J Bodywork and Movement Therapies 1997 (Jul): 1 (4): 208–213 ~ FULL TEXT
Clayton Skaggs DC
Head, Neck and Orofacial Rehab Center, Clayton Plaza, 7700 Clayton Road, Suite 109, St Louis, MO 63117, USA
Orofacial disorders (OFDs) often have histories that reveal predisposing and complicating factors that contribute significantly to the patient’s condition. This seemingly cumulative complexity of presentations observed with OFD
may be explained by Lewit’s reference to compensations often developing ‘upstream’ of joint dysfunction and muscle imbalance (Lewit 1991). This provides possible explanation for epidemiological studies showing a high prevalence of temporomandibular dysfunction (TMD) signs (90%) with approximately half of these presenting with symptoms (Solberg 1979).
Therefore early recognition, particularly in non-cervicocranial disorders of orofacial signs, may be critical in preventing chronic problems from developing. Management versus treating all of a given patient’s complicating factors is the difference between appropriate and poor care for the patient.
As mentioned earlier there are often many treatable factors and clinical presentations in chronic OFD. Using
the most current diagnostic classification, this case would fall under the categories of primary
headache disorders, temporomandibular disorders and associated structures (i.e. neck). The astute practitioner must be judicious in pursuing the elements that will produce the greatest beneficial effect with the least amount of risk and insult to future health. To put it simply, primary treatment should be conservative and simple. Qualification
as to what is considered appropriate conservative care is where disagreement persists within paradigms of management of OFD.
It is well established in the literature that management of occlusion is not essential in treating most TMD
(Carlsson et al 1984, Just 1991, McNamara 1995). It is also well established that cervical spine disorders
(CSDs) are predominant when TMDs are present and that CSD has more likelihood of being the primary mechanism vs TMD (McNeil 1990, Pandamesee 1994, Steenks et al 1996). It is strongly supported clinically as well as in the literature that muscle and myofascial dysfunction are more often the mechanism and source of pain in OFD than the TMJ (Janda 1986, Friction 1988). Additionally, it is suggested that there is high prevalence of abnormal illness behaviour, including parafunctional activity (such as nail-biting, bruxism) associated with the development or perpetuation of OFDs (Okeson 1996).
Therefore, the proposed conservative care for OFD of this classification should include:
manual techniques to address muscle imbalances of the masticatory system, neck and upper
exercises and training to facilitate good head posture and mandibular movement
behavioural techniques to address abnormal illness and parafunctional habits
Occlusal therapy, such as splint therapy, would then become secondary treatment applied only after legitimate
trial of the above. Secondary treatment would also require continuation of rehabilitation and behavioural
management if still indicated. This would include moving into more aggressive stages of active rehabilitation and functional restoration. Tertiary management might consist of further diagnostic considerations such as imaging, interdisciplinary care and psychological counselling. Phase II occlusal therapy (i.e. orthodontics, prosthedontics), microsurgery of the TMJ, trigger point injections and nerve blocks are some of the treatment options at this level of management. In this case, Louise would begin at the primary level of management (Skaggs 1996). (See Box 1.)
Manipulation and/or mobilization of the cervicocranial junction and other cervical segments is a very critical element and in the acute condition can have instantaneously beneficial effects. Rarely, however, is it the sole treatment for OFD. It
should be diagnosed and performed by a practitioner with proper training and a high level of skill and experience. It
is important to stress the proficiency in this procedure for two reasons: first, and most importantly, are the poor
results that will come forth with less than skilled application of this procedure; second, there is the wellknown
risk involved with thrusting and movements of the cervical spine.
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