Modern Bettfysiologi från n bett till själ Gunnar E Carlsson Modern bettfysiologi från n bett till själ Kortversionen: Bettstörningar i går Stress, psykosociala och själsliga faktorer i dag Del i allmän n smärtproblematik i morgon? Bettfysiologi sysslar med käksystemetksystemet Käk- eller tugg- systemet är en funktionell enhet av stor betydelse för r individen Vad är r käkledsbesvk kledsbesvär/tmd? Den klassiska symtom-triaden triaden: Smärta i käkled kled och tuggmuskler Käkledsljud Nedsatt eller störd käkfunktionkfunktion Patientrapporterade symtom: Ont i/framför öronen, ont i käkarna, ont i ansiktet, svårt att gapa, käken ken låser l sig, huvudvärk Idag är r begreppet vidgat till orofacial smärta och funktionsstörning Livskvaliteten är r sämre s hos patienter med käkledsbesvk kledsbesvär Acta Odontol Scand in press Temporomandibular disorders and oral healthrelated quality of life. A systematic review. Lars Dahlström & Gunnar E Carlsson A TMD patient Pain on the right side of the face in a 55-year year-old woman Slutsats: De granskade artiklarna visade övertygande att livskvaliteten är försämrad hos patienter med käkledsbesvär OPG shows osteo-arthrotic changes in left TMJ. Muscular or joint problem? 1
Käkledsbesvär är r ett kontroversiellt område de: terminologi, prevalens, diagnostik, behandling etc. Funktionsstörningar i tuggsystemet Käkledsbesvär Kraniomandibulär dysfunktion Käkfunktionsstörning TMD pain is by far the most common of the chronic orofacial pain conditions (LeResche 2001) Epidemiologi Läran om sjukdomars utbredning och deras samband med olika faktorer Costen s syndrome TMJ syndrome Myofascial pain-dys dys- function syndrome MPD Craniomandibular disorders CMD Temporomandibular disorders TMD Orofacial pain 1974 Göran Agerberg och Martti Helkimo,, de första TMD- epidemiologerna 1975 Prevalens av käkledsbesvk kledsbesvär Det är stor variation mellan olika studier men mellan 1/3 och 1/2 av vuxna har angett att de har åtminstone ett symtom Mer än hälften har kliniska tecken som kan relateras till funktionsstörning MEN, detta kan inte översättas till behandlingsbehov!!! Enstaka symtom är inte käkledsbesvk kledsbesvär! 3-7% har sökt s vård v för r TMD enligt olika studier Age and sex distribution of 3428 TMD patients in 3159 patients referred to a TMD specialist clinic in Sweden (Sundqvist,, Magnusson 2001) Age and sex distribution of 3428 TMD patients in Seattle, USA (Howard 1991) Women seek care for TMD more often than men in all studies all over the world. Why? Gender differences in TMD biological, physiological tolerance to pain hormonal (estrogen receptors in TMJ, exogenous hormones/oral contraceptives) psychosocial sex-role behavior cultural, expectations But there is no strong evidence for a dominating explanatory factor Summary of TMD Epidemiology In children, signs and symptoms of TMD are usually mild and fluctuating, and there is no evidence that they regularly progress to more severe conditions in adult age In elderly people, reporting of TMD symptoms decreases with increasing age, even if clinical signs are as or more prevalent than in younger subjects 20-50 50-year-old women have most TMD signs and symptoms and are the most prevalent patients in TMD clinics 2
Ökar prevalensen av TMD? 50-åringar undersökta 1992 och 2002 (Unell et al 2004, 2006) 50 45 40 35 30 25 20 15 10 5 0 Not healthy Medicine:2 w Sick list:3 m Smoke daily Snus daily Unemployed Shift work Element school 50 45 40 35 30 1992 25 2002 20 15 10 5 30 25 20 1992 2002 1992 15 2002 10 5 0 TMD pain TMJ sounds Diff open Bruxism mouth Incidence of TMD Our knowledge of incidence is limited because longitudinal studies are required, and they are rare The few studies available have reported 1% to 3% new cases per year With an incidence of 2% there will be 180 000 new TMD cases/year or 26 new patients per dentist/yr in Sweden 0 Toothache Sensitive teeth Dry mouth/n Mouth blisters Incidence new findings From Susanna Marklund s s thesis 2009 Umeå University, Sweden 2009 Orofacial pain may originate from: But there may be differential diagnostic problems Teeth, jaws Masticatory muscles, TMJs Sinus + ear, nose, throat Neuralgias, eyes Headaches and other origin Research Diagnostic Criteria for TMD Diagnostic groups RDC/TMD Muscle Disorders myofascial pain with and without limited opening Disc Displacements with reduction, without reduction with and without limited opening Arthralgia,, Arthritis, Arthrosis Jämför Helkimos Index 1974: ofta använt nt men kritiserat. RDC/TMD fick stark kritik av Steenks & de Wijer i JOP 2009 Dworkin & LeResche 1992 3
Käkledsbesvärens epidemiologi Även om prevalens av TMD symtom varierar mycket mellan epidemiologiska studier kan man dra slutsatsen att sådana s symtom är r vanligt förekommande i befolkningen Den höga prevalensen av TMD symtom visar att tandläkare behöver kunna diagnostisera och känna k till behandlingsmöjligheter vid käkledsbesvk kledsbesvär. Detta gäller g också läkare eftersom många m TMD patienter först f söker s dem! Käkledsbesvärens kontroversiella etiologi 1. Ocklusala störningar 2. Psykologiska faktorer 3. Kombination av 1 och 2 4. Multifaktoriell 5. Biopsykosocial 6. Idiopatisk TMD är r inte en sjukdom utan ett antal olika tillstånd och störningar i den orofaciala regionen, så det är självklart att orsakerna varierar Factors may be Predisposing increase the risk Initiating cause the onset Perpetuating interfere with healing Factors may serve any or all of these roles! The most well-known controversies in TMD etiology Occlusal / local Factors Occlusionists Combination of both Hybrid theories Psychological / general Factors Non-occlusionists Dogma: Occlusal disturbances cause or are closely related to TMD Why do women have more TMD signs and symptoms than men? They have no worse occlusion! Elders have less TMD problems but worse occlusion than young people!!! 4
Occlusion in dental practice Ulf Posselt (1914(1914-1966), internationally wellwell-known and much quoted during the latter half of the 20th century Every dentist is every day performing diagnostic and therapeutic procedures which include the occlusion 1:a uppl 1962; 2:a 1968. e.g. a simple filling, filling, a crown, crown, more extensive fixed prosthodontics, removable dentures, dentures, orthodontics, orthodontics, implantimplant-supported prostheses, prostheses, and perhaps on TMD patients? patients? Ulf Posselt (center), Henry Beyron (right) Occlusion is complex How to analyze occlusion? Malmö Malmö in 2009 Today Malmö is more known as the city with the Turning Tower 1981 Number of teeth Jaw relations Occlusal contacts Occlusal interferences Occlusal stability Individual occlusion is characterized by great variation in occlusal morphology jaw relations individual adaptability IJP 1999 Occlusion and TMD Management Occlusion is in general not at all or only very weakly associated with TMD Occlusal therapy has therefore hardly any place in management of TMD Counseling and simple reversible methods should be the first choice in management of TMD patients Tidigare bett-centrerade behandlingar har ersatts av fysioterapi och kognitiv beteendeterapi. Hur bettet ser ut betyder mindre än hur det används. 1973 5
Dogma: Bruxism is caused by occlusal interferences bruxism can be stopped by complete elimination of all occlusal interferences (Dawson 1974) Bruxism There is no evidence to support the concept that bruxism is caused by occlusal interferences, and it is now abandoned. The etiology is multifactorial and related to the central nervous system Bruxism during wakefulness is different from bruxism during sleep Sleep medicine calls bruxism a sleep movement disorder or a parasomnia Kato et al JOP 2003;17:191-213. 213. 264 references! Populära aspekter påp orsaker orsaker (AB 2006-11 11-13) 13) Role of psychosocial factors in the etiology of bruxism Wake clenching seems to be associated with psychopathological symptoms There is no evidence to relate sleep bruxism with psychosocial disorders Bruxism during wakefulness is different from bruxism during sleep, so future research must distinguish better between the two forms of bruxism! Manfredini & Lobbezoo 2009; systematic review The role of oral parafunctions in TMD etiology is not conclusive. Several studies have found significant associations, others have not Mundt et al. IJP 2008: yes,, to some extent Wänman, Marklund.. AOS 2008: yes Johansson et al. AOS 2008: yes Rosetti et al. CRANIO 2008: no Barbosa Tde et al. IJPO 2008, Review: Taken all evidence together, the relationship between bruxism and temporomandibular disorders, if it exists, seems to be controversial and unclear. Johansson et al. JOR 2006: The strongest risk indicator for both pain and dysfunction was reported bruxism 90 80 70 60 50 40 30 20 10 0 Gerodontology 2007;24:129-135 NB! Comorbidity between TMD and other health problems! Chest pain Relaxation difficulty Restlessness Concentration difficulty Easily irritated No symptom Headache No symptom 1 symptom Stomach pain 1 symptom Dizziness 2 symptoms 2 symptoms Eye complaints Breathlessness General tiredness Back pain Leg pain Bruxism Neck pain Burning Mouth Joint problem mouth dryness 0 20 40 60 80 6
Comorbidity of TMD and other diseases/conditions Headache Neck/shoulder pain Impaired general health Fibromyalgia / widespread pain Spinal pain (neck, shoulder, low back) Tinnitus Eating disorders Conclusion: TMD and these diseases may share risk factors, or they may influence each other TMD och funktionshinder Käkfunktion hos neurosedyn-skadade: i stort sett normal bett- och käkfunktion; 1/3 hade Klass III eller kant-i-kant bett; ökat tandslitage beroende på erosion: ofta sura uppstötningar (fanns hos 42%) Ekfeldt & Carlsson AOS 2008 Ätstörningar och TMD: starkt ökad prevalens av TMD och orofaciala symtom hos patienter med ätstörningar Johansson et al 2009 Sällsynta sjukdomar och TMD PubMed anger > 200 artiklar! Acta Odontol Scand 2009 Nov. Diagnosis and diagnostic methods 1. Limited functional examination in routine dental patients (1 to 2 minutes!) 2. Extended examination in TMD patients The all-important case history Listen carefully to the patient s s history it may give you the diagnosis Create as calm an atmosphere as possible Reassure and comfort the patient Focus on the patient s s main problem! Emphasize the good prognosis for simple treatment 7
Treatment of TMD The precise etiology of most TMD forms is not well known, but successful management is still possible! When working with TMD, it is not only the mouth that is of interest - the whole person! Not a probable TMD patient - rather treatment for TMD Job stress may lead to TMD and other disorders Interocclusal Appliances However, there are other possible mechanisms of efficacy: are common in treatment of TMD. The most common type is the Stabilization Appliance They are thought to be effective by means of occlusal stabilization Neurophysiological Behavior modification Increased vertical dimension Changed condylecondyle-fossa relationship Stress absorber Placebo effect Anterior Bite Plate (Relaxation Plate, Hawley Plate, etc) uses a quite different mechanism but are as effective effective And the Placebo Splint does not cover the occlusion at all but is also effective! Interocclusal appliances can be recommended as effective in treating TMD Placebo splints (without influence on occlusion) are almost as effective as real real the mechanism is not well known but may not be more than marginally related to occlusal factors are effective in protecting teeth in bruxism cannot predictably stop bruxism but may reduce bruxism after longlong-term use 8
Management of TMD The majority of TMD patients can and should be managed in general dental practice A minority of the TMD and orofacial pain patients need to be managed in specialist settings Vid behandling av käkledsbesvk kledsbesvär är Hippokrates regler ännu giltiga: ibland bota, ofta mildra, alltid trösta Kos,, Greece Hippokrates 460-370 BC Till slut en sammanfattning Historien om TMD är full av kontroverser av vilka många m ännu inte är r löstal Bristen påp välkontrollerade studier bör r göra g oss försiktiga f med tvärs rsäkra påstp ståenden Dock, även om vi inte alltid kan vara säkra s påp diagnostik och etiologi av patienternas besvär r finns det enkla behandlingar som kan hjälpa flertalet patienter och som kan användas ndas i allmänpraktiken Tack för uppmärksamheten rksamheten! Och snart är r nog våren v här h r igen! 9