Chronic facial pain: atypical facial pain and atypical odontalgia

Question 1

How to manage chronic pain?

Answer 1

Assess and diagnosis
Explanation and reassurance
Discuss/suggest tx options

Question 2

TMJ chronic pain?

Answer 2

Temple, ear, jaws, teeth
Poor localisation, usually unilateral
Lasts weeks to years
Dull, continuous
Precipitated by chewing, yawning
Signs - limited mouth opening, click
Aetiology - stress, parafunction
Tx - Physiotherapy, behavioural, antidepressants

Question 3

Neuralgic chronic pain?

Answer 3

Nerve distribution
Fair to good localisation
Lasts seconds
Precipitated by touch, wind, vibration
No signs
Causes - idiopathic, MS
Tx - tegretol, nerve block, neurosurgery

Question 4

Atypical chronic pain?

Answer 4

Diffuse, deep, across midline
Poor localisation
Lasts weeks to yrs
Dull, boring, continuous
Precipitated by stress, fatigue
No signs
Aetiology - nerve injury, stress
Tx - antidepressants, behavioural

Question 5

Vascular chronic pain?

Answer 5

Located in orbit or upper face
Usually good localisation
Duration - minutes to yrs
Character - throbbing, deep
Precipitated by alcohol
Signs - lacrimation, eye infected
Aetiology - vasomotor 
Tx - triptans

Question 6

Questionnaires for chronic pain?

Answer 6

McGill pain questionnaire

Visual analogue scale

Question 7

Biopsychosocial assessment for chronic pain? What are the 3 parts to pain?

Answer 7

3 parts to pain
Biological
Psychological - anxiety/depression
Social context - work/finance/family

Question 8

What is oral dysaesthesia?

Answer 8

Burning pain in the tongue from any cause

Aetiology - unknown
Management - CBT improved 6/12, oestrogen increased taste
Prognosis unknown

Question 9

Local causes of burning mouth? How to investigate these causes?

Answer 9

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

Question 10

Systemic causes of burning mouth?

Answer 10

Decreased iron folate B12
Diabetes
Menopause
Psychogenic 
Cancerphobia

Question 11

How to manage oral dysaesthesia?

Answer 11

Correct deficiencies
Alter medications
- Topical clonazepam
- Antideressants
- Alpha-lipoic acid
- Capsaicin capsule
- CBT
Manage symptoms

Question 12

Atypical facial pain?

Answer 12

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

Question 13

Associated features with atypical facial pain?

Answer 13

Facial swelling/flushing
Altered sensation
Lacrimation

Question 14

What did lascelles, 1966 find?

Answer 14

After 4 weeks of MOAI, Phenalzine 75% of pts showed an improvement in pain and 30% showed improved depression

Question 15

What is aypical odontalgia?

Answer 15

Severe throbbing pain in the tooth without major pathology

Pain associated with a tooth or socket without any major pathology
Precipitated by dental procedures
If tooth is extracted the pain often recurs after a few weeks at a new site

Question 16

Symptoms of atypical odontalgia?

Answer 16

Toothache with no dental pathology
Constant throb or ache
Dental tx makes no difference or improvement for a week

Question 17

What happens when you remove a tooth with atypical pain?

Answer 17

Pain remains same
Pain moves to adjacent teeth
Pain in gingival tissue that previously surrounded tooth

Question 18

Aetiology of atypical odontalgia?

Answer 18

Sensitisation of nerves may occur after infec, extraction or RCT
Changes within the CNS and possibly ongoing neural activity
Female prevalence
Tends to be older patients
Psychosocial factors

Question 19

What are abnormal pain responses?

Answer 19

At the site of injury or no injury e.g. chronic pain, abnormal pain responses can occur

Question 20

Define hyperalgesia

Answer 20

Stimulation is more painful

Question 21

Define allodynia

Answer 21

Non painful stimuli are painful

Question 22

Define spontaneous pain

Answer 22

Pain in the absence of stimulus

Question 23

Define central sensitisation/ secondary hyperalgesia?

Answer 23

Changes in the behaviour of central cells

• Induced by tissue injury
• Increased spontaneous background firing
• Hyperexcitability to other low threshold input
• Increased size of receptive fields

Question 24

Define wind up

Answer 24

Central enhanced responsiveness and increased AP firing rate leading to increased perceived pain intensity

Question 25

Types of therapy for chronic pain?

Answer 25

Stress management
Relaxation/hypnosis
CBT
Psychological help for other problems including talking therapy

Question 26

What is CBT?

Answer 26

A way of talking about

• How you think about yourself, the world and people
• How what you do affects your thoughts and feelings

Change the way you think and do

Question 27

What did Feinmann 1984 discover?

Answer 27

Dothiepin - after 9 weeks 71% pain free, withdrawal of drug at 6 months led to relapse in some patients

Question 28

Analgesic antidepressant drugs?

Answer 28

Helpful with chronic pain with known pathology as with unknown pathology or aetiology
e.g. chronic arthritis

e.g. Amitriptyline/nortriptyline 10-100mg nocte

Question 29

Abnormal signs for atypical pain?

Answer 29

Abnormal cranial nerve testing results

• Abnormal sensations
• Abnormal responses

Vomiting/headache - increased intracranial pressure