introduction to TMJ course 2days designed for medically qualified people

1. TMJ secrets
Islam Kassem,BDS,MSc,MFDS RCS Ed,MOMS RCPS Glasg,FFD RCSI
Consultant Oral & Maxillofacial Surgeon

2. Islam Kassem
• BDS Alexandria Dental school 2002
• MSc Oral & Maxillofacial surgery 2008
• MFDS RCS Ed 2005
• MOMS RCPS Glasg 2009
• FFD RCSI OS OM 2011
• AO-CMF Fellowship 2012
• American Aesthetic fellowship diploma 2013
• Implant Diploma Napoli university 2014
• Laser Diploma ALD 2015
• Oral & Maxillofacial Surgeon

4. Declaration
• There is no conflict of interest in this
Course .
• I have no monetary benefit from this
Course.
• No implied sponsorship by any company to
the speaker
• all photographed patients were treated by
the speaker and consented for
photographing and public publishing
ikassem@dr.com

6. How to treat
TMJ??

7. the answer will
take two days

8. And more
12 CME
8
online learning

9. TMJ Course

10. Content
Day 1
Introduction
Surgical anatomy
pathology of TMJ
Clinical Diagnosis
Different treatment of TMJ pathology
10

11. Day 2
Medical management of TMD
laser bio stimulation
neurotoxin
compilications of TMJ treatment
11

12. TMJ Syndrome an outdated concept
Should be able to distinguish between
muscular disorders and joint disorders
Must rule out joint pathology

13. Economics
$30 Billion lost productivity
550 million work days per year

14. Epidemiology
10 million people treated for “TMJ” at any one
time
50% of population
1/5 require some treatment
1/10 of those treated will need surgery

15. Epidemiology
Avg age onset 18-26
Females 5:1
50% have progressive Sx
50% accommodate by functioning within
physiologic limits
84% not treated improve
86% treated improve

17. Oro-Facial Pain

18. What is Pain?
• “Pain is an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage or described in terms of such
damage”
• “- pain is always subjective -”
Int. Assoc. for the Study of Pain

19. Oro-Facial Pain
• The remit of the dentist?
• Patients go to dentist to get
problem fixed
– Filling, extraction etc
• Problem arises when dentist
can’t fix it!
• Patients don’t go to dentist for
medical/psychological help!
• Dentist under pressure to do
something!
• Poor inter-professional
communication between
medicine and dentistry
• Dentists often isolated

20. Oro-facial Pain
• Oro-facial pain can be
difficult to diagnose!
• TMD can be a great
mimic!
• Beware of referred pain!

21. In the primary care setting
how much do each of the following contribute to
the diagnosis?
• History taking
• >80%
• Physical examination
• <10%
• Investigations
• <10%
• So why do we do so many investigations?

22. Why Do We Order So Many Tests?
• "Defensive" medicine in an increasingly
litigious environment
• Loss of confidence in our abilities to extract
meaningful information from the history and
examination

23. Consequences of Ordering So Many
Tests
– Time delay in diagnosis as one awaits the test
results
– The patient is exposed to the risk and side effects
of tests that may not be necessary

24. The pain history
• Onset, location and duration of facial pain
• Alleviating or aggravating factors
• Medical, dental & social history

25. KEY QUESTIONS
• IS THE PAIN PRESENT EVERY DAY ?
• WHAT IS A NORMAL DAY LIKE ?
• HOW SEVERE IS THE PAIN ? –
• (Score 0-10)

26. Rules of Thumb!
• Dental pain gets better or worse!
• Chronic pain is rarely dental!
• If an experienced dentist “feels” the pain is
not dental they are most often right !

27. 5th & 7th Cranial Nerves
1. Sensory root of
trigeminal nerve
2. Pons
3. Vestibulocochlear nerve
4. Facial nerve
5. Abducent nerve
6. Medulla oblongata
7. Motor root of
trigeminal nerve
8. Basilar sulcus

28. Nasopharyngeal Carcinoma
(Trotter’s Syndrome)
• Maxillary pain
– With numbness!!
• Unilateral
nosebleeds

29. Toothache

30. Dental caries

31. Dental Pain - radiation
• Caries in mandibular
molars can produce
pain around the ear
• Caries in maxillary
teeth can produce
maxillary, orbital, retro-
orbital

32. Dental Pain
• Dental pain can be difficult
to diagnose!
– Tooth sleuth!
– Hot water test!
• TMD can be a great
mimic!
– Headaches, jaw pain,
toothache etc.!
• Beware of referred pain
– sinuses, cervical spine, heart
etc.!

33. Acute Maxillary Sinusitis
• Unilateral or bilateral
pressure, fullness or
burning pain over
cheekbone, upper teeth
and around eyes
• Exacerbated by stooping
• Usually follows an URTI
• Most cases self limiting

34. Chronic Maxillary Sinusitis
• Feeling of pressure below
the eyes or toothache
• Computed Tomography
• Endoscopy

35. Sinusitis Management
• Decongestants
• Steam inhalations
• Antibiotics if indicated
• Local Heat
• Antihistamines if allergic component
• corticosteroids
• Sinus irrigation
• Endoscopic surgery

36. TEMPOROMANDIBULAR JOINT
DISORDERS
• Common
• More has been written about this topic than
for any other joint !
• Various classifications
• Many cases are self limiting
• Surgery is indicated in very few BUT
important exceptions

37. Temporomandibular Dysfunction
• Pain in the joint and/or surrounding muscles
• Joint “clicking”
• Periods of limitation of joint movement (trismus)

38. EPIDEMIOLOGICAL DATA
• Percentage of population with signs
50-75%
• Percentage of population with symptoms
20-25%
• Percentage of population who seek
treatment 3-4%

39. Temporomandibular Dysfunction
• Causes
• Parafunction
– Bruxism
– Clenching
• Emotional stress
• Predisposition (F>M)
– Joint hypermobility
• Occlusal factors – little
evidence

40. Bruxism
• Tooth wear
• Painful teeth
• Cracked cusps
• Mouth ulcers due to trauma
• Jaws ache in the morning

41. Temporomandibular Dysfunction
• Pain distribution
• Variable – a great mimic!!
• Joint pain
• Earache
• Toothache
• Facial pain
• Headache
• Can be associated with
neck and shoulder pain

42. Treatment of TMD

43. Trigeminal Neuralgia - Description
• A painful unilateral affliction of the face,
characterized by brief electric shock-like
(lancinating) pains limited to one or more
divisions of the trigeminal nerve
• Pain evoked by washing, shaving,
smoking, talking, brushing, air blowing, or
spontaneously occurring
• Pain is abrupt in onset and may remit for
varying periods

44. Trigeminal Neuralgia
• Subclassified into idiopathic and
symptomatic
• Idiopathic trigeminal neuralgia: due to an
interaction between trigeminal nerve and
vasculature
• Symptomatic trigeminal neuralgia: caused
by demonstrable structural lesion

45. Trigeminal Neuralgia
• Females > males
• Usually elderly – (if < than 40 -?MS)
• Restricted to Vth nerve
– Similar can affect IXth nerve – glossopharyngeal
neuralgia
• Trigger point – may bear no anatomical
relation to site of pain but on same side!
• Sleep often not affected
• May go into remission

46. Trigeminal Neuralgia
Diagnosis:
• History
• Examination
• MRI
– aberrant pontine blood
vessel?
– exclusion of other
cause (neoplasm, MS)
• (Response to trial of
carbamazepine)

47. Trigeminal Neuralgia
Treatment:
• Medical – anticonvulsants
( e.g. carbamazepine) –
needs medical monitoring!
• Use of additive drugs –
e.g. baclofen
• Damage to trigger point –
alcohol injection,
cryotherapy

48. Trigeminal Neuralgia – Surgical
Treatment
• Radiofrequency
ganglionolysis
• Microvascular
decompression

49. Establishment of VZV Latency in Sensory-Nerve
Ganglia.
After a primary VZV infection (chickenpox), latent VZV
infection is established in the dorsal-root ganglia, and
zoster occurs with subsequent reactivation of the virus
N Engl J Med Vol 356(13) P1338-1343

50. Zoster: Clinical Features
• Usually limited to 1 or 2
adjacent, unilateral
dermatomes
• “Grape-like” lesions
clustered on an
erythematous base
• Lesions usually heal
within 4 weeks1

51. Post Herpetic Neuralgia
• Burning, itching, prickly pain that worsens
with contact or movement
• Persists along any of the three trigeminal
nerve distributions affected by shingles
• Difficult to treat!
• Importance of adequate treatment of
shingles – especially the elderly
• Carbamazepine, tricyclics

52. Giant Cell Arteritis
• Over 50yrs,women>men
• recent onset headache,scalp tenderness
• Jaw/tongue claudication (tired tongue/
jawache)
• anorexia
• visual disturbances
• Swollen disc usually

53. GCA Diagnosis
• ESR/CRP
• BP, CXR
• Biopsy of temporal
artery

54. Treatment of GCA
• Give corticosteroids immediately in all
suspected cases
• Start with 1mg/Kg prednisolone daily with vitamin
D and calcium supplements.
• Refer for Ophthalmology

55. Psychogenic
Somatisation Disorders
Somatisation has been defined as “the
expression of personal and social distress in
an idiom of bodily complaints with medical
help seeking”

56. Common !
“In general medical practice, somatisation
associated with psychiatric illness accounts
for 20 - 30% of all consultations”

57. DEPRESSIVE ILLNESS
• Persistent low mood (> 2weeks)
• Feeling worthless, hopeless, suicidal
• Loss of interest in usual activities
– anhedonia
• Fatigue
• Poor concentration
• Reduced sleep
• Poor appetite
Warning Signs

58. Atypical Pain Conditions
• Atypical = poorly understood!
• Often regarded as purely “psychogenic”!
• But chronic pain will make you depressed!
• Other factors may be involved!
– There may be a cause?
– Patient may just be a poor historian!
• Be careful of labels!
• Keep an open mind!

59. “Atypical” Facial Pain Conditions
• Persistent idiopathic facial pain
• Persistent dento-alveolar pain (atypical
odontalgia)
• Oral dysaesthesia
• Phantom bite syndrome
• (TMD)
• Syndrome of bizarre oro-facial symptoms

60. Persistent Idiopathic Facial Pain
• Middle aged or older
• Mainly female
• Constant pain / discomfort
• Poorly localised
• May cross midline
• Does not waken patient from sleep
• Lack objective signs
• Investigations (-ve)
• Other symptoms (headaches,IBS,backache etc.)

61. Persistent Idiopathic Facial Pain
• Demand physical treatment
• Often do not accept psychological
explanation
• May have seen several specialists/
practitioners
• May be obsessed with symptoms

62. Psychogenic Toothache
• Patient reports that multiple teeth are often painful with
frequent change in character and location
• A general departure from normal or physiological patterns of
pain
• Patient presents with chronic pain behaviour
• Lack of response to reasonable dental treatment
• Unusual or unexpected response to therapy
• No other identifiable pain condition that can explain the
toothache

63. Non-Odontogenic Toothaches
Warning Symptoms- Summary
• Spontaneous multiple toothaches
• Inadequate local dental cause for the pain
• Stimulating, burning, non-pulsatile toothaches
• Constant, unremitting, non-variable toothaches
• Persistent, recurrent toothaches
• Local anesthetic blocking of the offending tooth does not
eliminate the pain
• Failure of the toothache to respond to reasonable dental
therapy

64. Chronic Orofacial pain
Burning mouth syndrome is characterized as a
burning, tender, or annoying sensation in the
mouth with no apparent mucosal lesion.
Descriptive symptom
Late middle age – elderly
Female>Male

65. Burning Mouth Syndrome
(glossodynia, glossopyrosis)
• Possible causes
• Haematinic deficiency
– Fe, B12, Folate
• Diabetes melitus
• Candidosis
• Dry mouth
• Denture problems
• Parafunctional
• Psychogenic
– Anxiety
• Cancerophobia+++
– Depression

66. Management – What You Should Do!
• History ( what’s the story in detail )
– Exacerbants, alleviation, associated features
• Exclude organic disease
• Be aware of emotional state
– Depression / anxiety (HAD score)
- Secondary gain – what benefits does the patient get
from being unwell?
• Life events – connections with onset etc.
• Discuss with GMP (with patients consent)
• Decide on need for medication / referral

67. Management – What You Should Do!
• Remember the patients pain is real even if a
physical cause can not be found – tact!
• Allow the patient to express themselves
– What do you understand about your pain?
– What do you feel it represents?
– Cancer phobia?
• It can take time
• Remember most complaints are regarding
communication – or lack of it!

68. Management Strategies
The Pain Clinic
• Medical – drugs – alter the chemical soup!
• Surgical – nerve ablation procedures e.g. for
cancer pain
• Physiotherapy – improving activity
• Clinical Psychology – living with the problem
– Cognitative, Behavioural Therapy (CBT)
Pain Management is multidisciplinary!
Liaise closely with the GMP

69. Take-Home Points
• Oro-facial pain is common
• Most cases are dental
• Diagnosis can be very difficult
• Patients are frequently frustrated & very
distressed by time they reach secondary
care
• Need a lot of listening too!

70. Conclusions
• Careful history taking is essential to correctly
diagnose facial pain
• Remember the anatomy of the trigeminal
nerve
• Many facial pain syndromes are wrongly
attributed to disease of the teeth or sinuses

71. OROFACIAL PAIN
The field of Dentistry that includes the
Assessment, Diagnosis and Treatment of
Complex chronic orofacial pain and dysfunction
Oromotor and jaw behaviour disorders
Chronic facial, head and neck pain

72. o Head
-meninges
-skull & scalp
-nerves
-trigeminal (V)
-C2-3 (GON/LON)
o Orofacial
-sinuses
-TMJ, ear
-teeth, nerves
o Neck & shoulders
Pain generators

73. Red flags
T.I.N.T
o Tumour
o Temporal arteritis
o Intracranial pressure
o Infection
o Neurovascular
o Trigeminal
o Trauma

74. Red Flag Case Presentation
Female 16 years
Hx of constant deep aching TMJ/jaw pain worse with
chewing, extending to occiput.
Initially treated with Occlusal Splint/Physio.
Headaches on exertion - paroxysmal with “fainting”.
Parents noted subtle personality changes.
MRI - Arnold Chiari formation- surgery.

75. Intracranial Pathology
Diagnostic Clues
Neurological type symptoms/signs.
No response to peripheral therapies.
Unusual or worsening symptoms despite therapy.
Negative response to somatic/sympathetic blocks.

76. Intracranial pathology
Common manifestations of raised intracranial pressure

77.
Space Occupying Lesions
Neoplasms
Arterial dissection
Aneurysms
Infection/Abscess
Infarction/haemorrhage
Oedema
Angioma

78. Temporal (Giant cell) Arteritis
RED FLAG
Headache emergency
New onset headache in >50 years
Uni/bilateral dull temporal pain
Claudication masticatory muscles
Visual disturbance
Polymyalgia-shoulder/hip, malaise
Swollen, tender temporal artery
Elevated ESR, CRP
Positive biopsy

79. Temporal Arteritis
RED FLAG
Headache of vascular origin
Initial symptoms may resemble TMD
- Pain/stiffness in jaw
- Pain/fatigue of jaw when chewing
- Pain may radiate to ear, teeth
- Temporal headache
If untreated may cause blindness, stroke and death!
Generally resolves with high dose steroids

80. Extracranial Sources of Orofacial Pain
Teeth and oral mucosa
ENT, paranasal sinuses
TMJs &myofascial
Tongue
Salivary Glands
Lymph Glands
Eyes
Vessels & nerves

81. Odontogenic Pain – Toothache
▪ Most common cause of orofacial pain!
▪ Often missed by medical people
▪ Dental caries into dentine / pulp
▪ Pulpitis, pulp necrosis
▪ Cracked teeth
▪ Periodontal infection
▪ ASK ABOUT HOLES IN TEETH
▪ Hot/cold/bite SENSITIVITY, PAIN AT NIGHT

82. TOOTHACHE
• Toothache - most common orofacial pain complaint
• 12.2% of population reported toothache in last 6M
• Diagnosis can be challenging and complicated
• Pain from one tooth may be referred from another
tooth or from other orofacial structures
• Other craniofacial pain disorders may mimic the
symptoms of toothache
• Proper diagnosis is critical

83. Consider all pains in the mouth and face to be
of dental origin until proven otherwise

84. TEMPOROMANDIBULAR DISORDERS
Major cause of Non Dental Pain in Orofacial Region

85. TEMPOROMANDIBULAR DISORDERS
Collection of medical and dental conditions
affecting the temporomandibular joint and/or
muscles of mastication and/or contiguous
tissues resulting in pain and/or dysfunction

86. NEUROVASCULAR PAIN

87. Case Presentation
48 year old female
Intermittent dull throbbing pain in upper tooth/jaw,
radiating to temple and eye.
Severe attacks, last 1-3 days with constant dull pain.
When severe, feels sick and prefers dark, quiet room to
sleep.
Attacks used to respond well to NSAIDs.
Had a root canal, crown of upper premolar + splint

88. Migraine

89. Case Presentation
Male in mid forties.
Right sided face pain attacks on/off over three years
Extending into right eye.
Often awakened from sleep with severe throbbing pain.
Would get up and pace around holding his R. eye.
Face would feel sweaty, tearing of eye.
Numerous dental visits – Root canals/ extractions.

90. Case Presentation
EXAMINATION
Cranial nerve screen - Normal
TMJ/Myofascial – Normal
Oro-dental- Normal
Medication Trial - response to oxygen/sumatriptan

91. TRIGEMINALAUTONOMIC
CEPHALGIAS (TACs)
CLUSTER HEADACHE
CHRONIC PAROXYSMAL HEMICRANIA
HEMICRANIA CONTINUA
Peri-orbital or maxillary pain.
Frequently leads to dental work including extractions.
Unilateral, severe attacks with typical autonomic
headache accompanying symptoms.

92. Cluster Headache
Clinical Features
• Attacks are severe - boring
• Strictly unilateraln in and
around eye and/or temporal
region - “hot poker”
• Attack duration 15-180 min
• Attacks occur from once
every 2nd day up to 8x day.
• Attacks occur in series
lasting weeks to months
Remissions mths-yrs
• Autonomic features +++
• Males 5-7:1
65% had dental Tx

93. Chronic Paroxysmal Hemicrania
Similar to Cluster but
Female preponderance (3:1)
Attacks are more frequent and of shorter duration
5-40 attacks per day (median 5-10)
Attacks last 2-45 minutes
At least one autonomic symptom on the side of pain
conjunctival injection lacrimation
nasal congestion rhinorrhoea,
ptosis eyelid oedema

94. Chronic Paroxysmal Hemicrania
Always unilateral orbital, and/or temporal.
Severe stabbing/boring type pain that throbs as it builds
up.
Episodic form occursin bouts lasting months to years with
clear intervals (rare).
In most cases responds rapidly and absolutely to
Indomethacin (diagnostic test).

95. Tension Type Headache (TTH)
Previously called tension headache, muscle contraction
headache, stress headache
Most common primary headache (30-70% prevalence)
Episodic (frequent/infrequent) and chronic forms
Usually frontal /temporal location
Tightness, pressure in hat-band like distribution
+/- pericranial muscle tenderness
Often co morbid with migraine w/o aura.

96. Tension Type Headache
NOT DUE TO ABNORMAL MUSCLE CONTRACTION

97. Neuropathic Orofacial Pains
EPISODIC
Trigeminal Neuralgia
Glossopharyngeal Neuralgia
CONTINUOUS
Painful Traumatic Trigeminal Neuropathy
Post Herpetic Neuralgia
Persistent Idiopathic Facial Pain (PIFP)
Persistent Dento-alveolar Pain (PADP)
Burning Mouth Syndrome

98. Case Presentation
▪ 65 year old female
▪ Sharp shooting pains upper anterior teeth 22/23
▪ Saw dentist - fillings, root canals, extraction,
bridge, removal of bridge
▪ Inserting denture triggers sharp pain
▪ Repeated denture adjustments

99. Case Presentation
EXAMINATION
Cervical spine - normal
Cranial nerve screen - normal
TMJ/MM - normal
Myofascial - tender masseter.
Intraoral - mucosa normal appearance
trigger area palatal to 23 site.

100. Orofacial Neuropathic Pain

101. Trigeminal neuralgia
Brief, electric shock-like, lancinating pains
that affects the face unilaterally affecting one
or more divisions of the trigeminal nerve

102. Trigeminal Neuralgia
Intermittent brief paroxysmal pain (secs-mins)
Limited distribution: V2 and/or V3 > V1
Trigger zone –minor stimuli- touch, wind, shave
Abrupt in onset and termination and may remit
Remission period can spontaneously occur that lasts for
weeks to years, and may return
Triggerable or spontaneous
No obvious local cause

103. Painful Post Traumatic Trigeminal
Neuropathy (AFP, PIFP)
Unilateral facial and/or oral pain
Usually continuous +/- sharp jolts of pain
History of trauma to same V nerve branch
Positive and/or negative neurosensory signs
(allodynia, hyperalgesia, hypoesthesia etc)
Equivocal response to LA nerve block
Varying degree of central & sympathetic involvement

104. Case presentation
40 yo female
Complains of 3 years continuous dull aching pain in
lower left quadrant. Occasional sharp pains.
Problem commenced after periodontal surgery and
surgical extraction of third molar.
Since had RCT of 1st and 2nd molars w/o effect
Aggravated by eating on that side and brushing teeth.

105. Persistent Dento-Alveolar Pain
Disorder (PDAP)
(Atypical Odontalgia, Phantom tooth pain)
Continuous variable pain
Localized to dento-alveolar region – tooth/extrn sites
Usually multiple (unsuccessful) dental procedures
No obvious local pathology-clinical/radiography
Not caused by another disease or disorder
+/- Sensory abnormalities
Somatic block equivocal

106. Case Presentation
48 year old female
2 years continuous dull, aching, burning pain in upper
right jaw
Presumed pulpitis so over time 3 x root canals
Extractions all upper molars, now wants premolar out
Extractions only aggravated pain, which has spread
Some sinus and menopausal symptoms
Hx of depression - not current

107. Case Presentation
Cervical Spine - normal
Cranial Nerve Screen - normal
Stomatognathic- normal
Myofascial – trigger points but not replicating pain
Intraoral- Extraction sites hyperaesthetic
Somatic block – negative
Sympathetic block- partially positive
Cone Beam CT, MRI- normal

108. Persistent Dento-Alveolar Pain
Disorder (PDAP)
(Atypical Odontalgia, Phantom Tooth pain)
Females > males – usually mid 40s on
Posterior maxillary quadrant most often
Hx of trauma - multiple dental procedures
Somatosensory abnormalities around tooth site
No evidence of psychopathology
<50% responded to LA block
Variable response to TCA, gabapentinoids, topicals etc
Repeated dental procedures are contraindicated

109. EETS
Excessive Endodontic Treatment Syndrome

110. Classification of Orofacial Pains
Somatic Pain
Superficial Pain
MucogingivalPain
Deep Pain
CutaneousPain
MusclePain
Myospasm
CentralMediatedMyalgia
MyofascialPain
LocalMuscleSoreness
ProtectiveCo-Contraction
TMJPain
OsseousPain
Connect.TissuePain
PeriodontalPain
VisceralPain
MusculoskeletalPain
VisceralMucosalPain
Glandular,ENTPain
PulpalPain
VascularPain
NeurovascularPain
CapsularPain
ArthriticPain
RetrodiscalPain
LigamentousPain
Neuropathic Pain
Episodic Pain
ParoxysmalNeuralgia
Continuous Pain
TrigeminalNeuralgia
PeripheralMediatedPain
MetabolicPolyneuropathies
CentralMediatedPain
EntrapmentNeuropathy
DeafferentationPain
NeuriticPain
BurningMouthDisorder
AtypicalOdontalgia
(PhantomPain)
NeurovascularVariants
OtherPrimaryHeadache
ClusterandotherTCA
ArteritisPain
PeripheralNeurits
HerpesZoster
PostHerpeticNeuralgia
Mood Disorders
BipolarDisorder
MoodDisorderdueto
aMedicalCondition
DepressiveDisorder
Anxiety Disorders
PosttraumaticStress
Disorder
AnxietyDisorderdueto
aMedicalCondition
GeneralizedAnxiety
Disorder
Somatoform Disorders
ConversionDisorder
PainDisorder
Undifferentiated
SomatoformDisorder
Other Conditions
PsychologicalFactors
AffectingMedCondition
OtherConditions
Malingering
Hypochondriasis
Axis II
(Psychological Conditions)
Axis I
(Physical Conditions)
OtherNeuralgias
Okeson, 2003ChronicRegional
PainSyndrome
Sympathetically Maintained Pain
Tension-Type
Migraine
Carotidynia
TraumaticNeuroma
MaladaptiveHealth
Behavior
Stress-Related
PhysiologicalResponse
PersonalityTraits
orCopingStyle
Axis I Axis II
Diagnosis

111. Thank you
• Islam Kassem
• ikassem@dr.com
• 00201222209842
• 002034810481
• 00201091472244

112. ikassem@dr.com
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