Chronic orofacial pain Flashcards
1
Q
what is a neuralgia?
A
an intense stabbing pain
pain usually brief but may be severe
2
Q
where does neuralgic pain appear?
A
it extends along the course of the affected nerve
3
Q
what is neuralgia usually caused by?
A
irritation of or damage to a nerve (but not exclusively)
4
Q
which nerves that mediate sensation in the head can be involved in neuralgia?
A
trigeminal (most common form)
glossopharyngeal and vagus
nervus intermedius (geniculate neuralgia) - branch of facial nerve
occipital
5
Q
incidence of trigeminal neuralgia
A
4.3:100 000 pop (USA)
6
Q
gender distribution of trigeminal neuralgia
A
higher in females
7
Q
age group usually affected by trigeminal neuralgia
A
elderly - predominantly in 60s and above
8
Q
causes of trigeminal neuralgia
A
idiopathic
classical - vascular compression of the trigeminal nerve (most common known cause)
secondary
- multiple sclerosis
- space-occupying lesion (intra-cranial tumours - benign/malignant)
- others: skull-base bone deformity, CT disease, arteriovenous malformation
9
Q
classical Trigeminal Neuralgia - why doesn’t a vessel near CN5 necessarily mean it is this?
A
need vascular trigeminal conflict - compression
often need high resolution MRI with contrast
10
Q
trigeminal neuralgia - where does the pain appear?
A
unilateral maxillary or mandibular division pain > ophthalmic division
11
Q
trigeminal neuralgia type of pain
A
stabbing pain
12
Q
trigeminal neuralgia duration
A
5-10s
single stabs
each attack is a cluster/group of stabs (up to a few mins)
if >few mins likely not trigeminal neuralgia
13
Q
trigeminal neuralgia triggers
A
cutaneous
wind/cold
touch
chewing/jaw movements
14
Q
paroxysmal trigeminal neuralgia
A
no pain at all between the stabbing attacks
15
Q
concomitant continuous pain in trigeminal neuralgia
A
superimposed stabbing attacks
16
Q
is trigeminal neuralgia continuous?
A
no - get remissions and relapses
17
Q
why can trigeminal neuralgia present as a hybrid?
A
because it is on continuum with other cranial nerve pain disorders
18
Q
other presentations of trigeminal neuralgia
A
acute spasms of ‘sharp shooting pain’
- may be more than one division
- may be bilateral
- may have burning component
- may have vasomotor component
19
Q
why do trigeminal neuralgia patients often have a ‘mask-like’ face?
A
inexpressive as fear of making a facial movement that may set off an attack
20
Q
trigeminal neuralgia - how does the excruciating pain appear?
A
disabling
patient will freeze
21
Q
what is the crucial aspect when considering trigeminal neuralgia?
A
no obvious precipitating pathology
22
Q
trigeminal neuralgia red flags
A
younger patient (<40yrs)
sensory deficit in facial region
- hearing loss - acoustic neuroma
other cranial nerve lesions
23
Q
what are two crucial investigations in trigeminal neuralgia?
A
test cranial nerves (identify sensory deficit)
MRI
24
Q
what drug group is predominantly used to treat trigeminal neuralgia?
A
anti epileptic drugs
25
first line drugs for trigeminal neuralgia
carbamazepine
oxcarbazepine
lamotrigine
26
what is the modified release carbamazepine called and why is it good in trigeminal neuralgia?
Tegretol
| good to decrease SEs as prevents fluctuations in serum concentration
27
lamotrigine onset of action
slow
28
second line drugs for trigeminal neuralgia
gabapentin
pregabalin
phenytoin
baclofen
29
trigeminal neuralgia - which drug should patients be responsive to?
carbamazepine if tolerated
30
trigeminal neuralgia - what should drug therapy aim for?
maximise efficacy and minimise SEs
31
trigeminal neuralgia - when is it often difficult to control pain?
first thing in the morning
32
trigeminal neuralgia - what can a pain diary be used for?
identify modifications necessary to therapy
33
can trigeminal neuralgia be responsive to LA?
yes
34
carbamazepine side effects
```
blood dyscrasias
electrolyte imbalances (hyponatraemia)
neurological deficits
liver toxicity
skin reactions
```
35
carbamazepine blood dyscrasias
thrombocytopenia
neutropenia
pancytopenia
36
carbamazepine electrolyte imbalances
hyponatraemia
37
what should you be careful combining carbamazepine with?
diuretics or PPIs that can cause hyponatraemia
38
carbamazepine neurological deficits
paraesthesia
vestibular problems
dizziness
39
carbamazepine - how severe can skin reactions be?
potentially life-threatening
40
blood monitoring on carbamazepine
weekly basis for first month then monthly
| FBC, urea, LFT, electrolytes
41
should you prescribe carbamazepine in GDP?
BNF dental preparations
SDCEP guidelines
expertise
facilities for monitoring toxicity
42
trigeminal neuralgia -when would surgery not usually be recommended?
if patient managing on medical therapy with moderate drug use and no significant SEs
43
trigeminal neuralgia - when to consider surgery
when approaching maximum tolerable medical management even if pain controlled
'younger' patients with significant drug use - will have many years of drug use
44
trigeminal neuralgia surgical options
```
microvascular decompression (MVD)
destructive central procedures
stereotactic radiosurgery
destructive peripheral neurectomies
```
45
trigeminal neuralgia - what is the preferred surgical treatment where possible?
MVD
46
trigeminal neuralgia - what does MVD require?
a vessel impinging on the trigeminal nerve root
47
trigeminal neuralgia MVD 12month mortality and morbidity
1% mortality
| 10% morbidity
48
trigeminal neuralgia - destructive central procedures
radio frequency thermocoagulation
retrogasserian glycerol injection
balloon compression
49
trigeminal neuralgia - balloon compression mortality at 9months
2%
50
trigeminal neuralgia - stereotactic radiosurgery
gamma knife - targeted radiation at the trigeminal ganglion to kill trigeminal nerve cells
good safety profile but only available in Sheffield
51
trigeminal neuralgia - destructive peripheral neurectomies
only performed as a last resort after trial LA
| 6 months pain free without medication - can result in allodynia as well as TN
52
trigeminal neuralgia - complications after surgery
```
local effects - peripheral treatments (cryotherapy)
sensory loss
- corneal reflex
- general sensation
- hearing loss
motor deficits
may be reversible or irreversible
```
53
causes of painful trigeminal neuropathy
herpes zoster virus (related to active VZV infection, post-herpetic 'neuralgia')
trauma (pain develops <6m of traumatic event)
idiopathic
54
painful trigeminal neuropathy - where is the pain usually localised to?
the distribution(s) of the trigeminal nerve
55
painful trigeminal neuropathy - how is the pain commonly described?
burning or squeezing
| likened to pins and needles
56
painful trigeminal neuropathy - duration and presentation of pain
primary pain is usually continuous or near-continuous
| superimposed brief pain paroxysms may occur, but not the predominant pain type
57
what symptoms more commonly present in painful trigeminal neuropathy than in Trigeminal Neuralgia?
clinically evident cutaneous allodynia - much larger than the punctate trigger zones present in TN
and/or
sensory deficits
58
what is allodynia?
pain elicited on innocuous stimuli e.g. touch
59
how are TN and PTN linked?
thought to be on continuum of the same spectrum
60
trigeminal autonomic cephalgias - symptoms
```
unilateral head pain - predominantly V1
v severe/excruciating
usually prominent cranial parasympathetic autonomic features (ipsilateral to the headache)
- conjunctival injection/lacrimation
- nasal congestion/rhinorrhoea
- eyelid oedema
- ear fullness
- mitosis and ptosis (Horner's syndrome)
attack frequency and severity differs
```
61
cluster headache attack frequency (daily)
1 every other day - 8 per day
62
paroxysmal hemicrania attack frequency (daily)
1 to 2 - 40
| no circadian rhythm
63
SUNCT attack frequency (daily)
3-200
64
what does SUNCT stand for?
```
Short-lasting
Unilateral
Neuralgiform with
Conjunctival injection and
Tearing
```
65
cluster headache duration of attack
15-180mins (majority 45-90mins)
66
paroxysmal hemicrania duration of attack
2-30mins
67
SUNCT duration of attack
5-240 secs
68
cluster headache pain quality
sharp, throbbing
69
paroxysmal hemicrania pain quality
sharp, throbbing
70
SUNCT pain quality
stabbing, burning
71
cluster headache pain intensity
v severe "suicide headache"
72
paroxysmal hemicrania pain intensity
v severe
73
SUNCT pain intensity
v severe
74
cluster headache circadian periodicity
70%
75
paroxysmal hemicrania circadian periodicity
45%
76
SUNCT circadian periodicity
absent
77
cluster headache - the attack: pain location
mainly orbital and temporal - affects first division of CN5
78
cluster headache - the attack: unilateral or bilateral?
strictly unilateral
79
cluster headache - the attack: onset
rapid
| max within 9mins in 86%
80
cluster headache - the attack: resolution
rapid cessation of pain
81
how do patients appear during a cluster headache attack (compared to migraines)?
restless and agitated
| vs migraines - motion sensitivity (want to stay still)
82
cluster headache attack other symptoms
prominent ipsilateral autonomic symptoms
| migrainous symptoms often present
83
migrainous symptoms
premonitory symptoms - tiredness, yawning
associated symptoms - nausea, vomiting, photophobia, phonophobia
aura in 14%
84
what % of cluster headache bouts are episodic?
80-90%
85
what % of cluster headache bouts are chronic?
10-20%
86
episodic cluster bouts defintion
attacks 'cluster' into bouts typically 1-3months with remission lasting at least one month
87
episodic cluster headaches pain between attacks?
may be continuous background pain between attacks or symptom free between attacks
88
episodic cluster headaches and alcohol
triggers attacks during a bout but not in remission
89
cluster headaches circadian periodicity
attacks occur at same time each day
| bouts occur at the same time each year
90
chronic cluster headaches definition
bouts last >1 year without remission
or
remissions last <1 month
91
location of pain in paroxysmal hemicrania
mainly orbital and temporal
| strictly unilateral
92
paroxysmal hemicrania - onset
rapid
93
paroxysmal hemicrania - resolution
rapid cessation of pain
94
paroxysmal hemicrania - what % are restless and agitated during an attack?
50%
95
paroxysmal hemicrania other symptoms
prominent ipsilateral autonomic symptoms
| migrainous symptoms may be present
96
what can 10% of paroxysmal hemicrania attacks be precipitated by?
rotating or bending the head
97
paroxysmal hemicrania - any background continuous pain?
may have
98
what % have chronic paroxysmal hemicrania?
80%
99
what % have episodic paroxysmal hemicrania?
20%
100
paroxysmal hemicrania - which drug do patients have an absolute response to (and is one of the diagnostic criteria)?
indomethacin (NSAID)
101
drug therapy for cluster headache - abortive for attack
subcutaneous sumatriptan 6mg or nasal zolmatriptan 5mg
100% O2 7-12l/min via a non-rebreathing mask (effective and safe)
- no smokers in household for home oxygen therapy
102
drug therapy for cluster headache - abortive for bout
occipital depomedrone/lidocaine injection (inject great occipital nerve)
or tapering course of oral prednisolone
103
drug therapy for cluster headache - preventative
verapamil
lithium
methysergide
topiramate
104
drug therapy for cluster headache - preventative verapamil
(high doses may be required) - contraindicated in patients with cardiac conduction problems, otherwise safety profile good
105
drug therapy for cluster headache - preventative lithium
can cause renal toxicity and diabetes insipidus, safety profile not great
106
drug therapy for cluster headache - preventative methysergide
inpatient setting
| retroperitoneal fibrosis
107
when would patients usually only qualify for CGRP monoclonal antibodies to treat cluster headaches preventatively?
if they have failed normal drug treatment
108
abortive treatment for paroxysmal hemicrania
none
109
prophylactic treatment for paroxysmal hemicrania
indomethacin
| alternatives if can't take NSAIDs not great - COX2 inhibitors, topiramate
110
definition of pain
an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
111
what can cloud a patients description of pain?
experience - what patient tells us is based on their experience and language skills
112
which group of patients find it difficult to describe pain?
children
113
4 ways of assessing a pain patient
numerical scale 1-10
physical symptoms
emotional symptoms
QOL scores
114
assessment of the pain patient - numerical scale
1-10
1D - can't show effect or emotional impact
can use a 100mm line without numbers and ask patient to point to severity of pain then measure - can be more accurate than when patient sees numbers
115
assessment of the pain patient - physical symptoms
pain scores McGill - choose a word from each box to describe quality of pain
116
assessment of the pain patient - emotional symptoms
psychological scores - HAD - Hospital Anxiety and Depression Scale - look at emotional impact of pain
117
assessment of the pain patient - QOL scores
Oral Health Impact Profile
| disability score: what you can't do because of pain
118
how do we feel pain?
nociception
peripheral nerve transmission
spinal modulation
central appreciation
pain is a decision your brain makes - understood in brain
- acute
- chronic - pain can be a decision your brain makes even when no tissue damage
119
motor supply to the face
facial nerve
120
motor branches of the facial nerve
```
temporal
zygomatic
buccal
mandibular
cervical
```
121
facial nerve - temporal branch
frontalis and procerus
122
facial nerve - zygomatic branch
eye and around orbit, mid face and smile
123
facial nerve - buccal branch
buccinator and upper lip
124
facial nerve - mandibular branch
L lip and orbicularis oris
125
facial nerve - cervical branch
platysma
126
sensory supply to the face
trigeminal nerve
127
ophthalmic nerve sensory branches to face
```
supratrochlear
supraorbital
lacrimal
infratrochlear
external nasal
```
128
mandibular nerve sensory branches to face
auriculotemporal
mental
buccal
129
maxillary nerve sensory branches to face
zygomaticotemporal
zygomaticofacial
infraorbital
130
which nerve other than trigeminal provides sensory innervation to the face?
great auricular C2, C3
131
which nerves provide sensory innervation to the back of the head?
spinal nerves
- greater occipital C3
- third occipital C3
- lesser occipital C2, C3
- great auricular C2, C3
132
which cranial nerve is associated with the first pharyngeal arch?
trigeminal nerve
133
which cranial nerve is associated with the second pharyngeal arch?
facial nerve
134
which cranial nerve is associated with the third pharyngeal arch?
glossopharyngeal nerve
135
which cranial nerve is associated with the fourth pharyngeal arch?
vagus (superior laryngeal branch)
136
what does the maxillary prominence (dorsal portion) become?
future maxilla, zygomatic bone and part of the temporal bone
| associated with the maxillary cartilage - gives rise to the incus
137
what does the mandibular prominence (ventral portion) become?
the future mandible
| associated with Meckel's cartilage - gives rise to the malleus and sphenomandibular ligament
138
motor branch of facial nerve
muscles of facial expression
139
sensory branch of facial nerve
small area around concha of external ear
140
special sensory branch of facial nerve
taste to anterior 2/3 of tongue via chorda tympani
141
p/s branch of the facial nerve
glands - submandibular, sublingual, lacrimal
142
2 roots of facial nerve
motor root and sensory root
143
nerves branching off facial nerve before the stylomastoid foramen
greater petrosal nerve
nerve to stapedius
chorda tympani
144
nerves branching off facial nerve after the stylomastoid foramen
posterior auricular nerve
nerve to digastric
nerve to stylohyoid
terminal motor branches
145
sensory innervation of the external ear
```
lesser occipital C2, C3
facial
great auricular C2, V3
auricular branch of vagus
auriculotemporal
```
146
what nerve supplies the internal surface of the tympanic membrane?
CN9
147
where are the cells in the trigeminal ganglion derived from?
neural crest
148
what are the 3 trigeminal nuclei and where are they located?
mesencephalic nucleus - midbrain
principle sensory nucleus (pontine trigeminal nucleus) - pons
spinal nucleus - medulla
149
nuclei vs ganglia
nuclei situated within CNS
| ganglia outside CNS
150
what does the trigeminal ganglion bring in?
peripheral nerves
151
why do all the nerves synapse in the trigeminal ganglion?
join up in same place as all came from same place embryologically
152
referred pain
where pain is felt is not where it is generated
| nerves all in close proximity so sometimes misperception - because of way nerves connect into the trigeminal nucleus
153
what condition is referred pain common in?
TMD - pain over midface
154
what can sensory nerve supply be split into?
somatic (part of CNS associated with voluntary control of body movements via skeletal muscles)
autonomic
- sympathetic
- parasympathetic
155
give an example of autonomic referred pain?
jaw pain when climbing stairs - may be angina
156
somatic reflex arc
sensory neuron - relay neuron - motor neuron
always involve CNS
info to brain but also local connection to motor nerve
automatic response - for protection
157
how does the autonomic reflex arc vary from the somatic?
motor output side
in CNS may or may not be an interconnector neuron involved
motor output involves 2 motor neurons
158
motor output in autonomic reflex arc
2 motor neurons
first located in CNS (spinal cord)
second in PNS in an autonomic ganglion
159
what is the effector in an autonomic reflex arc?
not skeletal muscle
may be smooth muscle e.g. gut wall, or sweat gland or adrenal medulla
peristalsis, nausea, sweating etc
160
what symptoms indicate autonomic pain transmission - reflex arc?
reflex vascular vasodilatation - sore area fills with blood - swelling and hot
161
long reflex
involves spinal cord - somatic and autonomic
| sensory receptor cell synapse with motor in CNS - if autonomic also peripheral ganglion
162
short reflex
autonomic only
completely peripheral, only involves the local integration of sensory input with motor output
sensory receptor cell synapses only in peripheral ganglion
163
peripheral sensitisation
"increased responsiveness and reduced threshold of nociceptive neurons in the periphery to the stimulation of their receptive fields"
164
Gate control of chronic pain (Melzak and Wall)
squeeze/rub area - cause sensory info to go up own nerve into brain, then synapse with pain nerve fibres
- make pain signal less easy to transmit - less pain
can also get descending facilitation/inhibition - descending nerves from brain
- e.g. if you expect pain it makes nerve easier to fire
165
neuronal plasticity
sprouting of spinal segment nerves - sensory fibre becomes stimulatory - so if you touch it it feels sore
a way body manages pain unhelpfully - normal feeling being felt as pain
can have real pain without a findable cause
166
pain modulating receptors - biochemical
adrenergic - effect on pain
opiate - effect on mood
NMDA - causes misery and pain (ketamine binds to this)
167
pain sensitisation
inflammation - sensitisation
peripheral or central
chemical balance within pain is complicated
168
learned pain
brain can learn to expect pain from an area - even when you remove cause they might still feel it
169
drugs which target nerve endings
LAs
| NSAIDs
170
drugs which target the primary afferent nerve
LAs
171
drugs which target the dorsal root ganglion
LAs, a2 agonists
172
drugs which target the dorsal horn
opioids
ketamine
gabapentinoids
173
drugs which target the descending noradrenergic and serotoninergic inhibitory fibres
opioids
a2 agonists
TCAs
SSRIs
174
location of CRPS
delocalised pain
spreads around 'anatomical' boundaries
bilateral
often autonomic nerve damage - don't follow boundary of somatic nerves
175
symptoms of CRPS
gripping, tight, burning
feeling of swelling and heat (increased blood flow)
colour change in overlying skin
significantly disabling
autonomic changes - autonomic nerve version of neuropathic pain
176
management of CRPS
analgesics e.g. ibuprofen won't help
but centrally acting e.g. morphine will as they interfere with pain process
- swelling and erythema may persist due to reflex arc (happens lower down)
177
nociceptive pain
caused by activity in neural pathways in response to potentially tissue damaging stimuli
178
examples of nociceptive pain
```
post-op pain
mechanical low back pain
sports/exercise injuries
sickle cell crisis
arthritis
```
179
mixed type pain
caused by a combination of both primary injury or secondary effects
180
what is neuropathic pain initiated/caused by?
primary lesion or dysfunction in the somatosensory nervous system
usually a history of 'injury' - can follow facial trauma, extractions, 'routine' treatment without complications
can get non-specific neuropathic pain
181
types of neuropathic pain
spinal cord injury
diabetic neuropathy
post-herpetic neuralgia (virus damages nerves)
neuropathic low back pain
distal polyneuropathy (e.g. diabetic, HIV)
central post-stroke pain (damage parts of brain processing pain)
trigeminal neuralgia
CRPS
MS
182
most common type of neuropathic pain
diabetic neuropathy
183
symptoms of neuropathic pain
constant burning/aching pain
fixed location
often a fixed intensity
- nerve damage there all the time and in the same place all of the time
184
neuropathic pain - genetic predisposition?
nerve ion channels that heal badly after injury
persistent inflow gives persistent information reporting
- inherit a particular type of channel that heals less well - more likely to get neuropathic pain
185
why can patient management with neuropathic pain be difficult?
patient perceives the pain in the end tissue not where the nerve is damaged
186
when can you see neuropathic pain dentally?
after a tooth extraction if tear nerve endings - analgesics not working
can present similarly to toothache - don't extract as won't get rid of pain
187
potential causes of neuropathic pain - 4 broad categories
disease process
trauma
genetic predisposition
therapeutic intervention
188
potential causes of neuropathic pain - disease process
infection/inflammation
neurotoxicity
tumour infiltration
metabolic abnormality
189
potential causes of neuropathic pain - trauma
external injury
nerve compression
inflammation
190
potential causes of neuropathic pain - genetic predisposition
inherited neurodegeneration
| metabolic/endocrine abnormalities
191
potential causes of neuropathic pain - therapeutic intervention
surgery
chemotherapy
irradiation
192
neuropathic pain - if autonomic nerve associated what other symptoms may you get?
associated heat/swelling
193
options for management of neuropathic pain
systemic medication
topical medication
physical
psychological
194
systemic medication for neuropathic pain
pregabalin
gabapentin
>they work on nerve conduction to turn down the vol
tricyclics - works centrally, reduces transmission in CNS
valproate
mirtazepine
opioid analgesics
195
topical medication for neuropathic pain
capsaicin
EMLA
benzdamine
ketamine
196
how does capsaicin work for neuropathic pain?
like gate theory - switches off nerve to pain
| but hard to use in mouth - chilli peppers - can give burning sensation
197
physical management of neuropathic pain
TENS - occ helpful (low frequency)
| acupuncture - good results
198
psychological management of neuropathic pain
distraction- train patient not to pay attention to pain
correct abnormal illness behaviour - people don't do things because of pain - make QOL better
improve self-esteem/positive outlook
199
understanding pain - barbie
your brain has a map of you "barbie", then projects pain to the actual bit of you - you have learned to 'feel' it in arras. brain projects it into a reconstruction of yourself
200
understanding pain - if you change balance of neurotransmitters what happens?
brain percepts things differently as env of perception has changed
201
phantom limbs
pts can still tell you exactly what it feels like as they feel it the same as we feel our arm
brain continues perception of arm even though physical inflammation gone
body perceives phantom as it perceives limb
often brain barbie persists as it was initially
202
phantom limbs- how do you re-educate the brain to behave differently with a phantom?
mirrored box
203
neglect as consequence of stroke
limbs don't match up with barbie
204
body dysmorphia
perception of how you see your body is wrong
| due to change in biochemistry and perception
205
cognitive deduction
make wrong decision about what is real
206
atypical odontalgia
dental pain without dental pathology (toothache without any disease)
treating the tooth won't make barbie's tooth better
v difficult to diagnose
207
gender distribution of atypical odontalgia
equal
208
atypical odontalgia - distinct pattern of pain
pain free or mild between episodes
intense unbearable pain
- 2-3 weeks duration
- settles spontaneously
209
sequelae of atypical odontalgia
```
acute pulpitis pain
endo relieves or reduces pain
- pain returns after a short time
extraction relieves pain
- pain returns in adjacent tooth after a short time
endo relieves/reduces pain
- pain returns after a short time
extraction relieves pain
- pain returns in adjacent tooth after a short time
pt referred
```
210
features of atypical odontalgia
typical acute pulpitis symptoms
'irrational behaviour' - high motivational drive
'beg' for dental extractions
go elsewhere with modified story if extraction refused
suspect in patient with unusual extraction distribution
211
management of atypical odontalgia - primary care
refer
212
management of atypical odontalgia - oral medicine
chronic strategy
- reduce chronic pain experience
- reduce frequency of acute episodes
acute strategy
- have a plan to control pain - opioid analgesics as required, high intensity/short duration
- be prepared to extract tooth if needed
213
persistent idiopathic facial pain
```
pain which poorly fits into standard chronic pain syndromes
- neuropathic
- CRPS
- TMD
- trigeminal neuralgia
- migrainous pain
- atypical odontalgia
often a diagnosis of exclusion - exclude all the other categories
```
214
symptoms of persistent idiopathic facial pain
often high disability level - autonomic component
similar symptoms to neuropathic pain in character
often anatomically challenging
often associated symptoms - heat, pressure, swelling - usually nothing seen by observer
215
management of persistent idiopathic facial pain
```
believe pt - do not blame any associated depression for symptoms
do not increase damage - surgery is not helpful
adopt holistic strategy
- QOL issues
- pain control a bonus
- realistic outcomes - pt and clinician
use QOL/pain scores as tx monitor
often respond poorly to treatment
```
216
oral dysaesthesia
abnormal sensory perception in absence of abnormal stimulus
somatoform or neuropathic?
- where is the problem?
anxiety makes barbie confused - usually anxious but not depressed
ALL modes of oral sensation involved
- burning or 'nipping' feeling. thermal
- dysgeusia. taste
- paraesthesic feeling. touch
- dry mouth feeling. moistness
217
oral dysaesthesia - predisposing factors
deficiency states?
- haematinics, zinc, vit B1, B6
fungal and viral infections?
anxiety and stress? - tend to be chronic worriers
218
aetiology of oral dysaesthesia
F sex predominance
dissociated anxiety disorder
often associated symptoms
- poor sleep pattern - early morning waking
- swallowing problems - 'globus sensation' - catching in throat when eating, GORD
- IBS, dyspepsia, back pain
- body pain conditions, fibromyalgia
219
burning mouth syndrome
dysaesthesia most likely to be associated with haematinic deficiency
site important
- lips and tongue tip/margin = parafct. - clenching and rubbing tongue on back of teeth - provide splint
- multiple other sites - dysaesthesia
220
dysgeusia
```
bad taste/ bad smell/ halitosis
nothing detected by practitioner (barbie has it)
nothing found on examination
remember
- ENT causes - chronic sinusitis
- perio/dental infection
- GORD
nothing detected by patients partner?
leads to patient being isolated
```
221
touch dysaesthesia
pins and needles/tingling
normal sensation to objective testing
pin/needle elicit pain
cranial nerves test essential - must exclude organic neurological disease
must exclude local causes - infection/tumour
MRI essential - demyelination/tumour - MS can cause it
222
dry mouth dysaesthesia
very common
C/O debilitating dry mouth/Sjogrens
eating ok, worse when waken at night
usually the most obviously associated with anxiety disorders
feel they have a dry mouth even if they don't - it is a perceptual change
223
management of dysaesthesia - medication
tricyclic antidepressants (for anxiety) e.g. nortriptyline
- SE is dry mouth - they feel it differently to their other "dry mouth"
"neuropathic" medication - gabapentin, pregabalin (slso anxiolytic)
slow tx - takes 3-6m, work gradually - get decrease in frequency of symptoms
neuropathic topical medication
- clonazepam - topical?
- works as some patients may have neuropathic problem whereas some may have perceptual problem
224
management of dysaesthesia - other than medication
explain the condition to the pt
- 'pins and needles' in the taste etc
- 'feeling' problem rather than physical problem - we need to treat the feeling rather than the presenting problem
```
assess degree of anxiety
- anxiolytic medication - nortriptyline, mirtazepine
- clinical psychology
tx empower the patient
- control is important
```
225
classifying TMD patients
joint degeneration (doesn't mean pain)
- pain on use plus crepitus, +/- rest pain
internal derangement - disc issues, meniscus
- locking open or closed
no joint pathology
226
what is the cause of TMD?
occlusion - not cause of TMD in vast majority of patients
grinding
clenching
stress
227
patients seeking treatment for TMD
F higher - more likely to present
want rid of pain
- occasionally noise or locking is the problem
don't want to take meds or change lifestyle
don't see any activity which aggravates the condition
228
TMD disorders
```
multi-axis problem
usually systemic disorder
- 'pain vulnerable people'
- many systemic symptoms
high anxiety and low depression
- no psychiatric diagnosis in most cases
parafct a strong feature
- scalloping of tongue, ridging on buccal mucosa
```
229
TMD disorders - what is barbie doing?
anxiety making barbie confused?
barbie reporting on body pathology?
is pain peripheral - sore muscles - making barbie sore?
is barbie sore - central pain - causing muscle contraction?
- barbie's pain can make you clench your teeth
230
physical signs in TMD
```
clicking joint
locking with reduction
limitation of opening mouth
tenderness of MofM
tenderness of cervico-cranial muscles
```
231
TMD with no pathology
can have a motor output even if nothing happening
232
TMD history
```
acute pain in face and neck
ANY chronic face, head and neck pain
symptoms show periodicity
- morning/evening exacerbation
parafct clenching
history is the key to successful management
```
233
TMD examination findings
```
focal muscle tenderness
- masticatory
- sternomastoid
- trapezius
tenderness over TMJ itself
limitation of opening
- progressive
joint noise
- incidental - degenerative OA changes
- related to muscle dysfunction - click
deviation on opening - common finding with muscle dysfunction
dental occlusion upset
```
234
TMD investigations
usually none indicated for 'functional' disorders
indications for imaging
- US scan: if functional visualisation of disc movement is needed
- DPT or CBCT: if bony problem suspected
- MRI: best image of the disc
arthroscopy to directly visualise the disc
235
management of TMD
```
eliminate organic cause
'empower' pt
- cognitive therapy
- chronic disease - self-help
physical therapy
- CBT education+/- exercises
- soft diet and analgesics
- bite splint
biochemical manipulation
- tricyclic (not SSRI)
- other anxiolytic meds
physiotherapy
acupuncture
clinical psychology
```
236
children and TMD
tendency to anxiety neurosis
- 'anxious parents have anxious children'
- maladaptive response to 'normal' change
reaction to abuse
- school - bullying, fear of failure
- home - parental disharmony, physical abuse
