OM- facial pain Flashcards
Compare pain and nociception?
Pain is what we percieve- so this differs depedent on patient.
Nociception is how pain signals are produced and how we can interfere with the pain.
Compare nociceptive pain to neuropathic pain?
Nociceptive pain-caused by activity in the neural pathways in response to potentially damaging stimuli (e.g. injury)
Neuropathic pain- initiated or caused by a primary lesion or dysfunction in the nervous system e.g. diabetic peripheral neuropathy.
it is constant (nerve damage is there all the time)
Fixed location
Often at fixed intensity (the nerve damage often doesn’t change)
How can we manage neuropathic pain?
Systemic medications e.g. pregabalin. gabapentin
Topical - Capsaicin/ ketamine/ Benzdamine/ EMLA
Physical- acupuncture
Psychological- distraction
How can we assess the pain?
Mcgills - Gives descriptive words for the patient to select about their pain
Oral health impact profile- what the patient can and cannot do because of the pain
Why do we get referred pain?
Upper 3 cervical nerves can share connection with the synapses from the cranial nerves. This makes it difficult for the patient’s brain to identify where the pain is coming from (upper cervical/ cranial nerves) This can result in referred pain (the source of pain and perceived site of pain are different)
e.g. Heart pain- e.g. left arm.
Describe the mechanism of peripheral nociception
Tissue damage causes chemical mediators (Bradykinin/ 5-HT) which act on the nociceptor in the tissue to produce an action potential that is transmitted to the spinal cord.
Explain the gate control of pain theory ?
By rubbing the affected region the Abeta fibres are stimulated & branch. The main branch enters the dorsal horne of the spinal cord. The little branch activates an inhibitory interneuron which inhibits the second order pain projection neuron. This stops conduction of pain via the pain projection pathway.
Why is neuronal plasticity cause an issue for chronic pain?
The sensation makes it easier for pain signals to be passed to the brain (More sprouting of nerve fibres to the nociceptor)
This is a problem for chronic pain as the adpatations make it easier for pain to pass. This can mean even though the pain has been removed (the adaptations cause the patient to still feel pain with normal sensation)
What is atypical odontalgia & describe the symptoms of this?
Dental pain WITHOUT dental pathology.
Symptoms:
Pain free/ mild between episodes
Intense unbearable pain that lasts 2-3 weeks
Pain that spontaneously settles.
Clinical scenario- Patient comes in with dental pain we treat it (Endodontics provides initial relief then pain comes back)
We do further treatment (Extracted then pain returns in another tooth) .
If we suspect a patient has atypical odontalgia how do we treat this?
Refer.
OM will
* Reduce the chronic pain experienced (Gabapentanoid)
* Reduce frequency of acute episodes (opiod analgesic to control the short bursts of pain)
What is persistent idopathic facial pain?
Pain that poorly fits into the standard chronic pain symtpoms. It is an unexplainable pain problem but the patients have a high disability level from their pain.
We want to help improve the patients quality of life and assoicated disability.
What is oral dysasesthisa and give examples of this?
Abnormal sensory perception in the absense of an abnormal stimuli. This could be neuropathic (Abnormal sensory stimulus) or somatoform (perception is wrong)
The nerve endings are lying.
e.g.
Burning mouth syndrome
Dysgeusia
Touch dysaesthesia
Dry mouth.
Give some predisposing factors to oral dysasesthesia
- Deficiency of Haematinics/Zinc/ Vit B1/ B6.
- Fungal and viral infections
- Anxiety and stress.
What is burning mouth syndrome?
Burning or nipping feeling.
More likely to be associated with a haematinic deficiency.
Where are patients with parafunction more likely to experience burning mouth syndrome?
Lips or tip of tongue.
What is Dysgeusia and how do we treat it ?
Patient believes they have a Bad taste/ bad smell/ halitosis. Nothing can be detected by the dentist.
Eliminate any problems (ENT/ perio infection/ Dental infections/ GORD)
What is touch dysaesthesia and how do we treat this ?
Pins and needles feeling. Patient feels like they are under Local anaesthetic but they can still feel other pain.
Refer for Cranial nerve tests/ MRI to exclude infection/ tumour/ loss of myelination.
Discuss the dry mouth feeling that patients can present with and how do we manage this?
This is a feeling of dry mouth but the patient does not need extra water to help with swallowing.
This is commonly associated with anxiety.
So try and treat the cause.
Tests- salivary flow/ ultrasound scans of the gland.
Management-
1. Explain the condition (like pins and needles- your mouth is normal but the way you feel it is not)
2. Provide reassurance
3. Assess degree of anxiety (Anxiolytic medications- Nortriptyline-periphreal pain killer/ Mirtazapine/ Vortioxetine)
4. Neuropathic patients - gabapentin/ pregabalin.
What is neuralgia?
An intense stabbing pain which extends along the course of the cranial nerve affected. This is normally caused by irritation/ damage of the nerve.
Name the types of neuralgia in order of increasing severity ?
- Trigeminal neuralgia.
- Painful trigeminal neuropathy
- Trigeminal autonomic cephalalgias.
What can cause trigeminal neuralgia?
- Idiopathic
- Vascular compression of the trigeminal nerve (Classical trigeminal neuralgia)
- Secondary (Multiple sclerosis and intercranial tumours)
How can trigeminal neuralgia present?
Unilateral maxillary or mandibular division pain.
Stabbing pain .
Lasts- 5-10 seconds can last minutes if its a cluster of attacks.
Triggers (Wind/ cold/ touch/ chewing/cutaneous)
Patient can be completely symptom free between attacks or concomitant continuous pain)
It can have remission and relapse.
describe a typical trigeminal neuralgia patient?
- Elderly
- Mask like face (pt avoiding movements that could set off an attack)
- Patient looks like they are in pain.
- No obvious precipitating pathology.
What are the red flags we are looking out for with patients suffering from trigeminal neuralgia?
Younger patients (<40)
Sensory deficit in the facial region.
All patients have their cranial nerve tested and get an MRI.
