Professional Documents
Culture Documents
1954
Schartz
reported
inactivation
of
TPs
by
Procaine
injection
was
an
important
1969
Laskin
emphasized
the
pshychophysiological
part
in
the
tx
of
TMJ
pain.
nature
and
proposed
MPD
Myofacial
Pain
Dysfunction
Orofacial
Pain
* Travell
JG,
Simmons
DG
Myofacial
Pain
and
Dysfunction
The
Trigger
Point
Manual
Ch
(2)
pp10-‐11
Orofacial
Pain
* Pain
is
defined
by
the
International
Association
for
the
Study
of
Pain
as
“
an
unpleasant
sensory
and
emotional
experience
associated
with
actual
or
potential
tissue
damage
or
described
in
terms
of
damage”
Pain:(Suppl
3):S1-‐S226,1996
The
thought
that
pain
can
be
felt
in
the
absence
of
any
tissue
injury
is
foreign
to
many
clinicians!
* Suffering:
Refers
to
the
way
in
which
the
individual
reacts
to
the
perception
of
pain.
Past
experiences,
expectations,
perceived
threat
of
the
injury
and
the
amount
of
attention
given
to
the
injury.
* Pain
behavior:
Refers
to
the
individual’s
audible
and
visible
actions
to
communicate
his/her
suffering
to
others.
* Considerations:
Orofacial
Pain
* Pain
is
one
of
the
most
powerful
negative
emotions
of
humans
experience.
* Acute
pain
provides
protection
from
environment
(nociceptive
reflex).
It
is
basic
to
survival!!!
* Chronic
pain
lasts
far
longer
than
healing,
has
no
protective
value!!
It
can
be
destructive
to
the
human
spirit
and
quality
of
Life.
* Prevalence
of
Orofacial
pain
in
the
general
population
in
30-‐31y/o
has
been
reported
23%.
Macfarlane
TV,
Kenealy
P,
Commun
Dent
Oral
Epidemiol
37(5):438-‐450,2009
* In
another
study
23%-‐24%
of
45
y/o
reported
pain
while
chewing.
Riley
JL
III,
Gilbert
GH
Pain
90(3):
245-‐256,2001.
* JP
Okeson
Management
of
Temporomandibular
Disorders
and
Occlusion
7th
ed
Ch(2)p39
Descending
Inhibitory
System
(down
* What
comes
first?
regulation)
Chronic
Pain
or
sleep
disturbance?
Non-‐REM
stage
(Serotonin
synthesis)
Stage
1
α
10/sec
80%
Non
REM:
Restoration
for
Stage
2
α
10/sec
One
complete
body
systems
cycle
60-‐90mins
(RNA,
proteins,
Stage
3
Δ
.4-‐5/sec
4-‐6cycles
per
neurotransmitters
night
sleep
etc.)
Physical
rest
Stage
4
Δ
.4-‐5/sec
cervical
region
can
commonly
be
referred
to
neurotransmitter
affects
a
the
face.
Neurons
from
V,VII,
X
share
in
the
second
neuron
N2,
perceiving
same
neuronal
pool
with
upper
spine
neurons.
pain
as
coming
from
TMJ.
N2
N 1
11
JP
Okeson
Management
of
Temporomandibular
Disorders
and
Occlusion
7
ed
th
Ch(2)p41
Central
Excitatory
Effect
* Clinical
Manifestation
of
Central
Excitatory
Effect
will
depend
on
type
of
interneuron
affected
(Afferent,
Efferent,
Autonomic)
* Afferent:
Referred
pain
is
often
reported,
local
provocation
on
site
of
pain
doesn't
increase
sensation
different
from
source
of
pain
stimulation.
LA
block
at
source
will
eliminate
pain
on
both
places,
(site
&
source).
* Efferent:
Protective
co-‐contraction/muscle
splinting
* Autonomic:
Variation
of
blood
flow
blanching,
reddening
of
tissue,
puffy
or
dry
eyelids,
stuffy
or
runny
nose.
Key:
symptoms
will
be
unilateral
JP
Okeson
Management
of
Temporomandibular
Disorders
and
Occlusion
7th
ed
Ch(2)p41
Central
Excitatory
Effect
* CNS
response
to
injury
or
threat
by
altering
function
to
protect
injured
part
from
further
injury.
* CNS
increases
the
activity
of
the
antagonist
m.
during
contraction
of
the
agonist
m.
* Protective
co-‐contraction
may
occur
during
normal
functional
activities
such
as
bracing
the
arm
while
using
fingers.
* In
the
presence
of
altered
sensory
input
or
pain
such
as
premature
contacting
new
restoration;
temporalis,
masseter
and
med.
pter.
may
co-‐contract
in
an
attempt
to
prevent
restoration
from
contacting.
* Constant
deep
pain
input
Central
Excitatory
Effect
* Increased
Emotional
Stress
γ
efferent
system
alter
muscle
spindle
sensitivity
muscle
tone.
Muscle
Tone
(Muscle
Spindle)
* Clinical
Manifestation:
* Any
restriction
to
mandibular
movement
is
secondary
to
pain,
but
ROM
will
be
almost
normal
if
opening
is
done
slowly.
* No
Pain
at
rest.
* Increased
pain
w
function
and
increased
restriction
of
movement.
* Feeling
of
muscle
weakness.
Pt
complains
of
muscle
getting
tired
quickly
while
chewing.
(No
evidence
found
of
muscle
weakness
when
EMG
is
done!)
* Co-‐contraction
is
a
common
phenomenon,
may
be
observed
during
many
normal
functional
activities.
JP
Okeson
Management
of
Temporomandibular
Disorders
and
Occlusion
7
ed
Ch(12)p291
th
Local
Muscle
Soreness
(non
inflammatory
myalgia)
JP
Okeson
Management
of
Temporomandibular
Disorders
and
Occlusion
7th
ed
Ch(20)p241
Myofacial
Pain
(Trigger
Point
Myalgia)
* We
classify
TPs
as
either
active
(producing
pain)
or
latent
(non-‐
painful).
* Latent
TP
although
non
painful
will
limit
ROM
and
report
weakness
of
affected
muscle.
* May
persist
for
years
after
apparent
recovery
and
may
reactivate.
* TPs
tend
to
occur
in
musculo-‐tendinous
junctions
(Golgi
tendon
organs),
not
related
to
any
anatomical
feature
of
muscle
such
as
muscle
spindle
and
neuromuscular
junctions
(found
in
proximity)
* Muscle
spindles
have
not
been
found
in
biopsy
of
TPs
Travell
G
Simmons
G
Myofacial
Pain
and
dysfunction
the
trigger
point
manual
1983
pp221
Myofacial
Pain
(Trigger
Point
Myalgia)
TX
Modalities
* Pain
at
rest,
due
to
algogenic
substances
released
from
neurogenic
inflammation.
* Muscle
contracture.
Muscle
contracture
is
a
painless
shortening
of
the
functional
length
of
a
muscle.
Periodic
stretching
and
lengthening
of
muscle
is
needed
to
maintain
its
working
length.
When
the
(Golgi
tendon)
inverse
stretch
reflex
is
not
stimulated
muscle
will
functionally
shorten
resisting
any
attempt
to
lengthening.
JP
Okeson
Management
of
Temporomandibular
Disorders
7th
ed
Ch
10
pp240-‐241
Fibromyalgia
* 1990
American
College
of
Rheumatology
consensus
report:
Fibromyalgia
is
a
widespread
musculoskeletal
pain
disorder
in
which
there
is
tenderness
at
11
or
more
of
18
specific
tender-‐point
sites
throughout
the
body.
Pain
must
be
felt
in
3
or
4
quadrants
of
the
body
and
be
present
for
at
least
3
months.
* These
numerous
tender
points
must
not
be
confused
with
TPs
of
MPD.
They
don’t
produce
heterotopic
pain
when
palpated.
* Etiology
has
not
been
well
documented.
Constant
deep
pain
and
increased
emotional
stress
may
be
significant.
* Increased
pain
with
function,
weakness
and
fatigue,
sedentary
physical
condition
as
a
consequence.
* Fibromyalgia
has
been
produced
in
healthy
university
students
by
keeping
them
awake
for
48
hrs,
producing
abnormal
alpha
intrusions
on
their
delta
stage
sleep.
Mahan
P
Alling
C
Facial
Pain
3
ed
p138
rd
JP
Okeson
Management
of
Temporomandibular
Disorders
7th
ed
Ch
10
pp240-‐241
Referred
Pain
Clinical
Rules
1. The
most
frequent
occurrence
of
Referred
Pain
is
within
a
single
root,
passing
from
one
branch
to
another
(Md
molar
referring
to
Mx
molar).
Or
in
a
laminated
manner
Incisors
to
incisors,
premolars
to
premolars
within
the
same
side
of
the
mouth.
2. In
the
Trigeminal
area
pain
rarely
crosses
midline
unless
its
origin
is
in
the
midline.
Observe
that
this
does
not
apply
to
cervical
and
below
region,
where
cervicospinal
pain
can
be
referred
across
midline.
Local
provocation
of
the
source
will
cause
an
increase
in
symptoms,
while
local
provocation
in
the
site
will
generally
not
increase
symptoms.
Cardiac
Pain
JP
Okeson
Management
of
Temporomandibular
Disorders
and
Occlusion
7th
ed
Ch(2)p41
Keys
to
Differential
Dx
Opioids
Contraindication
Pronociceptive
* Not
indicated
for
chronic
pain
because
of
analgesic
tolerance.
It
has
been
demonstrated
that
this
analgesic
tolerance
may
be
due
to
neoplastic
changes
of
cells
due
to
the
presence
of
the
opioid.
* One
such
change
may
be
the
activation
of
descending
pain
facilitation
mechanisms
arising
from
the
rostral
ventromedial
medulla
(RVM)
elicited
in
part
by
increased
activity
of
cholecystokinin
(CCK)
in
the
RVM.
A
cascade
of
pronociceptive
events
may
follow,
such
as
opioid-‐induced
upregulation
of
spinal
dynorphin
levels
that
promotes
enhanced
input
from
primary
afferent
nociceptors.
Pharmaco-‐Therapy
Pharmaco-‐Therapy
Topical
Medications
Topical
Lidocaine
Diclofenac
sodium
Capsaicin
Spray
and
Stretch