| Temporomandibular joint disorder |
| Classification and external resources |
Temporomandibular joint |
| ICD-10 |
K07.6 |
| ICD-9 |
524.60 |
| DiseasesDB |
12934 |
| MedlinePlus |
001227 |
| eMedicine |
neuro/366 radio/679 emerg/569 |
| MeSH |
C05.500.607.221.897.897 |
Temporomandibular joint disorder, TMJD (in the medical literature TMD), or TMJ syndrome, is an umbrella term covering acute or chronic pain, especially in the muscles of mastication and/or inflammation of the temporomandibular joint, which connects the mandible to the skull. The primary cause is muscular hyper- or parafunction, as in the case of bruxism, with secondary effects on the oral musculoskeletal system, like various types of displacement of the disc in the temporomandibular joint. The disorder and resultant dysfunction can result in significant pain, which is the most common TMD symptom, combined with impairment of function. Because the disorder transcends the boundaries between several health-care disciplines — in particular, dentistry and neurology — there are a variety of treatment approaches.
The temporomandibular joint is susceptible to many of the conditions that affect other joints in the body, including ankylosis, arthritis, trauma, dislocations, developmental anomalies, neoplasia and reactive lesions.[1]
An older name for the condition is "Costen's syndrome", after James B. Costen, who partially characterized it in 1934.[2][3][4][5]
Signs and symptoms of temporomandibular joint disorder vary in their presentation and can be very complex, but are often simple. On average the symptoms will involve more than one of the numerous TMJ components: muscles, nerves, tendons, ligaments, bones, connective tissue, and the teeth.[6] Ear pain associated with the swelling of proximal tissue is a symptom of temporomandibular joint disorder.
Symptoms associated with TMJ disorders may be:
- Blinking
- Biting or chewing difficulty or discomfort
- Clicking, popping, or grating sound when opening or closing the mouth
- Dull, aching pain in the face
- Earache (particularly in the morning)
- Headache (particularly in the morning)
- Hearing loss
- Migraine (particularly in the morning)
- Jaw pain or tenderness of the jaw
- Reduced ability to open or close the mouth
- Tinnitus
- Neck and shoulder pain
- Dizziness
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Contents
- 1 Temporomandibular joints
- 2 Cause
- 3 Treatment
- 3.1 Restoration of the occlusal surfaces of the teeth
- 3.2 Intra-aural (ear) device
- 3.3 Splint
- 3.4 Nighttime biofeedback
- 3.5 Pain relief
- 3.6 Prolotherapy
- 3.7 Long-term approach
- 3.7.1 Elimination of para-functional habits
- 3.7.2 Reversible treatments
- 3.7.3 Surgery
- 4 Jaw dislocation
- 5 See also
- 6 Footnotes
- 7 References
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Temporomandibular joints
Unlike a typical finger or vertebral junctions, each TMJ actually has two joints, which allows it to rotate and to translate (slide). With use, it is common to see wear of both the bone and cartilage components of the joint. Clicking is common, as are popping and deviations in the movements of the joint. Pain is the most conventional signifier of TMD.
The surfaces in contact with one another (cartilage) do not have any receptors to transmit the feeling of pain. The pain therefore originates from one of the surrounding soft tissues, or from the trigeminal nerve itself, which runs through the joint area. When receptors from one of these areas are triggered, the pain can cause a reflex to limit the mandible's movement. Furthermore, inflammation of the joints or damage to the trigeminal nerve can cause constant pain, even without movement of the jaw.
Due to the proximity of the ear to the temporomandibular joint, TMJ pain can often be confused with ear pain.[7] The pain may be referred in around half of all patients and experienced as otalgia (earache).[8][9] Conversely, TMD is an important possible cause of secondary otalgia.[10] Treatment of TMD may then significantly reduce symptoms of otalgia and tinnitus,[11] as well as atypical facial pain.[12] Despite some of these findings, some researchers question whether TMD therapy can reduce symptoms in the ear, and there is currently an ongoing debate to settle the controversy.[13]
The dysfunction involved is most often in regards to the relationship between the condyle of the mandible and the disc.[14] The sounds produced by this dysfunction are usually described as a "click" or a "pop" when a single sound is heard and as "crepitation" or "crepitus" when there are multiple, rough sounds.[citation needed]
Teeth
Disorders of the teeth can contribute to TMJ dysfunction.[15] Impaired tooth mobility and tooth loss can be caused by destruction of the supporting bone and by heavy forces being placed on teeth. The movement of the teeth affects how they contact one another when the mouth closes, and the overall relationship between the teeth, muscles, and joints can be altered. Pulpitis, inflammation of the dental pulp, is another symptom that may result from excessive surface erosion. Perhaps the most important factor is the way the teeth meet together: the equilibration of forces of mastication and therefore the displacements of the condyle. Many report TMJ dysfunction after having their wisdom teeth extracted.[citation needed]
Cause
There are many external factors that place undue strain on the TMJ. These include but are not limited to the following:
Bruxism has been shown to be a contributory factor in the majority of TMD cases.[16] Over-opening the jaw beyond its range for the individual or unusually aggressive or repetitive sliding of the jaw sideways (laterally) or forward (protrusive). These movements may also be due to parafunctional habits or a malalignment of the jaw or dentition. This may be due to:
- Bruxism (repetitive unconscious clenching or grinding of teeth, often at night).
- Loss of bite height (bite collapse), leading to an unnatural position of the lower jaw while chewing. Often occurs in patients over the age of 40 due to the natural aging process and/or bruxism. Overzealous equilibration by inexperienced staff or the improper use of air abrasion can also lead to the loss tooth height.
- Trauma (e.g. sports related injuries; whiplash from any automobile accident; accidental injuries from any source to one's chin to cause ones chin to move in an upward/backward direction)
- Mal-alignment of the occlusal surfaces of the teeth due to genetics, defective crowns, restorative procedures, lack of cooperation during orthodontic treatment.
- The controversial practice of extracting 4 bicuspids in orthodontic treatment of patients with small jaws and overcrowding, which has been shown to lead to joint dysfunction. It is now discouraged in favor of a palate expander based treatment plan. (This is conjecture -- needs reference)
- Jaw thrusting (causing unusual speech and chewing habits).
- Parafunctional Habits other than bruxism: Excessive gum chewing, nail biting, eating very hard foods. (Needs Reference)
- Exaggerated opening of mouth, when eating large sized foods, excessive opening during yawning/sneezing and in difficult cases of third molar (wisdom tooth) extraction.
- Degenerative joint disease, such as osteoarthritis or organic degeneration of the articular surfaces, recurrent fibrous and/or bony ankylosis, developmental abnormality, or pathologic lesions within the TMJ
- Myofascial pain syndrome
- Lack of overbite or cuspid protected occlusion will result in excessive forces directed to posterior teeth and hence, more stress to muscles of mastication
- Clenching from stress or anger and this will result in a common complaint of "sore jaws" noticed when one first awakens in morning.
Patients with TMD often experience pain such as migraines or headaches, and consider this pain TMJ-related. There is some evidence that some people who use a biofeedback headband to reduce nighttime clenching experience a reduction in TMD.[17] The dentist must ensure a correct diagnosis does not mistake trigeminal neuralgia as a temporomandibular disorder.[18] Oromandibular dystonia is another rare diagnosis which might cause some confusion [19]
Treatment
Restoration of the occlusal surfaces of the teeth
If the occlusal surfaces of the teeth or the supporting structures have been altered due to inappropriate dental treatment, periodontal disease, or trauma, the proper occlusion may need to be restored.[citation needed] Patients with bridges, crowns, or onlays should be checked for bite discrepancies. These discrepancies, if present, may cause a person to make contact with posterior teeth during sideways chewing motions. These inappropriate contacts are called interferences, and if present, they can cause a patient to subconsciously avoid those motions, as they will provoke a painful response. The result can be excessive strain or even spasms of the chewing muscles. Treatment could include adjusting the restorations or replacing them. (Christensen 1997, A Consumer's Guide to Dentistry).
Intra-aural (ear) device
Intra-aural (aural meaning having to do with the ear) device therapy treats TMJ disorder using an appliance worn in the ear canal. The ear canal is in immediate anatomical proximity to the temporomandibular joint (TMJ). "The Clayton Intra-Aural Device (CID) is a hollow, plastic, patented device which rests in the outer third of the ear canal when the jaw is slightly opened."[20] A randomized controlled clinical trial showed the CID to be a non-invasive, safe and effective therapy for the treatment of temporomandibular joint disorder.[21] Based on data submitted to the FDA the CID was given an indication for use "as an aid in reducing temporomandibular disorder (TMD) pain".[22] The CID is sold under the tradename TMDes (ear system).
Splint
Occlusal splints (also called night guards or mouth guards) reduce nighttime clenching in some patients, while increasing clenching activity in other patients.[citation needed] Thus, while occlusal splints do prevent loss of tooth enamel from grinding, use of a "one size fits all" splint can worsen TMJ disorder symptoms for some people.
Nighttime biofeedback
Nighttime EMG biofeedback (for instance by using a biofeedback headband or biofeedback device) can be used to reduce bruxism and thus reduce or eliminate the ongoing nightly cycle of damage that contributes to the majority of TMJ disorder symptoms. This treatment is non-invasive. The Bruxism Association warns that such devices can disrupt sleep and it does not consider them to be a safe treatment.[23]
Pain relief
While conventional analgesic pain killers such as paracetamol (acetaminophen) or NSAIDs provide initial relief for some sufferers, the pain is often more neurologic in nature, which often does not respond well to these drugs.[24]
An alternative approach is for pain modification, for which off-label use of low-doses of Tricyclic antidepressant that have anti-muscarinic properties (e.g. Amitriptyline or the less sedative Nortriptyline) generally prove more effective.[25][26] In TMJD the muscles are unbalanced. Biofeedback using EMG is successful in balancing these muscles. A mirror can be used as a biofeedback device: Draw a vertical line on mirror. Relax the jaw by relaxing as you exhale. See the jaw relax in the midline. Practice the breathing and relaxing daily using the mirror. When the jaw does open midline the symptoms should abate.[27]
Prolotherapy
There is on-going study of prolotherapy as a treatment option. A preliminary report claims "prolotherapy with 10% dextrose appears promising for the treatment of symptomatic TMJ hypermobility."[28]
Long-term approach
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This unreferenced section requires citations to ensure verifiability. |
It is suggested that before the attending dentist commences any plan or approach using medications or surgery, a thorough search for inciting para-functional jaw habits must be performed. Correction of any discrepancies from normal can then be the primary goal.
Patients may employ a nighttime biofeedback instrument such as a biofeedback headband or biofeedback device to help them modify para-functional jaw habits which take place in sleep. In addition, there are various treatment modalities which a well-trained experienced dentist may employ to relieve symptoms and improve joint function.[citation needed] They include:
- Manual adjustment of the bite by grinding the teeth (occlusal adjustment). This, too, is not a widely accepted practice and should be avoided as it is irreversible.
- Nighttime biofeedback for para-functional habit modification
- Mandibular repositioning splints which move the jaw, ligaments and muscles into a new position and myofunctional therapy
- Reconstructive dentistry
- Orthodontics
- Arthrocentesis (joint irrigation)
- Surgical repositioning of jaws to correct congenital jaw malformations such as prognathism and retrognathia
- Replacement of the jaw joint(s) or disc(s) with TMJ implants (This should be considered only as a treatment of last resort.)
Elimination of para-functional habits
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This unreferenced section requires citations to ensure verifiability. |
An approach to eliminating para-functional habits involves the taking of a detailed history and careful physical examination. The medical history should be designed to reveal duration of illness and symptoms, previous treatment and effects, contributing medical findings, history of facial trauma, and a search for habits that may have produced or enhanced symptoms. Particular attention should be directed in identifying perverse jaw habits, such as clenching or teeth grinding, lip or cheek biting, or positioning of the lower jaw in an edge-to-edge bite. All of the above strain the muscles of mastication (chewing) and result in jaw pain. Palpation of these muscles will cause a painful response.
Treatment is oriented to eliminating oral habits, physical therapy to the masticatory muscles, and alleviating bad posture of the head and neck. A biofeedback headband or biofeedback device may be worn at night to help patients train themselves out of the para-functional habit of nighttime clenching and grinding (bruxism). A flat-plane full-coverage oral appliance, e.g. a non-repositioning stabilization splint, reduces bruxism in some patients, and can take stress off the temporomandibular joint, although some individuals may bite harder on it, resulting in a worsening of their conditions. The anterior splint, with contact at the front teeth only, may prove helpful to some patients, but for those patients who bite harder on this type of splint, even more damage may occur. Thus, different types of splint therapy may work for different patients.
Reversible treatments
In line with the recommendations of the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH), treatments for TMJD should not permanently alter the jaw or teeth, but need to be reversible.[29][30] To avoid permanent change, over-the-counter or prescription pain medications may be prescribed.[31] Some sufferers may also benefit from gentle stretching or relaxation exercises for the jaw, which may be recommended by their healthcare providers.
Other interventions include:
- Stabilization splint (biteplate, nightguard) is a common but unproven treatment for TMJD. A splint should be properly fitted to avoid exacerbating the problem and used for brief periods of time. The use of the splint should be discontinued if it is painful or increases existing pain.[31]
- Feldenkrais TMJ Program claims to retrain muscles to reduce chronic tension in the jaw, face, neck, and upper back, and to reverse long-standing movement habits responsible for the original TMJD symptoms.[32][33]
- Mandibular Repositioning (MORA) Devices can be worn for a short time to help alleviate symptoms related to painful clicking when opening the mouth wide, but 24-hour wear for the long term may lead to changes in the position of the teeth that can complicate treatment. A typical long-term permanent treatment (if the device is proven to work especially well for the situation) would be to convert the device to a flat-plane bite plate fully covering either the upper or lower teeth and to be used only at night. According to an article on Quackwatch.org, MORA devices are considered the most widely used option although their scientific validity has not been proven.[citation needed]
- Cognitive Behavioral Therapy (CBT). Psychosocial risk factors have also been linked to TMJ syndrome. Studies have shown that changes in psychosocial issues can help reduce pain and increase jaw movement.[34][35] CBT starts by looking briefly at the patient's background for the therapist to gain an idea of their past and personality. Unlike psychodynamic therapy, which focuses on past events, this therapy aims to identify negative feelings and behaviors. When this has been done the patient is taught techniques that challenge these views/behaviors in order to turn them into more positive ones, resulting in improved quality of life. This can be achieved in a number of ways; the most common way is the use of a diary that is brought to the session with the therapist, who reads the diary and helps to identify and discuss problems. The patient then attempts to apply what was discussed in the therapy session into practice. The number of sessions required varies for each individual but can be between 6-20 visits with each visit being on a weekly basis.[36]
Surgery
Attempts in the last decade to develop surgical treatments based on MRI and CAT scans now receive less attention. These techniques are reserved for the most difficult cases where other therapeutic modalities have failed. Exercise protocols, habit control, and splinting should be the first line of approach, leaving oral surgery as a last resort. Other possible causes of facial pain and jaw immobility and dysfunction should be the initial consideration of the examining professional.[citation needed]
One option for oral surgery is to manipulate the jaw under general anaesthetic and wash out the joint with a saline and anti-inflammatory solution in a procedure known as arthrocentesis.[37] In some cases, this will reduce the inflammatory process.
Jaw dislocation
Main article: Dislocation of jaw
The jaw can dislocate if a person opens their mouth too wide, particularly when a person attempts to open the jaw widely in an effort to stretch the facial muscles i.e. to relieve tense facial muscles as the wisdom teeth develop and emerge.
The jaw can also "slide out" as the person is sleeping on their side.
See also
- Bruxism
- Condylar resorption
- ^ Zadik, Yehuda; Aktaş Alper; Drucker Scott; Nitzan W Dorrit (2012). "Aneurysmal bone cyst of mandibular condyle: A case report and review of the literature". J Craniomaxillofac Surg 40. DOI:10.1016/j.jcms.2011.10.026. PMID 22118925. http://www.sciencedirect.com/science/article/pii/S1010518211002551.
- ^ "Temporomandibular Disorders: eMedicine Neurology". http://emedicine.medscape.com/article/1143410-overview.
- ^ synd/4119 at Who Named It?
- ^ Costen JB (October 1997). "A syndrome of ear and sinus symptoms dependent upon disturbed function of the temporomandibular joint. 1934". Ann Otol Rhinol Laryngol 106 (10 Pt 1): 805–19. PMID 9342976.
- ^ Michael LA (1997 Oct). "Jaws revisited: Costen's syndrome". Ann Otol Rhinol Laryngol 106 (10 Pt 1): 820–2. PMID 9342977.
- ^ Okeson (2003), page 191.
- ^ Okeson (2003), page 233.
- ^ Tuz HH, Onder EM, Kisnisci RS (2003). "Prevalence of otologic complaints in patients with temporomandibular disorder". Am J Orthod Dentofacial Orthop 123 (6): 620–3. DOI:10.1016/S0889-5406(03)00153-7. PMID 12806339.
- ^ Ramírez LM, Sandoval GP, Ballesteros LE (2005). "Temporomandibular disorders: referred cranio-cervico-facial clinic". Med Oral Patol Oral Cir Bucal 10 Suppl 1: E18–26. PMID 15800464. http://www.medicinaoral.com/medoralfree01/v10Suppl1i/medoralv10suppl1ip18.pdf.
- ^ Peroz I (2001). "[Otalgia and tinnitus in patients with craniomandibular dysfunctions]" (in German). HNO 49 (9): 713–8. PMID 11593771.
- ^ Sobhy OA, Koutb AR, Abdel-Baki FA, Ali TM, El Raffa IZ, Khater AH (2004). "Evaluation of aural manifestations in temporo-mandibular joint dysfunction". Clin Otolaryngol Allied Sci 29 (4): 382–5. DOI:10.1111/j.1365-2273.2004.00842.x. PMID 15270827.
- ^ Quail G (2005). "Atypical facial pain--a diagnostic challenge" (PDF). Aust Fam Physician 34 (8): 641–5. PMID 16113700. http://www.racgp.org.au/afp/downloads/pdf/august2005/August_theme_quail2.pdf.
- ^ Okeson (2003), page 234.
- ^ Okeson (2003), page 204.
- ^ Okeson (2003), page 227.
- ^ van der Meulen MJ, Ohrbach R, Aartman IH, Naeije M, Lobbezoo F (2010). "Temporomandibular disorder patients' illness beliefs and self-efficacy related to bruxism". J Orofac Pain 24 (4): 367–372. PMID 21197508. [unreliable medical source?]
- ^ Crider A, Glaros AG, Gevirtz RN (2005 Dec). "Efficacy of biofeedback-based treatments for temporomandibular disorders". Appl Psychophysiol Biofeedback 30 (4): 333–45. DOI:10.1007/s10484-005-8420-5. PMID 16385422.
- ^ Drangsholt, M; Truelove, EL (July 2001). "Trigeminal neuralgia mistaken as temporomandibular disorder". J Evid Base Dent Pract (Mosby, Inc) 1 (1): 41–50. DOI:10.1067/med.2001.116846. http://www.jebdp.com/article/S1532-3382%2801%2970082-6/abstract. Retrieved 25 November 2010.
- ^ Viswanath A, Gordon SM (2012). "Two cases of oromandibular dystonia referred as temporomandibular joint disorder". Grand Rounds 12: 1–5. DOI:10.1102/1470-5206.2012.0001. http://www.grandrounds-e-med.com/articles/gr120001.htm.
- ^ Sollecito, Thomas; L.G. Clayton, S.S. DeRossi, L. Laster, M.S. Greenberg (April 2004). "The Clayton Intra Aural Device for Temporomandibular Disorders". Oral Surgery Oral Medicine Oral Pathology 97 (4): 455. http://www.journals.elsevierhealth.com/periodicals/ymoe/article/S1079-2104(04)00126-X/fulltext.
- ^ "Treatment Outcomes for Temporomandibular Disorders (TMD) Via the Clayton Intra-aural Device (CID) Clinical Trial". clinical trials .gov. http://clinicaltrials.gov/ct2/show/study/NCT00815776?sect=X0125.
- ^ FDA. "510(k) Summary CID". Clinical Trials .gov. http://www.accessdata.fda.gov/cdrh_docs/pdf9/K091880.pdf.
- ^ "Other Treatments". Bruxism Association. http://www.bruxism.org.uk/other-treatments.php. Retrieved 9 November 2011.
- ^ Vickers ER, Cousins MJ (2000). "Neuropathic orofacial pain. Part 2-Diagnostic procedures, treatment guidelines and case reports". Aust Endod J 26 (2): 53–63. DOI:10.1111/j.1747-4477.2000.tb00270.x. PMID 11359283.
- ^ Marbach JJ (1996). "Temporomandibular pain and dysfunction syndrome. History, physical examination, and treatment". Rheum. Dis. Clin. North Am. 22 (3): 477–98. DOI:10.1016/S0889-857X(05)70283-0. PMID 8844909.
- ^ Dionne RA (1997). "Pharmacologic treatments for temporomandibular disorders". Oral Surg Oral Med Oral Pathol Oral Radiol Endod 83 (1): 134–42. DOI:10.1016/S1079-2104(97)90104-9. PMID 9007937.
- ^ Grossan M (1989). "Treatment of Temporomandibular Joint Disease with Biofeedback". In Leland House.
- ^ http://www.ncbi.nlm.nih.gov/pubmed/21757278/ The Efficacy of Dextrose Prolotherapy for Temporomandibular Joint Hypermobility: A Preliminary Prospective, Randomized, Double-Blind, Placebo-Controlled Clinical Trial
- ^ Lipton JA, Ship JA, Larach-Robinson D (1993). "Estimated prevalence and distribution of reported orofacial pain in the United States". J Am Dent Assoc 124 (10): 115–21. PMID 8409001.
- ^ National Institutes of Health Technology Assessment Conference Statement. (1996). Management of temporomandibular disorders. Washington, D.C.: Government Printing Office.
- ^ a b The TMJ Association (2005). "Temporomandibular (Jaw) Joint Diseases and Disorders". http://www.tmj.org/site/pdf/TMJbrochure.pdf. Retrieved 2 December 2010.
- ^ http://www.tmj-lessons.com/ "See also"[unreliable medical source?]
- ^ http://www.feldenkrais.com/[unreliable medical source?]
- ^ Linda LeResche, University of Washington, R01 DE016212
- ^ Turner JA, Holtzman S, Mancl C. Mediators, moderators, and predictors of therapeutic change in cognitive–behavioral therapy for chronic pain. Pain 2007;127(3):276-86.
- ^ http://www.bupa.co.uk/individuals/health-information/directory/c/cbt-cognitive-behavioural-therapy
- ^ "Temporomandibular Disorders". The Cleveland Clinic. http://www.clevelandclinic.org/health/health-info/docs/3100/3152.asp.
References
- Okeson, Jeffrey P. (2003). Management of temporomandibular disorders and occlusion (5th ed.). St. Louis: Mosby. ISBN 0-323-01477-1.
- Edward F. Wright (2009). Manual of Temporomandibular Disorders (2 ed.). John Wiley and Sons. ISBN 978-0-8138-1324-0.
- Gremillion, Henry A. (2003). "Temporomandibular Disorders". In Edwab, Robert R.. Essential dental handbook: clinical and practice management advice from the experts (illustrated ed.). PennWell Books. pp. 251–309. ISBN 978-0-87814-624-6.
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Dentistry
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Recognized specialties
(in the United States) |
Endodontics · oral and maxillofacial pathology · Oral and maxillofacial radiology · Oral and maxillofacial surgery · Orthodontics and dentofacial orthopedics · Pediatric dentistry · Periodontics · Prosthodontics · Dental public health
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Fields that are not recognized specialties
(in the United States) |
Cosmetic dentistry · Dental Implantology · Temporomandibular joint disorder · Geriatric dentistry · Restorative dentistry · Forensic odontology · Dental traumatology
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| Dental surgery |
Dental extraction · Tooth filling · Root canal therapy · Root end surgery · Scaling and root planing · Teeth cleaning · Dental bonding · Tooth polishing · Tooth bleaching · Dental implant
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| See also |
Index of oral health and dental articles · Outline of dentistry and oral health · Oral hygiene · Dental instruments · Restorative materials · Infant oral mutilation
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noco/cong/jaws/tumr, epon, injr
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dent, proc (endo, orth, pros)
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Dentofacial anomalies and jaw disease (K07–K10, 524–526)
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| Jaw |
Dentofacial anomalies/
jaw abnormality/
malocclusion/
orthodontic |
Gnathitis
jaw size: Micrognathism · Maxillary hypoplasia
jaw-cranial base relationship: Prognathism · Retrognathism
dental arch relationship: Crossbite · Overbite
Temporomandibular joint disorder
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Maxillomandibular anomalies
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Cherubism · Congenital epulis · Keratocystic odontogenic tumour · Torus mandibularis · Torus palatinus
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noco/cong/jaws/tumr, epon, injr
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dent, proc (endo, orth, pros)
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