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Ok, great. I think we'll get started. So you're not here for too long. Um So for people who haven't been to the other lectures, um My name is Jan V. I'm a max fax specialty doctor with a background in dentistry and then medicine. Um This is the third uh lecture in our series. It's the final one and we're looking at all of the max fax conditions that basically don't fit in. Uh The first one we had was on facial trauma and the second one was infections. This one we're gonna cover quite a range of topics. Um So just let me know if there are any questions as we go along in the message box, if there are any um concerns or anything else you want to raise, just let me know. Um I'm sorry, it's a lot of information in this one. But hopefully we'll just give you an overall view on what kind of things to look out for when you're either in a GP practice or in the emergency department. Um Fine. So we'll get started. So what are we gonna cover today? So we're going to look at um salivary glands So the pathology lesions with the salivary, gland, oral lesions that will cover ulcers, lumps and bumps and any swellings, facial pain. Um and then TMJ pathology and kind of diagnosing problems with the TMJ. So why go through this? Uh often patients present to GP surgeries with oral and facial problems. Um especially because it's much easier to get a GP appointment than a dental appointment. And often people don't realize that dentists look at soft tissues as well as teeth. So they'll often go to their GP surgery. It's also important to know when to escalate this further and refer to the appropriate specialist and when it might be a systemic issue or a local issue and how you might be able to diagnose and treat it. So we'll start off with salivary glands. So just some basic anatomy to begin with. So we have three pairs of major salivary glands. The first one is the parotid which is located just anterior to the ear. Um then, then we have the submandibular and sublingual glands which lie just under your mandible in your neck, kind of at the top. We also have loads and loads of small salivary gland, minor salivary glands that range from everywhere in your mouth, but mainly in your lips, in inside of your lips. Um Then the important thing to remember is the parotid gland, the duct comes out in the cheek on the inside, just uh next to the upper molars and then the salivary, uh submandibular gland and sublingual glands, they open up on the floor of the mouth. So just underneath the tongue, so often people can get salivary gland stones. And that's because of the composition of saliva. It can often crystallize kind of like a kidney stone or something like that. And then it, the reason it causes problems is most people get them. They don't even know, don't realize. But if it gets stuck in this very thin duct where saliva comes out, um it can cause problems because saliva builds up behind and it can't express this stone out. Um So often patient gets patients get obstructive symptoms, so they get painful swelling, especially after meal times. And it's something called mealtime syndrome. And the reason for that is as we know, um when you eat or drink your uh salivary glands are triggered to produce more saliva. So that pressure builds up and you can get swelling and pain. This spontaneously resolves because obviously, the saliva just kind of, you don't produce as much saliva. When you're at rest, they can get single episodes. Often they're quite recurrent and they'll give you a very strong history and it's very obvious and then sometimes they can get infected and we talked about this in the previous lecture. So if you go back to that, you can have a look, um and the management and treatment of those. So in terms of investigations for stones, you can use a plain film X ray to look. So either a X ray of the jaw or the face. However, it's important to remember that some of these stones are radiolucent, similar with kidney stones and you might not see them. The gold standard is to do an ultrasound scan. So that looks at the gland itself and it can also see if there's any duct dilatation. So if there's an issue with the stone and if you want a really specific answer about the stone, you can do something called a XO gram. So that's done by a specialist um radiologist or surgeon where some dye is injected into the duct from inside the mouth, then an X ray is done. And basically that shows if there is a blockage or something that's obstructing the duct as it goes towards the gland. Obviously, if you're concerned and you don't know what's going on, you can always get a CT scan. So in terms of assessment, the most important thing is to buy manual palpation. So basically, it involves one hand on the outside of the face, one hand on the inside of the face and you rub and you see if you can feel a stone either on the floor of the mouth or in the cheek, you can also look at the ducts themselves and assess for any kind of salivary flow rate or inconsistencies. But that's quite hard to do in terms of management of these stones so often any stone under five millimeters resolves by itself. Um And we often don't do anything about them and often people don't even notice that they're there if they're larger than five millimeters and they're causing really bad symptoms, um, in, if they're really superficial. So if you can see them just underneath the duct and we've got a photo, you'll see that in a minute. They can just be excised by a Maxx or ent surgeon just under some local anesthetic. So some local anesthetics given little cut is made and the stone is expressed. If the stone is deeper inside and it's too difficult to get to, then they'll probably need surgical retrieval. And there's loads of different ways you can do that. You can go in through the duct uh with like a basket and try to get the stone out or if it's really, really deep inside, they may need actual surgery and be put to sleep for them. So I hope that made sense. Um This is just an example of a really obvious salivary stone coming from the submandibular gland. And you can see this one is really superficial. It's quite large patients definitely gonna have symptoms. And you could uh if you refer to Maxx, you can give some local anesthetic, little cut and just allow that to come out. But it has, you have to be really careful not to damage the duct underneath. So moving on. So salivary gland lumps So anyone who presents with a lump in the face, there's obviously loads of different causes and we talked about it a, a little bit in the last presentation about infections. But salivary gland lumps are normally very well localized to the parotid or submandibular region. Um A thorough history and examination is of course, needed to see how long it's been growing if there's any pain, any other symptoms. And the main thing to remember is most of these lumps are benign with salivary, gland. Malignancies are incredibly uncommon, but it's really important that we pick up on them if they do cos they don't have a very good prognosis. So they're very rare. They only pre uh present as about 1% of head and neck malignancies. And the other thing to remember is the smaller the salivary gland, the more likely that the chances that they are malignant. So to give you some figures doesn't really matter. But just so you have it in your head, in the parotid gland, 20% of lumps are malignant in the submandibular gland, 50% and in the sublingual, 85%. So more often than not, people will present with parotid masses and these are usually benign and they're in 80% of cases, something called a pleomorphic adenoma, which is a completely benign condition, but can get very large and can cause potential for malignant transformation. So most people tend to have these out either by excision of just the lump or the whole gland itself. Um just because it prevents problems in the future, but it's not like a rush to do it. It just has to be done at some point. There are loads of other tumors that can be benign or malignant and we won't go through all of them because it's not really relevant in this case. But the red flag symptoms to look out for are malignant tumors often are painful. They're fast growing and they can also, if it's in the parotid gland can cause because the facial nerve comes through, there can cause facial nerve palsy. I think if you're concerned about any of these lumps, unless the patient says it's been there for years and years and years, it's best to just do a two week wait referral to either Maxx or Ent and they can assess uh further imaging and see what's needed. But chances are, it's probably gonna be nothing to worry about, but they may need surgery in the future. So this is just a nice picture showing really two really obvious parotid gland, swellings. The thing to remember about the parotid gland is it lies here. So you get swelling, but the tail goes quite low down, so you can get a swelling further down as well. You can see this one is uh close to the ear. So it's displacing the ear as well. But as you can see from the anatomy exactly where it is, it's quite obvious that it's a salivary gland swelling. So that's it. On salivary glands. Sorry, very quick talk. You don't need to know too much about them. If there are any questions, just let me know. But otherwise we're gonna move on to the different oral lesions that you can see. And I think this one is a little bit more important because I think a lot of patients will come with kind of lumps and bumps in their mouth and they're not really sure what it is. So we're gonna go through that next. So we're gonna go through ulcers and I'm sure all of us have had an oral ulcer at some point and we know how painful they are. Um But normally we don't really seek medical attention for them. So we're gonna go through reasons people might present to the GP and often with ulcers, people do go to the GP and not to a dentist. So it's really important that you know what you're looking out for. So in terms of taking a history, there's really specific things to ask for ulcers. So we need to know the size the site. How many do they have at one time is a single ulcer or not? How long does it take for the ulcers to resolve the time between outbreaks? Do they get any symptoms before? So do they get any kind of tingling feeling? And are there any obvious triggers? So, for example, some people get ulcers when they're really stressed, they've had poor sleep or even premenstrual people get them as well. Do they have any systemic problems that can cause kind of, uh, systemic issues that cause ulcers? For example, things like Crohn's or Celiac disease or do they have problems with their bowels tummy problems, anything like that? Do they get scarring of the ulcers? And exactly what medications do they take? There are certain medications that can cause recurrent ulceration such as Nicorandil. Also, some people still use aspirin as kind of a medicine they put in and they hold it in their mouth and if they hold that in their mouth for a few minutes, it's obviously acidic and it will cause ulcers as well. The main things to be aware of are risk factors. So, are they a smoker? Do they have a heavy alcohol intake or are they a pan or beetle? Not? Sure. And obviously, if they have a history of oral cancer and then red flag features we need to look out for. So does it have an irregular border? And we'll look at some pictures where it's really obvious that there's an irregular border? Is it firm and indurated? So, is it really stiff when you press on it? Is there any cervical lymphadenopathy? Have they had any changes in sensation or weakness and all ulcers that have been present for more than three weeks without any changes? They're not getting smaller, they're not getting better should be referred. And are they painless? So if obviously, if you burn yourself, you cut yourself, you're obviously gonna know and you're gonna say that that's painful. Um And also if they have any loose teeth, so if they have loose teeth, there might be something else going on inside the bone or the gum. So if any of these red flag features are present, it's important that a two week wait referral is done to max fax or ent or whatever your local protocol is. And that's the really main thing to look out because we do. You don't wanna miss any oral cancer. So if we divide the ulcers up, so we have suspicious ulcers. So oral cancers are usually squamous cell carcinomas and they're normally very well associated with smoking pan or beaten, not chewing and an increased alcohol intake, you can see from this ulcer, it doesn't look good, it's indurated, it looks firm, it's got an irregular border. It's not very well demarcated, it's just quite large and it doesn't look like it's related to any obvious trauma or anything. What we do for all lumps, bumps, ulcers normally is if you're not sure what it is, a biopsy is done and just so you can explain to your patients how that's done. It's just you go to a Maxx Clinic, a little bit of local anesthetic is given around the tongue or cheek or wherever it is. And a small proportion is taken out local under a microscope and then we decide what to do. So, this one, obviously, I think I'd be very worried about moving on. You could have benign ulcerations. So single ulcers are very benign and they're normally traumatic. So normally it's next to like a sharp tooth or something and they just need it to be grind down. Um, and they just keep biting and biting and biting on that area. And also it can also be due to burns this ulcer. For example, I think you would probably, if you didn't, couldn't see that it was obviously a sharp tooth and the patient didn't say it. You would probably refer it, but you can see it looks a lot less suspicious than the other one. It's very clear cut. You can tell it's like a small enough area that people would bite on it. But I think what most, what we recommend to most people if you do see a sharp tooth is you go to the dentist have that sh uh tooth filed away and then if the ulcer is still there three weeks later, then it gets referred if you're worried though, obviously just refer him. So, recurrent ulceration, I'm sure we all know people who get loads and loads of mouth ulcers and the proper term for it is recurrent athous ulceration. Now, the most important thing with this is to do some investigations so often these can be linked to having iron deficiency anemia. So you need to do an FBC and iron studies, full hematinics because low B12 or FOLATE can also cause this zinc. So low zinc can cause it as well. And if you're suspecting celiac then do celiac antibodies. It's just to rule out because if there's something obvious like iron deficiency anemia, it can be treated and they won't get the ulcers anymore. Otherwise there's nothing to, unfortunately, to be really worried about. But there's also not much that we can do. Mostly we can do is symptomatic relief. So, Diam, so it's like a local, I'm sure we've all heard of that. Just a local anesthetic mouthwash. That's more mainly for symptom control. And we can also provide, um we can also prescribe steroid mouthwashes. So they're normally a tablet that you dissolve in some water. And we recommend some people depending on how often they have their outbreaks. They either take it when they have their outbreaks or they take it constantly to prevent outbreaks. But that's normally a decision made by the Max Vax team. If they're not responding to any of this, it's really impacting their quality of life. You can tell them to get rid of like trigger factors. For example, some people are just very stressed, they sleep poorly, things like that, that can cause it, it can refer to an oral medicine department. There are very few oral medicine departments, but they're really, really good at what they do and they can prescribe stronger drugs that can help to prevent ulceration. But they can't be done by normal doctors or dentist. It needs to be done through a specialist. So this is kind of a busy slide, but it just shows um the different kinds of, there's loads and loads of different kinds of recurrent ulceration. So normally they can be, they're either minor major or herpetiform. So herpetiform is not linked to herpes, but looks kind of like herpes. And most people will say that they've had it for years and years and years. It comes every few months and then it goes away. You don't really worry the minor ones so that normal a ulcers aren't normally too painful and they go away. But the major ones can be very, very painful and they're the ones that need more kind of rigorous drugs and things like that. So it's just just in interest terms to know what the difference is between all of them. So they're just big. Uh, her major ones are just bigger and they're more painful and they recur quite often. So that's everything about ulcer. So I think the main takeaway from ulcers is just any of these red flag symptoms. Anything you're worried about, just refer or the, if you're not that worried, but you also don't really know what's causing it. You can just call the patient back in 2 to 3 weeks and if it's still there, it still looks exactly the same then refer them. So we're gonna move on to different types of patches. So different colored lesions in the mouth. Now, obviously, there are loads and loads and loads of different colors that can be in the mouth. You can have white patches, red, matches mixed red and white patches and then pigmented lesions. I think the thing to remember is that unless there's an obvious cause again, most of these patches will need a biopsy and it's just deciding whether you do a normal referral, an urgent referral or a two week wait, referral, red and white patches are the most commonly premalignant or malignant lesions. Red patches are the next most common and then white patches, pigmented lesions are rarely something to worry about, but we'll talk about when they are. Um So yeah, just knowing when to do something, the patches are not usually malignant but they can be premalignant. So they have to be dealt with accordingly. So we'll go through each and of these and the differential diagnosis is that they could be so white patches. So a white patch that obviously doesn't rub off easily indicates a thickening of the epithelium. And as we all know, as doctors, if it's a white patch that does rub off easily, it's probably candida, they can be pretty malignant. So it's worth just checking them out and when no obvious cause can be found, it's called leukoplakia. So you often see that written down in places, especially in like patient diagnoses. Uh like I said earlier, a diagnosis is normally needed to rule out any premalignancy. Um The most common cause of uh white patches are, as you can see in this picture, they're normally in the inside of the cheek or the lateral borders of the tongue. And it's actually an oral manifestation of lichen planus. So most of us know lichen planus is the skin condition, but you can also get it in the mouth. And sometimes people have it in their mouth but not on their skin. Sometimes they have on the skin, not on their mouth and sometimes they can have both. So not having any skin lesions, doesn't rule this out. And it's really, really characteristic, they get like web like striations. Um but because this can also be premalignant. Normally, they do have a biopsy. They can have symptoms from this. But again, it's similar to what we said about the ulcers. It's symptomatic relief. It can be a candidal infection that's just a bit more difficult, a bit more stubborn to get rid of. Um or it can be something called frictional keratosis. And that's probably what this one is, but they will get again, need a biopsy. It's basically when you're constantly rubbing on one area, you promote thickening of the epithelium. So it shows up as a white patch, red patches. So this indicates epithelial atrophy. So the opposite of thickening and it's very suspicious for premalignancy or malignancy and requires a biopsy. Similar terminologies of no unknown origin red patch is called erythroplakia. And unless it's malignant, there are two other causes that I think is important to know. So it could be due to Candida as well. And this is a really classic case of denture related candida. You can see the red patch is so well defined to where someone's denture would sit and that's because people don't clean it, they don't take their denture out at night. This wouldn't need, it just needs something nice statin and to keep the denture out, to be honest, this is again, something that's quite common. Um And people who have it will normally know that they have it because it's a really odd phenomenon, something called geographic tongue. And it's basically you get these red patches all over your tongue and they're kind of always there, but they move around. So every time we look at the tongue, it's not exactly the same. Normally people don't have symptoms, they are completely fine. They've had it for years and years and we don't normally do anything. But if you see it for the first time or the patient just notices it, it can be worrying and they do normally have a biopsy just to rule anything else out. So, pigmented patches. So the important thing to remember about pigmented patches and we used to have a lot of referrals for this to max is it can just be normal. So if we look in this picture, people who are darker skinned can just have normal oral pigmentation and they've had it for years and years, obviously not a problem. Um And it's just really diffuse pigmentation. It can also be related to smoking. Obviously, the chemicals in smoking can cause your mouth and your teeth to go darker and then there are other uh systemic things that it could be. So, Addison's disease, I think we're all taught about. You can get pigmentation. Um Often it's something to do is um often pigmented lesions can look like this and it's normally next to a place that has a tooth or used to have a tooth. You can see this is the gingival ridge where the tooth used to be. And it's basically from when patients used to have amalgams put in. So silver fillings and the dentist slips and they get it in the gum as well and it tattoos there and you can't get rid of it. So it's there forever. And that's obviously nothing to worry about. And normally the location will help you find out where that is. If they have really poor oral hygiene, you can get black hairy tongue which isn't related to um hairy like leukoplakia that's related to HIV. So you can just get this with poor oral hygiene, really, really infrequent, obviously, because Melanoma is associated with sun exposure and you don't normally have sun exposure but it can be, can be really unlucky and you get oral Melanoma as well. So, if there is a dark patch that we're not sure what it is exactly. Um, it's worth referring it anyway, I think better safe than sorry. Um, and it's just an unusual presentation of Melanoma but it's really, really rare. So, I think that's it on different colored patches. Um, this is probably the most common thing you'll see in GP. So if you have any questions, just let me know and we can always come back to anything that's not clear. So, moving on. So we're gonna look at lumps and swellings. So da as we know, loads and loads of different things can cause lumps and swellings. The main thing to remember are the red flag features. So similar to the ulcers. So if they have associated ulceration, so a big lump inside the mouth with ulcers on top, that's worrying if it's fixed to the deeper tissues has an irregular border. Do you have any lymphadenopathy, nerve changes or sensation changes or weakness? They're in high risk areas. So basically, the way to remember high risk areas is it's normally where nicotine will pool or alcohol will pool. So it's on the lateral tongue, the floor of the mouth because a as gravity pulls it down the lips and the cheek because often pan chewers and people who chew nicotine or tobacco, sorry. Um They keep it in the inside of their cheek, previous oral cancer. And if it's rapidly growing, that's very worrying. Again, same risk factors, smoking, puncturing high alcohol intake. It's important to remember that that in most oral cancers there is a cause, but it's becoming more and more common as smoking rates decrease, that we're getting young patients that didn't have any risk factors. So it's important to just keep in the back of your mind. Don't think they're not a smoker. They can never have this still possible. Unfortunately, so again, we'll go through all the different causes. So malignant causes. So all presentations of a lump in the mouth really need to be investigated for malignancy unless there's a really obvious cause. As I said, squamous cell carcinoma is the most common can, it's normally a primary tumor, but it can be metastatic as well. Biopsy and further imaging is of course needed. This lump is of course, incredibly worrying. It's really, really irregular. It's just, it's called ulceration. It just doesn't look good at all. It's in a high risk area. Um Yeah, you would be very, very concerned with this. And then I thought just for interest sake, we should, we'll talk very briefly on how these are treated. So normally treatment of oral cancer is done with surgical excision, the lump is removed and normally with a good margin. So people often lose their mandibles, their maxillas, it's really, really aggressive surgery. They then have a neck dissection normally where the lymph nodes are removed from the neck to prevent um spread and then they can have chemo and radiotherapy afterwards. It's a really, really aggressive procedure to have. Um But unfortunately, that's the main stay of treatment for these cases. So, infection. So I think we, we all be very clear if a patient has an infection. So if we see the previous lecture, we can differentiate from the different types of infection, often has an obvious cause. They're often systemat systemically unwell. They will say I've got pain here. I've got fever. I've got this. It's really obvious when it's an infection, it's I think we're probably all aware, but you can always refer if you're unsure, take some observations, do some bloods and check. This is a really, really benign thing called a fibroepithelial polyp. So it's literally a polyp that's normally called like a little stalk or something. It's an obvious fleshy mobile lump on the gum or the mucosa. It's normally in areas where there's chronic irritation. So on like the lower lip or the inside of the tongue. So where people bite and then they keep biting and it keeps getting bigger. It's nothing to worry about. The diagnosis is normally clinical, but to prevent them becoming bigger, an excisional biopsy is done. So that's when the whole lump is taken away. Look at it under a microscope, check, it's nothing to worry about. N never really is and they're really, really characteristic. Once you've seen one, you won't forget it. You'll know exactly what it looks like. Next, we'll come on to a mucocele. So, like I was saying earlier, you have loads of minor salivary glands as well and they're mainly on the inside of your lower limb. So, if these get traumatized and you get kind of saliva coming out of them and they, they're not working very well. Basically, you can get a collection of saliva underneath the mucosa. It's often caused by trauma. So, lip biting and it's again a clinical diagnosis. It's nearly always in the lower lip inside and it's a really obvious kind of fleshy bump and it's fluctuant, you can feel almost the saliva in it. Patients will often say that oh I had one, it burst, the saliva went because the actual gland is ruined. You, they'll get recurrence and recurrence. And that's why treatment is you excise the mucoceles, the big ball of saliva. But you also try to take out the underlying gland as well to prevent um recurrence. It's nothing to worry about. They're just really annoying and they can get quite large and painful. Um Finally, we'll look at bony swellings. So normally these are sorry, spelling mistake there. The physiological outgrowth is called tori or the singular torus. And any, but any changes in appearance can be suspicious. Normally people have had this their whole life so they know about it. But if they say suddenly it's getting bigger or I've got ulcers on it or something. You worry and they're normally either a palatal torus. So it's in the top of the palate, a hard bony lump in the midline. Or you have the symmetrical bilateral swelling in the mandible on the inside. They're really combination. So sometimes you see them and you're like, oh, what is that? But the patient will normally say I've had that for years and years and all dentists will know to look at these. But again, nothing to really worry about. They're only removed if they cause real problems, but very, very rarely. And that's it on lumps and bumps and ulcers and things in the mouth. So just let me know if there are any questions again. Hopefully, it's all pretty straightforward and the only thing to know again is when to refer, when not to refer. Um We're gonna, gonna talk really briefly about facial pain as you can appreciate. Facial pain is a massive topic in itself. There's loads and loads of different causes and we're not even going on to headaches and things just looking at the face, but we'll run through them really quickly and just how we can diagnose and treat them. So, obviously, dental pain really, really common people will say my tooth is hurting, it can be well localized or poorly localized. So it's difficult to tell sometimes, but it's normally triggered by like eating hot, cold or sweet foods. Um I'm sure we've all had some sort of dental pain. We know what it feels like. We'd give some analgesia refer to a dentist to deal with it. Next T MJD. So we're not gonna talk about this too much because I wanna talk about it in the next few slides, but basically covers all TMJ disorders or dysfunction, myofascial pain. Again, we're gonna cover that in a second, but it's basically related to TMJ problems and it's all mus muscles and mastication pain. We'll talk about how to deal with that. People can get sinus or nasal problems. Um So worse when bending down, they have like a nasal drip or they have blocked nose again, if, if there's any red flag symptoms, they need to be referred to ent, but otherwise just manage as you normally do trigeminal neuralgia. So that's well localized pain to one of the distributions of the trigeminal nerve and it causes sharp shooting pain like lightning type pain, they say lasts for a few seconds and it's often described as the worst, worst pain ever. It's a clinical diagnosis, but all patients need an MRI just to rule out a space occupying lesion or in younger patients. MS treatment is normally through the use of anticonvulsants such as carBAMazepine. And then sometimes people use neuropathic agents, but they don't tend to work very well. Or if there's a cause that's found, then they can have either uh decompression of the nerve or they can have some cryotherapy to it, but that's all done. Specialist atypical facial pain is normally a diagnosis of exclusion and the way to kind of tell when it's normally related to psychological issues. So people often have a history of depression or anxiety and it's um not to stereotype people, but it's normally uh people who have um very vague symptoms, it doesn't normally affect their sleeping or their eating and because they're not aware of it then, but it often doesn't like match with anatomy. It crosses like the midline doesn't follow nerve distributions. It's just all a bit strange sounding and you can't find any um, clinical examination like findings. Normally these patients need reassurance, maybe referral to psychology or antidepressants if you can't get control of anything else. Burning mouth syndrome again, gets a really bad name because it, it's very, it's unfortunately, mainly people get it when they're middle aged women who are menopausal peri or postmenopausal. And they get really specific burning of the mouth. And they can also get dry mouth and altered taste like a metallic taste in their mouth. Unfortunately, really common, but it is normally transient and it does go away. Normally after menopause finishes, um, the thing to do with this is just to, again, rule out any Hema hematinic deficiencies, iron b12, folate zinc, just check there's nothing else going on. If there's not, it's normally reassurance. But you can also give things like antidepressants again to try to help control the pain and finally temporal arthritis. I think we all know about that. So, pain located to the temples can be a medical emergency because it can cause blindness. It needs to be urgently investigated and treated with steroids. So it's a real run through facial pain. But it's just simple things that makes it, that are a bit more difficult to diagnose. I think we all talked about different headaches and things, but it's hard to imagine them. So the next I'm gonna talk about TMJ pathology and this is often people come to see their GPS with this and it's really common. But first of all, we're gonna talk about TMJ dislocation. I hope you won't see this in GP, you'll normally see this in the emergency department because it's really, really distressing for patients. So just some basic anatomy. So the TMJ joint temporomandibular joint is where the temporal bone of the skull. So this bit and the fossa within it and the mandible and the condyle. So this bit sits in the fossa that's normally what happens. And when you open and close your mouth, the jaw moves slightly forward to here and then it goes back. Sometimes people can get dislocations. It's when the whole jaw joint comes out and it actually ends up this bit ends up here. Um Because of this bump, this articular tubbi tle or eminence, it can't get back into place and it can be incredibly distressing for patients. What you have to do is they normally come to A&E you need to treat them sooner rather than later before the muscle spasm and it's really difficult to get into place. You give them some analgesia, you give them sitting in a chair with their head resting back. You get one person behind you supporting the head. Like you can see in this photo, you stand in front of the patient with gauze and on your thumbs and you put your thumbs on the, try not to put them on the teeth because and then they close, they'll catch your thumbs as well. So try to put it on the gum behind the teeth and then you can appreciate from the anatomy. The motion that you have to make to get it over this bump is you have to push downwards then backwards and you'll hear a really satisfying clunk when it goes back into place. But you can appreciate, it's quite a lot of force needed to do that if patients are in a lot of pain and often it's incredibly distressing. Um you can give some sedation or some analgesia and if, if you can't get it back into place, very rarely, patients need a general anesthetic because you need to fully relax the muscle to get it back in, especially if they're really delayed in their presentation. It's often just a one off thing, but some people have really flexible joints and they get it really, really often so they'll know and they'll kind of be able to do it themselves or they'll come and tell you exactly what to do. But it's really, this is a really good skill to have because if you see it in the emergency department, you don't need to wait for someone to come, you can just do it yourself and the patient can just go home. The important thing after you relocate it, you tell the patient not to open their mouth for a few hours or it's susceptible to going back and get them to have a really, really soft diet for the next 48 to 72 hours. If it keeps happening, they need to be seen by a max fax surgeon to decide if there's something wrong with their anatomy. And that's why it keeps happening. And do they need some surgery for it? TMJ, dysfunction or disorder? So this is a really, really common problem and I think we've all probably had it in a way and sometimes it's really difficult to diagnose. Um but it's, it is really multifactorial and that's the issue. It kind of encompasses TMJ problems and problems with the muscles of mastication. And those are mainly the um mater so that sits here and the temporalis, which sits up here. So often patients complain of pain around the TMJ and the muscles of mastication, but it can radiate. So people can get headaches, jaw pain, everything. It's normally worse when opening or closing their mouth or when they're chewing, they can sometimes get locking of the jaw. So temporarily, they can't open fully or they can't close fully. You need to ask about the impact on their quality of life. So, does it actually need anything doing? Can they manage? Have they had any recent injuries or dental trauma? And do they have any history of bruxism? So, tooth grinding or clenching, because that's normally the most common cause examination. You wanna check for pain on palpation of the TMJ themselves and the muscles of mastication, especially the masta. Often they have pain, but you can also feel they're really bulky and it can cause you, you could feel the muscle has been overworking because they've grown it so much in the T MJ. You also want to check for any added sounds, any clicking, popping or crepitus um and then refer as needed. So, treatment of TMJ dysfunction. Again, it's another condition that gets kind of a bad rep because it is related to a lot of psychological issues. It's anxiety, stress, depression. People will say when the the problem is when you're stressed or anxious, you grind your teeth more and you get more pain. So if there is history of trauma, limited mouth opening or locking pain or reduced jaw function with known rheumatic disease or recurrent dislocations, they should be referred to max straight away. There's really, really good, nice guidelines on this actually, which are worth looking at, if you ever see a patient with this, all other people need a kind of a biopsychosocial approach. So that includes stress relief, good sleep, um, soft diet, no nail biting, no kind of gum chewing, just things that obviously gonna aggravate your muscles. You can also consider if they say we, I grind my teeth loads or I clench loads. You can refer them to a dentist and they can make a mouth guard, which sometimes helps. Um what the best thing to is if these simple measures, you give them about 6 to 8 weeks. If they don't work, you can refer to Maxx or ent or whatever the local protocol is. Um And unfortunately, these patients are very difficult to manage because it's so multifactorial and they want a quick fix, but it's really, really hard and you have to kind of, it's a kind of a all around holistic approach and it's normally to do with stress management. However, it's important to remember that there are some people who have actual pathology of the anatomy of the TMJ and they may need surgery to replace their TMJ or reshape it or something like that. So it's worth sending those a lot over, but it's often easy to tell the difference. So in conclusion, it's really important to have a basic knowledge of all Maxx conditions. They're poor, normally really poorly taught in medical school or not at all and often present to GPS, any red flag symptoms should be referred by a two week wait, if you're unsure, just refer and again, if you're unsure about certain oral lesions, you can also refer them to a dentist who obviously have much more training in looking at these things and seeing what they recommend and they can always do the two week wait, referral if needed. So I think I mentioned these references in my last few lectures, but I was just gonna say this second one is a really, really good book and it's Max Fax, but for medical students and medical professionals and it's available for free online and it's really good. It summarizes everything really nicely. So I'd be very grateful if you guys could complete get some feedback. Just so we know all of the stuff we've discussed. We're gonna have some articles that go up on the mind the bleep website. So you have a record of everything and the recordings will obviously be made available. Um If you guys have any questions or any comments or any just general questions about max facts, then please let me know in the messages if you think of anything later, just email me um or just send an email to mind the bleep and we'll be able to help you as much as we can. Um So yes, thank you for listening. Sorry. It's kind of a very quick tour of everything. The takeaway messages are just to refer if you are concerned at all and you normally you'll get a vibe for it, you'll know what to do. Um So yeah, if there are any questions, any comments just message me and let me know that's an option. No. Ok, perfect. Yeah. Anything anyone wants to ask or say please feel free and otherwise I'll hang around for a bit if anyone thinks of anything. So no worries. Thank you for coming. I'll give it another minute or so if anyone has any questions otherwise enjoy your evening. And, um, yeah, just let us know if you think of anything you wanna ask. Ok, perfect. Doesn't look like there are any questions. Um, but if you do think of anything, let me know, like I said, there'll be articles on all of this, on the mind, the blue website. Um, so you can always have a read. Um, but yes, thank you very much for attending and enjoy the rest of your evenings.