2014 self-study course one course

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ABOUT this FREQUENTLY asked COURSE… QUESTIONS… Q: Who can earn FREE CE credits? . READ the MATERIALS. Read and review the course materials. A: EVERYONE - All dental professionals in your office may earn free CE contact . COMPLETE the TEST. Answer the credits. Each person must read the eight question test. A total of 6/8 course materials and submit an questions must be answered correctly online answer form independently. for credit. us . SUBMIT the ANSWER FORM Q: What if I did not receive a ONLINE. You MUST submit your confirmation ID? answers ONLINE at: A: Once you have fully completed your p h o n e http://dent.osu.edu/sterilization/ce answer form and click “submit” you will be directed to a page with a 614-292-6737 . RECORD or PRINT THE unique confirmation ID. CONFIRMATION ID This unique ID is displayed upon successful submission Q: Where can I find my SMS number? of your answer form. t o l l f r e e A: Your SMS number can be found in the upper right hand corner of your

1-888-476-7678 monthly reports, or, imprinted on the back of your test envelopes. The SMS number is the account number for ABOUT your your office only, and, is the same for f a x FREE CE… everyone in the office. 614-292-8752 Q: How often are these courses . TWO CREDIT HOURS are issued for available? successful completion of this self- A: FOUR TIMES PER YEAR (8 CE credits). e - m a i l study course for the OSDB 2014-2015 [email protected] biennium totals. . CERTIFICATE of COMPLETION is used to document your CE credit and is mailed to your office. w e b . ALLOW 2 WEEKS for processing and www.dent.osu.edu/ mailing of your certificate. sterilization Page 1 OROFACIAL 2014 The purpose of this study is to introduce oral health care professionals to course 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 one they should seek appropriate care. INTRODUCTION Pain in the orofacial region is a common symptom of patients seeking care in dental clinics. In a majority of patients, the pain is odontogenic in origin and is relatively easy to diagnose and alleviate. Diagnosis and treatment of nonodontogenic is more complex, especially when no clinical and radiographic changes are identified. Affected patients have usually seen multiple Source: www.mdguidelines.com specialists and spent a significant amount of money on imaging and the surrounding bone and soft other studies. Typically, they are in tissues. This condition is common, extreme discomfort and vexed reported by 40-60% of the adult because no one seems to know population. Pain, limited opening, what is wrong with them. clicking and popping noises from the joint, and difficulty in In this continuing education course, mastication are common symptoms. we will discuss the following types of orofacial pain: Temporomandibular joint disorder is defined as a musculoskeletal, • Temporomandibular Joint rheumatological, psychogenic, Disorder neuromuscular, and functional • Masticatory Myofascial Pain disorder. There is a lot of controversy • Intra-Articular Derangement concerning the pathogenesis of the • Osteoarthritis process. Recent advances in the field written by • Rheumatoid Arthritis of imaging have allowed for better amber kiyani, dds • Trigminal understanding of joint function. This • Glossopharyngeal Neuralgia has led most authors to agree that • Postherpetic Neuralgia this is a multifactorial and complex • edited by disorder, rather than just a single • condition. rachel a. flad, bs • Benign and Malignant Tumors karen k. daw, mba, cecm THEORIES OF PATHOGENESIS TEMPOROMANDIBULAR Stress JOINT DISORDER Continued emotional stress can cause prolonged contraction of the Temporomandibular joint disorder is facial muscles and the induction of a broad term that encompasses any disorder of the temporomandibular joint, muscles of mastication, and Page 2 (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 Source: www.mouthhealthy.org chemical mediators that draw inflammatory cells to the joint space. These inflammatory cells have Classification of Temporomandibular Joint the ability to cause significant damage to the joint Disorders architecture. Genetic Factors • Articular Disorders: • Osteoarthritis Genetic marker studies have implicated that • Trauma certain genes are involved in the pain • Infectious Arthritis transmission pathway. These genes have the • Iatrogenic ability to interfere with pain reception and • Crystal Arthropathies processing, that may in turn, result in • Rheumatoid Arthritis hyperalgesia. One of the genes described with this • Psoriatic Arthritis process is catechol O-methyltransferase, or COMT. • Ankylosing Spondylitis Patients with temporomandibular joint disorders • Myogenous Disorders: have been reported to exhibit dysregulation of • Myofascial Pain this gene, and consequently, a lower threshold of • Acute Muscle Strain pain tolerance. • Muscle Spasm Psychogenic Factors • • Myotonic Dystrophy Cortical brain scans of patients with temporomandibular joint disorders show striking Clinical Features similarities to patients with other chronic pain disorders. Scientists speculate that this suggests a Temporomandibular joint disorders are usually disturbance in the pain processing mechanism in seen in individuals between 20 and 40 years of the trigeminal ganglion. Patients with muscular age. Women are more commonly affected than pain disorders rarely have any anatomical men. Unilateral pain is a common presenting abnormalities. They are considered to be “centrally symptom. The pain is commonly paroxysmal, sensitized,” meaning that the nerves in the brain poorly localized, and usually dull or aching in are transmitting faulty pain signals. nature. It can be elicited by simple contact or Controversial Theories movement of the joint. Radiation of the pain to the pre-auricular area, ears, periorbital region, or Some studies state that bruxism, clenching, and to the angle of mandible is common and may also other parafunctional habits are considered to be be accompanied by limited jaw opening that can detrimental to the joint structure. Similarly, other cause difficulties in eating and talking. studies link fluctuating estrogen levels to the increased frequency of temporomandibular joint disorders in females.

Page 3 Deviation of the jaw towards the affected side Arthroscopy is the insertion of a small camera may also be observed. Locking of the jaw may through a minimally invasive incision to directly either occur at a closing position with inability to visualize the joint. Problems such as synovitis and open the mouth or at an open position with perforation can be detected by this technique. inability to close the mouth. Popping, clicking and This technique is also employed for curative grating are common descriptions of the sound purposes. generated by the joint during opening or closing. The symptoms are usually worse in the morning, Temporomandibular joint disorders can be especially in patients with nocturnal broadly classified as articular or myogenous parafunctional habits such as bruxism and disorders (please refer to the list on Page 3). clenching. In more severe cases, , Although each disorder has a unique etiology and reduced hearing, ringing of the ears, dizziness, management regime, we are only able to discuss and pressure behind the eye may also be noted. the most common ones in the sections below.

Diagnosis MASTICATORY MYOFASCIAL Diagnosis of temporomandibular joint disorder is PAIN dependent on a thorough history and clinical examination. Imaging studies would also be Myofascial pain disorder can be defined as the beneficial and, on occasion, may be necessary. tenderness of the masticatory muscles involved in While obtaining patient history, a detailed jaw closure movements. It is one of the most description of the nature of pain with common temporomandibular joint disorders and exacerbating and relieving factors should be the second most frequent cause of orofacial pain. recorded. Information concerning parafunctional habits such as clenching and grinding of teeth Clinical Features should also be documented. Myofascial pain is characterized by a unilateral, Clinical examination allows for detection of joint dull, aching sensation that varies during the noises during opening and closing movements, course of the day. The pain can be elicited measurement of mandibular movements through a trigger point located on the muscle, (including incisal opening), lateral movements fascia, or tendon. The pain does not interfere with and protrusion, and palpation of the masticatory sleeping patterns, but it may be aggravated by muscles. The results of a clinic examination can certain types of jaw movements. It may also be rule out odontogenic and other causes of accompanied by tinnitus, dizziness, and pain orofacial pain. radiating to the oral cavity, ear, and neck region. Muscles are usually stiff and tender on palpation. Imaging studies are usually helpful in making a Imaging studies exhibit no evidence of anatomic definitive diagnosis. While panoramic radiographs pathology. Non-invasive management is and facial views may serve as helpful screening sufficient in most cases. tools, computed tomography is the gold standard for bony abnormalities. Advances in the MANAGEMENT technology allows for a three-dimensional and high resolution imaging of the Reassurance temporomandibular joint with low radiation exposures. For soft tissue changes, magnetic Patients are provided with a detailed description resonance imaging (MRI) is useful. This technique of the disease process, highlighting the role of allows for muscles, ligaments, and the vascular emotional stress and parafunctional habits. This structure to be evaluated. encourages patients to reduce these elements from their lives in order to improve their health.

Page 4 Rest Behavioral Approaches

Patients are instructed to limit jaw movements Relieving stress from life is an important step and are discouraged from extreme mechanical towards rehabilitation. For this purpose, movements such as yawning, laughing, and counseling, relaxation techniques, and stress clenching. Patients are also advised to refrain from management have shown some positive results. potential jaw damaging habits such as chewing gum, nail biting, or pencil chewing. Physiotherapy

Heat Massaging, manual manipulation, ultrasonography, and iontophoresis allow for Heat application to the affected area is beneficial retraining of the masticatory muscles and have in alleviating pain. The heat can be applied using a proven to be effective in patients with heating pad, hot towel, hot water bottle, or temporomandibular joint disorders. Numerous through more advanced techniques such as passive motion devices are also available ultrasound and short wave diathermy treatments. commercially. These devices serve as the initial step toward rehabilitation by providing protection Medications to the traumatized region, reducing pain and inflammation, and permitting limited jaw In acute stages of the disease, a 2-week course of movements. nonsteroidal, anti-inflammatory drugs may be beneficial in alleviating symptoms. Muscle relaxants (cyclobenzaprine), anxiolytic agents (diazepam, prazepam, and clonazepam), (gabapentin), or opioid are usually the next course of action. These drugs are used sparingly to limit dependency. Tricyclic (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 INTRA-ARTICULAR replacement of missing teeth can restore optimal DERANGEMENT occlusion and masticatory function. Intra-articular disk derangement is a category of Jaw Appliances temporomandibular joint disorder that includes anterior disk displacement, with and without These devices are made from acrylic and worn as reduction. Displacement of the orthodontic retainers or removable partial temporomandibular joint disk from its rest dentures. They come in a variety of shapes and position can result in significant joint dysfunction. forms. These appliances are designed to protect the masticatory muscles from harmful Clinical Features movements, such as clenching and bruxism, during sleep. They also make patients more aware Anterior disk displacement with reduction of their parafunctional habits and encourage them describes the displacement of the disk during to stop. closure; on opening, the disk returns to its original position with a “popping” sound. Page 5

Pain is not a frequent finding, especially in the cases, intra-articular injections of steroids may be earlier stages of the process. Deviation of the beneficial. Surgery is the only option in patients mandible towards the affected side is also noted. that are unresponsive to treatment. The situation may worsen over a period of time resulting in intermittent locking of the jaw. RHEUMATOID ARTHRITIS

Anterior disk displacement without reduction is Rheumatoid arthritis is an autoimmune disease characterized by pain, limited jaw opening, and that causes chronic inflammation of the joints and intermittent locking of the jaw. Locking of the jaw surrounding tissues. Most patients with is the result of the disk acting as a mechanical temporomandibular joint involvement have obstruction to condylar movement. complaints of pain, swelling, and limited jaw

movements. In children, temporomandibular joint Diagnosis involvement may impede the normal growth A thorough medical history, complete medical process. exam, and imaging studies are required for establishing diagnosis. MRIs are usually employed Rheumatoid arthritis is a generalized process to perform scans in both open and closed involving multiple joints at one time. This usually positions of the jaw. Disk displacement can be helps in establishing diagnosis. In earlier stages of visualized with MRI techniques along with the the disease, no changes in imaging studies are degenerative changes of the condyle. Arthroscopy identified. In later stages, condylar destruction may also prove beneficial at times and it can be may be noted. Medical management and employed for both diagnostic and treatment biomechanical alteration of the joint may help in purposes. alleviating symptoms. In non-refractory cases, surgical intervention becomes necessary. Management Anterior disk displacement with reduction is relatively easier to treat. The condition can usually be controlled using non-invasive techniques such Trigeminal neuralgia is a as rest, heat application, behavioral modifications, characterized by episodes of severe pain in the occlusal appliances, and physiotherapy. In some facial region originating from the . instances nonsteroidal inflammatory drugs and Pain can be elicited by contact with a trigger zone, muscle relaxants may be employed. a site usually located on cutaneous skin. It is a

relatively rare condition, affecting about 6 of every In patients with anterior disk displacement 100,000 individuals each year. The disorder without reduction, intra-articular steroid injections appears at a higher frequency in individuals with and arthrocentesis may be helpful. multiple sclerosis.

OSTEOARTHRITIS Pathogenesis Osteoarthritis is a degenerative joint disease that may result from trauma, , previous joint Compression of the trigeminal nerve in pons is surgery, and metabolic disorders. Osteoarthritis of attributed as the potential cause of this condition. the jaw tends to affect women between 30 and 40 It is postulated that compression causes years of age. Pain, limited mouth opening, and demyelination of the nerve (damage to the myelin deviation of the mandible towards the affected sheath) that may result in erratic nerve activity. side are some of the common symptoms. The joint may also produce gritty sounds on movement. Clinical Features

Imaging studies can usually identify the Trigeminal neuralgia usually occurs in individuals degenerative changes in the cartilage and bone. over 40 years of age. Women seem to be affected Most patients can be kept comfortable using non- steroidal anti-inflammatory drugs. In more severe Page 6 more commonly than men. The right side of the significant side effects, they are frequently not well face is more frequently involved. Either of the three tolerated by patients. Surgical intervention is an branches of trigeminal nerve may be affected. In option for patients who are either unresponsive to rare instances, more than one branch may be medical treatment or can no longer tolerate it. involved. Microvascular decompression, an open surgical procedure that allows for placement of a barrier Pre-trigeminal neuralgia is a term used to refer to between the offending vessel and the trigeminal the dull aching pain that appears before the onset nerve, has shown the most efficacy. Gamma knife of pain attacks. It is seen in over 18% of affected radiosurgery and radiofrequency rhizotomy may patients. This is the earlier form of the disease that also be used. Local glycerol injections may also shows significant response to the use of provide a few months of relief in non-refractory carbamazepine. cases.

The pain associated with trigeminal neuralgia is GLOSSOPHARYNGEAL often described as electric shock or lancinating. An obvious trigger point can be identified in a NEURALGIA significant number of patients. It is most Glossopharyngeal neuralgia is a pain disorder commonly located on the nasolabial fold, the characterized by paroxysmal attacks of severe pain vermillion of the lip, periorbital region, or the along the course of the glossopharyngeal nerve midface. The initiation of the pain can be a result of following activation of a trigger zone. This contact with the site, motions of mastication, and condition is extremely rare involving less than 1 even exposure to cold wind. The pain may last person per 100,000. In some instances from a few seconds to an hour. After the activation glossopharyngeal neuralgia may occur in of the trigger zone, the pain cannot be elicited for combination with trigeminal neuralgia or involve a small period of time. This interval is known as the branches of the vagus nerve. refractory period. Due to the intensity of the pain, it is not uncommon for patients to place their Pathogenesis hands over the site. Twitching of the muscles may be noted during the pain attack. Excessive Like trigeminal neuralgia, the pain is caused by lacrimation and an intense headache usually compression of the glossopharyngeal nerve by the follows the attack. ectopic branches of the superior cerebellar artery in pons. The compression allows for demyelination Diagnosis of the nerve that in turn impedes the ability of the glossopharyngeal nerve to inhibit pain signals. The diagnosis is made on characteristic . Imaging studies may help in Clinical Features identification of the responsible vessel. Glossopharyngeal neuralgia is frequently Management encountered in patients between the ages of 40 and 60 and shows a female sex predilection. In rare cases, spontaneous resolution of the Common sites of involvement include the ear, symptoms has been reported. Topical application infra-auricular area, tonsil, base of tongue, and the of capsaicin, a product derived from chilies that oropharynx. Trigger zones are usually not located has the ability to induce partial numbness, may be on cutaneous sites. The pain may be elicited by used to alleviate symptoms. Topical therapy swallowing, talking, chewing, or yawning. Once provides limited pain control and systemic the trigger zone is activated, the pain attacks can treatment is usually necessary. Carbamazepine is last anywhere from a few seconds to several preferred, however, other anticonvulsants like minutes. The pain associated with phenytoin and gabapentin, may also help with glossopharyngeal neuralgia has been described to symptoms. Trigeminal neuralgia is a chronic pain be sharp and deep in nature. Even between pain disease and requires medication to be taken on a attacks, a dull sensation in the region may persist. long-term basis. Since most of these drugs have Page 7 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 on the Face Source: www.cdc.gov controlling pain symptoms in patients with glossopharyngeal neuralgia in comparison to Diagnosis those with trigeminal neuralgia. For non-refractory History of shingles at the site of pain is necessary cases, surgery is treatment of choice. Microvascular to make the diagnosis of postherpetic neuralgia. decompression, intracranial and radiofrequency Viral cultures or antibody measurements may also rhizotomies, and stereotactic radiosurgery are help in confirming diagnosis. MRIs can identify some of the surgical techniques employed. some lesions associated with the virus in the brain stem. POSTHERPETIC NEURALGIA Management The varicella zoster virus is transmitted through air droplets and causes chickenpox. This is Use of antivirals at the onset of infection can help characterized by fever, malaise, pharyngitis, limit the course of pain. Topical and systemic rhinitis, and a rash that eventually evolves into analgesics, antidepressants, and anticonvulsants vesicles. The vesicles heal by crusting and the have been reported to show some improvement in infection usually heals within two weeks. Adults symptoms. have more severe symptoms than children. Prevention Following the initial infection, the virus moves up through the nerves into the spinal ganglion and A vaccine is now available and is only approved for remains latent until reactivation. In most cases, the individuals over 50 years of age to prevent the virus may remain latent until the patient is 50 years zoster infection. of age or older. The reactivated version of the virus is referred to as herpes zoster. It is responsible for ATYPICAL FACIAL PAIN shingles, the painful eruptions along the course of a dermatome. Usually only one dermatome is Atypical facial pain is described as persistent affected at any time. Most resolve chronic pain of undetermined origin that cannot completely within 10 days. For about 15% of the be classified as any other cranial nerve neuralgia. affected population, chronic pain may persist at The condition is also referred to as atypical facial the site of infection. This pain is neural in origin neuralgia, chronic idiopathic facial pain and and is referred to as postherpetic neuralgia. It is psychogenic facial pain. thought to be a result of damage to the nerve by the virus. The pain is severe in intensity and has Pathogenesis been described as burning, throbbing, aching, or stabbing. Spontaneous recovery may occur Some studies have linked the pain disorder to a anytime within a period of 12 months. In rare neuropathic origin, suggesting injury to branches cases, the pain may persist for several years. of the trigeminal nerve as being the etiological factor.

Page 8 Others have linked the disorder to psychological The presenting patient will have a long history of illness implicating the pain to be psychosomatic in dental procedures including several extractions in origin. the affected area, all in an attempt to alleviate pain. Once other nonodontogenic causes of pain Clinical Features have been excluded, a diagnosis of atypical odontalgia can be established. Women between the ages 40 and 60 appear to develop this condition at a higher frequency than BURNING MOUTH SYNDROME men in the same age group. The pain is usually poorly localized, with the maxilla being more Burning mouth syndrome is an oral sensory frequently involved. The onset of pain is usually neuropathy. It is a complex disorder that affects sudden and most patients link it to a previous the sensory nerves transmitting information about dental treatment. The pain may be localized to a pain, texture, and taste. The name of this condition small region or may affect the entire face. It is may be misleading in some instances, since the persistent in nature and is described as deep, burning sensation is not seen in all cases. diffuse, burning, or sharp in nature. Pathogenesis The pain may vary in intensity over periods of time and it does not affect sleep patterns of affected The cause of burning mouth syndrome remains patients. Most studies have linked the condition to unknown. While there are several theories that try and stress disorders. Exacerbation of to explain the process, the most popular one pain during periods of stress has also been indicates that the relaying ability of the chorda reported. The clinical exam is completely tympani nerve is disturbed resulting in pain and unremarkable and no anomalies are identified in the altered sensations. imaging studies. Clinical Features

Diagnosis Burning mouth syndrome is usually seen in A thorough medical and dental history, along with postmenopausal women. Only about a third of the both a complete clinical exam and imaging studies, patients that report with this condition are men. are usually required. In some patients, a The onset of burning mouth syndrome is rather psychological assessment may also be warranted. sudden. Patients usually link an ongoing event in The diagnosis of atypical facial pain is one of their lives with this condition such as stress, a exclusion and is made only when all other potential dental procedure, or initiation of medical causes of pain have been ruled out. treatment.

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. Page 9 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 , are common. Taste alteration includes a history of a metallic taste. Occasionally the taste may be described as Benign Salivary Source: www.jcda.ca salty or bitter. Gland

Diagnosis Tumors of neural origin, namely, traumatic neuromas and schwannomas, have also been A thorough history with clinical evidence of local or reported to cause pain. If obvious expansion is systemic disease is usually sufficient for diagnosis. not identified in the area of concern, imaging A large population of patients have already seen studies may be necessary to identify the lesion. numerous physicians for this problem and have Once the benign nature of the neoplasm has been scanned for many possible systemic or neural been established following biopsy, complete disorder. excision is the preferred course of treatment.

Management Pain is a frequent feature with several malignant . If no clinical expansion is noted, Unfortunately, there is no cure for nerve disorders. imaging studies can be beneficial. A biopsy is For most people, just knowledge of the fact that done to identify the type of malignancy. Once the this is a common benign disorder is enough for origin of the neoplasm is known, appropriate care relief. Such news may, however, be devastating for can be provided. 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, ORIGINATING FROM PAKISTAN, DR. KIYANI WENT TO RIPHAH however, but it does become more bearable for UNIVERSITY FOR THEIR 5-YEAR DENTAL SCHOOL PROGRAM. the patient. 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 BENIGN AND MALIGNANT DIAGNOSTIC AND TEACHING PURPOSES. TUMORS HER CURRENT RESEARCH STUDIES AS A FELLOW AT OSU INVOLVE EVALUATING THE ORAL CHANGES ASSOCIATED WITH Benign neoplasms of the head and neck region GASTROINTESTINAL DISEASES. may elicit pain when they grow large enough to DR. AMBER KIYANI CAN BE CONTACTED compress against the sensory nerves. AT: [email protected]

Page 10 post-test instructions - answer each question ONLINE - press “submit” - record your confirmation id - deadline is March 21, 2014

Temporomandibular joint disorders are 1 T F characterized by pain, noises from the joint and restricted jaw movements.

Myofascial pain can include tinnitus, 2 T F SUBMITdizziness, and syncope.

Magnetic resonance imaging plays no role in 3 T F diagnosing inter-articular derangement.

Burning mouth syndrome always presents as 4 T F ONLINEa burning sensation of the tongue.

Studies have not linked atypical facial pain to 5 T F injury to the trigeminal nerve. d i r e c t o r john r. kalmar, dmd, phd [email protected] Pain attacks in trigeminal neuralgia can be 6SUBMIT T F elicited by contact with a trigger zone and a s s i s t a n t d i r e c t o r are usually located on cutaneous sites. karen k. daw, mba, cecm [email protected] Rheumatoid arthritis with temporomandibular joint involvement may 7 T F channel coordinator impede the normal growth process in rachel a. flad, bs children. [email protected]

Glossopharyngeal neuralgia is caused by ONLINEnerve damage following an infection with 8 T F the varicella zoster virus. Page 11