Dr. Anton de Wijer is a specialist in special dental care, TMD and orofacial pain at the UMC St Radboud in the Netherlands. His practice focuses on treating temporomandibular disorders (TMD) using a multidisciplinary approach involving psychologists, manual therapists, dentists and other specialists. The document provides statistics on patients seen in his practice, describes the multidisciplinary treatment approach used at his clinic, and discusses the links between TMD and neck pain based on current research findings.

1. de kaak in al zijn facetten
dr. Anton de Wijer
UMC St Radboud Special Dental
Care, TMD and Orofacial pain
VSOP

2. Hoofd-hals team
Psycholoog FT-gnatholoog Manueel tx tandarts-specialist consultant
www.academieinstituut.nl
Praktijk; outdoor patient facility

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. 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. 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. Hoofdpijn
kaakpijn
Aangezichtspijn
Nekpijn
Diagnostiek Therapie

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. 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. Pijn gebieden TMD MYO

10. Myo-TMD patients with ‘widespread’ pain:
STx + NSTx

11. Neurologische, biomechanische en kinesiologische interacties

12. Anatomie

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. 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. 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. Persistant orofacial muscle pain [pomp]
R. Benoliel, Svensson, Heir, Zakrzewska et al Oral Diseases 2011,

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. 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. 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. 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. Casus

22. Casus

23. Casus

24. Casus

25. casus

26. casus
Kaakchirurg
Manueel
therapeut

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. 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. INSPECTIE

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. 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. 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. DC TMD update van RDC TMDSchiffman et al 2014
Conclusion:

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. Pain is dental until proved negative!
Panoramic photo
Teeth
Mucosa
Bone
Nerve
Muscle
Joint

36. Treat all circles
• Biopsychosocial model
pain
Cognitions
Physiology Behaviour

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. 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. 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. 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. 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. 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. 1959 TvT
Dento-maxillaire,
faciale, craniale en
cervicale orthopedie
JAC Duyzings
Posture
Total body
approach

44. challenge today

45. NVOF
Drs Marianne Gerrits, voorzitter

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