Oral Dysaesthesia and TMD Flashcards
What are phantom limbs?
Occur when amputees feel like their limbs are still present (if eyes were shut their limb would feel entirely real)
- Perception of limb presence remains even although it is gone
How do painful phantoms occur?
Lasting memory of pain from trauma can persist after amputation (very difficult to treat as it is an incorrect cognitive deduction)
- Difficult for patients to cope as they feel it to be real
How are painful phantoms treated?
Use mirror box, to let patient/brain accept visual signal that hand is working as normal
- If patient feels that hand is tightly clenched, let them see the reflection of their hand which appears like the amputated one is opening and closing normally (if done for long enough the patient can start to accept it cognitively- can override peripheral nerve signal as brain received information from visual centres)
- Gradually the pain can reduce
What is body dysmorphia?
Brain tells patient that they are overweight
- Can lead to anorexia as the patient stops eating (modifies behaviour to make internal view change)
- Patient would not resemble how they feel- overcomes mirrors or comments
What is an oral dysaesthesia?
Abnormal sensory perception in absence of abnormal stimulus
- Could be a somatoform disorder- perception is wrong (understanding of information coming from tissues is wrong)
- Neuropathic- dysfunction of nerves carrying info to CNS
- Anxiety can change the way that perception in the brain works (can cause confusion and mean that normal sensation is felt differently)
What are the symptoms of oral dysaesthesia?
- Burning
- Dysgeusia- Bad taste
- Numbness
- Tingling
- Dry mouth
*Frequently somatoform with no physical disease
What are the predisposing factors for oral dysaesthesia?
Deficiency
-> Haematinics, zinc, b12
Anxiety and stress
Fungal and viral infections
Gender- more common in females
What tests should we do if we think a patient is suffering an oral dysaesthesia?
- Check that medical problem is not treatable
- Do blood tests/swabs rinses and try anti-fungal/viral drugs
- Consider if patient is stressed or anxious- makes them predisposed to these somatoform dysaesthesias
How may patients with oral dysaesthesia use this as a sign of declining mental health?
Some patients may use somatoform symptoms as a way of realising that their anxiety or stress disorder is coming back
Can take steps to correct mental health
-> dysaesthesia can settle
What are the most likely causes of burning mouth syndrome?
Haematinic deficiency can affect oral mucosa and can result in change in perception (correcting deficiency can help sensation return to normal)
Parafunction and tongue thrust are more likely to get burning sensation affecting tongue tip/edges and lip
*people who do not present with parafunction often have pain in dorsum of tongue and vault of the palate- uncommon in parafunction
How is burning mouth related to parafunction managed?
Give lower acrylic splint to reduce damage to mucosa and symptoms
What is dyguesia?
Bad taste or halitosis (difficult to treat- clinicians may see no evidence of a reason for perception)
What are potential causes of non-somatoform dyguesia to check for in patients who present?
Perio
Dental infections
GORD
Chronic sinusitis
Pharyngeal pouches
How can dyguesia affect a patient’s mental health?
- Isolation as patient worried about other people’s reaction (can be linked to anxiety)
- Can be difficult to convince patients that they are normal physically (issue is with perception)
- Can be made worse if patient’s partner says patient has bad breath in morning (wrongly see something common as abnormal)
- Patients may become withdrawn if they feel you aren’t trying to fix their problem
What are the symptoms of touch dysaesthesia?
Feeling of pins and needles (like LA wearing off)
- Often overlaps with normal sensation too
- Can happen if there is a change in perception of sensory information going to the brain OR nerve lesions
What tests are done if a patient presents with touch dysaesthesia?
Check cranial nerves
MRI- ensure there is no demyelination or tumour
-> If brain tumour- the patient is likely to get true numbness
Check for infection
What are the signs that a patient’s dry mouth has a somatoform component?
- When eating extra fluid is not required
- Dry mouth when they wake up in night
- May be linked to anxiety- symptoms can come and go in a way that matches their anxiety
- May have reduced flow- often related to anxiety
What investigations would you do if a patient presented with dry mouth?
Investigations are as you would for Sjogren’s- look at flow, autoantibodies, ultrasound scans
-> largely no positive findings if somatoform
What is the issue with treating patients who have dry mouth due to anxiety?
Difficult to treat as the medicine used to treat anxiety can cause a dry mouth
-> dryness from dysesthesia will gradually improve, leaving only dryness from meds, when they stop treatment, everything should return to normal
How are oral dysaesthesias managed?
Explanation of dysesthesia
- Pins in needles in hand- looks normal but abnormal feeling (same but applied to mouth)
- Aim to get patient to understand treatment as it will help them control it
Anxiolytic medicine
Neuropathic medicine
Psychological intervention
What are the anxiolytic medications used in oral dysaesthesia?
Nortriptyline
Mirtazepine
Vortioxetine
-> can also be useful for neuropathic cause as initial or in combination with other treatment
What are the medications used to help with neuropathic cause of oral dysaesthesia?
Gabapentin/Pregabalin
Clonazepam – topical benzo (can be applied directly to affected site)
What are the different patient types with TMD?
Joint Degeneration (seen in psoriatic arthritis)
-> pain on use & crepitus, +/- rest pain
Internal derangement
-> LOCKING open or closed
No joint pathology- patient often struggles to localise pain
What are the causes of TMD?
Occlusion
Grinding
Clenching
Stress
OP changes
Why do patients present for medical treatment of TMD?
Patients with TMD often want rid of pain
-> Sometimes noise and locking is present but most would accept these occasionally if pain stopped
Some patients don’t like to take medicine- can often be treated with simple analgesia
Impossible to change stressful lifestyle
What is often seen in ‘pain vulnerable patients’?
Present to other clinics with somatoform symptoms (also seen in IBS)
What is the typical mental health features of someone with somatoform TMD?
High anxiety and low depression
- No psychiatric diagnosis- within range of normal
- More likely to clench and grind
- Anxiety can make soreness and discomfort feel worse
What are the physical signs of TMD?
Clicking joint
Locking with reduction
Limitation of opening mouth
Tenderness of masticatory muscles
Tenderness of cervico-cranial muscles
What are the signs in the oral cavity that parafunction is taking place?
- Crenelation around tongue- look as patient opens mouth before they move tongue
- Erythema of tongue tip
- Buccal mucosa ridging
What may be found on examination of the TMJ if patient has TMD?
Focal muscle tenderness
-> masticatory
-> sternomastoid
-> Trapezius
Tenderness over TMJ itself
-> limitation of opening
progressive
Joint noise
-> incidental - degenerative OA changes
Muscle dysfunction – click
-> Deviation on opening
Dental occlusion upset- be wary of doing occlusal adjustment
What investigations are carried out for TMD?
Ultrasound Scan
-> If functional visualisation of disc movement is needed
OPT or CBCT
-> if bony problem suspected
MRI - best image of the disc
Arthroscopy to directly visualise the disc
*NONE REQUIRED IF SOMATOFORM
How can TMD be managed?
Self-help information
CBT/Clincial psychology
Exercises
Soft diet
Analgesia
Bite splint
Physiotherapy
Acupuncture
Drugs
-> TCAs
-> Diazepam- if these work it can point to anxiety as cause
Which drugs not are used in TMD?
SSRIs- can make it worse
What are the features of TMD in children?
Pain was previously often thought to be due to caries
-> Now many patients are caries free but often present with pain
Children may be exposed to stress/anxiety- bullying at school, fear of failure, parental disharmony, physical abuse
How is TMD managed in children?
Managed through psychology as opposed to medication -> If somatoform disorder developed early it is likely to continue- so if they are educated on this at young age they can use what they learn as coping mechanism
