My Jaw Hurts! What do I do? An Overview of Diagnostic Techniques, Examination, and Management Strategies in Orofacial Pain

Transcription

1 My Jaw Hrts! What do I do? An Overview of Diagnostic Techniqes, Examination, and Management Strategies in Orofacial Pain SEENA PATEL DMD, MPH ASSISTANT PROFESSOR, ASSOCIATE DIRECTOR OF ORAL MEDICINE ARIZONA SCHOOL OF DENTISTRY & ORAL HEALTH, A.T. STILL UNIVERSITY, MESA, AZ SOUTHWEST OROFACIAL GROUP, PHOENIX, AZ DIPLOMATE, AMERICAN BOARD OF ORAL MEDICINE DIPLOMATE, AMERICAN BOARD OF OROFACIAL PAIN

2 1. Pain mechanisms

3 Mscles of mastication Protrsion, mediotrsive movement 1. Masseter 2. Temporalis 3. Medial pterygoid 4. Lateral pterygoid 5. Digastric Jaw closers Jaw opening

4 Diagnostic categories TMD 1. Internal derangements 2. Arthrogenos 3. Myogenos

5 1. Internal Derangements

6 2. Arthrogenos Disorders 1. Arthralgia/Capslitis 2. Localized osteoarthritis 3. Polyarthritis 4. Synovial chondromatosis 5. Chronic pain associated with TMJ dysfnction and joint arthrosis 6. Idiopathic condylar resorption

7 3. Myogenos Disorders A. Localized myalgia B. Myofascial pain C. Myofascial pain with referral D.Tendonitis E. Myositis F. Spasm G. Contractre H. Hypertrophy I. Neoplasm J. Movement disorders K. Masticatory mscle pain attribted to systemic/central pain disorders Schiffman E, Ohrbach R, Trlove E et al. Diagnostic criteria for temporomandiblar disorders (DC/TMD) for clinical and research applications: recommendations of the international RDC/TMD consortim network* and orofacial pain special interest grop. J Oral Facial Pain Headache. 2014; 28(1):6-27.

8 History and clinical examination

9 The Medical Interview Chief Complaint History of Present Illness Medical and Dental Hx Psychosocial History Review of Systems

10 History of present illness: TMJ/ Facial Pain Key Qestions Onset Location Qality Pain behavior Intensity Freqency Dration Modifying factors: ameliorating? Exacerbating? Associated symptoms? Prior treatments? Imaging?

11 History of present illness: Headaches Key Qestions History of ara? Presence of photophobia and/or photophobia? Presence of nasea or vomiting? Unilateral? Bilateral? Plsating? Non-plsating? Aggravated by physical activity? Any atonomic featres? Red flags?

12 Snoop4 red flags S: systemic/secondary factors N: nerological signs/symptoms O: onset O: older age of onset (>50 years) P: prior headache history New or different headache?

13 Snoop4 red flags 1. Systemic symptoms/signs Is there any history of fever, chills, night sweats, myalgias, weight loss Possible secondary cases of this: giant cell arteritis, infection, malignancy. 1. Systemic Disease Does the patient have any of the following in their medical history? malignancy, immnocompromised state, HIV Possible secondary cases: metastatic disease, opportnistic CNS infection

14 Snoop4 red flags 2. Nerological symptoms/signs Is the patient experiencing: focal or global nerological symptoms or signs inclding changes in behavioral or personality? Possible secondary cases of this: Neoplastic, inflammatory, infectios, vasclar CNS disease

15 Snoop4 red flags 3. Onset (sdden) How qickly did yo pain for from 0/10 to 10/10? Possible secondary cases of this: Vasclar crises (stroke, sbarachnoid hemorrhage, cerebral venos sins thrombosis, reversible cerebral vasoconstriction syndrome, arterial dissection) 4. Onset (after age 50) Possible secondary cases: Neoplastic, inflammatory, infectios CNS disease, giant cell arteritis

16 Snoop4 red flags 5. Pattern change Progressive headache Precipitated by valsalva manever Postral aggravation Papilledema

17 The Medical Interview Family History Social History Work Stress level Emotional stability Sleep qality Habits Disability/Litigation Prior diagnostic tests Chief Complaint Psychosocial History History of Present Illness Review of Systems Medical and Dental Hx

18 Review of Systems Constittional Symptoms (e.g. Fever, Weight Loss) 1) Head, Eyes, Ears, Nose, And Throat (HEENT) 2) Stomatognathic, 3) Cardiovasclar 4) Gastrointestinal, 5) Genitorinary 6) Mscloskeletal, 7) Integmentary (Skin) 8) Nerologic/Psychiatric, 9) Endocrine 10) Respiratory, 11) Immnologic, 12) Hematologic

19 58 yo male presents with severe pain in the right ear Onset: 3 months ago Location: right ear Qality: sharp Constant, daily Previos ENT conslt nremarkable; referred for eval of TMJs

20 CC: I have severe pain in the area I had an extraction in 2 months ago

21 Oclar pain Photosensitivity

22 Set p

23 Physical Exam General appearance Alert? Oriented? In any distress? Commnication ability Extraoral exam of head and neck soft tisses Any asymmetry? Exam of jaw/facial/cervical glands: Lymph node examination Salivary gland examination Thyroid gland examination

24 Physical Exam Exam of neck Cervical range of motion Altered hand/arm sensations Crepitation Exam of digits/wrist/nails

25 Physical Exam Palpation of the TMJs: Lateral pole Dorsal pole 2.2 lbs/1kg of pressre

26 Physical Exam Palpation of masticatory and cervical mscles 4.4 lbs/2 kg of pressre, hold for 1-2 seconds Check for tenderness and tat bands Evalate for trigger points Hold for 3-5 seconds to check for referral

27 Physical Exam Mscle palpations: Sperficial masseter Deep masseter Anterior temporalis Posterior temporalis Temporalis Tendon Sternocleidomastoid Trapezis Medial Pterygoid Lateral Pterygoid Digastric mscle

28 Mscloskeletal examination Anterior and Anterior and Upper Medial andand Lateral Sperficial Temporalis Tendon Sternocleidomastoid Posterior Digastric Deep Masseter Posterior Temporalis sholder trapezis Pterygoids Masseter Mscles 4 lbs of pressre

29 Physical Exam Exam TMJ for joint sonds Palpation Ascltation Typical joint sonds: clicking, crepits

30 Physical Exam Inspection of teeth, alveolar bone Inspection of oral and pharyngeal tisses Lesion description: Location, color, appearance, border Palpation, relationship to adjacent strctres

31 Physical Exam: Range of Motion Pain-free opening Active opening Passive opening: 1 kg of pressre, only perform if active opening is <40 mm *Normal range of motion: mm Lateral movements: normal range is 5-10 mm Protrsion Note any deviations, deflections

32 Physical Exam Occlsal exam Dental symmetry Fremits Attrition 0=no wear, 1=enamel wear only, 2=enamel wear with dentin exposre (<1/3 of clinical crown lost), 3=enamel wear with dentin exposre (>1/3 of clinical crown lost) Erosion/abraction/abrasion Posterior tooth contact Overbite/overjet

33 Physical Exam Clenching signs: Scalloped tonge Indentations in bccal mcosa Major malocclsion

34 Physical Exam

35 Cranial Nerve Exam I: Olfactory III: Oclomotor Smell Little information obtained from testing sense of smell Eyelid elevation, ppil size and reactivity IV: Trochlear Often omitted II: Optic Vision, ppil reactivity to light and vision Test visal acity, peripheral vision Downward and lateral movement of the eye V: Trigeminal Sensory and motor, 3 branches VI: Abdcens Lateral movement of the eye

36 Cranial Nerve Exam VII: Facial X: Vags Facial expression, eyelid and lip closre Corneal reflex Taste VIII: vestiblocochlear Hearing and eqilibrim IX: Glossopharyngeal Gagging, swallowing Taste Gagging, swallowing Phonation XI: Spinal accessory Sholder movement Head rotation Hypoglossal Tonge movement Speech

37 Cranial Nerve Exam MltimediaPlayer.aspx?mltimediaid=

38 Diagnostic Tests in Orofacial Pain

39 Diagnostic Tests Thorogh history Physical examination Radiographic examination MRI (soft-tisse) Panoramic, Cone Beam CT (hard tisse) Nerve blocks Medications Trigger point injections Laboratory examination

40 Limited opening of the jaw Mscle vs. Joint 1) Passive stretch test Apply ice or ethyl chloride spray 2) Stretch localization

41 Limited opening of the jaw 3) Joint anesthesia mobilization Mst have image of the joint Use 2% xylocaine withot epinephrine Mobilization is only sccessfl if the limited opening is acte

42 Imaging Modalities: Hard tisse 1) Periapical films 2) Panoramic film 3) Cone beam CT

43 Imaging Modalities: Soft Tisse MRI Closed lock Soft tisse pathology Salivary glands

44 Hypermobility Beighton s hypermobility score: total of 9 Threshold ranges from 4-6 Benign joint hypermobility syndrome: 4 or greater + arthralgia >3 months in 4 or more joints

45 Referred pain Spray and stretch Trigger point injection

46 Diagnostic Anesthesia Nerve blocks Trigeminal Spraorbital Infraorbital Greater occipital May apply topical anesthetic to an intraoral trigger zone

47 Topical anesthetic testing 3 applications (at 1-2 min intervals), pain goes from 2-3/10 to 0/10

48 Local nerve block test IA/L nerve block with 2% lidocaine, 1:100,000 epi

49 Laboratory Testing CBC with differential and platelet cont Comprehensive metabolic panel Renal fnction Liver fnction Rhematologic markers: Antincelar antibodies Rhematoid factor Erythrocyte sedimentation rate C-reactive protein Anti-SS-A and Anti-SS-B

50 Qestions?