TMJ/Facial Pain Flashcards
TMJ Ligaments
- Attaches medial/lateral, keeps disc/condyle together,
- Contains synovial fluid, attaches from neck up to eminence and fossa
- Inner horizontal part limits posterior movement, outer oblique limits rotation
- Limits excessive mouth opening
- Collateral: Attaches medial/lateral, keeps disc/condyle together,
- Capsular: Contains synovial fluid, attaches from neck up to eminence and fossa
- Temporomandibular: Inner horizontal part limits posterior movement, outer oblique limits rotation
- Sphenomandibular: Limits excessive mouth opening
TMJ blood supply
Posterior - Masseteric
Anterior - Maxillary, STA
TMJ innervation
Auriculotemporal
Scintigraphy
Isotope for bone remodeling (taken up by what cell?)
Isotope for inflammation, good for osteomyelitis
Technetium 99, osteoclasts
Gallium 67, tumor cells, inflammatory cells
Non-surgical Rx management TMD
5 medicine classes, common med and dose
- (NSAIDs): 600 mg of ibuprophen four times daily, 500 mg of naproxen twice daily
- Steroids: Medrol Dosepak (P”zer)
- Muscle relaxants: 5 to 10 mg cyclobenzaprine TID
- Antidepressants: Reduces muscle tension; 10 mg amitriptyline QID
- Anxiolytics: Reduces muscle tension; 0.25 mg alprazolam BID or 5 mg diazapam QID
3 splints for non-surgical TMD
- Stabilization Splint: flat, full coverage, prevents grinding only
- Modified Hawley: anterior teeth coverage, prevents grinding and clenching
- Repositioning splint: full coverage, incline to guide mandible anteriorly. Must monitor for shifting dentition
OA vs RA in TMJ
- Age
- Prevalence
- Duration of morning stiffness
- Swelling
- Speed of onset
- Unilateral vs bilateral
OA
- older age
- 8-16% OA have TMJ involvement
- AM stiff <1 hr
- No swelling
- Gradual onset
- Often unilateral
RA
- Any age
- 50% RA have TMJ involvement
- AM stiff >1 hr
- Swelling, pain, stiff
- Rapid onset (weeks)
- Often bilateral
JRA
- Age
- Diagnosis
- Labs (3 key labs)
- What % JRA have TMJ involvement
- Tx
- 1-12 yrs old
- Clinical, PE, Rad: progressive class II with open bite, bird beak deformity, condyle resportion, pain, limited function, preauricular swelling
- RA factor 20% of patient’s, ANA 60-80% of patients, Elevated ESR
- 50% JRA have TMJ involvement
- NSAIDS, antirheum agents, surgery once disease controlled
RA synovial fluid findings
Cloud
Reduced Viscosity
WBC >20,000
Psoriatic Arthritis
- clinical triad
- Treatment
- What % of people with cutaneous psoriasis have psoriatic arthritis
- psoriasis, erosive arthritis, negative RF
- Medical only: NSAIDS, steroids, disease modifiers
- 33%
Reactive Arthritis (Reiter Disease)
- Triggered by:
- Triad
- Triggered by infection: intestinal, STD
- Triad: Cannont:
- Climb (arthritis)
- See (Uveitis)
- Pee (urethritis)
Infectious arthritis
- Local etiologies
- Systemic etiologies
- Lab findings
- Key physical findings
- Treatment
- Ear/mandible infection, trauma
- Hematogenous spread of: Gohnorrhea, syphyllis, TB, actinomyces
- Leukocytosis, TMJ aspirate culture
- Preauricular skin warm, erythema
Still Disease
- Similar to what disease
- Gender/Age
- Diagnosis
- Lab findings
- Similar to JRA except boys
- Boys, <5yo
- Fever, joint swelling and pain, hepatosplenomegaly, lymphadenopathy
Gout vs Pseudogout
- Crystal type and shape
- Birefringence
- Imaging
- Lab values
- Gout - needle shapes
- pseudogout - rhomboid shape
- Gout - Monosodium urate monohydrate
- pseudogout - Calcium pyrophosphate dehydrate
- non-specific chronic destruction, intracapsular calcification
- Gout - elevated serum uric acid
Gout vs Pseudogout
- etiology
- risk factors
- age/gender
- affected joints
- prophylaxis
- Gout - excess uric acid production/undersecretion
- Pseudogout - excess inorganic pyrophosphate
- Gout - purine rich diet, EtOH, diuretics
- pseudogout - RA, hypothryroid, hyperparathyroid,
- Gout - Males 40+
- pseudogout - Females 60+
- Gout - small joints of hand, feet, elbow, knee
- pseudogout - TMJ, triangular ligament of hand, knee meniscus
- Gout - Colchicine, low-purine diet
- pseudogout - Colchicine
High Purine foods
- Foods high in purine include organ meats, bacon, anchovies, venison, veal, goose and yeast. Certain seafood
- Mushrooms, black gram, beans, peas, lentils, broccoli, cauliflower, carrots, aubergine and spinach.
- Yeast
Disc Displacement %
Anterior
Posterior
Medial rotation
Anterolateral
- Anterior 45%
- Posterior <15%
- Medial Rotation 30%
- Anterolateral 11%
Synovitis mediators
- What is released
- Affect of each
- Prostaglandin E
- Leukotriene B4
- Both cause vasodilation with edema/hyperemia
Wilkes Classification
Common stages
- Painful click
- Disc perforation
- Moderate bony changes
- Complete disc displacement without reduction
- Occasional painful click
- Painful click - Stage II
- Disc perforation - Stage V
- Moderate bony changes - Stage IV
- Complete disc displacement without reduction - Stage III
- Occasional painful click - Stage I
Arthrocentesis
- Rate of success
- 80-85% successful
Stage of Acute Synovitis
- Type 1
- Type 2
- Type 3
- Type 4
- Type 1: Minimal vasodilation, no hyperemia
- Type 2: Moderate vasodilation, early hyperemia
- Type 3: Considerable vasodilation, moderate hyperemia
- Type 4: Total hyperemia, completely obliterates vascular patterns
Hemimandibular Hyperplasia vs Elongation
- Why is there a crossbite and chin deviation in one type?
- Why is there open bite in other type
- Cross bite and chin deviation in Elongation because mandibular length is increased
- Ipsilateral posterior open bite in hyperplasia
TMJ Ankylosis Classification
- Topazian
- Sawhney
Topazian: Inferior extension of ankylotic bone
- stage 1: bone limited to condyle
- stage 2: bone extends to notch
- stage 3: bone extends to coronoid
Sawhney: Sequence of fibrous adhesions to relacement of joint with bone
- type 1: fibrous adhesions
- type 2: bony fusion (usually only at lateral aspect)
- type 3: bony bridge between ramus and arch/temporal bone
- type 4: joint replaced with bony mass
Anklysosis: 4 etiologies
- Trauma example?
- Infection exampl?
- Inflammation examples?
- Surgery example?
Anklysosis: 4 etiologies
- Trauma (esp pediatric condyle)
- Infection (otitis media, suppurative TMJ arthritis)
- Inflammation (RA, ankylosing spondylitis)
- Surgery (post op complication TMJ surgery)
TMJ tumor types
- 3 categories of TMJ tumors
- Rank in order of occurence
Pseudotumor 70%
Malignant neoplasm 20%
Benign neoplasms 10%
TMJ neoplasms - radiographic findings
- Radioopacity: likely lesions
- Radiolucency: likely lesions
- Mixed: likely lesions
- Radioopacity: likely pseudotumor
- Radiolucency: likely benign/malignant
- Mixed: Osteoid Osteoma, osteosarcoma
List 3 TMJ pseudotumors and one liner
- Osteochondroma: Condylar periosteum metaplasia, ossification continuous with condyle cortical bone tx with resection.
- Pigmented Villonodular Synovitis: proliferation of synovium, pigmented from hemosiderin, tx with synovectomy and capsulectomy.
- Synovial Chondromatosis: Synovial metaplasia to cartilage, chunks dettach forming joint mice, tx with synovectomy
List 2 Benign TMJ Tumors and one liner
- Osteoma: Hyperplasia normal bone usually <2cm, condyle often replaced, NSAIDs help, tx with resection
- Osteoid osteoma: Less bone and more vascularized fibrous stroma >2cm, mixed radiograph lesion, giant cells unique feature, NSAIDs don’t help, tx with curretage.
Malignant TMJ Tumors - most common
- most common TMJ malignancy is metastasis
Primary Malignant TMJ Tumors
All are Sarcomas. 3 types and one liner
- Osteosarcoma: most common, single poorly defined lytic lesion on radiograph, mets to lungs, tx with pre/post op chemo
- Chondrosarcoma: erosion of condyle with joint space calcifications, high grade 70% metastasis rate, Tx resection and adjuvant XRT
- Synovial Sarcoma: Originates from synovium, tx with WLE and adjuvant chemo/XRT
CN VII injury with TMJ surgery
- Which branch most commonly injured?
- Where is VII deepest?
- Where is VII most superficial?
- Temporal
- Preauricular tissue
- 5cm from parotid border
Management of TMJ prosthesis infection
- Remove device
- Replace with antibiotic bone cement spacer
Neuroanatomy - Trigeminal
- Foramina for each branch?
- Which branch brings parasympathetic to lacrimal gland from pterygopalatine ganglion?
*
- V1 - SOF
- V2 - Rotundum
- V3 - Ovale (oval mandibular arch)
- V2 parasympathetic fibers to lacrimal gland
3 nuclei of trigeminal nerve
- Located in which area of brain?
- Role of each nuclei
- Brainstem
- Mesencephalic nucleus: PDL and masticatory proprioception
- Main sensory nuceleus: Facial proprioception
- Spinal Trigeminal nucleus: Oralis (Tactile/Temp), Caudalis (nociception)
Which trigeminal nucleus receives nociception?
Spinal Trigeminal Nucleus - Caudalis
Neuropathic Pain Disorders - 2 categories
- Episodic: severe, paroxysmal electric shock, short duration
- Continuous: Aching/burning/throbbing/stapping
Quantitative sensory testing:
- What activates C-fibers?
- What activates A-delta?
- What activates A-beta?
- C-fibers = Heat
- A-delta = Cold, punctate mechanical
- A-beta = Electrical stimuli
2 main episodic neuropathic pain disorders
- Trigeminal neuralgia
- Glossopharyngeal neuralgia
TN / GN - pathophysiology
Vascular compression leading to demyelination and spontaneous nerve firing. Pain often elicited by trigger points
TN - S/S
- Laterality
- Most common branch
- Effect of diagnostic local anesthesia
- Other neuro deficits
- Relationship of trigger points
- R>L
- V2/V3 more common than V1
- Local anesthesia of TRIGGER point arrests pain
- No neurologic deficits
- Trigger points in same distribution of affected branch
TN - types and incidence
- 85% Classic TN (no pain between short attacks)
Remaining 15%
- Atypical TN (constant pain + longer attacks)
- Symptomatic TN (related to tumor or vascular malformation)
DDx for TN
DDx TN
- MS
- Intracranial tumor
TN - Treatment
Pharm
- 1st and 2nd line
Surgery
- Categories of procedures
Pharm
- 1st - Carbamazepine
- 2nd - Phenytoin
Surgery
- Peripheral: neurectomy, cryotherapy, alcohol injection
- Central: Gamma knife, microvascular decompression, percutaneous rhizotomy
Glossopharyngeal neuralgia GN
- 2 pain regions
- common triggers
- Cardiac effects
- Tx
2 regions of pain
- Pharyngeal
- Tympanic
Triggers: swallowing, chewing, coughing, yawning, talking
Can induce bradycardia/syncope
Tx: similar to TN: rhizotomy CN IX,X, microvasc decompression
Continuous neuropathic pain disorders
- Disorder: Chronic dental/facial pain that does not meet any diagnostic criteria?
- Disorder: pain with pale/reddish scars, often with allodynia, hyperalgesia, anesthesia dolorosa?
- Disorder: Develops 1 month after stroke in 8% stroke victims?
- Disorder: Swelling, pain, skin changes, lacrimation associated with nerve/tissue injury
Continuous neuropathic pain disorders
- Idiopathic Trigeminal Neuropathic Pain: Chronic dental/facial pain that does not meet any diagnostic criteria?
- Post-herpetic neuralgia: pain with pale/reddish scars, often with allodynia, hyperalgesia, anesthesia dolorosa?
- Central post-stroke pain: Develops 1 month after stroke in 8% stroke victims?
- Complex Regional Pain Syndrome: Swelling, pain, skin changes, lacrimation associated with nerve/tissue injury
- Which type of headache is more common in males?
Cluster headaches
Age 27-31, males > females
Headache pathophysiology
- Muscle contraction/tension =
- Neurovascular disorder =
- Hypothalmic abnormality =
- Giant cell vasculitis =
- Post-injury =
Headache pathophysiology
- Muscle contraction/tension = Tension HA
- Neurovascular disorder = Migraine
- Hypothalmic abnormality = Cluster HA
- Giant cell vasculitis = Temporal arteritis
- Post-injury = Posttraumatic HA
- What qualifies as chronic migraine?
- Whate qualifies as status migranosus?
- Symptomatic treatment
- Prophylactic treatment
- What qualifies as chronic migraine? >15 days per month
- Whate qualifies as status migranosus? Single migraine lasts >3 days
- Symptomatic treatment: 5-HT agonists (triptans)
- Prophylactic treatment: TCA, topiramate
- Unique symptoms with cluster headache
- unilateral periorbital pain
- 15-180 mins
- Rhinorrea, lacrimation, eyelid edema, miosis
Cluster Headache treatment
Symptomatic/abortive:
- Oxygen x15 mins
- Triptans
- Dihydroergotamine
Prophylactic:
- Verapamil, steroid, lithium, divalproex, topamax
Intractable:
- Trigeminal rhizotomy, microvascular decompression
List at least 2 triptan medications
Mechanism
Treatment Role
Triptans
- Imitrex, Maxalt
- Selective Serotonin Agonists (5-HT)
- Vasocontriction intra-cranial extra-cerebral vessels
- Inhibit release of Substance P and CGRP
- Block nociception transmission in spinal cord
- Abort Migraine and Cluster headaches
Secondary HA
- Define
- Types
Secondary HA = HA that occurs in close temporal relationship with other disorder
- Temporal Arteritis
- Post-Trauma/Concussion
Ages and Genders for Primary Headache disorders
- Starts 2nd decade, most frequent 4-5th decades
- F>M
- 3-4th decades
- F=M
- 3rd decade
- M>F
Clinical picture of Temporal Arteritis
Describe serious consequence if diagnos/tx delayed
Diagnosed with:
- Over 50 years old, new persistent HA in one or both temples, worse in cold temps, has jaw claudication (painful chewing)
- Giant cell occlusion of ophthalmic artery leading to blindness
- Suggestive: Increased ESR, C-reactive protein
- Gold standard: temporal artery biopsy (1.5-3cm specimen) shows giant cellls
55 year old female presents with new persistent HA over left face/temple, pain when chewing.
- Initial management and DDx
- DDx: Temporal arteritis, TMD, tumor/lesion
- Start steroids to prevent ophthalmic artery occlusion with giant cells until temporal arteritis ruled out.
Post-trauma headache
- Synonomous diagnoses
- Diagnostic criteria
- Treatment
Synonomous diagnoses:
- Post-closed head injury syndrome, post-concussion syndrome
Diagnostic criteria
- Initial injury: persistent amnesia OR neuropsych impairment, OR LOC
- and at least 3 of these symptoms for >3 months: HA, dizzy, affect changes, personality changes, sleep disturbance, irritable, fatigue, apathy
Treatment
- Eliminate extracranial pain sources
- Neuropsych rehab (counseling)
- TCA, Gabapentin, Pregabalin
Subtypes - Masticatory Muscle Disorders
- Repetitive strain, unilateral, dull/ache, limited ROM, HA/earache, pain worsens with function
- Inflammation secondary to trauma/infection with trismus
- Muscle fibrosis with painless shortening of muscle, severe limited ROM
- Acute overuse, involuntary, acute, muscle contraction, limited ROM
Subtypes - Masticatory Muscle Disorders
- Myofascial Pain = Repetitive strain, unilateral, dull/ache, limited ROM, HA/earache, pain worsens with function
- Myositis = Inflammation secondary to trauma/infection with trismus
- Muscle contracture = Muscle fibrosis with painless shortening of muscle, severe limited ROM
- Muscle spasm = Acute overuse, involuntary, acute, muscle contraction, limited ROM
Comparison of 4 masticatory muscle disorders
- Which have focal tenderness?
- Only painful when muscle forced to lengthen?
- Sensation of acute malocclusion (sub-clinical)
Comparison of 4 masticatory muscle disorders
- Which have focal tenderness = Myofascial pain
- Only painful when muscle forced to lengthen = Muscle contracture
- Sensation of acute malocclusion (sub-clinical) = Myofascial pain
Difference between Muscle Spasm and Muscle Contracture
Muscle spasm
- Acute onset, pain with function, muscle feels tight
Muscle contracture
- Severe trismus with hard stop, not always painful with function unless involved muscle forced to lengthen, h/o infection/trauma/extended period of disuse
Treatment for Myofascial pain
Treatment for Myofascial pain
- Soft diet
- heat/massage
- splint
- ROM exercise
- NSAIDS
- Muscle relaxants
- Tranquilizers (Diazepam)
- Cognitive behavioral therapy
Treatment for muscle spasm
Treatment for muscle spasm
- NSAIDS
- Heat/massage
- ROM exercises
- Electric nerve stimulation/ultrasound
Treatment for Myositis
Treatment for myositis
- NSAIDS
- Moist heat
- PT once acute symptoms resolve
- ABX (if infectious etiology)
Treatment for Muscle Contracture
- PT
- Surgery if PT unsuccessful (Myotomies, muscle stripping)
Fibromyalgia
Key diagnostic criteria
Fibromyalgia
- Pain >3 months in all 4 quadrants of body
- 11 of 18 standard tender points
- Tender points painful at local site
Main differences between fibromyalgia and Myofascial pain
- Gender
- Comorbidities
- Pain distribution
Main differences between fibromyalgia and Myofascial pain
- 90% fibromyalgia in women
- Always associated with depression and fatigue
- Pain in all 4 body quadrants
- Panic attacks in fibromyalgia
