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    1. DDx OF FACIAL PAIN

    ODONTOGENIC INFECTION NEUROLOGIC (Trigem. neuralgia, Atypical facial pain, Zoster-neuralgia) NEOPLASM (Cranial nerve impingement, Tonsillar SCC) CARDIAC (9-18% radiating to mandible) VASCULAR (Temporal /GC arteritis, Migraine, Cluster HA) TRAUMATIC (Impingement on mental nerve, Pathologic fx) MUSCULOSKELETAL

    2. DDx OF FACIAL PAIN

    ODONTOGENIC INFECTION NEUROLOGIC (Trigem. neuralgia, Atypical facial pain, Zoster-neuralgia) NEOPLASM (Tonsillar SCC, Cranial nerve impingement) CARDIAC (9-18% radiating to mandible) VASCULAR (Temporal GC arteritis, Migraine, Cluster headache) TRAUMATIC (Impingement on mental nerve, Pathologic fracture) MUSCULOSKELETAL

    3. DDx OF FACIAL PAIN

    ODONTOGENIC INFECTION NEUROLOGIC (Trigem. neuralgia, Atypical facial pain, Zoster-neuralgia) NEOPLASM ( Cranial nerve impingement, Tonsillar SCC) CARDIAC (9-18% radiating to mandible) VASCULAR (Temporal GC arteritis, Migraine, Cluster headache) TRAUMATIC (Impingement on mental nerve, Pathologic fracture) MUSCULOSKELETAL

    4. Diagnostic criteria for trigeminal neuralgia

    brief paroxysms of severe pain with refractory periods trigger zones unpredictable remissions and exacerbation lack of objective evidence of motor or sensory deficit of the involved nerve

    Among 2,972 patients with trigeminal neuralgia seen at the Mayo Clinic, 58 (2%) were diagnosed with a tumor NEUROLOGY 1993;43:2298-2302 Trigeminal neuralgia secondary to tumors

    6. Organic causes for trigeminal neuralgia

    multiple sclerosis (young age) tumors (any age) vascular contact or compression (older age)

    Symptoms of trigeminal nerve compression X First-line medical treatment of trigeminal neuralgia Carbamazepine (Tegretol®) LFT’s; CBC; plasma levels; Drowsiness; GI & All. Baclofen (Lioresal®) Drowsiness; dizziness Phenytoin (Dilantin®) Valproic acid (Depakene®) Gabapentin (Neurontin®) Surgical management of trigeminal neuralgia Peripheral nerve block: Cryotherapy (nerve freezing) NEUROPATHIC PAIN ATYPICAL FACIAL PAIN / ATYPICAL ODONTALGIA / PHANTOM TOOTHACHE / BURNING MOUTH SYNDROME Pain Trig. neuralgia Neuropathic pain Differences Location Unilateral; along nerve distribution Not along nerve distrib.; may wander Trigger Yes (diagnostic block) No Duration Brief, sec’s, up to 1-2 min.. Paroxysms Constant with fluctuant intensity Quality Sharp, stabbing, electr. shock-like Diffuse, burning, aching, dull Intensity Severe Moderate to severe Affective qual. Terrifying & torturing: Threatening Vicious & nagging: Angering Fct. impairm. Considerable to extreme Low Response to Tx Good Limited Tx of choice Anticonvulsants Tricyclic antidepressants; Anxiolytics Management of neuropathic pain Tricyclic antidepressants in low doses Amitriptylin (Elavil®) Doxepin HCl (Sinequan®) Cave: Glaucoma; Urinary retention; Cardiac arrhythmia S.E: morning drowsiness; weight gain; xerostomia Anxiolytics Clonazepam (Klonopin®) LFT’s & CBC; Drowsiness

    14. DDx OF FACIAL PAIN

    ODONTOGENIC INFECTION NEUROLOGIC (Trigem. neuralgia, Atypical facial pain, Zoster-neuralgia) NEOPLASM ( Cranial nerve impingement, Tonsillar SCC) CARDIAC (9-18% radiating to mandible) VASCULAR (Temporal GC arteritis, Migraine, Cluster headache) TRAUMATIC (Impingement on mental nerve, Pathologic fracture) MUSCULOSKELETAL

    MIGRAINE Age of onset: Childhood or adolescence; Family Hx Episodic Prodrome (Mood changes, fatigue) Aura (Precedes HA; typical visual: spots; jagged lines; scintillating images) Lateralized Accopanying symptoms (Nausea/vomiting; photophobia; phonophobia) Inhibits or prohibits daily activities Lasts 12-24 hours Management of Migraines Symptomatic Preventive Beta-blockers Calcium channel block. Tricyclic Anitdepress. Ergot derivates

    17. DDx OF FACIAL PAIN

    ODONTOGENIC INFECTION NEUROLOGIC (Trigem. neuralgia, Atypical facial pain, Zoster-neuralgia) NEOPLASM ( Cranial nerve impingement, Tonsillar SCC) CARDIAC (9-18% radiating to mandible) VASCULAR (Temporal GC arteritis, Migraine, Cluster headache) TRAUMATIC (Impingement on mental nerve, Pathologic fracture) MUSCULOSKELETAL

    18. Facial pain picture: teeth in the eyesFacial pain picture: teeth in the eyes

    TMD in large HMO n=3,428 Okeson JP. Orofacial pain. Quintessence books. 1996

    19. Facial pain picture: teeth in the eyesFacial pain picture: teeth in the eyes

    JAW JOINT MUSCLES TEETH AND THEIR SUPPORTING STRUCTURES ORAL MUCOSA TRIGEMINAL NERVE FUNCTION AS A UNIT 1-4

    20. Skull TMJ Temporalis muscle (most important jaw closer)on skull Other facial muscles on skull Trigeminal nerve Skull TMJ Temporalis muscle (most important jaw closer)on skull Other facial muscles on skull Trigeminal nerve

    JOINT LOAD & the Law of GRAVITY

    21. Fat woman eating Close-up lips with teeth apartFat woman eating Close-up lips with teeth apart

    CHEWING MUSCLE ACTIVITY Cumulative chewing: 9 minutes per 24 hrs. Cumulative swallowing: 17.5minutes per 24 hrs. (1,500x/d) Total: 26.5 minutes cumulative When relaxed teeth do not touch the TMJ is unloaded

    22. Close-up lips with teeth apartClose-up lips with teeth apart

    3 FORMS OF MUCSLE ACTIVITY EMOTIONAL REFLEX 1-4

    23. 1) Biceps muscle 2) Reflex circuit spinal nerve 3a) Netter: fight and flight reaction 3b) Progress in brain research: Motor system: voluntary - emotional 3c) Comic: Institute for the study of emotional stress 3d) Relationship between stress and nocturnal bruxism in young woman1) Biceps muscle 2) Reflex circuit spinal nerve 3a) Netter: fight and flight reaction 3b) Progress in brain research: Motor system: voluntary - emotional 3c) Comic: Institute for the study of emotional stress 3d) Relationship between stress and nocturnal bruxism in young woman

    Effects of prolonged or repetitive muscle activity leads to OVERLOAD

    24. Periodont Muscles Teeth Mucosa TMJ

    Comic: facial pressure (jaw on both cheeks)Comic: facial pressure (jaw on both cheeks)

    Potential causes of chronic overload injuries to facial tissue Absolute OVERLOAD Relative pain and dysfunction

    25. 1) facial tics 2) Women with lose dentures 3) Road rage 4) Fibromyalgia1) facial tics 2) Women with lose dentures 3) Road rage 4) Fibromyalgia

    1,2 Potential causes of acute tensile overload injuries to facial tissue Absolute OVERLOAD Relative pain and dysfunction reflex muscle hyperactivity

    26. 1) Netter: trigeminal motor root and sensory roots 2) Trigeminal convergence 3) Netter: Whiplash injury 4) Historical extraction 5) Ortho tx 1) Netter: trigeminal motor root and sensory roots 2) Trigeminal convergence 3) Netter: Whiplash injury 4) Historical extraction 5) Ortho tx

    27. EFFECTS ON THE JOINT COMPONENTS

    1,2 1) 3D TMJ 2) TMJ tomogram open/closed (we can visualize jaw movement) 3) Aging and degeneration 1) 3D TMJ 2) TMJ tomogram open/closed (we can visualize jaw movement) 3) Aging and degeneration

    TMD in large HMO n=3,428 Okeson JP. Orofacial pain. Quintessence books. 1996

    28. Aging and degenerationAging and degeneration

    TMJ osteoarthrosis (OA) in young patients (12-30 yrs) - TMJ OA in young patients is highly prevalent: more than 50% had osteoarthrosis in at least one joint - TMJ’s with oseoarthrosis did not cause more symptoms than TMJ’s without OA Wilberg and Wanman: OOOO 1998; 86: 158-64

    29. Aging and degenerationAging and degeneration

    Incidence of altered joint anatomy in the human TMJ “35% of the joints in the asymptomatic volunteers were found to have moderately or severely displaced discs” Davant TS et al.: A quantitative computer-assisted analysis of disc displacement in patients with internal derangement using sagittal view magnetic resonance imaging. J Oral Maxillofac Surg 51:974-9, 1993 “There was a 33% prevalence of disc displacement in asymptomatic voluteers” Katzberg RW et al.: Anatomic disorders of the temporomandibular joint disc in asymptomatic subjects. J Oral Maxillofac Surg 54:147-55, 1996

    30. 1) TMJ section showing disc (from Quinn’s atlas) 2) Quinn’s normal disc position 3) Ant. displaced disc1) TMJ section showing disc (from Quinn’s atlas) 2) Quinn’s normal disc position 3) Ant. displaced disc

    Postsurgical disc anatomy after “repositioning” surgery “Disc position was unchanged in 86% of the joints imaged at an average of 2 years following surgery” Montgomery MT et al. Changes in signs and symptoms following temporomandibular joint disc repositioning surgery. J Oral Maxillofac Surg 50:320-28, 1992

    31. Ant. displaced discAnt. displaced disc

    32. Disc displacement (n = 95 joints of 84 pts.)

    Clicking Pain on movement Restriction of movement Crepitus initially < 4 yrs 30 yrs 47% 31% 30% 68% 15% 3% 58% 16% 7% 8% 35% 40% DE LEEUWet al. J OROFACIAL PAIN. 8:18-24 1994 Ant. displaced discAnt. displaced disc

    33. EFFECTS ON TEETH AND THE TOOTH SUPPORTING STRUCTURES (PERIODONTIUM)

    1-3 1) Comic: Superman clenching 2) Occlusal wear 3) Buccal wear 4) Labial wear 1) Comic: Superman clenching 2) Occlusal wear 3) Buccal wear 4) Labial wear

    The periodontal ligaments Periodontal ligaments Bone

    34. Palcanis: effects of occl. overload on periodontal pressurePalcanis: effects of occl. overload on periodontal pressure

    Swelling causes painful tooth displacement

    35. Palcanis: effects of occl. overload on periodontal pressurePalcanis: effects of occl. overload on periodontal pressure

    36. EFFECTS ON ORAL MUCOSA

    1) Exaggerated linea alba buccal mucosa / tongue 2) Buccal ulceration 3) Inside look into mouth (intraoral exam important to discover objective evidence of parafunction)1) Exaggerated linea alba buccal mucosa / tongue 2) Buccal ulceration 3) Inside look into mouth (intraoral exam important to discover objective evidence of parafunction)

    37. EFFECTS ON THE CHEWING MUSCLES

    Injuries provoked by muscle-tendon overload 30-50 % of sports medicine injury Tennis / Golf: elbow epicondylitis Throwing athlete: rotator cuff tendinitis Runner, weight-lifter: supra- and infrapatellar tendinitis Runner/walker: Achilles tendinitis; plantar fascitis Musicians: ‘Overuse injuries are the most common playing - related medical problem’ Renstrom P. Overuse injuries in sports: A review. Sports med. 2:316.1985 (Lockwood AH. Medical Problems of Musicians. N Engl J Med. 320(4):221-7.1989)

    38. 1) Allaire masseter exam 2) Masster skull 3) Women with facial pain with hand on masseter 4) Women with headache and hand at temple 5) Temporalis on skull 6) Allaire temporalis exam 7) TP temporalis 8) TP masseter 9) Woman after radiation tx to sternomastoid: showing where her headache is 10) TP sternomastoid 11) TP trapezius 1) Allaire masseter exam 2) Masster skull 3) Women with facial pain with hand on masseter 4) Women with headache and hand at temple 5) Temporalis on skull 6) Allaire temporalis exam 7) TP temporalis 8) TP masseter 9) Woman after radiation tx to sternomastoid: showing where her headache is 10) TP sternomastoid 11) TP trapezius

    39. EFFECTS ON THE HEARING

    Tensor tympany muscleTensor tympany muscle

    40. Periodont Muscles Teeth Mucosa TMJ

    Review:Results of overload Postcard painting: the headache (devils hammering on skull)Postcard painting: the headache (devils hammering on skull)

    JAW-LOCK RESTRICTION Toothache PAIN forever NECKPAIN HEADACHE NOT COVERED Earache Jaw-clicking

    41. Postcard painting: the headache (devils hammering on skull) Postcard painting: the headache (devils hammering on skull)

    Pain Migraine Myofascial pain Differences Acge of onset Childhood or adolescence (F>M) Childbearing age (F>>M) Family Hx Yes No Location Unilateral (Hemicrania) Uni- or bilateral; may wander Aura Yes No precedes HA; typical visual spots; jagged lines; scintillating images Associated symptoms Nausea / photophobia Absent Duration Gradually develops, lasts 4-72 hrs. Constant with fluctuant intensity Quality Pulsating Diffuse, aching, spastic Intensity Severe Moderate to severe Fct. impairm. Considerable to extreme Considerable to extreme Tx of choice Medication Patient education, awareness training stress managment, muscle stretching, nightguard Trigger Hormonal, alcohol, drugs, food Sress, chewing, trauma

    43. Common historic TMD treatment-modalities

    Postcard painting: the headache (devils hammering on skull) Postcard painting: the headache (devils hammering on skull)

    44. 1) “The dentist should treat patients for TM disorders only when there is associated craniomaxillofacial pain and/or functional impairment.” 2) “The dentist should be responsible for educating the patient concerning self-management and the elimination of behaviors that may contribute to TM disorders. “ 3) “Initially the dentist should select the least invasive and most reversible therapy that may ameliorate the patient’s pain and/or functional impairment.” 4) “Before restorative and/or occlusal therapy is performed, the dentist should attempt to reduce, through the use of reversible modalities, the neuromuscular, myofascial and temporomandibular joint symptoms.”

    DENTAL PRACTICE PARAMETERS FOR TMD ADA, February 1997 Postcard painting: the headache (devils hammering on skull) Postcard painting: the headache (devils hammering on skull)

    45. Current TMD treatment-modalities

    PATIENT EDUCATION BEHAVIORAL MODIFICATION STRESS MANAGEMENT DIET RESTRICTION MUSCLE TREATMENT HOME EXERCISE PROGRAM PHYSICAL THERAPY Comic: Harold as water heater Comic: Harold as water heater

    STEP 1 Place the thumb of one hand on the teeth of the upper jaw. Place the index finger of your other hand on the lower jaw. STEP 2 Relax. STEP 3 Gently let your hand pull the lower jaw downward as much as possible without feeling pain. Hold this position for the count of ten. REPETITIONS: 10 per series - three or more series per day REMARKS: When available, you may place an icebag on the hurting parts of the face REMEMBER: Whenever your upper and lower teeth are touching indicates that your chewing muscles are not sufficiently relaxed! STRETCHING OF THE CHEWING MUSCLES

    46. Comic: Harold as water heaterComic: Harold as water heater

    47. Current TMD treatment-modalities

    HARD, FLAT, OCCLUSAL APPLIANCE TO ELIMINATE RESISTANCE Appliance on model and in mouthAppliance on model and in mouth

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