Download References Masticatory System • Psychosocial function

Steve Kraus PT OCS MTC CCTT CODN

5/17/14

The Triangles of Treatment of the Masticatory System Steve Kraus PT Biopsychosocial Approach Movement System Impairments

Manual Therapy

References Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992; 6:301-355. Kraus SL. Temporomandibular disorders. In: Saunders HD, Saunders Ryan R, editors. Evaluation, treatment and prevention of musculoskeletal disorders, vol. 1 - Spine. 4th edition. Chaska (MN): The Saunders Group, Inc.; 2004. p. 173–210. Kraus SL. Head and Orofacial Pain; Cervical Spine Implications Editor, H Gremillion Dental Clinics of North America 2007; 51(1):161- 93 Methodological quality of a systematic review on physical therapy for temporomandibular disorders: influence of hand search and quality scales Craane B, Dijkstra P, Stappaerts K & De Laat A Clin Oral Invest Dec 2010 American Academy of Orofacial Pain: Guidelines for Assessment Diagnosis, and Management, ed 5. De Leeuw R and Klasser GD (eds). Chicago: 2013. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for clinical and Research Applications. Schiffman E, Ohrbach R, Truelove E. et al J Oral Facial Pain Headache 2014; 28: 6-27

Masticatory System Masticatory system is important to an individual’s general health and quality of life. • Orofacial function chew

swallow

yawn

brushing of teeth

• Psychosocial function talk

smile

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laugh

kiss

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Steve Kraus PT OCS MTC CCTT CODN

5/17/14

Movement System Impairments

Masticatory System Impairment of the masticatory system may result from;


Malocclusion Imperfect positioning of the teeth when the jaws are closed. If the malocclusion is effecting the patient’s oral function and psychosocial function then necessary dental treatment is needed, i.e. orthognathic surgery, orthodontics, full mouth reconstruction and equilibration. There is an absence of evidence, from RCTs, that treatment of the malocclusion treats or prevents TMD. In only select cases should irreversible procedures to the occlusion be done for the treatment of TMD. The Cochrane Library, Issue 2, 2005.

Masticatory System
Temporomandibular Disorder  Temporomandibular Joint

 Muscles of mastication Conservative, reversible, and cost-effective treatments are recommended for the vast majority of patients suffering from acute or chronic TMD pain and dysfunction. Conservative treatments includes;
oral appliance therapy
pharmacologic management
physical therapy

Why physical therapy for the treatment of TMD?    

TMD is a musculoskeletal problem TMD ranks only second to low back pain in the US Physical therapy is conservative Physical therapy is cost effective

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Steve Kraus PT OCS MTC CCTT CODN

•

 Myalgia 728.85
local myalgia
myofascial pain
myofascial pain with referral
lateral pterygoid spasm
trismus

• •

5/17/14

Arthralgia 524.62 Subluxation 830.1 Disc Displacements 524.63
Disc displacement with reduction  Disc displacement with reduction with intermittent locking


Disc displacement without reduction with limited opening
Disc displacement without reduction without limited opening

•

Degenerative Joint Disease 715.18

RDC/TMD is a landmark paper providing operational definitions to distinguish TMD patients from controls and to diagnose the most common subtypes of TMD using reasonable reliable and valid tests and measurements

Myalgia

Opening and Closing Muscles Supra hyoid / infra muscles

Temporalis

Medial Pterygoid

Masseter

Lateral pterygoid

Myalgia History

.90 sensitivity and .99 specificity

In the past 30 days patient reports having; 1. Pain in the jaw, temple, in the ear or in front of the ear that; a. Is modified with jaw movement, function or parafunction and / or b. awakens them at night and / or is present in the AM upon awakening

Exam Positive for both of the following 1. 2.

Confirmation of pain location(s) in the temporalis and/or masseter muscle(s) Report of familiar pain in the temporalis or masseter muscle(s) with at least one of the following provocation tests; a. Palpation of the temporalis or masseter muscle(s) b. Maximum unassisted or assisted opening movement(s) Baseline measurements; measure interincisal opening (IO)

a. without pain

b. with max unassisted opening c. with assisted opening

Functional mouth opening; > 30mm interincisal opening (IO)

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a

b

c

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Steve Kraus PT OCS MTC CCTT CODN

5/17/14

Biopsychosocial Approach

Pain

Biopsychosocial issues

Pain, is much more than a physical entity. A patient's pain experience and reaction to pain is driven by the individual’s biopsychosocial makeup (depression / fear / anxiety) A bidirectional relationship between pain and emotions (D/F/A) Depression / anxiety / fear can develop as a result of pain or if patient is predisposed to depression, anxiety and fear, such emotions can be magnified because of pain. Giesecke, T., Gracely, R.H., Williams, D.A., et al 2005. The relationship between depression, clinical pain, and experimental pain in a chronic pain cohort. Arthritis Rheum. 2005; 52, 1577– 1584.

Patient Health Questionnaire (PHQ) Is short, reliable and valid screening instrument for detecting “psychological distress” due to anxiety and/or depression in patients in any clinical setting

Graded Chronic Pain Scale 2.0 Is short, reliable and valid screening instrument for measureing pain intensity and disability

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Steve Kraus PT OCS MTC CCTT CODN

Pain

5/17/14

Biopsychosocial issues

Biopsychosocial issues are enhanced by the patient’s journey to find relief in their pain.  Patients with TMD often consult with multiple healthcare providers, or consulted with family members, friends and the internet.  Each source is telling the patient something different as to what it is they have and what treatments are needed.  Patients become confused enhancing the feelings of hopelessness, fear, anxiety and depression.

Pain

Biopsychosocial issues Patient Education

Patient Education to reduce unnecessary fear and anxiety. Fear and anxiety may contribute to bruxism

 Educate the patient on your diagnostic findings.  Provide time for the patient to ask any questions about your diagnosis and expectations of treatment.

 ask the patient if they have any questions regarding what previous healthcare professionals have said about their condition.  ask what their primary stresses and concerns are

Manual Therapy

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Steve Kraus PT OCS MTC CCTT CODN

5/17/14

Treatments for Myalgia
Patient Education to reduce fear / anxiety. Fear and anxiety may contribute to bruxism. Bruxism is one of several oral parafunctional activities Parafunctional activity include habitual use of the mouth unrelated to eating, drinking, yawning or talking.
Behavioral Modification Decrease or eliminate oral parafunctional activity



– –

nocturnal bruxism – diurnal bruxism biting finger nails, chewing gum, ice, pencil, etc.


Modalities   

Electric stimulation (pre mod interferential) Ultrasound Iontophoresis

Cervical Spine Disorder Substantial evidence has shown cervical spine mobility and positioning influences the kinematics of the human mandible. Cervical Spinal Pain in Chronic Craniomandibular Pain Patients. Visscher CM. Printed by; Thela Thesis, Amsterdam; 2000

Satellite trigger points in the masticatory muscles may prove resilient to treatment until the primary trigger points in cervical spine muscles have been treated first. Reduction of pain and EMG activity in the masseter region by trapezius trigger point injection Carlson C, Okeson J, Falace D, et al. Pain, 55 (1993) 397-400

Summary Treatments for Myalgia


Patient Education to reduce fear / anxiety. Fear and anxiety may contribute to bruxism.


Behavioral Modification
Modalities
Cervical Spine Disorder
Dry Needling
Intraoral Massage

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Steve Kraus PT OCS MTC CCTT CODN

5/17/14

Massage the muscles of mastication to treat Myalgia Massaging jaw muscles will help;  reduce pain  reduce pain with chew, talk and yawn  increase mouth opening (if closing muscles are tight)  to get back teeth together (if opening muscle is tight)

Temporalis

Medial Pterygoid

Masseter

Lateral pterygoid

Massage Masseter

Masseter Origin:  Superficial portion – anterior 2/3 of lower border of zygomatic arch  Deep portion – medial surface of zygomatic arch Insertion:  Lateral surface of ramus and angle of mandible Function:  Elevates the mandible

Massage Indication for massaging the lateral pterygoid muscle; Lower head lateral pterygoid

 Facial pain not responding to other treatments for myalgia  Pterygoid muscle spasm

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Steve Kraus PT OCS MTC CCTT CODN

Lateral Pterygoid

Lower head lateral pterygoid

5/17/14

Massage

Origin:  lateral surface of the lateral pterygoid plate Insertion:  neck of condyle of the mandible Function:  Depresses mandible, protrude mandible, side to side movement of mandible

Pterygoid spasm may occur when; • blow to chin • unexpected resistance when chewing • yawning Patient unable to bring back teeth together on the side of the spasm.

Masseter massage

Lower head lateral pterygoid massage (area) Location of finger tip

 Brace finger against patient's upper gum line  Ask patient to open & close mouth  Opening will bring pterygoid muscle into palpation finger

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Steve Kraus PT OCS MTC CCTT CODN

5/17/14

The Triangles of Treatment of the Masticatory System Steve Kraus PT Patient Education Biopsychosocial Approach Movement System Impairments

Manual Therapy

Myalgia; Intraoral Massage  pain and limited oral functions  may or may not have limited mouth opening  may or may not be able to bring back teeth together

Thank You

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