Transcript occlusal factors

ETIOLOGY
Clinical A/P Chua Ee Kiam
(BDS, MDS, FAMS, Diploma in Guidance & Counselling
INTRODUCTION
 Disorders of the TMJ similar to other joints in the
body (/)
 Confusing terminology add to confusion of the
etiological factors (X)
 TMD became a multi-factorial etiology disorder (X)
CONCEPTS OF TMD
1. Costen’s Syndrome (1934)
He reinforced & established the occlusal &
biomechanical approaches
2. Psychophysiological (1960-70) -the impact of physiological
states and systems on psychological states and processes
3. Disc displacement (1970- 80’s)
Intra-capsular problems were clearly defined by
anatomical & radiological studies
4. Current Concepts
Emotive states and their impact on persons health
SIGNS & SYMPTOMS
1.
2.
3.
4.
Functional Jaw Pain
TMJ sounds (crepitations & clicks)
Limitation of mouth opening
Recurrent Headache
ETIOLOGY
 Macrotrauma
 Repetitive loading
 Occlusal factors
 Stress & bruxism
 Systemic conditions
 Abnormal growth
 Psychological factors
 Genetic / Gender factors
ETIOLOGY
Macrotrauma
- iatrogenic
[extraction of 3rd molar, intubation, long
dental procedures, yawning]
- accidental or intentional sudden force
[fights, RTA, falls]
ETIOLOGY
Macrotrauma
- 25 % had jaw trauma and 32% had iatrogenic trauma
[Katzberg et al, 1980]
- 30 % had major traumatic event [Pullinger et al, 1985]
TRAUMA – DISPUTED
FRACTURED, DISLOCATED CONDYLE
 Surgical fracture of condyles of Rhesus monkeys
 - reduced vs non-surgical closed reduction
 - regeneration in the latter (Walker,1960); little deformity
noted (Boyne, 1967)
Studies on trauma of the TMJ suggest remarkable
adaptive properties of the entire masticatory system
Application : Some patients would like you to attribute their current jaw problems
to their previous history of non-recent trauma to the oro-facial tissues
h/o Right retro-discitis and temporal
tendonitis, arthroscopy
Use of Cervical traction on painful
displaced TMJ disc (x)
ETIOLOGY
 Macrotrauma
 Repetitive loading
ETIOLOGY
Repetitive loading
Destructive oral habits
[excessive chewing, hard foods, unilateral
chewing, certain occupation or activities,
unnatural posturing]
ETIOLOGY
Biting force
- Average
=
- Maximum
=
- Controlling factors
22 kg [Gibbs et al, 1986]
3-5x in nocturnal bruxism
[emotional status, pain threshold, number of teeth, periodontal status]
Application
Can surgical disc reduction work?
Can replacement of disc with plasticized materials work?
ETIOLOGY
Repetitive or Chronic loading
Muscle and joint problems had been reported
by violinists and scuba divers
[Pinto,1966; Reider, 1976]
Common to clench during weights training
ETIOLOGY
 Macrotrauma
 Repetitive loading
 Occlusal factors
ETIOLOGY
OCCLUSAL FACTORS/ ROLE OF OCCLUSION
1. Malocclusion
2. Bruxism
3. State of occlusion
(NWSC, Canine or Group function, Dentate vs Edentulous)
4. Occlusal Dysharmony (Muscle symmetry)
5. Unilateral Chew
6. ICP VS RCP
7. Repositioning
8. Condylar positioning
ETIOLOGY
Malocclusion
Unstable occlusion lead to muscle hyperactivity
[Olson, 1970; Moller et al, 1984; Stohler et al, 1988]
Application : Use of Jaw pulsing machines to reduce “hyperactivity”?
ETIOLOGY
Malocclusion
Occlusal contacts & chewing patterns [Gibbs et al, 1971]
Subjects with malocclusion
- on mastication had shorter occlusal contacts;
- and chewing patterns are irregular & less coordinated
ETIOLOGY
Malocclusion
No difference in TMD S&S between subjects with or without
Ortho Tx n=402 adolescents followed up for 5 & 10 years
Egermark et al 2003
Using meta analysis–data does not indicate that Ortho tx
increased prevalence of TMD
Kim et al, 2002
ETIOLOGY
MALOCCLUSION
Early treatment of malocclusion to prevent grinding / clenching is not
supported by longitudinal studies
Vanderas & Manetas Pediatr Dent, 1995
ETIOLOGY
DENTAL OCCLUSION
Body of knowledge and practice of occlusion
should be taught systematically in the dental
curriculum
However, occlusal adjustment (OA) is
irreversible and is not usually recommended in
the Tx of TMD
Non-working (balancing side) in mediotrusive
position dentate patients is not an occlusal
interference
ETIOLOGY
OCCLUSAL ADJUSTMENTS
Meta-analysis on Occlusal Adjustments
Koh H & Robinson PG, Cochrane Database Systemic Review, 2003:
Occlusal adjustments are ineffective for treating or preventing
TMDs
ETIOLOGY
STATE OF OCCLUSION
1. Non-working side contacts
- Ramfjord, 1961 claimed NWS interference were destructive in nature (X)
- Ingervall, 1972 found 85% of his sample had NWS contact on lateral
excursion;
18% canine rise (/)
- Barghi & co, 1979 found no symptoms in those with NWS contacts (/)
ETIOLOGY
STATE OF OCCLUSION
2. Canine function vs Group function
Which type of occlusion reduces occlusal forces better in
splints?
ETIOLOGY
STATE OF OCCLUSION
3. Dentate vs Edentulous (loss of teeth)
ETIOLOGY
4. Others
cross-bites, overjet
dual bites
differential wear
large RCP to ICP slides
ETIOLOGY
OCCLUSAL FACTORS/ ROLE OF OCCLUSION
1. Malocclusion
2. Bruxism
3. State of occlusion
(NWSC, Canine or Group function, Dentate vs Edentulous)
4. Occlusal Dysharmony (Muscle symmetry)
5. ICP VS RCP
6. Condylar positioning
OCCLUSAL DISHARMONY
 No evidence that premature contact between
opposing teeth can initiate or maintain prolonged
hyperactivity of jaw closing muscles (Yemm, 1976)
 MPD syndrome patients were relieved of
symptoms by grinding the teeth
Ramfjord, 1983; Shore, 1976) (X)
(Dawson, 1974;
 64% of patients had improvements with mock
equilibration
(Goodman, 1976) (X)
 Interference not the cause (La Bell et al, 2002)
ETIOLOGY
OCCLUSAL FACTORS/ ROLE OF OCCLUSION
5. ICP VS RCP
More pain elicited in patients with TMD in RCP
Therapeutic position in splints
ETIOLOGY
Condylar positioning
- non-concentric or concentric position
ETIOLOGY
Occlusal Factors
1. Condylar positioning
- non-concentric or concentric position
- position of centric relation [Posselt, 1951]
ETIOLOGY
 Macrotrauma
 Repetitive loading
 Occlusal factors
 Stress & bruxism
ETIOLOGY
Stress
It is the disruption and disorganisation of the
individual's physical and mental condition
resulting from the effects of uncontrollable
external events.
Lundeen et al,1987 JOR 14:447
Stress is a non-specific response of the body to
any demand made upon it
Dr Hans Seyle
ETIOLOGY
Bruxism
Static or dynamic contact or occlusion in the teeth at times
other than for normal function such as mastication or
swallowing.
[or clenching or nocturnal grinding]
STRESS & BRUXISM
Bruxism is thought to be a physical
manifestation of an emotional problem
Stimulation of brain area associated with
responses to stress causes an increase in
excitability of motor neurons of jaw-closing
muscles (Landgren, 1977)
STRESS & BRUXISM
Grinding resolves when life crises
resolve
[Carlsson, 1976; Funch, 1980; Rugh,
1975, 1988]
Increased urinary levels of
cathecholamines
were correlated with nocturnal
masseter activity
[Clark, 1980]
ETIOLOGY
Stress
- High correlation between muscular pain and
stressful life events
[Brooke, 1977; Lundeen, 1987; Lupton, 1969; Rugh, 1983]
- TMD patients experienced 2x more stressful
events controls
[Speculand, 1984]
ETIOLOGY
Bruxism
1. Psychological Input
2. Muscular Input
3. Dental Input
EMG RECORDINGS
 Development of portable EMG instruments
(Burgar & Rugh, 1983)
 Aid in identification of oral habits due to
increase in masticatory muscle activity
 EMG evaluations of resting muscle activity
 Patients with MPD tended to respond to stress
with greater masticatory and facial muscle
activity (Johnson, 1972, Mercuri, 1979)
IDENTIFICATION OF MUSCLE HYPERACTIVITY
& ORAL HABITS
 Interviews – awareness, reports by others
 Questionaires – oral symptoms, life-styles
 Pain & activity charting - insights regarding
cyclic trends
 Clinical examination
 EMG recordings
BRUXISM
Effect on :1. Masticatory Muscles
- contraction of muscles bring teeth together
- which increases muscle tension
- lactic acid accumulation
- hypertrophy of muscle
- cause splinting, trismus, contracture
ETIOLOGY
BRUXISM
Effect on :- TMJ
- cause pain
- disc displacement
- bone changes
ETIOLOGY
BRUXISM
Effect on :- Teeth
- teeth are subjected to wear
- mobility of teeth
- fractured teeth and restorations
ETIOLOGY
Bruxism
Effect on :Teeth
ETIOLOGY
Bruxism
Effect on :Teeth
EFFECTS OF BRUXISM
ON TEETH & ORAL TISSUES
ETIOLOGY
Bruxism
Effect on :Mucosa
Association between
Nocturnal Bruxism & Sleep
Bruxing is a 8 sec per event [Clarke et al, 1979]
In bruxists those with pain had more bruxing events during
REM sleep [ Ware & Rugh, 1988]
Level of sustained contraction is higher in REM than nonREM sleep [Rugh & Ware, 1987]
Sleep Cycle
- In adult 80% non-REM & 20% REM sleep
-
REM sleep last about 5-15 mins.
complete cycle of sleep = 60-90 mins.
non-REM sleep restore body functions
REM sleep restore function of cortex &
brain
ETIOLOGY
Systemic Conditions
1. Joint Laxity
2. Rheumatoid Arthritis
3. Reiter’s Syndrome ("the patient can't see, can't pee and can't bend the
knee“)
4. Systemic Lupus Erythematosus
ETIOLOGY
Systemic conditions
1. Joint Laxity
No association was found between intra-articular disorders and systemic
hypermobility (p > 0.05).
Relationship between systemic joint laxity, TMJ hypertranslation, and intraarticular disorders.
Conti PC, Miranda JE, Arauio CR; Cranio. 2000 Jul;18(3):192-7.
ETIOLOGY
Systemic conditions
1. Joint Laxity
2. Rheumatoid Arthritis
ETIOLOGY
Systemic Conditions
In patients with systemic conditions such as
psoriasis, poly rheumatoid arthritis & Sjogren’s
syndrome
- 33% had radiographic erosions of TMJ and
- 54% had anterior open bite
[Nordahl S et al, Acta Odont Scan 1997]
RA
Rheumatoid Arthritis
- degenerative & inflammatory forms
- auto immune disease
- destruction of synovial tissues
- rapid arthritic breakdown produces painful articular
symptoms & masticatory muscle symptoms
Psoriatic Arthritis
Pain R TMJ x 3 years;
ROM 25/32mm; AOB
1 year later – flattened
L>R condyles; RA
ETIOLOGY
 Macrotrauma
 Repetitive loading
 Occlusal factors
 Stress & bruxism
 Systemic conditions
 Abnormal growth
ETIOLOGY
Abnormal growth
- Enlarged condyle
- Enlarged coronoid
- Hypertrophy of masticatory muscles
- Abnormal active growth of jaw
- Tumour
ABNORMAL GROWTH
 ENLARGED CORONOIDS
Past history of jaw stuck x 3 years; Jaw shifts to left on
opening;Class III
Dx: Hypoplasia R condyle
ETIOLOGY
 Macrotrauma
 Repetitive loading
 Occlusal factors
 Stress & bruxism
 Systemic conditions
 Abnormal growth
 Psychological factors
Prevalence of TMD subtypes, psychologic distress &
psychosocial dysfunction in Asian patients
Yap AUJ, Chua EK et al
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
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J Orofac Pain 2003 (17) 21-8
n=191 TMD patients
Mean Age: 38.4yrs (16-65, majority 25-44)
Female: Male
: 3.1 : 1
Muscle Disorders
: 31.4%
Disc displacements
: 15%
Arthralgia, arthritis, arthrosis
: 13%
Depression
: 39.8%
Somatization
: 47.6%
Depressive symptoms in Asian TMD patients and their
association with non-specific physical symptoms reporting
Yap AUJ, Chua EK & Tan KBC J Oral Pathol Med 2004; 33: 305-310
 Significant and strong correlation
(r = 0.74) was observed between
depression and reporting of
multiple non-specific physical
symptoms
ETIOLOGY
Psychological factors
1. Chronic pain
2. Anxiety levels
3. Depression
4. Personality Profile
5. Emotional Distress
ETIOLOGY
Psychological factors
1. Chronic pain
2. Anxiety levels
- 26% more anxious [Fricton, 1985]
- less tolerant of pain when anxious [Melzack, 1984]
ANXIETY (AN EMOTIONAL STATE)
Pain thresholds are lowered and pain conditions feel worse during
anxiety. Anxiety may elicit a variety of oral habits.
• 26% of MPD patients were clinically anxious
[n=16; Fricton, 1985]
• 17% suffer from anxiety [Gerschman, 1987]
• 62% had major life event preceding treatment
[Marbach, 1978]
FEAR
PAIN
SLEEP
DEPRIVATION
ANXIETY
ETIOLOGY
Psychological factors
1. Chronic pain
2. Anxiety levels
3. Depression
DEPRESSION
 Lowers pain threshold and decrease patient’s
willingness to tolerate pain
 Objective outcome maybe good but subjective outcome
poor
 52% moderately depressed (n=368 of chronic facial
pain patients) & 18% severely depressed
[Gerschman, 1987] Hamilton Depression Scale
 23% depression (n=164) [Fricton, 1985]
ETIOLOGY
Psychological factors
1. Chronic pain
2. Anxiety levels
3. Depression
4. Personality Profile
History of HA, Insomnia, difficulty breathing, tongue discomfort,
pain left masseter & temporal, discomfort on palatal of upper teeth,
upper teeth had descended, lower teeth shifted
RED FLAGS
1.
2.
3.
4.
5.
6.
7.
Clinically significant anxiety or
depression
Evidence of drug abuse
Repeated failures with conventional
therapies
Evidence of secondary gain
Over dramatization of symptoms
Inconsistent, vague or inappropriate
report of pain
Major life events
ETIOLOGY
Psychological factors
1. Chronic pain
2. Anxiety levels
3. Depression
4. Personality Profile
5. Emotional Distress
ETIOLOGY
Genetic factors
NATURE: The human genome
- The sequence of the human genome
(Feb 15, 1981)
Looking at diseases in a new way
ETIOLOGY
Genetic factors
NATURE: The human genome
- The sequence of the human genome
(Feb 15, 1981)
Looking at diseases in a new way
Zhifeng Zhu et al, Nature Vol. 452 24 April 2008 p 997-1002
Genetic variation in human Nucleopeptide Y (NPY) – gene that affects
mood
ETIOLOGY
Gender factors
Why women?
Bingekors K & Isaacson D European J of Pain 2004 :8, 435-450
Females are more prone to HA 3.6:1; Shoulder ache 2.6:1; Back ache >1:1 ; Arms & legs .1:1)
Females different pain system – different receptor system
Gender specific pains – Labour pains & menstrual pains are natural and second nature
Injected saline in 22 year olds males and females
During follicular phase in females -estrogens levels high
During this period, Males show up with less pain 3.5/10; females 5.5/10)
And to maintain same pain levels more infusion is needed in males.
ETIOLOGY
 Macrotrauma
 Repetitive loading
 Occlusal factors
 Stress & bruxism
 Systemic conditions
 Abnormal growth
 Psychological factors
 Genetic / Gender factors