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ABOUT this

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2014 course one

OROFACIAL PAIN

The purpose of this study is to introduce oral health care professionals to

some of the more common causes of nonodontogenic pain that they can

potentially encounter in their practices. Even if they are unable to definitively

diagnose the condition, they should be able to guide the patient to where

they should seek appropriate care.

written by amber kiyani, dds

edited by rachel a. flad, bs

karen k. daw, mba, cecm

INTRODUCTION

Pain in the orofacial region is a

common symptom of patients

seeking care in dental clinics. In a

majority of patients, the pain is

odontogenic in origin and is

relatively easy to diagnose and

alleviate. Diagnosis and treatment

of nonodontogenic orofacial pain is

more complex, especially when no

clinical and radiographic changes

are identified. Affected patients

have usually seen multiple

specialists and spent a significant

amount of money on imaging and

other studies. Typically, they are in

extreme discomfort and vexed

because no one seems to know

what is wrong with them.

In this continuing education course,

we will discuss the following types of

orofacial pain:

• Temporomandibular Joint

Disorder

• Masticatory Myofascial Pain

• Intra-Articular Derangement

• Osteoarthritis

• Rheumatoid Arthritis

• Trigminal Neuralgia

• Glossopharyngeal Neuralgia

• Postherpetic Neuralgia

• Atypical Facial Pain

• Burning Mouth Syndrome

• Benign and Malignant Tumors

TEMPOROMANDIBULAR

JOINT DISORDER

Temporomandibular joint disorder is

a broad term that encompasses any

disorder of the temporomandibular

joint, muscles of mastication, and Page 2

the surrounding bone and soft

tissues. This condition is common,

reported by 40-60% of the adult

population. Pain, limited opening,

clicking and popping noises from

the joint, and difficulty in

mastication are common symptoms.

Temporomandibular joint disorder is

defined as a musculoskeletal,

rheumatological, psychogenic,

neuromuscular, and functional

disorder. There is a lot of controversy

concerning the pathogenesis of the

process. Recent advances in the field

of imaging have allowed for better

understanding of joint function. This

has led most authors to agree that

this is a multifactorial and complex

disorder, rather than just a single

condition.

THEORIES OF PATHOGENESIS

Stress

Continued emotional stress can

cause prolonged contraction of the

facial muscles and the induction of

Source: www.mdguidelines.com

bruxism (grinding), which can frequently trigger

temporomandibular joint pain. This leads to a

series of events that generate an inflammatory

response in the joint that is followed by release of

chemical mediators that exacerbate the pain in

the region. To avoid pain, the affected individual

limits their muscle movements. Extended periods

of reduced muscle activity can result in a decrease

in muscle tone and strength, ultimately restricting

mouth opening.

Trauma

Damage to the ligaments, articular cartilage,

articular disk, and bone may result in the release of

chemical mediators that draw inflammatory cells

to the joint space. These inflammatory cells have

the ability to cause significant damage to the joint

architecture.

Genetic Factors

Genetic marker studies have implicated that

certain genes are involved in the pain

transmission pathway. These genes have the

ability to interfere with pain reception and

processing, that may in turn, result in

hyperalgesia. One of the genes described with this

process is catechol O-methyltransferase, or COMT.

Patients with temporomandibular joint disorders

have been reported to exhibit dysregulation of

this gene, and consequently, a lower threshold of

pain tolerance.

Psychogenic Factors

Cortical brain scans of patients with

temporomandibular joint disorders show striking

similarities to patients with other chronic pain

disorders. Scientists speculate that this suggests a

disturbance in the pain processing mechanism in

the trigeminal ganglion. Patients with muscular

pain disorders rarely have any anatomical

abnormalities. They are considered to be “centrally

sensitized,” meaning that the nerves in the brain

are transmitting faulty pain signals.

Controversial Theories

Some studies state that bruxism, clenching, and

other parafunctional habits are considered to be

detrimental to the joint structure. Similarly, other

studies link fluctuating estrogen levels to the

increased frequency of temporomandibular joint

disorders in females.

Classification of Temporomandibular Joint

Disorders

• Articular Disorders:

• Osteoarthritis

• Trauma

• Infectious Arthritis

• Iatrogenic

• Crystal Arthropathies

• Rheumatoid Arthritis

• Psoriatic Arthritis

• Ankylosing Spondylitis

• Myogenous Disorders:

• Myofascial Pain

• Acute Muscle Strain

• Muscle Spasm

• Fibromyalgia

• Myotonic Dystrophy

Clinical Features

Temporomandibular joint disorders are usually

seen in individuals between 20 and 40 years of

age. Women are more commonly affected than

men. Unilateral pain is a common presenting

symptom. The pain is commonly paroxysmal,

poorly localized, and usually dull or aching in

nature. It can be elicited by simple contact or

movement of the joint. Radiation of the pain to

the pre-auricular area, ears, periorbital region, or

to the angle of mandible is common and may also

be accompanied by limited jaw opening that can

cause difficulties in eating and talking.

Source: www.mouthhealthy.org

Page 3

Deviation of the jaw towards the affected side

may also be observed. Locking of the jaw may

either occur at a closing position with inability to

open the mouth or at an open position with

inability to close the mouth. Popping, clicking and

grating are common descriptions of the sound

generated by the joint during opening or closing.

The symptoms are usually worse in the morning,

especially in patients with nocturnal

parafunctional habits such as bruxism and

clenching. In more severe cases, headache,

reduced hearing, ringing of the ears, dizziness,

and pressure behind the eye may also be noted.

Diagnosis

Diagnosis of temporomandibular joint disorder is

dependent on a thorough history and clinical

examination. Imaging studies would also be

beneficial and, on occasion, may be necessary.

While obtaining patient history, a detailed

description of the nature of pain with

exacerbating and relieving factors should be

recorded. Information concerning parafunctional

habits such as clenching and grinding of teeth

should also be documented.

Clinical examination allows for detection of joint

noises during opening and closing movements,

measurement of mandibular movements

(including incisal opening), lateral movements

and protrusion, and palpation of the masticatory

muscles. The results of a clinic examination can

rule out odontogenic and other causes of

orofacial pain.

Imaging studies are usually helpful in making a

definitive diagnosis. While panoramic radiographs

and facial views may serve as helpful screening

tools, computed tomography is the gold standard

for bony abnormalities. Advances in the

technology allows for a three-dimensional and

high resolution imaging of the

temporomandibular joint with low radiation

exposures. For soft tissue changes, magnetic

resonance imaging (MRI) is useful. This technique

allows for muscles, ligaments, and the vascular

structure to be evaluated.

Arthroscopy is the insertion of a small camera

through a minimally invasive incision to directly

visualize the joint. Problems such as synovitis and

perforation can be detected by this technique.

This technique is also employed for curative

purposes.

Temporomandibular joint disorders can be

broadly classified as articular or myogenous

disorders (please refer to the list on Page 3).

Although each disorder has a unique etiology and

management regime, we are only able to discuss

the most common ones in the sections below.

MASTICATORY MYOFASCIAL

PAIN

Myofascial pain disorder can be defined as the

tenderness of the masticatory muscles involved in

jaw closure movements. It is one of the most

common temporomandibular joint disorders and

the second most frequent cause of orofacial pain.

Clinical Features

Myofascial pain is characterized by a unilateral,

dull, aching sensation that varies during the

course of the day. The pain can be elicited

through a trigger point located on the muscle,

fascia, or tendon. The pain does not interfere with

sleeping patterns, but it may be aggravated by

certain types of jaw movements. It may also be

accompanied by tinnitus, dizziness, and pain

radiating to the oral cavity, ear, and neck region.

Muscles are usually stiff and tender on palpation.

Imaging studies exhibit no evidence of anatomic

pathology. Non-invasive management is

sufficient in most cases.

MANAGEMENT

Reassurance

Patients are provided with a detailed description

of the disease process, highlighting the role of

emotional stress and parafunctional habits. This

encourages patients to reduce these elements

from their lives in order to improve their health.

Page 4

Page 5

Rest

Patients are instructed to limit jaw movements

and are discouraged from extreme mechanical

movements such as yawning, laughing, and

clenching. Patients are also advised to refrain from

potential jaw damaging habits such as chewing

gum, nail biting, or pencil chewing.

Heat

Heat application to the affected area is beneficial

in alleviating pain. The heat can be applied using a

heating pad, hot towel, hot water bottle, or

through more advanced techniques such as

ultrasound and short wave diathermy treatments.

Medications

In acute stages of the disease, a 2-week course of

nonsteroidal, anti-inflammatory drugs may be

beneficial in alleviating symptoms. Muscle

relaxants (cyclobenzaprine), anxiolytic agents

(diazepam, prazepam, and clonazepam),

anticonvulsants (gabapentin), or opioid analgesics

are usually the next course of action. These drugs

are used sparingly to limit dependency. Tricyclic

antidepressants (nortriptyline and duloxetine) and

some serotonin reuptake inhibitors (fluoxetine

and paroxetine) have been reported to be

effective in controlling symptoms as well.

Occlusal Adjustments

While limited proof supports the theory that

malocclusion is linked to temporomandibular joint

disorders, it may still be helpful to eliminate

occlusal discrepancies. Bite adjustments and

replacement of missing teeth can restore optimal

occlusion and masticatory function.

Jaw Appliances

These devices are made from acrylic and worn as

orthodontic retainers or removable partial

dentures. They come in a variety of shapes and

forms. These appliances are designed to protect

the masticatory muscles from harmful

movements, such as clenching and bruxism,

during sleep. They also make patients more aware

of their parafunctional habits and encourage them

to stop.

Behavioral Approaches

Relieving stress from life is an important step

towards rehabilitation. For this purpose,

counseling, relaxation techniques, and stress

management have shown some positive results.

Physiotherapy

Massaging, manual manipulation,

ultrasonography, and iontophoresis allow for

retraining of the masticatory muscles and have

proven to be effective in patients with

temporomandibular joint disorders. Numerous

passive motion devices are also available

commercially. These devices serve as the initial

step toward rehabilitation by providing protection

to the traumatized region, reducing pain and

inflammation, and permitting limited jaw

movements.

INTRA-ARTICULAR

DERANGEMENT

Intra-articular disk derangement is a category of

temporomandibular joint disorder that includes

anterior disk displacement, with and without

reduction. Displacement of the

temporomandibular joint disk from its rest

position can result in significant joint dysfunction.

Clinical Features

Anterior disk displacement with reduction

describes the displacement of the disk during

closure; on opening, the disk returns to its original

position with a “popping” sound.

cases, intra-articular injections of steroids may be

beneficial. Surgery is the only option in patients

that are unresponsive to treatment.

RHEUMATOID ARTHRITIS

Rheumatoid arthritis is an autoimmune disease

that causes chronic inflammation of the joints and

surrounding tissues. Most patients with

temporomandibular joint involvement have

complaints of pain, swelling, and limited jaw

movements. In children, temporomandibular joint

involvement may impede the normal growth

process.

Rheumatoid arthritis is a generalized process

involving multiple joints at one time. This usually

helps in establishing diagnosis. In earlier stages of

the disease, no changes in imaging studies are

identified. In later stages, condylar destruction

may be noted. Medical management and

biomechanical alteration of the joint may help in

alleviating symptoms. In non-refractory cases,

surgical intervention becomes necessary.

TRIGEMINAL NEURALGIA

Trigeminal neuralgia is a peripheral neuropathy

characterized by episodes of severe pain in the

facial region originating from the trigeminal nerve.

Pain can be elicited by contact with a trigger zone,

a site usually located on cutaneous skin. It is a

relatively rare condition, affecting about 6 of every

100,000 individuals each year. The disorder

appears at a higher frequency in individuals with

multiple sclerosis.

Pathogenesis

Compression of the trigeminal nerve in pons is

attributed as the potential cause of this condition.

It is postulated that compression causes

demyelination of the nerve (damage to the myelin

sheath) that may result in erratic nerve activity.

Clinical Features

Trigeminal neuralgia usually occurs in individuals

over 40 years of age. Women seem to be affected

Pain is not a frequent finding, especially in the

earlier stages of the process. Deviation of the

mandible towards the affected side is also noted.

The situation may worsen over a period of time

resulting in intermittent locking of the jaw.

Anterior disk displacement without reduction is

characterized by pain, limited jaw opening, and

intermittent locking of the jaw. Locking of the jaw

is the result of the disk acting as a mechanical

obstruction to condylar movement.

Diagnosis

A thorough medical history, complete medical

exam, and imaging studies are required for

establishing diagnosis. MRIs are usually employed

to perform scans in both open and closed

positions of the jaw. Disk displacement can be

visualized with MRI techniques along with the

degenerative changes of the condyle. Arthroscopy

may also prove beneficial at times and it can be

employed for both diagnostic and treatment

purposes.

Management

Anterior disk displacement with reduction is

relatively easier to treat. The condition can usually

be controlled using non-invasive techniques such

as rest, heat application, behavioral modifications,

occlusal appliances, and physiotherapy. In some

instances nonsteroidal inflammatory drugs and

muscle relaxants may be employed.

In patients with anterior disk displacement

without reduction, intra-articular steroid injections

and arthrocentesis may be helpful.

OSTEOARTHRITIS

Osteoarthritis is a degenerative joint disease that

may result from trauma, infection, previous joint

surgery, and metabolic disorders. Osteoarthritis of

the jaw tends to affect women between 30 and 40

years of age. Pain, limited mouth opening, and

deviation of the mandible towards the affected

side are some of the common symptoms. The joint

may also produce gritty sounds on movement.

Imaging studies can usually identify the

degenerative changes in the cartilage and bone.

Most patients can be kept comfortable using non-

steroidal anti-inflammatory drugs. In more severe Page 6

Page 7

more commonly than men. The right side of the

face is more frequently involved. Either of the three

branches of trigeminal nerve may be affected. In

rare instances, more than one branch may be

involved.

Pre-trigeminal neuralgia is a term used to refer to

the dull aching pain that appears before the onset

of pain attacks. It is seen in over 18% of affected

patients. This is the earlier form of the disease that

shows significant response to the use of

carbamazepine.

The pain associated with trigeminal neuralgia is

often described as electric shock or lancinating. An

obvious trigger point can be identified in a

significant number of patients. It is most

commonly located on the nasolabial fold, the

vermillion of the lip, periorbital region, or the

midface. The initiation of the pain can be a result of

contact with the site, motions of mastication, and

even exposure to cold wind. The pain may last

from a few seconds to an hour. After the activation

of the trigger zone, the pain cannot be elicited for

a small period of time. This interval is known as the

refractory period. Due to the intensity of the pain,

it is not uncommon for patients to place their

hands over the site. Twitching of the muscles may

be noted during the pain attack. Excessive

lacrimation and an intense headache usually

follows the attack.

Diagnosis

The diagnosis is made on characteristic signs and

symptoms. Imaging studies may help in

identification of the responsible vessel.

Management

In rare cases, spontaneous resolution of the

symptoms has been reported. Topical application

of capsaicin, a product derived from chilies that

has the ability to induce partial numbness, may be

used to alleviate symptoms. Topical therapy

provides limited pain control and systemic

treatment is usually necessary. Carbamazepine is

preferred, however, other anticonvulsants like

phenytoin and gabapentin, may also help with

symptoms. Trigeminal neuralgia is a chronic pain

disease and requires medication to be taken on a

long-term basis. Since most of these drugs have

significant side effects, they are frequently not well

tolerated by patients. Surgical intervention is an

option for patients who are either unresponsive to

medical treatment or can no longer tolerate it.

Microvascular decompression, an open surgical

procedure that allows for placement of a barrier

between the offending vessel and the trigeminal

nerve, has shown the most efficacy. Gamma knife

radiosurgery and radiofrequency rhizotomy may

also be used. Local glycerol injections may also

provide a few months of relief in non-refractory

cases.

GLOSSOPHARYNGEAL

NEURALGIA

Glossopharyngeal neuralgia is a pain disorder

characterized by paroxysmal attacks of severe pain

along the course of the glossopharyngeal nerve

following activation of a trigger zone. This

condition is extremely rare involving less than 1

person per 100,000. In some instances

glossopharyngeal neuralgia may occur in

combination with trigeminal neuralgia or involve

branches of the vagus nerve.

Pathogenesis

Like trigeminal neuralgia, the pain is caused by

compression of the glossopharyngeal nerve by the

ectopic branches of the superior cerebellar artery

in pons. The compression allows for demyelination

of the nerve that in turn impedes the ability of the

glossopharyngeal nerve to inhibit pain signals.

Clinical Features

Glossopharyngeal neuralgia is frequently

encountered in patients between the ages of 40

and 60 and shows a female sex predilection.

Common sites of involvement include the ear,

infra-auricular area, tonsil, base of tongue, and the

oropharynx. Trigger zones are usually not located

on cutaneous sites. The pain may be elicited by

swallowing, talking, chewing, or yawning. Once

the trigger zone is activated, the pain attacks can

last anywhere from a few seconds to several

minutes. The pain associated with

glossopharyngeal neuralgia has been described to

be sharp and deep in nature. Even between pain

attacks, a dull sensation in the region may persist.

Page 8

The pain presents more frequently on the left side

and bilateral involvement is rare. Syncope and

seizure disorders may occur alongside pain attacks

when the branches of the vagus nerve are

involved. Clinical features usually assist in

establishing diagnosis. Imaging studies of the

brain can be used to locate the blood vessel

compressing against the nerve.

Management

Topical application with capsaicin is rarely

beneficial. Anticonvulsants are less effective in

controlling pain symptoms in patients with

glossopharyngeal neuralgia in comparison to

those with trigeminal neuralgia. For non-refractory

cases, surgery is treatment of choice. Microvascular

decompression, intracranial and radiofrequency

rhizotomies, and stereotactic radiosurgery are

some of the surgical techniques employed.

POSTHERPETIC NEURALGIA

The varicella zoster virus is transmitted through air

droplets and causes chickenpox. This is

characterized by fever, malaise, pharyngitis,

rhinitis, and a rash that eventually evolves into

vesicles. The vesicles heal by crusting and the

infection usually heals within two weeks. Adults

have more severe symptoms than children.

Following the initial infection, the virus moves up

through the nerves into the spinal ganglion and

remains latent until reactivation. In most cases, the

virus may remain latent until the patient is 50 years

of age or older. The reactivated version of the virus

is referred to as herpes zoster. It is responsible for

shingles, the painful eruptions along the course of

a dermatome. Usually only one dermatome is

affected at any time. Most infections resolve

completely within 10 days. For about 15% of the

affected population, chronic pain may persist at

the site of infection. This pain is neural in origin

and is referred to as postherpetic neuralgia. It is

thought to be a result of damage to the nerve by

the virus. The pain is severe in intensity and has

been described as burning, throbbing, aching, or

stabbing. Spontaneous recovery may occur

anytime within a period of 12 months. In rare

cases, the pain may persist for several years.

Diagnosis

History of shingles at the site of pain is necessary

to make the diagnosis of postherpetic neuralgia.

Viral cultures or antibody measurements may also

help in confirming diagnosis. MRIs can identify

some lesions associated with the virus in the brain

stem.

Management

Use of antivirals at the onset of infection can help

limit the course of pain. Topical and systemic

analgesics, antidepressants, and anticonvulsants

have been reported to show some improvement in

symptoms.

Prevention

A vaccine is now available and is only approved for

individuals over 50 years of age to prevent the

zoster infection.

ATYPICAL FACIAL PAIN

Atypical facial pain is described as persistent

chronic pain of undetermined origin that cannot

be classified as any other cranial nerve neuralgia.

The condition is also referred to as atypical facial

neuralgia, chronic idiopathic facial pain and

psychogenic facial pain.

Pathogenesis

Some studies have linked the pain disorder to a

neuropathic origin, suggesting injury to branches

of the trigeminal nerve as being the etiological

factor.

Shingles on the Face Source: www.cdc.gov

Page 9

Others have linked the disorder to psychological

illness implicating the pain to be psychosomatic in

origin.

Clinical Features

Women between the ages 40 and 60 appear to

develop this condition at a higher frequency than

men in the same age group. The pain is usually

poorly localized, with the maxilla being more

frequently involved. The onset of pain is usually

sudden and most patients link it to a previous

dental treatment. The pain may be localized to a

small region or may affect the entire face. It is

persistent in nature and is described as deep,

diffuse, burning, or sharp in nature.

The pain may vary in intensity over periods of time

and it does not affect sleep patterns of affected

patients. Most studies have linked the condition to

depression and stress disorders. Exacerbation of

pain during periods of stress has also been

reported. The clinical exam is completely

unremarkable and no anomalies are identified in

imaging studies.

Diagnosis

A thorough medical and dental history, along with

both a complete clinical exam and imaging studies,

are usually required. In some patients, a

psychological assessment may also be warranted.

The diagnosis of atypical facial pain is one of

exclusion and is made only when all other potential

causes of pain have been ruled out.

Management

In a small percentage of affected individuals, the

condition may resolve spontaneously.

Psychotherapy is an important component in the

management process. Opioid analgesics and

tricyclic antidepressants are usually used for

treatment purposes. When medical treatment fails

to provide pain control, numbing of the potential

nerve may be achieved through surgical

intervention.

Atypical Odontalgia

Atypical odontalgia is a type of atypical facial pain

that is localized to a small area of the alveolus or

involves an entire quadrant.

The presenting patient will have a long history of

dental procedures including several extractions in

the affected area, all in an attempt to alleviate

pain. Once other nonodontogenic causes of pain

have been excluded, a diagnosis of atypical

odontalgia can be established.

BURNING MOUTH SYNDROME

Burning mouth syndrome is an oral sensory

neuropathy. It is a complex disorder that affects

the sensory nerves transmitting information about

pain, texture, and taste. The name of this condition

may be misleading in some instances, since the

burning sensation is not seen in all cases.

Pathogenesis

The cause of burning mouth syndrome remains

unknown. While there are several theories that try

to explain the process, the most popular one

indicates that the relaying ability of the chorda

tympani nerve is disturbed resulting in pain and

the altered sensations.

Clinical Features

Burning mouth syndrome is usually seen in

postmenopausal women. Only about a third of the

patients that report with this condition are men.

The onset of burning mouth syndrome is rather

sudden. Patients usually link an ongoing event in

their lives with this condition such as stress, a

dental procedure, or initiation of medical

treatment.

Tumors of neural origin, namely, traumatic

neuromas and schwannomas, have also been

reported to cause pain. If obvious expansion is

not identified in the area of concern, imaging

studies may be necessary to identify the lesion.

Once the benign nature of the neoplasm has

been established following biopsy, complete

excision is the preferred course of treatment.

Pain is a frequent feature with several malignant

neoplasms. If no clinical expansion is noted,

imaging studies can be beneficial. A biopsy is

done to identify the type of malignancy. Once the

origin of the neoplasm is known, appropriate care

can be provided.

Complaint of a burning sensation, especially

involving the tongue is frequent. Other common

sites of involvement include the palate and lips.

Pain usually occurs bilaterally and has a waxing and

waning phase. Most patients report a progressive

increase in pain as the day goes on. It does not,

however, disturb sleep patterns. Consumption of

certain forms of food, such as acidic or spicy, may

exacerbate the burning sensation. The pain may

also be accompanied by an altered textural

component or taste sensation. Complaint of

sensations of swelling and roughness, or a feeling

of hypersalivation or xerostomia, are common.

Taste alteration includes a history of a metallic

taste. Occasionally the taste may be described as

salty or bitter.

Diagnosis

A thorough history with clinical evidence of local or

systemic disease is usually sufficient for diagnosis.

A large population of patients have already seen

numerous physicians for this problem and have

been scanned for many possible systemic or neural

disorder.

Management

Unfortunately, there is no cure for nerve disorders.

For most people, just knowledge of the fact that

this is a common benign disorder is enough for

relief. Such news may, however, be devastating for

a small population. While several treatment

modalities have been tried, such as

antidepressants, antipsychotics and some forms of

vitamins, none of these have been proven

scientifically to have any effect on the condition.

Low doses of clonazepam, an anti-seizure

medication, has recently shown some

improvement in the pain component of this

process. The pain is not completely eliminated,

however, but it does become more bearable for

the patient.

BENIGN AND MALIGNANT

TUMORS

Benign neoplasms of the head and neck region

may elicit pain when they grow large enough to

compress against the sensory nerves.

Page 10

Benign Salivary

Gland Neoplasm

Source: www.jcda.ca

ORIGINATING FROM PAKISTAN, DR. KIYANI WENT TO RIPHAH

UNIVERSITY FOR THEIR 5-YEAR DENTAL SCHOOL PROGRAM.

GRADUATING WITH A 4.0 GPA, SHE CAME TO THE OHIO STATE

UNIVERSITY IN ORDER TO FURTHER HER STUDIES FOCUSING ON ORAL

AND MAXILLOFACIAL PATHOLOGY. SHE PLANS TO TAKE THE

INFORMATION SHE LEARNS BACK TO PAKISTAN FOR BOTH

DIAGNOSTIC AND TEACHING PURPOSES.

HER CURRENT RESEARCH STUDIES AS A FELLOW AT OSU

INVOLVE EVALUATING THE ORAL CHANGES ASSOCIATED WITH

GASTROINTESTINAL DISEASES.

DR. AMBER KIYANI CAN BE CONTACTED

AT: KIYANI.1@OSU.EDU

post-test instructions - answer each question ONLINE

- press “submit”

- record your confirmation id

- deadline is March 21, 2014

d i r e c t o r

john r. kalmar, dmd, phd

kalmar.7@osu.edu

a s s i s t a n t d i r e c t o r

karen k. daw, mba, cecm

daw.37@osu.edu

channel coordinator

rachel a. flad, bs

flad.4@osu.edu

SUBMIT

ONLINE

SUBMIT

ONLINE

1 T F Temporomandibular joint disorders are

characterized by pain, noises from the joint

and restricted jaw movements.

2 T F Myofascial pain can include tinnitus,

dizziness, and syncope.

3 T F Magnetic resonance imaging plays no role in

diagnosing inter-articular derangement.

4 T F Burning mouth syndrome always presents as

a burning sensation of the tongue.

5 T F Studies have not linked atypical facial pain to

injury to the trigeminal nerve.

6 T F Pain attacks in trigeminal neuralgia can be

elicited by contact with a trigger zone and

are usually located on cutaneous sites.

7 T F

Rheumatoid arthritis with

temporomandibular joint involvement may

impede the normal growth process in

children.

8 T F Glossopharyngeal neuralgia is caused by

nerve damage following an infection with

the varicella zoster virus.

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