Clinical significance of first phase treatment for tmd　final

Clinical Significance of First Phase Treatment for TMD Patients.

16th International Congress, October 20, 21 Vancouver Canada

Toshihiko Abey D.D.S,MICCMO

© 2011, Toshihiko Abey, DDS,MICCMO

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Introduction Temporomandibular Disorder affects many patients’ quality of life. Those patients suffer from severe pain and discomfort without any effective resolution being offered by professionals. These disorders are acutely related to the mandibular jaw position, so called craniomandibular disorder. Neuromuscular concept states we relocate the mandible to physiologic rest position in order to relax compressed joints and tense muscles. The result is that the great majority of the symptoms and discomfort disappear. To prove this theory and its clinical significance, ４０ TMD patients were examined and first phase treatment was performed on them by means of orthotic treatment.　

1.Pain of myogenous origin (muscle spasms) Neck & Shoulder pain, Back pain, Facial pain, Tension Headache, etc.

2.Symptoms related to TMJ Clicking, Popping, Difficulty opening, Jaw tiredness, Jaw stiffness, etc.

3.Symptoms effected on the autonomic nervous system Insomnia, Dizziness, Short breath, Constipation, etc. ( Dysautonomia )

4.Mental disturbances Depression, Anxiety, Insomnia, Nervousness, Despair, etc.

Four Categories of TMD Symptoms

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２． A wide variety of symptoms are seen among TMD patients. These symptoms are categorize in four major groups. Most common complains of the TMD patients is related to muscle discomfort and pain. The second major group of symptoms is related to TMJ. The third group is a collection of symptoms which is similar to “Dysautonomia” which is a disease of the autonomic nervous system. The forth group of symptoms is mental disturbances. These disturbances can overlap to other categories sometimes.

• Nerve and Vascular Entrapment

• Muscle Ischemia

Etiology of Temporomandibular Disorder


Myogenous TMD disorders

Musculoskeletal disorder

Muscle hyper function

• Distalization of the condyles

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３． Temporomandibular Disorders are defined as a collective term embracing a number of clinical ploblems that involve the muscles ,temporomandibular joint and associated structures. They are considered to be a sub classification of musculoskeletal disorders. Muscle hyper function is the principal cause of the myogenous TMD disorders, as the result of musculoskeletal disfunction. Most TMJ dysfunction begins with distalization of the condyle. It has been suggested that TMD pain occurs with about the same prevalence as abdominal pain and chest pain, but is less common than back pain and headache. These are considered to be caused by myogenous origin as a result of musculoskeletal disorder.

3 Kinds of Mandibular Torque

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４． The mandible changes it’s position in six dimensions: Vertical ,Anteroposterior, and Lateral. Also the mandible distorts or deviates from its normal position in three directions. These three distortions or deviations are “Pitch”, ”Roll”, and “Yaw”. When the mandible is forced to distort in any direction which is not physiologic in nature, the associated muscles and joints must accommodate to that distorted position. When those accommodations exceed those muscle’s or joint ‘s bio adaptability, pathologic status may start. All of these Torques are the biggest causative factors for the TMD Syndrome.

Etiology of Temporomandibular Disorder Pitch Torque Cause Internal Derangement of TMJ

Articular disk displacement

Physiologic Rest Position Pathologic Intercuspal Position


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５. The vast majority of TMJ patients show posterior open bite, when their jaws are in relaxed position. When those patients try to chew food, posterior open bite is ｃｌｏｓｅｄ, then the ｍａｎｄｉｂｌｅ rotates distal and upward (Pitch Torque). As a consequence, the articular disc is compressed and forced from the glenoid fossae and displaced. This is the mechanical reason for the articular disk displacement, and the main cause of arthlogeneous TMD symptoms.

Influence of PITCH Torque TMJ injury and loss of muscle co-ordination

Craniomandibular Disorder

Rest position of the mandible Distorted mandibular position

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６． Pathologic relation of the mandible to the skull is the result of the mandibular torques. The musculoskeletal dysfunction is frequently the result of a relationship of the mandible to the skull that is not compatible with the maintenance of normal muscle function or the normal relationship of the condyle in the articular fossae.

Habitual intercuspal position Physiologic rest position

Diagnosis of TMD Patients

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７. Diagnosis and treatment of TMD patients start with assessing the relationship of the mandible to the skull. This is accomplished by TENS　and using a jaw tracking measurement device, electromyography. Scan4/5 enables us to identify differences between the physiological rest position and habitual intercuspal position.

Habitual Intercuspal Position

Physiologic Rest Position


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８. These slides shows the differences of Habitual intercuspal Position and Physiologic Rest Position.

１） Match Habitual Path of Closure to Neuromuscular Path of Closure

２） Adjust torque of mandible to meet Relax musculature and TMJ

３） Establish Stable mandibular Position

Prescription to a TMD Paｔient:


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９. Prescription to the TMD patients. Most powerful and effective prescriptions or remedies for TMD patients are as follow: Match habitual path of closure to Neuromuscular path of closure. 2) Adjust torque of mandible to meet relaxed musculature and TMJ. 3) Establish stable mandibular position.

“Removable Neuromuscular Orthosis”

First Phase of TMD Treatment

eliminate or reduce patient’s symptoms

stabilizing the mandible

physiologic rest position.

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１０. The purpose of the first phase treatment of TMD patients is to eliminate or reduce patients symptoms by stabilizing the mandible to the physiologic neuromuscular position. For that purpose, removable neuromuscular orthotic appliances are fabricated and delivered to the patient. Such devices facilitate retention and stabilization of the mandible in its new found physiologic neuromuscular position. Three to six months of continuous full-time appliance usage shows that the new therapeutic position achieved remains intact.

Aligning Body Part to improve Function

Neuromuscular Orthotic Therapy

Orthosis:


support, align, prevent or correct deformities improve the function of movable parts of the body

An orthopedic appliance or apparatus

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１１. Orthosis is defined as an orthopedic appliance used to support, align, prevent or correct deformities, or to improve the function of movable parts of the body. The therapeutic objective of TMD Orthotic treatment is to reposition, to align, and to support the mandible in a neuromuscular position that will sustain a relaxed musculature and joints.

MYOGENOUS

DYSAUTONOMIA

TMJ

BITE

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12. This is my original Health “Questionnaire Form” on right side slide which is based on “MUSCULOSKELETAL OCCLUSAL SIGIN EXAM FORM” Click This questionnaire actually consist of three sections. Which are “TMJ and Bite” section , ”Myogenous” section and “Dysautonomia” section. Each section focuses on a different area.�

Please check Box below , and circle the Number which indicate your level of pain

“0” = No Pain, no discomfort “1” =Sometimes Bothered “2” = All the Time Bothered “3” =Severe Pain and Discomfort

ＴＭＪ＆ＢＩＴＥ

MYOGENOUS section DYSAUTONOMIA section

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１3. The first section on the left side, which is divided into 3 parts, asks patients about, first, TMJ issues, second, Bite issues, and third, substitute therapy. The section at the center of the slide, lists the questions concerning muscle pain and dysfunction. (Myogenous section) And finally the 3rd section at right side is the collection of symptoms which are similar to “Dysautonomia” which is a disorder of the autonomic nervous system. The final question at the bottom asks about medication the patient is taking.　Degree or severity of pain and dysfunction are reported by the patient as a Numerical Rating Scale.　These scale degrees are similar to Helkimo’s “ Anamnestic index (Ail)”.Which is Symptomless (Ai 0), Mild symptoms (AiⅠ), and Severe symptoms(AiⅢ）. The “Numerical rating scale system” is important for quantitative assessment of the symptoms and for later analysis. .


Distribution of the Pain Intensity Score of ３２ Symptoms complained by the 40 TMD Patients

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１4. This graph display the pain intensity scores of the ３２ symptoms which are expressed by the 40 TMD patients in their questionnaires before treatment. Stiff shoulders, Cervical pain, Weariness, Eye strain, and Headache, are the most prevalent symptoms among the 32 symptoms complained about by the 40 TMD patients.

ＨｏｗｔｏｃａｌｕｃｕｌａｔｅＩｍｐｒｏｖｅｍｅｎｔＲａｔｅ？


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１５. This slide explains the way to assess the result of the neuromuscular treatment by calculating improvement rate for each TMD symptoms. From this, a most favorable response symptom to the neuromuscular therapy becomes evident. To see these individual symptom’s response to the neuromuscular therapy, we calculated improvement rate of each symptom before and after treatment, using the formula listed at the bottom. For example, the stiff shoulder’s improvement rate is calculated as follows: The total scores of all patient’s intensity rates of pain and discomfort before treatment (SumA) are compared with the after treatment score (SumB). The difference between the total sore of symptoms before and after treatment shows the result of improvement by neuromuscular first phase orthotic therapy.


Improvement Rate of Pain Intensity Scores after the Neuromuscular Orthotic Therapy

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１６． This graph shows the improvement rate of the pain intensity scores after first phase neuromuscular orthotic therapy. Facial pain, pain in the Jaw, Back eye pain, Pain at wide opening ,and Constipation, show high improvement rates.

Improvement rate of each TMD Symptoms Related to TMJ disorder

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１７. This graph shows the improvement rate of TMJ related symptoms after neuromuscular first phase orthotic treatment. Before treatment, the pain intensity score for “Pain in the Jaw “symptom was 14. After first phase treatment, the pain intensity score drop down to 3. This means 79 % of the pain intensity score reduction happened because of first phase neuromuscular treatment. It is evident that first phase neuromuscular treatment is remarkable for the treatment of TMJ disorder

Improvement Rate of TMD Symptoms related to Muscle Disorder before and after Treatment

before after Improve . Rate (% )

Facial pain 19 3 84 Back eye pain 34 8 76 Headache 54 19 65 Back pain 47 17 64 Fingertip numbness 18 7 61 Pain in the h ips 45 18 60 Stif f shoulder (s) 76 32 58 Cervical pain 75 34 55

% % % % % % % %

Symptom


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１８. This table shows significant results of first phase neuromuscular treatment for relieving muscle pain and discomfort. Pain and discomfort scores of Facial pain were reduced by a staggering 84 %.

Improvement Rate of Symptoms Related to muscle disorders


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１９. This graph illustrates the previous table which shows the significant result of first phase neuromuscular treatment for relieving muscle pain and discomfort. Tension headache has now become a curable condition thanks to neuromuscular treatment. Up to now, treatment with pain relief medicine　has only yielded temporally relief.

Improvement Rate of TMD Symptoms related to Autonomic Nervous System before and after Treatment


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２０. This graph show improvement rates of symptoms similar to autonomic nervous system disorder. These symptoms show a high rate of improvement or resolution which is the success rate of treatment.　

Improvement Rate of Individual Patient

Individual patient Improvement Rate (%) = (SumA - SumB)/SumA x 100

Pｔ. A Pｔ. B Pｔ. C

Pｔ. Z

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２１. This slide is to explain the way of assessment of total improvement rate of symptoms for each individual patient. A high improvement rate means more satisfaction is provided to the patient by first phase neuromuscular therapy. The success rate data of neuromuscular therapy is the measurable evidence for the quantitative proof of neuromuscular concept.

Improvement Rate of Individual Patient

Improvement Rate No. of Pat ients

７０～８８％ 16 40%６０～６９％ 7 18%５０～５９％ 6 15%４０～４９％ 6 15%０～３９％ 5 13%TOTAL 40 100%

１６

７

６

６

５

N-40

７０～８４％

６０～６９％

５０～５９％

４０～４９％

０～３９％

（４０％）

（１８％）

（１５％）

（１５％）

（１３％）


= Patient’s Satisfaction Rate

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２２. This table and graph shows each individual patient’s satisfaction rate. 16 out of 40 patients (40%) 　experienced a 70-80 % reduction of pain or discomfort. These patients must logically, be delighted by the results of neuromuscular first phase treatment.

ＭｏｎｔｈＮｏ．of　Ｐｔ． %

2 5 13%3 6 15%4 6 15%5 3 8%6 2 5%7 1 3%10 5 13%12 1 3%13 4 10%

１４～ 7 18%

40 100

５

６

６

３２

５

４

７

N=40

2-month

3-month

4-month

5-month 6-month

10-month

13-month

14～month

Duration for individual Patient First Phase Treatment

12-month

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２３. This diagram shows the length of treatment time taken for improvement in first phase treatment for 40 patients. ５６％ of the patients finished their orthotic treatment within 6 month.

Conclusion

The curability of TMD symptoms Importance of quantitative data The validity of Neuromuscular Theory.


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２４. IN CONCLUSION First; From all of the data presented today, it logically states that most of TMD symptoms are curable within a period of 3-6 months, with success rates of 31-84 %, using neuromuscular orthotic therapy. Then; It is important to provide quantitative data to prove the significance of Neuromuscular Concept in the Dental field and Medical Community. Finally; Only through measurable data and proven techniques can dental clinicians and patients be persuaded of the validity of Neuromuscular Theory.


Thank you for your Kind Attention !

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２５．

The rate of response to First phase Treatment


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２４. This graph shows the 32 symptom’s success rate of first phase neuromuscular treatment for 40 the TMD patients.

Clinical significance of first phase treatment for tmd　final

Health & Medicine

Transcript of Clinical significance of first phase treatment for tmd　final

Clinical significance of first phase treatment for tmd final

Health & Medicine

Transcript of Clinical significance of first phase treatment for tmd final

Clinical significance of first phase treatment for tmd　final

Transcript of Clinical significance of first phase treatment for tmd　final