facial pain Flashcards
pain definition
“an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”
International Association for the Study of Pain
assessment of pain
Physical symptoms
* PAIN scores (McGill) – questionnaire, gives clinician some idea of what pt experiencing
Emotional symptoms
* Psychological scores (Hospital Anxiety and Depression scale (HAD) – useful to see how the pt perceives life with chronic pain)
QOL scores (Oral Health Impact Profile (OHIP) – what can you not to due to the pain e.g. chew, bite, yawn)
takes time, complex
assessment of pain
Physical symptoms
* PAIN scores (McGill) – questionnaire, gives clinician some idea of what pt experiencing
Emotional symptoms
* Psychological scores (Hospital Anxiety and Depression scale (HAD) – useful to see how the pt perceives life with chronic pain)
QOL scores (Oral Health Impact Profile (OHIP) – what can you not to due to the pain e.g. chew, bite, yawn)
takes time, complex
assessment of pain
Physical symptoms
* PAIN scores (McGill) – questionnaire, gives clinician some idea of what pt experiencing
Emotional symptoms
* Psychological scores (Hospital Anxiety and Depression scale (HAD) – useful to see how the pt perceives life with chronic pain)
QOL scores (Oral Health Impact Profile (OHIP) – what can you not to due to the pain e.g. chew, bite, yawn)
takes time, complex
how do we feel pain?
4
- Nociception – generation of pain
- Peripheral Nerve Transmission – nociception signal into CNS, damage to peripheral nerve can lead to chronic pain
- Spinal Modulation – in spinal cord where nerves synapse – can adapt and control them to defer or induce meaning of pain
- Central Appreciation
sensory nerve supply to the face by
trigeminal nerve (CNV)
somatic
how is referred pain generated
complicated
from embryonic nerve supply development
Pharyngeal arches and clefts – important as form head and neck systems
* Structure of nerve migrate – carry nerve and blood supply with them – can make head and neck appear v complex
pain location can be misinterpreted as source is elsewhere – co-synapse to same area of trigeminal nucleus
sensory (somatic) nerve supply of head and neck can be from
V, VII, IX, X & Cervical 1-3
Autonomic
* sympathetic
* parasympathetic
afferent info coming into CNS, relayed and then carried into brain and perceived as arisen in facial tissue (e.g. issues in any main salivary glands)
- pain transmitted through autonomic nerves
* e.g. cardiac pain – no somatic nerve supply, so autonomic nerves carry to brain
1st pharyngeal arch related to
nerve, artery
trigeminal nerve and maxillary artery – midface generally
2nd pharyngeal arch related to
nerve, artery
facial nerve and hyoid and stapedial artery
3rd pharyngeal arch related to
nerve, artery
glossopharyngeal nerve and internal carotid artery
4th pharyngeal arch related to
nerve, and vessels
vagus nerve and right subclavian artery and aorta
branches of facial nerve
temporal
zygomatic (1 and 2)
buccal
mandibular
cervical
autonomic referred pain of cardiac felt in
left arm
sternum
jaw
somatic reflex arc
pain produces a change
pass up to CNS via spinal cord – efferent would be sent when spinal cord receives it to cause muscle constriction to pull part of body away from sight of damage
autonomic reflex arc
when signal goes to brain – a efferent signal is sent out at same time (sweat glands, blood vessel dilation)
* have somatic reflex arc, but autonomic mediated pain will also have autonomic mediated changes
* e.g. changes in blood flow – swelling and red; lacrimation; nasal congestion (mucosal oedema)
consequence of autonomic pain
* symptoms we get are good guide for source of pain and what nerves pain going through (autonomic or somatic)
peripheral nociception
tissue damage causes chemical mediators to be released, act on nociceptor (chemoceptor) in the tissue to produce an action potential, which is transmitted through the peripheral nerve into spinal cord
perpheral sensitisation
spinal cord sends the information into the brain
gate control of chronic pain
pain response into peripheral nerve and into spinal nerve, stimulate ascending pain fibre to the brain
same information transmitted through standard touch – different pathway to the brain
there is some crossing between these fibres
* touch fibres stimulated inhibit the pain ascending pathway to CNS
* rubbing painful area makes pain less obvious – block pain sensation by normal touch sensation
descending facilitation and inhibition
* respond at lower threshold to pain or higher (e..g. want to keep functioning despite high levels of pain signals)
* inc or red sensitivity of interneuron
change in gate control of chronic pain
Neuronal Plasticity
Sprouting of Spinal Segment Nerves
* Easier for pain signals to be passed to the brain
* Even if cause of pain is removed but due to the positive connection existing normal sensation and pain interneurons
pain sensitisation
Complex process – happens peripheral and central
Chronic pain causes change in peripheral and central nervous system so pain felt even after intervention
(Change in gate control of pain)
how to prevent learned pain (chronic pain)
Prevent changes by early management of pain
Reduce pain reception so chance of adaptive change
consequences of adaptive pain response
5
CRPS - chronic regional pain
Delocalised pain
* Spreads around ‘anatomical’ boundaries
* bilateral
* ‘gripping’, tight, burning
Feeling of swelling & heat
Colour change in overlying skin – due to efferent reflexes
Autonomic changes
Significantly disabling
pain history
S - Site
O - Onset
C - Character
R - Radiation
A - Associations
T – Time Course
E – Exacerbating/Relieving
S - Severity
what is neuropathic pain
pain stimulated beyond nociceptor
* no nociception taking place, but pain perception happening, damage happened to pathway sending pain signal to brain – feel pain caused by tissue but the there is no pathological cause in that tissue to cause the pain
Constant burning/aching pain
Fixed location
Often a fixed intensity
Genetic predisposition?
* Nerve ion channels that heal badly after injury
* Persisting inflow gives persisting information reporting
Post herpetic neuralgia type of neuropathic pain – limit damage at time ptpresents, consequence neuropathic pain reduced
characteristics of neuropathic pain
usuallly a history of ‘injury’
* Can follow facial trauma
* Can follow extractions (nerve avulsed and healed in a way so constant CNS signal after XLA = constant neuropathic pain)
* Can follow ‘routine’ treatment without complications
* Can follow Herpes Zoster (Shingles) episode - POST HERPETIC NEURALGIA
* Can follow destructive treatment for pain
Constant, fixed pain as same nerve damage is there 24/7
can have a genetic predisposition - inherited neurodegeneration, metabolic/endo abnormalities (persisitent inflow)
neuropathic pain management
systemic medication
3 main
- **Pregabalin
- Gabapentin
- Tricyclic**
- Valproate
- Mirtazepine
- Opioid analgesics
Don’t stop afferent information going into CNS but reduce pain transmission within CNS (effect of signal being passed to central appreciation by slowing pain within the brain)
neurpathic pain management
topical medication
4
- Capsaicin
- EMLA
- Benzdamine
- Ketamine
Reduce the pain transmission within CNS using peripheral nerve sensory activation over the area of pain (Gate theory
neurpathic pain management
topical medication
4
- Capsaicin
- EMLA
- Benzdamine
- Ketamine
Reduce the pain transmission within CNS using peripheral nerve sensory activation over the area of pain (Gate theory
alternative managements for neuopathic pain
2 categories
Physical (short duration)
* TENS – occasionally helpful (Gate theory), Low frequency TENS
* Acupuncture – good results
Psychological
* Distraction
* Correct abnormal illness behaviour
* Improve self esteem/positive outlook
what is atypical odontalgia
Dental pain without dental pathology
Distinct pattern of pain
* Equal sex distribution
* Pain free or mild between episodes
* Intense unbearable pain
* 2-3 weeks duration
* Settles spontaneously
what should a GDP in case of atypical odontalgia
PRIMARY CARE – REFER!
Oral Medicine Management
Chronic strategy – medication (gabapentin)
* 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 – keep on offer as pt may not try other tx methods
persistent idiopathic facial pain
Pain which poorly fits into standard chronic pain syndromes
* Neuropathic
* CRPS
* TMD
* Trigeminal Neuralgia
* Migrainous Pain
* Atypical odontalgia
Often high disability level – suggest a high autonomic component, but not clear from symptoms
Challenge to tx – clinical psychology sometimes more successful
used to be called atypical facial pain
persistent idiopathic facial pain
Pain which poorly fits into standard chronic pain syndromes
* Neuropathic
* CRPS
* TMD
* Trigeminal Neuralgia
* Migrainous Pain
* Atypical odontalgia
Often high disability level – suggest a high autonomic component, but not clear from symptoms
Challenge to tx – clinical psychology sometimes more successful
used to be called atypical facial pain
management of persistent idiopathic facial pain
Believe patient
* Do not blame any associated depression for symptoms (they are suffering chronic pain – depression is likely consequence)
Do not increase damage
* likely a degree neuropathic pain involved so surgery is not helpful (can cause more nerve damage)
Adopt holistic strategy
* Quality of life issues and disability should be addressed
* Pain control a bonus
* Realistic outcomes – Patient & Clinician
Use QOL/pain scores as treatment monitor
phantom pain and congnitive deduction
Phantom Pain
* Brain learns how the body is – understanding persists throughout life even if source of pain removed will still feel pain
Cognitive deduction
* Phantom pain – incorrect cognitive deduction – feel the pain that is still there even through limb is not, hard to tx as not typical neurological pain to tx, need to override the peripheral nerve sensation that the pt has that the phantom limb is in pain – trick with mirrors?
* What the pt perceives and what is physically happening may not be the same
what is oral dysesthesia
Abnormal sensory PERCEPTION in ABSENCE OF ABNORMAL STIMULUS
Somatoform (perception) or Neuropathic (abnormal sensory stimulus)
ALL modes of oral sensation involved
* Burning or ‘nipping’ feeling
* Dysgeusia (bad taste)
* Paraesthesic feeling
* Dry mouth feeling
Issue can be neuropathic but is frequently somatoform – decision about condition wrong rather than there being any disease inside the mouth
4 predisposing factors to oral dysesthesia
Deficiency states?
* haematinics
* zinc
* vit B1, B6
Fungal and Viral infections?
Anxiety and stress?
Gender – more women present to OM than men
Ensure there is no tx medical problems
burning mouth syndrome
Dysaesthesia most likely to be associated with haematinic deficiency
* Correct deficiency – should go away
SITE important!
* Lips & tongue tip/margin = parafunction (tongue thrust) *tx this – lower acrylic Essix types splint to prevent damage to mucosa *
* Multiple other sites – dysaesthesia (dorsom of tongue, vault of palate)
dysgeusia
‘bad taste’ - ‘bad smell’ - ‘Halitosis’
* nothing detected by practitioner
* nothing found on examination
* pt still perceives they have it – so will become isolated as anxious others able to detect the bad smell – start overthinking things
REMEMBER – eliminate other causes
* ENT causes - chronic sinusitis
* perio/dental infection
* pouches
* GORD
touch dyseaseshesia
‘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 (true numbness of tissue)
MRI Essential – demyelination/tumour
dry mouth dysesthesia
VERY common
c/o debilitating dry mouth/‘sjogrens’
* but Eating OK – then not salivary gland issue
* worse when waken at night
usually the most obviously associated with anxiety disorders
investigate - same as sjogrens
* all negative, but likely reduced salivary flow issue due to anxiety
tx – need to explain that medication can cause a dry mouth to tx dry mouth (get 2 dry mouths – the annoying dysesthesia and the medication related dry mouth, as tx continues dysesthesia will go away and be left with tolerable medication dry mouth)
management of dysesthesia
3 steps
Explain the condition to the patient
* ‘pins and needles’ in the taste (feels funny but looks normal; mouth is normal but feels abnormal) etc
Assess degree of anxiety
* Anxiolytic medication
* Clinical psychology
Treatment empower the patient
Control is important
medication for dysesthesia
2 classes
depending on pt problem
Anxiolytic based medication (preference)
* Nortriptyline
* Mirtazepine
* Vortioxetine
Neuropathic Medication
* Gabapentin/Pregabalin
* Clonazepam – topical?
TMD
3 basic categories to put pts in
Joint Degeneration
* pain on use & crepitus, +/- rest pain
Internal derangement
* LOCKING open or closed
No joint pathology
possible causes of TMD when no joint pathology
4
occlusion
grinding
clenching
stress
what to look for when assessing pt who has TM pain
7
- clicking joint
- locking with reduction
- limitation of opening mouth
- tenderness of masticatory muscles
- tenderness of cervico-cranial muscles
- signs of parafunction - scalloped tongue, erythema tongue tip, buccal linea alba, cracked teeth
- see if systemic problems – need systemic management (CBT or medication)
history for TMD
Acute pain in face & neck
ANY chronic face, head and neck pain
symptoms show periodicity
morning/evening exacerbation
parafunctional clenching
History is the KEY to successful management
signs of TMD on examination
7
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
signs of parafuntion - scalloped tongue, erythema tongue tip, buccal linea alba, cracked teeth
investigation options for TMD
3 routes
usually none indicated for ‘functional’ disorders
Indications for Imaging
* Ultrasound 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
managemenet of TMD
8 steps
Information – how to self help – give pt information booklet #
CBT education (stress management) +/- exercises
Soft diet and analgesia
Bite splint (essix first as easiest)
Biochemical manipulation
* Tricyclic (not SSRIs)
* other anxiolytic medication
Physiotherapy
Acupuncture
Clinical Psychology
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 dysharmony, physical abuse
