Identification of TMD & Chronic Orofacial Pain

Temporomandibular joint disorders and orofacial pain

1. Identification of TMD & Chronic Orofacial Pain Mariam T. Siddiqui BDS, MS (CR), MS (OFP)

2. Placebo & Nocebo Responses

3. Gray Matter changes in chronic pain Decreased gray matter volume in specific brain regions (i.e. areas associated with pain processing) Loss of frontal cortex regions of the brain with longer lasting FMS 

4. Postural Muscles + MFP

5. Postural Muscles Postural muscles – mostly type 1/ slow twitch – don’t fatigue but painful easily Research - Women have 15% more type 1 fiber in their muscle than do men by cross section area

6. Possible Triggers Parafunction:  Tooth clenching, trauma and female gender strongly contributes to the presence of chronic MMP Direct muscular trauma: Whiplash Medication induced myalgia:  psychological stimulant, selective reuptake inhibitor (SSRI)  Stress-related muscle hypoperfusion- Job or personal stress 

7. Chronic MMP: Risk Factors Trauma/ accident/ MVA Female gender Postmenopausal women Autoimmune diseases Metabolic Disorders (DM, Hypertension, Thyroid) Sleep & Psych disorders Whiplash/ direct muscle trauma Medication induced myalgia:  psychological stimulant, selective reuptake inhibitor (SSRI) 

8. Central Sensitization Hyperalgesia & Allodynia Elevated levels of substance P in their CSF Increased excitability of spinal cord neurons Enlargement of their receptive fields, reduction in pain threshold Recruitment of novel afferent inputs Wind-up - summation of 2 nd pain or windup (WU) - blocked by NMDA blockers ketamine & dextromethorphan

9. TMJ Disorders

10. TMJ Arthralgia: + painful joint; - osseous changes; - joint sounds  (a.k.a.: capsulitis; synovitis and joint effusion) 

11. TMJ OA

12. Disc displacement no reduction (DDNR) Closed Lock

13. Open Locking of the TMJ (aka subluxation) 

14. Trismus of Jaw Closers when open! 

15. Stretch, stretch, stretch Hinge axis exercise for 6 seconds, 6 repetitions, 6 sets daily Rx for TMJ Pain

16. N position: N-stretch Tongue tip across roof of mouth Stretch jaw open in straight line without dropping tongue (2 inches), hold 5 secs 5 times/ day every 2 hours How to do Myofascial Stretching?

17. How to do Myofascial Stretching? Some patients need small force to help with N stretch exercises Put the index finger rested on inferior teeth and thumb against the superior teeth, pushing the jaw slightly apart.

18. How to do Myofascial Stretching? Jaw Hinge – open close jaw hinge 10-15 times with minimum opening (<15mm, 5x5x5) Head flexion- chin to the chest, 5x5x5

19. How to do Myofascial Stretching? Head ¾ flexion (chin to the armpit): Slowly rotate your head 45 degrees (halfway) to one side. Placing head your hand on top of head with elbow in front of your face. 5x5x5 on both sides

20. How to do Myofascial Stretching? Shoulder Stretching: Patient to lean a neutral Stretching position & improving circulation Raise hands – conducting a choir. Move arms backward & forward without causing pain 5times/ day 20-30 sec

21. How to do Myofascial Stretching? Aerobic Exercises therapy - endorsed by most medical societies Low adherence in Fibromyalgia- (Exception) Gut Health: Good versus bad bacteria Methods to Increase Endorphins: Runners high - feeling of pure elation, reduced stress, & a decreased ability to feel pain due to flood of endorphins released by exercise Opioids – Artificial Endorphins

22. Rx- TMJ Pain secondary to Inflammation

23. Step 1 Avoidance Protocol Step 2 For severe pain- meds to reduce neuronal activity Step 3 If patient has strong parafunction, consider orthotic device Step 4 For taut bands, teach stretch therapy For resistant TrPs , consider Botox to inactivate the taut bonds Thermal and Stretch Therapy (including vapocoolant spray) Heat /Ice packs dilation of blood vessels in the tissues- Removal of metabolic waste product Deep breathing versus shallow Breathing – Wim Hoff Breathing What is MYOFASCIAL PROTOCOL for treating chronic muscle pain?

24. Thermal therapy Indications : Taut bands in a muscle should be present. Chronically tender muscles is an indicator for thermal therapy Contraindications: All thermal therapy is more dangerous (i.e. could result in skin burns) if the area has substantial loss of sensation. Major thermal therapy (Sauna, hot tub, spa, hot bath) can: Elevate BP to dangerous levels , especially in patients with high BP Cause orthostatic hypotension so advise patient not to stand rapidly. Stretching ALWAYS advised after thermal therapy

25. Medications for Chronic Musculoskeletal Pain NSAID Agents (acute, 2 weeks) Nabumetanone (500 mg BID, 2 weeks) Rubefacient Combined with Salicylates TCAs (low doses for pain) SSRIs, SNRIs Tramadol Anticonvulsants (Gabapentinoids) for chronic neuropathic pain NMDA blockers (Ketamine)

26. Coronoid Elongation

27. Post Disk Displacement

28. Episodic Lateral Pterygoid Dystonia

29. Sternocleidomastoid

30. Trapezius Muscle

31. Cervical Range of Motion  Flexion Extension

32. R/L Rotation

33. Side bending

34. Office Based Myofascial Physical Medicine Procedures: Vapocoolant Assisted Myofascial Stretching: Identify patients with taut bands

35. Trigger Points in muscles

36. Myofascial Trigger points

37. TrP injection

38. Parafunction: Tooth clenching

39. Bruxism

40. Hdache Hx: “, R/O sec headache using “SNOOPPPP” vs “Prim” Any relevant findings?” i . Ask SNOOP4 to rule out secondary HA 1. Systemic s ymptoms & signs 2. Neurologic symptoms & signs 3. Onset : peak at onset or <1 minute 4. Older : after age 50 years 5. Previous h eadache: pattern change 6. Postural, positional aggravation 7. Precipitated by Valsalva, exertion, etc. 8. Papilledema (Systemic, Neurologic, Onset sudden, Older >50, Positional, Progressive, Precipitated with exertion, Papilledema) ii. Rapid assessment protocol Migraine “Any migrainous features” Nausea, vomiting, light or sound sensitivity or Avoidance/aggravation with activity & or seek a dark room to rest?” 1. Nausea or vomiting 2. Light & sound sensitivity 3. Avoids or aggravated by activity iii. Autonomic signs “Do U have any drooping eyelid (ptosis), tearing of eye/ nose, stuffy nose, reddening of face, etc. associated with ur hdache ?” iv. Auras “Do U experience any visual( m.common ), auditory, olfactory , or other sensations preceding or during your headache?” v. Using frequency, duration & the ICHD3 beta criteria determine headache Dx 1. Hdache Frequency: Less than 12/year = Infrequent Less than 15/month = Episodic 15 or more/month = Chronic 2. DURATION : “ Quarter to 3, 2:30, 1:10, > 3 months for TACs ”: 15 min to 3 hrs Cluster 2 min to 30 min Paroxysmal Hemicrania 1 sec to 10 min SUNCT/ Suna > 30 days Hemicrania Continua *4-72 hours Migraine; *>72 hours = Status migrainous

41. Migraine

42. Migraine Hygiene Very regimental/ boring lifestyle- sleep or wake at regular time Adequate hydration Avoid Triggers (excessive/ lack of sleep) Mg & Zn supplements Go to bed at same time every night

43. Most Important supplements for Migraine

44. Effective Migraine Management Patient education (Explain benign nature) Nonpharmacological management (Behavior interventions, Active therapies; biofeedback training, cognitive-behavioral therapy, psychotherapy, sleep hygiene) Pharmacological; Acute (Triptans) versus B & Ca channel blockers, Botox FDA Approved Pharmacological (medical) management

45. Migraine Management Step Care (start with simple analgesics & gradually escalate to Triptans) Stratified Care systematic approach as per severity + disability

46. Tension Type Headache

47. Trigeminal Autonomic Cephalalgias

48. Medication Overuse Headache

49. Pharmacologic approach: How different from General Dentistry? Caution; Do Not Use for too long

50. Tinnitus, Dizziness BPPV, Tensor Tympani syndrome

51. Tinnitus, Dizziness, BPPV

52. PDAPP (Persistent dentoalveolar pain) Tooth or gum was hurting Scaling, Cleaning- No improvement Possibility of caries – Filling did not help with pain RCT performed- pain did not go away Tooth extracted- Pain still present PDAPP/ Phantom Tooth pain

53. Figure showing a premolar implant placed too close to the inferior alveolar nerve 

54. Nerve Pain/ Neuropathy Acute Polyneuropathy ; critical illness, Inflammation of blood vessels, Tick paralysis) Chronic Polyneuropathy; Diabetes, Hypothyroid, Celiac Disease, chronic alcoholism, Immune mediated neuropathies, Chronic Vitamin B deficiency BUT avoid toxicity too!!

55. Most Important supplement for Nerve Issues!

56. Post-Operative Analgesia and NPP Preventive agents Migraine: Magnesium

57. Post-Herpetic Neuropathy  another prolonged viral induced nerve injury 

58. Burning Mouth Syndrome

59. Most commonly affected area in Burning Mouth syndrome

60. Sleep Apnea: STOP BANG STOP-BANG (3<) ESS (>10) Bed Partner questionnaires employed, Any relevant findings?” S nores , T ired, O bserved gasping, P ressure (BP), B MI>35, A ge>50 N eck>16”/ 40cm G ender Any weight gain?

61. MAD vs CPAP?

62. Trigeminal nerve inflammation secondary to compression & abrasion (dentures) 

63. Assessing Nerves Deficit!

64. TN (focus on integrated setup) V2>V3>V1

65. Trigeminal Neuralgia: Extra & Intra oral triggers

66. Vagal Neuralgia

67. Psychological Disorders Comorbid with OFP: Thought disorders ( Schizoaffective Disorder) Mood Disorders Anxiety Disorders (GAD, Subs induced Anxiety Disorder, OCD, PTSD) Somatic Symptom Disorders (Illness anxiety disorder, Body dysmorphic disorder, Factitious disorder, Malingering) Substance Use Disorders (Alcohol, Caffeine, Cannabis/ marijuana, Hallucinogens e.g LSD, PCP, Psilocybin, Ketamine, MDMA), Inhalants, Opioids, Stimulants e.g., Amphetamines, Methamphetamines, Cocaine Pain lasting > 4-6 months; chronic Brain changes with chronic pain CBT, Biofeedback

68. Mood Disorders comorbid with chronic pain

69. Viral Illnesses: Acute herpes simplex Acute herpes Zoster

70. MRI Dx of Herpes Simplex Virus

71. Ramsay Hunt syndrome seen when Facial Nerve is involved.

72. Central Sensitization  Hyperalgesia & Allodynia Elevated levels of substance P in their CSF Increased excitability of spinal cord neurons Enlargement of their receptive fields , reduction in pain threshold Recruitment of novel afferent inputs Wind-up - summation of 2 nd pain or windup (WU) - blocked by NMDA blockers ketamine & dextromethorphan

73. occipital nerve block as a therapy for chronic neck pain  injected near the occipital nerve on the back of the head near the base of the skull

74. Botox

75. Botox Rx for Masseter Hypertrophy

76. Botox Rx for Masseter Hypertrophy

77. Sjogren’s Syndrome

78. Rheumatoid Arthritis 

79. Nerve Pain/ Neuropathy Acute Polyneuropathy ; critical illness, Inflammation of blood vessels, Tick paralysis Chronic Polyneuropathy; Diabetes, Hypothyroid, Celiac Disease, chronic alcoholism, Immune mediated neuropathies, Chronic Vitamin B deficiency BUT avoid toxicity too!!

80. Availability & Offering; More healing – time spent at least hour and a half Focus not only on the Rx but also on multimodal approach for relieving pain Pts seen within 2-5 business days as compared to other practices (average wait time at least 2-3 months)

81. Chronic pain; > 3 months What all we Rx 1 st appointment: we review all history of the patients 2 nd appointment: self care Complicated Longstanding: teamwork, We work in coalition with: PT Sleep Docs PCP Neurologist Psychologist (health psychologist); emphasizing on lifestyle modifications OFP; 13 th CODA accredited specialty All billings Medical

82. Additive; Double sedation or double xerostomia Always inform If you are taking herbs, nutraceutical or supplements 90% of drugs metabolized in liver – Take care of your liver Drug Drug Interactions (DDIs)

83. Screening Chronic Pain: Onion Peel Approach Sleep Apnea screening TMD Headaches Pharmacological management Health Psychology MFP TrPs R/O: Dental, Neuralgic, neuropathic pain Siddiqui et al

84. Conclusion

85. Interesting biography & autobiographies reads!