Oral Medicie YR5 Flashcards

Question

Explain how to assess a patient with Persistent Idiopathic Facial Pai?

Answer 1

Believe patient - Do not blame any associated depression for symptoms Do not increase damage - Surgery is not helpful! Adopt holistic strategy - Quality of life issues - Pain control a bonus - Realistic outcomes – Patient & Clinician Use QOL/pain scores as treatment monitor

Answer 2

Abnormal sensory PERCEPTION in ABSENCE OF ABNORMAL STIMULUS Somatoform or Neuropathic? - Where is the problem?

Answer 3

ALL modes of oral sensation involved - Burning or ‘nipping’ feeling - Dysgeusia - Paraesthesic feeling - Dry mouth feeling

Answer 4

Deficiency states - haematinics - zinc - vit B1, B6 Fungal and Viral infections? Anxiety and stress? Gender – more women present to OM than men

Answer 5

Dysaesthesia most likely to be associated with haematinic deficiency SITE important! - Lips & tongue tip/margin = parafunction - Multiple other sites - dysaesthesia

Answer 6

bad taste’ - ‘bad smell’ - ‘Halitosis’ nothing detected by practitioner nothing found on examination REMEMBER! - ENT causes - chronic sinusitis - perio/dental infection - GORD nothing detected by patient’s partner?

Answer 7

pins and needles’ - ‘tingling’ Normal sensation to objective testing Pin/needle elicit pain! CRANIAL NERVES test essential MUST exclude organic neurological disease MUST exclude local causes infection Tumour MRI Essential – demyelination/tumour

Answer 8

VERY common c/o debilitating dry mouth/‘sjogrens’ Eating OK worse when waken at night usually the most obviously associated with anxiety disorders

Answer 9

Explain the condition to the patient - ‘pins and needles’ in the taste etc Assess degree of anxiety - Anxiolytic medication - Clinical psychology Treatment empower the patient - Control is important

Answer 10

Anxiolytic based medication - Nortriptyline - Mirtazepine - Vortioxetine Neuropathic Medication - Gabapentin/Pregabalin - Clonazepam – topical?

Answer 11

Joint Degeneration - pain on use & crepitus, +/- rest pain Internal derangement - LOCKING open or closed No joint pathology

Answer 12

Occlusion? Grinding? Clenching? Stress?

Answer 13

Multi-axis problem Usually SYSTEMIC disorder - ‘pain vulnerable people’ - many systemic symptoms High ANXIETY & low DEPRESSION - NO psychiatric diagnosis in most cases PARAFUNCTION a strong feature

Answer 14

Look for: - clicking joint - locking with reduction - limitation of opening mouth - tenderness of masticatory muscles - tenderness of cervico-cranial muscles - liea ala

Answer 15

Acute pain in face & neck ANY chronic face, head and neck pain symptoms show periodicity - morning/evening exacerbation parafunctional clenching History is the KEY to successful management!

Answer 16

Focal muscle tenderness - masticatory - sternomastoid - Trapezius tenderness over TMJ itself limitation of opening progressive Joint noise incidental - degenerative OA changes related to muscle dysfunction – click Deviation on opening common finding with muscle dysfunction Dental occlusion upset

Answer 17

usually none indicated for ‘functional’ disorders Indications for Imaging Ultrasound Scan if functional visualisation of disc movement is needed DPT or CBCT if bony problem suspected MRI - best image of the disc Arthroscopy to directly visualise the disc

Answer 18

Information – how to self help Physical therapy CBT education +/- exercises Soft diet and analgesia Bite splint Biochemical manipulation Tricyclic (not SSRI) other anxiolytic medication Physiotherapy Acupuncture Clinical Psychology

Answer 19

tendency to anxiety neurosis - ‘anxious parents have anxious children’ - maladaptive response to ‘normal’ change reaction to abuse - school - bullying, fear of failure - home - parental dysharmony, physical abuse

Answer 20

Madile Masseter Capsule Disc Temporal oe

Answer 21

Temporomandibular joint and muscle disorders, commonly called TMJ’, are a group of conditions that cause pain and dysfunction in the jaw joint and the muscles that control jaw movement.

Answer 22

Myofascial pain * Involves discomfort or pain in the muscles that control jaw function. Internal derangement * This involves a displaced disc, dislocated jaw or injury to the condyle. Arthritis * Refers to a group of degenerative/inflammatory joint disorder that can affect the TMJ

Answer 23

Headache: * 80% of patients with TMD complain of headache and 40% facial pain. 2. Ear pain: * 50% of patients with a TMJ disorder notice ear pain without any signs of infection. 3. Sounds: * Grinding, crunching or popping sounds, medically termed crepitus, are all common for patients with a TMJ disorder. Dizziness: - 40% of patients reported a vague dizziness or imbalance. 5. Fullness of the Ear: -33% of patient described muffled or clogged ears. They may notice fullness or pain during airplane take-offs and landings. 6. Ringing in the Ear: - 33% of patients reported noise or ringing (tinnitus) for unknown reasons.

Answer 24

- Pain on TMJ palpation * Pain on palpation of associated muscles * Limitations or deviation of mandibular movement * Joint sounds * Headache

Answer 25

Passive Mouth Opening: - Maximum interincisal opening with assistance of clinician without pain. (Max. opening ≥40mm) Masticatory muscle tenderness on palpation: - Palpation of the joint and the muscles for pain should be done with the muscles in a resting state. Palpation: - Masseter insertion ad origin point - Lateral ad itra-auricular palpation - Temporalis insertion ad origin point - Lateral pterygoid lateral ad vertical movement

Answer 26

Palpation of the TMJ will reveal pain and irregularities during condylar movement, described as clicking or crepitus. * The click that occurs on opening and closing is eliminated by bringing the mandible into a protrusive position. * Click before opening is most often associated with an articular disc displacement with reduction.

Answer 27

Grinding and clenching of teeth (bruxism) increases the wear on the cartilage lining of the TMJ, Many patient may awaken with jaw or ear pain in the morning. 2. Habitual gum chewing or fingernail biting 3. Dental problems and misalignment of teeth (malocclusion), patients may complain that it is difficult to find a comfortable bite. 4. Trauma to the jaws, previous history of broken jaw or fractured facial bones. 5. Stress frequently leads to unreleased nervous energy leading to conscious/unconscious clenching and grinding of teeth. 6. Occupational tasks such as holding telephone between the head and shoulder

Answer 28

- Moist heat * Ice application * Soft diet * Jaw exercise * Relation techniques * Sleep on one side * Pain relief, NSAIDs like ibuprofen work best.

Answer 29

A properly constructed splint supports a harmonious relationship of the muscles of mastication, disc assemblies, joints, ligaments , bones, teeth and tendons.

Answer 30

It is a removable appliance covering some or all of the occlusal surfaces of the teeth in either maxillary or mandibular arches. * The ideal is made from lab processed acrylic resin which should cover the occlusal surfaces of all the teeth in one arch.

Answer 31

Okesons Slavicek

Answer 32

- Stabilisation Splints ▪ Anterior repositioning ▪ Anterior bite plane ▪ Posterior bite plane ▪ Pivot splint ▪ Soft splint

Answer 33

- Myopathic splint ▪ Decompression splint ▪ Compression splint ▪ Verticalization splint ▪ Anterior Repositioning splint

Answer 34

permissive non-permissive pseudo permissive

Answer 35

Bite planes * Stabilisation splint

Answer 36

Anterior repositioning appliance * Mandibular orthopaedic repositioning appliance.

Answer 37

Soft splints * Hydrostatic splints

Answer 38

Occlusal disengagement theory 2. Vertical dimension theory 3. Maxillomandibular realignment theory 4. TMJ repositioning theory 5. Cognitive awareness theory

Answer 39

The occlusal disengagement theory suggests that providing an ideal occlusion by the use of splint therapy reduces abnormal muscle activity.

Answer 40

The same is true of the maxillo-mandibular realignment theory, which aims to produce ‘neuromuscular balance’.

Answer 41

The resorted vertical dimension theory is based on the concept that the patient has lost vertical height and thus causing abnormal muscle activity and an altered condyle/disc relationship. Restoration to the correct vertical height allows the muscles to function at their ‘correct length’.

Answer 42

The TMJ repositioning theory implies that the condyle should be repositioned within the glenoid fossa.

Answer 43

The cognitive awareness theory could be applied to all splints. It is based upon the concept that having something in the mouth alters behaviour and the opportunity to indulge in harmful muscle activity is reduced.

Answer 44

To relax the muscles 2. To allow the condyle to seat in CR 3. To provide diagnostic information 4. To protect teeth and associated structures from bruxism 5. To mitigate periodontal ligament proprioception 6. To reduce cellular hypoxia levels.

Answer 45

- Allow teeth to glide unhindered over the biting or contact surface. * When this condition is achieved the neuromuscular reflex that controls the closing of the jaw in maximum ICP is lost. * Hence these splints can also be called ‘muscle deprogrammers’.

Answer 46

- Covers all the teeth in the arch and its purpose is to relax the elevator muscles, provide joint stability and to protect the teeth from abnormal forces such as bruxism. * There must be bilateral, equal intensity posterior occlusal contact so that an environment of a stable physiological mandibular posture is created.

Answer 47

This is also known as the Tanner appliance, the Fox appliance, The Michigan splint, superior positioning appliance or the stabilisation appliance. * This splint provides a temporary and removable ideal occlusion. * The stabilisation appliance is given usually on the maxillary arch for the sake of stability. * When the appliance is in place, the condyles are the most stable position in the glenoid fossa. The posterior also disocclude during lateral movements by canine guidance.

Answer 48

Indications: * Muscle hyperactivity during periods of stress * Muscle hyperactivity due to centrally mediated myalgia and local muscle soreness. This appliance helps to reduce forces on the damaged teeth and to help in healing.

Answer 49

This position is the most stable musculoskeletal position of the mandible and hence it must be accurately located in the patient. It can be done by: 1. The bimanual palpation method 2. Using a flat anterior plane to disocclude about 3-6mm so that the posterior are in disocclusion by about 1-3mm

Answer 50

This is a partial coverage appliance used for occlusal disengagement. * By providing an ideal anterior guidance and temporarily disengaging the back teeth, a very tense masticatory musculature can be encouraged to relax.

Answer 51

Indications: 1. Muscle disorders related to orthopaedic instability or an acute change in the occlusal condition. 2. Short periods of parafunctional activity. RISK of creating anterior open bite if used for an extended period of time.

Answer 52

- It is a hard acrylic appliance which covers the posterior mandibular teeth and is connected by a cast lingual bar. * The objective of this appliance is to bring about changes in the vertical dimension and the mandibular positioning.

Answer 53

Indicated in severely worn dentition.

Answer 54

Non permissive splints do not allow free movements of the mandible on the contacting surface. These have ramps or indentation on the occluding surface that help in limiting the movements of the mandible. * Are also called ‘directive splints’ because these appliances direct the mandible in a specific relationship to the maxilla.

Answer 55

They function completely differently when compared to the permissive splints. * Main type being the Soft Bite Guard. * Soft appliance fabricated from a resilient material that is usually adapted to the maxillary teeth. * Functions by separating the teeth. Have been recommended for use in patients with high levels of clenching and bruxism. * Can also exacerbate bruxism due to the inability to achieve a balanced contact with them.

Answer 56

Fabrication * Polyvinyl splint is made by vacuum forming technique onto either upper or lower model. Occlusal registration usually not necessary.

Answer 57

Indication: * First line simple emergency management for patients with TMD pain The mode of action is uncertain but may be due to its soft nature and may also act as a habit breaker (cognitive awareness theory)

Answer 58

Limitations: * Can exacerbate bruxism. * Generally worn at night. * Cannot be occlusal adjusted * Only functional for about 4-6 months as tend to become firm and lose their flexibility.

Answer 59

Full coverage splint at night in acrylic.

Answer 60

Full coverage maxillary guard with all the teeth in contact is appropriate.

Answer 61

Mandibular splint will be effective.

Answer 62

Bite plane therapy is indicated but flat plane splints covering entire arch may help in unreliable patients.

Answer 63

Advisable to review patient after 7days to check contacts and occlusion has remained stable. * They should be reviewed regularly (1-2weeks) to achieve a stable retruded position if the splint is being used to treat MD. * Usually, no irreversible alteration is needed to the patient’s occlusion, and they may be weaned of the splint but told to wear it again if the discomfort returns

Answer 64

An intense stabbing pain * The pain is usually brief but may be severe. * Pain extends along the course of the affected nerve. * Usually caused by irritation of or damage to a nerve

Answer 65

- Trigeminal * Glossopharyngeal and Vagus * Nervus intermedius * Occipital

Answer 66

Idiopathic * Classical Secondary

Answer 67

Vascular compression of the trigeminal nerve

Answer 68

- Multiple sclerosis - Space-occupying lesion Others: - skull-base bone deformity, - connective tissue disease, - arteriovenous malformation

Answer 69

Unilateral maxillary or mandibular division pain > ophthalmic division Stabbing pain 5 - 10 seconds duration Triggers * cutanoues * Wind, cold * Touch * Chewing Purely paroxysmal or with concomitant continuous pain Remissions and relapses

Answer 70

Acute spasms of 'sharp, shooting pain' *May be more than on division *May be bilateral *May have burning component *May have vasomotor component

Answer 71

*Usually older patient *‘Mask-like’ face *Appearance of excruciating pain *NO obvious precipitating pathology

Answer 72

Younger patient (>40yrs) *Sensory deficit in facial region *hearing loss – acoustic neuroma *Other Cranial nerve lesions ALWAYS test cranial nerves (identify sensory deficit) ALL patients now get MRI

Answer 73

First line: *Carbamazepine - modified release *Oxcarbazepine *Lamotrigine (slow onset of action) Second line: *Gabapentin *Pregabalin *Phenytoin - Baclofen

Answer 74

Should be responsive to Carbamazepine (if tolerated!) *Maximise efficacy and minimise side effects *Often difficult to control pain first thing in the morning *Pain diary is very helpful to identify modifications necessary to therapy *Can be responsive to local anaesthesia

Answer 75

Blood dyscrasias *Thrombocytopenia *Neutropenia *Pancytopenia Electrolyte imbalances (hyponatremia) Neurological deficits *Paraesthaesia *Vestibular problems Liver toxicity Skin reactions

Answer 76

BNF Dental preparations *SDEP guidelines *Expertise *Facilities for monitoring toxicity

Answer 77

Not usually recommended if patient managing on medical therapy with moderate drug dose and no significant side effects Consider surgery: *when approaching maximum tolerable medical management even if pain controlled *‘Younger’ patients with significant drug use – will have many years of drug use

Answer 78

*Local effects – peripheral treatments (cryotherapy) *Sensory loss *Corneal reflex *General sensation *Hearing loss *Motor deficits

Answer 79

Herpes Zoster Virus (related to active VZV infection, post-herpetic ‘neuralgia’) *Trauma (pain develops <6 months of traumatic event) *Idiopathic

Answer 80

pain is localized to the distribution(s) of the trigeminal nerve *commonly described as burning or squeezing or likened to pins-and-needles. *primary pain is usually continuous or near-continuous. Superimposed brief pain paroxysms may occur, but not the predominant pain type. *more commonly accompanied by clinically evident cutaneous allodynia (much larger than the punctate trigger zones present in trigeminal neuralgia) and/or sensory deficits

Answer 81

Unilateral head pain * predominantly V1 Very severe / Excruciating Usually prominent cranial parasympathetic autonomic features (ipsilateral to the headache) * Conjunctival injection / lacrimation * Nasal congestion / rhinorrhoea * Eyelid oedema * Ear fullness * Miosis and ptosis (Horner’s syndrome) Attack frequency and duration differs

Answer 82

Pain: mainly orbital and temporal * Attacks are strictly unilateral * Rapid onset (max within 9 mins in 86%) * Duration: 15 mins to 3 hours (majority 45-90 mins) * Rapid cessation of pain * Excruciatingly severe (“suicide headache”) Patients are restless and agitated during an attack Prominent ipsilateral autonomic symptoms Migrainous symptoms often present * Premonitory symptoms: tiredness, yawning * Associated symptoms: nausea, vomiting, photophobia, phonophobia * Aura in 14%

Answer 83

Episodic in 80-90% * Attacks “cluster” into bouts typically 1-3 months with remission lasting at least 1 month * Attack frequency: 1 every other day to 8 per day * May be continuous background pain between attacks * Alcohol triggers attacks during a bout, but not in remission Striking circadian periodicity * attacks occur at the same time each day * bouts occur at the same time each year 10-20% chronic cluster * Bouts last >1 year without remission or * Remissions last <1 month

Answer 84

Pain: mainly orbital and temporal Attacks are strictly unilateral Rapid onset Duration: 2-30 mins Rapid cessation of pain Frequency: 2-40 attacks per day (no circadian rhythm) Excruciatingly severe 50% are restless and agitated during an attack Prominent ipsilateral autonomic symptoms Migrainous symptoms may be present 10% attacks may be precipitated by bending or rotating the head Background continuous pain can be present 80% have chronic PH, 20% have episodic PH Absolute response to indometacin

Answer 85

Cluster Headache: Abortive (attack) - Subcutaneous sumatriptan 6mg or nasal zolmatriptan 5mg - 100% oxygen 7-12 l/min via a non-rebreathing mask (effective and safe) Abortive (bout) - Occipital depomedrone/lidocaine injection - Or tapering course of oral prednisone Preventative * Verapamil (high doses may be required) * Lithium * Methysergide (retroperitoneal fibrosis) * Topiramate * CGRP monoclonal antibodies

Answer 86

No abortive treatment * Prophylaxis with indomethacin * Alternatives – COX-II inhibitors, Topiramate

Oral Medicie YR5 Flashcards

(114 cards)