Orofacial Pain Syndromes Flashcards
what are the classifications of TMD?
- Derangement of the condyle-disc complex
a. Disc displacement
b. Disc displacement with reduction (CLICK)
c. Disc displacement without reduction (NO CLICK) - Structural incompatibility of articular surfaces
- Inflammatory disorders (-itis)
- Arthrides (OA)
- Functional (TMJDS, myofascial pain dys synd)
What is the main causative factors for TMD?
- No obvious reason (query parafunction –> psychological)
- Stress
How is a clinical examination of TMD carried out?
- Be aware of referred pain (degen vertebral disease of C2-3 referred to angle of mand)
- Rule out odontogenic pain
- Rule out tumours (mylohyoid spasms- query tumour)
- Opening distance ~35mm
- Opening consistency? (distraction may allow pt to open wider than they think)
- Examine joint- effusions, swellings, NOISE etc.
What are the principles of TMD management?
- Re-assurance
- Address pts concerns
- Analgesia +/- diazepam
- Discuss parafunctional habits = clenching, grinding, chewing gum
- Address origin of pain = joint or muscle
- Physiotherapy = stretching, relaxing, massaging (hot/cold)
How are disc displacement disorders managed?
- Splint therapy
- ACUTE = conservative tx, if doesn’t work –> refer, MRI, arthroscopy, arthrocentesis
- CHRONIC = splint
What is myofascial pain?
- Chronic pain disorder
- Muscles are tender due to inflammation
- Causes = trauma, strain, autoimmune
What are the treatments for myospasms? (Muscle spasm)
- Analgesia
- Diazepam (2mg 3x daily OR 5x at night)
- Muscle stretching
- Stop chewing gum
- Phsysio, chiro, acupuncture
- CBT, hypno, stress management
- Topical NSAIDs, Tricyclic antidepressants (Amitrityline 10-75mg)
What are the features of a degenerative joint disease?
e.g. OA
- Dull ache
- Sharp pain
- Immobility
What are the classic features of trigeminal neuralgia?
- Female (~>40yrs)
- Commonly seen in lower branches of CNV (V2 > V3 > V2 & 3)
- Severe piercing/ electric-shock pain lasting seconds
- -> may present with ‘saw tooth’ effect
- No sensory disturbance
- Trigger spots (1/3 pts)
What is the pathology of trigeminal neuralgia?
- Focal demyelination of (peripheral) sensory branch of trig nerve nucleus
- Abnormal intra-cranial artery compression overlying sensory trigeminal nucleus)
==> REQUIRES BOTH PATHOLOGIES to trigger TN!
What are the aetiologies of trigeminal neuralgia?
- Trig n. ischaemia
- Abnormal electrical current in sensory trig n nucleus
- Age (+ abnormal artery)
- MS
- HIV
- Nasopharyngeal carcinoma (antrum)
- Basilar aneurysm
- Tumours
What is the MEDICAL management of trigeminal neuralgia?
- CARBAMAZEPINE (not painkillers)
100mg/ day and increase 100mg every 2-3 days
–> side effect = nausea, skin rash, ataxia
–> reduce dose AFTER 9months symptom-free - Second line drugs = gabapentin, pregabalin, phenytoin, oxcarbazepine
- Baseline blood test = FBC & LFT repeated every 3 months for indices
What is the SURGICAL management of trigeminal neuralgia?
- LOCAL = long acting LA (Bupivicaine ~ works up to 18hrs)
- CNS = MVD (ext dura mater between n. and artery), Fogarty Balloon Compression
What are the features of temporal (giant cell) arteritis?
- Female, >60yrs
- Intense throbbing unilateral headache over temples
- Prominent and tender temporal arteries
- Fever
- Weakness around shoulder
- Similar to Crohn’s histo (“granulomatous arteritis”); skip-lesions
- Blindness can result (ciliary artery involvement)
What is the management of Temporal Arteritis?
- Temporal artery biopsy
- Ophthalmology assessment
- Start oral steroid straight away = Prednisolone (40-60mg/ day) until inflammatory markers return to normal
