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ABOMS (Johnston) > TMJ/Facial Pain > Flashcards

TMJ/Facial Pain Flashcards

1
Q

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
A
  • 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
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2
Q

TMJ blood supply

A

Posterior - Masseteric

Anterior - Maxillary, STA

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3
Q

TMJ innervation

A

Auriculotemporal

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4
Q

Scintigraphy

Isotope for bone remodeling (taken up by what cell?)

Isotope for inflammation, good for osteomyelitis

A

Technetium 99, osteoclasts

Gallium 67, tumor cells, inflammatory cells

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5
Q

Non-surgical Rx management TMD

5 medicine classes, common med and dose

A
  • (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
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6
Q

3 splints for non-surgical TMD

A
  • 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
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7
Q

OA vs RA in TMJ

  • Age
  • Prevalence
  • Duration of morning stiffness
  • Swelling
  • Speed of onset
  • Unilateral vs bilateral
A

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
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8
Q

JRA

  • Age
  • Diagnosis
  • Labs (3 key labs)
  • What % JRA have TMJ involvement
  • Tx
A
  • 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
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9
Q

RA synovial fluid findings

A

Cloud

Reduced Viscosity

WBC >20,000

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10
Q

Psoriatic Arthritis

  • clinical triad
  • Treatment
  • What % of people with cutaneous psoriasis have psoriatic arthritis
A
  • psoriasis, erosive arthritis, negative RF
  • Medical only: NSAIDS, steroids, disease modifiers
  • 33%
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11
Q

Reactive Arthritis (Reiter Disease)

  • Triggered by:
  • Triad
A
  • Triggered by infection: intestinal, STD
  • Triad: Cannont:
    • Climb (arthritis)
    • See (Uveitis)
    • Pee (urethritis)
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12
Q

Infectious arthritis

  • Local etiologies
  • Systemic etiologies
  • Lab findings
  • Key physical findings
  • Treatment
A
  • Ear/mandible infection, trauma
  • Hematogenous spread of: Gohnorrhea, syphyllis, TB, actinomyces
  • Leukocytosis, TMJ aspirate culture
  • Preauricular skin warm, erythema
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13
Q

Still Disease

  • Similar to what disease
  • Gender/Age
  • Diagnosis
  • Lab findings
A
  • Similar to JRA except boys
  • Boys, <5yo
  • Fever, joint swelling and pain, hepatosplenomegaly, lymphadenopathy
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14
Q

Gout vs Pseudogout

  • Crystal type and shape
  • Birefringence
  • Imaging
  • Lab values
A
  • 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
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15
Q

Gout vs Pseudogout

  • etiology
  • risk factors
  • age/gender
  • affected joints
  • prophylaxis
A
  • 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
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16
Q

High Purine foods

A
  • 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
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17
Q

Disc Displacement %

Anterior

Posterior

Medial rotation

Anterolateral

A
  • Anterior 45%
  • Posterior <15%
  • Medial Rotation 30%
  • Anterolateral 11%
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18
Q

Synovitis mediators

  • What is released
  • Affect of each
A
  • Prostaglandin E
  • Leukotriene B4
  • Both cause vasodilation with edema/hyperemia
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19
Q

Wilkes Classification

Common stages

  • Painful click
  • Disc perforation
  • Moderate bony changes
  • Complete disc displacement without reduction
  • Occasional painful click
A
  • 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
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20
Q

Arthrocentesis

  • Rate of success
A
  • 80-85% successful
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21
Q

Stage of Acute Synovitis

  • Type 1
  • Type 2
  • Type 3
  • Type 4
A
  • 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
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22
Q

Hemimandibular Hyperplasia vs Elongation

  • Why is there a crossbite and chin deviation in one type?
  • Why is there open bite in other type
A
  • Cross bite and chin deviation in Elongation because mandibular length is increased
  • Ipsilateral posterior open bite in hyperplasia
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23
Q

TMJ Ankylosis Classification

  • Topazian
  • Sawhney
A

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
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24
Q

Anklysosis: 4 etiologies

  1. Trauma example?
  2. Infection exampl?
  3. Inflammation examples?
  4. Surgery example?
A

Anklysosis: 4 etiologies

  1. Trauma (esp pediatric condyle)
  2. Infection (otitis media, suppurative TMJ arthritis)
  3. Inflammation (RA, ankylosing spondylitis)
  4. Surgery (post op complication TMJ surgery)
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25
Q

TMJ tumor types

  • 3 categories of TMJ tumors
  • Rank in order of occurence
A

Pseudotumor 70%

Malignant neoplasm 20%

Benign neoplasms 10%

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26
Q

TMJ neoplasms - radiographic findings

  • Radioopacity: likely lesions
  • Radiolucency: likely lesions
  • Mixed: likely lesions
A
  • Radioopacity: likely pseudotumor
  • Radiolucency: likely benign/malignant
  • Mixed: Osteoid Osteoma, osteosarcoma
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27
Q

List 3 TMJ pseudotumors and one liner

A
  1. Osteochondroma: Condylar periosteum metaplasia, ossification continuous with condyle cortical bone tx with resection.
  2. Pigmented Villonodular Synovitis: proliferation of synovium, pigmented from hemosiderin, tx with synovectomy and capsulectomy.
  3. Synovial Chondromatosis: Synovial metaplasia to cartilage, chunks dettach forming joint mice, tx with synovectomy
28
Q

List 2 Benign TMJ Tumors and one liner

A
  1. Osteoma: Hyperplasia normal bone usually <2cm, condyle often replaced, NSAIDs help, tx with resection
  2. Osteoid osteoma: Less bone and more vascularized fibrous stroma >2cm, mixed radiograph lesion, giant cells unique feature, NSAIDs don’t help, tx with curretage.
29
Q

Malignant TMJ Tumors - most common

A
  • most common TMJ malignancy is metastasis
30
Q

Primary Malignant TMJ Tumors

All are Sarcomas. 3 types and one liner

A
  1. Osteosarcoma: most common, single poorly defined lytic lesion on radiograph, mets to lungs, tx with pre/post op chemo
  2. Chondrosarcoma: erosion of condyle with joint space calcifications, high grade 70% metastasis rate, Tx resection and adjuvant XRT
  3. Synovial Sarcoma: Originates from synovium, tx with WLE and adjuvant chemo/XRT
31
Q

CN VII injury with TMJ surgery

  • Which branch most commonly injured?
  • Where is VII deepest?
  • Where is VII most superficial?
A
  • Temporal
  • Preauricular tissue
  • 5cm from parotid border
32
Q

Management of TMJ prosthesis infection

A
  1. Remove device
  2. Replace with antibiotic bone cement spacer
33
Q

Neuroanatomy - Trigeminal

  • Foramina for each branch?
  • Which branch brings parasympathetic to lacrimal gland from pterygopalatine ganglion?
    *
A
  • V1 - SOF
  • V2 - Rotundum
  • V3 - Ovale (oval mandibular arch)
  • V2 parasympathetic fibers to lacrimal gland
34
Q

3 nuclei of trigeminal nerve

  • Located in which area of brain?
  • Role of each nuclei
A
  • Brainstem
  • Mesencephalic nucleus: PDL and masticatory proprioception
  • Main sensory nuceleus: Facial proprioception
  • Spinal Trigeminal nucleus: Oralis (Tactile/Temp), Caudalis (nociception)
35
Q

Which trigeminal nucleus receives nociception?

A

Spinal Trigeminal Nucleus - Caudalis

36
Q

Neuropathic Pain Disorders - 2 categories

A
  • Episodic: severe, paroxysmal electric shock, short duration
  • Continuous: Aching/burning/throbbing/stapping
37
Q

Quantitative sensory testing:

  • What activates C-fibers?
  • What activates A-delta?
  • What activates A-beta?
A
  • C-fibers = Heat
  • A-delta = Cold, punctate mechanical
  • A-beta = Electrical stimuli
38
Q

2 main episodic neuropathic pain disorders

A
  1. Trigeminal neuralgia
  2. Glossopharyngeal neuralgia
39
Q

TN / GN - pathophysiology

A

Vascular compression leading to demyelination and spontaneous nerve firing. Pain often elicited by trigger points

40
Q

TN - S/S

  • Laterality
  • Most common branch
  • Effect of diagnostic local anesthesia
  • Other neuro deficits
  • Relationship of trigger points
A
  • 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
41
Q

TN - types and incidence

A
  • 85% Classic TN (no pain between short attacks)

Remaining 15%

  • Atypical TN (constant pain + longer attacks)
  • Symptomatic TN (related to tumor or vascular malformation)
42
Q

DDx for TN

A

DDx TN

  • MS
  • Intracranial tumor
43
Q

TN - Treatment

Pharm

  • 1st and 2nd line

Surgery

  • Categories of procedures
A

Pharm

  • 1st - Carbamazepine
  • 2nd - Phenytoin

Surgery

  • Peripheral: neurectomy, cryotherapy, alcohol injection
  • Central: Gamma knife, microvascular decompression, percutaneous rhizotomy
44
Q

Glossopharyngeal neuralgia GN

  • 2 pain regions
  • common triggers
  • Cardiac effects
  • Tx
A

2 regions of pain

  1. Pharyngeal
  2. Tympanic

Triggers: swallowing, chewing, coughing, yawning, talking

Can induce bradycardia/syncope

Tx: similar to TN: rhizotomy CN IX,X, microvasc decompression

45
Q

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
A

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
46
Q
  • Which type of headache is more common in males?
A

Cluster headaches

Age 27-31, males > females

47
Q

Headache pathophysiology

  • Muscle contraction/tension =
  • Neurovascular disorder =
  • Hypothalmic abnormality =
  • Giant cell vasculitis =
  • Post-injury =
A

Headache pathophysiology

  • Muscle contraction/tension = Tension HA
  • Neurovascular disorder = Migraine
  • Hypothalmic abnormality = Cluster HA
  • Giant cell vasculitis = Temporal arteritis
  • Post-injury = Posttraumatic HA
48
Q
  • What qualifies as chronic migraine?
  • Whate qualifies as status migranosus?
  • Symptomatic treatment
  • Prophylactic treatment
A
  • 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
49
Q
  • Unique symptoms with cluster headache
A
  • unilateral periorbital pain
  • 15-180 mins
  • Rhinorrea, lacrimation, eyelid edema, miosis
50
Q

Cluster Headache treatment

A

Symptomatic/abortive:

  • Oxygen x15 mins
  • Triptans
  • Dihydroergotamine

Prophylactic:

  • Verapamil, steroid, lithium, divalproex, topamax

Intractable:

  • Trigeminal rhizotomy, microvascular decompression
51
Q

List at least 2 triptan medications

Mechanism

Treatment Role

A

Triptans

  • Imitrex, Maxalt
  • Selective Serotonin Agonists (5-HT)
    1. Vasocontriction intra-cranial extra-cerebral vessels
    2. Inhibit release of Substance P and CGRP
    3. Block nociception transmission in spinal cord
  • Abort Migraine and Cluster headaches
52
Q

Secondary HA

  • Define
  • Types
A

Secondary HA = HA that occurs in close temporal relationship with other disorder

  1. Temporal Arteritis
  2. Post-Trauma/Concussion
53
Q

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
A
54
Q

Clinical picture of Temporal Arteritis

Describe serious consequence if diagnos/tx delayed

Diagnosed with:

A
  • 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
Q

55 year old female presents with new persistent HA over left face/temple, pain when chewing.

  • Initial management and DDx
A
  • DDx: Temporal arteritis, TMD, tumor/lesion
  • Start steroids to prevent ophthalmic artery occlusion with giant cells until temporal arteritis ruled out.
56
Q

Post-trauma headache

  • Synonomous diagnoses
  • Diagnostic criteria
  • Treatment
A

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
57
Q

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
A

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
58
Q

Comparison of 4 masticatory muscle disorders

  • Which have focal tenderness?
  • Only painful when muscle forced to lengthen?
  • Sensation of acute malocclusion (sub-clinical)
A

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
59
Q

Difference between Muscle Spasm and Muscle Contracture

A

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
60
Q

Treatment for Myofascial pain

A

Treatment for Myofascial pain

  • Soft diet
  • heat/massage
  • splint
  • ROM exercise
  • NSAIDS
  • Muscle relaxants
  • Tranquilizers (Diazepam)
  • Cognitive behavioral therapy
61
Q

Treatment for muscle spasm

A

Treatment for muscle spasm

  • NSAIDS
  • Heat/massage
  • ROM exercises
  • Electric nerve stimulation/ultrasound
62
Q

Treatment for Myositis

A

Treatment for myositis

  • NSAIDS
  • Moist heat
  • PT once acute symptoms resolve
  • ABX (if infectious etiology)
63
Q

Treatment for Muscle Contracture

  • PT
  • Surgery if PT unsuccessful (Myotomies, muscle stripping)
A
64
Q

Fibromyalgia

Key diagnostic criteria

A

Fibromyalgia

  • Pain >3 months in all 4 quadrants of body
  • 11 of 18 standard tender points
  • Tender points painful at local site
65
Q

Main differences between fibromyalgia and Myofascial pain

  • Gender
  • Comorbidities
  • Pain distribution
A

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

ABOMS (Johnston) (8 decks)

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