5- muscular treatment

What is the most common and predominant symptom of TMD

Myalgia

How are muscle disorders classified?

Acute, chronic, systemic

CNS determined how chronic

If acute not resolved quickly CNS- transforms it into chronic- harder to treat

What is protective co contraction- etiology, when, causes, clinical signs

Initial physiological response (muscle splinting) to protect an injured part

Alteration of sensory stimulus, constant deep pain or acute increase in stress

Appears immediately after stimulus, persists for few days

Causes reduced range of motion, but can achieve MO

Minimal pain at rest but increases with function, muscle weakness

How do you treat protective co-contraction?

Must treat underlying cause- eliminate etiological factor

Restrict mandibular use to painless limits, soft diet

Short term analgesics (NSAIDs) if pain

NO vigorous physical exercise

What is local muscle pain- etiology, when, difference between protective co-contraction?

Primary non inflam pain- 1st response to unresolved co-contraction

Prolonged co contraction, local tissue trauma or chronic emotional stress

Delayed onset- hours or days after an event, injection or excessive MO

How do you treat local muscle pain?

Reduce sensory stimulus reaching CNS to break pain loop

Definitive- Muscle relaxation device (occlusal splint) at night if bruxism suspected

Painless range of motion- but not ABSOLUTE REST, soft diet, teeth apart, passive muscle stretching and massage

NSAIDs 5-7 days

What is myofascial pain- etiology, primary clinical sign, example, diagnosis?

Regional myogenic disorder characterised by hard hypersensitive bands of muscle tissue (trigger points)

Constant deep pain, stress, disturbed sleep, poor posture, fatigue

Central excitatory effects that generate referred pain

E.g traps or neck pain referred upwards perceived as tension headache

Palpating taut muscle band immediately increases referred pain- must treat this not secondary symptom

How do you activate/treat trigger point?

Painless stretching, correct posture and sleep habits

1- spray and stretch- apply vapocoolant spray (fluoromethane) then stretch muscle to full length

2- pressure and massage- up to 9kg for 30-60sec

3- inject LA (1-2% lidocaine no VC) then stretch

STRETCH most important- spray and needle just prevent triggering a pain reflex

What is a myospasm- acute tonic contraction- etiology, when, causes, exam?

Involuntary CNS induced tonic muscle contraction

Continuous deep pain, severe muscle fatigue, metabolic imbalances

Sudden

Severe restriction of mandibular mobility- acute malocclusion

Feels hard, rigid, difficult to palpate- intense pain even at rest, it’s physiologically locked

How do you treat myospasms?

1. Pain reduction by deep manual massage with with cool spray or lidocaine injection

2. Passive stretch after calming pain- full length

Prioritise prevention with muscle rest and electrolyte restoration

If recurrent- Botox A injections- temp paralysis for 3-4 months

What is centrally mediated chronic myalgia- etiology, when, clinical sign, long term risk?

Continuous chronic muscle pain disorder

Prolonged presence of algogenic substances due to neurogenic inflammation

Constant primary pain from unresolved acute pain event

Limited opening, sever pain at rest and palpation

Muscle atrophy or myostatic contracture- longer it goes untreated, higher chance that CNS will develop neuroplasticity and fix pain chronically

How do you treat chronic myalgia?

Strict restriction- limited mandibular opening to minimum, severe soft diet, local moist heat

Caution when taking NSAIDS- ibuprofen 600mg x 4 daily x 2 weeks + use relaxation splint

Avoid local injections and early stretching exercises

What is fibromyalgia- clinical signs, coexist, dental protocol, adjunct drugs?

Systemic chronic musculoskeletal pain disorder

Generalised pain, severe fatigue, poor sleep- diagnosed when tenderness in 11-18 specific points

Coexist with chronic masticatory muscle pain

Conservative and palliative care

Low dose tricyclic antidepressants (Amitriptyline 10-50mg) to improve sleep

Refer to rheumatologist

Disuse sequelae will appear after resolving chronic disorders with prolonged immobilisation…what types?

Hypotrophic alterations- loss of strength and amass in elevator muscles

Myostatic contractures- painless shortening of og muscle strength

Rehab phase- introduce activity slowing only after all acute and inflam symptoms gone

Do gentle isometric mandibular exercise against resistance and controlled passive stretching