafunctional habits and significant relationship to psychophysiologic disorders such as stress or depression

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Management

Initial (conservative)

Further (specialist)

Reassurance

Psychological intervention

Education

Antidepressants

Habit management

Occlusal adjustment

Modification of function

Intra-auricular steroids

Rest

Manipulation under GA

NSAID, analgesics and muscle relaxants

Arthroscopy

Removable occlusal splints

Surgery

Physiotherapy / Jaw exercises

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Anterior repositioning splint

When & How it Works!

It positions the condyle anteriorly

away from the fully seated joint position

Used in case of trauma inducing retrodiscal edema

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Guide the mandibular condyles away from retrodiscal tissues.

Used in case of anterior disc displacement

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Help aligning the disc over the condyle

(back to normal position)

hoping that it will keep this relation with time.

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Stabilization splint

Hard acrylic

Technically demanding

Maxillary splint is easier to adjust

Worn at night

Long-term use

must provide ideal occlusion at rest & function (CR =CO)

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Useful (?) in muscular signs & symptoms

Bruxism may become worse in some patients

Better tolerated in lower jaw

Quick and easy to make

Different thickness

No need for occlusal adjustment

Lasts for about 6 months