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Facial Pain - Tempormandibular Disorder Speaker Key RM Roddy McMillan IV Interviewer RM Hi, I'm Roddy McMillan. I'm consultant in oral medicine and facial pain at Eastman Dental Hospital which is part of UCLH. My talk today was on pain-related temporomandibular disorders, what we call TMD. IV What is TMD? RM Pain-related TMD is effectively pain affecting the temporomandibular joint and the associated muscles. So classically, it's going to affect the joint itself, which is either side in front of the ear, can spread from the temporal area down to the angle of the jaw and also can occasionally recruit muscles in the neck and shoulders. The key point is that there is no associated underlying significant joint pathology such as arthritis or mechanical joint problems and no associated other pathologies such as dental troubles. The pain can be acute. In other words, majority of patients who get this problem, about 80% will have pain that will last for a few days or a few weeks. 20% of people, it tends to be more of a longer term problem. Risk factors for developing TMD, classically, would be stress, anxiety, depression, sleep disturbance, chronic pains in other parts of the body such as conditions like fibromyalgia, irritable bowel syndrome, or lower back pain, for that matter, and headaches. Very commonly associated is migraine, with this particular condition. IV How is it diagnosed? RM TMD is diagnosed from the history alone. There aren't really any scans or investigations that one can conduct that will help to confirm the diagnosis. So anyone with a history of pain in the muscles of mastication, possibly spreading into the neck and shoulders, without any other identifiable cause of that pain, would be an appropriate diagnosis. If somebody presents over the age of 50 with lateral facial pain particularly affecting the temporal or the angle of the jaw area, then giant cell arthritis, or better known as temporal arthritis, is possibly a diagnosis to exclude, and one could potentially consider conducting an ESR or a CRP, because if those blood tests are negative, then they're highly unlikely going to have diagnosis of giant cell arthritis. IV Are there any treatments possible in primary care? RM The good thing about TMD is 80% of people who present with acute TMD will get better within a few days or a few weeks without any significant treatment. So simple discussion about the condition, some reassurance if possible, perhaps some analgesics, and that's probably all that's required initially. 1 About 20% of people it tends to be more of a longer term problem. These tend to be patients with comorbidities such as anxiety, depression, sleep problems, and chronic pains in other parts of the body. Also, migraines are involved there. And those patients may well require some support in terms of perhaps a referral for physiotherapy, for some education and physiotherapy exercises that the patient can conduct at home, or they may benefit from medications. The types of medications we tend to use initially as a first line would be standard chronic pain medications, prescriptions such as amitriptyline or nortriptyline would be appropriate in this case. Psychology is something which can be used, but that tends to be more of a secondary care measure, and we would normally recommend it if the initial treatments are not working. Then you would probably be best to refer into a secondary care facial pain setting. IV When should a GP refer on? RM Generally, as I said earlier, 80% of people get better without any significant intervention. So for the people that don't tend to respond to simple measures and have prolonged pain lasting longer than a three month duration, then certainly they should be referred into a secondary care pain management setting or a facial pain clinic. People that we would be happy to see in secondary care sooner than that three-month period would be people with significant comorbidities such as anxiety, depression, sleep disturbance, and chronic pains in other parts of the body. These patients tend to be the ones that are more likely to develop chronic pain, and therefore it would be appropriate in those circumstances to refer them a little bit sooner than the threemonth period. IV Which specialist or specialist service do GPs refer to? RM In terms of TMD, there's probably quite a selection of different services one can refer to. I would suggest, initially, if you are within easy reach of an oral medicine unit in one of the dental teaching hospitals, then a referral to one of those services would be appropriate. There are very few specialist facial pain services in the UK, but one service is based at the facial pain service within UCLH in London, and we'd be happy to receive referrals. The local oral and maxillofacial surgery or oral surgical services can see these patients who are perhaps developing more of a mechanical problem with the jaw, such as difficulty opening the mouth wider, significant deviation when they open the mouth wide. If you don't have ready access to an oral medicine unit or a facial pain service locally, then the oral maxillofacial surgeons probably would be the next best thing. IV What is the management in secondary care? RM The management of TMD generally in secondary care would be more chronic TMD patients. So these patients follow similar sort of patterns in terms of their management compared to other chronic pain conditions. So we would normally break that into the three pillars of pain management. 2 The first pillar of pain management being vitally important, and that is regular physical exercises and relaxations conducted by the patient themselves at home. Things like swimming, walking, yoga, tai chi, meditation or Pilates. Some other physical aspects of treatment can be physiotherapists. So physiotherapy can be involved, although it tends not to be hands-on physiotherapy, more direction of the patient towards exercising themselves. Another physical therapy would be acupuncture, which has got a small amount of scientific evidence to say it's useful in TMD. Moving on from that, the second pillar of pain management is medications. The types of medications we briefly talked about earlier. Generally, the first line treatments would be tricyclic antidepressants such as amitriptyline or nortriptyline. The reality is, there's very little in the way of really highly effective medications for the management of chronic pain, specifically TMD in this case. The third pillar of pain management is clinical psychology, and as with many other chronic pain conditions, clinical psychology can be very, very helpful in terms of enabling the patient to self-manage their condition and reduce the negative impact that the pain's having on their quality of life in spite of the pain being present there in the background. IV What is the prognosis? RM The prognosis of TMD is quite variable. At least 80% of patients who develop acute TMD will get better and dissipate on its own. Around about 20% of patients tend to have more prolonged symptoms. So either the pain is there all the time or it's there more frequently than not. In terms of the condition itself, we cannot promise patients that, with chronic TMD, that we'll be able to give them any treatments that will completely remove all of the symptoms... in other words, cure their pain. But we certainly can help them to self-manage their condition and to improve their quality of life in spite of the pain being present in the background. IV Where can GPs find out more? RM GPs can find out quite a bit of information on the Eastman Dental Hospital facial pain website. This is part of the main UCLH website and can be found quite easily on the internet. This has a lot of facilities on it, including details on how to contact the department and refer patients. And also, it has patient information leaflets and advice sheets that can be downloaded and given out to patients in primary care. 3