TMD

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TMD
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  1. N exercise
    • tongue to rugae not teeth
    • improve tongue elevator muscle strength
    • interrupt clenching
    • lazy tongue permits unopposed swamping by the jaw elevators/clenching
    • jaw elevator muscle function, and tongue lift and protrusion are antagonistic to prevent biting
  2. Fluorimethane spray & stretch therapy to be performed by your patient, it must be performed several times/day because it is effecting:
    pain inhibitory gating centrally, that then allows stretching: should not just be used for pain muscle pain crisis.
  3. Avoiding disc displacement derangement during opening stretching of splinting jaw elevator muscles permits
    jaw opening stretching without aggravating the disc displacement derangement
  4. The head was positioned more forward in the group with temporomandibular disorders than in the control group (P < .05) but only
    in the smaller ear-7th cervical vertebra-horizontal plane angle.
  5. c-spine nerve root pain
    • C-1, C-2, C-3 refer cranially and not into the upper extremity;
    • C-2 and C-3 can refer to the angle of the mandible and be confused with lower molar pain;
    • C-4 to T-1 refer into the upper extremity and not cranially
    • (NOTE THAT “TMJ” does NOT produce upper extremity symptoms!!
  6. “TMJ” does NOT produce upper extremity symptoms
    True
  7. cervical pain
    • stretch side pain: myofacial
    • compression side pain: facet or nerve root compression
  8. Chronically shortened muscles must relearn to relax or operate at a longer resting length. Lazy muscles must be reactivated.
    True
  9. If TM joint pain and inflammation has not been responsive to OTC NSAIDs then consider:
    switching to Medrol dose pack (or TM joint intra-articular injection of anti-inflammatory corticosteroid) since may be a TM joint neuritis (look up) which is not very responsive to NSAIDs.
  10. treating myofascial pain w trigger point injections must be accompanied with
    PT(within 2 hrs of injection), otherwise diagnositic and not therapeutic
  11. yerkes-dodson
    stress increases efficiency and performance to a certain point, then declines (bell curve)
  12. anxiety
    • sympathetic "flight/fight" overactivity
    • phobia: specific trigger
    • severe: panic attack
  13. Somatisation
    expression of personal and social distress in an idiom of bodily complaints, with medical help seeking and possible “SECONDARY GAIN”
  14. Body Dysmorphic Disorder
    • Preoccupation with an imagined defect in appearance.
    • slight physical anomaly-> concern is markedly excessive.
  15. the most commonly utilized psychological approach in treating patients with chronic
    • pain
    • cognitive-behavioral approach
    • hypnosis, relaxation (eg, guided imagery, progressive muscular relaxation,
    • meditation, music therapy), biofeedback, coping skills training, cognitive restructuring, supportive and group therapy, and stress-management techniques
    • integration of psychological interventions with conventional medical methods in the treatment of chronic pain isessential.
  16. referred dental pain from an adjacent tooth or from a tooth in the opposite arch (never right to left side referral except teeth at
    • midline)
    • Not locally blockable by topical or infiltration anesthetic at pain complaint tooth site (pain reference site).
    • Only blockable at anatomic source
  17. referred myofascial pain from muscles of mastication or cervical muscle group.
    • Duplicate the referred pain by locating and palpating muscle trigger points.
    • Not locally blockable by topical or infiltration anesthetic at tooth pain site.
    • Only blockable at anatomic source.
  18. Referred cervical nerve root pain (C-2 and C-3 refer to the angle of the mandible) Not locally blockable by topical or infiltration anesthetic at tooth site.
    Can mimic lower molar pain, as well as posterior head and temple pain.
  19. Neuroma (pain quality depends on types of nerve fiber overgrowth included).
    • Successful diagnostic neuroblockade with topical anesthetic depends on how superficial the neuroma is located.
    • Otherwise should be blockable by dental alveolar infiltration or IA block.
    • Injection of corticosteroid interrupts nerve growth factor and may control the neuroma tissue and its neuropathic pain. Some neuromas can be treated successfully by surgical excision.
    • Otherwise treat with neuralgia meds.
  20. C-fiber sensitization.
    • Damaged peripheral nerve ending continue output of Substance P which in turn sensitizes more neurons.
    • Locally blockable by topical then followed up with positive test to infiltration anesthetic.
    • Often desensitized by repetitive application of capsaicin. (usually 0.025% capsaicin mixed with 20% Benzocaine in a paste or gel, applied 4-5X/day for several weeks. Can be delivered underneath a customized intraoral stent. Can also try OroBase B (which is adhesive to hold the mixture of meds on the mucosa)
    • The capsaicin (pepper cream) is initially uncomfortable.
    • May also need neuralgia (antiseizure) meds, and tricyclics po to increase descending pain inhibition by increasing the amount of serotonin and nor-epinephrine at the trigeminal nucleus.
  21. traumatic neuralgia/traumatic trigeminal neuralgia.
    May be partially locally blockable by infiltration anesthetic at pain site but also needs medication to affect any centrally mediated pain
  22. Neuritis:
    • May be locally blockable by topical.
    • Blockable by infiltration anesthetic at pain/tenderness site.
    • Found in persistent pain scars and in persistent TM joint inflammation or repeat TM joint surgeries states.
    • Consider tx with corticosteroids if non responsive to NSAIDs since neurogenic inflammation does not respond well to NSAIDs.
  23. trigeminal neuralgia:
    • The acute large fiber mechanoreceptor allodynia response to local touch is often locally blockable by topical
    • or infiltration anesthetic at tooth site or cutaneous site (but not affected by topical capsaicin since this only affects the c-fibers).
    • Since also a centrally mediated pain, will also require neuralgia/antiseizure medication therapy.
    • Surgical or ablative neurosurgery procedure options available.
    • Not awakened from sleep by this pain.
    • Spontaneous pain as well as precipitated by non painful touch (allodynia).
    • Pain precipitation may d/c after frequent stimulation e.g. early in a meal, that then allows completion of the meal without paroxysmal pain.
  24. pretrigeminal neuralgia:
    • TN may be preceded by a period of episodic tooth or oral pain that may reflect the central pain of TN before a peripheral mechanoreceptor trigger is fully established
    • Very easy to confuse with dental pain.
    • Local anesthetic infiltration or block may be deceptively positive.
  25. Atypical odontalgia ("phantom tooth ache")
    • Not locally blockable by topical or infiltration anesthetic at tooth site, since is a referred pain from a sensitized trigeminal nucleus.[equivalent to phantom limb pain]. May have a efferent sympathetic pain component ].
    • Usually treated with a tricyclic po.
  26. referred neurovascular pain presenting as tooth ache:
    • Not locally blockable by topical or infiltration anesthetic at tooth site,
    • Follows a migraine pattern and duration, plus will be episodic, like a migraine.
    • May have accompanying nausea, photo- and phono-phobia
    • May have a prior typical migraine history yet not currently suffer classical migraine events
    • Upper premolar pain is a common site (especially in Cluster headache)
  27. Migraine with or without aura presenting as facial migraine.
    Not locally blockable by topical or infiltration anesthetic at tooth site,
  28. Midface cluster
    • (usually affects upper premolar segments)
    • (probable accompanying facial cutaneous, eye, and nasal autonomic symptoms)
    • Not locally blockable by topical or infiltration anesthetic at tooth site,
  29. vascular pain:
    • e.g. carotidynia: unilateral pain reference from tender carotids to lower face.
    • (MDs call THISfacial migraine)
    • Not locally blockable by topical or infiltration anesthetic at tooth site,
    • e.g. temporal arteritis; do not confuse with temporalis muscle pain.
    • Warning: Can lead to ipsilateral blindness within months.
  30. Glossopharyngeal neuralgia:
    • blockable by spraying topical local anesthetic into oropharynx.
    • Check to rule out tumor etiology.
  31. Cracked tooth syndrome:
    • pain only when loaded.
    • Blockable by local anesthetic infiltration at site.
  32. Cracked root syndrome:
    • development of endodontic symptoms.
    • Similarly blockable.
    • Cracks are difficult to see radiographically even with tomograms: instead observe for secondary endo-perio radiographic
    • findings in periodontal membrane.
  33. bruxism sensitivity
    • [exposed occlusal dentine sensitivity, pulpal hyperemia]:
    • a. periodontal sensitivity (low level discomfort and intensity only)
    • b. pulpal hyperemia (temperature sensitivity)
    • c. more tooth sensitivity on waking
    • d. try to duplicate pt's complaints by test clenching on shiny wear facets
    • e. probable bands of muscle hypertrophy matching the side of bruxism and of face-jaw pain, in a bruxer/clencher
  34. localized swelling and broad tenderness, involving most of the body of the masseter muscle without obvious infection is classified as
    myositis
  35. dull aching continuous, but variable pain which can be confirmed as local tenderness by palpation of masseter muscle
    local myalgia
  36. involuntary restriction of jaw opening due to contraction of jaw elevator muscles only when trying to open
    muscle splinting
  37. involuntary sustained contraction of jaw muscles, limiting jaw opening is
    • spasm
    • sustained wide open position of mandible (preventing closure) with the condyle at or anterior to articular emminence crest is
    • dislocation
  38. temporary transient interference with jaw movement, resulting in joint noises during both opening and closing is
    disc displacement with reduction
  39. temporary open lock that the patient can release and then continue normal jaw closure
    subluxation
  40. recent onset loss of max active and passive opening presenting typically 20 to 30mm interincisal opening with notable deflection of jaw to one side on opening and protrusive, earlier hx of TMJ clicking
    disc displacement w/o reduction
  41. recent onset loss of max active opening limiting opening to 20mm but not affecting protrusive or lateral range and no hx of TMJ clicking
    masseter muscle myofascial pain w/ splinting
  42. TMJ disc displacement without reduction (closed lock) usually but not always preceeded by hx of TMJ clicking (T/F)?
    T
  43. TMJ derangement case in which you wish to stabilize the displacing disc by a condyle anterior repositioning orthotic appliance
    temporary TMJ disc displacement without reduction, locking or jamming, mostly discovered on waking
  44. Which of the following is NOT one of the 5 cardinal signs of a temporomandibular disorder:
    A. Limited jaw opening or movements
    B. Headache
    C. Pain onjaw movements
    D. TMjoint and orjaw muscle tenderness on palpation
    E. TMJ clicking or crepitation noises
    B
  45. 2. A patient with complaint ofjaw pain and difficulty opening or using the jaw attends your office.
    On examination you record the following measurements.
    Maximum Active Range of Motion 30mm interincisally
    Maximum Passive Range of Motion 40mm interincisally
    And a soft end feel (elasticity) at 40mm
    What is the most likely system responsible for the functional restriction and pain:
    A. Myofascial pain in the jaw elevator muscles
    B. TMJ disc displacement disorder
    A
  46. Most TMD myofascial pain restriction findings are examples of muscle splinting. A medial
    pterygoid muscle post injection trismus is an example of which of the following:
    A. Muscle splinting
    B. Muscle spasm
    A
  47. According to the 1983 ADA Guidelines you should defer using invasive non reversible treatments for temporomandibular disorders until re-evaluated for need after controlling or improving the acute symptoms using more reversible therapies. [this would include avoiding adjustment of the occlusion, or using orthodontics or orthognathic surgery as the primary or initial therapy}
    A. True
  48. Occlusally equilibrating/adjusting/removing a 1.5mm RCP-ICP occlusal slide will stop a patient bruxing: (T/F)
    • B. False
  49. Bruxism is a jaw parafunction habit that is predominantly driven by malocclusion: (T/F)
    • B. False
  50. Bruxism is a jaw parafunction habit that is predominantly driven by central dysinhibition of oromotor patterns during the lighter phases of sleep and during bursts of motor activity  during REM sleep: (T/F)
    , A. True
  51. Bruxism can be prevented in a patient with very worn occlusion by reestablishing good canine guidance on crowns: (T/F)
    ,B. False
  52. Reestablishing some anterior guidance in a bruxism patient with very worn posterior occlusion, will reduce non axial forces on the posterior dentition, and redirect eccentric contact and bruxism habits to the anterior dentition which is less directly under the main force of the masseter muscles: (T/F)
  53. oA. True
  54. In TMJ disc displacement with reduction, the condyle is forward of the main fibrous part of the articular disc at ICP and moves onto the disc during opening, whereas in a late jaw openingsubluxation clicking the condyle is usually in a normal position on the disc at ICP and may moveoff the disc anteriorly at wide opening. (T/F)
    F
  55. According to epidemiological studies, what percentage of the population experiences temporomandibular disorders to a level probably requiring treatment or sufficient to seek treatment?
    A. 1%-2.5%
    B. 3.6%-7%
    C. 10%
    D. 20%
  56. According to epidemiological studies, in what percentage of the population are clinical findings of temporomandibular disorders (any TMJ clicking, crepitation, jaw muscle or TM jointtenderness, movement limitations) recorded· in a screening exam. [Many of these findings may beclassified as non-problem or benign but need to be documented and be part of informed consent in new dental ororthodontic patients as potential risk factors.]
    • A. 1%-2.5%
    • B. 3.6%-7%
    • C. 10%
    • D. 20%
  57. It is difficult to treat TMD and orofacial pain without also being able to recognize the contribution of headache and neck pain and organize their co-management. Which or the following describes UCLA's recommendations to the dentist regarding the dentist performing a screening examination of the neck.
  58. A. Only take a history and refer to a physical therapist
    • , B. Limit your examination to the neck muscles, palpating for trigger points and
    • documenting any pain reference to the jaws
    • C. Examine the neck muscles, and examine for pain and limited movements of the neck
    • using active movements only (patient generated/performed)
    • D. Examine the neck muscles, and examine for pain and limited movements of the neck
    • using passive movements (examiner performed)
  59. Can a TM joint or jaw muscle pain problem be responsible for causing tingling-numbness in the upper extremity (arm, hand)
  60. A. Yes
    • B. No
  61. Which of the following is INCORRECT regarding pain reference from the cervical spinal nerves, and the potential contribution of neck issues to head, jaw, neck and upper extremity pain.
    • • A. C-l, C-2, C-3, C-4, C-5 (upper and middle C-spine) refer up to the head and jaw
    • B. C-4, C-5, C-6, C-7, C-8 (lower C-spine) refer to the neck, shoulder and upper extremity
    • C. C-2, C-3 may refer to and contribute to pain at the angle of the mandible
    • D. C-1, C-2, C-3 (upper C-spine) refer to the head and jaw but not to the shoulder and arm
  62. Occipital neuralgia tends to be over-diagnosed and it proves to be myofascial pain in most cases.
    • , A. True
    • B. False
  63. In what position of priority should depression be placed in the diagnostic problem list of a temporomandibular joint dysfunction patient with additional widespread pain and headache of long standing who has obvious signs of clinical depression,
  64. A. Depression will be placed at the bottom of the problem list and treatment deferred until the TMD part of treatment is completed and the patient reassessed.
    • B. Ignore it because it is not patt of a dentists training to make that diagnosis
    • C. Avoid it if the patient says to just get on with the TMD part of treatment
    • • D. Place it at the top of the problem list and treat it first or at least co-treat it with other centrally mediated pain problem like headache.
    • E. Complete your treatment for the TM joint problem first because you know how to do this, and then if it doesn't work, refer the patient to a psychiatrist.
  65. Which of the following implies greater disc elongation, stretching, distortion and displacement in an open-closing reciprocal clicking joint, and implies poorer prognosis (unfavorable factor)regarding reversal by any TMD treatments.
    • A. Early opening click (0-15mm) and a closing click close to ICP
    • B. Mid opening click (l5-30mm) and a closing click close to ICP
    • C. Mid opening click (30mm) and a closing click at 20mm
    • , D. Late opening click (30-40mm) and a closing click at 25mm
  66. In a treatment plan presentation, is it a correct statement to tell a patient with complaint of mild occlusal appliance treatment because all TMJ disc displacement clicking leads to disc perforation and TMJ osteoarthritis over time if left untreated.
    • TMJ derangement that they must have 
    • A. Yes
    • • B. No
  67. In a treatment plan presentation, is it a correct statement to tell a young adult patient with normal jaw function that they need orthodontics to treat their malocclusion crowding in order to prevent future TMJ problems.
    • A. Yes
    • • B. No
  68. The vertical dimension of occlusion (VDO) is limited by the resting jaw position, and by the electrical resting length of the jaw muscles. In denture prosthodontics you usually determine the rest position by phonetic or other exercises and subtract 2mm to obtain the VDO. Comment on the following: Thus occlusal appliances have to be kept to less than 2mm thickness.
  69. A. True
    ,B. False
  70. Which of the following is the INCORRECT statement regarding the use of soft occlusal appliances in TMD patients:
    • A. Soft appliances can be used as an emergency short term occlusal disengagement appliance
    • B. In some bruxers they encourage more efficient clenching and increase symptoms
    • C. Contrary to common opinion, some sleep studies show that soft splints can be effective in some patients in the short term but not as good as hard acrylic appliances in reducing jaw elevator muscle activity
    • p D. Soft appliances are a good cheap alternative to laboratory made hard acrylic appliances
  71. There are several clinical manifestations of TM joint laxity. Which of the following does NOT indicate TM joint laxity? [TM joints with laxity have a potential risk for over-manipulation ' overmaneuvering of joint position in a centric relation occlusal adjustment, setting up an over retruded position for full dentures, or at greater risk in orthodontics if it includes an orthopedic component. Medically, laxity is associated with greater risk for developing atihritis.
  72. A: Mandibular sideshift of2mm
    • B. Jaw opening >60mm interincisally
    • C. A larger overjet and therefore longer protrusive pathway to incisal edge to edge function
    • D. Subluxation
    • • E. Disc displacement clicking
  73. In the interpretation of bruxofacets on upper occlusal appliances: A bruxofacet groove extending from ICP contact marks to a buccal direction on the appliance corresponds to which jaw bruxing movement habit:
    • A. Mediotrusion
    • • B. Latrerotrusion
    • C. Retrusion
    • D. Protrusion
  74. In the interpretation of bruxofacets on lower occlusal appliances: A bruxofacet groove extending from ICP contact marks toward the anterior part of the appliance corresponds to which jaw bruxing movement habit:
    • A. Mediotrusion
    • B. Laterotrusion
    • • C. Retrusion
    • D. Protrusion
  75. What is UCLA's recommendation for the jaw position to adjust a bruxing splint to for a patient with normal TMjoint function.
  76. • A. RCP then finish at MCP (habitual)
    • B. RCP only
    • C. Habitual only
    • D. Pulse the jaw elevator muscles with TENs or Myomoniotor and make the splint at
    • that position
  77. What is UCLA's recommendation for the jaw position to adjust a bruxing splint to for a patient with TM joint reciprocal clicking disc displacement.
  78. A. RCP then finish at MCP (habitual)
    • B. RCP only
    • , C. Habitual only
    • D. Pulse the jaw elevator muscles with TENs or Myomoniotor and make the splint at
    • that position
  79. Making a diagnosis of a temporomandibular pain presumes that this is a musculoskeletal pain. Which ofthe following describes the main quality of musculoskeletal pain.
  80. A. Episodes of brief sharp stabbing pain made worse by jaw movement
    • B. Throbbing pain
    • ~ C. Diffuse pain that is unrelated to function
    • D. Dull aching pain that is often made worse by function
    • E. Episodes of severe brief electric like pain made worse by light touch on the jaw or face
  81. Between which tissues in a TMJ disc displacement without reduction (closed lock) case, is disc adhesion maintaining the disc displacement, and restriction in condyle translation:
    • A. between the anteriorly displaced disc and the condyle
    • , B. between the anteriorly displaced disc and the articular eminence
  82. Please comment on the following statement: According to MRI studies, the articular disc remains forward, and therefore TMJ clicking does not return, in 94% of cases following arthroscopic surgery release of a disc displacement without reduction. This implies that the condyle is functioning posterior to the main fibrous portion of the disc, even though disc to articular eminence translation movement is regained. Most cases adapt well to this situation, and disc perforation does not occur in most cases.
  83. , A. True
    B. False
  84. •What disorders will actually awaken a patient from sleep?
    • Cluster Headache (migraine variant) tx Imitrex(tryptan)
    • Pulpitis
    • Invasive Tumor
    • NOT BRUXISM
  85. tooth ache not relieved by RCT(only temporary)
    pain from non-painful stimulous
    increased reflex
    not responsive to LA
    • Atypical Odontalgia
    • phantom toothache
    • sensitization of second order neurons
    • Centrally mediated neuropathic pain.
    • or chronic pain mediated through the sympathetic efferent nervous system
  86. disorders that can produce severe pain on waking
    • migrane:
    • bruxism: must be associated with local muscle pain due to overuse of that muscle, painful teeth, reproducible by clenching on symptom provoking contacts
    • withdrawal: analgesic rebound pain or headache secondary to overuse of short half life OTC and Rx. analgesic medications
    • psychogenic: anxiety fearing day
  87. 28 year old female 
    facial pain in the left maxillary region
    pain is variable in intensity
    aching and throbbing
    lasts 2-36 hours then resovles 2x/week
    when no pain, palpation of jaw muscles and ROM normal, teeth do not reproduce
    no joint noises
    nausea during severe pain
    lessened by sleep or dark, quiet room
    overuses Motrin too
    • facial migraine (neurovascular pain)
    • transformed migraine due to the effects of analgesic rebound (overuse of Motrin)
  88. 45 year old male patient 
    new onset severe headache
    fast onset, maximal intensity within minutes
    throbbing
    photophobia, phonophobia, nausea, vomiting
    muscles became tender-> neck stiffness
    painful jaw muscles, extensive attrition
    • Rule out subarachnoid hemorrhage w CT, MRI or spinal tap
    • Inquire about sentinel headaches
    • rule out meningitis
    • defer bruxism concerns
  89. 30 year old female 
    recent history of very disabling severe shooting pain in the angle of the mandible radiating up in front of the ear
    spontaneous or be precipitated by chewing although reduces as she continues eating
    also precipitated by cold air on her face and by light touch e.g. when putting on make-up
    minimal
    jaw muscle tenderness and normal TM joint function
    dentition on that side is intact and there are no restoration
    pain withdrawal reaction is produced by light touch to the left ramus cutaneously
    • Severe allodynia: typical of a trigeminal neuralgia.
    • However this patient is very young to have
    • trigeminal neuralgia.
    • Therefore rule out neuralgia secondary to other pathology e.g. Multiple Sclerosis (mostly female and this age group), or acoustic neuroma. Order brain MRIs, and refer to Neurology
  90. patient complains of pain in the jaw and face
    unable to duplicate the pain or have any positive findings in your musculoskeletal, TMD, neurologic tests,  or head and neck examination 
    • 1mm occlusal slide
    class II div. 2,
    few missing posterior teeth. 
    clicking TM joint which has been present for 5 years
    What do you do next?
    • more diagnostic information starting with facial and brain imaging, and possibly additional consults. 
    • 1st:  rule out orofacial causes by determining if there is any dental nociception or dental symptom provoking contacts, and whether the TMJ problem is just a benign derangement or whether it is associated with acute pain (can test by blocking the TMJ using an easily performed auriculo-temporal nerve block [the ascending
    • sensory division of the third division of the trigeminal nerve that supplies 75% of the TM joint and capsule: it does not require an intracapsular injections: check your anatomy books]).
  91. 55 year old male patient
    temple pain that increases with jaw use
    tenderness over a raised temporal artery and vein
    •What tests would you order?
    • SED rate 
    • temporal artery biopsy
    • Rule out temporal arteritis:
    • requires urgent steroid treatment to prevent rapid onset blindness.
  92. •Is it appropriate to use a bite splint 
    (intraoral orthotic appliance) and bite adjustment (coronoplasty, occlusal  equilibration) to treat migraine and tension type headache?
    • Not for migraine (neurovascular pain)
    • Possibly some help in tension-type headache if there is a lot of jaw muscle tension habits (daytime habit breaking appliance) and jaw muscle tenderness. However can only be used as co-treatment with therapy addressing centrally mediated
    • pain e.g. tricyclics.

    • Do not try to treat headache in isolation
    • by a bite splint unless there is a direct relationship of jaw use and eating to
    • bringing on a headache.
  93. Female, DOB: 4-10-54, referred by her periodontist
    1.Sharp pain between  teeth # 2, 3, 4, 
    described as being precipitated by flossing and touch interproximally but that heavier stimulation with use of a perio brush is OK.
    2.She describes the palate to #2, 3,
    4  as being sore  since her periodontal surgery,  6 months prior
    3.The bite feels disturbed,   which she  described as a habit of moving the jaw
    back and forward grinding on a spot .
    4.Painful jaw clenching,  especially since the cementation of #3 full crown 3 months prior
    5.Lower back pain, some upper quarter
    (shoulder and cervical) pain and tenderness over the right hip.
    6.Her overall pain intensity level was rated as usually 58 on a 0 to 100 VAS intensity scale, ranging from 50/100 to 80/100. Disability measured as the interference with general life function was rated as 45/100 and of jaw function 46/100. Her interference with sleep and rest was 70/100.
    History of chief complaint:  
    • Prior to her periodontal surgery of the upper and lower right quadrants she denies any symptoms.
    •She recalls a sensation of pressure, throbbing, and extreme hot/cold sensitivity following the subsequent preparation and temporary placement of a full crown on  #3 .
    •This pain reduced when the casting
    was permanently cemented 1 week later.
    •Following a root canal therapy on #3 in March 1995 the temperature sensitivity was resolved but a throbbing persisted.
    •Interproximal stimulation between #3 and #4 however precipitates sharp pain. The periodontist had applied normal post operative periodontal measures but this pain has persisted.
    • Peripheral allodynia:
    • partially blockable with topical anesthetic and more completely with an infiltration.
    • History doubts any missed dental cause.
    • The only dental pains that are blockable
    • by local anesthetic are gingivitis or mucosal ulceration, and possibly exposed root dentine. Otherwise probably a neuropathic pain.
    • Most probably a peripheral neuropathic pain or a chronic pain with a peripheral pain component.
    • Differential includes: traumatic neuralgia;
    • c-fiber sensitization; neuroma.
    • Defer additional dental procedures: if
    • regional treatment required dentally then make sure you block all nociception
    • and afferent input with good buccal and palatal local anesthesia infiltration, since this may otherwise worsen neuropathic sensitization.
  94. The only dental pains that are blockable by local anesthetic are
    • gingivitis
    • mucosal ulceration
    • possibly exposed root dentine
  95. Dysesthesia:
    Lingering altered sensation outlasts post-endo pain 2-12 months
  96. Allodynia
    • pain due to a stimulus which does not normally provoke pain
    • [ a) mechanical, b) thermal]. The peripheral trigger of trigeminal neuralgia is the exemplar of mechanical allodynia –which therefore therapeutically can only be blocked with topical local anesthetic and not by
    • capsaicin
  97. Most Post-Endo Pain is
    • self limiting central pain from neurogenic inflammation, second order neuron sensitization, Secondary hyperalgesia, dendrite pruning and regrowth.
    • 2-3 months to resolution
  98. Persistent tooth site or oro-facial pain of non-dental origin
    • Maxillary sinusitis
    • Neuroma
    • Dental abscess.
    • Cracked tooth syndrome
    • Neuritis (also occurs in TM joint).
    • C-fiber sensitization.
    • V Neuralgia trigger.
    • Traumatic neuralgia from surgical or injection (trauma or chemical injury) to IA n., lingual n., V, 2nd division block)
    • Neuroma in an oral soft tissue scar 
    • Trigeminal neuralgia
    • Pre-Trigeminal neuralgia
    • (?central part only)
    • Atypical odontalgia.
    • Deafferentation pain.
    • Central sensitization “phantom tooth ache”
  99. Persistent orofacial or tooth pain
    • Mid face cluster (maxillary premolar site usually)
    • Referred Myofascial pain* (*only blockable at primary site)
    • Referred Facial Migraine
    • (Same pain pattern as migraine
    • May have earlier typical migraine hx.)
    • Referred C-1, 2, 3 Pain*
    • (gonial angle of jaw)
    • Arteritis (temporal artertitis)
    • Differentiate from Temporalis myalgia, carotidinia
  100. _____ nerves are most often injured due to their proximity to common surgical site
    Lingual and inferior alveolar
  101. partial hypoesthesia, or hyperesthesia tx
    po systemic anti-inflammatory corticosteroids not NSAIDS
  102. neuropathic pain tx
    • Gabapentin: anti-seizure
    • Desipramine: enhancing 5HT and NE in CNS dorsal horn that contribute to descending  pain inhibition, e.g. antidepressant medications
  103. peripheral neuropathic pain component that is partially or completely blockable by topical local anesthetic TX?
    application (4-5 X/day for 5 weeks) e.g. of Orobase with 20% benzocaine, for 30 periods under an intraoral stent (acts as a mechanical protector and keeps the medication in place). Can add in Capsaicin 0.025%, and topical preparations of anticonvulsant meds e.g. Tegretol 4%
  104. neuroblockade tests
    • topical->infiltration->regional
    • if nonresponsive to all:
    • 1. centrally mediated neuropathic pain (atypical odontalgia, phantom tooth pain, TN, although TN should have peripheral mechanical trigger)
    • 2. referred myofascial pain
    • 3. referred neurvascular/migrane pain
  105. •responsive to topical anesthesia,
    • a. mechano trigger of trigeminal neuralgia
    • b.a field of c-fiber neuron receptorsensitization
    • c.a mucosal neuroma, or a neuroma in a scar
    • d.a traumatic neuralgia
    • •But cannot be dental/endodontic, and cannot be sinusitis
  106. not responsive to topical but responsive to infiltration, or regional block
    • could be peripheral neuropathic pain, but could also be dental.  
    • •Oral anesthesia does not usually block sinusitis, however, sinusitis and sinus
    • headache are seriously over-diagnosed.
  107. most frequent explanation for tooth site pain of non-dental origin.
    • referred myofascial pain 
    • jaw, neck and shoulder myofascial examination
  108. Trigeminal neuralgia peripheral triggers are mediated through ______ and not through A-delta or C-fibers
    • touch/myelinated peripheral nerves
    • no response to capsaicin
    • do respond to topical local under stent
  109. Anesthesia dolorosa
    • central sensitization of the thalamic nuclei in the CNS (is a higher center CNS version of atypical odontalgia where the second order neuron is sensitized or changed).
    • However this is very difficult to treat. Usually follows surgery or section of more peripheral nerves. Therefore cutting peripheral nerves to treat more peripheral neuropathic pain is not advised.
  110. 5 Cardinal signs of TM disorder
    • 1. abnormal range of jaw movements
    • 2. pain on jaw movements (TMJ or myogenous)
    • 3. pain on jaw muscle palpation (tenderness)
    • 4. pain on TM joint palpation (tenderness)
    • 5. TM joint noises (clicking, popping, crepitation
  111. bruxism
    • centrally driven
    • lighter phases of sleep
    • bursts of motor activity during REM
    • not linear w/age, tends to reduce
    • wear patterns show what muscles are recruited
    • static clenching not symptom provoking
  112. splinting
    • elevators: limited vertical, normal lateral, protrusive
    • test: apply moist heat, vapocoolant, stretch  or triggerpoint injection->passive open
  113. vapocoolants
    • ethyl Chloride: colder 12-18 inches
    • fluoromethane: 6-12 inches
  114. Disc Displacement without Reduction (closed lock)
    • history
    • •Age (<35)
    • •female
    • •ROM findings
    • •Normal osseous /tomogram findings in a recent closed lock
    • •MRI disk anterior dislocation finding
  115. intra-capsular ROM reasons
    • Osteoarthrosis: tx Hyalgan injections
    • Osteoarthritis: NSAIDs, steroids
    • disc adhesion: trauma?, dx TMJ arthrograms
    • disc displacement w/o reduction (closed lock)
    • TMJ ankylosis: small ROM, no translation
    • Synovial chondromatosis: small calcifications
  116. Eagle’s syndrome
    • elongated and calcified styloid process and stylohyoid ligament
    • “burning” pain, some limited opening. Eagles Sn. is rare, but over-diagnosed because of frequently seen non problem elongated styloid processes on panorex.
    • Tx: Inject corticosteroid early + jaw mobilization
    • Rarely surgically
  117. extra-capsular ROM restriction reasons
    • splinting: dx: lido injections
    • trismus(continuous contraction, emg): NSAIDs, medial pterygoid post IA block
    • contracture: ancillary muscles, hard end feel not responsive to heat, spray, stretch or blocks
    • temporalis tendinitis: (bursitis, adhesions) tx: corticosteroid injection (intraoral by coronoid or extraoral by zygomatic), NSAIDs
    • myositis ossificans: direct masseter trauma->fibrous or calcific change
    • coronoid hyperplasia: against zygomatic arch tx: surgery
    • condylar neck fracture
    • eagle's: elongated styloid process & ligament
    • hysteria
  118. hypermobility/laxity
    • large CR-ICP slide
    • large Bennett mandibular side shift
    • increases the risk for arthritis
    • subluxation: (temporary dislocation and open locking of the condyle forward beyond the articular eminence crest).
  119. -itis
    ROM can be improved for most -inflammatory reasons
  120. senior normal opening
    • >35mm
    • vs. 40mm
  121. hyalgan injections
    Osteoarthrosis
  122. Crepitation
    • frictional sounds on altered or perforated articular disc or “bone on bone” condyle translation.
    • Probably osteoarthrosis or osteoarthritis.
  123. “Reciprocal clicking”: Disc Displacement with Reduction
    • condyle is ‘off’ [posterior] to fibrous part of disc at ICP
    • condyle repositions onto disc during opening, and disc displaces anteriorly again when condyle returns to ICP on closure
  124. “Closed lock”: Disc Displacement without Reduction
    condyle is ‘off’ [posterior] to fibrous part of disc at ICP, condyle does NOT reposition onto disc during opening, and blocks the condyle full translation/ opening pathway
  125. TMJ position manipulation
    increasing VDO is easier than anterior repositioning of ICP
  126. If you induce TM joint pain or induce TMJ disk displacement clicking during your occlusal examination when you manipulate the jaw into Centric Relation, this may indicate that Centric Relation Occlusion is
    • not a physiologic position to do your dentistry in this patient.
    • occlusal splint adjusted to Centric Relation or a permanent occlusal change to Centric Relation Occlusion may therefore be contraindicated in a patient with TMJ disk displacement clicking.
  127. in pts with TMJ clicking or osteoarthritis
    hold on to the patient’s ICP by doing only a few crowns at a time rather than quadrant dentistry
  128. new onset clicking in >40yr old:
    rule out (r/o) an underlying osseous or OA change as the primary diagnosis and treat as OA and not a simple soft tissue or disc problem.
  129. TMJ crepitation in a young adult in the absence of trauma hx is unexpected
    rule out a systemic arthritis or tissue trait (on a modern diet, ? it is unlikely to be a simple wear and tear degenerative joint disease (DJD) diagnosis)
  130. TMJ disk locking in a male (closed lock/disk displacement without reduction) is
    statistically very rare so r/o trauma, and underlying TMJ osseous or OA changes
  131. New onset jaw pain in a senior is
    unusual: most probably a TM joint OA; otherwise r/o other pathology or neuropathic pain e.g. trigeminal neuralgia
  132. Trigeminal neuralgia in a young adult is
    unusual: r/o MS
  133. Trigeminal neuralgia in a senior: is most likely a
    classical V neuralgia but do imaging to r/o brain or nerve pathology
  134. Acute malocclusion (reversible):
    • •TM joint or dental pain avoidance
    • •Posturing onto an otherwise displacing disc
    • •Jaw posn affected by muscle splinting
    • •Jaw trying to find a more stable and supported position due to tooth loss or an ICP interference
  135. Occlusal changes (permanent) secondary to:
    • •condylar bone loss in TMJ osteoarthrosis
    • •Condyle neck hyperplasia (continued growth)
    • •Mandibular fracture
    • •TM joint tumor (exceptionally rare)
  136. Local Myalgia
    • understandable & identifiable local cause, effect & response to local Tx, (NSAIDs, icing, rest, soft diet, simple jaw stretching exercises, muscle relaxant meds, splint therapy? than complex chronic myofascial pain
    • Sustained muscle pain may progress from local myalgia to more centrally driven and self sustaining chronic pain
  137. masseter
    • origin: zygomatic arch
    • insertion: inferior mandible
    • Differentiate deep Masseter from TMJ capsulitis(more superior/posterior)
    • referred: tooth, ear
  138. temporalis
    coronoid insertion: tendinitis & bursitis Dx is a possibility
  139. medial pterygoid
    • insertion: medial border or mandible
    • body: pterygomandibular raphe
  140. lateral pterygoid
    • Palpate with the jaw semi-closed or the coronoid process gets in the way
    • Differentiate from temporalis tendon pain activated at the needed wider opening.
    • Differentiate from masseter pain activated by inadvertent lateral pressure from your finger intraorally.
    • Resistance testing: activates and works the lateral pterygoids isometrically to determine if they are painful, while not confusing pain symptoms with TM joint pain
  141. Referred cervical and shoulder muscle pain is usually in _____ direction
    • the cranial direction
    • treat the anatomic referring site and not the site to which pain is projected
  142. cervical pain
    • pain on stretching side: myofascial
    • pain on compression: r/o facet problem
  143. trapezius
    refer to temporal, angle of mandible, lateral neck
  144. SCM
    • contribute a sense of dizziness
  145. Thoracic Outlet Syndrome
    • patient’s complaint is pain or tingling symptoms into arm and hand is duplicated
    • Palpation of Anterior Triangle
  146. Lower C-spine nerves, and T-1,2 innervate and refer pain into the
    upper extremity.
  147. C-1,2,3 refer pain
    up to the head.
  148. TMD is not the source or responsible for upper extremity pain or focal local neurologic changes in the upper extremity.
    True
  149. C-2,3, can be sensory to the mandibular gonial angle and lower molars, [and should be on the differential diagnosis for unexplained lower molar tooth site pain “of non-dental origin”].
    True
  150. Myofascial trigger points are usually found on ________
    taught muscle bands: these sometimes initiate a twitch response when palpated
  151. Palpation of anatomic source vs. palpation of the referred pain site.
    • Palpating anatomic source activate site of pain
    • Palpation of the referred pain site NO INCREASE IN PAIN
  152. Functional hypertrophy:
    • apparent “swelling”, functional “pumping up” and firmness of the whole masseter muscle,and often as a raised band within the temporalis or masseter muscles :
    • It is a clinical sign of:
    • chronic overuse,
    • • often of unilateral use
    • • chronic unilat. or bilat. clenching/bruxism habit
  153. Spray and stretch therapy acts:
    • centrally
    • activating Gating (inhibit tension->spasm) in the dorsal horn (or the trigeminal nucleus which is the trigeminal analog of the dorsal horn)
  154. Limit corticosteroid injection (e.g. betamethasone) to
    • tendinitis:
    • temporalis tendon
    • tendon insertions of posterior cervical muscles at the nuchal line
    • and possibly the fibrous origin of the superficial masseters along the zygomatic arch
  155. posterior temporalis is antagonistic to the
    • lateral pterygoids
    • Muscle tend to operate in couples with opposing actions: both may be involved and both need treatment
  156. Myofascial protocol
    • Reduce inflammation: rest, soft diet, icing prn, NSAIDs at anti-inflammatory doses for 10 days. ? short term muscle relaxant meds?
    • •Start home therapeutic PT muscle stretching exercise program q6h for 8 wks then maintenance daily for ever
    • •Jaw opening stretching ( from protrusive position if disc displacement with reduction)
    • •Demonstrate and use home spray and stretch tx
    • •Psychometric testing prn if strong behavioral issues suspected
    • •Plan stabilization appliance if end point of jaw closure * unstable [*needed for coordinated muscle function]
    • •Reduction in sources of ongoing afferent dental nociception if present
    • •PT referral prn if regional or whole body problem
    • •MD or OFP referral for headache and widespread pain
    • Week 2.
    • •PT 2@/ wk
    • •Posture training
    • •Refer for psycho-behavioral therapy prn
    • Week 3.
    • •PT 2@/ wk
    • •Re-eval for: centrally acting meds;
    • •MF TrPt injections prn into resistant sites;
    • Week 4.
    • •PT 2@/ wk
    • •Re-eval for intraoral orthotic appliance if jaw MF Sx persist while cervical site improving
    • •Re-evaluate/refine diagnosis of headache if persistent
    • Week 5.
    • •PT 2@/ wk
    • •MF TrPt injections;
    • Week 6.
    • •PT 2@/ wk
    • •Set up next phase of pain management rehab plan
    • •Beware “Goof –off”
  157. *Centrally directed myofascial therapies include:
    • •Increase activation of descending pain inhibition systems (5HT, NE) [antidepressant meds mostly]
    • •Biofeedback
    • •Myofascial trigger point injections
    • •Co-address other signs of neurotransmitter dysregulation
    • –Depression, fibromyalgia, Tension-Type Headache, Migraine, Sleep disorders.
  158. Rules for prioritized diagnostic problem list
    • Treat centrally mediated problems first:
    • Psychiatric/Psychobehavioral:
    • Depression
    • Anxiety
    • Sleep disturbance (also other explanations for sleep pathology)
    • Chronic pain that is centrally mediated/central sensitization
    • Widespread myofascial pain (including Tension Type Headache [ that may also be classified on a continuum with migraine])
    • Centrally mediated neuropathic pain/ V. Neuralgia, atypical odontalgia, sympathetic mediated pain
    • Neurovascular pain [migraine and migraine variants]
    • Vascular pain [temporal arteritis]
    • Psychogenic pain [conversion syndromes]
    • List any ongoing sources of nociception input: interrupt to reduce c-fiber afferent nociception and continuing chronic peripheral and central sensitization:
    • Reevaluate for dental occlusal structural changes only after control of centrally mediated and other chronic pain unless can prove that the nociception is directly relatable to the occlusal variation seen.
    • Beware over-indictment of dental attrition and a Dx of bruxism as THE cause of the chronic pain since in most individuals bruxism and attrition is present and is asymptomatic: therefore an erroneous correlation is being made by many dentists. Nevertheless endogenous trauma may be a co-factor.
    • Note & Tx. an unstable end point of jaw closure with a splint /bite stabilization appliance if Tx is needed to rehabilitate TM musculature.
  159. Patients with chronic pain require comprehensive work-ups to assess usually complex, multisite problems that often involve more than one pain system.
    • The purpose is to
    • 1.screen out any dangerous pathologic causes
    • 2.r/o dental, mucosal, dental alveolar nociceptive pain
    • 3.r/o TMD/TMJ/musculoskeletal-or orthopedic
    • 4.identify if a multisite rather than a localized problem
    • 5.identify if central or peripheral pain or both
    • 6.identify a problem list of possible pain systems operating (based on pain descriptors and history plus clinical testing)
    • 7.generate an ordered (prioritized) diagnostic problem list;
    • 8.develop a sequenced treatment plan directed at each pain system involved;
    • 9.use medications & Txs that are directed at specific pain systems (e.g. tryptans in neurovascular pain) rather than non specific analgesics such as NSAIDs and narcotics
    • 10.address perpetuating causes if possible.
  160. Interferences in a patient's occlusion justify initiating an orthodontic treatment to treat TMJ dysfunction?
    False
  161. What is the the morphologic mal occlusion that has the largest tendency to give some sign of TMJ dysfunction?
    • a) Class I
    • b) Class II div.1
    • c) Class II div .2
    • d) Class III
    • e) none of the above.
    • Answer is B
  162. Clonidine, an alpha 2 adrenergic agonist has been used as a topical agent for neuropathic pain because it is able to interrupt the peripheral release of what substance?
    Answer: Norepinephrine
  163. What are three methods of local medication delivery?
    1) mucoadhesive creams, transdermal creams, dissolving tablets, adhesive patches
  164. How are Tri-cyclic antidepressants and Topical Anesthetics such as Benzocaine 20% similar in the mechanism of relieving neuropathic pain?
    block Na+ channels
  165. What is the overall clinical result seen in a muscle after an injection with BTX-A?
    - The exact mechanisms of BTX-A activity is not clear, but overall reduction in the maximum contractive force of injected muscle is seen in addition to a reduction in the resting muscle tone.
  166. Mention the main benefit of BTX-A therapy seen in patients with neurophatic pain?
    relieves pain symptoms.
  167. Are topical medications helpful for central or peripheral pain?
    • Topical medications are only helpful with peripheral pain.
    • To determine if the pain is peripheral, if local anesthetic is given in that area the pain will be relieved. Local anesthetics will not help with central pain.
    • Therefore you must first differentiate if the source of the pain is central or peripheral and only prescribe topical medications for peripheral pain.
  168. What is the mechanism that Ketamine use to alleviate neurogenic pain?
    • Ketamine is an NMDA receptor inhibitor that binds to a specific site for phencyclidine
    • (PCP)-like drugs in the NMDA receptor-gated channel and inhibits the excitatory effect of
    • glutamate selectively at these receptors.
    • By targeting peripheral glutamate receptors in chronic pain and inflammatory state, Ketamine can be administered topically for sympathetically pain and for pain in a palliative setting.
  169. Orthodontic therapy is the standard of care for all TMD patients. (T or F)
    F
  170. There is substantial evidence TMD is caused by malocclusion. (T or F)
    F
  171. What symptoms of TMD seem to diminish after treatment with a combination of orthodontics and orthognathic surgery?
    A: Headache, lateral deviation of the mandible greater than 2mm, TMJ sounds, and pain on movement of the mandible.
  172. Does malocclusion play a role in TMD?
    Many population studies have been done in the past and they have concluded that malocclusion should only be seen as a cofactor, a tiny piece of the puzzle, when looking ant the multifactorial problem of TMD.
  173. What medication(s) and dosage would you prescribe to manage a patient with acute orofacial pain due to complications of mandibular implant placement? For chronic pain?
    • For acute pain, Rx NSAID, i.e. motrin 600mg qid.
    • For severe, chronic or nonresponsive pain, Rx opioid analgesics, tri-cyclic antidepressants, and/or anti-convulsants.
  174. Aside from stimulus-response neurosensory testing, what other test could you perform to determine if the neuropathic complication is primarily peripheral or central in origin?
    Additional testing would involve local infiltration, trigeminal block anesthesia or IV anesthesia to determine source of the pain
  175. Which of the following categories of medications can be used in treating neuropathic pain?
    • a) Trycyclic antidepressants
    • b) Opiate analgesics
    • c) Anticonvulsants
    • d) Topical anesthetics
    • e) All of the above
    • e
  176. The best method of treating neuropathic pain is:
    • a) Surgical means
    • b) Systemic medications
    • c) Psychological counseling
    • d) Prevention
    • e) None of the above
    • D
  177. Name 3 distinctive characteristics of acute and chronic pain
    • • Acute pain
    • a. Identifiable inflammation and pathology usually accompany pain
    • b. Usually requires locally directed txs
    • c. Reversible over healing cycle of 2-8 wks
    • • Chronic pain
    • d. No obvious cause – local pathology or injury may have already healed
    • e. Peripheral or central neurologic pain
    • f. Possible permanent sensitization of the peripheral nociceptors and/or second order neurons ( loss of pain inhibitory neurons, sensitization of peripheral c-fibers, referred pain due to central spread of sensitization)
  178. What are some undesirable outcomes from wearing occlusal appliances to treat headache and/or orofacial pain?
    increased pain in jaw joints, jaw muscle soreness, loosening of some teeth, and changes in occlusion
  179. What is the mechanism by which Botox works?
    Botulinum toxin denervates muscles by inhibiting acetylcholine release from motor neurons.
  180. What is the difference between Botox A and B?
    They both inhibit acytylcholine, but they do so by breaking up different proteins.
  181. The anterior bite plane is an appliance made from acrylic that is worn over the maxillary arch, contacting only which areas of the mandibular teeth?
    Answer: mandibular anterior teeth
  182. Partial selective grinding is indicated in patients with headache and orofacial pain. True of False?
    Answer: False
  183. Can headache be treated with appliance therapy?
    • A: Only when the peripheral activation is responsible for the headache.
    • Appliance therapy will not help if there is no peripheral cause and when headache is associated with more complex widespread pain.
  184. Is coronoplasty recommended for treatment of TMD?
    A: There is no evidence that Occlusal adjustment treats or prevents TMD and thus it cannot be recommended for the management of TMD
  185. What are 3 qualities of pain felt with sensory system involvement and define them
    • The results of these sensory systems involvement are specific pain qualities such as allodynia, hyperalgesia, and hyperpathia.
    • Allodynia: pain resulting from low intensity, normally non-noxious stimuli.
    • Hyperalgesia: occurs when a stimulus that is usually noxious results in enhanced pain response.
    • Hyperpathia: increase in pain threshold, leading to a delay between onset of stimulus and pain but, once the pain is felt, is far more intense than normal.
  186. What 5 criteria must be met to diagnose post tramatic neuralgia?
    • 1. Continuous pain/dysesthesia
    • 2. Pain limited to distribution of the injured nerve(s)
    • 3. History of trauma and likely injury to nerve branch
    • 4. Associated local hyperalgesia (hyperesthesia) over pain territory
    • 5. Pain can be abolished or greatly reduced by local anesthetic nerve block
  187. What is the first line of treatment in orofacial neuropathic pain?
    • Pharmacological therapy
    • The goal is to reduce neuronal hyper-excitability in the central and peripheral nervous system. For most types of facial neuralgia, Carbamazepine is the main stay of pharmacotherapy. Other drugs include oxcarbazepine, lamotrigine, phenytoin, gabapetin, and tizantidine. Combinations of drugs are often used to maximize effectiveness and minimize the adverse effects. Anticonvulsants and TCA’s may also be used.
  188. Which one of the following is/are the advantages of topical medication for the patients with orofacial pain?
    • a. slow onset
    • b. low side-effects -> answer
    • c. need to penetrate the skin barrier
    • d. accumulation in non-target area
  189. Which are the main ingredients of PLO base?
    • a. Pluronic gel, lecithin, and isopropyl palmitate -> answer
    • b. Pluronic gel, lecithin, and organic gel
    • c. Pluronic gel, lidocaine, and orobase cream
    • d. Pluronic gel, lidocaine, and oxycodone
  190. Name a theory that researchers have used to explain why men and women experience pain differently.
    • a. High levels of estrogen (which only women can have) have been shown to suppress pain. OR
    • b. Women have a specific melanocrotin-1 receptor (McIr) gene that modulates that way they experience pain. OR
    • c. Men and women may have different autonomic responses to pain that causes women to generally have a lower pain threshold than males.
  191. What role does estrogen play during a painful stimulus?
    a. Estrogen has been shown to suppress pain. It has been shown that during high levels of estrogen, the brain responds more actively to pain by releasing higher level of endorphins
  192. Explain why some people think orthodontia may actually reduce TMD symptoms.
    Answer: there is some correlation between destructive forces resulting from malocclusion and TMD. Because orthodontia seeks to improve occlusion it is hypothesized that it actually relieves TMD symptoms. However, there is not enough evidence to support this claim and that which does exist is not statistically significant.
  193. Why have some hypothesized that orthodontic tx causes TMD?
    • 1) some patients develop TMD symptoms during orthodontic tx. (anecdontal evidence)
    • 2) in some orthodontia tx the condyle is positioned posteriorly causing bone to contact between the posterosuperior surfaces of the condyles and the postglenoid tubercles and tympanic plate destroying the contents of this region of the glenoid fossa.
  194. Which subtype of headache is the only type that will possibly benefit from treatment with Botox according to the Evers study?
    • tension type headache
    • - migraine
    • - cluster-type and cervicogenic headache
    • - chronic daily headache who are severely impaired and not receiving other prophylactic treatment.
    • A: chronic daily headache who are severely impaired and not receiving other prophylactic treatment.
  195. What are the indications and contraindications for use of Botox-A in treating Myofascial Pain Syndrome?
    • A: Botox-A is indicated in MPS pt resistant to more conventional treatment and has been shown to decrease depression and anxiety in MPS pt.
    • Botox-A is not recommended as the 1st choice in Tx of MPS due to its high cost and associated discomfort, which includes mild flulike symptoms, injection-site pain and weakness of neck muscles.
  196. Regarding the treatment of myofascial pain syndrome (MPS) with Botox A,
    • which of the following is true?
    • a. Botox A should be used over bupivicaine for trigger point injections because Botox A is less expensive.
    • b. Botox A is approved by the FDA for treatment of myofascial pain syndrome.
    • c. Results from clinical trials have been contradictory as to the effectiveness of using Botox A for MPS.*******
    • d. Results from clinical trials have clearly shown that Botox A should never be used for MPS due to severe side effects.
  197. The approved label indication for Myobloc (Botulinum neurotoxin B)is
    • > a. axillary hyperhidrosis
    • > b. myofascial pain
    • > c. glabellar lines
    • > d. cervical dystonia ***
  198. What are the advantages of topical medication over systemic agents in treating orofacial pain?
    Greater safety, rapid onset of action, and fewer side effects.
  199. Explain the mechanism by which Capsaicin acts to control pain in some of the orofacial neuropathies?
    It depresses the function of type-C nociceptive fibers by depleting substance P, the principal neurotransmitter of pain, from synaptic terminals.
  200. How does emotion processing explain the difference in gender-based pain?
    Positive emotions inhibit pain perception and negative emotions facilitate pain perception. Females are more reactive to negative emotions, thus more sensitive to pain.
  201. What is the affect of the menstural cycle on female's pain threshold?
    In the early days of the cycle, females exhibit a low pain threshold that gradually increases during the cycle. The threshold reaches its maximum at the end of the cycle and is higher than that of males and females on oral contraceptives.
  202. All the followings are the indications for coronoplasty or occlusal adjustment except:
    • A. Gross occlusal interferences in patient with TMD
    • B. Occlusal trauma associated with tooth hypermobility or tenderness
    • C. Patients with phantom bite syndrome or occlusal neurosis*
    • D. improvement After orthodontic or periodontic treatment
    • E. Esthetics
  203. A traditional full coverage splint
    • A. Can reduce strain in the TMJ’s in excursive movements.
    • B. Can protect the teeth from traumatic occluding.
    • C. Can allow for an increase or perpetuation of clenching intensity
    • D. All of the above*
  204. If nerve injury has possibly occurred, what are the problems with waiting too long to perform corrective microneurosurgery?
    If you wait too long, then the success rate for the surgery decreases. The reason is that Wallerian degeneration can occur where the distal portion of the nerve degenerates, making it harder to re-attach. Also, the earlier the surgery, the easier it is to align the fascicles of the nerve to limit fibrosis and promote nerve regeneration and proper signal conduction.
  205. What pre-operative step is very important to the clinician that can help them limit nerve damage when placing mandibular implants?
    Accurate radiographs are important in giving the clinician an idea of what they are working with. Standard panoramics, periapicals, and sometimes computer tomographic images should be used to know the approximate level of bone and presence of vital nerve structures. Being able to have an idea of where the nerves are and the thickness of the bone can help in determining location and depth of the implant. Keeping the implant a safe distance away from the nerve can help minimize neurosensory problems after surgery
  206. In studies of patients with chronic pain, pain management programs have
    • been shown to:
    • a) effectively reduce chronic pain symptoms during treatment in both
    • men and women
    • b) produce lasting pain reduction in both men and women after cessation
    • of treatment
    • c) produce lasting pain reduction in men but not women after cessation
    • of treatment
    • d) answers a and b are correct
    • e) answers a and c are correct
    • Correct answer is E
  207. Studies have shown that pain levels in women:
    • a) drop at the end of the luteal phase, when estrogen and progesterone
    • decrease rapidly
    • b) increase at the end of the luteal phase
    • c) drop during the follicular phase, when estrogen levels are rising
    • d) both a and c are correct
    • e) both b and c are correct
    • Correct answer is E
  208. Q: How can we use opiod medication topically?
    A: Turns out that opiod receptors are also expressed and transported to the peripheral terminal of sensory fibers. And this seems to be enhanced by inflammation.
  209. Q: How can doxepine, which is an anti-depressant drug, be used as an analgesic topical?
    A: We are still not sure of the exact mechanism, however it has shown that it has an inhibitory property on NMDA receptors, noradrenaline, 5-HT reuptake, nicotine and histamine receptors etc… all of which can cause analgesia
  210. What is the treatment protocol when you find TMJ changes during
    • orthodontic treatment?
    • The patient must be observed closely when a TMD is diagnosed during or
    • after orthodontic treatment. Any ongoing orthodontic treatment must be
    • stopped until the etiology for the existing condition is made. The
    • possibility of a pre existing systemic disorder such as
    • hyperparathyroidism and rheumatoid disease also must be ruled out and
    • it is invaluable to do routine radiographic examination at least once
    • every 3 months.
  211. Based on today’s available research, are there any evidence that
    • suggest or prove that orthodontics prevents TMD?
    • There are no evidence from literature that proves or suggest that
    • orthodontics prevents TMD.
  212. How does Botox use compare with Myobloc for the treatment of headache?
    The decision to use A vs. B is largely a physician preference. One consideration is selection a specific product is that Myobloc has a lower Ph value and is more stable compared with Botox but as a result produces greater discomfort, typically a burning sensation.
  213. Define Trigger point injection used during myofascial pain treatment
    • Trigger point injection is a procedure often used to treat painful areas
    • of muscle that contain trigger points. During trigger point procedure a
    • small needle is inserted into the patients. The injection may contain a local
    • anesthetic, corticosteroid or Botox. The purpose of the injection is to inactivate the trigger point and alleviate the pain associated with it.
  214. Does orthodontic tx. cause TMD?
    A: According to all the clinical studies reviewed,there was no evidence that orthodontic tx. causes TMD;so the answer is no.
  215. In the 1980's what event spurred the orthodontic community to pursue research in the relationship of orthodontics to TMD?
    A: A litigation that alleged that orthodontic treatment was the proximal cause of TMD in orthodontic patients in which the courts awarded the plaintiffs substantially monetarily.
  216. What are the three main muscles that are targeted with treating TMD
    • with Botox?
    • Lateral pterygoid, masseter and temporalis.
  217. What is the company that manufactures Botox A? -
    Allergan
  218. Before puberty, males and females have the same incidence of migraine; however, after puberty, women experience migraines at over three times the rate of their male counterparts. Why?
    hormonal fluctuations are predominant in a woman’s life post-puberty. It has been noted that migraine prevalence in women appears most frequently between the ages of 10 and 39 years. The extent and prevalence of the migraines appear to be associated with hormonal changes relating to menstruation, the use of oral contraceptives, pregnancy, and menopause.
  219. Name some drugs that are useful in reducing dilating blood vessels in the head thereby decreasing headache pain.
    Triptans--serotonin receptor agonists--such as Zomig and Imitrex
  220. How is pain tolerance and threshold measured?
    Variance in time response with regards to recognition and withdrawl from a noxious stimulus (ie. Cold pressor test, heat plates, various needle gauges being pressed into skin)
  221. Can migraines be triggered by varying levels of hormones, for example the peaks and falls in estrogen levels?
    Answer: Yes
  222. Are men or women affected the most from the pain reducing effect of positively-valenced emotional stimuli?
    Answer: Men
  223. Name one criterion for occlusal adjustments?
    • 1. Simultaneous bilateral contact in CR
    • 2. No lateral slide between RCP and ICP
    • 3. Canine or group function guidance on working side
    • 4. No interference on nonworking side
    • 5. No posterior contacts during protrusion
  224. T/F Otalgia is a referred pain from muscle/joints that is connected to TMD.
  225. What are the various clinical manifestations of Neuropathology caused by implant placement? Please describe them.
    • Paresthesia: Abnormal sensation
    • Dysesthesia: Unpleasant paresthesia
    • Anesthesia: Absence of sensitivity to all stimuli
    • Analgesia: Absence of sensitivity to noxious stimuli
    • Allodynia: Pain from normally unpainfull stimuli
    • Hyperesthesia: Increased sensitivity to all stimuli
    • Hyperalgesia: Increased sensitivity to noxious stimuli
    • Hypoesthesia: Decreased sensitivity to all stimuli
    • Hypoalgesia: Decreased sensitivity to noxious stimuli
  226. Please describe when and what surgical intervention is appropriate when neuropathology is discovered following the placement of mandibular implants.
    • Decompression of nerve
    • Partial excision of nerve
    • Resection of nerve
    • Primary anastomosis
    • Nerve grafting
    • Success rate improves with early surgery in first 3 months
    • Must treat before distal nerve degeneration develops
    • Total return of normal sensation is rare Only 50% of patients get noticeable improvement in sensation
    • Success improves with non-painful sensory deficits vs hyperaesthetic pain (Gregg, 2000)
  227. What is the mechanism of action of Capsaicin?
    • 1. Sodium channel blocker
    • 2. Inhibits peripheral nociceptor terminal function
    • (P substance)
    • 3. Blocks prostaglandin production through COX inhibition.
    • 4. Antagonist to NMDA receptor
    • 2
  228. All the following medications are used as topical medications for the treatment of chronic orofacial pain except:
    • 1. Benzociane in orabase 20 %
    • 2. Amitrypyline 2%
    • 3. Carbemazapine 2%
    • 4. Temovate 0.05%
    • 4
  229. Interferences in a patient's occlusion justify initiating anorthodontic treatment to treat TMJ dysfunction?
    False
  230. What is the the morphologic mal occlusion that has the largest tendency to give some sign of TMJ dysfunction?
    • a) Class I
    • b) Class II div.1
    • c) Class II div .2
    • d) Class III
    • e) none of the above.
    • Answer is B
  231. Clonidine, an alpha 2 adrenergic agonist has been used as a topical agent for neuropathic pain because it is able to interrupt the peripheral release of what substance?
    Norepinephrine
  232. What are three methods of local medication delivery?
    1) mucoadhesive creams, transdermal creams, dissolving tablets, adhesive patches
  233. How are Tri-cyclic antidepressants and Topical Anesthetics such as Benzocaine 20% similar in the mechanism of relieving neuropathic pain?
    They both block Na+ channels.
  234. What is the overall clinical result seen in a muscle after an injection with BTX-A?
    - The exact mechanisms of BTX-A activity is not clear, but overall reduction in the maximum contractive force of injected muscle is seen in addition to a reduction in the resting muscle tone.
  235. Mention the main benefit of BTX-A therapy seen in patients with neurophatic pain?
    A clear benefit of BTX-A is that it often relieves pain symptoms.
  236. Are topical medications helpful for central or peripheral pain?
    Topical medications are only helpful with peripheral pain. To determine if the pain is peripheral, if local anesthetic is given in that area the pain will be relieved. Local anesthetics will not help with central pain. Therefore you must first differentiate if the source of the pain is central or peripheral and only prescribe topical medications for peripheral pain.
  237. What is the mechanism that Ketamine use to alleviate neurogenic pain?
    • Ketamine is an NMDA receptor inhibitor that binds to a specific site for phencyclidine
    • (PCP)-like drugs in the NMDA receptor-gated channel and inhibits the excitatory effect of
    • glutamate selectively at these receptors. By targeting peripheral glutamate receptors in
    • chronic pain and inflammatory state, Ketamine can be administered topically for
    • sympathetically pain and for pain in a palliative setting.
  238. Orthodontic therapy is the standard of care for all TMD patients. (T or F)
    F
  239. There is substantial evidence TMD is caused by malocclusion. (T or F)
    F
  240. What symptoms of TMD seem to diminish after treatment with a combination of orthodontics and orthognathic surgery?
    A: Headache, lateral deviation of the mandible greater than 2mm, TMJ sounds, and pain on movement of the mandible.
  241. Which of the following categories of medications can be used in treating neuropathic pain?
    • f) Trycyclic antidepressants
    • g) Opiate analgesics
    • h) Anticonvulsants
    • i) Topical anesthetics
    • j) All of the above
    • all
  242. The best method of treating neuropathic pain is:
    • f) Surgical means
    • g) Systemic medications
    • h) Psychological counseling
    • i) Prevention
    • j) None of the above
    • prevention
  243. Name 3 distinctive characteristics of acute and chronic pain
    • • Acute pain
    • a. Identifiable inflammation and pathology usually accompany pain
    • b. Usually requires locally directed txs
    • c. Reversible over healing cycle of 2-8 wks
    • • Chronic pain
    • d. No obvious cause – local pathology or injury may have already healed
    • e. Peripheral or central neurologic pain
    • f. Possible permanent sensitization of the peripheral nociceptors and/or second order neurons ( loss of pain inhibitory neurons, sensitization of peripheral c-fibers, referred pain due to central spread of sensitization)
  244. What are some undesirable outcomes from wearing occlusal appliances to treat headache and/or orofacial pain?
    • increased pain in jaw joints, jaw muscle soreness, loosening of some teeth, and changes in occlusion
  245. What is the mechanism by which Botox works?
    Botulinum toxin denervates muscles by inhibiting acetylcholine release from motor neurons.
  246. What is the difference between Botox A and B?
    They both inhibit acytylcholine, but they do so by breaking up different proteins.
  247. The anterior bite plane is an appliance made from acrylic that is worn over the maxillary arch, contacting only which areas of the mandibular teeth?
    Answer: mandibular anterior teeth
  248. Partial selective grinding is indicated in patients with headache and orofacial pain. True of False?
    Answer: False
  249. Can headache be treated with appliance therapy?
    A: Only when the peripheral activation is responsible for the headache. Appliance therapy will not help if there is no peripheral cause and when headache is associated with more complex widespread pain.
  250. Is coronoplasty recommended for treatment of TMD?
    A: There is no evidence that Occlusal adjustment treats or prevents TMD and thus it cannot be recommended for the management of TMD
  251. What 5 criteria must be met to diagnose post tramatic neuralgia?
    • 6. Continuous pain/dysesthesia
    • 7. Pain limited to distribution of the injured nerve(s)
    • 8. History of trauma and likely injury to nerve branch
    • 9. Associated local hyperalgesia (hyperesthesia) over pain territory
    • 10. Pain can be abolished or greatly reduced by local anesthetic nerve block
  252. What is the first line of treatment in orofacial neuropathic pain?
    • Pharmacological therapy
    • The goal is to reduce neuronal hyper-excitability in the central and peripheral nervous system. For most types of facial neuralgia, Carbamazepine is the main stay of pharmacotherapy. Other drugs include oxcarbazepine, lamotrigine, phenytoin, gabapetin, and tizantidine. Combinations of drugs are often used to maximize effectiveness and minimize the adverse effects. Anticonvulsants and TCA’s may also be used.
  253. Which one of the following is/are the advantages of topical medication for the patients with orofacial pain?
    • e. slow onset
    • f. low side-effects -> answer
    • g. need to penetrate the skin barrier
    • h. accumulation in non-target area
  254. 3. Which are the main ingredients of PLO base?
    • a. Pluronic gel, lecithin, and isopropyl palmitate -> answer
    • b. Pluronic gel, lecithin, and organic gel
    • c. Pluronic gel, lidocaine, and orobase cream
    • d. Pluronic gel, lidocaine, and oxycodone
  255. 3. Name a theory that researchers have used to explain why men and women experience pain differently.
    • a. High levels of estrogen (which only women can have) have been shown to suppress pain. OR
    • b. Women have a specific melanocrotin-1 receptor (McIr) gene that modulates that way they experience pain. OR
    • c. Men and women may have different autonomic responses to pain that causes women to generally have a lower pain threshold than males.
  256. 4. What role does estrogen play during a painful stimulus?
    a. Estrogen has been shown to suppress pain. It has been shown that during high levels of estrogen, the brain responds more actively to pain by releasing higher level of endorphins
  257. Explain why some people think orthodontia may actually reduce TMD symptoms.
    Answer: there is some correlation between destructive forces resulting from malocclusion and TMD. Because orthodontia seeks to improve occlusion it is hypothesized that it actually relieves TMD symptoms. However, there is not enough evidence to support this claim and that which does exist is not statistically significant.
  258. Why have some hypothesized that orthodontic tx causes TMD?
    Answer: 1) some patients develop TMD symptoms during orthodontic tx. (anecdontal evidence) 2) in some orthodontia tx the condyle is positioned posteriorly causing bone to contact between the posterosuperior surfaces of the condyles and the postglenoid tubercles and tympanic plate destroying the contents of this region of the glenoid fossa.
  259. Which subtype of headache is the only type that will possibly
    • benefit from treatment with Botox according to the Evers study? -
    • tension type headache
    • - migraine
    • - cluster-type and cervicogenic headache
    • - chronic daily headache who are severely impaired and not receiving
    • other prophylactic treatment.
    • A: chronic daily headache who are severely impaired and not receiving
    • other prophylactic treatment.
  260. 2. What are the indications and contraindications for use of Botox-A in
    • treating Myofascial Pain Syndrome?
    • A: Botox-A is indicated in MPS pt resistant to more conventional
    • treatment and has been shown to decrease depression and anxiety in MPS
    • pt. Botox-A is not recommended as the 1st choice in Tx of MPS due to
    • its high cost and associated discomfort, which includes mild flulike
    • symptoms, injection-site pain and weakness of neck muscles.
  261. Regarding the treatment of myofascial pain syndrome (MPS) with Botox A,
    • which of the following is true?
    • a. Botox A should be used over bupivicaine for trigger point injections
    • because Botox A is less expensive.
    • b. Botox A is approved by the FDA for treatment of myofascial pain syndrome.
    • c. Results from clinical trials have been contradictory as to the
    • effectiveness of using Botox A for MPS.*******
    • d. Results from clinical trials have clearly shown that Botox A should
    • never be used for MPS due to severe side effects.
  262. The approved label indication for Myobloc (Botulinum neurotoxin B)is
    • > a. axillary hyperhidrosis
    • > b. myofascial pain
    • > c. glabellar lines
    • > d. cervical dystonia ***
  263. What are the advantages of topical medication over systemic agents in treating orofacial pain?
    Greater safety, rapid onset of action, and fewer side effects.
  264. Explain the mechanism by which Capsaicin acts to control pain in some of the orofacial neuropathies?
    It depresses the function of type-C nociceptive fibers by depleting substance P, the principal neurotransmitter of pain, from synaptic terminals.
  265. How does emotion processing explain the difference in gender-based pain?
    Positive emotions inhibit pain perception and negative emotions facilitate pain perception. Females are more reactive to negative emotions, thus more sensitive to pain.
  266. What is the affect of the menstural cycle on female's pain threshold?
    In the early days of the cycle, females exhibit a low pain threshold that gradually increases during the cycle. The threshold reaches its maximum at the end of the cycle and is higher than that of males and females on oral contraceptives.
  267. All the followings are the indications for coronoplasty or occlusal adjustment except:
    • F. Gross occlusal interferences in patient with TMD
    • G. Occlusal trauma associated with tooth hypermobility or tenderness
    • H. Patients with phantom bite syndrome or occlusal neurosis*
    • I. improvement After orthodontic or periodontic treatment
    • J. Esthetics
  268. A traditional full coverage splint
    • A. Can reduce strain in the TMJ’s in excursive movements.
    • B. Can protect the teeth from traumatic occluding.
    • C. Can allow for an increase or perpetuation of clenching intensity
    • D. All of the above*
  269. If nerve injury has possibly occurred, what are the problems with waiting too long to perform corrective microneurosurgery?
    A: If you wait too long, then the success rate for the surgery decreases. The reason is that Wallerian degeneration can occur where the distal portion of the nerve degenerates, making it harder to re-attach. Also, the earlier the surgery, the easier it is to align the fascicles of the nerve to limit fibrosis and promote nerve regeneration and proper signal conduction.
  270. What pre-operative step is very important to the clinician that can help them limit nerve damage when placing mandibular implants?
    A: Accurate radiographs are important in giving the clinician an idea of what they are working with. Standard panoramics, periapicals, and sometimes computer tomographic images should be used to know the approximate level of bone and presence of vital nerve structures. Being able to have an idea of where the nerves are and the thickness of the bone can help in determining location and depth of the implant. Keeping the implant a safe distance away from the nerve can help minimize neurosensory problems after surgery
  271. In studies of patients with chronic pain, pain management programs have been shown to:
    • a) effectively reduce chronic pain symptoms during treatment in both
    • men and women
    • b) produce lasting pain reduction in both men and women after cessation
    • of treatment
    • c) produce lasting pain reduction in men but not women after cessation
    • of treatment
    • d) answers a and b are correct
    • e) answers a and c are correct
    • Correct answer is E
  272. Studies have shown that pain levels in women:
    • a) drop at the end of the luteal phase, when estrogen and progesterone
    • decrease rapidly
    • b) increase at the end of the luteal phase
    • c) drop during the follicular phase, when estrogen levels are rising
    • d) both a and c are correct
    • e) both b and c are correct
    • Correct answer is E
  273. Q: How can we use opiod medication topically?
    A: Turns out that opiod receptors are also expressed and transported to the peripheral terminal of sensory fibers. And this seems to be enhanced by inflammation.
  274. Q: How can doxepine, which is an anti-depressant drug, be used as an analgesic topical?
    A: We are still not sure of the exact mechanism, however it has shown that it has an inhibitory property on NMDA receptors, noradrenaline, 5-HT reuptake, nicotine and histamine receptors etc… all of which can cause analgesia
  275. What is the treatment protocol when you find TMJ changes during orthodontic treatment?
    • The patient must be observed closely when a TMD is diagnosed during or after orthodontic treatment.
    • Any ongoing orthodontic treatment must be stopped until the etiology for the existing condition is made.
    • The possibility of a pre existing systemic disorder such as hyperparathyroidism and rheumatoid disease also must be ruled out and it is invaluable to do routine radiographic examination at least once every 3 months.
  276. Based on today’s available research, are there any evidence that suggest or prove that orthodontics prevents TMD?
    There are no evidence from literature that proves or suggest that orthodontics prevents TMD.
  277. How does Botox use compare with Myobloc for the treatment of headache?
    The decision to use A vs. B is largely a physician preference. One consideration is selection a specific product is that Myobloc has a lower Ph value and is more stable compared with Botox but as a result produces greater discomfort, typically a burning sensation.
  278. Define Trigger point injection used during myofascial pain treatment
    Trigger point injection is a procedure often used to treat painful areas of muscle that contain trigger points. During trigger point procedure a small needle is inserted into the patients. The injection may contain a local anesthetic, corticosteroid or Botox. The purpose of the injection is to inactivate the trigger point and alleviate the pain associated with it.
  279. Q: Does orthodontic tx. cause TMD?
    • A: According to all the clinical studies reviewed,there was no evidence
    • that orthodontic tx. causes TMD;so the answer is no.
  280. Q: In the 1980's what event spurred the orthodontic community to pursue research in the relationship of orthodontics to TMD?
    A litigation that alleged that orthodontic treatment was the proximal cause of TMD in orthodontic patients in which the courts awarded the plaintiffs substantially monetarily.
  281. What are the three main muscles that are targeted with treating TMD with Botox? - Lateral pterygoid, masseter and temporalis.
  282. What is the company that manufactures Botox A? -
    Allergan
  283. Before puberty, males and females have the same incidence of migraine; however, after puberty, women experience migraines at over three times the rate of their male counterparts. Why?
    Answer: This may be due to the fact that hormonal fluctuations are predominant in a woman’s life post-puberty. It has been noted that migraine prevalence in women appears most frequently between the ages of 10 and 39 years. The extent and prevalence of the migraines appear to be associated with hormonal changes relating to menstruation, the use of oral contraceptives, pregnancy, and menopause.
  284. Name some drugs that are useful in reducing dilating blood vessels in the head thereby decreasing headache pain.
    Answer: Triptans--serotonin receptor agonists--such as Zomig and Imitrex
  285. How is pain tolerance and threshold measured?
    Answer: Variance in time response with regards to recognition and withdrawl from a noxious stimulus (ie. Cold pressor test, heat plates, various needle gauges being pressed into skin)
  286. Can migraines be triggered by varying levels of hormones, for example the peaks and falls in estrogen levels?
    Answer: Yes
  287. Are men or women affected the most from the pain reducing effect of positively-valenced emotional stimuli?
    Answer: Men
  288. Name one criterion for occlusal adjustments?
    • 1. Simultaneous bilateral contact in CR
    • 2. No lateral slide between RCP and ICP
    • 3. Canine or group function guidance on working side
    • 4. No interference on nonworking side
    • 5. No posterior contacts during protrusion
  289. What are 3 qualities of pain felt with sensory system involvement and define them
    • The results of these sensory systems involvement are specific pain qualities such as allodynia, hyperalgesia, and hyperpathia.
    • Allodynia refers to pain resulting from low intensity, normally non-noxious stimuli. Hyperalgesia occurs when a stimulus that is usually noxious results in enhanced pain response.
    • Hyperpathia refers to an increase in pain threshold, leading to a delay between onset of stimulus and pain but, once the pain is felt, is far more intense than normal.
  290. What 5 criteria must be met to diagnose post tramatic neuralgia?
    • 11. Continuous pain/dysesthesia
    • 12. Pain limited to distribution of the injured nerve(s)
    • 13. History of trauma and likely injury to nerve branch
    • 14. Associated local hyperalgesia (hyperesthesia) over pain territory
    • 15. Pain can be abolished or greatly reduced by local anesthetic nerve block
  291. Question 3
    What is the first line of treatment in orofacial neuropathic pain?
  292. Pharmacological therapy
    The goal is to reduce neuronal hyper-excitability in the central and peripheral nervous system. For most types of facial neuralgia, Carbamazepine is the main stay of pharmacotherapy. Other drugs include oxcarbazepine, lamotrigine, phenytoin, gabapetin, and tizantidine. Combinations of drugs are often used to maximize effectiveness and minimize the adverse effects. Anticonvulsants and TCA’s may also be used.
  293. Myofacial Trigger Points: an injection tech
    • Procaine-least myotoxic
    • Injection in to the trigger point, or bundle of aggravated muscle tissue
    • L. pteryoid Injection:
    • Betadine for antiseptic, then alcohol, mouth prop to lower mand, vapocoolant spray
    • Extroral injection through mand notch, walking along lateral pterygoid plate
    • Complications: May inject into pterygoid plexus of veins resulting in hematoma
  294. All the following medications are used as topical medications for the treatment of chronic orofacial pain except:
    • 1. Benzociane in orabase 20 %
    • 2. Amitrypyline 2%
    • 3. Carbemazapine 2%
    • 4. Temovate 0.05%
    • 4
  295. 2. Explain why some people think orthodontia may actually reduce TMD symptoms.
    Answer: there is some correlation between destructive forces resulting from malocclusion and TMD. Because orthodontia seeks to improve occlusion it is hypothesized that it actually relieves TMD symptoms. However, there is not enough evidence to support this claim and that which does exist is not statistically significant
  296. Q: How can we use opiod medication topically?
    A: Turns out that opiod receptors are also expressed and transported to the peripheral terminal of sensory fibers. And this seems to be enhanced by inflammation.
  297. Q: How can doxepine, which is an anti-depressant drug, be used as an analgesic topical?
    A: We are still not sure of the exact mechanism, however it has shown that it has an inhibitory property on NMDA receptors, noradrenaline, 5-HT reuptake, nicotine and histamine receptors etc… all of which can cause analgesia
  298. 1. What is the treatment protocol when you find TMJ changes during orthodontic treatment?
    • The patient must be observed closely when a TMD is diagnosed during or after orthodontic treatment. Any ongoing orthodontic treatment must be stopped until the etiology for the existing condition is made. The possibility of a pre existing systemic disorder such as
    • hyperparathyroidism and rheumatoid disease also must be ruled out and it is invaluable to do routine radiographic examination at least once every 3 months.

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