Transcript il danno perimetrico come danno biologico in responsabilita* civile

TMJ Pain and Neuropathic Pain
in Patients with
Temporomandibular Joint Disorders
Dr. Gaetano Meli
Symptoms and signs of TMJ
disorders
•Lateral deviation of the jaw during the mandibular
range of motion
•Bruxism
•Presence of sounds or clicks during the jaw movement
•TMJ pain
•Neuropathic pain (facial numbness and dysesthesia,
headache, toothache and earache)
•Reduction of the mandibular opening
•Sleep and Psychological disorders
•Spine disorders
Okeson JP, Management of Temporomandibular Disorders and Occlusion, 2006
Different types of Pain
TMJ PAIN
•When pain is located in the proximity of the
temporomandibular joint
NEUROPATHIC PAIN
•Involving greater portion of the orofacial region
and it is associated with the onset of sensory
deficits of the head (facial paresthesia,headaches,
toothache, and ear sounds)
Okeson JP, Management of Temporomandibular Disorders and Occlusion, 2006
Neuropathic pain prevalence
Dupont JS, Cranio, 2003
Bell classification OF TMD
Masticatory muscle
disorders
Temporomandibular joint
disorders
Chronic mandibular
hypomobility
Growth disorders
Disc displacement with or
without reduction
Ankylosis
Congenital or
developmental
bone disorders
Local muscle
soreness
Structural incompatibility of
the articular surfaces
Muscle contracture
Congenital or
developmental
muscle disorders
Myofascial pain
Inflammatory
conditions
Coronoid impedance
Protective
co-contraction
Myospasm
Centrally mediated
myalgia
Okeson- Bell; American academy of orofacial pain, 1996
Relationship among pain and MRI findings
Emshoff, 2001-2003
“Not all patients have the
same reaction to a given
stimulus.
They exhibit a differing
grade of individual
physiological tolerance
(Okeson)
Temporomandibular joint disorders
Click
Temporomandibular joint disorders
Lock
Temporomandibular joint disorders
Osteoarthrosis
Subchondral Cyst
Which are the causes of the onset
of neuropathic pain?
The first mention of a possible clinical
relationship among atypical trigeminalgia and
temporomandibular disorders was proposed by
Costen and dates back to 1934.
He hypothesized that in those patients
the disc and/or condyle may directly damage
the mandibular nerve and/or its branches by
exerting intermittent compression, traction or
friction during the jaw opening
Anatomy
Netter plates
MRI
Prospective case-control analysis
Study Group A
16 TMJs with TMJ-D
and neuropathic pain
Control Group B
16 TMJs with TMJ-D
without neuropathic pain
Control Group C
16 healthy TMJs
Selection criteria
No significant sex or age differences among the three
groups
Clinical diagnosis of TMJ-D achieved by
“Clinical diagnostic criteria for TMD” (Truelove)
Presence of neuropathic pain assesed by
the “neuropathic pain diagnostic questionnaire” (Bouhassira)
DN4 Neuropathic Pain Diagnostic Questionnaire.
Interview of the patient
Question 1 : Does the pain have one or more of the following characteristics?
1.Burning
yes
no
2.Painful cold
yes
no
3.Electric shocks
yes
no
Question 2: Is the pain associated with one or more of the following symptoms in the same area?
4.Tingling
5.Pins and needles
6.Numbness
7. Itching
yes
yes
yes
yes
no
no
no
no
Examination of the patient
Question 3: Is the pain located in an area where the physical examination may reveal one or more
of the following characteristics ?
8.Hypoesthesia to touch
yes
no
9.Hypoesthesia to prick
yes
no
Question 4: In the painful area, can the pain be caused or increased by?
10.Brushing
yes
no
Disc – mandibular nerve
distance
Case
Control
Pedullà, Meli, Garufi et al ; AJNR Am J Neuroradiol. Aug. 2009
Healthy subjects
Patients with TMJ-D
without neuropathic pain
Pedullà, Meli, Garufi et al ; AJNR Am J Neuroradiol. Aug. 2009
Distance of the TMJ disc to the mandibular nerve at the maximum jaw opening
in the study group A and in the two control groups B and C
TMJ
Study Group A
Control Group B
Control Group C
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Mean Value
Standard
10
6
4
9
8
5
9
3
7
6
7
5
5
4
5
7
6,25
2,01
10
8
9
10
9
9
10
5
7
9
6
7
11
9
5
7
8,18
1,83
10
11
12
9
8
10
10
11
8
7
7
8
13
11
8
8
9,43
1,82
Conclusion
•TMJ PAIN could be correlated to the presence of
internal derangement, effusion, osteoarthrosis, and
bone marrow edema within the TMJ
•TMJ NEUROPATHIC PAIN could be associated
to the presence of a mechanical impingement of the
TMJ disc on the mandibular nerve fibers
Thanks
for your time