Paediatric Oral Medicine Flashcards
(98 cards)
1
Q
what are the 3 causes of oro-facial soft tissue infections
A
- viral
- bacterial
- fungal
2
Q
what are examples of viral oro-facial soft tissue infections
A
○ Primary herpes ○ Herpangina ○ Hand foot and mouth ○ Varicella Zoster ○ Epstein Barr Virus ○ Mumps ○ Measles ○ Rubella
3
Q
what are examples of bacterial oro-facial soft tissue infections
A
○ Staphylococcal ○ Streptococcal ○ Syphilis ○ TB ○ Cat Scratch Disease
4
Q
what are examples of fungal oro-facial soft tissue infections
A
○ Candida
5
Q
what is primary herpetic gingivostomatitis
A
Acute Infectious disease caused by Herpes Simplex Virus I
6
Q
how is primary herpetic gingivostomatitis transmitted
A
Transmission by droplet formation with 7 day incubation period
7
Q
why are children in their first year of life rarely infected with primary herpetic gingivostomatitis
A
Degree of immunity from circulating maternal ABs therefore infection rare in 1st 12/12
ie Children in their first year of life are rarely infected because they tend to be protected due to circulating maternal antibodies
8
Q
what are the signs and symptoms of primary herpetic gingivostomatitis
A
○ Fluid filled vesicles – rupture to painful ragged ulcers on the gingivae, tongue, lips, buccal and palatal mucosa
§ Therefore ulceration is more commonly seen on presentation
○ Severe oedematous marginal gingivitis
○ Fever
○ Headache
○ Malaise
○ Cervical lymphadenopathy
These lesions are extremely painful and the child may be reluctant to eat or drink leading to a risk of dehydration
9
Q
what is the treatment for primary herpetic gingivostomatitis
A
○ Bed rest ○ Soft diet/hydration ○ Paracetamol ○ Antimicrobial gel or mouthwash ○ Aciclovir for immunocompromised children [Not normally helpful but may be indicated for immunocompromised children]
10
Q
what is the most common complication of primary herpetic gingivostomatitis
A
Most common complication = dehydration
If there is a concern that the child is unable to eat or drink whilst these lesions are present then medical advice should be sought
11
Q
how long does it take for primary herpetic gingivostomatitis to heal
A
Lasts 14 days
Heals with no scarring
12
Q
what does the virus that causes primary herpetic gingivostomatitis do after the primary infection
A
• Remains dormant in epithelial cells
○ Following the primary infection, herpes simplex virus 1 remains dormant then presents as a secondary infection as herpes labialis
○ Recurrent disease in 50-75% = herpes labialis (cold sores)
13
Q
what triggers the secondary infection of herpes labialise
A
Triggered by:
○ Sunlight
○ Stress
○ Other causes of ill health
14
Q
how is herpes labialis managed
A
Management of herpes labialis is with topical acyclovir cream
15
Q
what 2 herpes like viral infections does coxsackie A virus cause
A
- Herpangina
- Hand, foot and Mouth
16
Q
what is herpangia
A
Mild condition presenting like primary herpetic gingivostomatitis with vesicles rupturing to ulceration
In contrast however these vesicles present further back in the mouth in the tonsillar / pharyngeal region
17
Q
how long does herpangia last
A
Lasts 7-10 days
18
Q
what is hand, foot and mouth
A
Ulceration on the gingivae/tongue/cheeks and palate
Maculopapular rash on the hands and feet
19
Q
how long does hand foot and mouth last
A
Lasts 7-10 days
20
Q
how does the patient present if they have hand, foot and mouth
A
○ Presents initially with a sore throat, high temperature and a reluctance to eat
§ Mouth ulcers and a maculopapular rash appears on the hand and feet a few days later
○ Painful condition which makes eating and drinking uncomfortable
21
Q
what is oral ulceration
A
“a localised defect in the surface oral mucosa where the covering epithelium is destroyed leaving an inflamed area of exposed connective tissue”
22
Q
what are the 10 key facts that needs to be asked about the history of the oral ulceration
A
• Onset
○ When did the ulceration first begin?
• Frequency
○ How often do the ulcers appear?
• Number
○ How many ulcers are there at any one time?
• Site
○ Where do the ulcers occur?
• Size
○ What size are the ulcers?
○ Are they always the same size?
• Duration
○ How long does each episode of ulceration normally last?
• Exacerbating dietary factors
○ Has the patient / parent noticed any diet factors which exacerbate the ulceration?
• Lesions in other areas
○ Does the patient ever experience ulceration elsewhere?
• Associated medical problems
○ What is the patient’s medical history?
○ Could this be associated?
○ What medications does the patient take?
• Treatment so far (helpful/unhelpful)
○ What treatment has the patient tried so far?
○ Was it helpful or unhelpful?
23
Q
what are the causes of oral ulceration
A
- Infection:
- Immune mediated Disorders:
- Vesiculobullous disorders:
- Inherited or acquired immunodeficiency disorders
- Neoplastic/Haematological:
- Trauma
- Vitamin deficiencies
• Recurrent Aphthous Stomatitis (RAU)
○ Ulceration can have no clear underlying cause
24
Q
what infections can cause oral ulceration
A
○ Viral: § Hand foot and mouth § Coxsackie Virus § Herpes Simplex § Herpes Zoster § CMV § EBV § HIV
○ Bacterial:
§ TB
§ syphilis
25
what immune mediated disorders cause oral ulceration
```
○ Crohns,
○ behcets,
○ SLE,
○ Coeliac,
○ Periodic fever syndromes
```
26
what vesiculobullous disorders cause oral ulceration
○ Bullous or mucous membrane pemphigoid,
○ pemphigus vulgaris,
○ linear IgA disease,
○ erythema multiforme
27
what neoplastic / haematological problems can cause oral ulceration
○ Anaemia
○ Leukaemia
○ Agranulocytosis
○ cyclic neutropenia
28
what happens if ulcers do not heal as expected
Where ulcers do not heal as expected then the ulcer cannot be dismissed as benign, a biopsy or referral to the local oral cancer unit should be actioned
29
how can trauma cause oral ulceration
○ Can be physical, thermal or chemical trauma
○ Usually a local factor in these instances can be identified
○ The ulcer presents where the trauma has occurred and will resolve approximately 2 weeks after the causative factor (eg a sharp tooth) has been managed
30
what vitamin deficiencies cause oral ulceration
○ Iron
§ An iron deficiency can often present in a growing child given that iron demands in this period increases
○ B12,
○ Folate
31
what is the most common cause of ulceration in children
RAU is the most common cause of ulceration in children
32
what do aphthous ulcers present like
Typically, aphthous ulcers are round or ovoid in shape with a grey or yellow base and have a varying degree of perilesional erythema.
33
what are the 3 sub-groups of RAU
○ Minor - <10mm
§ These are always found on the non-keratinised mucosa
§ Tend to heal within a 10-14 day period
○ Major - >10mm
§ These ulcers can also affect the keratinised tissues
§ Healing of larger ulcers may take several weeks and these may heal with residual scarring
○ Herpetiform – 1-2mm
§ Normally present with multiple ulcers [up to 100 at a time]
§ This can appear similar to primary herpetic gingivostomatitis
§ However, unlike the viral infection, RAU will not normally be accompanied by a fever and can be recurrent
34
what is the aetiology of RAU
The aetiology is unclear ~ no single causative factor identified
Aetiological factors:
• Hereditary predisposition (FH in 45%)
○ Holds the strongest risk for a child developing ulcers
○ There may be times however in a child with genetic predisposition to oral ulceration where the pattern of ulceration changes (eg becomes more frequent)
§ This may indicate other factors at play during this time such as haematological deficiency
• Haematological and deficiency disorders (iron Def in 20%)
○ Iron demands increase with a growing child and therefore low iron levels and subsequent oral ulceration may be seen during periods of growth
○ Deficiencies of vitamin B12 and folate are more uncommon in children but may be suggestive of coeliac disease
§ Lower levels of vitamin B12 or folate therefore warrant referral to a paediatrician for further investigation
* Gastrointestinal disease (Coeliac in 2-4%)
* Minor trauma in a susceptible individual
• Stress
○ Including anxiety
```
• Allergic disorders
○ toothpaste containing SLS
○ Foods containing benzoate or sorbate preservatives ~ Benzoic acid
○ Chocolate
○ Tomatoes
```
• Hormonal disturbance: Menstruation
35
what initial investigations should be done for a patient with RAU
○ Diet diary
○ Full Blood Count
○ Haematinics (Folate/B12/Ferritin)
○ Coeliac Screen: Anti-transglutaminase antibodies
36
How should RAU be managed
○ Diet analysis may suggest exacerbating food groups
○ Low Ferritin = 3 months of iron supplementation
○ Low Folate/B12 or positive Anti-transglutaminase antibodies = referral to paediatrician for further investigation
○ Worth noting that tea can inhibit the absorption of iron so it is important that this is not taken with meals
37
how can the exacerbating factors of RAU be managed
• Nutritional deficiencies
○ Correction of nutritional deficiencies
○ Removal of any predisposing factors
• Traumatic factors
• Avoid sharp or spicy food
○ These can be uncomfortable and exacerbate the ulceration
• Allergic factors:
○ Dietary exclusion
○ SLS free toothpaste
38
what is the pharmacological management of RAU
Management in GDP:
• Prevention of Superinfection:
○ Corsodyl 0.2% Mouthwash
• Protect healing ulcers
○ Gengigel topical gel (hyaluronate)
○ Gelclair mouthwash (hyaluronate)
• Symptomatic relief
○ Difflam (0.15% benzydamine hydrochloride)
○ Local anaesthetic Spray
• Other pharmacological interventions such as the use of steroid medication can be useful however should be considered in liaison with oral medicine
39
What is the main aim of pharmacological intervention
The main aim of pharmacological intervention is to prevent superinfection, protect healing ulcers and provide relief of symptoms
40
what is orofacial granulomatosis (OFG)
Uncommon chronic inflammatory disorder
Idiopathic or associated with systemic granulomatous conditions (Crohn’s disease or Sarcoidosis)
41
what is the average age of onset for OFG
Average age of onset = 11 years old
42
is OFG more common in males or females
males
43
what are the clinical features of OFG due to
Clinical features are thought to be due to a combination of an allergic component resulting in lymphoedema and swelling of the oral tissues and the presence of non-caseating granulomas in the oral tissues preventing normal lymphatic draining
44
what are the clinical features of OFG
* Lip Swelling – most common
* Full thickness gingival swelling
* Swelling of the non labial facial tissues
* Peri-oral erythema
* Cobblestone appearance of the buccal mucosa
* Linear oral ulceration
* Mucosal tags
* Lip/ tongue fissuring
* Angular cheilitis
45
what is the aetiology of OFG
• Largely unknown
• Limited evidence of genetic factors
○ Unlike RAU
• However, there is a strong relationship between OFG and atopic allergy and exposure to various allergens including cinnamon compounds and benzoates are often seen
• Numerous associated allergens reported:
○ Cinnamon Compounds
○ Benzoates
○ Much higher IgE mediated atopy rates compared to the general population
46
what is involved in the diagnosis of OFG
• Clinical
○ Often made solely on a clinical basis
• Lip biopsy not essential
• Investigations:
○ Measure growth – paediatric growth charts
○ Full Blood Count
○ Haematinics
§ Iron deficiency can result in oral ulceration over and above the OFG lesions seen
○ Patch testing – ID triggers
○ Diet diary to ID any triggers
○ Faecal Calprotectin
§ Where Crohn's disease is suspected
○ Endoscopy risky in childhood
○ Serum Angiotensin Converting Enzyme (raised in sarcoidosis)
47
why is a biopsy not always essential for OFG
Biopsy can be uncomfortable and distressing and can also result in additional post-operative swelling
48
how can paediatric growth charts help with the diagnosis of OFG
§ These can help to track the patient's weight and height
§ Growth failure or pubertal delay is seen in Crohn's disease and may be another indication of this disease
49
why would the Serum Angiotensin Converting Enzyme investigation be useful in diagnosing OFG
§ This investigation may be useful if other granulomatous conditions are suspected like sarcoidosis
○ It may also be useful to assess acute phase reactants such as C-reactive protein and erythrocyte sedimentation rate which are usually raised in Crohn's disease
50
how can OFG be managed
• Can be difficult
○ Patients with OFG should be referred for specialist oral medicine and paediatric dental input
• Oral hygiene support
○ Oral hygiene may be more difficult given oral discomfort
• Symptomatic relief as per oral ulceration
The oral lesions of OFG can be uncomfortable and this may be helped to some degree by symptomatic relief as discussed for oral ulceration
• Dietary exclusion (does not cure just reduces orofacial inflammation)
• Manage nutritional deficiencies which may contribute to oral ulceration
Nutritional deficiencies should be managed as per oral ulceration
Other management options exist such as:
• Topical steroids
• Topical tacrolimus
• Short courses of oral steroids (severe or unresponsive to topical)
• Intralesional corticosteroids
• Surgical intervention – unresponsive long standing disfigurement
These can be considered after careful consideration regarding the pros and cons of each approach by a specialist
51
what is the most common mucosal lesion of the tongue seen in children
The most common mucosal lesion of the tongue seen in children is geographic tongue
May be seen at a young age
52
what is geographic tongue
* Geographic tongue is a benign change to the tongue mucosa
| * Idiopathic and non contagious [The cause of geographic tongue is unknown but it is an entirely benign condition]
53
how does geographic tongue present
• Shiny red areas on the tongue with loss of filiform papillae are surrounded by white margins
○ Characterised by smooth red areas on the tongue resulting from loss of filiform papillae, surrounded by white margins
○ These red areas appear to migrate over time
The name geographic tongue related to the lesions 'map of the world'-like appearance
54
what problems can geographic tongue cause
• Can cause intense discomfort in children
• Discomfort with spicy food/ tomato or citrus fruit/juice
○ This is due to children have a thinner oral mucosa and a more intense sense of taste
○ It is likely discomfort will improve with age, and therefore dietary restrictions can gradually decrease
• Likely to become less troublesome with age
55
how is geographic tongue managed
Management: bland diet during flare ups
○ Where tongue sensitivity is present it can be helpful to rule out haematinic deficiencies of iron, folic acid and vitamin B12
○ Otherwise, management includes reassurance and a bland diet when the condition is active
56
what are common causes of solid swellings
* Fibroepithelial Polyp
* Epulides
* Congenital epulis
* HPV-associated mucosal swellings
* Neurofibromas
57
what are fibroepitehlial polyps
Benign lesions which present as a pink lump which can be pedunculated or sessile
58
how does fibroepithelial polyp presents
• Firm pink lump (pedunculated or sessile)
• Mainly in the cheeks (along occlusal line); lips or tongue
○ They can present anywhere in the oral cavity but are more common in areas more easily traumatised such as the gingivae, tongue and lips
• Once established remains constant size
59
what causes fibroepithelial polyp
Thought to be initiated by minor trauma
○ Or irritation
Such as accidental biting or sharp tongue edges
60
how is fibroepithelial polyp treated
• Surgical excision is curative
○ Easily managed
○ This treatment may need to be delayed until the child can co-operate for it and given their benign nature, a GA is difficult to justify for their removal
61
what are epulides
• Common solid swelling of the oral mucosa
○ Present as localised gingival enlargements
• Benign hyperplastic lesions
○ Most arise from the interproximal dental tissues
• They are related to chronic irritation, particularly related to the presence of calculus and plaque
62
what are the 3 main types of epulides
○ Fibrous epulis
○ Pyogenic granuloma
○ Peripheral giant cell granuloma
63
what do all 3 types of epulides share
All of these lesions share common clinical features with the majority occurring anterior to the molar teeth and being more common in the maxilla
64
how are epulides managed
Management of all lesions is surgical removal along with identification and management of exacerbating factors
However, these lesions do have a tendency to recu
65
what is a fibrous epulis
A fibrous epulis represents a similar lesion to a fibroepithelial polyp when found on the gingivae
66
how does fibrous epulis presents
* Pedunculated or sessile mass
* Firm consistency
* Similar colour to surrounding gingivae
* Inflammatory cell infiltrate and fibrous tissue
67
what are names of vascular epulis
Pyogenic Granuloma / Pregnancy Epulis
They are clinically and histologically identical with the distinction purely based on whether they are found on a patient who is pregnant or not
68
how does pyogenic granuloma / pregnancy epulis present
• Soft, deep red/purple swelling
○ These lesions present as soft red / purple swellings which are often ulcerated and haemorrhage spontaneously or with mild trauma
* Often ulcerated
* Haemorrhage spontaneously or with mild trauma
* Vascular proliferation supported by a delicate fibrous stroma
* Probably a reaction to chronic trauma e.g. calculus
69
how should pregnancy epulis be treated
When lesions occur in pregnancy they have a tendency to regress spontaneously or decrease in size and assume features of a fibrous epulis after the child is born, therefore where possible excision should be delayed until this time
70
how does the peripheral giant cell granuloma present
* Pedunculated or sessile swelling
* Typically dark red and ulcerated [Deep red appearance]
• Usually arises inter-proximally and has an hour-glass shape
○ As per other epulis it occurs most commonly in the interdental region
* Can have an hour-glass shape with buccal and lingual swellings joined by a narrow middle section between the teeth
* Multinucleate giant cells in a vascular stroma
71
why are radiographs needed for peripheral giant cell granuloma
• Radiographs may reveal superficial erosion of the interdental bone
○ Radiographically superficial bone erosion may be seen
○ It is important radiographs are taken to rule out central giant cell lesion which has perforated the cortex and presented similarly as a peripheral swelling
72
what is a congenital epulis
Granular cells covered with epithelium
○ Histologically it consists of large, closely packed granular cells
Benign
73
who does the congenital epulis affect and where
* Rare lesion
* Occurs in neonates / new born infants
• Most commonly affect the anterior maxilla
○ Ie the incisor area
• F>M
74
how is congenital epulis treated
Simple excision is curative
| Does not recur after surgical excision
75
what is HPV
Human Papilloma Virus
| associated with a number of benign conditions of the skin and mucous membranes
76
what is verruca vulgaris
○ Solitary or multiple intra-oral lesions
○ May be associated with skin warts
§ These can be transferred to the mouth by autoinoculation from lesions on the fingers
○ Caused by HPV 2 and 4
○ Most commonly on keratinized tissue – gingivae and palate
○ Most resolve spontaneously
§ Most childhood warts resolve spontaneously however surgical removal can be considered if required
○ Can be removed surgically
77
what is squamous cell papilloma
○ Small pedunculated cauliflower like growths
○ Benign
○ HPV 6 and 11
○ Vary in colour from pink to white
○ Usually solitary
○ Treatment = surgical excision
78
name types of fluid swellings
* Mucoceles
* Ranula
* Bohn’s nodules
* Epstein Pearls
* Haemangiomas
• Vesiculobullous lesions
○ Primary herpes
○ Epidermolysis bullosa
○ Erythema Multiforme
79
what are mucocele
a cyst arising in connection with the minor salivary glands
80
what are the 2 variants of mucocele
○ Mucous extravasation cyst – normal secretions rupture into adjacent tissue
§ Can arise as result of extravasation of mucus from a ruptured salivary duct
§ The majority of mucoceles seen in children will be extravasation cysts
○ Mucous retention cyst – secretions retained in an expanded duct
§ Due to cystic dilation of a duct
81
how do mucoceles present
• Bluish, soft, transparent cystic swelling
○ Clinically these present as bluish or translucent swellings which may present with a history of rupture, collapse and refilling
• Can affect minor or major salivary glands
• Most = minor glands of the lower lip
§ Normally occur in the lower lip
• They are normally related to an incidence of minor trauma such as lip biting which cause damage to the minor salivary gland or duct
82
how are mucoceles resolved
• Most will rupture spontaneously
• Surgery only if lesion fixed in size as will likely damage adjacent glands leading to recurrence
○ In most cases the lesion will resolve spontaneously however surgical intervention with removal of the lesion and affected gland may be considered in the lesion is causing a disturbance to daily activities or distress to the child
○ However given the benign nature of the lesion and their tendency to recur following removal, GA is not normally indicated for removal
• Surgical excision involves removal of the cyst and the adjacent damaged minor salivary gland
83
what is a ranula
• Mucocele in the floor of mouth
• Can arise from minor salivary glands or ducts of sublingual/submand gland
It is said to resemble a frogs belly
84
what further investigations are needed for ranula
• Ultrasound or MRI needed to exclude plunging ranula (extend through the FOM into the submental or submandibular space)
○ Ultrasound or MRI investigation of these lesions is required to assess the extent of the lesion
○ Some lesions, referred to as plunging ranulas, extend through the floor of the mouth into the submental or submandibular space and these have to be managed by a specialist
85
what are ranulas occasionally found to be
Occasionally found to be lymphangioma – benign tumour of the lymphatics
86
what are bohn's nodules
= benign lesions seen commonly on the alveolar ridge in neonates
Gingival cysts
These are keratin filled lesions thought to be remnants of the dental lamina
87
where are bohn's nodules found
Occur on the alveolar ridge
88
what age does bohn's nodules affect
Found in neonates (1st 28 days)
Usually disappear in the early months of life
They are of no concern
Often disappear by 3 months of age
89
what are Epstein pearls
Small cystic lesions
Found along the palatal mid-line
Thought to be trapped epithelium in the palatal raphe
90
who are Epstein pearls found in
In ~ 80% neonates
○ Common, appear in the majority of neonates
Don’t cause any concern
91
how do Epstein pearls resolve
Disappear in the 1st few weeks
| / a few weeks after birth
92
what is the most common condition affecting the temporamandibular region
Temporomandibular Joint Dysfunction Syndrome (TMJDS)
93
what is TMJDS characterised by
○ Pain
○ Masticatory muscle spasm
○ Limited jaw opening
94
what needs to be asked within a history for a patient with TMJDS
• A description of presenting symptoms
○ Ie a history of the presenting symptoms which may include:
§ Pain
§ Swelling
§ Clicking or cracking
§ Limitation of jaw opening or locked jaw
§ Generalised facial discomfort
§ Ear ache
§ Feeling of numbness over the masseter muscles
• When did the discomfort begin?
○ Find out when the discomfort first began
○ And whether there were any predisposing factors such as a traumatic injury at this time
• Is the pain worse at any time during the day?
○ A pain which is worse in the morning may indicate a nocturnal clenching or grinding habit
• Exacerbating factors
○ Chewing
§ Gums? Pens? etc
○ Yawning
• Habits
○ Any other habits which may exacerbate the discomfort
§ Are they aware of leaning on their jaw while studying or working at school
§ Are they (or their parents) aware of grinding teeth which can often present with a distressing noise at night time
• Stress
○ Ask the parents sensitively about whether there are any possible causes of stress in their life such as pending examinations or traumatic life events such as bereavement or divorce within the family
95
What should be included in an extra oral examination for TMJDS
* Palpation of the muscles of mastication both at rest and when the teeth are clenched to assess tenderness and/or hypertrophy
* Palpation of the TMJ at rest and when opening and closing to assess tenderness and click/crepitus
• Assessment of opening
○ Check for any deviation of the jaw
○ Assess extent of opening (normal = 40-50mm)
96
What should be included in an intra oral examination for TMJDS
• Assessment of any dental wear facets
• Signs of clenching/grinding:
○ Scalloped lateral tongue surface
○ Buccal mucosa ridges
97
how is TMJDS managed
• Explain the condition
• Reduction of exacerbating factors:
○ Management of stress – mindfulness/yoga
○ Avoid habits such as clenching, grinding, chewing gum, nail biting or leaning on the jaw
○ A bite raising appliance may be considered if there is nocturnal grinding/clenching
§ These are sub-conscious habits and can be difficult to stop
• Allow the over worked muscles to rest:
○ Avoid wide opening – stifle yawns with a closed fist
○ Soft diet which required little chewing
○ Patients should avoid opening wide to eat any food consumed
§ Food can be cut up into small pieces and eaten on both sides of the mouth
○ Patients should avoid incising food which requires anterior movement of the mandible and stretching of the muscles
○ Patients must always ensure a small gap remains between the teeth, with teeth only coming into contact when food is swallowed or chewed
• Most TMJDS will resolve spontaneously over a few months
○ Measures can be put in place to help this
○ However, it is worth noting and discussing with the patient, so there are realistic expectations from the outset
○ These measures often need to be followed for several months to result in improvement
• Patients prone to TMJDS may experience exacerbation of this condition through their life during for example periods of stress
○ It may be that they need to adopt some prevention measures to avoid exacerbating this when it tends to occur
• Symptomatic relief:
○ Use of ibuprofen which has anti-inflammatory action
§ If the patient can tolerate this
○ Alternating use of hot and cold packs
§ Held over the jaw in times of exacerbation of the condition
If these measures are unsuccessful referral for specialist care is indicated.
98
how could you explain TMJDS to a patient
○ That TMJDS and the muscle discomfort is normally due to overworking and misuse of the muscles
○ I liken this to the effect that completing exercise each evening might have on the legs ~ you would expect leg pain and in an attempt to keep more comfortable this might result in alteration to how you walk
§ This is the same with the jaws
○ If the jaws are overworked by for example increased nocturnal grinding during a period of stress, the muscles will then be sore and not be able to function correctly and this can lead to an alteration in how we use the jaw which can, in turn, make the problem worse
§ To help manage this, the jaw needs time to rest and exacerbating factors need to be managed
