Non-Dental Facial Pain Flashcards
What are the 6 classifications of orofacial pain?
- intra oral
- extra oral
- musculoskeletal
- neuropathic
- neurovascular
- psychological
What is an example of episodic neuropathic pain?
trigeminal neuralgia
What are 3 examples of continuous neuropathic pain?
- trigeminal neuropathy
- atypical odontalgia
- post-herpetic neuralgia
Which neurovascular pain condition would need an emergency referral?
temporal arteritis
What are 4 examples of facial pain red flags?
- bilateral facial pain described as toothache
- toothache with absence of dental pathology
- pain radiating to forehead, temple, cervical regions
- toothache with hearing changes, vertigo, tinnitus, facial weakness, altered facial sensation
What are the 7 main components of history taking when assessing non dental facial pain?
- principle complaint
- presenting illness
- past medical history
- past dental history
- habits: smoking, alcohol, drugs
- psychosocial history: stress, depression, anxiety
- consider all symptoms
What are the 4 most common causes of facial pain?
- oral ulceration
- sinus pain (maxillary, frontal, ethmoid)
- TMJ
- idiopathic trigeminal neuralgia
How is the TMJ examined?
- assess joint click/crepitus
- examine muscles of mastication esp. temporalis, masseter, pterygoids difficult to palpate
- range of opening and lateral movement
- deviation/deflection on opening
What conservative treatment options are there for a patient with TMJ?
- rest and soft diet
- NSAIDs
- physio and exercises
- heat pack if joint/muscle is uninjured
- reduce stress
- acupuncture
What are examples of splints that can be given to patients with TMJ and conservative treatment has not worked?
- emergency splint (de-programming Lucia jig)
- soft splint
- hard acrylic splint
- local occlusal interference splint (LOIS)
What medication can be used for TMJ that has not been responsive to other treatments?
diazepam
What is the surgery used to help with TMJ if other treatment has not worked?
arthroscopy (is the disc damaged and needing surgery? manipulation under GA)
The symptoms of which condition is the following?
- pain over upper cheek and teeth, may be bilateral
- worse when being forward
- history of upper respiratory tract infection (cold)
sinusitis
Signs of which condition are the following?
- maxillary teeth TTP
- may be nasal discharge
- tenderness, erythema over maxilla
sinusitis
What special investigations can be done to assess potential sinusitis?
- bitewing and/or PA to exclude dental cause
- radiograph may show fluid level in maxillary antrum, OPG (not justified for diagnosis unless dental involvement in suspected)
What are the treatment options for sinusitis?
- decongestants
- steam inhalations
- analgesics
- antibiotics last resort
What are the 2 types of trigeminal neuralgia?
- classic/idiopathic trigeminal neuralgia
- symptomatic/secondary trigeminal neuralgia
Which type of neuralgia would present with pain - ear, base of tongue, tonsillar regions?
glossopharyngeal neuralgia
Which type of neuralgia would present with pain - deep in ear canal?
nervus intermedius neuralgia
Which type of neuralgia would present with pain - distribution of greater and lesser occipital nerve?
occipital neuralgia
Which type of neuralgia would present with pain - post herpes zoster - often ophthalmic branch?
post herpetic neuralgia
Which medication is the following?
- drug of choice for trigeminal neuralgia
- anti-epileptic drug
- interactions common eg. Warfarin
- side effects: drowsiness, nausea, folic acid deficiency, megaloblastic anaemia
carbamazepine
Which type of trigeminal neuralgia is the following?
- predominantly forehead or orbit
- may be bilateral
- facial sensory or motor impairment
- red flag: tumours, aneurysm, MI, MS
secondary trigeminal neuralgia
What are 4 things that should be done for a patient presenting with trigeminal neuralgia?
- exclude dental causes of pain
- advisable to consult GP first
- diagnostic carbamazepine and review
- arrange prompt referral to specialist
What are 5 differences between pulpitic pain and trigeminal neuralgia?
pulpitic pain:
dental pathology
throbbing
exacerbated with hot and cold
LA blocks pain
sleep disturbed
trigeminal neuralgia:
no local cause
shooting, lacerating, burning pain
food temperature no effect
LA may not block pain
no effect on sleep
What are 4 neurological causes of facial pain?
- trigeminal neuralgia
- glossopharyngeal neuralgia
- herpes zoster
- multiple sclerosis
Which cause of facial pain is the following?
- sudden, brief, severe, recurrent pain in the distribution of the glossopharyngeal nerve
- unilateral pain in throat/ear
- sharp, stabbing
- sudden onset, last a few seconds/mins
- may be triggered by coughing or swallowing
- 10% also have trigeminal neuralgia
glossopharyngeal nerve
Which cause of facial pain is the following?
- common, 20% of adults
- oral symptoms are less common
- painful vesicles that ulcerate, do not cross midline
- severe lancing pain may occur before vesicles - difficult diagnosis
- management: reassurance, paracetamol
zoster - shingles
Which cause of facial pain is the following?
- persists after shingles outbreak
- increases with age
- severity increases with age
- treatment: anti depressants
post-herpetic neuralgia
What are 5 psychogenic causes of facial pain?
- TMJ
- atypical facial pain
- atypical odontalgia
- burning mouth syndrome
- Münchausen syndrome
Which type of psychogenic facial pain is the following?
- dull ache
- maxillary > mandibular
- present all day, everyday
- does not follow anatomical nerve distribution
- other complaints: dry mouth, altered taste, thirst, IBS, chronic back pain
atypical facial pain
Which type of psychogenic facial pain is the following?
- variant of atypical facial pain
- pain well localised to a tooth/teeth
- symptoms may mimic pulpitis or periodontitis
- dental intervention can aggravate the pain
- extraction may lead to transfer of pain to other teeth or alveolus
atypical odontalgia
Which type of psychogenic facial pain is the following?
- usually middle aged females
- can be generalised or localised burning or soreness of the mouth
- often affects tongue (glossodynia)
- oral mucosa appears normal
- 1-2 cases per year in GDP
burning mouth syndrome
What are 6 other potential causes of facial pain?
- diabetes
- xerostomia
- geographic tongue
- lichen planus
- candidosis
- glossitis associated with vitamin deficiency
Which 4 testing methods should be carried out to diagnose cause of facial pain?
- blood, urine, thyroid function
- microbiology (candida)
- salivary flow rate
- psychological screening
Which antidepressants are used to treat atypical facial pain?
- tricyclic anti depressants
- SSRIs
What are 4 side effects of tricyclic anti depressants?
- sedation
- xerostomia
- constipation
- blurred vision
What are 4 side effects of SSRIs?
- nausea
- xerostomia
- dyspepsia
- vomiting
What are 3 vascular causes of facial pain?
- migraine
- cluster headaches
- temporal arteritis
Which type of vascular cause of facial pain is the following?
- severe, unilateral headache
- lasts for hours-days
- nausea or vomiting
- triggers: stress, diet, light
- aura: visual, sensory, motor or speech disturbance
migraine
Which type of vascular cause of facial pain is the following?
- male > female, age 30-50
- unilateral, dull pain
- can wake patient at night
- localised around eye
- can be associated with watering eye and nasal discharge
cluster headaches
Which type of vascular cause of facial pain is the following?
- aged 50 years +
- new onset of localised headache
- unilateral, deep throbbing pain in temple
- worse when lying flat
- malaise, fever, weight loss
- tenderness of temporal arteries
- treatment: urgent referral - corticosteroids as sight at risk
temporal arteritis
