how to practice at today’s standard of care in: orofacial ... · in: how to practice at today’s...

in: How to Practice at Today’s Standard of Care

OROFACIAL PAIN: Standard of Care

Charles McNeill, DDS, FACD, FICD Professor Emeritus & DirectorPatricia A. Rudd, PT, DPT CCTT

Associate Clinical ProfessorUCSF Center for Orofacial Pain

4. Inflammatory Disorders & DJD

Monday, August 31, 15

v TM Joint Painv Masticatory Muscle Pain

ACUTE TMD DIAGNOSES

Acute TMD Mgt (Localized Musculo-skeletal Disorders)


AAOP TMD Dx Classification:Localized Disorders


ARTICULAR • Devel./ Acquired Disord.• Disc Disorders • Inflammatory Disorders• Degenerative Disorders• TMJ Dislocation• Ankylosis





AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013


Inflammatory & Degenerative Disorders





๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides




๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides

๏ Degenerative Joint Disease• Osteoarthrosis• Osteoarthritis


INFLAMMATORY DISORDERS:Synovitis / Capsulitis


vDESCRIPTION: Inflam. of the Synovial Lining &/or Capsule 2º to Infection, Trauma, or Cartilage Degeneration



vDESCRIPTION: Inflam. of the Synovial Lining &/or Capsule 2º to Infection, Trauma, or Cartilage Degeneration


vCLINICAL PRESENTATION:v Localized Jt. Pain Provoked by Palp., Loading, Distraction or Fx.

v Fluctuating Swelling w ↓ Post. Occl. v Probable Marked ↓ Mobilityv Radiographic Changes: Possible Increase in Joint Space

v Positive T2 MRI Signal


Goal Oriented Plan: Synovitis/Capsulitis



�PAIN CONTROL:• Patient Education• Self-Management (Rest, Ice)• Meds (NSAIDs, Analg., Steroids, Jt. Inj.) • Physical Therapy (Cold, ES, US, Cold • Laser & Gentle Joint Mobilization)



�PAIN CONTROL:• Patient Education• Self-Management (Rest, Ice)• Meds (NSAIDs, Analg., Steroids, Jt. Inj.) • Physical Therapy (Cold, ES, US, Cold • Laser & Gentle Joint Mobilization)

� INCREASE MOBILITY:• Physical Therapy (Gentle Joint

Mobilization & ROM Exercises)


§ Sulindac (Clinoril) 150-200mg. bid§ Naproxen (Naprosyn) 500mg. bid§ Nabumetone (Relafen) 500-750mg. bid§ Meloxicam (Mobic) 7.5-15mg d § Celecoxib (Celebrex) 100-200mg. bid§ Diclofenac (Voltaren) 1.3% Flector Patch bid § Voltaren Gel 1% 2 Grams qid§ Topical Compounds 2 drops tid, qid§ Methyprednisolone (Medrol Dosepak) 24-32mg d/1wk

followed by 1wk 4mg 6 day Tapering Dose

*Misoprostol (Cytotec) 200 µg qid *Omeprazole (Prilosec) 20mg bid

ANTI-INFLAMMATORY MEDS


INTRA-ARTICULAR INJECTION ARTHROCENTESIS


PHYSICAL THERAPY

§ Patient Education§ Therapeutic Exercises§ Joint Mobilization /

Manipulation§ Soft-tissue Mobilization§ Modalities

§ Heat & Ice § Spray & Stretch§ Elect Stim. / Iontophoresis§ Ultrasound / Phonophoresis


INFLAMMATORY DISORDERS:Polyarthritides

v DESCRIPTION: Bilateral Joint Inflam. & Struct. Changes 2º to Gen. Systemic Polyarthritic Condition

v CLINICAL PRESENTATION:vJt Pain Provoked by Palp., Loading, &/or FxvCrepitus & ↓ ROM 2º to PainvMult. Jt. Involvmentv+ Serology Test


¤PAIN CONTROL:• Self-Mgt (Rest, Ice, Pt. Ed., Behavior Mod.)• Meds (NSAIDs, Analg., Steroids;• Collaborate w Rheumatologist & PCP • Physical Therapy (Cold, ES, US, Jt. Mob.)

¤ INCREASE MOBILITY:• P.T. (Gentle Jt. Mob. & ROM Exercises)

Goal Oriented Plan:Polyarthritides


DEGENERATIVE JOINT DISEASE (DJD)

deBont LGM et al: OOO 1997;83:51-60


❖ OSTEOARTHROSIS: A Non-painful, Non-inflammatory Degenerative Condition Characterized by of Articular Tissues Due to Overload of the Remodeling System




❖ OSTEOARTHROSIS: A Non-painful, Non-inflammatory Degenerative Condition Characterized by of Articular Tissues Due to Overload of the Remodeling System



v OSTEOARTHRITIS: A Painful Inflammatory Degenerative Condition Characterized by

Progressive Deterioration & Abrasion of the Articular Surfaces


DEGENERATIVE JOINT DISEASE:



v ACTIVE: Characterized by Active Deterioration & Abrasion of the Articular Tissues (Cortical Outline) Due to Overload of the Remodeling System




v ACTIVE: Characterized by Active Deterioration & Abrasion of the Articular Tissues (Cortical Outline) Due to Overload of the Remodeling System



v STABLE: Characterized by a Stable or Unchanging Relationship of the Articular Surfaces of Formerly Active Arthrosis/Arthritis


ACTIVE OSTEOARTHROSIS(Non-inflammatory)

deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60

CLINICAL PRESENTATION:vNo Joint Pain/InflammationvJoint Crepitus vLtd ROM w/ DeflectionvPossible Change in Post. Occl.vRadiographic Bony Changes

v Loss of Cortical Integrityv Possible Osteophytic Formationv Subchondral Bone Cystsv Narrowed Superior Jt. Space


GOAL ORIENTED PLAN: Ac/ve Osteoarthrosis

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¤ JOINT PROJECTION• Self-Management (Pt. Ed.)• Meds (Flexeril ?)



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¤ JOINT PROJECTION• Self-Management (Pt. Ed.)• Meds (Flexeril ?)

¤ INCREASE MOBILITY:• Physical Therapy (Gentle Jt.

Mobilization & ROM Ex.)


ACTIVE OSTEOARTHRITIS(Inflammatory)


CLINICAL PRESENTATION:vJoint Pain at Rest & w FunctionvJoint Crepitus vLtd ROM w/ Deflec. 2º PainvPossible Change in Post. Occl.vRadiographic Bony Changes

v Loss of Cortical Integrityv Possible Osteophytic Formationv Subchondral Bone Cystsv Narrowed Superior Jt. Space


ACTIVE EROSIONSv Un-corticated Erosionv“Cupping Defects”


GOAL ORIENTED PLAN: Ac/ve Osteoarthri/s

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¤ PAIN CONTROL:• Self-Management (Rest, Ice, Pt. Ed.)• Joint Protection Education• Meds (NSAIDs, Acetaminophen, Analgesics, Steroids

[Methylpredisone DosePak]) • Physical Therapy (Cold, ES, US, Jt. Mob.)

¤ INCREASE MOBILITY:• Physical Therapy (Gentle Jt.

Mobilization & ROM Ex.)


deLeeuw R, Boering G et al: J Orofacial Pain 1994deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60

v DDw/oR to Osteoarthritis - nearly 100%v Osteorthrosis/Osteoarthritis

vFollows a Natural CoursevReduction of Symptoms - 3+ Mos.vStable Bony Changes - 2- 4+ Yrs.

PROGRESSION of DJD


STABLE OSTEOARTHROSIS


CLINICAL PRESENTATION:vNo Joint Pain/InflammationvJoint Crepitus vLimited ROM w/ Deflec.vPossible Change in Post. Occl.vRadiographic Bony Changes

v Cortical Integrity Re-establishedv No Subchondral Bone Cystsv Narrowed Superior Jt. Spacev Possible Osteophytic Formation


GOAL ORIENTED PLAN: Stable Osteoarthrosis

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Therabite Therapy

“Reassure Patient of Favorable Prognosis”



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¤JOINT PROJECTION• Self-Management • Understand Risk Factors

Therabite Therapy




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¤JOINT PROJECTION• Self-Management • Understand Risk Factors

Therabite Therapy


¤INCREASE MOBILITY:• Physical Therapy (Jt. Mobilization)• Home Exercise Program


STABLE OSTEOARTHRITIS


CLINICAL PRESENTATION:vPain/Chronic InflammationvJoint Crepitus vMinimum ROM w/ Deflec.vPossible Change in Post. Occl.vRadiographic Bony Changes

v Cortical Integrity Re-establishedv Possible Osteophytic Formationv No Subchondral Bone Cystsv Narrowed Superior Jt. Space


GOAL ORIENTED PLAN: Stable Osteoarthri/s

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¤INFLAMM. MANAGEMENT PRN¤JOINT PROJECTION

• Self-Management • Unerstand Risk Factors

¤ INCREASE MOBILITY:• Physical Therapy (Jt. Mobilization)• Home Exercise Program



IDIOPATHIC CONDYLAR RESORPTION:a.k.a., Juvenile Idiopathic Arthritis

Wolford LM Proceedings Baylor Univ 2001;14:246-252



A Spontaneous Lytic Event Causing the Condyle to Become Rapidly & Progressively Smaller & in Some Cases Completely Disappear .Patients Commonly Become Severly Retrognathic (Receding Chin)




A Spontaneous Lytic Event Causing the Condyle to Become Rapidly & Progressively Smaller & in Some Cases Completely Disappear .Patients Commonly Become Severly Retrognathic (Receding Chin)


๏ 9X More likely Female Than Male

๏ Hormonal Mediation May Be Involved๏ More Common Among Teenagers๏ “Cheerleaders Syndrome”


Condylysis Etiology: Hormonal TMJ ReceptorsGENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS



SOFT TISSUES:❖ Relaxin & beta-‐estradiol Induces Matrix

Metalloproteinase (MMP) expression ❖ Loss of Collagen & Gylcosaminoglycans

(GAGs)





(GAGs)BONE:❖ Decreased beta-‐estradiol❖ Increased Osteoclast Activation❖ Increased Remodeling Rate❖ Increased Trabecular spaces



§ Females are vulnerable during child bearing years






§ Females are vulnerable during child bearing years

§ Rarely develops after 20 years of age






CLINICAL PRESENTATION:v Typically Severe Bilateral Joint Pain at Rest / Functionv Joint Crepitusv Significant Change in Occlusion

with Open Anterior Bitev Radiographic Bony Changes

v Loss of Condylar Size/Cortical Integrityv Possible Osteophytic Formationv Subchondral Bone Cysts



GOAL ORIENTED PLAN: Idiopathic Condylar Resorp/on

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¤ PAIN CONTROL:• Self-Management (Rest, Ice, Pt. Ed.)• Joint Protection Education• Meds (NSAIDs, Analgesics, Steroids) • Physical Therapy (Cold, ES, US, Jt. Mob.)



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๏ INCREASE MOBILITY:• Physical Therapy (Gentle Jt. Mobilization & ROM Ex.)



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๏ INCREASE MOBILITY:• Physical Therapy (Gentle Jt. Mobilization & ROM Ex.)

¤ LONG-TERM MANAGEMENT:• Orthodontics, Orthognathic Surgery, • Joint Replacement Surgery


DEGENERATIVE JOINT DISEASE

DJD

OSTEOARTHROSISNo Pain/Inflammationv Joint Crepitus v Possible Ltd ROM w/

Deflectionv Possible Change in Post.

Occl.

OSTEOARTHRITIS Pain at Rest & w Function

v Joint Crepitus v Ltd ROM w/ Deflectionv Possible Change in Post.

Occl.

ACTIVEBony Changes

v Loss of Cortical Integrityv Subchondral Bone Cystsv Possible Osteophytic Formationv Possible Narrowed Sup. Jt.

Space

STABLE

v Cortical Integrity Re-establishedv No Subchondral Bone Cystsv Probable Osteophytic Formationv Narrowed Superior Jt. Space

Bony Changes


Behavior Modification

Symptomatic Care

Patient Education

Pharmacotherapy

Physical Rehabilitation(Orthoses/Splints)

Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013


MANAGEMENT PHILOSOPHY

Diagnostically Driven Problem-Based Goal Oriented


Symptomatic Care

Patient Education

Pharmacotherapy




MANAGEMENT GOALS Relieve Pain

Promote Healing Restore Functional ROM

Optimize Masticatory Function Return to Previous Level of ADL

MANAGEMENT PHILOSOPHY

Diagnostically Driven Problem-Based Goal Oriented


Symptomatic Care

Patient Education

Pharmacotherapy




MANAGEMENT GOALS Relieve Pain

Promote Healing Restore Functional ROM

Optimize Masticatory Function Return to Previous Level of ADL


Symptomatic Care

Patient Education

Pharmacotherapy





Symptomatic Care

Patient Education

Pharmacotherapy




NO SURGERY or TREATMENT

of the OCCLUSION


Symptomatic Care

Patient Education

Pharmacotherapy




“The art of medicine is in amusing the patient

while nature cures the disease”VOLTAIRE


how to practice at today’s standard of care in: orofacial ... · in: how to practice at today’s...

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