Nyeri TMJ TMJ Pain
Yuliati Departemen Biology Oral FKG UNAIR
Sistem Sensoris Somatik • Sensasi sensoris somatik rasa raba, vibrasi, 2-point discrimination, rasa tekan, propiosepsi → serat Aβ → medulla spinalis
rasa nyeri, panas & dingin ( nosisepsi ) → serat Aδ atau tipe C medulla spinalis
• Sinyal nyeri melewati 2 jaras otak traktus neospinotalamikus → nyeri cepat traktus paleospinotalamikus → nyeri lambat, kronis
Table 46–1
Classification of Sensory Receptors
I. Mechanoreceptors Skin tactile sensibilities (epidermis and dermis) Free nerve endings Golgi tendon tip endings Muscle Expanded apparatus spindle II. Merkel’s discs Plus several other variants Spray endings Ruffini’s endings of somatic sensory nerve endings. Encapsulated endings III. Meissner’s corpuscles Krause’s corpuscles Hair end-organs IV. Deep tissue sensibilities Free nerve endings Expanded tip endings mpulses.Spray Therefore, endings how is it that V. Ruffini’s endings modalities of bers transmit different Encapsulated endings corpuscles hat each Pacinian nerve tract terminates at a Plus a few other variants the central nervous system, and Muscle endings tion felt when nerve fiber is stimuMuscleaspindles ed by the Golgi pointtendon in thereceptors nervous system Hearing r leads. For instance, if a pain fiber Sound receptorspain of cochlea e person perceives regardless Equilibrium imulus excites the fiber. The stimulus Vestibular receptors y, overheating of the fiber, crushing Arterial pressure imulation of the pain nervesinuses ending Baroreceptors of carotid and aorta II. Thermoreceptors e tissue cells. In all these instances,
Muscle spindles Golgi tendon receptors Hearing Sound receptors of cochlea Equilibrium Vestibular receptors Free nerve Expanded tip Tactile hair endings receptor Arterial pressure Baroreceptors of carotid sinuses and aorta Thermoreceptors Cold Cold receptors Warmth Warm receptors Pacinian Meissner’s Krause’s corpuscle corpuscle corpuscle Nociceptors Pain Free nerve endings Electromagnetic receptors Vision Rods Cones Ruffini’s Golgi tendon Muscle end-organ apparatus spindle Chemoreceptors Taste Figure 46–1 Receptors of taste buds Several types of somatic sensory nerve endings. Smell Receptors of olfactory epithelium Arterial oxygen Receptors of aortic and carotid bodies transmit only impulses. Therefore, how is it tha Osmolality different nerve fibers transmit different modalities o Neurons in or near supraoptic nuclei sensation? The answer is that each nerve tract terminates at Blood CO2 point in the central nervous system, an Receptors in or on surfacespecific of medulla and in aortic and the type of sensation felt when a nerve fiber is stimu carotid bodies lated is determined by the point in the nervous system which the fiber leads. For instance, if a pain fibe Blood glucose, amino acids, to fatty acids is stimulated, the person perceives pain regardles Receptors in hypothalamus of what type of stimulus excites the fiber. The stimulu
can be electricity, overheating of the fiber, crushin of the fiber, or stimulation of the pain nerve endin
Penjalaran Sinyal • ‘Fast-pain’ ( nyeri cepat, tajam ) Rangsangan mekanik atau suhu → serat Aδ ( 6-30 m/dtk ) Lokalisasi pada bagian tubuh lebih pasti Melibatkan reseptor raba Jaras melewati Traktus Neospinotalamikus → brainstem & talamus Neurotransmiter : Glutamat
• ‘Slow-pain’ ( nyeri lambat, kronik ) Rangsangan kimiawi, mekanis/suhu persisten → serat C ( 0,5-2 m/dtk )
Jaras Traktus Paleospinotalamikus → juga menjalarkan sinyal serabut serat Aδ Neurotransmiter : Substan P
Glutamat Neurotransmiter serat Aδ Disekresi : medulla spinalis pada ujung2 serabut nyeri saraf Aδ Sifat : eksitasi Mula kerja : segera Durasi kerja : beberapa milidetik
Substan P Neurotransmiter serat C Mula kerja : lebih lambat drpd Glutamat ( bbrp detik sd menit ) Disekresi : medulla spinalis pada ujung2 serabut nyeri saraf C
Somesthetic areas
Motor cortex
Dendrites Thalamus
Brain Pons
Cell body Cerebellum
Medulla Spinal cord
Jalur Somatosensoris pada Sistem Saraf
nal cord
Bulboreticular formation Skin Pain, cold, warmth (Free nerve ending) Pressure (Pacinian corpuscle) (Expanded tip receptor) Touch (Meissner's corpuscle)
Axon
Golgi tendon apparatus
Muscle spindle Muscle
Kinesthetic receptor
Synapses Joint Second-order
Rasa Nyeri • Termasuk sensasi sensoris somatik • Dapat dirasakan oleh hewan tingkat rendah → human • Sensasi yg phemomenal : sesuatu yg dibutuhkan tetap ada tapi harus dieliminasi • Respons nyeri : • intensitas ( ringan, sedang, berat ) • sifat rangsangan • memori
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Cortex Cerebri sisi kiri ( hemispher kiri ) Pusat kontraksi otot
Pusat intelegensi
Pusat bicara
Pusat visual
Cortex cerebri adalah lapisan paling luar otak , merupakan lapisan paling tebal – serta mencerminkan intelegensia
Cortex cerebri 1. Pusat persepsi dan interpretasi sistem sensoris somatik. 2. Pusat pengendalian sistem motorik somatik ( gerakan anggota tubuh ). 3. Pusat intelegensia. 4. Pusat penglihatan, pendengaran, bicara, taste / pengecapan.
Reseptor • Reseptor nyeri ( nosiseptor )
- free nerve endings - axon saraf sensoris : Aδ ( fast pain ) → mekanis, termal tipe C ( slow pain ) → kimiawi, mekanis & termal (persisten) tersebar hampir di seluruh tubuh → termasuk daerah muka ( facial ) dan dental
• Reseptor somatosensorik daerah kepala dilayani n. trigeminus divisi somatosensoris
Rangsangan yg dapat menimbulkan nyeri:
mekanik, kimiawi, termal, elektrik, tissue ischemia, skeletal muscle spasm
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• Beberapa bahan yang dapat menimbulkan nyeri ๏ Bradikinin ๏ Serotonin ๏ Histamin ๏ Prostaglandin ๏ Leukotrien ๏ Substance P ๏ Enzim proteolitik ๏ ion K yg berlebihan ๏ asam atau basa yang berlebihan
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Trauma/kerusakan jaringan
pengeluaran ion K+, sintesa prostaglandin & bradikinin
Keradangan Jaringan Infeksi - Non infeksi sekresi peptida (substan P) merangsang mast cell, platelet, kapiler inflammatory agents ( Histamin, bradikinin, serotonin, platelets factors )
permeabilitas membran nosiseptor ↑ influks ion Na+ potensial aksi (impuls) membran neuron medulla spinalis
Impuls Nyeri Input sensoris: - kulit fasial - mukosa oral - geligi - pembuluh darah kranial - otot - TMJ
S.S.A I : Gyrus Postcentralis Thalamus Tr.Spinothalamicus
Aδ / C Free nerve endings
Medulla Spinalis
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Klasifikasi Nyeri ( berdasarkan etiologi )
A. Nyeri Fisiologik • Nyeri tjd krn rangsangan, singkat dan tidak merusak jaringan • Korelasi positif antara stimuli dan persepsi nyeri
B. Nyeri Inflamasi / Nosiseptif • Terjadi akibat keluarnya mediator inflamasi yg mengaktivasi nosiseptor
C. Nyeri Neuropatik • Nyeri yang didahului/disebabkan oleh lesi (trauma, toksin, gangguan metabolik) atau disfungsi primer sistem saraf • Tidak berhubungan dg aktivasi nosiseptor
D. Nyeri Psikogenik • Nyeri yg tidak berhubungan dg nyeri nosiseptif maupun nyeri neuropatik • Didapatkan simptom psikologis
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ntral-acting α-adrenergic agonist for
TYPES OF PAIN
en identified as a neuromodulator in ei that project to the spinal cord. It has c antidepressant compounds, such as gesic properties independent of their hese drugs, which enhance the effects g its presynaptic uptake, have been the management of certain types of
■ Pain can be classified according to location, site of
echanisms. There is evidence that the tides, morphine-like substances synof the CNS including the spinal cord in the CNS. Three families of opioid tified—the enkephalins, endorphins, h the endogenous opioid peptides aptransmitters, their full significance in hysiologic functions is not completely greater importance in understanding trol has been the characterization of ndogenous opioid peptides. The idenrs has facilitated a more thorough unns of available opioid drugs, such as s facilitated ongoing research into the reparations that are more effective in Copyright©yuliati ewer side effects.
■ Visceral pain is a diffuse and poorly defined pain that
Beberapa Tipe Nyeri
referral, and duration. ■ Cutaneous pain is a sharp, burning pain that has its
origin in the skin or subcutaneous tissues. ■ Deep pain is a more diffuse and throbbing pain that
originates in structures such as the muscles, bones, and tendons and radiates to the surrounding tissues. results from stretching, distention, or ischemia of tissues in a body organ. ■ Referred pain is pain that originates at a visceral site
but is perceived as originating in part of the body wall that is innervated by neurons entering the same segment of the nervous system. ■ Acute pain usually results from tissue damage and
is characterized by autonomic nervous system responses. ■ Chronic pain is persistent pain that is accompanied
by loss of appetite, sleep disturbances, depression, and other debilitating responses.
What is Orofacial Pain ?
• Orofacial pain merupakan istilah umum nyeri daerah oral & fasial • Meliputi sejumlah kelainan klinis termasuk pada otot mastikasi atau temporomandibular joint. • Tipe nyeri orofasial : nyeri inflamasi dan neuropatik • Etiologi akut : terutama dental pain ( pulpa, jar.periodontal ) kronis : sebag.besar dari otot, tendon TMJ
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TMJ Dysfunction • Merupakan salah satu penyebab facial pain • Terjadi saat hubungan sendi rahang keluar ligamen, menyebabkan RA dan RB pada posisi tidak seimbang • Patogenesis : distal displacement mandibulare overclosure • TMJ pain terjadi akibat ketidakseimbangan aktivitas otot rahang & spasme otot • Struktur yg diperiksa: otot, sendi Temporomandibular, geligi
• Simptom 1. Jaringan keras a. Rahang : clicking, nyeri otot daerah pipi, gerakan rahang / lidah tak terkontrol b. Geligi : clenching, grinding at night, ke-ausan gigi belakang 2. Jaringan lunak a. Mulut : discomfort, gangguan membuka mulut, hilangnya kemampuan membuka mulut dg pelan ( smothly ) deviasi rahang pada satu sisi saat buka mulut, tidak dapat menggigit ( open bite )
b. Tenggorokan : gangguan menelan, laringitis, perubahan suara, sering batuk merasa ada benda asing di tenggorokan c. Masalah pada leher : penurunan gerak leher, nyeri
• Etiologi 1. Teeth grinding & teeth clenching kebiasaan tidak disadari, nyeri saat bangun tidur
2. Kebiasaan mengunyah permen karet / menghisap ibu jari 3. Maloklusi restorasi 4. Mengunyah satu sisi 5. Trauma rahang riwayat kecelakaan ( patah tulang rahang atau fasial )
6. Stres memicu sistem saraf
7. Pekerjaan misal : kebiasaan memegang gagang telepon antara bahu & kepala
Gejala lain a. Sakit kepala keluhan sakit saat membuka rahang
b. Nyeri telinga
bagian depan/dalam telinga, tidak ada infeksi
c. Pusing ( belum jelas ) d. Rasa penuh pada telinga
terutama saat take off & landing pesawat diduga disfungsi Eustachian tube
e. Tinnitus ( suara bising dlm telinga )
Prosedur Pemeriksaan Klinis 1. Mengukur pembukaan inter-insisal ( mm ) 2. Mengukur gerak lateral & protusif ( mm ) 3. Memperhatikan koordinasi & simetri saat membuka & menutup mulut 4. Memperhatikan ada tidaknya suara TMJ ( mis : clicking ) 5. Palpasi TMJ dari arah lateral & posterior ( dari eksternal auditory meatus )
6. Palpasi otot elevator & depressor 7. Evaluasi ada tidaknya prematur kontak 8. Memperhatikan pola oklusal 9. Evaluasi skeletal symmetries dari kranial / fasial 10. Mencatat overjet, overbite & garis median ( mm )
Penjalaran Impuls TMJ Pain Persepsi Nyeri TMJ
S.S.A I : Gyrus Postcentralis Thalamus
Free nerve endings pada disk parenkim TMJ
Tr.Spinothalamicus
Aδ / C
Medulla Spinalis
Spasme Otot - Iskemia Jaringan • Spasme otot → Iskemia • Hambatan suplai darah jaringan • Peningkatan metabolisme • Timbunan asam laktat → aktivitas metabolisme anaerob • Bahan metabolit - bradikinin, enzim proteolitik → kerusakan jaringan
Terapi / Tata laksana TMJ Pain Terdiri atas 2 Fase
Prinsip : 1. Dimulai setelah diagnosis 2. Diutamakan terapi konservatif 3. Didahului dengan terapi yang bersifat reversibel, terapi iireversibel hanya bila diperlukan
Fase Pertama Tujuan : a. mengatasi keluhan utama, b. mengembalikan Range of Motion ( ROM ) mandibula, c. mengembalikan kondili pada posisi normal, d. rehabilitasi otot yg fatique & cedera , e. membangkitkan semangat penderita memecahkan masalahnya ( faktor psikogenik ), f. memperbaiki postur tubuh.
Fase Kedua Merupakan lanjutan fase pertama, jika diperlukan terapi lanjutan untuk menstabilkan kondisi perawatan fase 1.
Fase Pertama 1. Istirahat menggurangi aktivitas rahang ( menghindari mkn-an dg konsistensi keras/kenyal, tidak membuka mulut lebar )
2. Stress reduction & management program 3. Biofeedback penderita mengatur tonus ototnya sendiri ( mengatur kontraksi - relaksasi otot )
4. Physical therapy antara lain : perubahan postural ( koreksi posisi mandibula ) pemijatan terapi panas ( melancarkan sirkulasi ) muscle exercise dll
Fase Kedua 1. Equilibration grinding oklusal yg berkontak berat efektif pada penderita tanpa spasme otot & tidak banyak gigi hilang
2. Orthodonsi mengharmoniskan hubungan sendi dg mengkoreksi geligi
3. Overlays 4. Rekonstruksi ( Restorasi, Replacing ) gigi belakang aus akibat pengunaan atau akibat karies
5. Pembedahan
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