Chronic facial pain: atypical facial pain and atypical odontalgia Flashcards
How to manage chronic pain?
Assess and diagnosis
Explanation and reassurance
Discuss/suggest tx options
TMJ chronic pain?
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
Neuralgic chronic pain?
Nerve distribution Fair to good localisation Lasts seconds Precipitated by touch, wind, vibration No signs Causes - idiopathic, MS Tx - tegretol, nerve block, neurosurgery
Atypical chronic pain?
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
Vascular chronic pain?
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
Questionnaires for chronic pain?
McGill pain questionnaire
Visual analogue scale
Biopsychosocial assessment for chronic pain? What are the 3 parts to pain?
3 parts to pain
Biological
Psychological - anxiety/depression
Social context - work/finance/family
What is oral dysaesthesia?
Burning pain in the tongue from any cause
Aetiology - unknown
Management - CBT improved 6/12, oestrogen increased taste
Prognosis unknown
Local causes of burning mouth? How to investigate these causes?
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
Systemic causes of burning mouth?
Decreased iron folate B12 Diabetes Menopause Psychogenic Cancerphobia
How to manage oral dysaesthesia?
Correct deficiencies Alter medications - Topical clonazepam - Antideressants - Alpha-lipoic acid - Capsaicin capsule - CBT Manage symptoms
Atypical facial pain?
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
Associated features with atypical facial pain?
Facial swelling/flushing
Altered sensation
Lacrimation
What did lascelles, 1966 find?
After 4 weeks of MOAI, Phenalzine 75% of pts showed an improvement in pain and 30% showed improved depression
What is aypical odontalgia?
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
Symptoms of atypical odontalgia?
Toothache with no dental pathology
Constant throb or ache
Dental tx makes no difference or improvement for a week
What happens when you remove a tooth with atypical pain?
Pain remains same
Pain moves to adjacent teeth
Pain in gingival tissue that previously surrounded tooth
Aetiology of atypical odontalgia?
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
What are abnormal pain responses?
At the site of injury or no injury e.g. chronic pain, abnormal pain responses can occur
Define hyperalgesia
Stimulation is more painful
Define allodynia
Non painful stimuli are painful
Define spontaneous pain
Pain in the absence of stimulus
Define central sensitisation/ secondary hyperalgesia?
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
Define wind up
Central enhanced responsiveness and increased AP firing rate leading to increased perceived pain intensity
Types of therapy for chronic pain?
Stress management
Relaxation/hypnosis
CBT
Psychological help for other problems including talking therapy
What is CBT?
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
What did Feinmann 1984 discover?
Dothiepin - after 9 weeks 71% pain free, withdrawal of drug at 6 months led to relapse in some patients
Analgesic antidepressant drugs?
Helpful with chronic pain with known pathology as with unknown pathology or aetiology
e.g. chronic arthritis
e.g. Amitriptyline/nortriptyline 10-100mg nocte
Abnormal signs for atypical pain?
Abnormal cranial nerve testing results
- Abnormal sensations
- Abnormal responses
Vomiting/headache - increased intracranial pressure
