how to practice at today’s standard of care in: orofacial ... · • tmj dislocation ... 51-60...
TRANSCRIPT
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in: How to Practice at Today’s Standard of Care
OROFACIAL PAIN: Standard of Care
Charles McNeill, DDS, FACD, FICD Professor Emeritus & DirectorPatricia A. Rudd, PT, DPT CCTT
Associate Clinical ProfessorUCSF Center for Orofacial Pain
4. Inflammatory Disorders & DJD
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v TM Joint Painv Masticatory Muscle Pain
ACUTE TMD DIAGNOSES
Acute TMD Mgt (Localized Musculo-skeletal Disorders)
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AAOP TMD Dx Classification:Localized Disorders
Monday, August 31, 15
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ARTICULAR • Devel./ Acquired Disord.• Disc Disorders • Inflammatory Disorders• Degenerative Disorders• TMJ Dislocation• Ankylosis
AAOP TMD Dx Classification:Localized Disorders
Monday, August 31, 15
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ARTICULAR • Devel./ Acquired Disord.• Disc Disorders • Inflammatory Disorders• Degenerative Disorders• TMJ Dislocation• Ankylosis
AAOP TMD Dx Classification:Localized Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
Monday, August 31, 15
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Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
Monday, August 31, 15
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Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
Monday, August 31, 15
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Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
Monday, August 31, 15
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Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
Monday, August 31, 15
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Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
๏ Degenerative Joint Disease• Osteoarthrosis• Osteoarthritis
Monday, August 31, 15
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Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
๏ Degenerative Joint Disease• Osteoarthrosis• Osteoarthritis
Monday, August 31, 15
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Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
๏ Degenerative Joint Disease• Osteoarthrosis• Osteoarthritis
Monday, August 31, 15
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Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
๏ Degenerative Joint Disease• Osteoarthrosis• Osteoarthritis
Monday, August 31, 15
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INFLAMMATORY DISORDERS:Synovitis / Capsulitis
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vDESCRIPTION: Inflam. of the Synovial Lining &/or Capsule 2º to Infection, Trauma, or Cartilage Degeneration
INFLAMMATORY DISORDERS:Synovitis / Capsulitis
Monday, August 31, 15
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vDESCRIPTION: Inflam. of the Synovial Lining &/or Capsule 2º to Infection, Trauma, or Cartilage Degeneration
INFLAMMATORY DISORDERS:Synovitis / Capsulitis
vCLINICAL PRESENTATION:v Localized Jt. Pain Provoked by Palp., Loading, Distraction or Fx.
v Fluctuating Swelling w ↓ Post. Occl. v Probable Marked ↓ Mobilityv Radiographic Changes: Possible Increase in Joint Space
v Positive T2 MRI Signal
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Goal Oriented Plan: Synovitis/Capsulitis
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Goal Oriented Plan: Synovitis/Capsulitis
�PAIN CONTROL:• Patient Education• Self-Management (Rest, Ice)• Meds (NSAIDs, Analg., Steroids, Jt. Inj.) • Physical Therapy (Cold, ES, US, Cold • Laser & Gentle Joint Mobilization)
Monday, August 31, 15
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Goal Oriented Plan: Synovitis/Capsulitis
�PAIN CONTROL:• Patient Education• Self-Management (Rest, Ice)• Meds (NSAIDs, Analg., Steroids, Jt. Inj.) • Physical Therapy (Cold, ES, US, Cold • Laser & Gentle Joint Mobilization)
� INCREASE MOBILITY:• Physical Therapy (Gentle Joint
Mobilization & ROM Exercises)
Monday, August 31, 15
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§ Sulindac (Clinoril) 150-200mg. bid§ Naproxen (Naprosyn) 500mg. bid§ Nabumetone (Relafen) 500-750mg. bid§ Meloxicam (Mobic) 7.5-15mg d § Celecoxib (Celebrex) 100-200mg. bid§ Diclofenac (Voltaren) 1.3% Flector Patch bid § Voltaren Gel 1% 2 Grams qid§ Topical Compounds 2 drops tid, qid§ Methyprednisolone (Medrol Dosepak) 24-32mg d/1wk
followed by 1wk 4mg 6 day Tapering Dose
*Misoprostol (Cytotec) 200 µg qid *Omeprazole (Prilosec) 20mg bid
ANTI-INFLAMMATORY MEDS
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INTRA-ARTICULAR INJECTION ARTHROCENTESIS
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PHYSICAL THERAPY
§ Patient Education§ Therapeutic Exercises§ Joint Mobilization /
Manipulation§ Soft-tissue Mobilization§ Modalities
§ Heat & Ice § Spray & Stretch§ Elect Stim. / Iontophoresis§ Ultrasound / Phonophoresis
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PHYSICAL THERAPY
§ Patient Education§ Therapeutic Exercises§ Joint Mobilization /
Manipulation§ Soft-tissue Mobilization§ Modalities
§ Heat & Ice § Spray & Stretch§ Elect Stim. / Iontophoresis§ Ultrasound / Phonophoresis
Monday, August 31, 15
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INFLAMMATORY DISORDERS:Polyarthritides
v DESCRIPTION: Bilateral Joint Inflam. & Struct. Changes 2º to Gen. Systemic Polyarthritic Condition
v CLINICAL PRESENTATION:vJt Pain Provoked by Palp., Loading, &/or FxvCrepitus & ↓ ROM 2º to PainvMult. Jt. Involvmentv+ Serology Test
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¤PAIN CONTROL:• Self-Mgt (Rest, Ice, Pt. Ed., Behavior Mod.)• Meds (NSAIDs, Analg., Steroids;• Collaborate w Rheumatologist & PCP • Physical Therapy (Cold, ES, US, Jt. Mob.)
¤ INCREASE MOBILITY:• P.T. (Gentle Jt. Mob. & ROM Exercises)
Goal Oriented Plan:Polyarthritides
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AAOP TMD Dx Classification:Localized Disorders
Monday, August 31, 15
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ARTICULAR • Devel./ Acquired Disord.• Disc Disorders • Inflammatory Disorders• Degenerative Disorders• TMJ Dislocation• Ankylosis
AAOP TMD Dx Classification:Localized Disorders
Monday, August 31, 15
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ARTICULAR • Devel./ Acquired Disord.• Disc Disorders • Inflammatory Disorders• Degenerative Disorders• TMJ Dislocation• Ankylosis
AAOP TMD Dx Classification:Localized Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
Monday, August 31, 15
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DEGENERATIVE JOINT DISEASE (DJD)
deBont LGM et al: OOO 1997;83:51-60
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❖ OSTEOARTHROSIS: A Non-painful, Non-inflammatory Degenerative Condition Characterized by of Articular Tissues Due to Overload of the Remodeling System
DEGENERATIVE JOINT DISEASE (DJD)
deBont LGM et al: OOO 1997;83:51-60
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❖ OSTEOARTHROSIS: A Non-painful, Non-inflammatory Degenerative Condition Characterized by of Articular Tissues Due to Overload of the Remodeling System
DEGENERATIVE JOINT DISEASE (DJD)
deBont LGM et al: OOO 1997;83:51-60
v OSTEOARTHRITIS: A Painful Inflammatory Degenerative Condition Characterized by
Progressive Deterioration & Abrasion of the Articular Surfaces
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DEGENERATIVE JOINT DISEASE:
deBont LGM et al: OOO 1997;83:51-60
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v ACTIVE: Characterized by Active Deterioration & Abrasion of the Articular Tissues (Cortical Outline) Due to Overload of the Remodeling System
DEGENERATIVE JOINT DISEASE:
deBont LGM et al: OOO 1997;83:51-60
Monday, August 31, 15
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v ACTIVE: Characterized by Active Deterioration & Abrasion of the Articular Tissues (Cortical Outline) Due to Overload of the Remodeling System
DEGENERATIVE JOINT DISEASE:
deBont LGM et al: OOO 1997;83:51-60
Monday, August 31, 15
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v ACTIVE: Characterized by Active Deterioration & Abrasion of the Articular Tissues (Cortical Outline) Due to Overload of the Remodeling System
DEGENERATIVE JOINT DISEASE:
deBont LGM et al: OOO 1997;83:51-60
v STABLE: Characterized by a Stable or Unchanging Relationship of the Articular Surfaces of Formerly Active Arthrosis/Arthritis
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v ACTIVE: Characterized by Active Deterioration & Abrasion of the Articular Tissues (Cortical Outline) Due to Overload of the Remodeling System
DEGENERATIVE JOINT DISEASE:
deBont LGM et al: OOO 1997;83:51-60
v STABLE: Characterized by a Stable or Unchanging Relationship of the Articular Surfaces of Formerly Active Arthrosis/Arthritis
Monday, August 31, 15
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ACTIVE OSTEOARTHROSIS(Non-inflammatory)
deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60
CLINICAL PRESENTATION:vNo Joint Pain/InflammationvJoint Crepitus vLtd ROM w/ DeflectionvPossible Change in Post. Occl.vRadiographic Bony Changes
v Loss of Cortical Integrityv Possible Osteophytic Formationv Subchondral Bone Cystsv Narrowed Superior Jt. Space
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GOAL ORIENTED PLAN: Ac/ve Osteoarthrosis
16
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GOAL ORIENTED PLAN: Ac/ve Osteoarthrosis
16
¤ JOINT PROJECTION• Self-Management (Pt. Ed.)• Meds (Flexeril ?)
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GOAL ORIENTED PLAN: Ac/ve Osteoarthrosis
16
¤ JOINT PROJECTION• Self-Management (Pt. Ed.)• Meds (Flexeril ?)
¤ INCREASE MOBILITY:• Physical Therapy (Gentle Jt.
Mobilization & ROM Ex.)
Monday, August 31, 15
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ACTIVE OSTEOARTHRITIS(Inflammatory)
deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60
CLINICAL PRESENTATION:vJoint Pain at Rest & w FunctionvJoint Crepitus vLtd ROM w/ Deflec. 2º PainvPossible Change in Post. Occl.vRadiographic Bony Changes
v Loss of Cortical Integrityv Possible Osteophytic Formationv Subchondral Bone Cystsv Narrowed Superior Jt. Space
Monday, August 31, 15
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ACTIVE EROSIONSv Un-corticated Erosionv“Cupping Defects”
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GOAL ORIENTED PLAN: Ac/ve Osteoarthri/s
19
¤ PAIN CONTROL:• Self-Management (Rest, Ice, Pt. Ed.)• Joint Protection Education• Meds (NSAIDs, Acetaminophen, Analgesics, Steroids
[Methylpredisone DosePak]) • Physical Therapy (Cold, ES, US, Jt. Mob.)
¤ INCREASE MOBILITY:• Physical Therapy (Gentle Jt.
Mobilization & ROM Ex.)
Monday, August 31, 15
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GOAL ORIENTED PLAN: Ac/ve Osteoarthri/s
19
¤ PAIN CONTROL:• Self-Management (Rest, Ice, Pt. Ed.)• Joint Protection Education• Meds (NSAIDs, Acetaminophen, Analgesics, Steroids
[Methylpredisone DosePak]) • Physical Therapy (Cold, ES, US, Jt. Mob.)
¤ INCREASE MOBILITY:• Physical Therapy (Gentle Jt.
Mobilization & ROM Ex.)
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deLeeuw R, Boering G et al: J Orofacial Pain 1994deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60
v DDw/oR to Osteoarthritis - nearly 100%v Osteorthrosis/Osteoarthritis
vFollows a Natural CoursevReduction of Symptoms - 3+ Mos.vStable Bony Changes - 2- 4+ Yrs.
PROGRESSION of DJD
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STABLE OSTEOARTHROSIS
deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60
CLINICAL PRESENTATION:vNo Joint Pain/InflammationvJoint Crepitus vLimited ROM w/ Deflec.vPossible Change in Post. Occl.vRadiographic Bony Changes
v Cortical Integrity Re-establishedv No Subchondral Bone Cystsv Narrowed Superior Jt. Spacev Possible Osteophytic Formation
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GOAL ORIENTED PLAN: Stable Osteoarthrosis
22
Therabite Therapy
“Reassure Patient of Favorable Prognosis”
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GOAL ORIENTED PLAN: Stable Osteoarthrosis
22
Therabite Therapy
“Reassure Patient of Favorable Prognosis”
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GOAL ORIENTED PLAN: Stable Osteoarthrosis
22
¤JOINT PROJECTION• Self-Management • Understand Risk Factors
Therabite Therapy
“Reassure Patient of Favorable Prognosis”
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GOAL ORIENTED PLAN: Stable Osteoarthrosis
22
¤JOINT PROJECTION• Self-Management • Understand Risk Factors
Therabite Therapy
“Reassure Patient of Favorable Prognosis”
¤INCREASE MOBILITY:• Physical Therapy (Jt. Mobilization)• Home Exercise Program
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STABLE OSTEOARTHRITIS
deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60
CLINICAL PRESENTATION:vPain/Chronic InflammationvJoint Crepitus vMinimum ROM w/ Deflec.vPossible Change in Post. Occl.vRadiographic Bony Changes
v Cortical Integrity Re-establishedv Possible Osteophytic Formationv No Subchondral Bone Cystsv Narrowed Superior Jt. Space
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GOAL ORIENTED PLAN: Stable Osteoarthri/s
24
¤INFLAMM. MANAGEMENT PRN¤JOINT PROJECTION
• Self-Management • Unerstand Risk Factors
¤ INCREASE MOBILITY:• Physical Therapy (Jt. Mobilization)• Home Exercise Program
“Reassure Patient of Favorable Prognosis”
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IDIOPATHIC CONDYLAR RESORPTION:a.k.a., Juvenile Idiopathic Arthritis
Wolford LM Proceedings Baylor Univ 2001;14:246-252
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IDIOPATHIC CONDYLAR RESORPTION:a.k.a., Juvenile Idiopathic Arthritis
A Spontaneous Lytic Event Causing the Condyle to Become Rapidly & Progressively Smaller & in Some Cases Completely Disappear .Patients Commonly Become Severly Retrognathic (Receding Chin)
Wolford LM Proceedings Baylor Univ 2001;14:246-252
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IDIOPATHIC CONDYLAR RESORPTION:a.k.a., Juvenile Idiopathic Arthritis
A Spontaneous Lytic Event Causing the Condyle to Become Rapidly & Progressively Smaller & in Some Cases Completely Disappear .Patients Commonly Become Severly Retrognathic (Receding Chin)
Wolford LM Proceedings Baylor Univ 2001;14:246-252
๏ 9X More likely Female Than Male
๏ Hormonal Mediation May Be Involved๏ More Common Among Teenagers๏ “Cheerleaders Syndrome”
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Condylysis Etiology: Hormonal TMJ ReceptorsGENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS
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Condylysis Etiology: Hormonal TMJ ReceptorsGENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS
SOFT TISSUES:❖ Relaxin & beta-‐estradiol Induces Matrix
Metalloproteinase (MMP) expression ❖ Loss of Collagen & Gylcosaminoglycans
(GAGs)
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Condylysis Etiology: Hormonal TMJ ReceptorsGENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS
SOFT TISSUES:❖ Relaxin & beta-‐estradiol Induces Matrix
Metalloproteinase (MMP) expression ❖ Loss of Collagen & Gylcosaminoglycans
(GAGs)BONE:❖ Decreased beta-‐estradiol❖ Increased Osteoclast Activation❖ Increased Remodeling Rate❖ Increased Trabecular spaces
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Condylysis Etiology: Hormonal TMJ ReceptorsGENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS
§ Females are vulnerable during child bearing years
SOFT TISSUES:❖ Relaxin & beta-‐estradiol Induces Matrix
Metalloproteinase (MMP) expression ❖ Loss of Collagen & Gylcosaminoglycans
(GAGs)BONE:❖ Decreased beta-‐estradiol❖ Increased Osteoclast Activation❖ Increased Remodeling Rate❖ Increased Trabecular spaces
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Condylysis Etiology: Hormonal TMJ ReceptorsGENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS
§ Females are vulnerable during child bearing years
§ Rarely develops after 20 years of age
SOFT TISSUES:❖ Relaxin & beta-‐estradiol Induces Matrix
Metalloproteinase (MMP) expression ❖ Loss of Collagen & Gylcosaminoglycans
(GAGs)BONE:❖ Decreased beta-‐estradiol❖ Increased Osteoclast Activation❖ Increased Remodeling Rate❖ Increased Trabecular spaces
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deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60
CLINICAL PRESENTATION:v Typically Severe Bilateral Joint Pain at Rest / Functionv Joint Crepitusv Significant Change in Occlusion
with Open Anterior Bitev Radiographic Bony Changes
v Loss of Condylar Size/Cortical Integrityv Possible Osteophytic Formationv Subchondral Bone Cysts
IDIOPATHIC CONDYLAR RESORPTION:a.k.a., Juvenile Idiopathic Arthritis
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GOAL ORIENTED PLAN: Idiopathic Condylar Resorp/on
28
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GOAL ORIENTED PLAN: Idiopathic Condylar Resorp/on
28
¤ PAIN CONTROL:• Self-Management (Rest, Ice, Pt. Ed.)• Joint Protection Education• Meds (NSAIDs, Analgesics, Steroids) • Physical Therapy (Cold, ES, US, Jt. Mob.)
Monday, August 31, 15
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GOAL ORIENTED PLAN: Idiopathic Condylar Resorp/on
28
¤ PAIN CONTROL:• Self-Management (Rest, Ice, Pt. Ed.)• Joint Protection Education• Meds (NSAIDs, Analgesics, Steroids) • Physical Therapy (Cold, ES, US, Jt. Mob.)
๏ INCREASE MOBILITY:• Physical Therapy (Gentle Jt. Mobilization & ROM Ex.)
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GOAL ORIENTED PLAN: Idiopathic Condylar Resorp/on
28
¤ PAIN CONTROL:• Self-Management (Rest, Ice, Pt. Ed.)• Joint Protection Education• Meds (NSAIDs, Analgesics, Steroids) • Physical Therapy (Cold, ES, US, Jt. Mob.)
๏ INCREASE MOBILITY:• Physical Therapy (Gentle Jt. Mobilization & ROM Ex.)
¤ LONG-TERM MANAGEMENT:• Orthodontics, Orthognathic Surgery, • Joint Replacement Surgery
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DEGENERATIVE JOINT DISEASE
DJD
OSTEOARTHROSISNo Pain/Inflammationv Joint Crepitus v Possible Ltd ROM w/
Deflectionv Possible Change in Post.
Occl.
OSTEOARTHRITIS Pain at Rest & w Function
v Joint Crepitus v Ltd ROM w/ Deflectionv Possible Change in Post.
Occl.
ACTIVEBony Changes
v Loss of Cortical Integrityv Subchondral Bone Cystsv Possible Osteophytic Formationv Possible Narrowed Sup. Jt.
Space
STABLE
v Cortical Integrity Re-establishedv No Subchondral Bone Cystsv Probable Osteophytic Formationv Narrowed Superior Jt. Space
Bony Changes
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Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
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MANAGEMENT PHILOSOPHY
Diagnostically Driven Problem-Based Goal Oriented
Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
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MANAGEMENT GOALS Relieve Pain
Promote Healing Restore Functional ROM
Optimize Masticatory Function Return to Previous Level of ADL
MANAGEMENT PHILOSOPHY
Diagnostically Driven Problem-Based Goal Oriented
Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
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MANAGEMENT GOALS Relieve Pain
Promote Healing Restore Functional ROM
Optimize Masticatory Function Return to Previous Level of ADL
Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
Monday, August 31, 15
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Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
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NO SURGERY or TREATMENT
of the OCCLUSION
Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
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NO SURGERY or TREATMENT
of the OCCLUSION
Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
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“The art of medicine is in amusing the patient
while nature cures the disease”VOLTAIRE
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