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Neuropathic & Intraoral Pain Flashcards

1
Q

Neuropathic
pain

A

Pain caused by a lesion or disease of the
somatosensory nervous system

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2
Q

Episodic
(Paroxysmal)
(4)

A

a. Trigeminal neuralgia
b. Glossopharyngeal neuralgia
c. Occipital neuralgia
d. Nervus intermedius neuralgia

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3
Q

skipped
Continuous
(5)

A

a. Persistent idiopathic facial pain
b. Painful post-traumatic trigeminal
neuropathy
c. Trigeminal post-herpetic neuralgia
d. Burning mouth syndrome
e. Occlusal dysesthesia (phantom
bite/occlusion)

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4
Q

Nociceptive
(somatic) pain

A

Pain that arises from actual or
threatened damage to non-neural
tissue and is due to the activation
of nociceptors

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5
Q

Superficial
somatic pain
(2)

A

a. Cutaneous pain
b. Muco-gingival
pain

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6
Q

Deep somatic
pain
(2)

A

a. Muscoluskeletal
pain
b. Visceral pain

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7
Q

Neuropathic
Pain
 Definition:

A

 Pain initiated or caused by a primary
lesion or dysfunction in the nervous
system (1)

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8
Q

Dysesthesia-

A

an unpleasant
abnormal sensation, whether
spontaneous or evoked (1)

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9
Q

Neuropathic Pain
Dysfunction may be caused by:
(5)

A
  1. virus (i.e. herpes zoster, shingles)
  2. demyelinating disease (i.e. multiple sclerosis)
  3. trauma, injury, surgery
  4. dental extractions, root canal therapy, dental
    implant placement, restorative procedures
  5. Idiopathic
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10
Q

Neuropathic Pain
Often misdiagnosed & mistreated by

A

doing multiple unnecessary dental
procedures (i.e. multiple root canals,
extractions)

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11
Q

 Inferior Alveolar Nerve
(IAN) Injury incidence
varies from –%
 IAN is the most
commonly injured
nerve —%
 Lingual nerve injury
incidences is —%

A

0-40
64.4
28.8

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12
Q

Etiology
- Intra-operative
(5)
- Post-operative
(2)

A
  • Mechanical
  • Injection needle
  • Implant Drill
  • Thermal
  • Chemical
  • Thermal Stimuli
  • Peri-implant infection and hematoma
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13
Q

IAN injury due to traumatic local anesthesia injection
- –% of the long beveled needles were barbed at
their tips after the procedure
- –% of the patients got an “electric shock
type” sensation on IAN block
- –% of the –% suffer from prolonged
neuropathy

A

78
1.3 – 8.6
57
1.3-8.6

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14
Q

IAN injury due traumatic local anesthesia injection
- Local anesthetics represent the safest and most effective
drugs in all medicine for the prevention and
management of pain
- — being the least irritant followed by (3)

A

Lidocaine

articaine,
mepivicaine and bupivicaine

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15
Q

Neuropathic pain
* can vary widely in clinical
presentation in regard to
* can be caused by either —
and/or by —
* somewhat less responsive to
— and more likely to respond
to other drugs, such as
— (among others)
* can be —evoked or
—independent
(spontaneous).

A

pain
quality and location
central
nervous system dysfunction
peripheral nerve
lesions.
opioids
anticonvulsants
stimulus

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16
Q
  • CENTRAL CAUSES OF FACIAL PAIN
    (6)
A

– 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

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17
Q

skipped
NEURALGIAS – follows distribution of a nerve(s)
(9)

A

– Trigeminal neuralgia
– Post-herpetic neuralgia
– Traumatic neuralgia
– Glossopharyngeal neuralgia
– Occipital neuralgia
– Superior laryngeal neuralgia (from branch of CN X)

Geniculate neuralgia (Ramsay Hunt/Nervus
intermediate neuralgia)- sensory of CN VII with lancinating pain
– in the auditory canal/middle ear
Auriculotemporal neuralgia

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18
Q
  • OTHER CAUSES
    (5)
A

– Cancer pain
– Dental pain
– Post-traumatic and post-surgical pain
– Primary headache
– Temporomandibular joint syndrome

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19
Q

Neuralgia
 Definition:

A

 “Paroxysmal or constant pain typically with sharp, stabbing,
itching, or burning character in the distribution of a nerve “

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20
Q

Neuralgia
* a form of neuropathic pain that is characterized by the
following features:
1. …
2. Typically, there is no objective — in the
distribution of the affected nerve
3. Attacks can be provoked by …
4. A — period follows attacks; the duration of the
— period shortens as the disease progresses

A

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
neurologic deficit
non-painful stimulation
(allodynia) of trigger zones (i.e. flossing elicits gingival
pain)
refractory

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21
Q

Pre-trigeminal
neuralgia
 …
 Pain duration varies widely
from —
 Pain may go into —
 This brief, milder pain is
sometimes suspected to
have a dental origin and
unnecessary dental
procedures have been
performed in many cases

A

Dull, continuous, aching or
burning pain in the oral
cavity or teeth or jaw
evolving eventually into
trigeminal neuralgia (TN)
hours to months
remission

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22
Q

Trigeminal neuralgia
(TN)

A

The International Association for
the Study of Pain (IASP) defines 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
(trigeminal) nerve

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23
Q

EPIDEMIOLOGY
* The annual incidence of TN is — per 100,000
people
* — new cases occur in the US each year.
* TN is one of the most frequently seen neuralgias in the —.
* incidence increases with —
* Onset after age —, although may occur in the second and third decades or, rarely, in children.
* male to female ratio is about —

A

4 to 13
15,000
elderly
age
50
1:1.5

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24
Q

Pathophysiology
* Most cases of trigeminal neuralgia (TN) are caused
by

A

compression of the trigeminal nerve root, usually
within a few millimeters of entry into the pons
* Compression by an aberrant loop of an artery or vein is
thought to account for 80 to 90 percent of cases.
* Other causes of nerve compression include
* vestibular schwannoma (acoustic neuroma)
* Meningioma
* epidermoid or other cyst,
* saccular aneurysm or AV malformation

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Focal Demyelination
Causes ectopic firing of nerve due to demyelination disrupting normal nerve transmission.
26
-- fibers-most susceptible to demyelination due to compression,or MS-areas of segmental demyelination are the location of ectopic impulse generation Cruccu et al., 2020
A-β
27
CLINICAL FEATURES * The pain of TN tends to occur in --- and is maximal at or near onset. * The pain (5) * (2) are involved more frequently than --- * --- in most cases * Facial muscle spasms can be seen with severe pain especially the --- muscle
paroxysms * "electric shock-like" or "stabbing“ * typically does not awaken patients 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. V2 and/or V3, V1 unilateral masseter
28
Clinical Features  TN can be precipitated by ...  --- may be present  Triggers can be (11)  Episodes may last ---, followed by pain-free intervals or remission of pain for years.  Recurrence is common
dental procedures (i.e. root canal therapy, dental extraction) Trigger zones light touching, chewing, talking, brushing teeth, cold air, smiling, shaving, washing face and/or grimacing, brushing or flossing teeth. weeks or months
29
13.1.1 Classical trigeminal neuralgia A. At least -- attacks of unilateral facial pain fulfilling criteria B and C B. In -- divisions of trigeminal nerve, with no radiation beyond trigeminal distribution C. Pain has ≥3 of the following 4 characteristics: ... D. No clinically evident neurological deficit E. Not better accounted for by another ICHD-3 diagnosis
3 ≥1 1. recurring in paroxysmal attacks lasting from a fraction of a second to 2 minutes 2. severe intensity 3. electric shock-like, shooting, stabbing or sharp in quality 4. precipitated by innocuous stimuli to affected side of face
30
Differential diagnosis (5)
1. Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) 2. Cluster-tic syndrome 3. Giant Cell Arteritis 4. Multiple sclerosis 5. Other neuralgias
31
Imaging studies to rule out brain pathology * Magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA) of the brain * MRI should be obtained in the following groups to rule out a mass lesion or multiple sclerosis: (4)
* Patients with sensory loss * Young patients (under the age of 40) * Patients with bilateral symptoms * Patients who do not respond to conservative therapy
32
SURGICAL THERAPY FOR TN (6)
 Microvascular decompression  Radiofrequency rhizotomy  Glycerol rhizolysis  Balloon compression  Gamma knife radiosurgery – NON-INVASIVE  Peripheral neurectomy (not recommended)
33
Gamma Knife Radiation: Neuroablative Procedure (2)
 Destroys portions of the nervous system to block transmission of nociceptive information.  Nociception: a complex series of electrochemical events that occurs between a site of active tissue damage and the perception of pain
34
Pathophysiology - Microvascular Compression theory (4)
 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 (cross-talk)  Microvascular Decompression Surgery can improve Trigeminal Neuralgia pain
35
Herpes Zoster (HZ) Virus HZ (shingles) features: (4)
 acute inflammation caused by varicella zoster virus (chickenpox)  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 & hemorrhage  Pain subsides within weeks typically but can last months to years then classified as Post-herpetic neuralgia
36
Herpes Zoster (HZ)  Commonly affects:  1. --- if spinal nerves involved  2. trigeminal nerve(V1) if cranial nerves involved and may cause ...  3. facial nerve (VII) causing ...  4. C2 & C3 causing pain over ...  Treatment:
torso blindness and palsies affecting CN III, IV, VI. facial weakness, hearing loss, tinnitus. posterior head. anti-virals and steroids as soon as possible. Pain medications to manage pain.
37
Vaccine for Shingles Prevention (2)
* (CDC) recommends that appropriate adults 50 or older get vaccinated to help prevent Shingles. * Shingrix (recombinant zoster vaccine) the preferred vaccine over ZOSTAVAX ("ZOS-tah-vax")to help reduce your risk of getting Shingles in the future.
38
POST-HERPETIC NEURALGIA (PHN)  a common form of ...  Risk of developing PHN increases with age & affects --% of patients > 60 years old  A pain developed during the --- phase of HZ and recurring or persisting for more than -- months after the onset of the HZ.  Risk factors:  a --- component may contribute to the varied susceptibility of some patients to developing PHN after an attack of HZ.
chronic neuropathic pain 60 acute,3 age, female, prodrome, etc. genetic
39
Post-Herpetic Neuralgia  Clinical Characteristics: (3)
 a constant, deep, aching/burning pain; a brief, intense shooting pain with hyperalgesia (an increased response to a  stimulus that is normally painful) or allodynia (pain due to a stimulus that does not normally provoke pain) ( with light touch producing pain (80-90%).  May be superimposed brief stabbing exacerbations of pain
40
Post-Herpetic Neuralgia  Pathophysiology: (3)
 sensory deficits in the affected dermatomes 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.
41
Management of PHN PAIN Systemic (6)
 a SNRI/TCAs, such as amitriptyline/nortriptyline  Gabapentin/pregabalin may be as effective as TCAs with fewer contraindications  Lyrica  Opioids  Steroids  NSAIDs
42
Management of PHN PAIN Topicals (8)
 5% lidocaine patches  NSAID gel or cream – Diclofenac  Sodium topical gel 1%  Shingles gel:  Amitriptyline (2%)  Ketoprofen (10%)  Tetracaine (4%)  Deoxy d-glucose
43
3.18.4 Persistent idiopathic facial pain (PIFP) (6)
A. Facial and/or oral pain fulfilling criteria B and C B. Recurring daily for >2 h per day for >3 mo C. Pain has both of the following characteristics: 1. poorly localized, and not following distribution of a peripheral nerve 2. dull, aching or nagging quality D. Clinical neurological examination is normal E. Dental cause excluded by appropriate investigations F. Not better accounted for by another ICHD-3 diagnosis
44
Persistent Idiopathic Facial Pain (trigeminal deafferentation pain) (4)
* PIFP is best defined as persistent pain in apparently normal teeth or adjacent oral tissues * (phantom tooth pain, idiopathic toothache, idiopathic odontalgia, facial migraine, atypical facial neuralgia, and atypical facial pain have been used in the past) * Affects women in the fourth or fifth decade (peri- menopausal or menopausal) * Previously called Atypical Toothache
45
Persistent Idiopathic Facial Pain (trigeminal deafferentation pain) * Precipitating factors: (3) * AO is more likely to develop in a tooth that was painful immediately prior to any dental intervention.
1. traumatic injury 2. various routine dental procedures such as endodontic therapy, apicoectomy, tooth extraction, periodontal surgery, or implants. 3. can even follow seemingly innocuous dental procedures such as crown preparation, drilling of dentin and periodontal scaling.
46
skipped Differential Diagnosis of PIFP (7)
 Odontogenic toothache  Myofascial trigger point pain  Pre-Trigeminal neuralgia  Neurovascular toothache (facial or midface migraine, cluster headache)  Maxillary sinusitis  Neuritic toothache  Temporomandibular disorder (TMD)
47
Diagnostic Workup  Obtain a thorough ---  eliminate any --- cause  R/O a  PIFP frequently arises spontaneously and is not related to functional demands. However, the tooth may be sensitive to --- and a patient may complain of pain on eating
history odontogenic myofascial trigger point, trigeminal neuralgia, neurovascular toothache due to facial or midface migraine or cluster headache(episodic and throbbing or pulsating), tooth pain from a maxillary sinusitis / neuritic toothache/ pressure
48
skipped Persistent Idiopathic Facial Pain Treatment (Anti-epileptics or Membrane Stabilizers)  Medications: Dosage(mg/day) (8)
 Tegretol (carbamazepine) 200-1200  Baclofen (Lioresal) 10-80  Neurontin (gabapentin) 300-3000  Depakote (divalproex sodium) 125-2000  Klonopin (clonazepam) 0.5-8  Phenytoin (Dilantin) 100-400  Trileptal (oxcarbazepine) 600-1200  Topomax (topiramate) 400-1200
49
skipped Central Acting Medications (Antidepressants)  Medications: Dosage(mg/day) (6)
 Amitriptyline (Elavil) 10-150  Desipramine (Norpramin) 10-150  Doxepin (Sinequan) 10-150  Imipramine (Tofranil) 10-150  Nortriptyline (Pamelor) 10-150  Trazodone (Desyrel) 50-300
50
skipped Topical Medications (5)
 Viscous Lidocaine  Topical Ketamine  Zostrix (OTC) – contains capsaicin- depletes substance P  NOTE: These medications may be combined & used in a stent as a medication delivery system.  Stent covers sensitive gingival tissue.
51
Burning Mouth Syndrome * characterized by * Other associated common conditions :
an intraoral burning sensation for which no medical or dental cause can be found – 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- (i.e. denture acrylic or nickel clasps) – geographic tongue – candidiasis – diabetes – denture-related pain – thyroid abnormalities – menopause
52
Burning Mouth Syndrome Epidemiology & Treatment  predominantly affects  --- % improve spontaneously  The frequency of burning mouth syndrome are unknown  Topical --- troches (4mg) dissolve in mouth up to 3x/day  --- (sedating)
women especially post-menopausal due to decreased estrogen 30 - 50 amitriptyline Klonopin
53
IHS Diagnostic Criteria Beta III 13.10 Burning mouth syndrome (BMS) A. Oral pain fulfilling criteria B and C B. Recurring daily for -- h per day for -- mo C. Pain has both of the following characteristics: ... ... D. Oral mucosa is of normal appearance and clinical examination including sensory testing is normal E. Not better accounted for by another ICHD-3 diagnosis
>2 >3 1. burning quality 2. felt superficially in the oral mucosa
54
Site of Oral Burning  Oral pain represents the cardinal symptom of BMS  Type of pain is a prolonged “---” sensation  Distribution of the burning sensation is nearly always --- but it does not follow anatomical landmarks  Most common site is ...
burning bilateral anterior two-thirds and tip of the tongue.
55
Site of Oral Burning (2)  Many patients complain of burning in
 Anterior hard palate, mucosal aspect of lower lip, and mandibular alveolar regions are also affected.  Buccal mucosa and floor of mouth rarely involved. more than one intraoral area at the same time
56
Oral Burning  Onset :  --- with no known precipitating factors  Sudden and linked to a ...  The timing of the symptoms is variable.  Some patients complain of --- discomfort throughout the day  Others find that it gradually increases during the day and reaches maximum intensity by ---  Pain usually --- nightly during sleep
Gradual preceding dental procedure (tooth cleaning, filling or a new denture), upper respiratory infection or a course of antibiotics. continuous evening remits
57
Burning mouth syndrome Management Medication (5) Surgical therapy (1)
 Clonazepam (“topical”)  Alpha-lipoic acid  Tricyclic anti- depressants: (Amitriptyline) oral or as a troche 4mg tid  Gabapentin  Pregablin * No surgical treatment is recommended
58
Glossopharyngeal Neuralgia  Severe paroxysmal, lancinating pain that radiates to the ...  Rare, --- condition  Affects  Triggered by movement in the ...  Due to a lesion in the petrosal and jugular ganglion of CN ---  Branches of carotid artery can trigger a ...
throat, ear, teeth and tongue unilateral males > age 50 years tonsillar region by swallowing or coughing IX vasovagal response (i.e. BP, cardiac output, altered respiration)
59
Geniculate Neuralgia  Known as nervus intermedius neuralgia, Ramsay Hunt’s syndrome  Painful disturbance of the sensory portion of the ---  Causes lancinating pain in the...  Treatment:
Facial nerve - CN VII middle ear and the auditory canal Methyl prednisone (10mg) start with 80mg dose, then taper by 10 mg every 3 days until 20 mg dose. Maintain pt on 20mg for 14 days then taper off.
60
Eagle’s syndrome  What?  Symptoms: (6)  Pain may occur with swallowing, talking, chewing, turning the head to the contralateral side, yawning  Usually unilateral, constant, deep, throbbing or aching  Exam:  Radiograph:  Refer to Ear, Nose & Throat (ENT) specialist
Elongation or ossification of the stylohyoid ligament sore throat, dysphagia, otalgia, glossodynia, headache or vague pain in the neck includes palpation of the stylohyoid area to attempt to reproduce pain & turning head to side reveals elongated stylohyoid process
61

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