( 1)
An scrotal tradition which influenced dentists approaches to may be attributed to the following principles :
Absolute uniqueness of TMT-1
Role ad jaw position and clausal relations play in etiological theories. -2
Advent of technological methods for diagnosis and TX -3
The reciprocal linkage ad pain and dysfunction-4
The resolution at the problems complexity by adhering to unifying problem -5
Variation on a theme of stress and disease - 6
TMJ sign and symptoms most of on improve with time. With or without TX - 7
Uniqueness of the TMJ: -
* the dental education approach to stupefying the musculoskeletal
System emphasize maxilla – mandible aspect exclusively and because ad the anatomical and function al characteristics which are not found on other joint led to interpreted the TMJ as unique joint
* Recently argument suggested commonalities between TMJ and other body Joint
De Bont ctal and stegenga ctal " orgued that osteo arthartic thy aline cartilage fibro cartilage demonstrated similarities at altra structure level and proposed that osteo earthrises (ad)
Dollops in the same manner in both cartilaginous types
* I plenty ad remedies over the counter meds heat massage appear to be successful and suggest not regarding TMJ as absolutely unique in muscbskeletal disorders
* placebo aspect which prevails in the management of this disorder must by recognized
2))
2 ) jaw position and occlusal relation :-
* strong beliefs as mechanical displacement ad condoyle form its central position in the fosse resulting from loss ad vertical dimension of occlusion or occlusal inter fervencies are regarded as faith
* the profession appears reluctant to interpect the role ad occlusal and TMD rather thain inrariably casising TMD por se
* skills and clinieal tudyement to determiner when and is the irreversible acclusal adjustment can be preformed
(3)
3 ) the technology era of diagnosis and treatment
Several technologies in recognizing and management of TMJ ) appear attractive and sophisticated but authors concluded that these technologies are not required since they have failed to meet proper standards as valid diagnostic or tx tools
4 ) reciprocal linkage ad pain and dysfunction ::
Pain causes dysfunction and riceversa one rcinforces the other but not frequent parhagen esis
Lund etal reviewed evidence linking pain and dys function and conclude that mechanism ad pain onset is inadequately explained and under
The concept of vicious pain cycle may remain as basis ad explaining the condition s progress
4 ))
Sym to mates treatment: -
- control ad pain and discomfort
- reassurance , biofeedback , general rclefion , lifestyle , sympathy , simple explanation ad the problem
- medication
- physical therapy
Reasscirance:
Combination ad reassurance with an analgesic medication for pain relay and Jaw exercise , and other physical therapy should be regarded as initial TX program
- evaluation after 2-3 weeks ----- if no reduction in the symptoms has accused further
But other TX should be considered
- reassurance is an important parlay behavioral therapy and considered as a part ad current guideline say or managing TMD
- this TX out come are similar to occlusal of Pharmacologic therapies
Medication : -
Pain relief ----- major part ad TX ad TMD
Pt with painful muscular and tav doint disorder should be provided with n sad
- musle tent ion ---- anti anxiety meds
- choice depend on the expense
- TCA ----- for man gent ad chronic or facial pain
- intra auricular icortico steroids injection in pt with TMJ disease
Physical therapy :-
Musch exercise . heat , cold application -
-electrical stimulation , ultrasard although there specific affect are not known
5 ))
Attraction to untying concept : -
- unifying concept attmpts to reconcile the dirorse piece ad TMD
- attempts are made to unify complex and diverse consideration as suggested by stegenga " they propose OA as the cause of cranio mandibular pain and dysfunction * they pointed out that OA ad TMJ is under fater as structural basis ad TMD
* crested that early fibro – cartilaginous degeneration can not be deteoted on x ray tech
* OA is unlikely to be a sequel ad long – standing occlusal chi harmony
* they emphasize the complex relation ship between OA and disckal displacement which in an important sign
- risk ad over simplification may develop
( 6 )
6 ) TMD as a variant ad stress dis ease
- many health professional have been convinced that the cause ad the muscle roluted disorder is stress
- stress term is loosely defined
- evidence suggests that stress does not appear to directly cause pain _____may aggravate the pain . or modify pt .s tolerance
- limitation ad study is how to relate stress ----- to pain
( 7 )
7 ) the limitation regression to the mean " outcome
- most pt. s signs & symptorns improves with tiern with out TX
- this factor has dramatically influenced TX approaches
Management strategy -:
Page ( 534 )
- soft life , avoid parajuncfion habits
- rest via roluntry immobilization ad the mandible
___. Excellent for self management
--- refuel to professional physical therapy for with more muscle and joint problem
- tissue rest – soft olief --- avoid excessive mandibulor more met
- inter arch wiring in extreme cases ---- forced rest
--- another aspect is to make the pt a wave ad the relation ship between stress and muscle ten lin
Exercise therapy :-
Purpose :
1 ) relax tense muscle
2) retrain rhythmic muscle function
3 ) mand range ad movement
4 ) muscle strength
- isometric : strengthing the muscle
- isotonil muscle : stretching tontion is constant
1 ) relax lens muscle :-
Simple tech --- instruct the pt to perform small smooth moven
--- reciprocal inhabitation : -
Opening the mouth against resistance tonds to rcl contracted elevators muscle
2 ) retrain the muscle function
Perform mandibular relearning exercise practice opening and clasing along straight line
3 ) range ad mand mor by stretching exercises mand . should be moveel to maximal openwy , latral , protrusive without eliciting pain
Repeat to times for one set ssets 6 times a day
7 )
4 ) muscle strength
Opening , protrusion , latervl resistance ----muscle strength pt an use their hands to a chive resistance
Control recollection of contributory or predisposing factors :-
- pr whave there in contributing factor from Para function e . g kennedy cl I – dental TX in adequate
1 – inter occlusal stabilization appliance ( s A )
- most common --- whomever max or mand arch
- designed to preclude any teeth contact
- surfaces are smooth
- canine rise can be added ---- to ensure easy glide
- numerous reason have been proposed to account for haw SA,S prove pain relief
- muscle hyper activists
- change in vertical dement ion
- change in intra joint pressure
- placebo effect
- behavioral modification via cognition awareness
- lingual response to oral space restriction
B ) repositioning appliance :- ---- for ant . displacement
- to produce row mandibular position to prevent the disc candy complex from returning to fully occluded position ( recapturing the disck )
- effective in TMJ clicking ----- but it,s recurrent
- may pros or the probe --- do stepping the mand back
( 8 )
8 ) is appearance ad clicking is difficult with man surgical t x method
Mechanism ad action :-
- it , s not yet clear how occlusal appli ever produce it s t x effect c lark ,s presertel 5 theoriel
- ocelusul disengagement
- vertictal dimention ad occlusion
- max andibibular realignment
- TMJ repositioning
- cognitive awareness
* occlusal adjusted
- no compute sanative eve dance to justify occlusal adjustment as management
- adjust is logical when individual tooth is loadul
And can be performed ---- to improve com fort and function ad the mascle
- occlusion as a etiological factor for TMD remain elusisive
Treatment path logical sequelae :-
Management ad TMD lead to group (1) :- pt feel better but some pt will exhibit intermittent exacerbation ad symptoms
group (2): pt take a long time before the management provide symptoms relied
group (3):- pt don’t respond to management tx: meds pay ecological tx
( 9 )
9 ) behavioral psychological management : -
20 – 30 % ad managed pt their pain continue
-psychological health , life style , coping skills are important ,
Became ad risk ad emotional and behavioral problem related to chronic pain
Cuoals :- 1 ) modify pt behaviour & beliefs that pain
A ) provicle stratigies to allow the pt to cope . with pain
3 ) identify and management psychological as behavioral problem
Management based upon clinical experience -
1 ) pt eduation and orientation :
- diagnose
- explain the condition
- a key factor ( pt education ) for success
- develop realistic expectation for succeerfual coping
- increase competence to by pt acceptance ad the management
2 – behavioral modification : -
Management ad TMD involves modification ad the behavior
Group therapy -
- relaxation
- psycologial counseling
( 10 )
10 ) coping skills
A specific behavior or cognitive activity pt may use to cope uith pain
* modification ad belief regarding the priming ad pain
* distraction , activity which absorb pt attention
- psychological problem s resulting from TMD
- is the pt psychological condition cause or result from TMD
- clinical Tudjman is important to identify
Pt with serious emotion al condition
Pt depression may continue
Even after TMD resolved
- evaluation by mental health professional is important
- psychological there copy and splint therapy provided better outcome than ether ad TX alone .