The mouth is the window into human health. This course provides an overview of dental medicine to engage, educate, excite and assist you in improving the oral health of your patients and members of your community. We will review topics in dental medicine including scope of the field, what to expect in function, and some of the many ways that dysfunction may present for different patients. This will include discussions of mouth, jaw, and tooth anatomy, pathology, and treatment. We will talk about differences between patients and the unique roles that different members of the dental field may play in treatment depending on the patient and condition. This course starts from basic concepts and proceeds to review trends in current research and technology. We offer scientific background, some skills for patient evaluation and interview, and some suggestions for further learning for those interested in or involved in dental education.
Lecture 4: Common Orofacial Pain Conditions: Articular Disc Disorders and Arthritic Conditions (14min)
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來自 University of Pennsylvania 的課程
Introduction to Dental Medicine
278 個評分
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Week 6 - The Science of Pain Affecting the Intraoral and Extraoral Structures
These modules address oral and facial pain from common conditions to rare ones, including an exploration of the psychological aspects of oral and facial pain. Dental pain can originate not only from diseased dentition, but also from various disorders affecting the TMJ, nerves, soft and hard tissue infections and other sources. Dental pain can have underlying psychosocial etiology as well, and the diagnosis in such cases can be challenging.
與講師見面
Dr. Uri HangorskyAssociate Dean for Academic Affairs/ Director PASS
School of Dental Medicine
Dr. Thomas P. SollecitoProfessor and Chairman of Oral Medicine
School of Dental Medicine
Dr. Eric StooplerAssociate Professor of Oral Medicine
School of Dental Medicine
[MUSIC]
Welcome, to appropriately examine the patient for suspected TMD.
The clinician must examine the relevant structures in a thorough and
systematic manner.
Clinicians who are unaccustomed to this type of examination
may feel uncomfortable performing initially,
but will gain confidence in these techniques with experience.
For patients presenting orofacial pain complaints,
it is generally recommended to perform a cranial nerve examination.
Complaints of altered sensation or
loss of sensation of facial structures may indicate a non-TMD facial pain condition,
and a cranial nerve examination should be performed to detect cranial nerve
abnormalities that may indicate central nervous system pathology.
If abnormalities are detected on cranial nerve examination,
patient should be promptly referred to an appropriate health care provider for
further evaluation and management.
Measurement of interincisal
opening is completed to evaluate the patient's ability to open their jaw.
A measurement device with a millimeter scale, placed between the maxillary
central incisors and mandibular central incisors with the patient in the open
position is typically how this measurement is obtained.
Normal range of opening is approximately 35 to 55 millimeters in adults, but
this may vary due to many factors.
Clinicians should know presence, location, and
severity of pain with jaw opening and closing.
Lateral jaw movements are evaluated by asking the patient
to move their mandible left and right, and
measuring the range of motion with the measuring devices previously mentioned.
Normal lateral movements typically range between 8 to 12 millimeters in adults.
To appreciate mandibular deviation, ask the patient to open and
close their jaw in a regular manner, and look for mandibular movements that do not
follow a typical straight opening and closing pattern.
Patients with TMJ articular discs that are stuck,
often demonstrate mandibular deviation in a straight line to the affected side.
Other individuals who have TMJ discs that are malpositioned, but
in a physiological position may demonstrate a c shaped or
s shaped deviation on opening and closing movements.
Auscultation of the TMJ may be accomplished by using a stethoscope
to listen for joint noises.
Placing the diaphragm of the stethoscope in front of the ear,
known as the preauricular area, and asking the patient to repeatedly open and
close their mandible, allows the clinician to hear joint noises,
such as clicking, popping, or crunching if they are present.
These sounds should be noted if heard on either opening or
closing movement or both.
In addition, the clinician should ask the patient,
if they feel pain when experiencing the joint noises.
Alternatively, the clinician may also place their pinky
fingers inside the patient's external auditory meatus, and
ask the patient to open and close to appreciate joint noises and pain.
Palpating the TMJ will inform the clinician if a patient is experiencing
pain in and around the joint.
Typically, pressure ranging from two to four pounds is exerted when palpating
the TMJ, and associated structures.
And if pain is reported when performing this technique, it is commonly associated
with an inflammatory condition of the TMJ, such as capsulitis and/or synovitis.
Palpation of the masculatory muscles is a critical component of the TMD examination,
as many patients with TMD experience pain associated with these muscles.
Using pressure as noted previously, the clinician should palpate all portions of
the temporalis and masseter muscles bilaterally from an external approaching,
and noting severity of pain if present.
The medial and lateral pterygoid muscles are typically palpated from an intra-oral
approach with the patient in an open position to gain access to these muscles.
Again, the clinician should note presence of,
and severity of pain when palpating these muscles as
this is often an indication of a masticatory muscle disorder.
In addition,
the patient's dental relationship should be grossly evaluated in the closed or
biting position to determine if there are any major bite discrepancies.
Finally, it is important to assess the patient's teeth for
signs of wear that may be indicative of a parafunctional habit.
TMJ articular disorders refer to malpositioning of the articular disc
relative to the condyle and articular eminence.
Typically, the articular cartilages in the 12 o'clock position superior to
the condyle.
The majority of articular disc disorders represent disc displacement
anterior to the condyle.
The term TMJ articular disc disorder with reduction refers to an anteriorly
displaced disc that resumes its position on top of the condyle on opening movement,
which does not typically cause restricted movement.
Clinically, this phenomenon is most commonly observed as a joint click
with opening.
It is common to hear joint clicking when a patient closes their mandible.
This is known as a reciprocal click.
The clinician should note if there is pain associated with the clicking noise and
severity if present.
The term TMJ articular disc disorder without the reduction,
refers to a disc that remains mal-positioned on opening attempts,
resulting in restricted mouth opening in acute cases.
Another term for the condition is closed lock.
Patients with this condition typically open to approximately 20 millimeters as
the condyle is capable of rotational movement only.
This condition often causes significant pain and dysfunction, and
patients typically seek acute care to treat this condition as it often
compromises nutritional intake, daily function, and overall quality of life.
Subluxation of the jaw is considered a hypermobility disorder.
Patients with hypermobility typically have laxity of their ligaments and
tendons, thereby increasing their flexibility and range of motion.
Subluxation of the jaw occurs when patients open very wide, resulting in
overextension of the disc-condyle complex beyond the articular eminence.
Individuals who can easily open their jaw to 55 millimeters or
greater are considered to be hypermobile.
Another key feature of subluxation is that patients can passively return their jaw to
a comfortable resting position, meaning a return to the normal disc-condyle
position in relation to the articular eminence
without typically getting their jaw stuck or locked in an open position.
Joint dislocation occurs when the entire disc-condyle
complex extends beyond the articular eminence,
combined with the inability to return passively into the fossa.
This is also commonly referred to as open lock.
This can be very distressing for patients as it is often accompanied by significant
pain, emotional upset, and negative social implications.
Patients with open lock are typically seen on an urgent basis, and correction of this
problem usually requires use of potent analgesics, and muscle relaxants,
coupled with physical manipulation of the mandible to its normal position.
The most common etiology for TMJ articular disc disorders is trauma, and
may be considered in three categories, Macrotrauma, microtrauma, and
indirect trauma.
Perhaps, the most evident type of macrotrauma that can cause articular
disc disorders is direct injury to the face, mandible, or TMJ area.
Direct injury to these areas typically occurs during physical altercations,
motor vehicle accidents, bicycle accidents, and sports related injuries.
Dental procedures may also be attributed to development articular disc disorders.
Dental procedures that create excessive force on the mandible,
and/or TMJ area, may cause development of an articular disc disorder.
It is common for patients to complain of new onset joint clicking and
pain after their jaw has been opened for
a long period of time owing to prolonged dental procedures.
Microtrauma has historically been attributed to application of
prolonged forces on the TMJ complex over a period of time.
Jaw parafunction has long been considered the type of microtrauma that might cause
TMJ articular disc disorders, as well as jaw muscle pain.
Indirect trauma has been implicated in TMJ articular disc disorders.
The most common type of indirect trauma that may precipitate TMDs
including articular disc disorder is whiplash injury.
This refers to a violent jerking motion of a body part during a sudden
traumatic event.
In the case of TMD, whiplash injuries of the head and
neck have been associated with TMJ articular disc disorders,
which often occur during motor vehicle accidents.
Patients may complain of immediate facial or TMJ pain after the incident, but
it is not uncommon for
patients to develop TMD pain and/or dysfunction months after the incident.
We will now discuss another type of disorder that commonly causes
TMJ pain and/or dysfunction.
Arthritis typically affects various joints of the body, and the TMJ is no exception.
The most common type of arthritic condition to affect the TMJ
is osteoarthritis.
This is also commonly referred to as degenerative joint disease.
Osteoarthritis is considered a non- to low-inflammatory
condition that can cause bony changes, which may be evident in the TMJ area.
Ultimately, these bony changes can cause pain and/or dysfunction in the TMJ area.
The etiology of TMJ osteoarthritis is usually attributed to mechanical
overloading of the articular services, which leads to the degeneration of bony
and/or cartilaginous structure of the TMJ complex.
This condition is more frequently seen in elderly individuals compared to younger
patients due to more years of joint use.
Patients with TMJ osteoarthritis are often very specific regarding their pain
complaints.
These individuals typically complain of unilateral joint pain
often pointing directly to the TMJ area, which is exacerbated with jaw movement.
In addition, many patients with TMJ osteoarthritis complain of crunching or
crackling sounds, referred to as crepitus in the TMJ area with jaw movement.
Careful examination of a patient with suspected TMJ osteoarthritis often yields
important diagnostic clues.
Patients with this condition often have limited jaw opening, as stated previously,
it is common to detect crepitus on auscultation of the TMJ
which is highly suspicious for osteoarthritis.
Palpation of TMJs affected by osteoarthritis is often painful,
the most basic type of plain film imaging of the TMJs is the panoramic radiograph.
This type of imaging is completed in the dental office, and allows for
visualization of the maxillary and mandibular bones, and
the bony structures of the TMJ.
In patients with TMJ osteoarthritis,
it is typical to see varying degrees of flattening of the condylar head,
possible erosion of the condylar surface and/or bone spur formation in these areas.
Other less common types of arthritic conditions that effect the TMJs
are rheumatoid arthritis, and traumatic arthritis.
In contrast to the non and low inflammatory nature of osteoarthritis,
rheumatoid arthritis is considered a persistent inflammatory disorder,
that leads to destruction of articular surfaces, and bony structures of the TMJ.
This disease has an autoimmune etiology, and
is typically diagnosed through laboratory evaluation and clinical history.
It is not uncommon for patients to present with signs and symptoms consistent with
TMJ arthritic pain, who are not aware they have rheumatoid arthritis.
In my practice I've seen several adolescents and
teenagers complaining of TMJ arthritic pain, and
after appropriate evaluation were discovered to have juvenile
idiopathic arthritis, historically known as juvenile rheumatoid arthritis.
Finally, traumatic arthritis can cause signs and symptoms of TMJ arthritic pain,
as evidence on clinical examination and radiographic imaging.
This type of arthritis manifests as bony changes that develop secondary to sudden
macrotrauma, the most common being direct injury to the TMJ area from incidents such
as motor vehicle accidents, sports-related injuries, and/or physical altercations.
We now turn our attention to TMD muscular disorders, these account for
many cases of TMD, either as the sole ideology,
or a combination with articular disorders, and/or arthritic conditions.
It is important to understand basic terminology of muscular disorders,
as they are often used interchangeably and not always in the appropriate context.
Myalgia refers to localized muscle soreness that does not typically include
or affect other muscles.
For example, if a patient has pain only of the masseter muscle without referred pain,
it would be appropriate to diagnose the condition as myalgia
of the masseter muscle.
Myalgia also typically causes muscle weakness, in contrast,
myofascial pain refers to regional muscle soreness associated with trigger points.
Which are hypersensitive areas or bands within the affected muscle
that typically cause referred pain throughout the affected region.
Pain arising from trigger points within the masseter that radiates throughout
the facial region would be consistent with myofascial pain.
Typically, this is the most common type of TMD muscular disorder encountered in
clinical practice.
Since most TMD muscular disorders are consistent with a myofascial pain
diagnosis, we will discuss some key considerations for
patients with TMD myofascial pain.
Many patients with this condition often complain of dull, achy pain,
and/or the sensation of fatigue involving the masticatory muscles.
These patients also complain of pain at rest that typically increases with
jaw function.
Trigger points, which represent firm,
hypersensitive bands of muscle are felt on palpation.
Thy symptoms of TMD myofascial pain can be wide ranging, from mild ache, or
pain of the jaw muscles to severe disabling pain that may
compromise function and significantly effect a patient's quality of life.
TMD myofascial pain disorders maybe, and
are often associated with TMJ articular disc disorders and arthritic conditions,
and often cause referred pain to other structures of the head and neck.
Therefore, active therapy for TMD muscular disorders is often indicated for
patients with these conditions.
In the next segment, we will discuss, Imaging considerations and
management strategies for TMDs.
