DIAGNOSIS CDS 846
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This 17 page Class Notes was uploaded by Savanna Fahey on Friday October 23, 2015. The Class Notes belongs to CDS 846 at University of Kentucky taught by Jeffrey Okeson in Fall. Since its upload, it has received 23 views. For similar materials see /class/228189/cds-846-university-of-kentucky in Dental Public Health Sciences at University of Kentucky.
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Date Created: 10/23/15
CBS 846 Okesun nutes fur usle CBS 845 Sums meunam Quesuuns m Dugms ma mm Om P 1 Wm wwwme Wm Cmmnmm 2 mmmmmm WW JameypokgstMD 3 nmmmbmmmgymmkm Pm ssoxmdchmr mmmrommmcm mm madam117 mezom39an PmCm39 nmmmmum mmmmmm ok mukyampn mew Mm mum tmgomznt mm m momma A pnmsfehmthz W rm m m mm mm mqu l DentalFams 1W MW 3 mp3 Euvud39r mwmn h Fanudun39zl SW Emma my 7 mm w examml What is TMD l Danni Fams A consc ve tame bumrg Axmmhexofdmmzl a 11931 mum hmwm k mmmmmhm b Fenudun39zl kmhrdmocmedsmcmnsmbumquot 2 TMD Fams CBS 846 Okesm mus m um Tanpummandlbulzr sturders quot quot Musculnskzlem pnm disaxdns afthz mgcmxy sysmm 76017111 We ianAzml pmr mmmmm 1 Dental Pam quot a m H3517 pal w Myquot b Pemannm mmnm 2 MD Pm r ammo gammy CDS 846 Okeson notes for test 1 Some Impo ant Questions 1What types of orofacial pain disorders should you treat 2 Why pain is more than a mere sensation Pain is not a sensation 3 How can you be sure the patient s pain complaint is a related to a TM disorder Palm Is an expenence39 4 How can We differentiate and classify orofacial pain disorders Th 39 di 39d al 39 f Pain 1s useful as em V1 u Sexpmme pain and suffering is not deterrnlned a protectlve mechamsm by the amount missus damage but instead b however y most pains occur too 1 The threat of lejnjmy late to have protective value and 2 The attention draw to the injmy DI ew individuals sensing The Primitive Reptilian Brain identical nwciaus stimulationfeel pain in different ways and react at di erent levels the Spinal cord ofsu ering the medullary structures WEBell 1989 As a clinical symptom pain can not be shared It is wholly personal re ex pain fastpain belonging to the su er alone 39 WEBell 1989 CDS 846 Okeson notes for test 1 The Mammalian Brain I the spinal cord the medullary structures the limbic structures pain pleasure center emotions behavior instincts and drives The Primate Brain I the spinal cord the medullary structures the limbic structures the cortex motivational response reason meaning consequence De nition of Pain A more or less localized sensation of discomfort distress or agony resulting from the stimulation of specialized nerve endings It serves as a protective mechanism insofar as it induces the sufferer to remove or withdraw from the source Darlandlr Wdica Dictiomry 1988 De nition of Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage Bonita 1990 De nition of ciception The mechanism that provides for the reception of noxious or potentially noxious stimuli into neural impulses that are transmitted to the CNS De nition of Pain The subject s conscious perception of modulated nociceptive impulses that generate an unpleasant sensory and emotional experience associated with actual or potential tissue damage CDS 846 Okeson notes for test 1 Definition of Suffering The emotional response to pain and other factors that re ects the subj ect s anticipated impending and future threat to his wellbeing Definition of Pain Behavior The subject s audible and visible actions that communicate his suffering to others The Human Being is a musculoskeletal system muscles amp bones with an envelope skin amp mucosa and a supply system digestive amp vascular with a coordination system peripheral amp central nervous systems Superficial Somatic Structures the envelope Cutaneous Tissues Mucogingival Tissues Musculoskelatal System Muscles Bones Joints Tendons Ligaments Related Connective Tissues Visceral Structures the supply system Cardio Vascular Structures Digestive Structures Glandular Structures Ocular Structures Auricular Structures Mucosal Structures Pulmonary Structures CDS 846 Okeson notes for test 1 Neurogenous Structures the control center The control center perceives the Brain sensory input from each of these Brain Stem systems differently Peripheral Nervous System Autonomic Nervous System Sensory Input from the Envelope Sensory Input from the Envelope Extemceptorr P 39d 39 t f th 39 t l Tactile to skin Meissner s Corpuscles rOVI es mpu mm 6 envmmmen 2 Tactile to mucosa Merkel s Corpuscles 3 Pressure amp Warmth Ruffin s Corpuscles 4 Cold Krause s Corpuscles 5 Pain amp Touch Free Nerve Endings Sensed at a conscious level Pain generally stimulates action from the individual Sensory Input from the Musculoskeletal sensory Input from the Musculoskeletal System System Proprioceptors Provides information on presence position and 1 Stretch Receptors Muscle Spindles mOvement 2 Tension Receptors Golgi Tendon organs Chie y unconscious but easily brought to a 3 Pressure Receptors Pacinian Corpuscles conscious level 4 Periodontal Mechanoreceptors 5 Pain Receptors Free Nerve Endings Pain generally inhibim action of the individual CDS 846 Okeson notes for test 1 Sensory Input from the Supply System Sensory Input from the Supply System Jntemreptoriv Prov1des information needed to maintain function of the supply system 1 Pressure Receptors Pacinian Corpuscles 2 Pain Receptors Free Nerve Endings sensed below a conscious level Pain generally inhibim action of the individual classification ofPrimary Affermt Neurons fiber function diameter velocity Abeta cutaneoustouch 8 microns 100 msec pressure Trigeminal entry zone A delta nociception lt3 microns 15 msec mechanoreceptors Lhamoreceptors l d l t 1 1 cpo ymo a nocl ep ion L micron m sec Subnuclm mks 66 momsquot 0 Subnueleus mta pulans morecepto s Subnucleus caudalis chemorecepiors The Evolution of Pain Theories Types of Second Order Neurons The Adsmtehan Timmy I The Speci city Sensory Theory Low Threshold Mechanoreceptive 39 The InthiVe Summation Theory Neurons LTM I The Pattern Theory I The Pain PerceptionReaction Theory Nociceptive Speci c Neurons NS The Gate Control Theory I The Concept of Pain Modulation I The Biopsychosocial Model of Pain I The Neurornatrix Theory Wide Dynamic Range Neurons W DR cm 846 ohm mus fax m m mmmm mm x m mummmmmm mum mm mummmm hymw mw mm mmsmmm Pmmwlmhdusmmsmme mmmm human Sm m lanumvf39hmm w mmau mym CDS 846 Okeson notes for test 1 Heterotopic Pain Treatment Considerations Pains in which the site and source are not in the same location In order for treatment to be effective it must be directed towards the Source of pain not the Site of pain Types of Heterotopic Pains Central Pain Pain emanating from structures of the central nervous system is felt peripherally Types of Heterotopic Pains Projected Pain Pain felt in the peripheral distribution of the same nerve that mediates the pain Types of Heterotopic Pains Referred Pain Pain felt in a different nerve from the one that mediates the pain Referred Pain Constant deep pain input can alter the central processing of nociception Referred pain arises from central excitatory e ects central sensitization CDS 846 Okeson notes for test 1 Now the patient feels pain in the shoulder and also in the TMJ Referred Pain Possible Central Excitatory Effecm l Sensory afferent Effects a Referred Pain b Secondary Hyperalgesia 2 Motor efferent Effects a Protective CoContraction b Trigger Points 3 Autonomic Effects The Clinical Characteristics of Referred Pain l Referred pain most commonly occurs in other divisions of the same nerve that mediates the pain a vertical laminated pattern b does not cross the midline in the trigeminal 2 If another nerve is affected it is usually cephalad to the nerve that mediates the pain How can you differentiate primary pain from referred pain remember Referred pain is wholly spontaneous and dependent upon the original source of pain Diagnostic Rules for Identifying Referred Pain 1 Local provocation of the site of pain does not increase the pain 2 Local provocation of the source of ain increases the pain not only at the source but so the site 3 Local anesthesia at the site of pain does not decrease the pain 4 Local anesthesia at the source ofpain decreases the pain not only at the source but also at the site Etiologic Considerations of TMD Occlusion Orthopedic Instability Trauma Emotional Stress Deep Pain Input Muscle Hyperactivity CDS 846 Okeson notes for test 1 How does occlusion relate to TMD The optimum orthopedically stable relationship 1 Orthopedic stability instability 2 An acute change in the occlusal position Condylar Stability The condyles are in their most superior anterior position in the fossae resting against the posterior slop es ofthe articular eminentiae musculoskeletally stable The discs are properly interposed between the condyles and the fossae Occlusal Stability Even and simultaneous contact of all teeth with posterior teeth contacting slightly heavier than anterior teeth Adequate toothguided contacts on the laterotrusive side In the alert feeding position posterior teeth contact heavier than anterior teeth Orthopedic Stability Joint Stability Occlusal Stability Orthopedic instability plus loading leads to intracapsular disorders Joint instability Occlusal stability another important concept A stable malocclusion A dental malocclusion that is orthopedically stable CDS 846 Okeson notes for test 1 A stable dental malocclusion Types of Muscle Activity Some muscle activity is used for carrying out functional tasks FunctionalActiviry ex chewing swallowing and speaking Some muscle activity has no obvious functional benefit mfunctionalActivity ex clenching bruxisrn and other oral habits Functional Muscle Activity Controlled by CNS Engrams central pattern generator and Sensory Input Sudden or unusual peripheral sensory input inhibiw functional muscle activity the nociceptive re ex Parafunctional Muscle Activity Parafunctional activity commonly occurs at subconscious times Williamson EH and Lundquist DO Anterior guidance Its effect on electromyographic activity of the temporal and masseter muscles J of Pmsthet Dent 49 816 1983 Rugh JD Barghi N and Drago C Experimental occlusal discrepancies and nocturnal bruxism JomesthetDent 51548 1984 CDS 846 Okeson notes for test 1 Remember These studies examine two different types of muscle activity 1 Conscious voluntary muscle activity 7 Williamson amp Lundquut 1983 r 2 Subconscious involuntaly muscle activity 7 Rugh Barghl amp Draga 1984 r Conclusions I How do occlusal interferences affect muscle activity cle type of occlusal interference m s acu functional or para inctional acute or chronic Peripheral CNS In uenced In uenced Activity Activity 39 Functional Activity 39 Parafunctional Activl chzwmg swallowing bmxmg clenching omz speaking habits Peripheral sensory input CNS input inhibits activity increases activity Parafunctional Activity Functional Activity w u protective cocontraction muscle splinting altered muscle engrams or amasticatory muscle disorder decreases activity little to no effect How do occlusal interferences affect TM Disorders Summary l Occlusal interferences and muscle pain disorders An acute change in the occlusal condition leadsto altered muscle e adaptaunn naams amastieatnry muscle disnrder How do occlusal interferences affect TM Disorders Summary l Occlusal interferences and muscle pain disorders 2 Occlusal interferences and intracapsular disorst Orthopedic irstnbilny Orthopedic instability plus loading leads to intracapsular disorders CDS 846 Okeson notes for test 1 In summary comider this thought Problems with bring the teeth into occlusion are answered in the muscles once the teeth have occluded problems with loading are answered in the joints Anatomy and Biomechanics of the Temporomandibular Joint Function and Dysfunction 39 he superi rlateral pt oid retrodiscal tissues the inferior lateral yg oi d Some general orthopedic principles 1 Every synovial joint is held together by the muscles that pull across the joint 2 The articular surfaces of the joints are always in constant contact 3 The amount of interarticular pressure is determined by the muscle that pull across the joint How is the TMJ loaded Inter N o artic the directional forces ofloading Characteristics of Ligaments l Collagenous structures that attach bone to one 2 The purposes of ligaments are to limit oint movement lquot Ligaments have specific lengths Je Ligaments do not stretch V Ligaments do not actively participate in normal function CDS 846 Okeson notes for test 1 Ligaments of the TMJ ral The condyledisc assemble 4170th 39 int collateral ligament gjo Joint Lubrication The function of the superior lateral pterygoid muscle 1 Synovial uid provides a transport system for nutrient and wastes for the articular surfaces 2 Synovial uid lubricates the joint surfaces a boundary lubrication b weeping lubrication Biting hard unilaterally reduces interarticular pressure in the ipsilateral joint The function of the superior lateral pterygoid muscle The function of the superior lateral pterygoid muscle Activity ofthe superior lateral pterygoid pulls the conder forward When interarticular force is again returned to the joint the disc and c dyle return back to the musculoskeletal position bracing it against the posterior slope ofthe articular eminence CDS 846 Okeson notes for test 1 Types of Temporomandibular Joint Disorders Summary 1 Ligaments do not actively participate in normal joint function 2 Ligaments do not stretch 3 The articular surfaces of the TM are always maintained in constant contact l Derangemenw of the CondyleDisc Complex a disc displacement b disc dislocation With reduction 0 disc dislocation Without reduction 2 Structural incompatibilities a adhesions b deviation in form c subluxation d spontaneous dislocation Click Disc displacement with reduction Disc dislocation With reduction Clinical signs of acute dislocation Without reduction 1 Apositive history 2 Limited mouth opening 2530 mm 3 Normal lateral movement to the ipsilateral side 4 Restricted lateral movement to the contralateral side 5 A sudden elimination ofthe click CDS 846 Okeson notes for test 1 1 What is the etiology of disc derangement disorders 1 Macrotrauma a Gross trauma b Iatrogenic trauma ACCidenE Iatrogenic Trauma Motor Vehicle Accidenm Sporting ACCide m Intubation Procedures Unexpeaed Blows Third Molar Extractions d 1 Long Dental Procedures a ne mo rauma Fe Cervical Traction v5 closed mouth trauma 1 What is the etiology of disc derangement disorders 2 Microtrauma a Chronic muscle hyperactivity b Orthopedic instability Orthopedic Instability plus Loading bruxism clenchin parafunctional habits 2 Are disc derangement disorders always progressive Adaptation destruction of cells repair of cells destruction repair of of cells cells
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