Intro into tmj pain and imagining Flashcards
List the different causes of chronic primary ono facial pain
- TMJ Pain (facial arthromyalgia)
- Atypical facial pain
- Burning mouth syndrome
- Atypical odontalgia
How do we classify chronic pain
- Pain that presents for 3 months or longer
- Pain that has significant functional and emotional impairment
Define pain
An unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage
Define nociplastic pain
Pain that arises from altered nocicpetion despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral noicicpetors or evidence got disease or lesion of the somatosensory system causing the pain
What is involved in moving the TMJ
- Muscles: Temporalis + Master + neck muscles
- Teeth
- Joints
What do we need to gather when gathering a history of a patent with chronic TMJ pain
Physical signs and symptoms
Psychosocial symptoms
How do we ensure we have all try information from A pt with TMJ pain
By using the masticatory system examination
What does the masticatory system examination include
- Temderness on palpation
- Range of motion
- Notes on the joints eg clicks
- Muscle tenderness
- Trismus check list
What should the history of a patent with TMJ pain include
- Site, descriptors
- Duration, pattern, exacerbating/ reliving factors
- Psychosocial history
- Co morbidities
Give examples of some TMD diagnosises
- Intra articular joint disorders
- Degerneative joint disorders
- Pain related TMD and headache
Give examples of intra articular joint disorders
Disc displacement with or without reductio and with to without locking
Give examples fo degenerative joint disorders
Osteo / rheumatoid arthritis
Give examples of pain related TMD and headache
- Myalgia
- Myofascial pain
- Headache attributed to TMD
- Arthralgia
What can TMD be mis diagnosed for
Otalgia
Toothache
Persistent idiopathic facial pain
Acute and chronic maxillary sinusitis
What can TMD be mis diagnosed for
Otalgia
Toothache
Persistent idiopathic facial pain
Acute and chronic maxillary sinusitis
What are some physical self regulation tips, advice and techniques we can give to pts with TMD pain
- Soft diet
- Avoid activities that involve wide opening (yawning)
- Clenching and grinding reversal exercises
- Massage muscles and hot/cold compress
- Posture contro
What is the role of imaging in TMJ pain patients
1, To supplement information gained through clinical examination
2. To evaluate integrity and relationship of hard and soft tissues
3. To confirm extent and progression of known disease
4. To evaluate effects of tx
Which radiogrpahs can we take to assess TMJ
- Plain film
- CT and Cone beam CT
- MRI
What can a plain film examination give us an assessment of
Low to moderate value in the assessment of:
1. TMJ Osseous components
2. Facial skeletel symmetry
3. Internal jaw anatomy/ pathology
What are the disadvantages of plain film examination
Cannot assess soft tissue component of joint
What are the advantages of panoramic radiographs
- Quick and readily available
- Comfortable position for patent
- Dedicated programme for condyles
- Open and closed views
- Can assess for referred causes of pain
What are some of the limitations of panoramic radiogrpahs
- Fronto lateral view of condyle
- Inconsistent magnification and hermetic distortion
- Sensitive to positioning errors
- Superimposition of structures and ghost images
- Cannot exclude early bony change
- Does not image soft tissue component of the joints
What the indications to take an OPT for TMJ problems
- Change in occlusion
- Mandibular shift
- Change in movement range
- Sensory or motor alterations
- Recent trauma
What the contra indications to take an OPT for TMJ problems
- Joint noises
- Myofacial pain
What is TMJ dislocation
Condyle displacement out of glenoid fossa but remaining within the joint capsule
Where is TMJ dislocation most common
Anterior dislocation where condyle is anterior to articular eminence
Patient cannot close mouth
What is a key difference between Cone beam CT and normal CT
Cone beam CT cannot view soft tissues
What can CBCT/CT allow us to do
Allows bony structures to be assessed without super imposition
Good for assessing osseous structures and extent of ankylosis
When is a CT scan indicated
When a neoplasm is suspected to extend beyond the osseous structures
What does an MRI provide
Contrast between soft tissues
What are the contra indications for an MRI
- Claustrophobia
- Pacemaker
- Metallic foreign body
What are some indications for an MRI
- Assessment of disk position/ status
- To asses presence of synovitis in inflammatory arthritis
- Bony changes for diagnosis of arthritis
Name the most common disorder in the TMJ region
Myofascial pain syndrome
What is myofascial pain syndrome caused by
Pain caused by muscle tension fatigue or spasm
coudl be related to parafuncitonal habits such as bruxism
How can we diagnose myofacial pain syndrome
History and examination
Describe the radiograph of a pt with myofascial pain syndrome
As joints are often normal there is usually no relevant imaging findings
What are the symptoms fo internal derangement
- Clicking
- Pain from joint and/or musculature
- Trismus/ locking
What is internal derangement
Displacement of disk from normal position most commonly anterior to the condylar head
What is degenerative joint disease
Non inflammatory process of wear and tear due to sustained micro trauma over prolonged periods
What can happen in degenerative joint disease
Deterioration of articular cartilage exposing bone and causing flattening of the condylar head and bony defects
What are the symptoms of degenerative joint disease
May be asymptomatic and an incidental finding
Coudl be painful crepitus and trismus
What is an osteophyte
A projection of bone at the site of muscle attachment usually seen anteriorly in the TMJ
What can happen to an osteophyte
can fracture and form loose bodies in the joint
What is sclerosis
Increased density in the condylar head
How does sclerosis appear on a radiograph
Bone appears lighter on plain film and CT
BUT Bone marrow appeared darker on MRI
What is a subcentral cyst
Formation of fluid filled cavity beneath the articular surface
Give examples of inflammatory arthropathies
- Rheumatoid arthritits
- Juvenile idiopathic arthritis
What is rheumatoid arthritis
A synovial membrane inflammation and secondary bony erosion
Granulomatous tissue growth int eh synovial
What is juvenile idiopathic arthritis
Chronic intermittent synovial inflammation causing swollen and painful joints
List some imaging features of rheumatoid arthritis
- Sharpened pencil like erosions condylar head
- Joint effusion and marrow oedema
- Synovial enhancement on MRI
List some imaging features of juvenile idiopathic arthritis
- flat deformed condyle with wide glen oid fossa
- Joint effusion and marrow oedema
- Synovial enhancement on MRI
What is joint effusion
Collection of fluid in the joint spaces leaden to an increase in joint space seen on plain film or CT
What is ankylosis
Fusion of elements of the joint causing truisms
can be fibrous or bony
What is ankylosis usually a result of
- Trauma
- Infection
- Severe juvenile inflammatory arthritis
Give some radiographic features of ankylosis
Reduced or no joint spave
Bony bridge or jigsaw puzzle interlocking articular surfaces
What happens in condylar hyperplasia
Large condyle with normal morphology
Glenoid fossa may remodel to accommodate enlarged condyle
What is condylar hyperplasia associated with
Enlargement of ipsilateral hemimandible
What might a patient with condylar hyperplasia present with
Facial asymmetry
What are some of the indications for imaging
- Suspected osseous abnormality or infection
- Failure of conservative treatment
- Worsening symptoms
- History of trauma
- Significant dysfucntion
- Alteration in range of motion
- Sensory of motor abnormalities
- Significant change in occlusion
When is imaging not indicated
- Joint sounds in the absence of other signs or symptoms
- Asymptotic children/ adolescences prior to starting orthodontic treatment
