Oral Dysaesthesia and TMD Flashcards
How does cognitive deduction influence oral disease?
It is difficult to decipher whether the symptoms are coming from dental tissues, somewhere else or if it is a cognitive issue.
The patient has no dental pathology which matches with their symptoms but their brain makes it so that the patient perceives this as pain.
What is Oral Dysaesthesia?
Abnormal sensory perception in absence of abnormal stimulus.
Where could the symptoms in oral dysaesthesia be coming from?
Neuropathic- abnormal sensory stimulus, nerves aren’t functioning properly.
Somatoform- perception is wrong, the signal coming from the tissues is wrong.
What symptoms may someone have if they have oral dysaesthesia?
All modes of oral sensation involved
- burning or nipping feeling
- Dysgeusia
- Paraesthetic feeling
- Dry mouth feeling
- Chronic back pain
Usually a deep, dull, burning sensation that does not waken the patient from being asleep.
Altered behaviour- anxiety, depression.
What are the pre-disposing factors for oral dysaesthesia?
Deficiency states- haematinics, zinc, B12.
Fungal and viral infections
Anxiety and stress
Recent bereavement
Gender- more women present to OM than men
What is burning mouth syndrome?
Chronic condition which presents as a burning, scalding or tingling sensation in the oral cavity.
What is the clinical presentation of burning mouth syndrome?
Burning, tingling, scalding or numbness feeling in the oral cavity- bilateral and fluctuate in intensity.
Poorly localised pain
Pain is worse during the day
Relieved with drinking and/or eating
Common site- tongue, hard palate, gingivae, lips.
Absence in abnormalities in mucosa, despite symptoms.
Can also present with dry mouth, altered taste.
Usually stressed, anxious, depressed.
What is burning mouth syndrome most likely to be associated with?
Haematinic deficiency.
If the lips and tongue tip/margin are involved, then it is most likely parafunction.
If involved in any other site- then it is paraesthesia.
Describe the pathogenesis of BMS?
Neuropathic- number of nerve fibres innervating taste buds are reduced. This means there is a reduction in input from the Chorda Tympani, therefore, trigeminal and glossopharyngeal nerves need to compensate. Causes changes in how sensory information is processed in the brain with regards to pain.
Endocrinological- reduction in progesterone metabolites during menopause can cause adrenal steroid deficiency, this can reduce neuroprotective effects leading to dry mouth- can cause dysaeathesia.
Psychosocial- Depression and anxiety.
What investigations might you want to do in a BMS patient?
FBC, haematinics.
HbA1c, thyroid function test.
Autoantibody screen.
Contact allergy test
Psychiatric investigation
Fungal culture
What are the management strategies for BMS?
As a GDP
- refer to OM.
- Give analgesia advice- benzydamine 0.15% mouthwash, avoid hot and spicy foods, suck on ice and drink plenty of cold water, referral to GMP for FBC and haematinic checks.
In OM
- Clonazepam oral rinse and can also be given systemically.
- Capsaicin cream (0.025%)
- lidocaine gel (2%)
- Could also use Gabapentin, Pregabalin.
Nortriptyline- tricyclic.
- CBT.
What is Dysgeusia?
Oral condition whereby patients feel a bad taste, bad smell in their mouth but nothing is detected by the practitioner and nothing found on examination.
If someone complains of a bad taste in their mouth/smell, what would you do?
Full history- pain, swellings, pus.
Examine the mouth- look for perio/dental infections.
Ask if a partner has noticed it.
GORD
ENT causes- chronic sinusitis
Dry socket
Ulcer bursting- salty
What is Touch Dysaesthesia?
Patient feels they have pins and needles, tingling but have normal sensation when you test the area.
If someone presented to you with pins and needles or tingling, what would you do?
Cranial nerve examination.
Poke the area with a sharp object- does the patient feel pain? If they do, then the area is not numb.
2-point discrimination test.
Contact GMP to request an MRI.
Must exclude local cause- infection, tumour.
What is Dry mouth dysaesthesia?
Pt C/O debilitating dry mouth.
Worse when waken at night but eating is fine.
What investigations would you do in someone who you suspect has dry mouth dysaesthesia?
Look in the mouth- challacombe scale.
Salivary flow rate
FBC- anti-ro and anti-la antibodies
Ultrasound scan
How would you manage dysaesthesia?
Explain the condition to the patient.
Assess degree of anxiety- refer to GMP for anxiolytic medication and psychiatric referral.
CBT
Treatment empower the patient- control is important.
Reattribution may be helpful- shows the patient the link between the complaints they have and how it is related to the way they feel.
Avoid operative intervention.
What anxiolytic medication may be prescribed?
Amitriptyline
Nortriptyline
Mirtazepine
Vortioxetine
Gabapentin
Pregabalin
What is Temperomandibular disorder?
Disorder of the jaw muscles, jaw joint and nerve supply of the jaw joint which can cause chronic facial pain.
What are the causes of TMD?
Myofascial pain
Disc displacement
- anterior with reduction
- Anterior without reduction
Degenerative disease- osteoarthritis, rheumatoid arthritis
Chronic recurrent dislocation
Ankylosis
Condylar hyperplasia
Neoplasia
Infection in the joint
Autonomic-based issue
What are the physical signs of TMD?
Clicking joint
Locking jaw
Limitation of mouth opening
Tenderness of masticatory muscles, sternomastoid, trapezius.
Tenderness of cervico-cranial muscles
Tenderness of TMj itself
Masseter hypertrophy
Facial asymmetry
Deviation on opening
Dental occlusion upset
Ear pain
Headaches
Intermittent pain of several months or years duration
I/O- scalloped tongue, linea alba, attrition, erythema of the tongue tip.
Exclude any dental pathology if C/O dental pain.
What aspects of the patient’s history might you expect to see in someone with TMD?
Acute pain in face and neck
Pain is worse in the morning/evening
Parafunctional clenching
Stressed, anxious, work-life balance
Any recent trauma to the head/jaw.
What investigations might you want to request if you suspect someone has TMD?
In primary care- nil.
Secondary care- ultrasound if functional visualisation of disc movement is needed.
CBCT if bony problem suspected.
MRI best image of the disc.
What are the management strategies for TMD?
Information on the disease.
Advice- stick to a soft diet, no wide yawning, don’t chew gum or pencils, avoid nail biting, try not clench, chew on both sides of the mouth, don’t incise foods, cut food into small pieces.
Massage muscles, apply ice and heat.
CBT education and exercises.
Acupuncture
Relaxation
Hypnotherapy
Bite raising appliances- Michigan splint, hard acrylic bite raising appliance.
TMJ surgery.
Medication- NSAIDs, tricyclic antidepressants (amitriptyline), anticonvulsants (Gabapentin).
Botox into masseter.
What are your differential diagnoses?
Dental pain
Sinusitis
Ear pathology
Salivary gland pathology
Referred neck pain
Headache
Atypical facial pain
Trigeminal neuralgia
Angina
Condylar fracture
If someone presents with pain symptoms, what would you do?
Full history
E/O and I/O examination
Percussion test
Palpation test
Radiographs of the teeth and other facial anatomy.
Vitality testing
Tooth sleuth to check for fractured tooth
Systemic investigations
