Chronic Facial Pain Flashcards
What is chronic pain also known as? (3)
- Atypical facial pain
- Atypical odontalgia
- Burning mouth syndrome
What is the epidemiology of chronic facial pain? (2)
- 7 - 14% of the population MAY have chronic facial pain
- 10 million chronic pain sufferers in the UK
What are the stages of management of chronic pain? (1+1,2)
- Assessment and diagnosis
- Ensure no cause for concern
- Explanation and reassurance
- Discuss / suggest treatment options
What are the eight ways to characterise facial pain? (8)
- Location
- Localisation
- Duration
- Character
- Precipitating factors
- Signs
- Aetiology
- Treatment
Summarise TMJ facial pain with the eight indications (8)
- Location: temple, ear, jaws, teeth
- Localisation: poor, but usually unilateral
- Duration: weeks to years
- Character: dull, continuous
- Precipitating factors: chewing, yawning
- Signs: limited mouth opening, ?click
- Aetiology: stress, parafunction
- Treatment: physiotherapy, behavioural, antidepressants
Summarise Neuralgic facial pain with the eight indications (8)
- Location: nerve distribution
- Localisation: fair to good
- Duration: seconds
- Character: lancinating, paroxysmal
- Precipitating factors: touch, wind, vibration
- Signs: none
- Aetiology: idiopathic, MS
- Treatment: tegretol, nerve block, neurosurgery
Summarise Atypical facial pain with the eight indications (8)
- Location: diffuse, deep ?across midline
- Localisation: poor, does not fit anatomical boundaries of trigeminal nerve
- Duration: weeks to years
- Character: dull, boring, continuous, can be throbbing, aching “like a toothache”
- Precipitating factors: stress, fatigue, ill
- Signs: none
- Aetiology: nerve injury, stress
- Treatment: antidepressants, behavioural (CBT), LA block does not help
Summarise Vascular facial pain with the eight indications (8)
- Location: orbit or upper face
- Localisation: usually good
- Duration: minutes to hours
- Character: throbbing, deep
- Precipitating factors: alcohol
- Signs: lacrimation, eye injection
- Aetiology: vasomotor, ?allergic
- Treatment: triptans
What questionnaires are available for investigating chronic pain? (2)
- McGill Pain questionnaire
- Visual analogue scale
What is the theory behind biopsychosocial assessment? (1+3)
- Three parts to pain:
- Biological
- Psychological – anx/dep
- Social context – work/finance/family
What is oral dysaesthesia? Include reference (2)
- Burning pain in the tongue from any cause
- IASP 1994
What is the aetiology of oral dysaethesia? How is it diagnoses? What is the management and prognosis? (4)
- Aetiology: unknown
- Diagnosis: exclusion initially
- Management: CBT improved 6/12, oestrogen increased taste
- Prognosis: unknown
What local causes do you need to eliminate for burning mouth? How would you do this? (7)
- Bacterial oral swabs
- Fungal oral rinse for candida
- Allergy patch test
- Geographic tongue observe over time
- Parafunction dental examination
- Oesophageal reflux tooth erosion
- Xerostomia salivary flow rates
What systemic causes are there for burning mouth? (5)
- Decreased Iron folate B12
- Diabetes
- Climacteric (menopause – in women)
- Psychogenic
- Cancerphobia
What is the management for burning mouth? (2)
- Correct deficiencies
- Alter medications
In what areas can controlled trials investigate pain improvement? (4)
- Topical
- Systemic
- Psychological
- Not all placebo
With what medication have positive trials have taken place for burning mouth? (5)
- Topical clonazepam
- Antidepressants
- Alpha-lipoic acid
- Capsaicin capsule
- Cognitive behavioral therapy -EB
What four symptoms are important in atypical facial pain? (4+1 reference)
- Present daily and persist for most or all of the day
- Should be confined at onset to a limited area of one or both sides of the face, but may spread to the upper or lower jaws and a wider area of the face and neck
- Should not be associated with sensory loss or other physical signs
- The pain may be initiated by trauma, but persist without any demonstrable local cause
- Reference: IHS 1988
What should laboratory investigations demonstrate in atypical facial pain? (1+1 reference)
- Laboratory investigations should not demonstrate relevant abnormalities
- Reference: IHS 1988
What are the associated features of atypical facial pain? (3)
- Facial swelling/flushing
- Altered sensation
- Lacrimation (tears)
What was Lascelles, 1966? (5)
- 40 patients with Atypical facial pain (depressed)
- 4 week crossover trial of MOAI, phenalzine (15mg tds) vs. placebo
After 4 weeks - 75% of patients showed improvement in pain and
- 30% showed improved depression
Define and reference atypical odontalgia (1+reference)
- Severe throbbing pain in the tooth without major pathology
- IASP 1994
Describe atypical odontalgia (5)
- Pain associated with a tooth or tooth socket without any major pathology
- Constant throb or ache
- Precipitated by dental procedures
- Dental treatment: no difference or improvement for a week
- If the tooth is extracted the pain often recurs after a few weeks at a new site
Describe what happens after removal of a tooth with atypical pain (3)
- Pain remains same (with no tooth)
- Pain moves to adjacent teeth
- Pain in gingival tissue that previously surrounded tooth
What is the aetiology of atypical odontalgia? (5)
- Sensitisation of nerves may occur after infection, extraction or even RCT
- Changes within the CNS and possibly ongoing neural activity
- ?? Female prevalence
- Tends to be older patients
- ?? Psychosocial factors
What are abnormal pain responses? Give three examples (2)
- At the site of injury or no injury e.g. chronic pain, abnormal pain responses can occur
- e.g. phantom limb pain, AFP, traumatic lingual nerve dysaesthesia
What is Hyperalgesia? (1)
Stimulation is more painful
What is Allodynia? (1)
Non painful stimuli are painful
What is Spontaneous pain? (1)
Pain in the absence of stimulus
What is Central sensitisation / secondary hyperalgesia? Describe (5)
- Changes in the behaviour of central (SC) cells
- Induced by tissue injury
- Increased spontaneous background firing
- Hyperexcitability to other low threshold input
- Increased size of receptive fields
What are the possible types of therapy for atypical odontalgia? (4)
- Stress management - ? through GMP
- Relaxation / hypnosis
- Cognitive behaviour therapy, CBT (probably includes both of above)
- Psychological help for other problems inc. talking therapy
What is CBT? How can it help? (1+2, 1)
- It is a way of talking about:
- How you think about yourself, the world and other people
- How what you do affects your thoughts and feelings.
- CBT can help you to change how you think (‘Cognitive’) and what you do (‘Behaviour’).
What is the theory in CBT? (1, 1+4)
- A Situation - a problem, event or difficult situation
- From this can follow:
- Thoughts
- Emotions
- Physical feelings
- Actions
Describe Feinmann, 1984 (4)
- 93 patients with AFP or FAM (35% depressed)
- Double blind controlled trial of dothiepin vs. placebo with dose titration
- After 9 weeks - 71% pain free
- Withdrawl of drug at 6 months led to relapse in some patients
Describe Harrison et al, 1997 (4)
- 181 patients with AFP or FAM
- 3 months Randomised Controlled Trial of fluoxetine /placebo +/- CBT
- CBT improved pain scores
- These improvements were maintained when drug therapy ceased and the pt had CBT
Describe analgesic antidepressant drugs with regards to management, including dosage example (4)
- As helpful with chronic pain with known pathology as with unknown pathology or aetiology
- e.g.Chronic arthritis, post herpetic neuralgia
- Mainstay of management of AFP/AO
- Amitriptyline/nortriptyline 10-100mg nocte
What are abnormal signs when assessing chronic facial pain? (1+2, 1)
- Abnormal Cranial nerve testing results
- Abnormal sensations
- Abnormal responses
- Vomiting/Headache - ICP
