Oral Medicie YR5 Flashcards
name 3 ways to assess pain?
Physical symptoms
- PAIN scores (McGill)
Emotional symptoms
- Psychological scores (HAD)
QOL scores (OHIP)
Explain how we feel pain?
Nociception
Peripheral Nerve Transmission
Spinal Modulation
Central Appreciation
Describe the sensory nerve pathway for pain?
Somatic
- V nerve
Describe the sensory nerve split of the facial nerve?
Describe the parasympathetic vs sympathetic nervous system?
Describe the general symptoms of a heart attack?
Describe the somatic reflex arc?
Describe the autonomic nervous system?
Descri the peripheral nociception pathway?
Describe the gate control system for chronic pai?
Describe the pai sensation pathway?
Explain the ways we lock pain with medications?
Descri chronic regional pai?
Delocalised pain
- Spreads around ‘anatomical’ boundaries
- bilateral
- ‘gripping’, tight, burning
Feeling of swelling & heat
Colour change in overlying skin
Autonomic changes
Significantly disabling
Descri the acronym SOCRATES?
S - Site
O - Onset
C - Character
R - Radiation
A - Associations
T – Time Course
E – Exacerbating/Relieving
S - Severity
Descri the difference between nociceptive vs neuropathic pai?
What is the definition of neuropathic pai?
Constant burning/aching pain
Fixed location
Often a fixed intensity
Genetic predisposition?
- Nerve ion channels that heal badly after injury
- Persisting inflow gives persisting information reporting
Descri the likely history ad causes of a patient with neuropathic pai?
Usually a history of ‘injury’
Can follow facial trauma
Can follow extractions
Can follow ‘routine’ treatment without complications
Can follow Herpes Zoster (Shingles) episode
POST HERPETIC NEURALGIA
Can follow destructive treatment for pain
ame 6 forms of systemic medications for neuropathic pai?
Pregabalin
Gabapentin
Tricyclic
Valproate
Mirtazepine
Opioid analgesics
ame 6 forms of topical medications for neuropathic pai?
Capsaicin
EMLA
Benzdamine
Ketamine
Descri the alterative ways to treat neuropathic pai?
Physical
- TENS – occasionally helpful
- Low frequency TENS
- Acupuncture – good results
Psychological
- Distraction
- Correct abnormal illness behaviour
- Improve self esteem/positive outlook
What is the definition of atypical odontalgia?
Dental pain without dental pathology
- How difficult is this to diagnose
Distinct pattern of pain
Equal sex distribution
Pain free or mild between episodes
Intense unbearable pain
2-3 weeks duration
Settles spontaneously
Descri the treatment options ad their following effects for patient’s with atypical odontalgia?
Acute pulpitis pain
Endodontics relieves or reduces pain
- Pain returns after a short time
Extraction relieves pain
- Pain returns in adjacent tooth after a short time
Endodontics relieves or reduces pain
- Pain returns after a short time
Extraction relieves pain
- Pain returns in adjacent tooth after a short time
Patient Referred
Descri the pathway for a dentist trying to diagnose atypical odontalgia?
PRIMARY CARE – REFER!
Oral Medicine Management
Chronic strategy
- Reduce chronic pain experience
- Reduce frequency of acute episodes
Acute strategy
- Have a plan to control pain
opioid analgesics as required
high intensity/short duration
- Be prepared to extract tooth if needed
What is the definition of Persistent Idiopathic Facial Pain?
Pain which poorly fits into standard chronic pain syndromes
- Neuropathic
- CRPS
- TMD
- Trigeminal Neuralgia
- Migrainous Pain
- Atypical odontalgia
Often high disability level – autonomic component
Explain how to assess a patient with Persistent Idiopathic Facial Pai?
Believe patient
- Do not blame any associated depression for symptoms
Do not increase damage
- Surgery is not helpful!
Adopt holistic strategy
- Quality of life issues
- Pain control a bonus
- Realistic outcomes – Patient & Clinician
Use QOL/pain scores as treatment monitor
What is the definition of Oral Dysaesthesia?
Abnormal sensory PERCEPTION in ABSENCE OF ABNORMAL STIMULUS
Somatoform or Neuropathic?
- Where is the problem?
ame the 4 symptoms of Oral Dysaesthesia?
ALL modes of oral sensation involved
- Burning or ‘nipping’ feeling
- Dysgeusia
- Paraesthesic feeling
- Dry mouth feeling
ame the 4 predisposig factors for Oral Dysaesthesia?
Deficiency states
- haematinics
- zinc
- vit B1, B6
Fungal and Viral infections?
Anxiety and stress?
Gender – more women present to OM than men
What is the definition of Burning Mouth Syndrome?
Dysaesthesia most likely to be associated with haematinic deficiency
SITE important!
- Lips & tongue tip/margin = parafunction
- Multiple other sites - dysaesthesia
What is the definition of Dysgeusia?
bad taste’ - ‘bad smell’ - ‘Halitosis’
nothing detected by practitioner
nothing found on examination
REMEMBER!
- ENT causes - chronic sinusitis
- perio/dental infection
- GORD
nothing detected by patient’s partner?
What is the definition of Touch Dysaesthesia?
pins and needles’ - ‘tingling’
Normal sensation to objective testing
Pin/needle elicit pain!
CRANIAL NERVES test essential
MUST exclude organic neurological disease
MUST exclude local causes
infection
Tumour
MRI Essential – demyelination/tumour
What is the definition of dry mouth dysaesthesia?
VERY common
c/o debilitating dry mouth/‘sjogrens’
Eating OK
worse when waken at night
usually the most obviously associated with anxiety disorders
Descrie the management of dysaesthesia?
Explain the condition to the patient
- ‘pins and needles’ in the taste etc
Assess degree of anxiety
- Anxiolytic medication
- Clinical psychology
Treatment empower the patient
- Control is important
ame the types of medication for dysaesthesia?
Anxiolytic based medication
- Nortriptyline
- Mirtazepine
- Vortioxetine
Neuropathic Medication
- Gabapentin/Pregabalin
- Clonazepam – topical?
ame the 3 categories for TMJ pai?
Joint Degeneration
- pain on use & crepitus, +/- rest pain
Internal derangement
- LOCKING open or closed
No joint pathology
ame the 4 mai causes to TMJ pai?
Occlusion?
Grinding?
Clenching?
Stress?
ame the 4 main route causes for TMJ pai?
Multi-axis problem
Usually SYSTEMIC disorder
- ‘pain vulnerable people’
- many systemic symptoms
High ANXIETY & low DEPRESSION
- NO psychiatric diagnosis in most cases
PARAFUNCTION a strong feature
ame the 5 physical symptoms for TMD pai?
Look for:
- clicking joint
- locking with reduction
- limitation of opening mouth
- tenderness of masticatory muscles
- tenderness of cervico-cranial muscles
- liea ala
ame the general history for a pt struggling with TMD pai?
Acute pain in face & neck
ANY chronic face, head and neck pain
symptoms show periodicity
- morning/evening exacerbation
parafunctional clenching
History is the KEY to successful management!
Descrie the examination findings for a patient with TMD pai?
Focal muscle tenderness
- masticatory
- sternomastoid
- Trapezius
tenderness over TMJ itself
limitation of opening
progressive
Joint noise
incidental - degenerative OA changes
related to muscle dysfunction – click
Deviation on opening
common finding with muscle dysfunction
Dental occlusion upset
What investigations ca e completed for TMD pai?
usually none indicated for ‘functional’ disorders
Indications for Imaging
Ultrasound Scan
if functional visualisation of disc movement is needed
DPT or CBCT
if bony problem suspected
MRI - best image of the disc
Arthroscopy to directly visualise the disc
Descrie the management of TMD pai?
Information – how to self help
Physical therapy
CBT education +/- exercises
Soft diet and analgesia
Bite splint
Biochemical manipulation
Tricyclic (not SSRI)
other anxiolytic medication
Physiotherapy
Acupuncture
Clinical Psychology
What childre ad TMD pai ca e associated with?
tendency to anxiety neurosis
- ‘anxious parents have anxious children’
- maladaptive response to ‘normal’ change
reaction to abuse
- school - bullying, fear of failure
- home - parental dysharmony, physical abuse
Describe the anatomy of the TMJ?
Madile
Masseter
Capsule
Disc
Temporal oe
Descri the anatomy of the intricacies of the capsule?
What is the definition of TMJ disorder?
Temporomandibular joint and muscle disorders, commonly called TMJ’, are a group of conditions that cause pain and dysfunction in the jaw joint and the muscles that control jaw movement.
ame 3 of the mai causes of TMJ disorder?
Myofascial pain
* Involves discomfort or pain in the muscles that control jaw function.
Internal derangement
* This involves a displaced disc, dislocated jaw or injury to the condyle.
Arthritis
* Refers to a group of degenerative/inflammatory joint disorder that can affect the TMJ
ame the 6 main symptoms of TMJ disorder?
Headache:
* 80% of patients with TMD complain of headache and 40% facial pain.
2. Ear pain:
* 50% of patients with a TMJ disorder notice ear pain without any signs of infection.
3. Sounds:
* Grinding, crunching or popping sounds, medically termed crepitus, are all common for patients with a TMJ disorder.
Dizziness:
- 40% of patients reported a vague dizziness or imbalance.
5. Fullness of the Ear:
-33% of patient described muffled or clogged ears. They may notice fullness or pain during airplane take-offs and landings.
6. Ringing in the Ear:
- 33% of patients reported noise or ringing (tinnitus) for unknown reasons.
ame the 3 outcomes for TMJ disorder?
What is the definition of pai dysfunction syndrome (TMJ)?
- Pain on TMJ palpation
- Pain on palpation of associated muscles
- Limitations or deviation of mandibular movement
- Joint sounds
- Headache
Explain the clinical examination to assess TMJ dysfunction?
Passive Mouth Opening:
- Maximum interincisal opening with assistance of clinician without pain. (Max. opening ≥40mm)
Masticatory muscle tenderness on palpation:
- Palpation of the joint and the muscles for pain should be done with the muscles in a resting state.
Palpation:
- Masseter insertion ad origin point
- Lateral ad itra-auricular palpation
- Temporalis insertion ad origin point
- Lateral pterygoid lateral ad vertical movement
What are the causes of crepitus i the TMJ?
Palpation of the TMJ will reveal pain and irregularities during condylar movement, described as clicking or crepitus.
* The click that occurs on opening and closing is eliminated by bringing the mandible into a protrusive position.
* Click before opening is most often associated with an articular disc displacement with reduction.
ame 6 parafunctional habits that ca cause TMJ disorder?
Grinding and clenching of teeth (bruxism) increases the wear on the cartilage lining of the TMJ, Many patient may awaken with jaw or ear pain in the morning.
2. Habitual gum chewing or fingernail biting
3. Dental problems and misalignment of teeth (malocclusion), patients may complain that it is difficult to find a comfortable bite.
4. Trauma to the jaws, previous history of broken jaw or fractured facial bones.
5. Stress frequently leads to unreleased nervous energy leading to conscious/unconscious clenching and grinding of teeth.
6. Occupational tasks such as holding telephone between the head and shoulder
ame the 7 conservative management techniques for TMJ pai?
- Moist heat
- Ice application
- Soft diet
- Jaw exercise
- Relation techniques
- Sleep on one side
- Pain relief, NSAIDs like ibuprofen work best.
What is the aim of occlusal split therapy for TMJ disorder?
A properly constructed splint supports a harmonious relationship of the muscles of mastication, disc assemblies, joints, ligaments , bones, teeth and tendons.
What is the definition of a occlusal split?
It is a removable appliance covering some or all of the occlusal surfaces of the teeth in either maxillary or mandibular arches.
* The ideal is made from lab processed acrylic resin which should cover the occlusal surfaces of all the teeth in one arch.
ame the 2 classifications for occlusal splits?
Okesons
Slavicek
ame the 6 types of Okeso’s occlusal splits?
- Stabilisation Splints
▪ Anterior repositioning
▪ Anterior bite plane
▪ Posterior bite plane
▪ Pivot splint
▪ Soft splint
ame the 5 types of Slavicek occlusal splits?
- Myopathic splint
▪ Decompression splint
▪ Compression splint
▪ Verticalization splint
▪ Anterior Repositioning
splint
ame the 3 mechanisms of action for occlusal splits?
permissive
non-permissive
pseudo permissive
ame 2 types of permissive occlusal splits?
Bite planes
* Stabilisation splint
ame 2 types of o-permissive occlusal splits?
Anterior repositioning appliance
* Mandibular orthopaedic repositioning appliance.
ame 2 types of pseudo-permissive occlusal splits?
Soft splints
* Hydrostatic splints
ame the 5 main theories of how occlusal splits work?
Occlusal disengagement theory
2. Vertical dimension theory
3. Maxillomandibular realignment theory
4. TMJ repositioning theory
5. Cognitive awareness theory
What is the definition of the occlusal disengagement theory?
The occlusal disengagement theory suggests that providing an ideal occlusion by the use of splint therapy reduces abnormal muscle activity.
What is the definition of the Maxillomandibular realignment theory?
The same is true of the maxillo-mandibular realignment theory, which aims to produce ‘neuromuscular balance’.
What is the definition of the vertical dimension theory?
The resorted vertical dimension theory is based on the concept that the patient has lost vertical height and thus causing abnormal muscle activity and an altered condyle/disc relationship.
Restoration to the correct vertical height allows the muscles to function at their ‘correct length’.
What is the definition of the TMJ repositioning theory?
The TMJ repositioning theory implies that the condyle should be repositioned within the glenoid fossa.
What is the definition of the cognitive awaress theory?
The cognitive awareness theory could be applied to all splints. It is based upon the concept that having something in the mouth alters behaviour and the opportunity to indulge in harmful muscle activity is reduced.
ame the 6 functions of occlusal splits?
To relax the muscles
2. To allow the condyle to seat in CR
3. To provide diagnostic information
4. To protect teeth and associated structures from bruxism
5. To mitigate periodontal ligament proprioception
6. To reduce cellular hypoxia levels.
What is the definition of permissive splits?
- Allow teeth to glide unhindered over the biting or contact surface.
- When this condition is achieved the neuromuscular reflex that controls the closing of the jaw in maximum ICP is lost.
- Hence these splints can also be called ‘muscle deprogrammers’.
What is the definition of a flat plane appliance?
- Covers all the teeth in the arch and its purpose is to relax the elevator muscles, provide joint stability and to protect the teeth from abnormal forces such as bruxism.
- There must be bilateral, equal intensity posterior occlusal contact so that an environment of a stable physiological mandibular posture is created.
What is the definition of a centric relation split?
This is also known as the Tanner appliance, the Fox
appliance, The Michigan splint, superior positioning
appliance or the stabilisation appliance.
* This splint provides a temporary and removable ideal
occlusion.
* The stabilisation appliance is given usually on the
maxillary arch for the sake of stability.
* When the appliance is in place, the condyles are the
most stable position in the glenoid fossa. The
posterior also disocclude during lateral movements by
canine guidance.
ame the 2 indications for for a centric relation split?
Indications:
* Muscle hyperactivity during periods of stress
* Muscle hyperactivity due to centrally mediated myalgia and local muscle soreness.
This appliance helps to reduce forces on the damaged teeth and to help in healing.
Explain how to fid the centric relation point for a centric relation split?
This position is the most stable musculoskeletal position of the mandible and hence it must be accurately located in the patient. It can be done by:
1. The bimanual palpation method
2. Using a flat anterior plane to disocclude about 3-6mm so that the posterior are in disocclusion by about 1-3mm
What is the definition of the anterior bite plane?
This is a partial coverage appliance used for occlusal disengagement.
* By providing an ideal anterior guidance and temporarily disengaging the back teeth, a very tense masticatory musculature can be encouraged to relax.
What are the 2 indications for a anterior bite plane?
Indications:
1. Muscle disorders related to orthopaedic instability or an acute change in the occlusal condition.
2. Short periods of parafunctional activity.
RISK of creating anterior open bite if used for an extended period of time.
What is the definition of a posterior bite plane?
- It is a hard acrylic appliance which covers the posterior mandibular teeth and is connected by a cast lingual bar.
- The objective of this appliance is to bring about changes in the vertical dimension and the mandibular positioning.
What is the indication of a posterior bite plane?
Indicated in severely worn dentition.
What is the definition of a non-permissive bite split?
Non permissive splints do not allow free movements of the mandible on the contacting surface. These have ramps or indentation on the occluding surface that help in limiting the movements of the mandible.
* Are also called ‘directive splints’ because these appliances direct the mandible in a specific relationship to the maxilla.
What is the definition of a pseudo permissive bite split?
They function completely differently when compared to the permissive splints.
* Main type being the Soft Bite Guard.
* Soft appliance fabricated from a resilient material that is usually adapted to the maxillary teeth.
* Functions by separating the teeth. Have been recommended for use in patients with high levels of clenching and bruxism.
* Can also exacerbate bruxism due to the inability to achieve a balanced contact with them.
What is the definition of a soft split?
Fabrication
* Polyvinyl splint is made by vacuum forming technique onto either upper or lower model. Occlusal registration usually not necessary.
What is the indication for a occlusal soft split?
Indication:
* First line simple emergency management for patients with TMD pain
The mode of action is uncertain but may be due to its soft nature and may also act as a habit breaker (cognitive awareness theory)
ame the 4 limitations for a occlusal soft split?
Limitations:
* Can exacerbate bruxism.
* Generally worn at night.
* Cannot be occlusal adjusted
* Only functional for about 4-6 months as tend to become firm and lose their flexibility.
Patient with bruxism and headaches no TMD - type of split?
Full coverage splint at night in acrylic.
Patient with isometric clenching?
Full coverage maxillary guard with all the
teeth in contact is appropriate.
Patient with parafunction in lateral and protrusive directions?
Mandibular splint will be effective.
If muscle disorder in TMD patients is suspected?
Bite plane therapy is indicated but flat plane splints covering entire arch may help in unreliable patients.
What is a suitable time for a TMJ disorder review?
Advisable to review patient after 7days to check contacts and occlusion has remained stable.
* They should be reviewed regularly (1-2weeks) to achieve a stable retruded position if the splint is being used to treat MD.
* Usually, no irreversible alteration is needed to the patient’s occlusion, and they may be weaned of the splint but told to wear it again if the discomfort returns
What is the definition of neuralgia?
An intense stabbing pain
* The pain is usually brief but may be severe.
* Pain extends along the course of the affected nerve.
* Usually caused by irritation of or damage to a nerve
ame the 4 nerves involved that mediate sensation i the head?
- Trigeminal
- Glossopharyngeal and Vagus
- Nervus intermedius
- Occipital
ame the 3 types of trigeminal neuralgia?
Idiopathic
* Classical
Secondary
What is the definition of classical trigeminal neuralgia?
Vascular compression of the trigeminal nerve
What is the definition of secondary trigeminal neuralgia?
- Multiple sclerosis
- Space-occupying lesion
Others: - skull-base bone deformity,
- connective tissue disease,
- arteriovenous malformation
ame the symptoms/presentation of trigeminal neuralgia?
Unilateral maxillary or mandibular division pain > ophthalmic division
Stabbing pain
5 - 10 seconds duration
Triggers
* cutanoues
* Wind, cold
* Touch
* Chewing
Purely paroxysmal or with concomitant continuous pain
Remissions and relapses
ame typical pai description for trigeminal neuralgia?
Acute spasms of ‘sharp, shooting pain’
*May be more than on division
*May be bilateral
*May have burning component
*May have vasomotor component
Describe a typical trigeminal neuralgia pai?
*Usually older patient
*‘Mask-like’ face
*Appearance of excruciating pain
*NO obvious precipitating pathology
What are the red flags for sensory deficit?
Younger patient (>40yrs)
*Sensory deficit in facial region
*hearing loss – acoustic neuroma
*Other Cranial nerve lesions
ALWAYS test cranial nerves (identify sensory deficit)
ALL patients now get MRI
Describe the 1st and 2d line drug therapy for trigeminal neuralgia?
First line:
*Carbamazepine - modified release
*Oxcarbazepine
*Lamotrigine (slow onset of action)
Second line:
*Gabapentin
*Pregabalin
*Phenytoin
- Baclofen
Describe the typical management for trigeminal neuralgia?
Should be responsive to Carbamazepine (if tolerated!)
*Maximise efficacy and minimise side effects
*Often difficult to control pain first thing in the morning
*Pain diary is very helpful to identify modifications necessary to therapy
*Can be responsive to local anaesthesia
ame the side effects of carbamazepine?
Blood dyscrasias
*Thrombocytopenia
*Neutropenia
*Pancytopenia
Electrolyte imbalances (hyponatremia)
Neurological deficits
*Paraesthaesia
*Vestibular problems
Liver toxicity
Skin reactions
Should you prescribe carbamazepine as a GDP?
BNF Dental preparations
*SDEP guidelines
*Expertise
*Facilities for monitoring toxicity
When should a patient with trigeminal neuralgia e referred for surgery?
Not usually recommended if patient managing on medical therapy with moderate drug dose and no significant side effects
Consider surgery:
*when approaching maximum tolerable medical management even if pain controlled
*‘Younger’ patients with significant drug use – will have many years of drug use
ame the 4 surgical options for trigeminal neuralgia?
ame the 6 complications post trigeminal neuralgia surgery?
*Local effects – peripheral treatments (cryotherapy)
*Sensory loss
*Corneal reflex
*General sensation
*Hearing loss
*Motor deficits
ame the 3 causes for paiful trigeminal neuropathy?
Herpes Zoster Virus (related to active VZV infection, post-herpetic ‘neuralgia’)
*Trauma (pain develops <6 months of traumatic event)
*Idiopathic
What are the characteristics for paiful trigeminal neuropathy?
pain is localized to the distribution(s) of the trigeminal nerve
*commonly described as burning or squeezing or likened to pins-and-needles.
*primary pain is usually continuous or near-continuous. Superimposed brief pain paroxysms may occur, but not the predominant pain type.
*more commonly accompanied by clinically evident cutaneous allodynia (much larger than the punctate trigger zones present in trigeminal neuralgia) and/or sensory deficits
ame the symptoms of trigeminal neuralgia cephalalgias?
Unilateral head pain
* predominantly V1
Very severe / Excruciating
Usually prominent cranial parasympathetic autonomic features (ipsilateral to the headache)
* Conjunctival injection / lacrimation
* Nasal congestion / rhinorrhoea
* Eyelid oedema
* Ear fullness
* Miosis and ptosis (Horner’s syndrome)
Attack frequency and duration differs
ame the 3 different types of Trigeminal Autonomic Cephalalgias?
What is the defiitio of the attack of a cluster headache?
Pain: mainly orbital and temporal
* Attacks are strictly unilateral
* Rapid onset (max within 9 mins in 86%)
* Duration: 15 mins to 3 hours (majority 45-90 mins)
* Rapid cessation of pain
* Excruciatingly severe (“suicide headache”)
Patients are restless and agitated during an attack
Prominent ipsilateral autonomic symptoms
Migrainous symptoms often present
* Premonitory symptoms: tiredness, yawning
* Associated symptoms: nausea, vomiting, photophobia, phonophobia
* Aura in 14%
What is the definition of the bout of a cluster headache?
Episodic in 80-90%
* Attacks “cluster” into bouts typically 1-3 months with remission lasting at least 1 month
* Attack frequency: 1 every other day to 8 per day
* May be continuous background pain between attacks
* Alcohol triggers attacks during a bout, but not in remission
Striking circadian periodicity
* attacks occur at the same time each day
* bouts occur at the same time each year
10-20% chronic cluster
* Bouts last >1 year without remission or
* Remissions last <1 month
What is the definition of paroxysmal hemicrania?
Pain: mainly orbital and temporal
Attacks are strictly unilateral
Rapid onset
Duration: 2-30 mins
Rapid cessation of pain
Frequency: 2-40 attacks per day (no circadian rhythm)
Excruciatingly severe
50% are restless and agitated during an attack
Prominent ipsilateral autonomic symptoms
Migrainous symptoms may be present
10% attacks may be precipitated by bending or rotating the head
Background continuous pain can be present
80% have chronic PH, 20% have episodic PH
Absolute response to indometacin
ame the 3 drug therapies for cluster headaches?
Cluster Headache:
Abortive (attack)
- Subcutaneous sumatriptan 6mg or nasal
zolmatriptan 5mg
- 100% oxygen 7-12 l/min via a non-rebreathing
mask (effective and safe)
Abortive (bout)
- Occipital depomedrone/lidocaine injection
- Or tapering course of oral prednisone
Preventative
* Verapamil (high doses may be required)
* Lithium
* Methysergide (retroperitoneal fibrosis)
* Topiramate
* CGRP monoclonal antibodies
ame the drug therapy for paroxysmal hemicrania?
No abortive treatment
* Prophylaxis with indomethacin
* Alternatives – COX-II inhibitors,
Topiramate
