8. Orofacial Pain

Question 1

TRIGEMINAL NEURALGIA

What are the aetiological factors associated with trigeminal neuralgia ?

Answer 1

• Idiopathic.
• Vascular compression of trigeminal nerve.
• Secondary to other medical conditions e.g. MS, space occupying lesions, skull base bone deformity, arteriovenous malformation, CT disease.

Most commonly affects elderly.

Question 2

TRIGEMINAL NEURALGIA

What is the signs/symptoms of trigeminal neuralgia ?

Answer 2

• Unilateral, stabbing pain.
• Usually associated with CNV2 and CN3.
• 5-10 second duration.
• Paroxysmal.
• Mask like face.
• Freeze.
• Have to stop talking.

Question 3

TRIGEMINAL NEURALGIA

What are some red flags you should be concerned about if your patient presents with trigeminal neuralgia-like symptoms ?

Answer 3

• Young patients.
• Other cranial nerve lesions.
• Associated with sensory deficit on same side i.e. hearing loss.

Question 4

TRIGEMINAL NEURALGIA

What medications can be prescribed for patients suffering with trigeminal neuralgia ?

Answer 4

• Anti-epileptics - carbamazepine, oxycarbazine, lamotrigine.
• Gabapentin and pregabalin.

Carbamazepine can be prescribed in primary care but likely to refer for OM opinion.

Question 5

TRIGEMINAL NEURALGIA

What special investigations should be carried out if you are suspicious of trigeminal neuralgia ?

Answer 5

• MRI with contrast.
• Cranial nerve examination.
• Pain diary.

Question 6

TRIGEMINAL NEURALGIA

Your patient has an acute trigeminal neuralgia attack in your dental chair - what can you do for them ?

Answer 6

Give nerve block with LA.

Question 7

TRIGEMINAL NEURALGIA

What are some surgical options for treating trigeminal neuralgia ?

Answer 7

• Microvascular decompression.
• Balloon compression.
• Radiofrequency thermocoagulation.
• Peripheral nerve resection.

Risk of sensory and motor deficit following surgery.
Appropriate for young patients or patients on high dose of medication.

Question 8

TRIGEMINAL NEUROPATHY

Explain the causes of trigeminal neuropathy.

Answer 8

• VZV.
• Trauma.
• Idiopathic.

Question 9

TRIGEMINAL NEUROPATHY

How does trigeminal neuropathy differ from trigeminal neuralgia ?

Answer 9

• Pins and needles like feeling.
• Localised to CNV nerve.
• Continuous sensation.
• +/- paroxysmal.

Question 10

TRIGEMINAL AUTONOMIC CEPHALALGIA

What are some of the signs/symptoms of cluster headache ?

Answer 10

• Usually associated with CNV1 - orbital and temporal.
• Unilateral.
• Rapid onset.
• Severe.
• +/- aura.
• Nausea, vomitting, photophobia, yawning.
• Restless and agitated during attack.
• Can last 15mins to 3 hours.

Bout lasts 1-3 months, with 1 month remission.

Question 11

TRIGEMINAL AUTONOMIC CEPHALALGIA

What are some of the signs/symptoms of paroxysmal hemicrania ?

Answer 11

• Unilateral.
• Orbital and temporals.
• Rapid onset.
• Last 2-30 mins.
• Can have between 2-40 attacks a day.
• Severe.
• Ipsilateral autonomic symptoms - miosis, ptosis, lacrimation, eyelid oedema.
• Attacks preciptated by bending/rotating head.

Question 12

ORAL DYSAESTHESIA

Define oral dysaesthesia.

Answer 12

Abnormal sensory preception in absence of stimuli.

Question 13

ORAL DYSAESTHESIA

What are the two types of oral dysaesthesia and explain them ?

Answer 13

Somatoform - perception of stimuli in CNS is abnormal.
Neuropathic - nerves from PNS to CNS are not working appropriately.

Question 14

ORAL DYSAESTHESIA

What are the possible dysaesthesias ?

Answer 14

• Burning mouth.
• Dry mouth.
• Dysgeusia.
• Paraesthesia.

Question 15

ORAL DYSAESTHESIA

How can burning mouth be managed ?

Answer 15

Correct haematinic deficiency.
Assess if parafunction and treat.

Question 16

ORAL DYSAESTHESIA

How can touch dysaesthesia investigated ?

Answer 16

Cranial nerve examination.
MRI - to exclude tumour or demyelination.