CNS/HN - Facial Pain

Question 1

Differential Diagnosis - TMJ

Answer 1

Differential Diagnosis

• TMJ Dysfunction
• Dental infection
• Fracture/Dislocation of Mandible
• Gout
• Temporal arteritis
• Cluster headache
• Migraine
• Trigeminal neuralgia
• Otitis media
• Sinusitis

Question 2

Differential Diagnosis - Trigeminal Neuralgia

Answer 2

○ Trigeminal neuralgia
			• Maxillary and mandibular
○ Herpes Zoster / Postherpetic neuralgia.
			• Rash
			• Rash on dermatomal levels - ocular
○ Ramsay Hunt syndrome
○ Persistent idiopathic facial pain.
○ Temporomandibular disorders.
○ Otitis (externa or media).
○ Referred pain (eg,dental abscess).
○ Carcinoma of the nasopharynx.
○ Sinusitis
○ Sialolith

Question 3

Management - TMJ

Answer 3

• Pain medication
• OPG (orthopantogram) xray, CT or MRI
• Advise:
• When eating avoid opening your mouth wider than the thickness of your mouth and cut all food in small pieces.
• Do not bite any food with your front tooth.
• Avoid food that requires prolonged chewing.
• Do not protrude your jaw and avoid clenching your teeth together.
• Sleep on your back and do not sleep on your jaw.
• Avoid chewing gum.
• Once acute phase has settled you can perform a set of exercises: chewing soft wood exercise. Place a soft piece of wood so that your back teeth and clench your teeth rhythmically for 2-3 minutes 3x a day.
• If no response to conservative treatment, or with painful RA or OA then steroid injection can be given.
• Others: muscle relaxants, moist heat of massage;
• dental management may be required for malfunction of bite includes dental occlusal splinting

Question 4

Diagnosis - TMJ

Answer 4

Diagnosis
- You have a condition called TMJ dysfunction. It is the abnormal movement of the jaw bone in its socket where it connected to the temporal bone at the base of the skull. This joint along with its attached muscles allows the movements needed for chewing, speaking, and facial expressions.

Question 5

Treatment - Trigeminal Neuralgia

Answer 5

Ix - clinical, if in doubt may order MRI 
Tx - 
Carbamazepine - usual treatment 
If carbamazepine doesnt work or with se may use 
- Gabapentin
- Lamotrigine 
- Baclofen
- Oxcarbazepine 

Deep brain stimulation
Surgical
- Decompression surgery
- Ablative surgical treatment

Question 6

Red flags - Trigeminal Neuralgia

Answer 6

• depressed and anxious.
• You may neglect to clean your teeth or not eat for fear of triggering the pain.
• This can then lead to poor diet, weight loss and poor mouth hygiene.
• sometimes occurs in multiple sclerosis