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
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
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
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)
