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1 2014 course one self-study course The Ohio State University College of Dentistry is a recognized provider for ADA, CERP, and AGD Fellowship, Mastership and Maintenance credit. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit house by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at The Ohio State University College of Dentistry is approved by the Ohio State Dental Board as a permanent sponsor of continuing dental education contact us p h o n e t o l l f r e e f a x e - m a i l smsosu@osu.edu w e b sterilization ABOUT this COURSE READ the MATERIALS. Read and review the course materials. COMPLETE the TEST. Answer the eight question test. A total of 6/8 questions must be answered correctly for credit. SUBMIT the ANSWER FORM ONLINE. You MUST submit your answers ONLINE at: RECORD or PRINT THE CONFIRMATION ID This unique ID is displayed upon successful submission of your answer form. ABOUT your FREE CE TWO CREDIT HOURS are issued for successful completion of this selfstudy course for the OSDB biennium totals. CERTIFICATE of COMPLETION is used to document your CE credit and is mailed to your office. ALLOW 2 WEEKS for processing and mailing of your certificate. FREQUENTLY asked QUESTIONS Q: Who can earn FREE CE credits? A: EVERYONE - All dental professionals in your office may earn free CE credits. Each person must read the course materials and submit an online answer form independently. Q: What if I did not receive a confirmation ID? A: Once you have fully completed your answer form and click submit you will be directed to a page with a unique confirmation ID. Q: Where can I find my SMS number? A: Your SMS number can be found in the upper right hand corner of your monthly reports, or, imprinted on the back of your test envelopes. The SMS number is the account number for your office only, and, is the same for everyone in the office. Q: How often are these courses available? A: FOUR TIMES PER YEAR (8 CE credits). Page 1

2 2014 course one written by amber kiyani, dds edited by rachel a. flad, bs karen k. daw, mba, cecm OROFACIAL PAIN The purpose of this study is to introduce oral health care professionals to some of the more common causes of nonodontogenic pain that they can potentially encounter in their practices. Even if they are unable to definitively diagnose the condition, they should be able to guide the patient to where they should seek appropriate care. INTRODUCTION Pain in the orofacial region is a common symptom of patients seeking care in dental clinics. In a majority of patients, the pain is odontogenic in origin and is relatively easy to diagnose and alleviate. and treatment of nonodontogenic orofacial pain is more complex, especially when no clinical and radiographic changes are identified. Affected patients have usually seen multiple specialists and spent a significant amount of money on imaging and other studies. Typically, they are in extreme discomfort and vexed because no one seems to know what is wrong with them. In this continuing education course, we will discuss the following types of orofacial pain: Temporomandibular Joint Disorder Masticatory Myofascial Pain Intra-Articular Derangement Osteoarthritis Rheumatoid Arthritis Trigminal Neuralgia Glossopharyngeal Neuralgia Postherpetic Neuralgia Atypical Facial Pain Burning Mouth Syndrome Benign and Malignant Tumors TEMPOROMANDIBULAR JOINT DISORDER Source: the surrounding bone and soft tissues. This condition is common, reported by 40-60% of the adult population. Pain, limited opening, clicking and popping noises from the joint, and difficulty in mastication are common symptoms. Temporomandibular joint disorder is defined as a musculoskeletal, rheumatological, psychogenic, neuromuscular, and functional disorder. There is a lot of controversy concerning the pathogenesis of the process. Recent advances in the field of imaging have allowed for better understanding of joint function. This has led most authors to agree that this is a multifactorial and complex disorder, rather than just a single condition. THEORIES OF PATHOGENESIS Stress Continued emotional stress can cause prolonged contraction of the facial muscles and the induction of Temporomandibular joint disorder is a broad term that encompasses any disorder of the temporomandibular joint, muscles of mastication, and Page 2

3 bruxism (grinding), which can frequently trigger temporomandibular joint pain. This leads to a series of events that generate an inflammatory response in the joint that is followed by release of chemical mediators that exacerbate the pain in the region. To avoid pain, the affected individual limits their muscle movements. Extended periods of reduced muscle activity can result in a decrease in muscle tone and strength, ultimately restricting mouth opening. Trauma Damage to the ligaments, articular cartilage, articular disk, and bone may result in the release of chemical mediators that draw inflammatory cells to the joint space. These inflammatory cells have the ability to cause significant damage to the joint architecture. Genetic Factors Genetic marker studies have implicated that certain genes are involved in the pain transmission pathway. These genes have the ability to interfere with pain reception and processing, that may in turn, result in hyperalgesia. One of the genes described with this process is catechol O-methyltransferase, or COMT. Patients with temporomandibular joint disorders have been reported to exhibit dysregulation of this gene, and consequently, a lower threshold of pain tolerance. Psychogenic Factors Cortical brain scans of patients with temporomandibular joint disorders show striking similarities to patients with other chronic pain disorders. Scientists speculate that this suggests a disturbance in the pain processing mechanism in the trigeminal ganglion. Patients with muscular pain disorders rarely have any anatomical abnormalities. They are considered to be centrally sensitized, meaning that the nerves in the brain are transmitting faulty pain signals. Controversial Theories Some studies state that bruxism, clenching, and other parafunctional habits are considered to be detrimental to the joint structure. Similarly, other studies link fluctuating estrogen levels to the increased frequency of temporomandibular joint disorders in females. Source: Classification of Temporomandibular Joint Disorders Articular Disorders: Osteoarthritis Trauma Infectious Arthritis Iatrogenic Crystal Arthropathies Rheumatoid Arthritis Psoriatic Arthritis Ankylosing Spondylitis Myogenous Disorders: Myofascial Pain Acute Muscle Strain Muscle Spasm Fibromyalgia Myotonic Dystrophy Temporomandibular joint disorders are usually seen in individuals between 20 and 40 years of age. Women are more commonly affected than men. Unilateral pain is a common presenting symptom. The pain is commonly paroxysmal, poorly localized, and usually dull or aching in nature. It can be elicited by simple contact or movement of the joint. Radiation of the pain to the pre-auricular area, ears, periorbital region, or to the angle of mandible is common and may also be accompanied by limited jaw opening that can cause difficulties in eating and talking. Page 3

4 Deviation of the jaw towards the affected side may also be observed. Locking of the jaw may either occur at a closing position with inability to open the mouth or at an open position with inability to close the mouth. Popping, clicking and grating are common descriptions of the sound generated by the joint during opening or closing. The symptoms are usually worse in the morning, especially in patients with nocturnal parafunctional habits such as bruxism and clenching. In more severe cases, headache, reduced hearing, ringing of the ears, dizziness, and pressure behind the eye may also be noted. of temporomandibular joint disorder is dependent on a thorough history and clinical examination. Imaging studies would also be beneficial and, on occasion, may be necessary. While obtaining patient history, a detailed description of the nature of pain with exacerbating and relieving factors should be recorded. Information concerning parafunctional habits such as clenching and grinding of teeth should also be documented. Clinical examination allows for detection of joint noises during opening and closing movements, measurement of mandibular movements (including incisal opening), lateral movements and protrusion, and palpation of the masticatory muscles. The results of a clinic examination can rule out odontogenic and other causes of orofacial pain. Imaging studies are usually helpful in making a definitive diagnosis. While panoramic radiographs and facial views may serve as helpful screening tools, computed tomography is the gold standard for bony abnormalities. Advances in the technology allows for a three-dimensional and high resolution imaging of the temporomandibular joint with low radiation exposures. For soft tissue changes, magnetic resonance imaging (MRI) is useful. This technique allows for muscles, ligaments, and the vascular structure to be evaluated. Arthroscopy is the insertion of a small camera through a minimally invasive incision to directly visualize the joint. Problems such as synovitis and perforation can be detected by this technique. This technique is also employed for curative purposes. Temporomandibular joint disorders can be broadly classified as articular or myogenous disorders (please refer to the list on Page 3). Although each disorder has a unique etiology and management regime, we are only able to discuss the most common ones in the sections below. MASTICATORY MYOFASCIAL PAIN Myofascial pain disorder can be defined as the tenderness of the masticatory muscles involved in jaw closure movements. It is one of the most common temporomandibular joint disorders and the second most frequent cause of orofacial pain. Myofascial pain is characterized by a unilateral, dull, aching sensation that varies during the course of the day. The pain can be elicited through a trigger point located on the muscle, fascia, or tendon. The pain does not interfere with sleeping patterns, but it may be aggravated by certain types of jaw movements. It may also be accompanied by tinnitus, dizziness, and pain radiating to the oral cavity, ear, and neck region. Muscles are usually stiff and tender on palpation. Imaging studies exhibit no evidence of anatomic pathology. Non-invasive management is sufficient in most cases. MANAGEMENT Reassurance Patients are provided with a detailed description of the disease process, highlighting the role of emotional stress and parafunctional habits. This encourages patients to reduce these elements from their lives in order to improve their health. Page 4

5 Rest Patients are instructed to limit jaw movements and are discouraged from extreme mechanical movements such as yawning, laughing, and clenching. Patients are also advised to refrain from potential jaw damaging habits such as chewing gum, nail biting, or pencil chewing. Heat Heat application to the affected area is beneficial in alleviating pain. The heat can be applied using a heating pad, hot towel, hot water bottle, or through more advanced techniques such as ultrasound and short wave diathermy treatments. Medications In acute stages of the disease, a 2-week course of nonsteroidal, anti-inflammatory drugs may be beneficial in alleviating symptoms. Muscle relaxants (cyclobenzaprine), anxiolytic agents (diazepam, prazepam, and clonazepam), anticonvulsants (gabapentin), or opioid analgesics are usually the next course of action. These drugs are used sparingly to limit dependency. Tricyclic antidepressants (nortriptyline and duloxetine) and some serotonin reuptake inhibitors (fluoxetine and paroxetine) have been reported to be effective in controlling symptoms as well. Behavioral Approaches Relieving stress from life is an important step towards rehabilitation. For this purpose, counseling, relaxation techniques, and stress management have shown some positive results. Physiotherapy Massaging, manual manipulation, ultrasonography, and iontophoresis allow for retraining of the masticatory muscles and have proven to be effective in patients with temporomandibular joint disorders. Numerous passive motion devices are also available commercially. These devices serve as the initial step toward rehabilitation by providing protection to the traumatized region, reducing pain and inflammation, and permitting limited jaw movements. Occlusal Adjustments While limited proof supports the theory that malocclusion is linked to temporomandibular joint disorders, it may still be helpful to eliminate occlusal discrepancies. Bite adjustments and replacement of missing teeth can restore optimal occlusion and masticatory function. Jaw Appliances These devices are made from acrylic and worn as orthodontic retainers or removable partial dentures. They come in a variety of shapes and forms. These appliances are designed to protect the masticatory muscles from harmful movements, such as clenching and bruxism, during sleep. They also make patients more aware of their parafunctional habits and encourage them to stop. INTRA-ARTICULAR DERANGEMENT Intra-articular disk derangement is a category of temporomandibular joint disorder that includes anterior disk displacement, with and without reduction. Displacement of the temporomandibular joint disk from its rest position can result in significant joint dysfunction. Anterior disk displacement with reduction describes the displacement of the disk during closure; on opening, the disk returns to its original position with a popping sound. Page 5

6 Pain is not a frequent finding, especially in the earlier stages of the process. Deviation of the mandible towards the affected side is also noted. The situation may worsen over a period of time resulting in intermittent locking of the jaw. Anterior disk displacement without reduction is characterized by pain, limited jaw opening, and intermittent locking of the jaw. Locking of the jaw is the result of the disk acting as a mechanical obstruction to condylar movement. A thorough medical history, complete medical exam, and imaging studies are required for establishing diagnosis. MRIs are usually employed to perform scans in both open and closed positions of the jaw. Disk displacement can be visualized with MRI techniques along with the degenerative changes of the condyle. Arthroscopy may also prove beneficial at times and it can be employed for both diagnostic and treatment purposes. Anterior disk displacement with reduction is relatively easier to treat. The condition can usually be controlled using non-invasive techniques such as rest, heat application, behavioral modifications, occlusal appliances, and physiotherapy. In some instances nonsteroidal inflammatory drugs and muscle relaxants may be employed. In patients with anterior disk displacement without reduction, intra-articular steroid injections and arthrocentesis may be helpful. OSTEOARTHRITIS Osteoarthritis is a degenerative joint disease that may result from trauma, infection, previous joint surgery, and metabolic disorders. Osteoarthritis of the jaw tends to affect women between 30 and 40 years of age. Pain, limited mouth opening, and deviation of the mandible towards the affected side are some of the common symptoms. The joint may also produce gritty sounds on movement. Imaging studies can usually identify the degenerative changes in the cartilage and bone. Most patients can be kept comfortable using nonsteroidal anti-inflammatory drugs. In more severe cases, intra-articular injections of steroids may be beneficial. Surgery is the only option in patients that are unresponsive to treatment. RHEUMATOID ARTHRITIS Rheumatoid arthritis is an autoimmune disease that causes chronic inflammation of the joints and surrounding tissues. Most patients with temporomandibular joint involvement have complaints of pain, swelling, and limited jaw movements. In children, temporomandibular joint involvement may impede the normal growth process. Rheumatoid arthritis is a generalized process involving multiple joints at one time. This usually helps in establishing diagnosis. In earlier stages of the disease, no changes in imaging studies are identified. In later stages, condylar destruction may be noted. Medical management and biomechanical alteration of the joint may help in alleviating symptoms. In non-refractory cases, surgical intervention becomes necessary. TRIGEMINAL NEURALGIA Trigeminal neuralgia is a peripheral neuropathy characterized by episodes of severe pain in the facial region originating from the trigeminal nerve. Pain can be elicited by contact with a trigger zone, a site usually located on cutaneous skin. It is a relatively rare condition, affecting about 6 of every 100,000 individuals each year. The disorder appears at a higher frequency in individuals with multiple sclerosis. Pathogenesis Compression of the trigeminal nerve in pons is attributed as the potential cause of this condition. It is postulated that compression causes demyelination of the nerve (damage to the myelin sheath) that may result in erratic nerve activity. Trigeminal neuralgia usually occurs in individuals over 40 years of age. Women seem to be affected Page 6

7 more commonly than men. The right side of the face is more frequently involved. Either of the three branches of trigeminal nerve may be affected. In rare instances, more than one branch may be involved. Pre-trigeminal neuralgia is a term used to refer to the dull aching pain that appears before the onset of pain attacks. It is seen in over 18% of affected patients. This is the earlier form of the disease that shows significant response to the use of carbamazepine. The pain associated with trigeminal neuralgia is often described as electric shock or lancinating. An obvious trigger point can be identified in a significant number of patients. It is most commonly located on the nasolabial fold, the vermillion of the lip, periorbital region, or the midface. The initiation of the pain can be a result of contact with the site, motions of mastication, and even exposure to cold wind. The pain may last from a few seconds to an hour. After the activation of the trigger zone, the pain cannot be elicited for a small period of time. This interval is known as the refractory period. Due to the intensity of the pain, it is not uncommon for patients to place their hands over the site. Twitching of the muscles may be noted during the pain attack. Excessive lacrimation and an intense headache usually follows the attack. The diagnosis is made on characteristic signs and symptoms. Imaging studies may help in identification of the responsible vessel. In rare cases, spontaneous resolution of the symptoms has been reported. Topical application of capsaicin, a product derived from chilies that has the ability to induce partial numbness, may be used to alleviate symptoms. Topical therapy provides limited pain control and systemic treatment is usually necessary. Carbamazepine is preferred, however, other anticonvulsants like phenytoin and gabapentin, may also help with symptoms. Trigeminal neuralgia is a chronic pain disease and requires medication to be taken on a long-term basis. Since most of these drugs have significant side effects, they are frequently not well tolerated by patients. Surgical intervention is an option for patients who are either unresponsive to medical treatment or can no longer tolerate it. Microvascular decompression, an open surgical procedure that allows for placement of a barrier between the offending vessel and the trigeminal nerve, has shown the most efficacy. Gamma knife radiosurgery and radiofrequency rhizotomy may also be used. Local glycerol injections may also provide a few months of relief in non-refractory cases. GLOSSOPHARYNGEAL NEURALGIA Glossopharyngeal neuralgia is a pain disorder characterized by paroxysmal attacks of severe pain along the course of the glossopharyngeal nerve following activation of a trigger zone. This condition is extremely rare involving less than 1 person per 100,000. In some instances glossopharyngeal neuralgia may occur in combination with trigeminal neuralgia or involve branches of the vagus nerve. Pathogenesis Like trigeminal neuralgia, the pain is caused by compression of the glossopharyngeal nerve by the ectopic branches of the superior cerebellar artery in pons. The compression allows for demyelination of the nerve that in turn impedes the ability of the glossopharyngeal nerve to inhibit pain signals. Glossopharyngeal neuralgia is frequently encountered in patients between the ages of 40 and 60 and shows a female sex predilection. Common sites of involvement include the ear, infra-auricular area, tonsil, base of tongue, and the oropharynx. Trigger zones are usually not located on cutaneous sites. The pain may be elicited by swallowing, talking, chewing, or yawning. Once the trigger zone is activated, the pain attacks can last anywhere from a few seconds to several minutes. The pain associated with glossopharyngeal neuralgia has been described to be sharp and deep in nature. Even between pain attacks, a dull sensation in the region may persist. Page 7

8 The pain presents more frequently on the left side and bilateral involvement is rare. Syncope and seizure disorders may occur alongside pain attacks when the branches of the vagus nerve are involved. Clinical features usually assist in establishing diagnosis. Imaging studies of the brain can be used to locate the blood vessel compressing against the nerve. Topical application with capsaicin is rarely beneficial. Anticonvulsants are less effective in controlling pain symptoms in patients with glossopharyngeal neuralgia in comparison to those with trigeminal neuralgia. For non-refractory cases, surgery is treatment of choice. Microvascular decompression, intracranial and radiofrequency rhizotomies, and stereotactic radiosurgery are some of the surgical techniques employed. POSTHERPETIC NEURALGIA The varicella zoster virus is transmitted through air droplets and causes chickenpox. This is characterized by fever, malaise, pharyngitis, rhinitis, and a rash that eventually evolves into vesicles. The vesicles heal by crusting and the infection usually heals within two weeks. Adults have more severe symptoms than children. Following the initial infection, the virus moves up through the nerves into the spinal ganglion and remains latent until reactivation. In most cases, the virus may remain latent until the patient is 50 years of age or older. The reactivated version of the virus is referred to as herpes zoster. It is responsible for shingles, the painful eruptions along the course of a dermatome. Usually only one dermatome is affected at any time. Most infections resolve completely within 10 days. For about 15% of the affected population, chronic pain may persist at the site of infection. This pain is neural in origin and is referred to as postherpetic neuralgia. It is thought to be a result of damage to the nerve by the virus. The pain is severe in intensity and has been described as burning, throbbing, aching, or stabbing. Spontaneous recovery may occur anytime within a period of 12 months. In rare cases, the pain may persist for several years. Shingles on the Face History of shingles at the site of pain is necessary to make the diagnosis of postherpetic neuralgia. Viral cultures or antibody measurements may also help in confirming diagnosis. MRIs can identify some lesions associated with the virus in the brain stem. Use of antivirals at the onset of infection can help limit the course of pain. Topical and systemic analgesics, antidepressants, and anticonvulsants have been reported to show some improvement in symptoms. Prevention A vaccine is now available and is only approved for individuals over 50 years of age to prevent the zoster infection. ATYPICAL FACIAL PAIN Atypical facial pain is described as persistent chronic pain of undetermined origin that cannot be classified as any other cranial nerve neuralgia. The condition is also referred to as atypical facial neuralgia, chronic idiopathic facial pain and psychogenic facial pain. Pathogenesis Source: Some studies have linked the pain disorder to a neuropathic origin, suggesting injury to branches of the trigeminal nerve as being the etiological factor. Page 8

9 Others have linked the disorder to psychological illness implicating the pain to be psychosomatic in origin. Women between the ages 40 and 60 appear to develop this condition at a higher frequency than men in the same age group. The pain is usually poorly localized, with the maxilla being more frequently involved. The onset of pain is usually sudden and most patients link it to a previous dental treatment. The pain may be localized to a small region or may affect the entire face. It is persistent in nature and is described as deep, diffuse, burning, or sharp in nature. The pain may vary in intensity over periods of time and it does not affect sleep patterns of affected patients. Most studies have linked the condition to depression and stress disorders. Exacerbation of pain during periods of stress has also been reported. The clinical exam is completely unremarkable and no anomalies are identified in imaging studies. A thorough medical and dental history, along with both a complete clinical exam and imaging studies, are usually required. In some patients, a psychological assessment may also be warranted. The diagnosis of atypical facial pain is one of exclusion and is made only when all other potential causes of pain have been ruled out. The presenting patient will have a long history of dental procedures including several extractions in the affected area, all in an attempt to alleviate pain. Once other nonodontogenic causes of pain have been excluded, a diagnosis of atypical odontalgia can be established. BURNING MOUTH SYNDROME Burning mouth syndrome is an oral sensory neuropathy. It is a complex disorder that affects the sensory nerves transmitting information about pain, texture, and taste. The name of this condition may be misleading in some instances, since the burning sensation is not seen in all cases. Pathogenesis The cause of burning mouth syndrome remains unknown. While there are several theories that try to explain the process, the most popular one indicates that the relaying ability of the chorda tympani nerve is disturbed resulting in pain and the altered sensations. Burning mouth syndrome is usually seen in postmenopausal women. Only about a third of the patients that report with this condition are men. The onset of burning mouth syndrome is rather sudden. Patients usually link an ongoing event in their lives with this condition such as stress, a dental procedure, or initiation of medical treatment. In a small percentage of affected individuals, the condition may resolve spontaneously. Psychotherapy is an important component in the management process. Opioid analgesics and tricyclic antidepressants are usually used for treatment purposes. When medical treatment fails to provide pain control, numbing of the potential nerve may be achieved through surgical intervention. Atypical Odontalgia Atypical odontalgia is a type of atypical facial pain that is localized to a small area of the alveolus or involves an entire quadrant. Page 9

10 Complaint of a burning sensation, especially involving the tongue is frequent. Other common sites of involvement include the palate and lips. Pain usually occurs bilaterally and has a waxing and waning phase. Most patients report a progressive increase in pain as the day goes on. It does not, however, disturb sleep patterns. Consumption of certain forms of food, such as acidic or spicy, may exacerbate the burning sensation. The pain may also be accompanied by an altered textural component or taste sensation. Complaint of sensations of swelling and roughness, or a feeling of hypersalivation or xerostomia, are common. Taste alteration includes a history of a metallic taste. Occasionally the taste may be described as salty or bitter. Benign Salivary Gland Neoplasm Source: A thorough history with clinical evidence of local or systemic disease is usually sufficient for diagnosis. A large population of patients have already seen numerous physicians for this problem and have been scanned for many possible systemic or neural disorder. Unfortunately, there is no cure for nerve disorders. For most people, just knowledge of the fact that this is a common benign disorder is enough for relief. Such news may, however, be devastating for a small population. While several treatment modalities have been tried, such as antidepressants, antipsychotics and some forms of vitamins, none of these have been proven scientifically to have any effect on the condition. Low doses of clonazepam, an anti-seizure medication, has recently shown some improvement in the pain component of this process. The pain is not completely eliminated, however, but it does become more bearable for the patient. BENIGN AND MALIGNANT TUMORS Benign neoplasms of the head and neck region may elicit pain when they grow large enough to compress against the sensory nerves. Tumors of neural origin, namely, traumatic neuromas and schwannomas, have also been reported to cause pain. If obvious expansion is not identified in the area of concern, imaging studies may be necessary to identify the lesion. Once the benign nature of the neoplasm has been established following biopsy, complete excision is the preferred course of treatment. Pain is a frequent feature with several malignant neoplasms. If no clinical expansion is noted, imaging studies can be beneficial. A biopsy is done to identify the type of malignancy. Once the origin of the neoplasm is known, appropriate care can be provided. ORIGINATING FROM PAKISTAN, DR. KIYANI WENT TO RIPHAH UNIVERSITY FOR THEIR 5-YEAR DENTAL SCHOOL PROGRAM. GRADUATING WITH A 4.0 GPA, SHE CAME TO THE OHIO STATE UNIVERSITY IN ORDER TO FURTHER HER STUDIES FOCUSING ON ORAL AND MAXILLOFACIAL PATHOLOGY. SHE PLANS TO TAKE THE INFORMATION SHE LEARNS BACK TO PAKISTAN FOR BOTH DIAGNOSTIC AND TEACHING PURPOSES. HER CURRENT RESEARCH STUDIES AS A FELLOW AT OSU INVOLVE EVALUATING THE ORAL CHANGES ASSOCIATED WITH GASTROINTESTINAL DISEASES. DR. AMBER KIYANI CAN BE CONTACTED AT: KIYANI.1@OSU.EDU Page 10

11 post-test instructions - answer each question ONLINE - press submit - record your confirmation id - deadline is March 21, 2014 Temporomandibular joint disorders are characterized by pain, noises from the joint and restricted jaw movements. 1 T F SUBMIT 2 T F Myofascial pain can include tinnitus, dizziness, and syncope. 3 ONLINE T F 4 T F Magnetic resonance imaging plays no role in diagnosing inter-articular derangement. Burning mouth syndrome always presents as a burning sensation of the tongue. SUBMIT 5 T F are usually located on cutaneous sites. ONLINE 6 T F 7 T F 8 T F Studies have not linked atypical facial pain to injury to the trigeminal nerve. Pain attacks in trigeminal neuralgia can be elicited by contact with a trigger zone and Rheumatoid arthritis with temporomandibular joint involvement may impede the normal growth process in children. Glossopharyngeal neuralgia is caused by nerve damage following an infection with the varicella zoster virus. d i r e c t o r john r. kalmar, dmd, phd kalmar.7@osu.edu a s s i s t a n t d i r e c t o r karen k. daw, mba, cecm daw.37@osu.edu channel coordinator rachel a. flad, bs flad.4@osu.edu Page 11