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Smerte og dysfunktion i kæben
Peter SvenssonDDS, Ph.D., Dr.Odont., Odont.Dr. (h.c.).
Professor and head
Section of Orofacial Pain and Jaw Function
Department of Dentistry, Aarhus University
Denmark
Horsens, Dansk Smerteforums Årsmøde, 11.3.2016
Agenda
1. New classification of TMD
2. Referred pain and risk factors
3. Principles for management
Important steps forward…… From chaos to order !
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Temporomandibular disorders
• TMDs is a collective term embracing a number of clinical
problems that involve the masticatory musculature, the TMJ and
associated structures, or both
• Pain
• TMJ sounds
• Limited movements
Reseach Diagnostic Criteria - TMD
• Axis I Physical status
– I: Myofascial pain (2)
– II: Disc displacements (3)
– III: Arthralgia, osteoarthritis, osteoarthrosis (3)
• Axis II Disability and psychological status
– Graded chronic pain score
– Symptom check list (SCL-90)
Dworkin & LeResche 1992
RDC/TMD dual axes system
Axis I
Axis II
VAS = 7
VAS = 7
Dworkin and LeResche 1992
www.rdc-tmdinternational.org
• History form
• Examination form
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Clinical examination – axis I
• TMJ– Palpation
• Noise / crepitation• Pain
– Range of motion
• Muscle– Palpation
• Pain
Palpation of m. temporalis
1 kg
1. Is palpation painful (No – Yes)
Validity of RDC / TMD
Diagnostic group Sensitivity Specificity
Ia 0.75 0.97Ib 0.83 0.99
IIa 0.44 0.90IIb 0.23 0.99IIc 0.05 0.99
IIIa 0.45 0.88IIIb 0.11 1.00IIIc 0.21 0.99
Schiffman et al. 2010
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Refinement of criteria
• Based on the RDC/TMD v.1. and results from a validation study
group (Schiffman et al. JOP 2010) and Conscensus workshops in Miami
2009 and San Diego 2011…….
DC/TMD
Schiffman et al. JOP Headache 2014
History + clinical examination – DC/TMD
• TMJ– Palpation
• Noise / crepitation• Pain
– Range of motion
• Muscle– Palpation
• Pain Almost the same !
Palpation of temporalis and masseter
1. Is palpation painful (No – Yes)2. Is pain familiar (No –
Yes)3. Is pain referred (No – Yes)
Submandibular regionPosterior mandibular regionLateral
pterygoidTemporalis tendon
Lateral TMJ polePosterior TMJ
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New exam forms + questionnaires
New specifications
rdc-tmdinternational.org
Diagnostic Criteria for the
Most Common
Temporomandibular DisordersGROUP I: MUSCLE DISORDERS
I.a. Myalgia (ICD-9 729.1). I.b. Local myalgia (ICD-9 729.1).
I.c. Myofascial Pain (ICD-9 729.1).I.d. Myofascial Pain with
Referral (ICD-9 729.1).
GROUP II: JOINT DISORDERSII.a. Arthralgia (ICD-9 524.62). II.b.
Disc Displacement with Reduction (ICD-9 524.63).II.c. Disc
Displacement with Reduction with Intermittent Locking. (ICD-9
524.63).II.d. Disc Displacement without Reduction with Limited
Opening (ICD-9 524.63). II.e. Disc Displacement without Reduction
without Limited Opening (ICD-9 524.63).II.f. Degenerative Joint
Disease (ICD-9 715.18). II.g Dislocation (ICD-9 830.0).
GROUP III: HEADACHEIII.a. Headache attributed to TMD (ICHD
339.0).
Schiffman et al. JOP Headache 2014
**
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A few concerns …….. Myalgia
Myofascial pain with referral
Inf.
Ant.Sup.
Post.
Masseter pain mapsPain ratings
”50”
Pain ratings
”0-50-100”
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Anterior
Inferior
Left Baseline 0.5 kg
90-100
80-90
70-80
60-70
50-60
40-50
30-40
20-30
10-20
0-10
Anterior
Inferior
Left Baseline 1.0 kg
90-100
80-90
70-80
60-70
50-60
40-50
30-40
20-30
10-20
0-10
Anterior
Inferior
Left Baseline 2.0 kg
90-100
80-90
70-80
60-70
50-60
40-50
30-40
20-30
10-20
0-10
Masseter pain maps
0-10
11-20
91-100
81-90
71-80
61-70
51-60
41-50
31-40
21-30
NRS
0-10
11-20
91-100
81-90
71-80
61-70
51-60
41-50
31-40
21-30
NRS
0-10
11-20
91-100
81-90
71-80
61-70
51-60
41-50
31-40
21-30
NRS 0.5 kg 1.0 kg 2.0 kg
Inf.
Ant.
Castrillon et al. – in progress 2016
COG
Entropy
12.5%referral
18.8%referral
50.0%referral
Summary
• RDC/TMD has been essential to start the standardization of TMD
classification and diagnoses
• New DC/TMD will be the future tool for both clinicians and
researchers– Improve diagnosis – Describe risk factors /
pathophysiology– Facilitate management
Current classification of TMD
• Based on reliable and validated measures of
signs and symptoms = IMPORTANT
• Mechanisms underlying the pain are still
poorly understood and require more research
= VERY IMPORTANT
Possible TMD pain mechanisms
1. Nociceptive pain
2. Inflammatory pain
3. Neuropathic pain
4. Functional pain
1. 1.
1.
2.
2.2.
1.
2.
Amplification
Svensson et al. 2008 (modified from Woolf 2004)
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TMD pain spectrum
Healthy Simple Complex
Complex TMD pain model
TMD
Pain
Benoliel, Svensson, Eliav 2012
A new proposal !
• We think in orderly, linear terms !
– Risk factor A may lead to pain
– Risk factor B may lead to pain
– Risk factor C may lead to pain
– Etc…….
• But what if interactions between risk factor
occur in a random fashion?
A
Pai
n
B
Pai
n
C
Pai
n
A / B / C
Pai
n
?
Stochastic variation
a new conceptual model for orofacial pain
• Imagine 100 different factors associated with
pain
– Some may be facilitatory (+ pain)
• Different potency 0-100 (low – high)
– Some may be inhibitory (- pain)
• Different potency -100 to 0 (high – low)
Poor sleepHigh depression scoresHigh serotonin expressionHigh
somatization….
Good sleepLow depression scoresLow serotonin expressionNo
somatization….
Svensson and Kumar 2016
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Random variation
100 random values -100 to 100
-200
-150
-100
-50
0
50
100
150
200
0 10 20 30 40 50 60 70 80 90 100
”Random noise”
A
Facil
itati
on
Inh
ibit
ion
Random numbers - addition
Random interaction model
-600
-400
-200
0
200
400
600
0 20 40 60 80 100
PAIN
NO PAIN
A
Su
mm
ed
sco
re
Random interaction model
-600
-100
400
900
1400
0 20 40 60 80 100
-600
-400
-200
0
200
400
600
0 20 40 60 80 100
-600
-400
-200
0
200
400
600
800
1000
0 20 40 60 80 100
-600
-400
-200
0
200
400
600
0 20 40 60 80 100
B
C
D
E
PAIN NO PAIN
PAIN
Recurrent PAIN
Su
mm
ed
sc
ore
Su
mm
ed
sc
ore
Su
mm
ed
sc
ore
Su
mm
ed
sc
ore
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Different trajectories Pain trajectories
Dunn et al. Pain 2011 N = 1336 adolescents (11 yrs)
Implications
• Simple stochastic variation could explain
different trajectories / patterns of pain
• We need to think in terms of multiple
interactions (multi-factorial) and that system
biology not always follows linear relationships
Pain x emotions x genes
Positive pictures / mood
Neutral pictures / mood
Negative pictures / mood
N = 50N = 50N = 50
0.2
ml
5%
HS
in
to m
assete
r
Horales et al. Pain 2013
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RDC/TMD dual axes system
Axis I
Axis II
VAS = 7
VAS = 7
Dworkin and LeResche 1992
Dual axes
• Axis 1– Myofascial TMD– TMJ arthralgia
• VAS pain = 7
• Axis 1– Myofascial TMD– TMJ arthralgia
• VAS pain = 7
Management
• Information• Councelling• Physiotherapy• Oral appliance•
NSAIDs
Dual axes
• Axis 1– Myofascial TMD– TMJ arthralgia
• VAS pain = 7
• Axis 2– Disability score = 5– Depression score = 2–
Somatization score = 1
• Axis 1– Myofascial TMD– TMJ arthralgia
• VAS pain = 7
• Axis 2– Disability score = 1– Depression score = 0–
Somatization score = 0
Management
• Information• Councelling• CBT• Physiotherapy• Oral appliance•
NSAIDs• TCA
Management
• Information• Councelling• Physiotherapy• Oral appliance•
NSAIDs
Triple axes system
Axis I
Axis II
Axis III
Third axis• Synovial fluid
•e.g. TNFα• Genes
•e.g. COMT• Microdialysis
•NGF• Brain activity
•DLPF• ……?
VAS = 7TNFα ▲▲▲VAS = 7
TNFα ▲
Svensson – IADR 2010, 2012
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Triple axes
• Axis 1– Myofascial TMD– TMJ arthralgia
• VAS pain = 7
• Axis 2– Disability score = 4– Depression score = 2–
Somatization score = 1
• Axis 3– TMJ TNF-alpha +++
• Axis 1– Myofascial TMD– TMJ arthralgia
• VAS pain = 7
• Axis 2– Disability score = 4– Depression score = 2–
Somatization score = 1
• Axis 3– TMJ TNF-α = 0
Management• Information• Councelling• CBT• Physiotherapy• Oral
appliance• NSAIDs• TCA
Management
• Information• Councelling• CBT• Physiotherapy• Oral appliance•
NSAIDs• TCA• Anti-TNF-α
Take-home messages
• TMD signs and symptoms can be classified (RDC/TMD –
DC/TMD)
• Not all TMDs are painful• Consider the mechanisms behind the
pain• Simplistic pain models can not account for
chronic TMD pain• Complex disease models should guide
diagnoses and management
Scandinavian Center for Orofacial Neurosciences
GoalTo bring together in a brickless center, leading
Scandinavian groups in the field of
orofacial neurosciences including oral physiology and orofacial
pain, and to strengthen the research activities and impact on
education and treatment in oral rehabilitation.
http://www.sconresearch.eu/
2014
Section Orofacial Pain and Jaw Function
TMS/MEP
Motor learning
QST /ANS
Pain
EMG / Force
Pain-motor function
DC/TMD
CBT / hypnosis
Sessle lab Dubner lab Lund lab Dworkin lab
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DC-TMD course Thanks for your attention
[email protected]
