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de kaak in al zijn facetten
dr. Anton de Wijer
UMC St Radboud Special Dental
Care, TMD and Orofacial pain
VSOP
Hoofd-hals team
Psycholoog FT-gnatholoog Manueel tx tandarts-specialist consultant
www.academieinstituut.nl
Praktijk; outd...
Carien Beurskens, 2004
Pieter Dijkstra, 1993
Jules Hesse, 1996
Annemiek Rollman 2013
Caroline Speksnijder 2011
Corine Viss...
instroom
• 90% ♀, µ 43 jaar
• hoger opgeleid
• Tx: 0-9 sessies 92%
• geen tx na 1e consult 17%
Praktijk:
• 66% ♀, µ 47 yea...
selfcare
Complex
cases
High risk
cases
80% of
people
High % of
professional care
Equally shared
care
High %
of self
care
P...
Hoofdpijn
kaakpijn
Aangezichtspijn
Nekpijn
Diagnostiek Therapie
Temporomandibular disorders is a collective term that embraces a number of clinical
problems [musculoskeletal conditions] ...
Von Sölder 1890
Kunc 1970
V1
V2
V3
lesser
occip. n.
(C2)
greater
auric. n.
(C2,3)
greater
occip. n.
(C2)
third
occip. n.
(...
Pijn gebieden TMD MYO
Myo-TMD patients with ‘widespread’ pain:
STx + NSTx
Neurologische, biomechanische en kinesiologische interacties
Anatomie
How to explain?
Neck/ shoulder
Phrenicus nerve
BRAIN
Perception
Emotional brain
nV
neck
Co-activation
Birgitta Haggman Hen...
How to explain?
Neck/ shoulder
Phrenicus nerve
BRAIN
Perception
Emotional brain
nV
neck
Co-activation
Birgitta Haggman Hen...
Reciprocal nature of cervical-trigeminal interaction
Cervical nociception facilitate trigeminal sensation
Trigeminal nocic...
Persistant orofacial muscle pain [pomp]
R. Benoliel, Svensson, Heir, Zakrzewska et al Oral Diseases 2011,
Unicausal explanatory models
Presumed causation
Misalignment
Occlusal interferences
Stress-induced
parafunction
Targeted a...
Unicausal explanatory models
TMD unicausaal ???
Occlusale therapie als behandeloptie en zelfs houdingsproblemen
worden beï...
Unicausal explanatory models
TMD monocausaal ???
Occlusale therapie als behandeloptie en zelfs houdingsproblemen
worden be...
casus
Secundaire hoofdpijn
Dr. Paul Schokker J Craniomandib Disord. 1990 Spring;4(2):126-30.
The result of treatment of th...
Casus
Casus
Casus
Casus
casus
casus
Kaakchirurg
Manueel
therapeut
Casus
Sluderse neuralgie = Vidian neuralgia ( Vail 1932)
SN CH
Pain type boring, burning stabbing
or nagging boring
Severi...
Key Questions
Timing: onset, duration, periodicity
Location and radiation
Quality and severity
Relieving and aggravating [...
INSPECTIE
Diagnostic value of Orthopedic tests in patients with TMD
J Dental Research, 1993, 1443-1453
Conclusion:
in routine clini...
Diagnostic value of Orthopedic tests in patients with TMD
J Dental Research, 1993, 1443-1453 , Lobbezoo-Scholte et al
Conc...
DC TMD update van RDC TMDSchiffman et al 2014
Conclusion:
The newly recommended Diagnostic Criteria for TMD (DC/TMD) Axis...
DC TMD update van RDC TMDSchiffman et al 2014
Conclusion:
DC TMD update van RDC TMDSchiffman et al 2014
• Part two: the secondary
headaches
• 11. Headache or facial pain
attributed...
Pain is dental until proved negative!
Panoramic photo
Teeth
Mucosa
Bone
Nerve
Muscle
Joint
Treat all circles
• Biopsychosocial model
pain
Cognitions
Physiology Behaviour
Treat all circles
Nociception
Prevention/ medication
Pain awareness
Local anaesthethic/ anti- depressant/ -
epileptics/ mo...
Treat all circles
Nociception tx
Prevention/ medication
Pain awareness
Local anaesthethic/ anti- depressant/ -
epileptics/...
Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular
Disorders: Systematic Review and Meta-Analy...
Pain intensity at 4 weeks to 3 months: manual therapy plus excercises versus control group in patients with arthrogenous
t...
Tx
Randomized or quasi randomized clinical trials have
reported that all treatment methods are equally
effective and that ...
An average painintensity reduction of 27% was found after the first consultation, which
provided only a diagnosis and no s...
1959 TvT
Dento-maxillaire,
faciale, craniale en
cervicale orthopedie
JAC Duyzings
Posture
Total body
approach
challenge today
NVOF
Drs Marianne Gerrits, voorzitter
Dank voor uw aandacht
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De kaak in al zijn facetten

Dr. Anton de Wijer

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De kaak in al zijn facetten

  1. 1. de kaak in al zijn facetten dr. Anton de Wijer UMC St Radboud Special Dental Care, TMD and Orofacial pain VSOP
  2. 2. Hoofd-hals team Psycholoog FT-gnatholoog Manueel tx tandarts-specialist consultant www.academieinstituut.nl Praktijk; outdoor patient facility
  3. 3. Carien Beurskens, 2004 Pieter Dijkstra, 1993 Jules Hesse, 1996 Annemiek Rollman 2013 Caroline Speksnijder 2011 Corine Visscher, 2000 Anton de Wijer, 1995 Simone Gouw Monique Bot Dutch PhD studies: 1972 Stafleu &Tholen N.V. Leiden Kaakchirurg R.F. van Hoof 1995
  4. 4. instroom • 90% ♀, µ 43 jaar • hoger opgeleid • Tx: 0-9 sessies 92% • geen tx na 1e consult 17% Praktijk: • 66% ♀, µ 47 year • 68% lager en middelbaar opgeleid • 40% sociaal en emotioneel disfunctioneren  Frequent comorbiditeit CBT Radboud:
  5. 5. selfcare Complex cases High risk cases 80% of people High % of professional care Equally shared care High % of self care Patient education Psychosocial support Assessment self management Collaborative decision making Guidelines available instroom
  6. 6. Hoofdpijn kaakpijn Aangezichtspijn Nekpijn Diagnostiek Therapie
  7. 7. Temporomandibular disorders is a collective term that embraces a number of clinical problems [musculoskeletal conditions] that involve the masticatory muscles, the TMJ,and the associated stuctures .
  8. 8. Von Sölder 1890 Kunc 1970 V1 V2 V3 lesser occip. n. (C2) greater auric. n. (C2,3) greater occip. n. (C2) third occip. n. (C3) transv. cut. n. of neck (C2,3) V o V i V c PeripheralBranchesvsDermatomes C2 C3 Vc Vi Vo Neuropathic pain projection areas Nociceptive referral pain areas
  9. 9. Pijn gebieden TMD MYO
  10. 10. Myo-TMD patients with ‘widespread’ pain: STx + NSTx
  11. 11. Neurologische, biomechanische en kinesiologische interacties
  12. 12. Anatomie
  13. 13. How to explain? Neck/ shoulder Phrenicus nerve BRAIN Perception Emotional brain nV neck Co-activation Birgitta Haggman Henrikson PhD 2004 Functional jaw movements with simultaneous movements in tmj, atlantooccipital and cervical joints!
  14. 14. How to explain? Neck/ shoulder Phrenicus nerve BRAIN Perception Emotional brain nV neck Co-activation Birgitta Haggman Henrikson PhD 2004 • Preparatory head extension before the start of chewing • Association between size and texture of bolus with head extension and mandibular movements • Neck muscle activity is present in rhytmic jaw activities • In wAD patients smaller amplitudes and disturbed coordination of head and mandibular movements Functional jaw movements with simultaneous movements in tmj, atlantooccipital and cervical joints!
  15. 15. Reciprocal nature of cervical-trigeminal interaction Cervical nociception facilitate trigeminal sensation Trigeminal nociception facilitates cervical perception Association between neck and jaw disability is strong and clinically relevant Serious TMD increased 19.32 / 50 points on NDI Differences in craniocervical posture & max strength cervical flexor muscles not clinically relevant for patients with TMD How to explain? Susan Olivio
  16. 16. Persistant orofacial muscle pain [pomp] R. Benoliel, Svensson, Heir, Zakrzewska et al Oral Diseases 2011,
  17. 17. Unicausal explanatory models Presumed causation Misalignment Occlusal interferences Stress-induced parafunction Targeted action Repositioning Adjustment Habit control Treatment goal Condylar concentricity Proper disk-condyle relationship Proper occlusal relations Normal function
  18. 18. Unicausal explanatory models TMD unicausaal ??? Occlusale therapie als behandeloptie en zelfs houdingsproblemen worden beïnvloed door occlusie tx Causale relatie malocclusie en houdingsproblemen en vice versa Er is geen biologische plausabiliteit voor een pathologische relatie tussen occlusie en houding. Er is geen evidentie dat stabilometrische (zwaartepuntverplaatsingen) en posturografische testen diagnostisch valide zijn.
  19. 19. Unicausal explanatory models TMD monocausaal ??? Occlusale therapie als behandeloptie en zelfs houdingsproblemen worden beïnvloed door occlusie tx Causale relatie malocclusie en houdingsproblemen en vice versa Er is geen biologische plausabiliteit voor een pathologische relatie tussen occlusie en houding. Er is geen evidentie dat stabilometrische (zwaartepuntverplaatsingen) en posturografische testen diagnostisch valide zijn. xNEEN
  20. 20. casus Secundaire hoofdpijn Dr. Paul Schokker J Craniomandib Disord. 1990 Spring;4(2):126-30. The result of treatment of the masticatory system of chronic headache patients.
  21. 21. Casus
  22. 22. Casus
  23. 23. Casus
  24. 24. Casus
  25. 25. casus
  26. 26. casus Kaakchirurg Manueel therapeut
  27. 27. Casus Sluderse neuralgie = Vidian neuralgia ( Vail 1932) SN CH Pain type boring, burning stabbing or nagging boring Severity (moderately) severe severe / very Site Unilateral/ bi unilat orbital peri, intra orbital supraorbital root or lat side nose temporal Radiation maxilla, mastoid, head occiput, neck shoulder Attack freq attacks or continuous 1 every other day to 8 per day, in cluster periods Duration hour(s) to days 15-180 minutes Autonomic yes yes features K. Oomen Cephalalgia 2010 N III, vll , lx en x// ggl pterygopalatinum
  28. 28. Key Questions Timing: onset, duration, periodicity Location and radiation Quality and severity Relieving and aggravating [screen] Associated factors [clenching, locking, clicking, nasal, eye, taste, salivary flow, ear eg.] Other pain condition [headache, chronic widespread pain] Impact of pain [sleep, mood, concentration, fatigue, beliefs, quality of life] SCEGS!! WAT DOET DE MANUEEL THERAPEUT
  29. 29. INSPECTIE
  30. 30. Diagnostic value of Orthopedic tests in patients with TMD J Dental Research, 1993, 1443-1453 Conclusion: in routine clinical practice, besides history taking and conventional radiography, a functional examination consisting of active movements, passive opening, and palpation provides valuable diagnostic information. % class. 89.3 sens. 95, spec. 67, OR 36  in patients with specific diagnostic problems additional tests might be indicated. FUNCTIE
  31. 31. Diagnostic value of Orthopedic tests in patients with TMD J Dental Research, 1993, 1443-1453 , Lobbezoo-Scholte et al Conclusion: active movement was the most powerful test for distinguishing the different subgroups.  Palpation and passive opening were additional useful for distinguishing between patients and controls and between the subgroups myogenous and arthrogenous. N= 621 patients, 144 matched controls DC TMD update van RDC TMD Schiffman et al 2014 Expanding DC TMD Peck et al 2014 Topical review JOP; Steenks, Türp, de Wijer; submitted
  32. 32. DC TMD update van RDC TMDSchiffman et al 2014 Conclusion: The newly recommended Diagnostic Criteria for TMD (DC/TMD) Axis I protocol includes both a valid screener for detecting any pain-related TMD as well as valid diagnostic criteria for differentiating the most common pain- related TMD (sensitivity ≥ 0.86, specificity ≥ 0.98) and for one intra-articular disorder (sensitivity of 0.80 and specificity of 0.97). The 12 common TMD include arthralgia, myalgia, local myalgia, myofascial pain, myofascial pain with referral, four disc displacement disorders, degenerative joint disease, subluxation, and headache attributed to TMD.
  33. 33. DC TMD update van RDC TMDSchiffman et al 2014 Conclusion:
  34. 34. DC TMD update van RDC TMDSchiffman et al 2014 • Part two: the secondary headaches • 11. Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure • 11.7 Headache attributed to temporomandibular disorder 10-15%/ 5% / 1.5%
  35. 35. Pain is dental until proved negative! Panoramic photo Teeth Mucosa Bone Nerve Muscle Joint
  36. 36. Treat all circles • Biopsychosocial model pain Cognitions Physiology Behaviour
  37. 37. Treat all circles Nociception Prevention/ medication Pain awareness Local anaesthethic/ anti- depressant/ - epileptics/ morfine/ TENS Gate Control th Explanation/ counseling/ re-assure/ relaxation/ self confidence / CBT,Anxiolytica Sleepmedication Graded activity Keep on moving Positive
  38. 38. Treat all circles Nociception tx Prevention/ medication Pain awareness Local anaesthethic/ anti- depressant/ - epileptics/ morfine/ TENS Gate Control th Explanation/ counseling/ re-assure/ relaxation/ self confidence / CBT,Anxiolytica Sleepmedication Graded activity Keep on moving Positive
  39. 39. Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis 2016 • The overall evidence for this systematic review was considered low. The trials included in this review had unclear or high risk of bias. Thus, the evidence was generally downgraded based on assessments of risk of bias. Most of the effect sizes were low to moderate, with no clear indication of superiority of exercises versus other conservative treatments for TMD. However, MT alone or in combination with exercises at the jaw or cervical level showed promising effects • No high-quality evidence was found, indicating that there is great uncertainty about the effectiveness of exercise and MT for treatment of TMD Susan Armijo-Olivo, Laurent Pitance, Vandana Singh, Francisco Neto, Norman Thie, Ambra Michelotti
  40. 40. Pain intensity at 4 weeks to 3 months: manual therapy plus excercises versus control group in patients with arthrogenous temporomandibular disorders. Susan Armijo-Olivo et al. PHYS THER 2016;96:9-25 © 2016 American Physical Therapy Association
  41. 41. Tx Randomized or quasi randomized clinical trials have reported that all treatment methods are equally effective and that treatment success rate is not therapy specific but due to an interaction of confounding factors such as spontaneous remission, counseling and information, context effect, patient expectation and cognitive tx
  42. 42. An average painintensity reduction of 27% was found after the first consultation, which provided only a diagnosis and no specific treatment. Extensive research by Benedetti and colleagues provide detailed information about several aspects of the neurobiological mechanisms of the placebo (and nocebo) effect. The key aspect of the placebo effect is expectation. Frisaldi E, Piedimonte A, Benedetti F. Placebo and nocebo effects: a complex interplay between psychological factors and neurochemical networks. Am J Clin Hypn. 2015;57(3):267-284. Benedetti F. Placebo effects: from the neurobiological paradigm to translational implications. Neuron. 2014;84(3):623-637.
  43. 43. 1959 TvT Dento-maxillaire, faciale, craniale en cervicale orthopedie JAC Duyzings Posture Total body approach
  44. 44. challenge today
  45. 45. NVOF Drs Marianne Gerrits, voorzitter
  46. 46. Dank voor uw aandacht
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    Apr. 23, 2016

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