TMD Flashcards
Explain radiation and referral of pain
-Referral= pain in one part of your body, but the real source of that pain is coming from somewhere else. eg. toothache in upper arch when it is lower arch. (rarely crosses centreline)
-Radiation= pain spreads
Give examples of the 4 main groups of orofacial pain: odontogenic, musculoskeletal, neurovascular, neuropathic
- Odontogenic- toothache
- Musculoskeletal- TMD
- Neurovascular- migraine, trigeminal autonomic cephalgias
- Neuropathic- trigeminal neuralgia, burning mouth syndrome, phantom tooth pain
How long does normal healing take. when would it become chronic pain
Persistent (chronic) is lasting ≥3 months. It is no longer protective pain
– normal healing takes < 3 months
Explain allodynia, hyperalgesia, paraesthesia, dysthaesia, anaesthesia. Which of these occurs in toothache, TN and TMD
-Allodynia - painful response to something that should not cause pain
-Hyperalgesia- exaggerated response
-Parasthesia - abnormal sensation- tingling, numbness
-Dysaesthesia - painful abnormal sensation
-Anaesthesia - loss of sensation
Toothache=usually hyperalgesia
TMDs and trigeminal neuralgia often allodynia
What is TMD and describe the pain symtpoms that occurs
-group of disorders affecting the TMJ and MOMs.
-Can co-exist with migraines.
-Aching pain in masseters, temporals, ear, jaw . Trigmeinal nerve supplies the pain
-Pain is dull, deep, aching, throbbing. Usually constant.
-sudden/ gradual. Acute/chronic
-can be either uni or bilateral
-can radiate and refer
-Jaw movements can be limited/ deviate/ uncoordinated
-Clicking and crepitus of jaw
-Usually worse in morning, eases throughout day
-Periods of flare up. Exacerbating factors= chewing, talking, yawning, movement, palpation
What is temporal arteritis and symptoms
-presents similar to TMD (but is not musculoskeletal)
-localised constant temporal headache
-due to inflammatory vasculitis where the lumen narrows causing lock of local blood flow
-symptoms= tender and inflamed superficial temporal arteries, visual disturbances, tired jaw when eating, crampy, jaw pain
-unilateral
-managed with systemic steroids as can cause blindness
Pain features of migraines. Symptoms.
-most common neurovascular pain
-headache, persistent throbbing, stabbing pain up to 72 hours
-photophobia, nausea, vomitting, aura
-triggered by chocolate
-want to lie in dark room
-decreased ability to function with headache
-treatment can be prophylactic or abortive (when symptoms come on)
-affects sleep
What is orofacial neuropathic pain. Name types. Diagnosing. Management
-pain due to nerve-based pathology (mediated by trigeminal nerve)
-Episodic (comes and goes) or continuous
-aching or burning pain
-analgesia usually no help
-high intensity due to protective function for the brain
-spontenous or evoked
-BMS, Post SR wisdom teeth, Phantom tooth pain, Trigeminal neuralgia, persistent idiopathic dentoalveolar pain, normal CN test
-Diagnosing: history, imaging, exclude dental pathology, LA block, Qualitative sensory testing
-Management: Neuro-modulatory drugs to disrupt nociceptive impulses or modify receiving stations in brain (antidepressants, carbazeipone), reassurance, education, psychosocial management, do not over treat, cognitive behavioural therapy
What is trigeminal neuralgia and its symptoms. Investigations
-sharp shooting stabbing pain mediated by CNV, likely due to superior cerebellar artery or vein compressing trigeminal nerve as it enters pons. Theory that demyelination causes spontaneous nerve firing, or injured compressed nerves causes hyper excitable nerves
-V2>V3>V1
-sudden, short bursts (secs), severe and episodic
-electric shock feeling
-Unilateral
-no swelling/erythema/fever
-triggers include talking, chewing, touch, wind, temperature change
-periods of remission
-investigations= MRI, bloods, CN test [normal], rule out dental pathology with sensibility tests, pain diary
First line pharmacological management of trigeminal neuralgia
- carbamazepine on a titrating dose: anticonvulsant that blocks voltage gates Na and Ca channels to reduce neurones firing
- Oxcarbazepine anticonvulsant: not used long term due to nausea, haematological issues
Long term management of trigeminal neuralgia
-Carbamazepine, lamotrigine, baclofen, gabapentin, pregabalin, lidocaine spray/ointment, botox
-Surgery: usually better pain management, better tolerated and less side effects than meds. Eg. Microvascular decompression (dissect vessel away from nerve), Neurolysis (agents applied to degenerate nerve fibres), Nerve ablative procedure (using glycerol)
-Psychosocial: CBT, improve sleep, remove triggers
Potential side effects of carbamazepine and its contraindications
-Steven-Johnson’s syndrome – widespread rashes/ ulceras
-Anameia, decreased platelets and WBCs– Infections, unusual clotting, easy bruising
-Liver disorders (hepatic enzyme inducers)
-Xerostomia, glossitis, ulcers, cervical lymphadenopathy
=Bloods needed every 6 weeks (so ask these patients if monitored)
Contraindications:
AV conduction abnormalities, bone marrow depression, liver disease
Dose of carbamazepine and its maximum dose
-100-200mg 1x daily, increase slowly to a 3x daily dose
-Max 1600mg total daily dose
What is burning mouth syndrome. symptoms. Investigations
-Persistent intra oral burning sensation, worsens throughout day. Recurrent daily for more than 2 hours for more than 3 months. No underlying cause (idiopathic) – SMALL FIBRE neuropathy
-symptoms= bilateral, diurnal variation, moderate to severe intensity, impacts quality of life, taste alteration, no ulcers, psychological issues
-Investigations -history and examine to identify any cause. Tests to exclude causative factors (ferritin levels, thyroid function tests, Haematinics, biopsy, HbA1c)
Causes of secondary BMS
-Secondary BMS is burning symptoms with underlying cause - drug reactions (ACEI), anaemia, B12 and folate deficiencies, diabetes, candidiasis,
xerostomia, hypothyroidism, inadequate tongue space, lichen plenus, sjogren’s syndrome, fibromylalgia, erythroleukoplakia
Management of BMS
-Address the underlying cause if it is secondary BMS.
-Topical capsaicin - mouthwash to desensitise pain receptors. Causes initial increase in burning, not used in GI disorders
-Topical benzodiazepines -hold in mouth for 3 mins then spat out. Only short term due to dependence, Xerostomia, fatigue effects
-Cognitive behavioural therapy
-Psychological management
-Alpha-lipoic acid -but evidence for efficacy inconclusive
What is phantom tooth pain and its symptoms.
-Pain following extraction or >3 months after RCT
-Injury to primary afferent nerves
- Persistent pain. Localised to dentoalveolar region. deep in tooth/ bone. Pressurized. Prone to exacerbation. Difficult to describe. Itchiness/ crawling/ warmth/burning/aching
Age demographic affected by trigeminal neuralgia, migraines, BMS, TMD
All more common in females
-TN= 50-70 year olds
-Migraine= 35-45 year olds
-BMS >40 year olds
-TMD= increases with age
Why ask about sleep when patients experiencing orofacial pain
-ask about whether they can get to sleep and can they stay asleep
o Very few things other than TOOTHACHE or MIGRAINE will wake someone up from sleep
Differential diagnosis to consider when patient experiencing orofacial pain. How to diagnose
-TMD, trigeminal neuralgia, temporalis arteritis, migraine, sinusitis (palpate maxillary sinuses extra orally, pain when bend forward), parotid infection (pain when eat), MOM abnormality, tooth fracture/ infection, phantom pain, BMS, fibromyalgia, neoplasm, degenerative joint disease, infection, trauma, arthritis, hyperplasia
-SOCRATES history (+sleep and systemic), stressors, social and medical history, awareness of parafunction, previous treatment
-Examination= intra and extra oral (TMJ, MOM, glands) Cranial nerve examination
-Investigations: provocation testing to elicit familiar pain, radiographs
Warning red flag symptoms that indicate malignancy (ENT and general signs)
-Recurrent epistaxis (nose bleeds)
-Anosmia (loss of smell)
-Persistent nasal obstruction or purulent discharge
-Objective hearing loss
-Lymphadenopathy
-Near absolute trismus
-Erythroplakia, erythroleukoplakia, leukoplakia or frank ulceration of oral mucosa
-Cranial nerve dysfunction
-Previous head and neck carcinoma
-Preauricular masses
-Young age (<40)
-weight loss, unexplained weakness
-jaw claudication, occlusal change, ipsilateral hearing change, pyrexia, masses
-facial asymmetry
-unexplained neck lump, ulcer, hoarsness
Causes of TMD - (predisposing, precipitating and prolonging factors)
-Genetics and hormones. eg. low COMT increases pain sensitivity
-Trauma: injury, whiplash, iatrogenic (long opening at dentist, difficult incubation), postural habits
-Occlusal changes
-Parafunction- Bruxism, grinding
-arthritis
-Fibromyalgia
-Agenesis- total failure to develop
-Hypoplasia (eg teacher collins syndrome) or hyperplasia (eg. acromegaly) -increased or decreased growth
-infection, radiotherapy, neoplasm
-Psychological stress, anxiety, negative mood, major depressing life events
-Parafunction
Explain the DC TMD 2014 diagnosis system
-Axis 1: classification of TMD into subcategories depending on whether it is myogenous (coming from muscle), arthrogenous (joint/disc) or a combination.
-Axis 2: Psychosocial diagnosis
Done by examining the MOM and TMJ. History. Ask patient about familiar pain. Patient fills out form asking how it affects their mood etc. [Management is same if it is disc/joint/muscle]
Explain the subcategories for myogenous origin for TMD
- Local myalgia – pain localised to palpation
- Myofascial pain – pain within body of muscle
- Myofascial pain with referral – pain is familiar then spreads outside the muscle
- Headache attributed to TMD
Explain the subcategories for arthrogenous origin of TMD
- Arthralgia: pain is same as myalgia but on examination the pain is in the TMJ region
- Intra-articular disorders: disc displacement with/without reduction and with/without limited opening. Degenerative joint disease (osteoarthritis). Subluxation (locking)
Explain the following disc displacements: with reduction, with reduction with intermittent locking, without reduction with limited opening, without reduction without limited opening
- With reduction: when open mouth, disc moves back into condyle causing reproducible Click/pop/snap
- With reduction with intermittent locking: Same as above but jaw can also lock
- Without reduction with limited opening: Decreased mouth opening, interference with eating., When opening, disc does not reduce and go back onto condyle. Sometimes causes jaw locking. Jaw points to the side affected
- Without reduction without limited opening: History of previous limited opening. Over time, disc has remodelled allowing opening to become normal
Boundaries of the infra temporal fossa
- Roof -greater wing of sphenoid, and squamous part of temporal bone
- Lateral – Zygomatic arch, coronoid process and ramus of the mandible
- Medial – lateral pterygoid plate of sphenoid (tensor veli palatini,levator veli palatini and superior constrictor muscles)
- Anterior – posterior wall of maxilla
- Posterior – mandibular fossa, styloid process, spine of sphenoid bone
- Inferior – no physical boundary (alveolar border of the maxilla, medial pterygoid muscle)
