Outline. Limiting your risk when treating patients with TMD. Temporomandibular Disorders 20/01/2014. TMD diagnosis. Condylar position and TMD risk

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1 Outline American Association of Orthodontists Limiting your risk when treating patients with TMD Ambra Michelotti TMD diagnosis Condylar position and TMD risk Occlusal interference and TMD risk Red Flags and TMD risk University of Naples Federico II Temporomandibular Disorders ModifiedbyDiatchenkoetal, 2006 ModifiedbyBenoliel etal, 2011 Temporomandibular disorders (TMDs) encompass a group of musculoskeletal and neuromuscular conditions that involve the temporomandibular joints (TMJs), the masticatory muscles and all associated tissues. The signs and symptoms associated with these disorders are diverse, and may include difficulties with chewing, speaking and other orofacial functions. They also are frequently associated with acute or persistent pain, and the patients often suffer from other painful disorders (comorbidities). Environment Occlusion Orthodontics TMD The chronic forms of TMD pain may lead to absence from or impairment of work or social interactions, resulting in an overall reduction in the quality of life. GAD65 Serotonin MAO receptor Cannabinoid Dopamine Serotonin Na+, K+transporter NET receptors receptors CACNA1A ATPase IKK COMT Adrenergic Opioid NMDA CREB1 GR receptors DREAM POMC receptors BDNF NGF Prodynorphin Interleukins AMERICAN ASSOCIATION FOR DENTAL RESEARCH TMD POLICY STATEMENT REVISION, MARCH 3, 2010 Xp q11.2 9q q23 5q31-q32 5q q24-q25 1p q11.21 Fatigue, stiffness or pain of the jaw muscles Pain TMJ Sounds Jaw movements impairment Click Crepitus Deviation Deflection 1

2 Main complaints Preauricular pain, right and left TMJs clicking sounds, headache, malocclusion, missing posterior teeth X X X X X X Sharp pain, at the left and right preauricular regions; during click sound, during chewing and opening movements Headache - localization: temporal region, bilaterally - frequency: often (2-3 times/week) - intensity: moderate-high (5-7 VAS) - decreases with rest and increases with jaw movements Vertical range of motion Jaw excursions Unassisted opening without pain 41 mm Maximum unassisted opening 46 mm Maximum assisted opening 49 mm Right lateral Excursion 5 mm Protrusion 3 mm Left lateral excursion 2 mm Vertical incisor overlap 3 mm FAMILIAR PAIN FAMILIAR PAIN Joint Palpation FAMILIAR PAIN FAMILIAR HEADACHEE FAMILIAR PAIN Joint Sounds Right joint Left joint LR LL P C O O C P LL LR Click Crepitus X X X X X X X X Click sound at right and left TMJs during chewing, opening, closing and lateral movements 2

3 Not necessary Outline TMD diagnosis Condylar position and TMD risk Occlusal interference and TMD risk Red Flags and TMD risk 3

4 Reduction of posterior vertical dimension 11 cases in which disturbance of mandibular joint function was considered the chief etiologic factor of abnormal ear and head conditions Left Ronald H. Roth San Mateo, California Angle Orthod patients 2 controls The condyles should be seated superior and anterior in the fossae against the articular disks and the distal slope of the articular eminence, and centered transversely. Mounting dental casts on an articulator helps in measuring the centric relation-centric occlusion discrepancy in 3 planes of space. This is important information when the goal is to treat to a musculoskeletal stable position. Objective: to evaluate the reliability and validity of 3 bite registrations in relation to condylar position in the glenoid fossae using magnetic resonance imaging in a symptom-free population. Centric Occlusion Centric Relation (Am J Orthod Dentofacial Orthop 2013;144:512-7) Roth Power Centric Relation The centricity of the condyles in the glenoid fossa involves a range, and eccentricity does not necessarily indicate TMD. Therefore, the analysis of articulated casts will not be diagnostic of TMD per se. 4

5 Interestingly OOOO, 2009 The differences between the 3 bite positions were small and, more importantly, highly variable. Variability in the findings between the bite registrations appear to reflect the lack of accuracy and predictability. Based on the findings that we are not positioning the condyles in specific positions in the fossae with various bite registrations, the clinical significance followed by the routine practice of condylar positioning must be questioned. No association between condylar position and signs and symptoms of TMD was found Angle Orthod, 2010 normal joints normal joints CONCLUSION Mandibular dysfunction and incisor relationship. A theoretical explanation for the clicking joint. Berry DC, Waltkinson AC Br Dent J, 1978 Great overlap Left Deep bite / Class II 2 Wide distribution Condyle position per se is not diagnostic and would fail any useful prediction values Pullinger A, JOR

6 The extraction non extraction dilemma as it relates to TMD RP McLaughlin, JC Bennett. Angle Orthod, 1995 however Excessive anterior interferences resulting in possible posterior condyle displacement are the result of treatment mechanics CONCLUSION There is no evidence that asymptomatic TM joints with posterior positioned condyles are at risk for disc displacement derangements. There is no evidence that centric condylar position means healthy TM joint. There is no evidence that centric condylar position limits risk when treating patients with TMD. Outline TMD diagnosis Condylar position and TMD risk Occlusal interference and TMD risk Red Flags and TMD risk 6

7 However In animal models, artificial occlusal alterations can result in disorders or damage of TMJs, masticatory muscles, and the nervous system. Long term mechanistic nociception is related not only to peripheral sensitization of nociceptive neurons but also to central sensitization Xie et al, JOR 2013 Results from animal studies cannot be directly extrapolated to humans Xie et al, JOR % MVC Gallo LM, Palla S. J Oral Rehabil 1995; 22: Decrease in number of activity periods Decrease of contraction intensity however sometimes None of the subjects developed signs and symptoms of TMD No changes in PPT 7

8 why? Effects of occlusal interference in patients with muscle pain Michelotti et al., in preparation Different adaptation Artificial interferences seem to play a different role in responses in subjects with an earlier TMD history compared to those without No differences in number of activity periods during active interference Dur (s) IFCbefore DIC AIC IFCafter Session CTR TMD TMD subjects showed higher number of events with higher intensity compared to healthy subjects A mean (%MVC) * CTR TMD N/hr * CTR TMD 5 20 Different adaptation to occlusal changes 0 0 IFCbefore DIC AIC IFCafter Session IFCbefore DIC AIC IFCafter Session 10 Aim 250 subjects filled the Oral Behavior Checklist (OBC) Oral Behaviour Checklist Markiewicz et al, th 90 th 80% Hans Christian Andersen The Princess and the Pea Avignon Palais de Popes 10 without parafunctions (npar) (6 f,4 m; mean age ±SD 22.3±1.8) Michelotti et al. JOP with parafunctions (PAR) (9 f,1 m; mean age ± SD 20.4±1.17) Exclusion criteria Dentalprostheses Orthodontic treatment Oneormoremissingteethwiththeexception ofthirdmolars Neurological disorders Assumptions ofdrugsaffecting thecentralnervoussystem. 8

9 p<0.01 State Anxiety Trait Anxiety Visual Analogue Scale (VAS) - occlusal discomfort - spontaneous pain - headache Higher values of trait anxiety in Parafunctional subjects Conclusion Perceived the occlusal interference as cause of high discomfort Perceived the occlusal interference as cause of discomfort They reported pain or signs of dysfunctions They did not report pain or signs of dysfunctions During AIC occlusal discomfort, headache and spontaneous pain were higher in Parafunctional Subjects High trait anxiety individuals Low trait anxiety individuals NORMAL FUNCTION Take Home Message Decreased parafunctional activities Occlusal hypovigilance TMD diagnosis Outline Occlus al change Adaptabilit y Physiologic al tolerance Physiological tolerance exceeded Occlusal hypervigilanc e Somatosensory amplification Condylar position and TMD risk Occlusal interference and TMD risk Michelotti and Iodice, JOR 2010 TMD SYMPTOMS Increased parafunctiona l activities Red Flags and TMD risk 9

10 P. A. 45 ys P. A. 45 ys Main complaints Facial pain Limited jaw movement Headache Axis I 1 Myofacial Pain with referrals FAMILIAR PAIN Facial Pain from 1 years (24h/24h; 7days/7days). The tongue is affected too. Started after the prosthodontic rehabilitation. She changed many prosthetic manufactory but the pain is always present. Headache (bilateral) Cervical and back pain 2 Headache attributed to TMD FAMILIAR HEADACHEE 3 Cervical Pain RDC/TMD Psychological Evaluation Axis II Graded Chronic Pain Scale 20 10

11 Psychological Evaluation Axis II Treatment protocol 1 Counseling 2 Physiotherapy Depression and non specific physical symptoms 3 Prosthetic rehabilitation 4 Psychiatric Consultation Flag areas that might be associated with history taking Chronicity Functional limitation Discrepancy in findings Overuse of medication Inappropriate behaviour Inappropriate expectations Inappropriate responsiveness to prior treatment Identify red-flags from self-report screener Recommendations on rehabilitation of TMDs Cairns B, List T, Michelotti A, Ohrbach R, Svensson P 11

12 Orthodontic treatment Range of motion WNL Surgery Two months later M.S. 25 ys Main complaint Bilateral facial pain. Severe pain on both sides in the masseter and temporal regions. Pain increases during mandibular movements, chewing and yawning, so that he could eat only soft meals Headache, bilateral, localizedattemples. Present everyday, worse in the evening. Stress increases headache. Myofascial pain 1) Counseling 2) Physiotherapy 3) Drugs Headache attributed to TMD For 3 weeks 12

13 M.S. 25 ys During class II elastics Suspend class II elastics Distraction of the right TMJ Coordination exercise of the jaw opening Preauricular pain on right Limited jaw movement Pain during jaw movement Home regimen physiotherapy Symptom free Take Home Message Conservativ e treatment No pain Patient develops TMD signs and symptoms during orthodontic treatment Patient information and counseling + Suspend temporarily active orthodontic treatment Differential diagnosis Conservativ e treatment Myofascial pain TMJ disease Continue the orthodontic treatment Revaluate the orthodontic treatment plan Michelotti and Iodice, JOR 2010 No pain 13