2018 Oregon Dental Conference Course Handout James Rapson, DDS, MS / Susan Rustvold, DMD, MS, EdD

Transcription

1 2018 Oregon Dental Conference Course Handout James Rapson, DDS, MS / Susan Rustvold, DMD, MS, EdD Course 9153: Essentials of Orofacial Pain and Temporomandibular Disorders Friday, April 6 2-3:30 pm

2 Objectives 1. Classify three fundamental types of non-odontogenic orofacial pain 2. Outline at least eight questions to ask to augment and supplement the subjective description of the patient s chief complaint. 3. List at least three behavioral contributors to pain and be able to observe or interview to identify these contributing factors. 4. Identify at least one feature each of Cluster Headache, dystonia, and Giant Cell Arteritis (temporal arteritis) that may present suggesting aspects of temporomandibular disorders.

3 Essen*als of Orofacial Pain and Temporomandibular Disorders Diagnos*c Algorithms Susan Rustvold, DMD, EdD Jim Rapson, DDS, MS Oregon Dental Associa*on 2018 Scope of Orofacial Pain Non-Odontogenic Pain Musculoskeletal Glandular Pharyngeal Otic Ocular Rhinologic Mucosal Vascular Neuropathic 1

4 What will you face? Mas*catory myalgia & referred otalgia Cervical muscle pain referred to the face Closed lock (hindered opening) Open lock (disloca*on) Sleep posture induced strain (lateral pterygoid) Temporal tendoni*s Referred odontalgia Neuropathic pain Atypical pulpi*s Atypical odontalgia Giant Cell arteri*s (Temporal arteri*s) Dystonia Cluster Headache Migraine Acute Pain Sudden onset, usually with a specific iden*fiable cause Injury Surgery Usually persists less than 6 months References: Ins*tute for Chronic Pain. Chronic Pain Syndrome. NIH. Pain Management: Acute and Chronic 2

5 Chronic Pain from chronos = *me any pain las*ng more than 6 months muscle component muscle tension myofascial pain (muscle bundle) muscle spasm pain perpetuates tension -> cycle of pain chronic pain leads to discouragement and aspects of depression Chronic Pain Chronic pain is linked with Headache Arthri*s: rheumatoid, osteoarthri*s, infec*ous Cancer Nerve pain Back pain Fibromyalgia (FMS) 3

6 Chronic Pain References: Ins*tute for Chronic Pain. Chronic Pain Syndrome. NIH. Pain Management: Acute and Chronic Diagnos*c Rou*ne: SOAP S: Subjec*ve complaint. (Quote pa*ent) O: Objec*ve tests (rads, meds et cetera) Symptoms in ques*on Outcome of imaging Outcome of exam & tes*ng A: Assessment P: Plan to address subjec*ve complaint 4

7 SOAP: example S: A back tooth on the lower lef side hurts, especially with cold or some*mes when I bite down. O: Exam type: focused HQR WNL, NKD/LA Meds: Tylenol 1000mg Q4h x 12 hours Pano & PA films #19 caries, other & WNL Visual exam w/ transillumina*on: Frx ML cusp 19 Isolated cusp loading: Frx ML cusp 19, provoked CC Pulp vitality: #19 cold provoked CC, 17-22, & WNL A: #19 Pulpi*s w/ caries & fracture of ML cusp, likely restorable. P: 1) Direct restora*on # 19 2) F/U exis*ng Tx plan dtd 23 Jan 2018 Modified SOAP S: Generalized chief complaint (Let the pa)ent vent for 60 seconds.) O: T-1 or T-3, Rads, Labs, HQR, Reconcile Meds (DPRX) CC#1 CC#2 CC#... A: P: 5

8 Diagnos*c Rou*ne CC#1 Type of pain, quality, & loca*on/extent Type: stabbing, aching, sharp, dull, burning, throbbing, Dura*on: brief, a few minutes, prolonged; *me of day Loca*on: localized area, broad area; deep, superficial, unilateral/bilateral Diagnos*c Rou*ne CC#1 Type of pain, quality, & extent Onset: Ini*al & subsequent precipita*ng event or condi*on. What makes it worse? What provides relief? Frequency? (24/7) 3/7 days 9/24 hours Intensity??/10 Now, best, worst? Course: staying the same, geqng worse, improving over *me 6

9 Diagnos*c Rou*ne Sleep Onset, quality (interrup*ons), dura*on, posture Parafunc*on Headache & other pain Hx Diet, Hydra*on? Caffeine (Coffee, Mt. Dew, Excedrin, energy drinks) Nico*ne Diagnos*c Rou*ne Breathing rate & type observa*on Head and Neck Exam Radiographs Intraoral hard & sof *ssue Exam Cranial & Cervical (C 2 -C 4 ) Nerve Exam Cervical ROM Exam Mandibular ROM Exam Palpa*on, func*onal loading, resisted movement of cervical & jaw muscles, TMJ & temporalis tendon 7

10 Diagnos*c Rou*ne Serial anesthesia of the teeth Diagnos*c blocks of branches of the Trigeminal nerve (Auriculo-temporal, etc.) Trigger point injec*ons Glandular provoca*on Posture observa*on (sta*c & dynamic) Diagnosis What structure, when provoked, causes exacerba*on of the chief complaint? Is the structure normal? Under what condi*ons, and during what behavior does the pa*ent typically provoke that anatomical structure? Is the behavior excessive? What contribu*ng factors exist? Can the pa*ent modify the contribu*ng factors? 8

11 Treatment Educa*on Educa*on Educa*on Interven*on Treatment Non-invasive Interven*on Physiologic Self-regula*on & Behavior Modifica*on Address fa*gue with rest and avoidance of inappropriate muscle use. Address dysfunc*on (ROM limita*ons) with PT Sleep Hygiene Ortho*cs 9

12 Invasive Interven*on medica*ons surgery orthodon*cs prosthodon*cs occlusal adjustment Treatment Life Stress Stress is linked to all leading causes of death, including cancer, heart disease, lung diseases, accidents, cirrhosis, even suicide % of visits to primary care physicians are for stress related disorders/complaints. 43% of all adults suffer adverse health effects due to stress. Stress management, stress reduction, and stress relief can prevent so many problems. And prevention is far less costly, and far easier, than the alternatives. hsp:// 10

13 Giant Cell Arteri*s/Temporal Arteri*s Systemic inflammatory vasculi*s of unknown e*ology Occurs predominantly afer age 50, more commonly in females than males Systemic, neurologic, and ophthalmologic complica*ons Systemic symptoms include low grade fever, poor appe*te and weight loss Local symptoms include visual disturbances, headache, jaw claudica*on, neck pain, scalp tenderness (par*cular over the temporal artery, which may be indurated) Vasculi*s Founda*on: vasculi*sfounda*on.org Dystonia From dys- (ill, bad) and -tonia (muscle or nerve tension) A movement disorder in which a person s muscles contract uncontrollably Possibly related to problems in basal ganglia Dystonia may be a symptom of many diseases and condi*ons If it occurs in episodes rather than constantly, the terms dyskinesia and paroxysmal dystonia are used Focal dystonia affects only one part of the body Cranial dystonia affects the head, face, and neck muscles Dystonia Medical Redical Research Founda*on: dystonia-founda*on.org 11

14 Cluster Headache Headaches occur in series or clusters las*ng weeks or months, separated by remission periods las*ng months or years Trigeminal autonomic cephalalgia (TAC) Severe, unilateral HA, centered around eye Burning, boring, suicide headache Autonomic symptoms such as red eye, runny nose, swea*ng or flushing of the face, drooping eyelid, sense of fullness in the ear. American Migraine Founda*on. americanmigrainefounda*on.org Interna*onal Headache Society: hsps:// Migraine Severe, intense headache, ofen unilateral Throbbing Associated with nausea and sensi*vity to light, noise, and odors Worse with physical ac*vity Lasts from four hours to several days May be preceded by visual aura American Migraine Founda*on. americanmigrainefounda*on.org Interna*onal Headache Society: hsps:// 12