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DMOP > Masticatory Muscle Disorders and Treatment > Flashcards

Masticatory Muscle Disorders and Treatment Flashcards

1
Q

Musculoskeletal Disorders
(5)

A
  1. Myofascial Pain Syndrome (MFPS)- Centrally Maintained
    Pain
  2. Myalgia
  3. Fibromyalgia- Centrally Maintained Pain
  4. Spasm
  5. Myositis
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2
Q

Mechanisms that produce Pain for
Masticatory skeletal muscles (1)
(3)
Masticatory Muscle
Pain

A

Overuse or
Ischemia (i.e.
bruxism)
Endogenous
substances (2) can
sensitize nociceptive
nerve endings
Psychological or
emotional states
can alter muscle
tone (i.e. anxiety)

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3
Q

Myofascial Pain Syndrome (MFPS) classified by
International Association for the Study of Pain
 Characterized by the presence of

A

Trigger Points (TPs) in any voluntary
muscle which cause referred pain and referred tenderness and may
be active or latent. (3)
 TPs evoke referred pain which usually originates from a distant site
rather than the site of the pain complaint.

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4
Q

Muscle Palpation Examination
(2)

A

 Remember that the pain location MAY not be the source of pain
 Palpate the Masseter and Temporalis muscles with mouth open

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4
Q

 ACTIVE TPs:

A

are painful to palpation or spontaneously produce local
pain OR refer pain and autonomic symptoms (i.e. erythema) to
remote areas in reproducible patterns characteristic of each muscle.

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4
Q

 LATENT TPs:

A

exhibit local tenderness but do not currently cause
spontaneous clinical pain or symptoms.

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4
Q

Myofascial Pain Syndrome (MFPS)
(3)

A

 May be found in any voluntary muscle
 Is a Centrally Mediated Pain. Fields (4) described a means where the CNS may switch
on Nociception by stimulating the “on” cells which causes activation of the Trigeminal
Nucleus nociceptors.
 Is chronic, continuous muscle pain (myalgia) that is aggravated by function and refers
pain beyond the boundary of the masticatory muscle being palpated (5).

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4
Q

Myofascial Trigger Point
 DEFINITION:

A

 An irritable locus within a taut band of skeletal muscle or fascia which when stimulated
elicits referred pain & tenderness (“secondary hyperalgesia- increased sensitivity to
normally painful stimuli outside & surrounding a zone of primary hyperalgesia”). (1)
 Referred pain from myofascial trigger points is dull and aching, usually deep, and can range
from discomfort to incapacitating pain

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5
Q

 Nociception:

A

“stimulation of specialized nerve endings designed to transmit
information to the central nervous system concerning potential or actual tissue
damage (5).

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6
Q

 Nociceptor:

A

“a specialized nerve ending that senses painful or harmful sensations”
(i.e. a primary afferent nerve) (5)

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7
Q

Myofascial Pain
 The most elusive and difficult to diagnose since it

A

refers
pain to other locations in the mouth and in the face and
head & does Not always follow Cranial Nerve Distributions-
(CN XI with active SCM trigger point refers to CN V in face
and head)

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8
Q

Myofascial Pain
 Diagnostic Criteria: (must be present)
(3)

A

 Regional dull, aching pain aggravated by mandibular function when muscles
of mastication are involved.
 Trigger points have a characteristic pattern of pain referral & alters the pain
complaint on palpation or spontaneously.
 > 50% pain reduction occurs with vapocoolant spray or local anesthetic
injection (trigger point injection) using 1% Procaine without vasoconstrictor.

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9
Q

skipped
Myofascial Pain
 May be accompanied by:
(6)

A

 Muscle stiffness
 Sensation of acute malocclusion not verified clinically.
 Ear Symptoms, tinnitus, vertigo, toothache, tension-type headache.
 Decreased mouth opening (if masticatory muscles involved).
 Hyperalgesia in region of referred pain.

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10
Q

Hyperalgesia:

A

“an increased response to a stimulus that is normally painful”

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11
Q

Pathophysiology of Masticatory Myofascial
Pain
 Not fully understood
1. Suspect — pain thresholds in these individuals
2. — may cause increased nociception
which causes pain sensitivity
3. — in CNS & upregulation of nociceptive processing (decreased
inhibition of pain)

A

lower
Estrogen and nerve growth factor (NGF)
Hyperexcitability

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12
Q

Nociception-

A

Stimulation of specialized nerve endings designed to
transmit information to the CNS concerning potential or actual tissue damage.

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13
Q

Windup-

A

repetitive nerve stimulation leading to exuberant response in the CNS

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14
Q

Thalamus_

A

relays sensory impulses to the cerebral cortex (i.e. pain, temperature, & touch.

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15
Q

Locus ceruleus-

A

part of a major NE route of CNS

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16
Q

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Calcitonin Gene Related Peptide-

A

contributes to pain transmission & inflammation in migraine & neurogenic inflammation & is released
from the primary terminals of primary sensory neurons. Cell bodies of these neurons in the dorsal root and trigeminal ganglia give origin
to unmyelinated and myelinated fibers conducting in the slow C or A- alpha range respectively.

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17
Q

Glutamate-

A

major mediator of excitatory signals in CNS. Glutamate receptors are contained in most of the nerve cells & glial cells.
NMDA receptor is a subtype of glutamate receptors

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18
Q

Pain Referral Patterns
TMJ & Ear Pain:
 Referred by:
(5)

A

 MASSETER (deep)
 LATERAL PTERYGOID
 MEDIAL PTERYGOID
 STERNOCLEIDOMASTOID (clavicular)

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19
Q

Toothache:
 Referred by:
(3)

A

 TEMPORALIS
 MASSETER (superficial)
 DIGASTRIC (anterior)

20
Q

Myofascial Pain
 May be
 Avoid

A

transient and self-limiting, resolving without serious long-term
effects.
irreversible treatments (i.e. occlusal adjustments)

21
Q

Myalgia
 Diagnostic Criteria: (must be present)
(3)
 May be present:
(1)

A
  1. Muscle pain reported by patient in the jaw, temple, ear or pre-auricular area in the
    last 30 days
  2. Pain is aggravated by jaw movement or parafunction (i.e. bruxism)
  3. Muscle palpation exam causes report of localized muscle pain at palpation site
  4. Limited range of mouth opening MAY be present
22
Q

Myalgia
Secondary to:
(6)

A

 Ischemia
 Bruxism
 Fatigue
 Metabolic alterations
 Delayed onset muscle soreness from overuse
 Protective splinting

23
Q

Myositis
 Diagnostic Criteria must be present: (5)
(2)
May be present:
(4)

A
  1. Local muscle pain following injury (non-infective) or infection (infective)
  2. Edema, erythema, &/or increased temperature over the muscle
  3. Serologic tests may reveal elevated enzyme levels (i.e. creatine kinase), markers
    of inflammation & the presence of an autoimmune disease.
  4. Diffuse tenderness over the entire muscle.
  5. Increased pain with jaw use if masticatory muscles involved.
  6. Limited range of motion of unassisted mandibular movements secondary to pain
24
Q

Myospasm
 Diagnostic criteria Must be present(5)
(4)
contralateral unaffected muscle.
5. MAY be present:
(1)

A
  1. Acute onset of pain at rest & with function.
  2. Immediate report of limited range of jaw motion <40mm for vertical opening
  3. Continuous involuntary muscle contraction
  4. EMG will Confirm elevated electromyographic activity compared to the
  5. Acute Malocclusion
25
Q

Myospasm
 Also known as
 Occurs relatively infrequently in orofacial pain population & typically is caused
by —.
 Difficult to differentiate between

A

“trismus” or “cramp”.
trauma
disc displacement without reduction
clinically when limited unassisted vertical range of mouth opening is <40mm.

26
Q

Contracture
 What is it?
 Usually not painful unless muscle is —
 History of … is often present

A

Shortening of a muscle due to fibrosis of tendons, ligaments, or
muscle fibers
overextended
radiation therapy, trauma, or infection

27
Q

Contracture
 Diagnostic Criteria MUST be present:
(1)

A
  1. Progressive loss of range of motion with unassisted and assisted
    opening < 40mm causing a “hard end feel”
28
Q

Fibromyalgia
Pathophysiology
 is poorly understood but
believed to involve a —
 little evidence of — abnormalities
 may involve dysfunction of
—

A

central
sensitivity syndrome
peripheral
tissue
autonomic nervous system

29
Q

Fibromyalgia
ssociated Co-morbid Medical
Disorders:
(5)

A

 TMD (10% of population)
 Inflammatory & neuroendocrine
disorders
 IBS, functional chest pain from
esophageal origin
 Chronic pelvic pain
 Headaches especially Migraines

30
Q

Fibromyalgia (FM)
DIAGNOSIS:
 Widespread pain with…
 Associated with exaggerated
tenderness in at least —
specified anatomic sites.
 Commonly shows up as
—.
 May be associated with …
 Refer to a — for
evaluation & treatment

A

bilateral
diffuse musculoskeletal aches &
stiffness both above & below
the waist for > 3 months.
11 of 18
masticatory muscle pain
sleep
deprivation & depression.
rheumatologist

31
Q

FM
symptoms

A

Tingling, numbness, tightness,
stiffness & swelling may affect
the jaw. Dizziness is common.
Toothache & gingival pain occur
commonly in fibromyalgia
patients.

32
Q

FIBROMYALGIA
 Diagnostic Criteria MUST be present:
(3)

A
  1. Tenderness on palpation of at least 11 of 18 specified sites
  2. Presence of wide-spread pain with concurrent masticatory muscle pain
  3. Pain is bilateral and present above & below the waist
33
Q

Fibromyalgia Medications
Effective:
(3)
Minimally Effective:
(3)

A

 Lyrica
 Antidepressants (i.e. amitriptyline)
 Savelle (SNRI)

 NSAIDs
 Opioids
 Benzodiazepines

34
Q

Fibromyalgia Conservative Treatment
(4)

A
  1. Sleep hygiene- keep bedtime & awakening time the same each day; only
    sleep while in bed- no TV or computers; rule out obstructive sleep apnea
  2. Cognitive behavioral therapy to cope with pain
  3. Light impact aerobic activity (i.e. swimming, beginner’s aerobic class)
  4. Strength training with light weights
    Avoid electronic devices in bed Low impact exercises
    are recommended
35
Q

MOVEMENT DISORDERS: OROFACIAL
DYSKINESIA
 INVOLVES —MOVEMENTS
 MAY involve the (3)
 MAY cause traumatic injury to the (2)
 More common with (4)
 Patient must provide a history of — involving the orofacial region,
history and examination is positive for myalgia and arthralgia that worsens
with episodes of —
 Cranial nerve examination is positive for …
 Intramuscular — confirms the dystonia diagnosis

A

INVOLUNTARY, CHOREATIC
face, lips, and/or the jaw.
tongue or oral mucosa
advancing age, use of neuroleptic medications and/or
traumatic brain injury, psychiatric or certain neurologic disorders
dyskinesia
dyskinesia
sensory &/or motor nerve
conduction deficit (i.e. Trigeminal nerve)
EMG

36
Q

Treatment of Masticatory Muscle Pain
 Goals of Treatment:
(4)

A
  1. Decrease pain
  2. Increase range of motion
  3. Resumption of normal daily activities (i.e. talking, eating a normal diet)
  4. Onabotulinum A injections for Oromandibular Dyskenesia and Dystonias
37
Q

MANAGEMENT MASTICATORY
MUSCLE PAIN (8)

A

REST (soft/liquid diet x 2 wks)
HEAT/ICE THERAPY (10 min. 2x/day)
ELIMINATE PARAFUNCTIONAL HABITS
TRIGGER POINT INJECTION
MUSCLE RELAXANTS
NSAID’s
PHYSICAL THERAPY
SPLINT THERAPY

38
Q

MUSCLE Pain Treatment
(4)

A
  1. Physical therapy (i.e. stretching exercises, ultrasound, topical
    steroids with iontophoresis, deep tissue release, vapocoolant)
  2. Stabilization splint
  3. Medications (i.e. NSAIDs, Medrol dose pack, muscle relaxants,
    sleep medications, TCAs, local anesthetic injections)
  4. Behavioral modification (i.e. stress management, cognitive
    therapy, elimination of parafunctional habits)
39
Q

Trigger point injection using —
without vasoconstrictor - may require repeat
injections — x to inactivate trigger points

A

1% Lidocaine
2-3

40
Q

H2 Blocker

A

 Prescribe an H2 blocker with the NSAIDs if use will exceed 2 weeks or if GI
symptoms develop. This will inhibit gastric secretion and serve to protect
from GI side effects.
 Examples:
 Prilosec (20mg) 1 tab q d- OTC
 Nexium (40 mg) 1 tab qd

41
Q

skipped
Muscle Relaxant Adverse Effects

A

 Dizziness
 Drowsiness
 Lightheadedness
 Paradoxical stimulation
 Abdominal pain
 Nausea
 Vomiting
 Headaches
 Nervousness
 Uticaria
 Hypotension
 Blurred vision
 Fatigue
 Dry mouth
 Constipation

42
Q

Steroids
(3)

A

 Medrol dose pack (4mg)- as directed
 Methyl prednisone 30-40mg qd for 3-4 days then taper by 10mg q 3-4 days
until discontinued
 Prescribe for patients with moderate to severe pain and no resolution of pain
occurred with NSAIDs

43
Q

Topical Analgesics:

A

less likely than systemic analgesics to
produce side effects & can treat a variety of painful disorders

44
Q

Used for muscle or TMJ pain (i.e. arthritis)
 NSAIDS: Compounded
(4)

A

 10% or 20% Indomethacin
 10% or 20% Ibuprofen
 10%, 15% or 20% Ketoprofen
 3%, 5%, or 10% Diclofenac

45
Q

 Used for musculoskeletal pains
(3)

A

 NSAID with muscle relaxants
 1% flexeril with10% ketoprofen/10% ibuprofen
 1% diclofenac sodium gel(Voltaren) Rx or OTC

46
Q

PHYSICAL THERAPY for Muscle Pain
(4)

A

 Ultrasound
 Electrical stimulation
 Stretching exercises
 Stabilization exercises

47
Q

Treatment of Musculoskeletal Pain
(3)

A

 Physical therapy or Massage
 Biofeedback/relaxation training or psychotherapy
 Acupuncture

48
Q

Stabilization Appliances for Myalgia or
Myofascial Pain
(5)

A
  1. Provide joint stabilization
  2. Relax the elevator (closing) muscles
  3. Provide stable occlusion
  4. Increases awareness of jaw habits
  5. Alters rest position of jaw to a more relaxed, open position
49
Q

Onabotulinum toxin type A (Botox)
(4)

A

 Potent neurotoxin that inhibits acetylcholine (ACh)
on both afferent & efferent motor nerves
 Weakens painful muscles & inhibits muscle
contractions
 Interrupts pain cycle & may block peripheral
neurotransmitters (i.e. Substance P, glutamate, &
calcitonin gene-related peptide (CGRP)
 Therapeutic injections have an average duration of
12 weeks before re-injection is necessary

50
Q

skipped
Oromandibular Motor Disorders & Facial spasms
treated by onabotulinum A Injections:

A

 Severe bruxism
 Hypertrophy of
masseter/temporalis
 Secondary muscle spasm (i.e.
radiation, multiple sclerosis,
amyotrophic sclerosis,
scleroderma)
 Hemimasticatory spasm
 Dystonia
 Tongue hyperactivity
 Motor tics
 Palatal myoclonus which may cause
tinnitus
 Sialorrhea (i.e. ALS)
 Hemifacial spasm- CN VII
(synkinesis

51
Q

Psychotherapy
(3)

A

 Biofeedback (EMG, thermal)
 Relaxation techniques (imagery, muscle contraction/relaxation, deep
breathing)
 Cognitive therapy (decrease life stressors, caffeine, alcohol; & coping
techniques)

52
Q
A

DMOP (15 decks)

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