Neuropathic and Intraoral Pain Flashcards
1
Q
what is pain
A
an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or describe in terms of such damage (IASP definition)
2
Q
what are the two types of pain
A
- neuropathic pain
- nocicpetive (somatic pain)
3
Q
what is neuropathic pain
A
pain caused by a primary lesion or dysfunction in the nervous system
4
Q
what is nocicpetive pain
A
pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nocicpetors
5
Q
what are the types of neuropathic pain
A
- episodic (paroxysmal)
- continuous
6
Q
what are the types of episodic pain
A
- trigeminal neuraliga
- glossophayrngeal neuralgia
- occiptal neuralgia
- nervus intermedius neuralgia
7
Q
what are the types of continuous pain
A
- persistent idiopathic facial pain
- painful post traumatic trigeminal neuropathy
- trigeminal post herpetic neuralgia
- burning mouth syndrome
- occlusal dysthesia (phantom bite)
8
Q
what are the types of nocicpetive pain
A
- superficial somatic pain
- deep somatic pain
9
Q
what are the types of superficial somatic pain
A
- cutaneous pain
- muco ginvgival pain
10
Q
what are the types of deep somatic pain
A
- musculoskeletal pain
- visceral pain
11
Q
what is dysethesia
A
an unpleasant abnormal sensation, whether spontaneous or evoked
12
Q
neuropathic pain is often:
A
misdiagnosed and mistreated by doing multiple unnecessary dental proceudres
13
Q
dysfunction may be caused by:
A
-virus (herpes zoster, shingles)
- demyelinating disease
- trauma, injury, surgery
- dental extractions, root canal therapy, dental implant placement, restorative procedures
- idiopathic
14
Q
IAN injury incidence varies from:
A
0-40%
15
Q
IAN is the most commonly injured nerve at _____-
A
64.4%
16
Q
lingual nerve injury incidence is _____
A
28.8%
17
Q
what are the etiologies for intra operative injury
A
- mechanical: injection needle, implant drill
- thermal
- chemical
18
Q
what are the post operative etiologies for injury
A
- thermal stimuli
- peri implant infection and hematoma
19
Q
____ of the long beveled needles were barbed at their tips after the procedure
A
78%
20
Q
1.3-8.6% of the patients got an _________ sensation on IAN block
A
electric shock type
21
Q
_______ of the 1.3-8.6% suffer from prolonged neuropathy
A
57%
22
Q
local anesthetic represent:
A
the safest and most effective drugs in all of medicine for the prevention and management of pain
23
Q
what is the order of least irritating followed by most irritating anesthetics
A
lidocaine, articaine, mepivicaine and bupivicaine
24
Q
neuropathic pain can vary widely in clinical presentation in regard to:
A
pain, quality, and location
25
neuropathic pain can be caused by either:
central nervous system dysfunction and/or by peripheral nerve lesions
26
neuropathic pain is somewhat ________ to opiods and more likely to respond to other drugs such as_______
less responsive to opioids; anticonvulsants
27
neuropathic pain can be ________ or _______
stimulus evoked; stimulus independent (spontaneous)
28
what are the central causes of facial pain
- anesthesia dolorosa (pain in an area that is anesthetic
- central post stroke pain
- facial pain attributed to multiple sclerosis
- persistent idiopathic facial pain (previously known as atypical face pain)
- burning mouth syndrome
- multiple sclerosis
29
what are the neuralgias
- trigeminal neuralgia
- post herpetic neuralgia
- traumatic neuralgia
- glosspharyngeal neuralgia
- occipital neuralgia
- superior laryngeal neuraliga
- geniculate neuralgia: in auditory canal/middle ear)
- auriculotemporal neuralgia
30
what are the other causes of facial pain
- cancer pain
- dental pain
- post traumatic and post surgical pain
- primary headache
- TMJ
- neuralgias
31
what is the definition of neuralgia
- paroxysmal or constant pain typically with a sharp, stabbing, itching, or burning character in the distribution of a nerve
32
neuralgia is a form of neuropathic pain that is characterized by the following features
- paroxysmal, brief (seconds to a few minutes), shock like or lightning-like pain that follows a peripheral or cranial nerve distribution and can spread to adjacent areas in the course of the attack
- typically there is no objective neurologic defecit in the distribution of the affected nerve
- attacks can be provoked by non painful stimulation (allodynia) of trigger zones
- a refractory period follows attacks, the duration of the refractory period shortens as the disease progresses
33
what does PERLA stand for
pupils equal, responsive to light and accommodation
34
what is ptosis
eyelid drop
35
what is pre trigeminal neuralgia
dull continuous, aching or burning pain in th eoral cavity or teeth or jaw evolving eventually into trigeminal neuralgia
- pain duration varies widely from hours to months
- pain may go into remission
- this brief, milder pain is sometimes suspected to have a dental origin and uneccesary dental procedures have been performed in many cases
36
the IASP defined TN as:
sudden, usually unilateral, severe, brief, stabbing or lancinating, recurrent episodes of pain in the distribution of one or more branches of the fifth cranial nerve
37
what is the epidemiology of TN
- 4 to 13 per 100,000 people
- TN is one of the most frequently seen neuralgias in the elderly
- incidence increases with age
- onset after age 50, although may occur in the second and third decades or rarely in children
- male to female ratio is about 1:1.5
38
what is the pathophysiology of TN
compression of the trigeminal nerve root, usually within a few mm of entry into the pons
- compression by an abberant loop of an artery or vein is thought to account for 80-90% of cases
39
what are the other causes of nerve compression
- vestibular- schwannoma (acoustic neuroma)
- meningioma
- epidermoid or other cyst
- saccular aneurysm or AV malformation
40
what does focal demyelination cause
ectopic firing of nerve due to demyelination disruption normal nerve transmission
41
why are A beta fibers most susceptible to demyelination
due to compression or MS- areas of segmental demyelination are the location of ectopic impulse generation
42
what are the clinical features of TN
- pain of TN tends to occur in paroxysms and is maximal at or near onset
- the pain is:
- electric shock like or stabbling
- typically does not awaken pt at night
- lasts from several seconds to minutes but may occur repetitively
- a refractory period of several minutes during which a paroxysm cannot be provoked is common due to nerve repolarization
- may also be a co-existing continuous, deep, dull pain
43
what nerves are commonly involved in TN
V2 and V3 are involved more frequently than V1
44
TN is unilateral or bilateral in most cases
unilateral
45
what can be seen with severe TN pain and where
facial muscle spasms in the masseter muscle especially
46
TN can be precipitated by:
dental procedures
47
describe triggers in TN
- trigger zones may be present
- triggers can be light touching, chewing, talking, brushing teeth, cold air, smiling shaving, washing face and/or grimacing, brushing or flossing teeth
48
TN episodes may last:
weeks or months followed by pain free intervals or remission of pain for years
49
what are the classical trigeminal neuralgia features
- at least 3 attacks of unilateral facial pain fulfilling criteria B and C
- in 1 or more divisions of trigeminal nerve with no radiation beyond trigeminal distribution
- pain has 3 or more of the following 4 characteristics: recurring in paroxysmal attacks lasting from a fraction of a second to 2 minutes, severe intensity, electric shock like, shooting, stabbing or sharp in quality, precipitated by innocuous stimuli to affected side of face
- no clinically evident neurological deficit
50
what is the DDX for TN
- short lasting unilateral neuralgiform headache with conjunctival injection and tearing
- cluster tic syndrome
- giant cell arteritis
- MS
- other neuralgias
51
what imaging studies are done to rule out brain pathology
MRI
52
MRI should be obtained in the following groups to rule out a mass lesion or MS:
- patient with sensory loss
- young patients (under the age of 40)
- patients with bilateral symptoms
- patients who do not respond to conservative therapy
53
what are the meds for neuropathic pain management
- phenytoin
- lidocaine
- carbamazepine - biggest one
- gabapentin
- lamotrigine
- oxcarbazepine
- valproate
- baclofen
- topiramate
- tizanidine
- tiagabine
- pimozide
- clonazepam
54
how much carbamazepine is given
400-1200mg/day
55
what are the surgeries for TN
- microvascular decompression
- radiofrequency rhizotomy
- glyucerol rhizolysis
- balloon compression
- gamma knife radiosurgery - non invasive
- peripheral neurectomy- not recommended
56
gamma knife radiation is better for:
elderly
57
what does the gamma knife radiation do
- destroys portion of the nervous system to block transmission of nociceptive information
58
what is nociception
a complex series of electrochemical events that occurs between a site of active tissue damage and the percpetion of pain
59
what is the compression theory
compression of the trigeminal nerve root at or near the dorsal root entry zone by a blood vessel (usually the superior cerebellar artery)
- segmental demyelination of A-beta and A-delta fibers at the site of vascular compression
- generation of ectopic impulses and spreading of these impulses to adjacent neurons through ephaptic transmission
60
microvascular decompression surgery can improve:
TN pain
61
what are the features of shingles
- acute inflammation caused by varicella zoster virus (chicken pox)
- multiple, painful vesicular skin or mucosal eruptions
- occurs in cutaneous areas supplied by the cranial or spinal nerve ganglia inflamed by the virus causing necrosis and hemorrhage
- pain subsides within weeks typically but can last months to years then classified as post herpetic neuralgia
62
herpes zoster commonly affects:
- torso if spinal nerves involved
- trigeminal nerve (V1) if cranial nerves involved and may cause blindness and palsies affected CN III, IV, and VI
- facial nerve (VII) causing facial weakness, hearing loss, tinnitus
- C2 and C3 causing pain over posterior head
63
what is the treatment for HZ
anti-virals and steroids as soon as possible. pain medications to manage pain
64
CDC recommends who gets vaccine for shingles
adults 50 years or older
65
what is the preferred vaccine for shingles
shingrix (recombinant zoster vaccine)
66
post herpetic neuralgia is a common form of:
chronic neuropathic pain
67
risk of developing PHN increases with age and affects:
60% of patients over 60 years old
68
what is PHN
a pain developed during the acute phase of HZ and recurring or persisting for more than 3 months after the onset of HZ
69
what are the risk factors for PHN
age, female, prodrome
70
is there a genetic component of PHN
yes
71
what are the clinical characteristics of PHN
- a constant, deep, aching/burning pain; a brief, intense shooting pain with hyperalgesia or allodynia with light touch producing pain 80-90%
- may be superimposed brief stabbing exacerbations of pain
72
what is hyperalgesia
an increased response to a stimulus that is normally painful
73
what is allodynia
pain due to a stimulus that does not normally provoke pain
74
what is the pathophysiology of PHN
- sensory deficits in the affected dermatome as well as pigmentary changes and scarring
- major degenerative changes occur in afferent pathways with loss of axons and myelin in peripheral sensory nerves
- both peripheral and central mechanisms are involved in PHN
75
what are the systemic managements for PHN pain
- a SNRI/TCAs such as amitriptyline/nortriptyline
- gabapentin/pregabalin may be as effective as TCAs with fewer contraindications
- lyrica
- opiods
- steroids
- NSAIDs
76
what are the topical agents for PHN pain
- 5% lidocaine patches
- NSAID gel or cream- diclofenac
- sodium topical gel 1%
- shingles gel:
- amitriptyline 2%
- ketoprofen 10%
- tetracaine 4%
- deoxy d-glucose
77
what are the qualifications for persistent idiopathic facial pain
- facial and/or oral pain fulfilling criteria B and C
- recurring daily for more than 2 hours per day for more than 3 months
- pain has both of the following characteristics: poorly localized and not following distribution of a peripheral nerve, dull, aching or nagging quality
- clinical neurological exam is normal
- dental cause excluded by appropriate investiagtions
- not better accounted for by another ICHD-3 diagnosis
78
what is PIFP
persistent pain in apparently normal teeth or adjacent oral tissues
79
what are the types of PIFP
phantom tooth pain, idiopathic toothache, idiopathic odontalgia, facial migraine, atypical facial neuralgia, and atypical facial pain
80
who does PIFP affect
women in the fourth or fifth decade (peri menopausal or menopausal
81
PIFP is previously called
atyical toothache
82
what are the precipitating factors for PIFP
- trauamtic injury
- various routine dental procedures such as endodontic therapy, apicoectomy, tooth extraction, periodontal surgery, implants
- can even follow seemingly innocuous dental procedures such as crown preparation, drilling of dentin and periodontal scaling
83
AO is more likely to develop in a tooth that was:
painful immediately prior to any dental intervention
84
what are the DDX for PIFP
- odontogenic toothache
- myofascial trigger point pain
- pre-trigeminal neuralgia
- neurovascular toothache ( facial or midface migraine, cluster headache)
- maxillary sinusitus
- neuritic toothache
- TMD
85
what does the diagnostic workout for PIFP consist of
- obtain a thorough history
- eliminate any odontogenic cause
- R/O a myofascial trigger point, TN, neurovascular toothache due to facial or midface migraine or cluster headache, tooth pain from a maxillary sinusistis/neuritic toothache
86
PIFP frequently arises:
spontaneously and is not related to functional demands. however the tooth may be sensitive to pressure and a pt may complain of pain on eating
87
what are the neurosensory tests
- intraoral cotton swab test
- the intraoral pinprick test
- intraoral spatula test using hot or cold
88
what are the etiological factors for PIFP
- pressure
- heat
- chemical
89
what are the antiepileptic meds and dosages for PIFP
- tegretol (carbamazepine): 200-1200mg/day
- baclofen: 10-80
- neurotonin( gabapentin): 300-3000
- depakote: 125-2000
- klonopin (clonazepam): 0.5-8
- phenytoin (dilantin): 100-400
- trileptal (oxcarbazepine): 600-1200
- topamax: 400-1200
90
what are the antidepressants for PIFP
- amitriptyline:10-150
- desipramine: 10-150
- doxepin: 10-150
- imipramine: 10-150
- nortiptyline: 10-150
- trazadone: 50-300
91
what are the topical meds for PIFP
- viscous lidocaine
- topical ketamine
- zostrix (OTC)- contains capsaicin - depletes substance P
- note: these medications may be combined and used in a stent as a medication delivery system
- stent covers sensitive gingival tissue
92
what is burning mouth syndrome
characterized by an intraoral burning sensation for which no medical or dental cause can be found
93
what are the other associated common conditions with burning mouth syndrome
- psychiatric disorders such as depression
- xerostomia (from drugs, connective tissue disease, or age)
- nutritional deficiencies (vitamin B12, iron, folate, zinc, vitamin B6) so blood tests needed first to rule out vitamin deficiency
- allergic contact stomatitis
- geographic tongue
- candidiasis
- diabetes
- denture related pain
- thyroid abnormalities
- menopause
94
what is the epidemiology and treatment for burning mouth syndrome
- predominantly affects women especially post menopausal due to decreased estrogen
- 30-50% improve spontaneously
- the frequency of burning mouth syndrome are unknown
- topical amitriptyline troches (4mg) dissolve in mouth up to 3x a day
- klonopin (sedating)
95
what are the diagnostic criteria for burning mouth
- oral pain fulfilling criteria B and C
- recurring daily for more than 2 hours per day for more than 3 months
- pain has both of the following characteristics: burning quality, felt superficially in the oral mucosa
- oral mucosa is of normal appearance and clinical examination including sensory testing is normal
96
describe the sites of oral burnign
- oral pain represents the cardinal symptom of BMS
- type of pain is a prolonged burning sensation
- distribution of the burning sensation is nearly always bilateral but it does not follow anatomical landmarks
- most common site is anterior two thirds and tip of the tongue
- anterior hard palate, mucosal aspect of lower lip, and mandibular alveolar regions are affected
- buccal mucosa and floor of mouth are rarely involved
- many patients complain of burning in more than one intraoral area at the same time
97
describe the onset of oral burning
- gradual with no known precipitating factors
- sudden and linked to a preceding dental procedure (tooth cleaning, filling or a new denture), upper respiratory infection or a course of antibiotics
98
describe the timing of symptoms for oral burning
- variable
- some patients complain of continuous discomfort throughout the day
- others find that it gradually increases during the day and reaches maximum intensity by evening
- pain usually remits nightly during sleep
99
what are the medications used to manage oral bruning
- clonazepam (topical)
- alpha- lpoic acid
- TCAs: amitriptyline oral or as a troche 4mg TID
- gabapentin
- pregablin
100
what are the surgical therapies for oral burning
none are recommended
101
what does the glossopharyngeal nerve do
- sensory to pharynx, carotid body and carotid sinus, tongue for taste (posterior 1/3 of tongue) and general sensation
- parasympathetic: to parotid gland, jugular ganglion, petrous ganglion
- motor to stylopharyngeus muscle and palatine tonsil
102
describe glossopharyngeal neuralgia
- severe paroxysmal, lancinating pain that radiates to the throat, ear, teeth and tongue
- rare, unilateral condition
- affects males over 50 years old
- triggered by movement in the tonsillar region by swallowing or coughing
- due to a lesion in the petrosal and jugular ganglion of CN IX
- branches of carotid artery can trigger a vasovagal response
103
describe geniculate neuralgia
- known as nervus intermedius neuralgia, Ramsay Hunt's syndrome
- painful disturbance of the sensory portion of the facial nerve- CN VII
- causes lancinating pain in the middle ear and the auditory canal
104
what is the treatment for geniculate neuralgia
- methyl prednisone 10mg start with 80mg dose, then taper by 10mg every 3 days until 20mg dose. maintain pt on 20mg for 14 days then taper off
105
what is eagles syndrome
elongation or ossification of the stylohyoid ligament
106
what are the symptoms of eagles syndrom
- sore throat, dysphagia, otalgia, glossodynia, headache or vague pain in the neck
- pain may occur with swallowing, talking, chewing, turning the head to the contralateral side, yawning
- usually unilateral, constant, deep, throbbing or aching
107
what is the exam for eagles syndrome
includes palpation of the stylohyoid area to attempt to reproduce pain and turning head to side
108
what does the radiograph for eagles syndrome show
elongated stylohyoid process
109
what do you do for eagles syndrom
refer to ENT
110
