Schindler / Türp Occlusal Splints for Painful Craniomandibular Dysfunction

1. Auflage 2021
ISBN: 978-1-64724-136-0
Verlag: Quintessence Publishing Co, Inc
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)

E-Book, Englisch, 183 Seiten

Therapy for painful craniomandibular dysfunction (CMD) is a field of dentistry that is quite different from traditional subjects in dental medicine (eg, periodontics, restorative dentistry, or oral surgery). In these subject areas, innovation essentially means adapting clinical procedures to new technologies, such as the use of digital resources. However, better basic treatment of CMD cases cannot be achieved simply by better technique but by a new way of thinking that emphasizes patients, their suffering, and what they tell their dentists. Therefore, this book offers a clear guide to help practitioners address the issue of CMD in theory and practice and provide their CMD patients with the best possible treatment. The book is split into two parts: first a practical guide to the basic treatment of CMD patients, followed by chapters that build on that basic knowledge by exploring scientific and theoretical principles in more depth. The two parts complement each other to form a rounded and complete picture. A series of detailed charts, diagrams, and sample forms are included to supplement the important history-taking section, and chapters on splint fabrication and rehabilitation include step-by-step photographs. The book concludes with chapters on neurobiology to discuss CMDs and their treatment at an anatomical level for a more thorough understanding.

Hans Jürgen Schindler, Prof Dr Med Dent, is a professor in the Department of Prosthodontics at the University of Würzburg, Germany, and senior researcher at the Institute of Mechanics, Karlsruhe Institute of Technology, Karlsruhe, Germany.

Autoren/Hrsg.

Schindler, Hans Jürgen

Türp, Jens Christoph

Leseproben

1 INTRODUCTION Jens C. Türp Craniomandibular Dysfunction Terminology Technical terms must be clarified to avoid misconceptions and misunderstandings, especially when describing the factors relating to function. In particular, a distinction must be made between “dysfunction of the masticatory system,” “craniomandibular dysfunction,” and “myoarthropathy of the masticatory system”; these terms should not be considered synonymous. In 2016, the German Society for Functional Diagnostics and Therapy published proposed definitions for these and other important terms for the first time.1 Dysfunction of the masticatory system Dysfunction of the masticatory system refers to a “short- or long-term disturbance of the homeostasis or economy of the masticatory system caused by any structurally or functionally substantiated deviation from normal function, such as functional deficits due to trauma, injury to the structural integrity, and functional/parafunctional stress, including deviations that justify prosthodontic, orthodontic, or surgical measures.”1 Craniomandibular dysfunction Craniomandibular dysfunction (CMD) is classified as “a specific functional disorder that affects the muscles of mastication, the temporomandibular joints (TMJs), and/or the occlusion.”1 Clinically, CMD encompasses the areas of pain and/or dysfunction. Pain is manifest as: Masticatory muscle pain TMJ pain Toothache of (para)functional origin Dysfunction can appear in the form of: Painful or nonpainful limitation of movement of the mandible (aspect aimed at mandibular movements) Hypermobility or incoordination of the mandible (aspect aimed at mandibular movements) Painful or nonpainful intra-articular dysfunction (aspect aimed at the TMJ) Premature contacts interfering with function and gliding obstacles (aspect aimed at the occlusion) CMD is a collective term that encompasses symptoms not in need of treatment and symptoms that do need treatment. In principle, there is always a need for treatment when pain is present; in the case of dysfunction, the need for treatment is dependent on the severity of the dysfunction. Myoarthropathy of the masticatory system Myoarthropathy of the masticatory system (MAP), a term introduced in 1970 by Tübingen dentist Willi Schulte,2 denotes a subgroup of craniomandibular dysfunction. It refers to symptoms and findings affecting the muscles of mastication, the TMJs, or associated tissue structures; it does not take into consideration the occlusion. This term equates to the term “temporomandibular disorder (TMD).” If pain is involved, these symptoms can be summarized under the heading “myoarthropathic pain.” Etiology Numerous mechanisms have previously been held responsible for the etiology of myofascial pains of the muscles of mastication and pains in the TMJs. Nociceptive pain is currently the underlying basis of models for these musculoskeletal symptoms. This nociceptive pain can be triggered by overloading of the tissue and promoted by a number of disposing factors. Microtrauma and local ischemia3—together with their structural and functional counterparts, such as activated osteoarthritis,4 the myofascial trigger point,5 local muscle fatigue, and aching muscles6—essentially serve as overarching pathophysiologic explanatory models. Common to these hypotheses is the assumption that, at the end of the causal chain, afferent nerve fibers and tissue cells release protons7 and other endogenous algesic substances (eg, glutamate, substance P, bradykinin, histamine, prostaglandin E, serotonin, potassium ions, adenosine triphosphate) that mediate the excitation and sensitization of nociceptors (group III and IV muscle afferents). Modern concepts4,8 distinguish between the following influencing factors: Predisposing (eg, genetic, structural, systemic, psychologic) Initiating (eg, microtrauma, macrotrauma, overloading) Sustaining/perpetuating (eg, psychosocial) The classification into the individual categories is not intended to be rigid. For instance, overload of the sustaining and psychosocial conditions may be the predisposing factor in one patient, whereas the opposite pattern will apply in another patient. It is important to interpret this conceptual framework correctly, in the sense that a single influencing factor is not usually capable of causing musculoskeletal pains. Meanwhile, there is evidence that endogenous or exogenous substances, such as estrogen,9 nerve growth factor (NGF),10 and glutamate,11 might play a key role in the etiology of painful CMD. The fact that glutamate is able to cause peripheral sensitization without discernible signs of inflammation is extremely important in this context.11 These new findings have rarely been discussed in the dental literature, but they offer a plausible explanation for the observation, which has long been made and is proven through epidemiologic studies, that females, especially women of child-bearing age, more commonly suffer from myoarthropathic pain than men.12,13 Epidemiology The typical patient with painful CMD is a woman of child-bearing age with pains in the muscles of mastication. Women seek professional assistance because of their symptoms at an overwhelmingly higher rate than men. The more specialized the facility, the higher the proportion of women patients. In university pain centers, the ratio of women to men can be as high as 9:1. Individual Need for Treatment The question of whether an individual needs treatment automatically follows from the preceding comments. Traditionally, the range of dysfunction has been widely interpreted in dentistry. In the past, anyone who did not function like an articulator performing symmetric, noise-free movements would have run the risk of being regarded by a dental practitioner as potentially dysfunctional. Fortunately, this view has changed considerably. CMD treatment not required Current thinking is that certain CMD symptoms do not usually require any special (additional) diagnostic investigation and do not need treatment when people are otherwise pain-free: Clicking or popping noises in the TMJs. The most common cause of TMJ clicking or popping is an anterior position of the articular disc. Clicking or popping noises without other symptoms (pains) are also not an indication for further diagnostics or treatment in the field of orthopedics. Carrying out magnetic resonance imaging for TMJ clicking or popping can thus be viewed as an excessive use of diagnostic tools. If patients report joint pains as well as TMJ noises—if they have painful joint clicking—the pain symptoms, but not the noise, require a more thorough examination and (usually) need treatment. An exception is a very loud clicking or popping of the joints that is not tolerable for the patient and his/her social environment. In this case, the available treatment methods that are indicated need to be fully explored, bearing in mind their particular risk-benefit relationship. Grating noises in the TMJs. Grating noises in the TMJs are generally a clinical sign of contact between two bone surfaces. However, grating without other symptoms (pain) is not an indication for treatment. Deviation (corrected lateral deviation) of the mandible during mouth opening. Differences in the extent of maximum laterotrusion to the left and right. These tend to be more the rule than the exception14 and reflect the fluctuating asymmetry typical of mammals. Sensitivity on palpation of jaw muscles and/or TMJs detected during a routine functional diagnostic examination. These areas are not painful during the course of the patient’s daily mandibular function. Signs of osteoarthritis on radiographs (dental panoramic radiography). All these symptoms, which used to be classified as dysfunctions, are today viewed as a variation from normality. This means the range of normal function—or “eufunction”—has been greatly expanded. Albert Gerber (Zurich) warned as early as 1964 that “not every TMJ that causes discomfort must eo ipso be diseased” and not all discomfort must be treated.15 CMD treatment required By contrast, further diagnostic investigation and treatment are advisable in certain clinical situations: Painful symptoms in the area of the jaw muscles and/or TMJs. Pains reported by patients must always be taken seriously. As a general rule, pain-related information provided by patients must not be doubted in terms of its veracity. This is especially true of the maxillofacial area, since it is extremely unlikely that pains in this area will result in early retirement—unlike back pains, for example. Pains in the region of the jaw muscles or in one or both TMJs are the key symptom in more than 90% of dental patients with painful CMD—and not a reduced range of mandibular movement or TMJ noises. However, a large proportion of patients with myoarthropathic pains do not consult a clinician for treatment. Anxiety about their existing problems is an important factor in whether patients decide to have their symptoms investigated and, if necessary, get therapeutic assistance. Pains in the muscles of mastication and/or TMJs are accompanied by a distinct limitation of the range of mandibular...