Facial pain Flashcards
What are the risk factors of persistent idiopathic facial pain?
● History of widespread pain
● Genetic susceptibility
● Female
● Stress
What would a typical SOCRATES look like for a patient with Glossopharyngeal Neuralgia?
S – Unilateral & involving ear, base of tongue, tonsillar fossa or angle of mandible
O – Initiated by swallowing, chewing, talking or coughing
C – Severe stabbing pain
R – N/A
A – Syncope or Arrhythmias (due to Vagal nerve involvement)
T – Transient
E – Alleviating (sometimes pulling on earlobe)
S – Severe
Arrhythmias - Irregular heart beat
What are the 3 biopsychosocial factors affecting pain?
1) Disease – History & Presenting disease
2) Environment – Lifestyle, Culture, Upbringing & Trauma
3) Patient Characteristics – Genetics, Gender, Etc
What is the aetiology of trigeminal neuralgia?
- Trigeminal nerve compression at Root Entry Zone (REZ) by tumours/blood vessels
- Which lead to Nerve damage
- Which lead to Abnormal nerve firing
What type of disease is chronic/persistent pain?
Disease of neuromatrix
Define HYPOALGESIA
Diminished pain response to a normally painful stimulus
E.g. In MS (Multiple Sclerosis)
Define atypical odontalgia
Pain in a tooth or edentulous alveolar ridge but NO clinical or radiological abnormalities can be detected
(80% pts relate with dental treatment)
Define HYPERALGESIA
Increased response to stimulus which is normally painful
What is giant cell arteritis?
Granulomatous arteritis affecting large/medium sized arteries
Most frequently the Temporal arteries
Define burning mouth syndrome
An idiopathic burning discomfort or pain affecting people with clinically normal oral mucosa in whom a medical or dental cause has been excluded
What are some associated symptoms of cluster headaches?
Same side lacrimation
Nasal stuffiness
Restlessness
Nausea
What topical and sytemic tx can be given to pts with atypical odontalagia?
Topical Treatment
* Capsaicin or Lidocaine
Systemic Treatment
* Tricyclic Antidepressants (Amitriptyline or Nortryptilline)
* Anti-epileptics (Gabapentin or Pregabalin)
Define DYSAESTHESIA
Unpleasant sensation whether spontaneous or evoked
How do you manage a pt with burning mouth syndrome?
Strong reassurance to Px
Consider cognitive behaviour therapy if moods are causing issue
What are the risk factors of trigeminal neuralgia?
Multiple sclerosis and hypertension
MS - lifelong condition that affects the brain and nerves
Define ANALGESIA
Absence of pain in response to a normally painful stimulus
What are some systemic causes of burning mouth syndrome?
● Systemic disease (e.g. Diabetes)
● Medications (e.g. ACE inhibitors)
● Hormone & Vitamin deficiencies
What is the most common non-dental facial pain?
Temporomandibular Disorders (TMD)
What affected anatomy contributes to orofacial pain?
Pain involving area above the neck, anterior to ears & below the orbitomeatal line (including pain from oral cavity)
How do you diagnose Persistent Idiopathic Facial Pain?
Diagnosis is via Exclusion of other causes
(due to non-specific symptoms – “poorly localised pain with widespread radiation” OR no help after several dental interventions - Ie several XLAs and still pain)
What are the pharmalogical tx options for TMD?
● Analgesics – NSAIDs, Paracetamol or Opioids
● Corticosteroids – Iontophoresis or Intra-capsular injections
● Antidepressants
● Anxiolytics
● Sedative-Hypnotics
● Muscle relaxants
Think that a patient with TMD is normally stressed/anxious/depressed
How do you manage pts with atypical odontalagia?
Reassure Px no dental cause & stop on-going cycle of dental interventions
Consider congitive behaviour therapy
How do you manage a pt with persistent idiopathic facial pain?
Hold off on unnecessary dental treatments till pain resolved (assure Px unrelated to dental and explain likely cause ie stress)
Consider congitive behaviour therapy or use of antidepressants
How do you mange giant cell arteritis?
Corticosteroids (40-60mg/day Prednisolone)
Calcium or Vit D supplements
How long does pain need to be present for it to be considered chronic or persistent?
Over 3 months
How long can cluster headaches last for?
Pain builds up over 5-10 mins & can last hours (average 45 mins)
What do the words;
Chronic
Persistent
Imply about the pain itself?
Chronic implies may never go
Persistent suggests able to live with
What are the conserative tx options for TMD?
● Behavioural changes (parafunctional habits)
● Relaxation
● Diet advise – avoid hard/brittle foods
● Jaw exercises
● Massage
● Warmth to joints
What is the aetiology of Glossopharyngeal Neuralgia?
1) Primary = Nerve compression
2) Secondary = Congenital vascular anomalies, Tumour or Aneurysm
How do you diagnose burning mouth syndrome?
Diagnosis is via Exclusion of Actual causes of Burning mouth (e.g. Vit B/Folate deficiency anaemia)
Define Temporomandibular Disorders (TMD)
Collective term – Mucoskeletal disorders involving muscles of mastication and/or TMJ
What would a typical SOCRATES look like for a patient with Trigeminal Neuralgia?
S – Normally UNILATERAL (60% right side)
O – Anytime
C – Flashing, Sharp, Shooting, Unbearable, Terrifying
R – Distributions of the Trigeminal Nerve (first division rare)
A – Weight loss
T – Intermittent (Bouts last seconds, followed by pain free periods weeks-months)
E – Provoking (Light touch, Eating or Talking)
S – Moderate to Severe
What would a typical SOCRATES look for a patient with TMJD?
S – TMJ may be uni or bilateral
O - Any
C – Dull/Aching/Throbbing pain
R – Pre/Post ear or Muscles of mastication
A – Stress, Clicking, Tender muscles, Headache/Migraine
T – Intermittent or constant
E – Provoking (Chewing, Yawning or Opening wide)
S – Mild to Moderate
What would a typical SOCRATES look like for a patient with Burning Mouth Syndrome?
S – Tongue, Lips, Palate (can radiate to whole mouth)
O – Anytime
C – Burning, Tender & “Irritating”/”Tiring”
R – Whole mouth
A – Feeling of Oral Dryness, Altered Taste, Depression/Anxiety
T – Intermittent or constant (worse in evening)
E – Provoking (Eating or Tension)
S – Mild to Moderate
What special investigations need to be carried out for trigeminal neurlagia?
FBC
MRI scan of posterior fossa to detect compression and rule out tumours and MS
Define PARAESTHESIA
Abnormal (not unpleasant) sensation whether spontaneous or evoked
What is the likely age of onset for giant cell arteritis?
Above 50 y/o
Consider this diagnosis in any elderly Px with recent onset headache or facial pain
What are cluster headaches?
Unilateral excruciating attacks of pain principally involving orbital, frontal and temporal regions
What are different disorders included in TMD?
Myofascial pain disorder
TMJ disc interference disorders
TMJ degenerative joint disease
Define ALLODYNIA
Pain due to a stimulus that would not normally provoke pain
E.g. VZV Post-Herpetic Trigeminal Neuralgia can lead to pain touching skin or clothes
Define trigeminal neuralgia
Sudden, usually unilateral, severe, brief, recurring, stabbing pain in the distribution of one or more branches of the trigeminal nerve
What would a typical SOCRATES look like for a patient with Atypical Odontalgia?
S – Well localised (Max molars and premolars most affected)
O – In conjunction with dental interventions
C – Persistent Dull/Ache/Throbbing pain
R – N/A
A – N/A
T – Intermittent or constant
E – Provoking (Chewing)
S – Moderate
What are some complocations associated with giant cell arteritis?
Visual ischaemic complications
Irreversible visual loss
Increased risk of mortality from cardiovascualr disease
What are the adjunctive tx options for TMD?
Alongside conserative and pharmalogical tx
● Splint therapy
● Cognitive Behavioural Therapy
● Physiotherapy
● Acupuncture
● Botox injections
What would a typical SOCRATES look like for a patient with persistent idiopathic facial pain?
S - Poorly localised pain w/ widespread radiation
O - Any
C - Nagging, Dull, Throbbing, Sharp or Aching
R - Widespread (Can go anywhere)
A – Pain in other areas (headaches, neck or back)
T – Intermittent or constant
E – Provoking (Chewing, Stress, Cold weather or Dental Stress)
S – Mild to Severe
How do you manage Glossopharyngeal Neuralgia?
Medication such as Carbamazepine
Cardiac pacing may be required (if heart involvement)
Surgical nerve decompression
What age and gender has the highest prevalence of trigeminal neuralgia
50-60 years, more common in men
RARE CONDITION
What may patients with persistent idiopathic facial pain also complain about that they experience in their everyday life?
50% complain of chronic fatigue
50-70% complain of sleep disturbance
What are the five potential indicators of degenerative change in TMD?
How many changes need to be observed to suggest that it is becoming degenerative?
● Clicking
● Crepitus (sand paper like feeling on palpation)
● Limitation of movement – Locking
● Momentary hesitation/pause in movement
● Sudden inability to fully close teeth
What hormonal changes can cause burning mouth syndrome and how?
Menopause = Reduction in gonadal & neuroactive steroids
Chronic stress = Impaired HPA axis leads to reduced adrenal steroid levels
Loss of hormones = Loss of their neuroprotective effect
HPA Axis - hypothalamic-pituitary-adrenal axis
What are the risk factors of TMJD?
Depression (or other psychological distress)
Multiple pain conditions
Females
18-44 y/o
Bruxism
Sleep problems
Facial trauma
Contraceptive pill
Think females and their problems
As tigeminal neurlagia progresses how are periods of exacerbation and remission affected?
As disease progresses, periods of exacerbation increase and periods of remission decrease
What ages do cluster headaches normally start between?
28-30
What are the 3 main symptoms of burning mouth syndrome?
1) Px complains of Oral Dryness BUT THIS IS NOT THE CASE ON EXAMINATION
2) Px complains of Altered Taste
3) Tongue thrusting (pushing forward)
What is the ratio of M to F for cluster headaches?
M>F ratio 5:1
What may you see in blood reports of pts with giant cell arteritis?
ESR (Erythrocyte Sedimentation Rate) above 50mm/min
What is the local and systemic tx options for burning mouth syndrome?
Symptomatic management
* Saliva substitutes
* Benzydamine oral rinse
Systemic Treatment
* Tricylicantidepssants (Nortriptyline/Amitriptyline)
* SSRIs (Fluoxetine)
SSRIs Selective serotonin reuptake inhibitors
What are the different classifcations of trigeminal neuralgia?
Idiopathic
– Typical
– Atypical
Secondary
– Intrinsic brainstem pathology (eg MS, Stroke)
– Extrinsic cerebellopontine angle pathology (e.g. aneurysms)§
What are some side effects to warn a pt about when taking carbamazepine?
Drowsiness
Dizziness
Diplopia (double vision)
Ataxia (lack of voluntary movement)
Allergic Reactions
What are some local causes of burning mouth syndrome?
● Mucosal diseases
● Infection
● Parafunctional habits (e.g. bruxism)
● Ill-fitting dentures
● Hypersensitivity reactions
What should be avoided in pts experiencing cluster headaches?
Avoid alcohol (major trigger)
What can be prescribed to a patient with trigeminal neuralgia?
Carbamazepine (GOLD STANDARD)
Oxcarbamezepine (less drug interactions & less side effects)
Lamotrigene
Baclofen
Phenytoin
