35 yo female presents with persistent pain on #10

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1 Myogenos Disorders Seena Patel DMD, MPH Assistant Professor, Associate Director of Oral Medicine Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, AZ Sothwest Orofacial Grop, Phoenix, AZ Diplomate, American Board of Oral Medicine Diplomate, American Board of Orofacial Pain

2 35 yo female presents with persistent pain on #10 Trama to the face, sbseqent observation Describes a mild tenderness to #10 Endo #1 Pain persists Endo #2 Pain persists Extraction and implant

3 Case: Pain History Onset 18 years ago Location #10 Qality Severe pressre Freqency Began episodically, now daily Attack dration Constant Severity 9/10 Ameliorating factors Ibprofen Exacerbating factors Associated symptoms Brxism L TMJ clicking, day- and nighttime parafnctional habits Wakes with her jaw clenched

4 Myogenos Disorders A. Localized myalgia B. Myofascial pain C. Myofascial pain with referral D.Tendonitis E. Myositis F. Spasm G. Contractre H. Hypertrophy I. Neoplasm J. Movement disorders K. Masticatory mscle pain attribted to systemic/central pain disorders Schiffman E, Ohrbach R, Trlove E et al. Diagnostic criteria for temporomandiblar disorders (DC/TMD) for clinical and research applications: recommendations of the international RDC/TMD consortim network* and orofacial pain special interest grop. J Oral Facial Pain Headache. 2014; 28(1):6-27.

5 Diagnostic criteria: Myalgia 1) History: positive for both of the following Pain in the jaw, temple, in the ear or in front of the ear AND Pain modified with jaw movement, fnction, or parafnction 2) Exam: positive for both of the following Confirmation of pain location in the temporalis or masseter AND Report of familiar pain in the temporalis or masseter with at least one of the following provocation tests: Palpation of the temporalis or masseter OR Maximm nassisted or assisted opening movement(s) Validity: sensitivity 0.90 and specificity: 0.99 Schiffman E, Ohrbach R, Trlove E et al. Diagnostic criteria for temporomandiblar disorders (DC/TMD) for clinical and research applications: recommendations of the international RDC/TMD consortim network* and orofacial pain special interest grop. J Oral Facial Pain Headache. 2014; 28(1):6-27.

Myofascial pain Regional pain disorder characterized by localized mscle tenderness and limited range of motion Defined by the presence of myofascial trigger points

6 Myofascial pain Regional pain disorder characterized by localized mscle tenderness and limited range of motion Defined by the presence of myofascial trigger points Masticatory mscle involvement can be a sorce of tooth pain Described as dll, achy, tiring, deep, pressre-like Kim ST. Myofascial pain and toothaches. Ast Endod J 2005;31(3):

7 Diagnostic criteria: myofascial pain with referral 1) History: positive for both of the following Pain in the jaw, temple, in the ear or in front of the ear AND Pain modified with jaw movement, fnction, or parafnction 2) Exam: positive for both of the following Confirmation of pain location in the temporalis or masseter AND Report of familiar pain in the temporalis or masseter AND Report of pain at a site beyond the bondary of the mscle being palpated Validity: sensitivity 0.86 and specificity: 0.98 Schiffman E, Ohrbach R, Trlove E et al. Diagnostic criteria for temporomandiblar disorders (DC/TMD) for clinical and research applications: recommendations of the international RDC/TMD consortim network* and orofacial pain special interest grop. J Oral Facial Pain Headache. 2014; 28(1):6-27.

Travell & Simons myofascial pain and dysfnction: the trigger

8 Mscle Referral Patterns Anterior temporalis Masseter Cervical msclatre Simons DG, Travell JG, Simons LS. Travell & Simons myofascial pain and dysfnction: the trigger point manal:pper half of body (Vol. 1). Philadelphia: Lippincott Williams & Wilkins, 1999.

9 Mscle referral patterns: Masseter

10 Mscle referral patterns: Temporalis

11 Mscle referral patterns: medial pterygoid

12 Mscle referral patterns: lateral pterygoid

13 Mscle referral patterns: digastric

14 Mscle referral patterns: scalene

15 Mscle referral patterns: splenis capitis

16 Mscle referral patterns: splenis cervicis

17 Mscle referral patterns: sternocleidomastoid

18 Mscle referral patterns: semispinalis capitis

Myofascial Pain: Clinical Featres Spontaneos dll, aching pain and localized tenderness Mscle stiffness Sstained mscle fnction cases fatige easily Upon palpation: hyperirritable spot within a tat band

19 Myofascial Pain: Clinical Featres Spontaneos dll, aching pain and localized tenderness Mscle stiffness Sstained mscle fnction cases fatige easily Upon palpation: hyperirritable spot within a tat band that exhibits referral Trigger point (TP): motor endplate with spontaneos firing Decreased ROM Weakness w/o atrophy or nerological deficit Fricton J. Myofascial Pain: Mechanisms to Management. Oral Maxillofac Srg Clin North Am. 2016;28(3):

20 Strctral abnormalities Environment Lifestyle Mind Myofascial Pain: protective and risk factors Emotions Spirit Spport system

21 Sleep distrbances Tramati c or whiplash injries Occpatio n/repetitive strain injries Metabolic / ntritional Myofascial Pain: contribting factors Physical disorders Postral and repetitiv e strains Parafnction

22 The image part with relationship ID rid3 was not fond in the file. Case: Exam Findings Lateral Condyle (TMJ) R 3 3 Dorsal Condyle 2 3 Sperficial Masseter 3 L 3 (referred down the jaw) Anterior temporalis 3 3 (referred down the head, into her anterior teeth; replicated her CC) SCM 3 3 Upper trap 3 3 Sholder trap 3 3

23 The image part with relationship ID rid3 was not fond in the file. Case: Exam Findings Range of motion Pain-free Passive Protrsive R Lateral L Lateral 27 mm 40 mm, pain on left sperficial masseter, soft-end feel 8 mm 11 mm 12 mm

24 Myogenos pain: casation Stress-indced hypoperfsion Direct mscle trama Adverse effect of medication 2 0 pathology indced trisms Parafnctions Peripheral and central sensitization

Pathophysiology Injry to Type I mscle fibers Metabolic distress at motor endplates Peripheral sensitization Increase in mscle nociception Mscle

25 Pathophysiology Injry to Type I mscle fibers Metabolic distress at motor endplates Peripheral sensitization Increase in mscle nociception Mscle co-contraction Central sensitization Fricton J. Myofascial Pain: Mechanisms to Management. Oral Maxillofac Srg Clin North Am. 2016;28(3):

26 Central sensitization Radiation of Pain

27 Myofascial pain: pain mechanisms

28 Diagnostic Tests: Spray and Stretch Romero-Reyes M & Uyanik JM. Orofacial pain management: crrent perspectives. J Pain Res. 2014;21(7):

29 Diagnostic Tests: Trigger Point Injection Kim ST. Myofascial pain and toothaches. Ast Endod J 2005;31(3):

30 18 yo female presents with jaw pain and headaches Jaw pain Jaw popping Jaw locking Headaches Neck pain Ear pain Ear fllness Jaw Pain: started a few years ago, has worsened over time and is very severe Location Headaches: bilateral TMJs and masseters Intensity is 5-10/10 Neck Location Pain: Neck temples, pain sins started area, Described as achy years forehead, ago back of head, Occrs Described behind daily eyes as throbbing Lasts ntil pain meds (ibprofen) are Stress Described aggravates as throbbing neck pain taken chewing, Sond, laghing, stress, pressre yawning, talking, smiling, aggravate teeth brshing the headache aggravates pain pain pills, heat sometimes help- bt ofte nothing relieves pain

31 Exam Palpations Rects Anterior capits temporalis R R 2 Rects Anterior capits temporalis L L 2 Upper Posterior trap temporalis R R 32 Upper Posterior trap temporalis L L 32 Lateral SCM R capsle R 3 Lateral SCM L capsle L 3 Dorsal Scalene capsle R R 3 Dorsal Scalene capsle L L 3 Sperficial Occipital nerve masseter R R 32 Sperficial Occipital nerve masseter L L 2 Temporalis Splenis capits Tendon R R 32 Temporalis Splenis capits Tendon L L 32

32 Exam Comfort Opening: mm Passive Opening: 30mm Pain RT Laterotrsive: Pain R TMJ 10mm LFT Laterotrsive: Pain L TMJ 11mm Midline: WNL 1mm Opening Path: left Deviation on opening TMJ Noise Dysfnction: left side late opening; left side mid closing

33 Diagnostic tests and treatment In-office spray and stretch: significant improvement Anterior repositioning splint: significant improvement 2 sessions of trigger point injections and nerve blocks 2 months later, all pain went from 9/10 to 2-3/10

34 Myositis Acte condition Inflammation of the mscle and connective tisse Associated with pain, edema, decreased range of motion What is the most common case of myositis in dentistry?

35 What do yo think? HPI: RCT #31 3/29/17 Reports limited moth opening, swelling and pain Rx: Mscle relaxant Then sent to ER and given IV antibiotics for celllitis Since, the swelling has looked the same Referred for eval of TMJs Moth opening is progressively becoming more limited with time

37 Trisms Any restriction in moth opening (msclerelated) Can reslt from trama, srgery, radiation Other terms: involntary bracing, mscle splinting, protective garding What is the most common case of trisms in dentistry?

38 Differential diagnosis Infectios/inflammatory Medication-indced Nerologic Trama Dental Congenital Radiation-indced Srgery

39 Pathophysiology Limited jaw mobility Inflammation Pain Protective reflex Disse/ atrophy

40 Mscle spasm Continos, involntary contraction of the mscle *Even at rest Painfl if sstained Feels firm to palpation Casation: sally a normal protective reflex to the presence of regional pain (similar to trisms)

41 24 yo male presents with painfl clicking in the left TMJ Clicking began 2 weeks ago Feels constant pain Cannot bring the back teeth together on the left side No strctral abnormalities present?

42 Masticatory mscle contractre Abnormal redction in the extensibility of the jaw mscles Clinical exam findings: Limited opening Unyielding passive opening stretch Lateral movements are normal Casation: Trama-indced scar Slowly developing shortening of mscles withot hypertrophy or enlargement

43 Masticatory mscle hypertrophy Jaw mscle enlargement Masseters Temporalis Casation Increased fnctional demand of the mscles Usally bilateral Rarely painfl Kamble V & Mitra K. A rare association of bilateral and nilateral masseter hypertrophy with hypertrophy of pterygoids. J Clin Diagn Res. 2016; 10(2):TJ03-TJ04.

44 Movement disorders Sleep Brxism 20% of max volntary contraction of at least 2 seconds Begins arond ages % of the poplation grind their teeth at some point in life Most common in stage 2 Occrs dring transition from deeper to lighter stages of sleep

45 Movement disorders Dyskinesia Spontaneos 3-4% of elderly Milder symptoms: involves jaw and lips Tardive High-dose antipsychotic se Involntary, repetitive perioral, tonge, or jaw movements Grimacing, tonge protrsion, lip smacking

46 Movement disorders Orofacial Dystonia Intermittent, involntary Momentarily, sstained contraction of the jaw/ orofacial mscles Movements disappear dring sleep Meige s Syndrome Orofacial Tremor Orofacial Tics

$reveals fractred #28 Ulceration on the tonge approximates this fractre The tonge ncontrollably moves over this$

47 80 yo female presents with a chronic lcer on the tonge Reports severe pain on the tonge for a year Examination reveals fractred #28 Ulceration on the tonge approximates this fractre The tonge ncontrollably moves over this site

48 70 yo male presents with inability to close his moth Chief complaint is that he cannot close his moth on his own Began a few months ago, spontaneosly Denies weakness in any mscles, pain or joint noises

49 Centrally mediated myalgia Chronic, continos mscle disorder 1. History of prolonged and continos mscle pain 2. Regional dll, aching pain at rest 3. Pain is aggravated by fnction of the affected mscle 4. Pain is aggravated by palpation Associated factors: Trigger points and pain referral on palpation Report of mscle stiffness, weakness, and/or fatige Report of acte malocclsion not verified clinically Ear symptoms, tinnits, vertigo, toothache, tension-type headache Limited range of motion Hyperalgesia

50 Pain mechanisms

51 Otologic symptoms and TMD Tinnits Dizziness Vertigo Ear ache Fllness Prevalence of otologic symptoms in TMD is p to 85% TMD treatment modalities may help symptoms

52 Qestions?

My Jaw Hurts! What do I do? An Overview of Diagnostic Techniques, Examination, and Management Strategies in Orofacial Pain

My Jaw Hurts! What do I do? An Overview of Diagnostic Techniques, Examination, and Management Strategies in Orofacial Pain My Jaw Hrts! What do I do? An Overview of Diagnostic Techniqes, Examination, and Management Strategies in Orofacial Pain SEENA PATEL DMD, MPH ASSISTANT PROFESSOR, ASSOCIATE DIRECTOR OF ORAL MEDICINE ARIZONA