in: How to Practice at Today’s Standard of Care
OROFACIAL PAIN: Standard of Care
Charles McNeill, DDS, FACD, FICD Professor Emeritus & DirectorPatricia A. Rudd, PT, DPT CCTT
Associate Clinical ProfessorUCSF Center for Orofacial Pain
4. Inflammatory Disorders & DJD
Monday, August 31, 15
v TM Joint Painv Masticatory Muscle Pain
ACUTE TMD DIAGNOSES
Acute TMD Mgt (Localized Musculo-skeletal Disorders)
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AAOP TMD Dx Classification:Localized Disorders
Monday, August 31, 15
ARTICULAR • Devel./ Acquired Disord.• Disc Disorders • Inflammatory Disorders• Degenerative Disorders• TMJ Dislocation• Ankylosis
AAOP TMD Dx Classification:Localized Disorders
Monday, August 31, 15
ARTICULAR • Devel./ Acquired Disord.• Disc Disorders • Inflammatory Disorders• Degenerative Disorders• TMJ Dislocation• Ankylosis
AAOP TMD Dx Classification:Localized Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
Monday, August 31, 15
Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
Monday, August 31, 15
Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
Monday, August 31, 15
Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
Monday, August 31, 15
Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
Monday, August 31, 15
Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
๏ Degenerative Joint Disease• Osteoarthrosis• Osteoarthritis
Monday, August 31, 15
Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
๏ Degenerative Joint Disease• Osteoarthrosis• Osteoarthritis
Monday, August 31, 15
Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
๏ Degenerative Joint Disease• Osteoarthrosis• Osteoarthritis
Monday, August 31, 15
Inflammatory & Degenerative Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
๏ Inflammatory Disorders• Synovitis/Capsulitis• Polyarthritides
๏ Degenerative Joint Disease• Osteoarthrosis• Osteoarthritis
Monday, August 31, 15
INFLAMMATORY DISORDERS:Synovitis / Capsulitis
Monday, August 31, 15
vDESCRIPTION: Inflam. of the Synovial Lining &/or Capsule 2º to Infection, Trauma, or Cartilage Degeneration
INFLAMMATORY DISORDERS:Synovitis / Capsulitis
Monday, August 31, 15
vDESCRIPTION: Inflam. of the Synovial Lining &/or Capsule 2º to Infection, Trauma, or Cartilage Degeneration
INFLAMMATORY DISORDERS:Synovitis / Capsulitis
vCLINICAL PRESENTATION:v Localized Jt. Pain Provoked by Palp., Loading, Distraction or Fx.
v Fluctuating Swelling w ↓ Post. Occl. v Probable Marked ↓ Mobilityv Radiographic Changes: Possible Increase in Joint Space
v Positive T2 MRI Signal
Monday, August 31, 15
Goal Oriented Plan: Synovitis/Capsulitis
Monday, August 31, 15
Goal Oriented Plan: Synovitis/Capsulitis
�PAIN CONTROL:• Patient Education• Self-Management (Rest, Ice)• Meds (NSAIDs, Analg., Steroids, Jt. Inj.) • Physical Therapy (Cold, ES, US, Cold • Laser & Gentle Joint Mobilization)
Monday, August 31, 15
Goal Oriented Plan: Synovitis/Capsulitis
�PAIN CONTROL:• Patient Education• Self-Management (Rest, Ice)• Meds (NSAIDs, Analg., Steroids, Jt. Inj.) • Physical Therapy (Cold, ES, US, Cold • Laser & Gentle Joint Mobilization)
� INCREASE MOBILITY:• Physical Therapy (Gentle Joint
Mobilization & ROM Exercises)
Monday, August 31, 15
§ Sulindac (Clinoril) 150-200mg. bid§ Naproxen (Naprosyn) 500mg. bid§ Nabumetone (Relafen) 500-750mg. bid§ Meloxicam (Mobic) 7.5-15mg d § Celecoxib (Celebrex) 100-200mg. bid§ Diclofenac (Voltaren) 1.3% Flector Patch bid § Voltaren Gel 1% 2 Grams qid§ Topical Compounds 2 drops tid, qid§ Methyprednisolone (Medrol Dosepak) 24-32mg d/1wk
followed by 1wk 4mg 6 day Tapering Dose
*Misoprostol (Cytotec) 200 µg qid *Omeprazole (Prilosec) 20mg bid
ANTI-INFLAMMATORY MEDS
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INTRA-ARTICULAR INJECTION ARTHROCENTESIS
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PHYSICAL THERAPY
§ Patient Education§ Therapeutic Exercises§ Joint Mobilization /
Manipulation§ Soft-tissue Mobilization§ Modalities
§ Heat & Ice § Spray & Stretch§ Elect Stim. / Iontophoresis§ Ultrasound / Phonophoresis
Monday, August 31, 15
PHYSICAL THERAPY
§ Patient Education§ Therapeutic Exercises§ Joint Mobilization /
Manipulation§ Soft-tissue Mobilization§ Modalities
§ Heat & Ice § Spray & Stretch§ Elect Stim. / Iontophoresis§ Ultrasound / Phonophoresis
Monday, August 31, 15
INFLAMMATORY DISORDERS:Polyarthritides
v DESCRIPTION: Bilateral Joint Inflam. & Struct. Changes 2º to Gen. Systemic Polyarthritic Condition
v CLINICAL PRESENTATION:vJt Pain Provoked by Palp., Loading, &/or FxvCrepitus & ↓ ROM 2º to PainvMult. Jt. Involvmentv+ Serology Test
Monday, August 31, 15
¤PAIN CONTROL:• Self-Mgt (Rest, Ice, Pt. Ed., Behavior Mod.)• Meds (NSAIDs, Analg., Steroids;• Collaborate w Rheumatologist & PCP • Physical Therapy (Cold, ES, US, Jt. Mob.)
¤ INCREASE MOBILITY:• P.T. (Gentle Jt. Mob. & ROM Exercises)
Goal Oriented Plan:Polyarthritides
Monday, August 31, 15
AAOP TMD Dx Classification:Localized Disorders
Monday, August 31, 15
ARTICULAR • Devel./ Acquired Disord.• Disc Disorders • Inflammatory Disorders• Degenerative Disorders• TMJ Dislocation• Ankylosis
AAOP TMD Dx Classification:Localized Disorders
Monday, August 31, 15
ARTICULAR • Devel./ Acquired Disord.• Disc Disorders • Inflammatory Disorders• Degenerative Disorders• TMJ Dislocation• Ankylosis
AAOP TMD Dx Classification:Localized Disorders
AAOP TMD Guidelines, Quintessence; 1990, 1993, 1996, 2008, 2013
Monday, August 31, 15
DEGENERATIVE JOINT DISEASE (DJD)
deBont LGM et al: OOO 1997;83:51-60
Monday, August 31, 15
❖ OSTEOARTHROSIS: A Non-painful, Non-inflammatory Degenerative Condition Characterized by of Articular Tissues Due to Overload of the Remodeling System
DEGENERATIVE JOINT DISEASE (DJD)
deBont LGM et al: OOO 1997;83:51-60
Monday, August 31, 15
❖ OSTEOARTHROSIS: A Non-painful, Non-inflammatory Degenerative Condition Characterized by of Articular Tissues Due to Overload of the Remodeling System
DEGENERATIVE JOINT DISEASE (DJD)
deBont LGM et al: OOO 1997;83:51-60
v OSTEOARTHRITIS: A Painful Inflammatory Degenerative Condition Characterized by
Progressive Deterioration & Abrasion of the Articular Surfaces
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DEGENERATIVE JOINT DISEASE:
deBont LGM et al: OOO 1997;83:51-60
Monday, August 31, 15
v ACTIVE: Characterized by Active Deterioration & Abrasion of the Articular Tissues (Cortical Outline) Due to Overload of the Remodeling System
DEGENERATIVE JOINT DISEASE:
deBont LGM et al: OOO 1997;83:51-60
Monday, August 31, 15
v ACTIVE: Characterized by Active Deterioration & Abrasion of the Articular Tissues (Cortical Outline) Due to Overload of the Remodeling System
DEGENERATIVE JOINT DISEASE:
deBont LGM et al: OOO 1997;83:51-60
Monday, August 31, 15
v ACTIVE: Characterized by Active Deterioration & Abrasion of the Articular Tissues (Cortical Outline) Due to Overload of the Remodeling System
DEGENERATIVE JOINT DISEASE:
deBont LGM et al: OOO 1997;83:51-60
v STABLE: Characterized by a Stable or Unchanging Relationship of the Articular Surfaces of Formerly Active Arthrosis/Arthritis
Monday, August 31, 15
v ACTIVE: Characterized by Active Deterioration & Abrasion of the Articular Tissues (Cortical Outline) Due to Overload of the Remodeling System
DEGENERATIVE JOINT DISEASE:
deBont LGM et al: OOO 1997;83:51-60
v STABLE: Characterized by a Stable or Unchanging Relationship of the Articular Surfaces of Formerly Active Arthrosis/Arthritis
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ACTIVE OSTEOARTHROSIS(Non-inflammatory)
deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60
CLINICAL PRESENTATION:vNo Joint Pain/InflammationvJoint Crepitus vLtd ROM w/ DeflectionvPossible Change in Post. Occl.vRadiographic Bony Changes
v Loss of Cortical Integrityv Possible Osteophytic Formationv Subchondral Bone Cystsv Narrowed Superior Jt. Space
Monday, August 31, 15
GOAL ORIENTED PLAN: Ac/ve Osteoarthrosis
16
Monday, August 31, 15
GOAL ORIENTED PLAN: Ac/ve Osteoarthrosis
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¤ JOINT PROJECTION• Self-Management (Pt. Ed.)• Meds (Flexeril ?)
Monday, August 31, 15
GOAL ORIENTED PLAN: Ac/ve Osteoarthrosis
16
¤ JOINT PROJECTION• Self-Management (Pt. Ed.)• Meds (Flexeril ?)
¤ INCREASE MOBILITY:• Physical Therapy (Gentle Jt.
Mobilization & ROM Ex.)
Monday, August 31, 15
ACTIVE OSTEOARTHRITIS(Inflammatory)
deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60
CLINICAL PRESENTATION:vJoint Pain at Rest & w FunctionvJoint Crepitus vLtd ROM w/ Deflec. 2º PainvPossible Change in Post. Occl.vRadiographic Bony Changes
v Loss of Cortical Integrityv Possible Osteophytic Formationv Subchondral Bone Cystsv Narrowed Superior Jt. Space
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ACTIVE EROSIONSv Un-corticated Erosionv“Cupping Defects”
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GOAL ORIENTED PLAN: Ac/ve Osteoarthri/s
19
¤ PAIN CONTROL:• Self-Management (Rest, Ice, Pt. Ed.)• Joint Protection Education• Meds (NSAIDs, Acetaminophen, Analgesics, Steroids
[Methylpredisone DosePak]) • Physical Therapy (Cold, ES, US, Jt. Mob.)
¤ INCREASE MOBILITY:• Physical Therapy (Gentle Jt.
Mobilization & ROM Ex.)
Monday, August 31, 15
GOAL ORIENTED PLAN: Ac/ve Osteoarthri/s
19
¤ PAIN CONTROL:• Self-Management (Rest, Ice, Pt. Ed.)• Joint Protection Education• Meds (NSAIDs, Acetaminophen, Analgesics, Steroids
[Methylpredisone DosePak]) • Physical Therapy (Cold, ES, US, Jt. Mob.)
¤ INCREASE MOBILITY:• Physical Therapy (Gentle Jt.
Mobilization & ROM Ex.)
Monday, August 31, 15
deLeeuw R, Boering G et al: J Orofacial Pain 1994deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60
v DDw/oR to Osteoarthritis - nearly 100%v Osteorthrosis/Osteoarthritis
vFollows a Natural CoursevReduction of Symptoms - 3+ Mos.vStable Bony Changes - 2- 4+ Yrs.
PROGRESSION of DJD
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STABLE OSTEOARTHROSIS
deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60
CLINICAL PRESENTATION:vNo Joint Pain/InflammationvJoint Crepitus vLimited ROM w/ Deflec.vPossible Change in Post. Occl.vRadiographic Bony Changes
v Cortical Integrity Re-establishedv No Subchondral Bone Cystsv Narrowed Superior Jt. Spacev Possible Osteophytic Formation
Monday, August 31, 15
GOAL ORIENTED PLAN: Stable Osteoarthrosis
22
Therabite Therapy
“Reassure Patient of Favorable Prognosis”
Monday, August 31, 15
GOAL ORIENTED PLAN: Stable Osteoarthrosis
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Therabite Therapy
“Reassure Patient of Favorable Prognosis”
Monday, August 31, 15
GOAL ORIENTED PLAN: Stable Osteoarthrosis
22
¤JOINT PROJECTION• Self-Management • Understand Risk Factors
Therabite Therapy
“Reassure Patient of Favorable Prognosis”
Monday, August 31, 15
GOAL ORIENTED PLAN: Stable Osteoarthrosis
22
¤JOINT PROJECTION• Self-Management • Understand Risk Factors
Therabite Therapy
“Reassure Patient of Favorable Prognosis”
¤INCREASE MOBILITY:• Physical Therapy (Jt. Mobilization)• Home Exercise Program
Monday, August 31, 15
STABLE OSTEOARTHRITIS
deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60
CLINICAL PRESENTATION:vPain/Chronic InflammationvJoint Crepitus vMinimum ROM w/ Deflec.vPossible Change in Post. Occl.vRadiographic Bony Changes
v Cortical Integrity Re-establishedv Possible Osteophytic Formationv No Subchondral Bone Cystsv Narrowed Superior Jt. Space
Monday, August 31, 15
GOAL ORIENTED PLAN: Stable Osteoarthri/s
24
¤INFLAMM. MANAGEMENT PRN¤JOINT PROJECTION
• Self-Management • Unerstand Risk Factors
¤ INCREASE MOBILITY:• Physical Therapy (Jt. Mobilization)• Home Exercise Program
“Reassure Patient of Favorable Prognosis”
Monday, August 31, 15
IDIOPATHIC CONDYLAR RESORPTION:a.k.a., Juvenile Idiopathic Arthritis
Wolford LM Proceedings Baylor Univ 2001;14:246-252
Monday, August 31, 15
IDIOPATHIC CONDYLAR RESORPTION:a.k.a., Juvenile Idiopathic Arthritis
A Spontaneous Lytic Event Causing the Condyle to Become Rapidly & Progressively Smaller & in Some Cases Completely Disappear .Patients Commonly Become Severly Retrognathic (Receding Chin)
Wolford LM Proceedings Baylor Univ 2001;14:246-252
Monday, August 31, 15
IDIOPATHIC CONDYLAR RESORPTION:a.k.a., Juvenile Idiopathic Arthritis
A Spontaneous Lytic Event Causing the Condyle to Become Rapidly & Progressively Smaller & in Some Cases Completely Disappear .Patients Commonly Become Severly Retrognathic (Receding Chin)
Wolford LM Proceedings Baylor Univ 2001;14:246-252
๏ 9X More likely Female Than Male
๏ Hormonal Mediation May Be Involved๏ More Common Among Teenagers๏ “Cheerleaders Syndrome”
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Condylysis Etiology: Hormonal TMJ ReceptorsGENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS
Monday, August 31, 15
Condylysis Etiology: Hormonal TMJ ReceptorsGENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS
SOFT TISSUES:❖ Relaxin & beta-‐estradiol Induces Matrix
Metalloproteinase (MMP) expression ❖ Loss of Collagen & Gylcosaminoglycans
(GAGs)
Monday, August 31, 15
Condylysis Etiology: Hormonal TMJ ReceptorsGENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS
SOFT TISSUES:❖ Relaxin & beta-‐estradiol Induces Matrix
Metalloproteinase (MMP) expression ❖ Loss of Collagen & Gylcosaminoglycans
(GAGs)BONE:❖ Decreased beta-‐estradiol❖ Increased Osteoclast Activation❖ Increased Remodeling Rate❖ Increased Trabecular spaces
Monday, August 31, 15
Condylysis Etiology: Hormonal TMJ ReceptorsGENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS
§ Females are vulnerable during child bearing years
SOFT TISSUES:❖ Relaxin & beta-‐estradiol Induces Matrix
Metalloproteinase (MMP) expression ❖ Loss of Collagen & Gylcosaminoglycans
(GAGs)BONE:❖ Decreased beta-‐estradiol❖ Increased Osteoclast Activation❖ Increased Remodeling Rate❖ Increased Trabecular spaces
Monday, August 31, 15
Condylysis Etiology: Hormonal TMJ ReceptorsGENDER, AGE, GENETIC (COMT Gene Variants) RISK FACTORS
§ Females are vulnerable during child bearing years
§ Rarely develops after 20 years of age
SOFT TISSUES:❖ Relaxin & beta-‐estradiol Induces Matrix
Metalloproteinase (MMP) expression ❖ Loss of Collagen & Gylcosaminoglycans
(GAGs)BONE:❖ Decreased beta-‐estradiol❖ Increased Osteoclast Activation❖ Increased Remodeling Rate❖ Increased Trabecular spaces
Monday, August 31, 15
deBont LGM et al: Oral Surg Oral Med, Oral Pathol 1997;83:51-60
CLINICAL PRESENTATION:v Typically Severe Bilateral Joint Pain at Rest / Functionv Joint Crepitusv Significant Change in Occlusion
with Open Anterior Bitev Radiographic Bony Changes
v Loss of Condylar Size/Cortical Integrityv Possible Osteophytic Formationv Subchondral Bone Cysts
IDIOPATHIC CONDYLAR RESORPTION:a.k.a., Juvenile Idiopathic Arthritis
Monday, August 31, 15
GOAL ORIENTED PLAN: Idiopathic Condylar Resorp/on
28
Monday, August 31, 15
GOAL ORIENTED PLAN: Idiopathic Condylar Resorp/on
28
¤ PAIN CONTROL:• Self-Management (Rest, Ice, Pt. Ed.)• Joint Protection Education• Meds (NSAIDs, Analgesics, Steroids) • Physical Therapy (Cold, ES, US, Jt. Mob.)
Monday, August 31, 15
GOAL ORIENTED PLAN: Idiopathic Condylar Resorp/on
28
¤ PAIN CONTROL:• Self-Management (Rest, Ice, Pt. Ed.)• Joint Protection Education• Meds (NSAIDs, Analgesics, Steroids) • Physical Therapy (Cold, ES, US, Jt. Mob.)
๏ INCREASE MOBILITY:• Physical Therapy (Gentle Jt. Mobilization & ROM Ex.)
Monday, August 31, 15
GOAL ORIENTED PLAN: Idiopathic Condylar Resorp/on
28
¤ PAIN CONTROL:• Self-Management (Rest, Ice, Pt. Ed.)• Joint Protection Education• Meds (NSAIDs, Analgesics, Steroids) • Physical Therapy (Cold, ES, US, Jt. Mob.)
๏ INCREASE MOBILITY:• Physical Therapy (Gentle Jt. Mobilization & ROM Ex.)
¤ LONG-TERM MANAGEMENT:• Orthodontics, Orthognathic Surgery, • Joint Replacement Surgery
Monday, August 31, 15
DEGENERATIVE JOINT DISEASE
DJD
OSTEOARTHROSISNo Pain/Inflammationv Joint Crepitus v Possible Ltd ROM w/
Deflectionv Possible Change in Post.
Occl.
OSTEOARTHRITIS Pain at Rest & w Function
v Joint Crepitus v Ltd ROM w/ Deflectionv Possible Change in Post.
Occl.
ACTIVEBony Changes
v Loss of Cortical Integrityv Subchondral Bone Cystsv Possible Osteophytic Formationv Possible Narrowed Sup. Jt.
Space
STABLE
v Cortical Integrity Re-establishedv No Subchondral Bone Cystsv Probable Osteophytic Formationv Narrowed Superior Jt. Space
Bony Changes
Monday, August 31, 15
Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
Monday, August 31, 15
MANAGEMENT PHILOSOPHY
Diagnostically Driven Problem-Based Goal Oriented
Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
Monday, August 31, 15
MANAGEMENT GOALS Relieve Pain
Promote Healing Restore Functional ROM
Optimize Masticatory Function Return to Previous Level of ADL
MANAGEMENT PHILOSOPHY
Diagnostically Driven Problem-Based Goal Oriented
Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
Monday, August 31, 15
MANAGEMENT GOALS Relieve Pain
Promote Healing Restore Functional ROM
Optimize Masticatory Function Return to Previous Level of ADL
Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
Monday, August 31, 15
Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
Monday, August 31, 15
NO SURGERY or TREATMENT
of the OCCLUSION
Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
Monday, August 31, 15
NO SURGERY or TREATMENT
of the OCCLUSION
Behavior Modification
Symptomatic Care
Patient Education
Pharmacotherapy
Physical Rehabilitation(Orthoses/Splints)
Acute Musculoskeletal TMD/OFPManagement Model NIDCR Policy Statement 2013
Monday, August 31, 15
“The art of medicine is in amusing the patient
while nature cures the disease”VOLTAIRE
Monday, August 31, 15
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