Lo 11

Question 1

Describe neuropathic orofacial pain

Answer 1

Neuropathic pain can mimic dental and periodontal pain and be confusing to both patient and clinician

Question 2

What are the two main categories of neuropathic pain?

Answer 2

1. Episodic
2. Continuous or chronic

Question 3

Describe burning mouth syndrome

Answer 3

1. Characterized by an unexplained and usually continuous burning sensation of the oral soft tissues
2. Most likely a neuropathic etiology
3. Onset is usually spontaneous and can occur in episodes with periods of latency
4. Evaluation involves a careful workup
5. Laboratory testing may identify undiagnosed systemic diseases such as anemia and diabetes mellitus

Question 4

Describe Trigeminal Neuralgia

Answer 4

1. Pathologic condition involving the fifth cranial nerve
2. Characterized by a unilateral sharp, shooting, knifelike, or electric shock–type pain
3. Etiology is unknown can be related to nerve damage
4. Sometimes related to local anesthetic injections
5. Diagnosis is based on history and onset of pain, and associated clinical symptoms

Question 5

Describe Bell Palsy

Answer 5

1. Acute loss of muscle control on one side of the face
2. Related to the 7th cranial (facial) nerve
3. Occurs in people of all ages; mostly between ages 15 and 45
4. Usually resolves in 6 weeks- 4 months, sometimes permanent
5. Dental hygiene contraindicated until resolution due to injury risk
6. Cause unknown, trauma related in some cases

Question 6

Describe Diseases Affecting the Temporomandibular Joint (TMJ)

Answer 6

1. Disorders of the TMJ include myofascial pain and dysfunction (MPD), internal derangement syndrome, osteoarthritis, and rheumatoid arthritis
2. Benign and malignant tumors can also affect the TMJ

Question 7

Describe the anatomy of the TMJ

Answer 7

1. The TMJ is an articulation between the condyle of the mandible and the glenoid fossa of the temporal bone
2. Fibrocartilage covers the bony articulating surfaces
3. Ginglymoarthrodial movement
4. An articular disk divides the space
5. Avascular and devoid of nerve fibers
6. Synovial fluid provides nourishment and lubrication

Question 8

Palpation of the muscles of mastication may be done to determine whether muscle spasm or dysfunctional muscle activity is occurring. Such as:

Answer 8

1. Masseter
2. Temporalis
3. Medial pterygoid
4. Lateral pterygoid
5. Anterior digastric
6. Mylohyoid

Question 9

Describe normal function of the TMJ

Answer 9

1. In the position of maximal occlusal contact, the mandibular condyle rests within the glenoid fossa
2. The articular disk is situated between the condyle, the roof of the glenoid fossa, and the articular eminence
3. The first phase of opening is characterized by a rotational (hinge) movement of the condyle followed by an anterior translation (sliding)

Question 10

List the demographic and physiologic factors associated with TMDs

Answer 10

1. Majority of patients are female
2. Between 20 and 40 years of age
3. Female sex hormones play a role
4. Depression
5. Rheumatoid arthritis
6. Chronic fatigue syndrome
7. Chronic headache
8. Fibromyalgia
9. Sleep disturbances
10. Irritable bowel syndrome

Question 11

Describe the Pathophysiology of TMDs

Answer 11

1. Trauma - Direct (assault); Indirect (whiplash injury); Resulting from parafunctional habits such as clenching or bruxism
2. Psychosocial factors (stress)
3. Dentofacial deformities
4. May be associated with disorders in growth and development as in condylar hyperplasia or hypoplasia
5. Abnormalities are associated with a number of systemic diseases - Depression; Rheumatoid arthritis and osteoarthritis; Chronic fatigue syndrome; Chronic headache; Fibromyalgia; Sleep disturbances; Irritable bowel syndrome
6. Female sex hormones play a role
7. Iatrogenic cause

Question 12

Describe patient evaluation for orofacial pain

Answer 12

1. Dysfunction may be caused by disorders of muscles of mastication or by internal derangements of components of the joints
2. Evaluation involves a comprehensive history and thorough clinical examination - Chief complaint; History: Chief complaint, medical, dental; Examination; Imaging
3. Patient management - Reduced mouth opening; Shorter appointments; Pain control
4. Three cardinal features of TMDs - must have at least 1 - Orofacial pain; Joint noise; Restricted jaw function

Question 13

What questions related to patient history should you ask related to orofacial pain

Answer 13

1. Medical/dental history
2. Precipitating events
3. Circumstances that exacerbate or diminish symptoms
4. Onset and progression of symptoms - Joint symptoms (clicking, popping); Pain; Problems with mastication; Trismus (lockjaw); Malocclusion; Parafunctional habits (bruxing, clenching); Extensive dental or orthodontic treatment; History of surgical treatment of the jaws

Question 14

Describe clinical examination of the TMJ

Answer 14

1. Includes examination of the joint, muscles of mastication, oral cavity, and cervical spine
2. Palpitation upon jaw movement
3. Are joint noises such as clicking, crepitus, or popping related to mandibular movement?
4. Evaluate movement of mandible in a normal rotation and translatory cycle
5. Measure interincisal opening and note any obvious deflection to the right or left side
   6 . Note lateral excursions, protrusions, deviations, and deflection
6. Evaluate occlusion

Question 15

What are the options for imaging for orofacial pain?

Answer 15

1. Panoramic
2. Transcranial
3. Magnetic resonance imaging
4. Computed tomography
5. Tomography
6. Arthrography

Question 16

What are the types of TMDs?

Answer 16

1. Myofascial pain and dysfunction (MPD)
2. Internal derangements
3. Arthritis

Question 17

Describe Myofascial Pain and Dysfunction (MPD)

Answer 17

1. A dysfunctional muscle hyperactivity with regional pain, tenderness in affected muscles, and variable amounts of reduced opening and complaints of malocclusion
2. Comprises at least 50% of all TMDs

Question 18

Describe internal derangements (TMD)

Answer 18

1. An abnormal positional relationship of the disk relative to the mandibular condyle and the articular eminence
2. Continuous pain exacerbated by jaw movement

Question 19

Describe Disk Displacement (TMD) with and without reduction

Answer 19

1. With reduction - It may be displaced anteriorly and returns to normal position when the mouth is opened or movement is away from the affected side
2. Without reduction - It may act as an obstacle to the sliding condyle; Patients may complain of problems such as intermittent locking of the jaw; a sudden onset of limited mouth opening, usually associated with cessation of joint sounds; deflection of the mandible, with a midline correction on opening; and restricted lateral excursive movements away from the affected side

Question 20

Describe osteoarthritis

Answer 20

1. Characterized by degenerative changes of the cartilage
2. Pain symptoms that are worse in the evening
3. Limited opening
4. Muscle splinting
5. Crepitus

Question 21

Describe rheumatoid arthritis

Answer 21

1. An inflammatory, immunologic disorder of the joints
2. Symptoms that are worse in the morning
3. Limited opening
4. Occlusal changes
5. Preauricular edema
6. Tenderness

Question 22

Describe hypermobility disorders of the TMJ

Answer 22

1. Dislocation - When one or both of the condyles translates anterior to the articular eminence, leading to an open lock the patient cannot reduce
2. Subluxation - Hypermobility in which the patient can relocate the mandible back into the glenoid fossa

Question 23

Describe Ankylosis

Answer 23

1. Immobility of the condyle caused by fibrous or bony union between articulating surfaces
2. Joint infection after trauma accounts for 50% of all cases
3. Thirty percent result from trauma without infection

Question 24

How is ankylosis classified?

Answer 24

1. Tissue type (fibrous, bony)
2. Location (intraarticular, extra articular)
3. Extent of fusion (complete, incomplete)

Question 25

Tumors of the TMJ

Answer 25

1. Osteochondroma 2. Osteoblastoma 3. Chondroblastoma 4. Osteoma 5. Synovial chondromatosis: Most common benign neoplasm of the synovium 6. Osteogenic sarcoma: Commonly occurring malignant bone tumor

Question 26

What categories of treatment are available for TMDs

Answer 26

1. Nonsurgical treatment 2. Surgical treatment 3. Multidisciplinary treatment

Question 27

Describe non-surgical treatment for TMDs

Answer 27

1. Goals involve improving function, reducing pain, and preventing further joint damage 2. Pharmacologic therapy: Pain medication, muscle relaxants, and antianxiety agents 3. Moist heat 4. Physical therapy 5. Soft mechanical diet 6. Jaw stretching 7. Coordination exercises 8. Occlusal adjustments 9. The second phase involves the use of occlusal appliances - These may relax muscles, protect dentition, stabilize and protect the joint, and provide biofeedback by making patients aware of their bruxing habits or by relieving the load on the disk

Question 28

Describe the surgical treatments for TMDs

Answer 28

1. **Arthrocentesis** - Lavaging the joint through a needle 2. **Arthroscopy** - Allows direct visualization and manipulation of the joint 3. **Open joint surgery** - Used to perform disk reconstruction with a prosthetic device or autogenous graft 4. **Eminectomy** - Removal of the articular eminence of the temporal bone

Question 29

Describe Multidisciplinary Management of TMDs

Answer 29

Patients may require referral to specialists such as a neurologist or an otolaryngologist