Oral Med Flashcards
What are the 2 main classification systems for orofacial pain?
International Classification of Headache Disorders Edition 3 2018
International Classification of Orofacial Pain, 1st edition (ICOP) 2020
What are the 6 classification groups of orofacial pain ICOP?
- Orofacial pain attributed to disorders of dentoalveolar and anatomically related structures
- Myofascial orofacial pain
- TMJ pain
- Orofacial pain attributed to lesion or disease of the cranial nerves
- Orofacial pain resembling presentations of primary headaches
- Idiopathic orofacial pain
What conditions could be pain attributed to lesion or disease of the trigeminal nerve?
Trigeminal neuralgia
Painful trigeminal neuropathies
What conditions are pain attributed to lesion or disease of the glossopharyngeal nerve?
Glossopharyngeal neuralgia
Painful glossopharyngeal neuropathies
What conditions could come under type 5 - orofacial pains resembling presentations of primary headaches?
Migraine
Tension type headache (TTH)
Trigeminal autonomic caphalalgies ( TACs)
Other primary headache disorders
ICHD-3
What conditions come under class 6 - idiopathic orofacial pain?
Burning mouth syndrome (BMS)
Persistent idiopathic facial pain (PIFP)
Persistent idiopathic dentoalveolar pain
What is trigeminal neuralgia?
A disorder characterised by recurrent unilateral brief electric shock-like pains
Abrupt in onset and termination
Limited to the distribution of one or more divisions of the trigeminal nerve and triggered by innocuous stimuli
What is the diagnostic criteria for trigeminal neuralgia?
A. Recurrent paroxysms of unilateral facial pain in the distributions of one or more divisions of the trigeminal nerve, with no radiation beyond, and fulfilling criteria B and C
B. Pain has all of the following characteristics:
1. Lasting from a fraction of a seconds to 2 minutes
2. Severe intensity
3. Electric shock like, shooting, stabbing to sharp in quality
C. Precipitated by innocuous stimuli within the affected trigeminal distribution
D. Not better accounted for by another ICHD-3 diagnosis
What is the incidence of trigeminal neuralgia?
4-13 in 100,000
Who is most affected by trigeminal neuralgia?
50-60 years
Females > males
What % of trigeminal neuralgia is related to dental tx or disease?
22%
What is classical trigeminal neuralgia?
Develops without apparent cause other than neurovascular compression
What is the diagnostic criteria for classical trigeminal neuralgia?
Recurrent paroxysms of unilateral facial pain fulfilling criteria of trigeminal neuralgia
Demonstration on MRI or during surgery of neurovascular compression, with morphological changes in the trigeminal nerve root
What is the root entry zone for classical trigeminal neuralgia?
Point where the peripheral & central myelins of Schwann cells and astrocytes meet
What is abnormal firing of the nerve?
Ignition hypothesis
What is classical trigeminal neuralgia with concomitant continuous pain?
Classical trigeminal neuralgia with persistent background facial pain
What is the diagnostic criteria for classical trigeminal neuralgia with concomitant continuous pain?
Concomitant continuous or near-continuous pain between attacks in the affected trigeminal distribution
What is secondary trigeminal neuralgia?
Trigeminal neuralgia caused by an underlying disease. Clinical exam shows sensory changes in a significant proportion of these patients
What is the diagnostic criteria for secondary trigeminal neuralgia?
An underlying disease has been demonstrated that is known to be able to cause, and explaining, the neuralgia
What 3 underlying diseases can cause secondary trigeminal neuralgia?
Multiple sclerosis
Space occupying lesion
Other cause
Who is most affected by secondary TN?
Younger pts <30 years old
What is present clinically for secondary TN?
Trigeminal sensory defects
Bilateral TN
Low sensitivity so imaging is mandatory, if not available can use trigeminal reflexes
What is idiopathic TN?
TN with neither electro physiological tests nor MRI showing significant abnormalities
What is the diagnostic criteria for idiopathic TN?
Neither classical or secondary has been confirmed by adequate investigation including electro physiological tests and MRI
What 2 types of idiopathic TN is there?
Purely paroxysmal
Paroxysmal with concomitant continuous pain
What red flags may necessitate urgent referral when diagnosing TN?
- sensory or motor deficits
- deafness or other ear problems
- optic neuritis
- history of malignancy
- bilateral TN pain
- systemic symptoms (fever, weight loss)
- patients under 30
What is first line pharmacological tx for TN?
Carbamazepine - can be prescribed by GDPs
Oxcarbazepine
What is carbamazepine?
Tegretol
Anti-convulsant
How does carbamazepine work?
Binds to voltage dependent sodium channels
Metabolised in the liver
Predominantly excreted in urine
What are the safe prescribing highlights for carbamazepine?
Do not prescribe for patients of Han Chinese or Thai origin - testing for HLAB1502 allele required - increases likelihood of Stevens-Johnson syndrome
What are the contraindications of carbamazepine?
Pregnancy - congenital malformations
Hepatic and renal impairment - caution and monitoring
Cross sensitivity with other anticonvulsants
What interacts with carbamazepine?
Herbal medicines - St John’s Wort
Alcohol
Grapefruit
What must patients know when prescribed carbamazepine?
How to recognise disorders of the liver, skin and bone marrow
Get immediate attention if rash, fever, mouth ulcers, bruising or bleeding develop
What is the dosing regime of carbamazepine?
100mg, 2x daily for 1-3 day as
Review
If necessary, increase by 100mg every 2 days
Therapeutic range 800 - 1200mg per day
Once pain free for 4 weeks trial dose reduction
How are pts taking carbamazepine monitored?
3 monthly FBC, LFTs and C&Es
What is second line pharmacological tx for TN?
Lamotrigine
Baclofen
Gabapentin
Pregablin
What other management can be prescribed for TN by GDPs working under NHS?
Lidocaine 10mg per dose nasal spray
Lidocaine 5% ointment applied to trigger point as required
Lidocaine 2% 1:80000 as infiltration/block to trigger point
When would you consider surgical management for TN?
Medical management ineffective
Medication not tolerated
Medication contra-indicated
What are the indications for surgical management of TN?
Short/no pain free period
Complications
Adverse impact on quality of life
What are the 2 surgical managements for TN?
Palliative destruction at the level of the grasserion ganglion
Posterior cranial fossa surgery
What is the ideal surgical treatment for classical TN?
Micro vascular decompression as long as not contra-indicated
What is the ideal surgical tx for idiopathic TN?
Neuroblative procedure
What is the role of the GDP with TN?
Diagnosis
Exclusion of dentoalveolar pathology
Initiate medical management in conjunction with GMP
Refer
What is glossopharyngeal neuralgia?
Same as TN but in the glossopharyngeal nerve, the Auricular nerve and pharyngeal branches of the vagus nerve.
Commonly provoked by swallowing, talking or coughing
Pain in the ear, base of tongue, tonsillar fossa and/or beneath angle of mandible
What is the diagnostic criteria for glossopharyngeal neuralgia?
A. Recurring paroxysmal attacks of unilateral pain in the distribution of the glossopharyngeal nerve and fulfilling criterion B
B. Pain has all of the following:
1. Lasting from a few seconds to 2 mins
2. Severe intensity
3. Electric shock-like, shooting, stabbing, sharp pain
4. Precipitated by swallowing, coughing, talking or yawning
C. Is not better accounted for by another ICHD-3 diagnosis
what are 3 painful trigeminal neuropathies?
painful trigeminal neuropathy attributed to herpes zoster virus
trigeminal post-herpetic neuralgia
painful post-traumatic trigeminal neuropathy
what is allodynia?
pain in response to a stimulus which would not normally cause pain
what is hyperalgesia?
increased response to a stimulus which would normally cause pain
What is hypoalgesia?
Reduction in response to a stimulus which could normally cause pain
What is hyperesthesia?
Increased cutaneous/mucosal sensitivity to a stimulus e.g. touch, temperature changes
What is dysesthesia?
An unpleasant abnormal sensation affecting the skin or mucosa e.g. burning, tingling, crawling, stinging, pain
What is painful trigeminal neuropathies?
Facile pain in the distribution of one or more branches of the trigeminal nerve caused by another disorder and indicative of nerve damage
What does painful trigeminal neuropathies feel like?
Primary pain is continuous or near-continuous and usually burning or squeezing or likened to pins and needles
What else is associated with painful trigeminal neuropathies? (Sensory)
Sensory deficits:
Mechanical allodynia
Cold hyperalgesia
What are the characteristics of painful trigeminal neuropathy attributed to the herpes zoster virus?
Unilateral facial pain of less than 3 months duration, caused by and associated with other symptoms of acute herpes zoster
How is shingles prevented?
Immunisation against herpes zoster for 70-79 year olds
How can prevention of trigeminal post-herpetic neuralgia?
Antivirals up to 72h following appearance of lesions of hingles (herpes zoster)
What is the immediate management of trigeminal post-herpetic neuralgia?
Paracetamol and codeine
What is the self management of PTNhsv & post-herpetic neuralgia?
Relaxation
Distraction
Exercise
Mindfulness
What is the topical management of PTNhsv & post-herpetic neuralgia?
Capsaicin cream/patches
Lidocaine patches
What is the systemic management of PTNhsv & post-herpetic neuralgia?
Duloxetine (SSNRI)
Amitriptyline (tricyclic)
Amantadine (dopamine agonist)
What is post-traumatic trigeminal neuropathy?
Unilateral or bilateral facial or oral pain following and caused by trauma to the trigeminal nerve(s) with other symptoms and/or clinical signs of trigeminal nerve dysfunction
What is the diagnostic criteria for painful post-traumatic trigeminal neuropathy?
History of an identifiable traumatic event to the trigeminal nerve(s), with clinically evident positive (hyperalgesia/allodynia) and/or negative (hypoesthesia/hypoalgesia) signs of trigeminal nerve dysfunction
What are 3 types of idiopathic orofacial pain?
Persistent idiopathic facial pain
Persistent idiopathic dentoalveolar pain
Burning mouth syndrome
What are common features of idiopathic orofacial pain?
Daily pain
>2 hours duration per day
>3 months
No apparent abnormality to account for symptoms
What are the psychological aspects of idiopathic orofacial pain?
Stress
Anxiety
Depression
Social isolation
Catastrophising
Cancerphobia
What is the role of GDP in chronic orofacial pain?
Good pain history
Exclude dental causes
Check cranial nerves, urgent referral if abnormalities
Reassure, suggest self-management techniques
Refer
What are systemic treatments for idiopathic orofacial pain?
Tricyclics - amitriptyline
SNRI - duloxetine
SSRI - fluoxetine
May benefit from gabapentin or pregablin if neuropathic component
What is persistent idiopathic facial pain?
Persistent facial and/or oral pain, with varying presentations but recurring daily for more than 2 hours/day over 3 months, in the absence of clinical neurological deficit
What are the clinical features of persistent idiopathic facial pain?
F>M
14-19% bilateral
Constant daily pain 57-90%
17-35% pain free months
What are the characteristics of persistent idiopathic facial pain?
Deep
Poorly localised
Nagging
Burning
Gripping
Throbbing
Pressure
What are the provoking factors of persistent idiopathic facial pain?
Stress
Cold weather
Chewing
Head movements
Life events
What are the relieving factors of persistent idiopathic facial pain?
Warmth
Pressure
Medication
What is persistent idiopathic dentoalveolar pain?
Persistent unilateral intraoral dentoalveolar pain, rarely occurring in multiple sites, with variable features but recurring daily for more than 2 hours per day for more than 3 months in the absence of any preceding causative event
What are the clinical features of persistent dentoalveolar pain?
Severe throbbing/aching
Provoked by - hot, cold, dental tx, pressure on tooth
Relieved by - warmth, pressure, medication
Associated with - bruxism, emotional problems, anxiety
What is the incidence of persistent idiopathic dentoalveolar pain after dental treatment involving removal of a sensory nerve?
1.6%
What is the role of a GDP in persistent idiopathic dentoalveolar pain?
Excluded dental causes
Avoid unnecessary pulp extrications and extraction
Check cranial nerves
Suggest self-management techniques
Refer
What investigations are taken for persistent idiopathic dentoalveolar pain?
MRI
CT
CBCT
What is the secondary care management of persistent idiopathic dentoalveolar pain?
Explanation and reassurance
Self management (relaxation, exercise, distraction, mindfulness)
Cognitive behavioural therapy
Acceptance and commitment therapy
What topical treatments can be used for persistent idiopathic dentoalveolar pain?
Lidocaine ointment
What are the systemic treatments for persistent idiopathic dentoalveolar pain?
Amitriptyline/nortriptyline
Duloxetine
What is painful post-traumatic trigeminal neuropathy?
Unilateral facial or oral pain following trauma to the trigeminal, with other symptoms and/or clinical signs of trigeminal nerve dysfunction?
What is the previous name for burning mouth syndrome?
Oral dysaesthesia
Glossodynia (just tongue)
What is burning mouth syndrome?
An intraoral burning or dysaesthetic sensation, recurring daily for more than 2 hours per day for more than 3 months, without evident causative lesions on clinical exMam
What is the diagnostic criteria for burning mouth syndrome?
> 2 hours per day >3 months
Burning quality
Felt superficial in oral mucosa
What is the incidence of burning mouth syndrome?
1-15% general population
18-33% post menopausal women
F>M 3:1
What sites do you find burning mouth syndrome?
Tongue
Palate
Lips
What local causes would you exclude for burning mouth syndrome?
Parafunctional habits
Dry mouth
GORD - particularly if posterior part of mouth affected
Candidosis - less likely if no mucosal abnormality
What systemic causes should be excluded for burning mouth syndrome?
Anaemia
Haematinic deficiency
Diabetes - undiagnosed or poorly controlled
Thyroid dysfunction
Medication - ACE inhibitors
What is the management for burning mouth syndrome?
Explanation
Reassurance
Self management
CBT
What is the topical treatment given in primary care for burning mouth syndrome?
Benzydamine as mouthwash or oromucosal spray (Difflam)
What topical treatment is given in secondary care for burning mouth syndrome?
Capsaicin mouthwash - Tabasco sauce in water
Clonazepam - oral rinse/tablet sucked and spat out
What topical treatments are given in secondary care for burning mouth syndrome?
Capsaicin mouthwash - Tabasco in water
Clonazepam - oral rinse/tablet sucked and spat out
what are the systemic txs for burning mouth?
amitriptyline/nortriptyline
duloxetine
what are some dry mouth symptoms?
difficulty eating/swallowing/speaking
mucosa sticks to mucosa/teeth
bad/altered taste
halitosis
how is oral dryness assessed?
challacombe scale
what does score 1-3 on challacombe scale indicate?
mild dryness - routine check up monitoring
what does score 4-6 on challacombe scale indicate?
moderate dryness - further investigations if cause not clear
what does score 7-10 on challacombe scale indicate?
severe dryness - cause needs to be determined, exclude sjogren’s, refer
what tx is given for score 1-3 challacombe?
may not need tx
sugar free chewing gu,
attention to hydration
what tx is given for score 4-6 challacombe?
sugar free gum or sialogogues
consider saliva substitutes and topical fluoride
what tx is given for score 7-10 challacombe?
saliva substitutes and topical fluoride
what is often found with dry mouth?
candidosis - angular cheilitis, erythematous mucosa, thrush, denture stomatitis
traumatic ulceration
poor denture retention
bacterial sialadenitis
what is the objective test for dry mouth?
unstimulated salivary flow rate test
what is normal unstimulated saliva flow rate?
> 0.2ml/min
what is a significantly reduced unstimulated saliva flow rate?
<0.1ml/min
what main medications cause dry mouth?
urologicals - oxybutinin
fluoxetine, amitriptyline
what is the pathology of sjogrens?
autoimmune chronic inflammatory condition polycolonal B cell proliferation
acinar atrophy secondary to infiltration by lymphocytes
excocrine glands
what are symptoms of sjogrens syndrome?
dry mouth
dry eyes
connective tissue disorder e.g. rheumatoid arthritis, lupus erythematosus
what investigations would be done for sjogrens?
unstimulated whole salivary flow rate
lacrimal flow rate
ocular staining score
serology
ultrasound
why is a diagnosis of sjogrens important?
increased risk of lymphoma
may lead to diagnosis of an associated connective tissue disease in secondary sjogrens?
What are some extra-glandular manifestations of sjogrens?
Arthralgia
Arthritis
Myalgia
Neuropathy
What is the role of GDP in dry mouth?
History
Exam - challacombe score
Is referral necessary?
Management
What can GDP under NHS prescribe for dry mouth?
Artificial saliva pastilles DPF (Salivix)
SST (saliva stimulating tablets) - only with impaired salivary gland function and patent salivary ducts
What systemic therapy is there for when dry mouth is caused by radiation or sjogrens?
Pilocarpine
What salivary replacements can dentists prescribe?
Artificial saliva oral Sprays
Glandosane aerosol spray
Artificial saliva gel
BioXtra gel mouthspray/gel
What advice can be given to prevent dry mouth?
Dietary advice
Improve and maintain OH
Sodium fluoride mouthwash 0.05% alc free
Sodium fluoride toothpaste 0.619 or 1.1%
What 2 oral complications are associated with dry mouth?
Bacterial sialadenitis
Staphylococcal mucositis
What is the name for excess saliva production?
Sialorrohea
What medications cause sialorrhea most?
Clozapine
Olanzapine
Vanlafaxine
What condition causes sialorrohea and why?
Parkinson’s - swallowing difficulties
What is the name for salivary gland swelling?
Sialadenosis
What are the 3 traumatic ulcers?
Physical
Chemical
Thermal
What are causes of ulcers preceded by blisters?
Infective - viral (herpes simplex)
Autoimmune - mucous membrane pemphigoid, pemphigus vulgaris
What medication can cause chemical ulcers?
Aspirin
What is the course of action if you are confident re diagnosis of ulcer?
Eliminate source of trauma and review after no more than 14 days
If lesion hasn’t resolved/doesn’t show definite signs of healing, refer
Name 4 drugs that cause oral ulceration
Methotrexate
Nicorandil
Bisphosphonates
NSAIDs
Describe how methotrexate causes drug induced ulceration?
Antimetabolite and immune modulating
Reduces DNA synthesis and cell turnover by inhibiting dihydrofolate reductase
What else can methotrexate cause?
Mucositis
What is normally prescribed alongside methotrexate?
Folate supplement
What are the key issues with methotrexate in respect to risk of ulceration?
Error in dosing regimen for non-neoplastic conditions
No/insufficient folate supplementation
Myelosuppression
What is the management for methotrexate induced ulceration?
Refer if suspected and liaise with GMP
Urgent referral if Mucositis/widespread ulceration
Ask regarding other site involvement
What is nicorandil
Potassium channel activator?
What are the indications for nicorandil?
Second line prophylaxis of stable angina
What is the incidence of oral ulceration caused by nicorandil?
0.4 to 5%
What kind of ulceration for nicorandil cause?
Large, deep, persistent
What type of ulceration do oral bisphosphonates cause?
Superficial - may be extensive
What is the definition of recurrent apthous stomatitis?
Recurrent ulcers confined to the mouth seen in the absence of systemic disease
Can be similar to ulcers seen in GI disease n
What is the incidence of RAS?
F>M
Childhood - 40 years
20-25% population
White
Non-smokers
High socioeconomic status
What 3 forms of RAS is there?
Minor
Major
Herpetiform
What is the pathogenesis of RAS?
T lymphocyte mediated immune response
3 phases - pre-ulcerative, ulcerative, healing
What is the aetiology os RAS?
Stress
Menstrual cycle
Hypersensitivity to foods
GI tract disease
Anaemia/haematinic deficiency
Drugs
Smoking cessation
Family history
Why does anaemia/haematinic deficiency predispose to mucosal disease?
Epithelial atrophy
Compromised cell mediated immunity
Cytotoxicity of leukocytes
What must be done in all cases of recurrent oral ulceration?
Exclusion of anaemia/haematinic deficiency
What investigates are taken for recurrent oral ulceration?
FBCs
Haematinics
Immuniology for coaeliac disease
What are the 2 ways GI disease can cause recurrent ulceration?
Direct involvement of the oral mucosa by disease process
Secondary to disease elsewhere in GI tract - blood loss, malabsorption
What % of coaeliac disease initial presentation is RAS?
6%
What is the prevalence of coeliac disease?
0.8 to 1.9%
What management are there for RAS?
Diet modification - consider benzoate and cinnamon avoidance
SLS free toothpaste
Topical analgesic
Topical steroids
What topical therapy can GDPs prescribe for RAS?
Analgesic mouthwashes - Benzydamine mouthwash/spray, lidocaine ointment 5%, lidocaine spray 10%
Antimicrobial mouthwashes
Topical steroids - metamethasone, clinic modulate, hydrocortisone
What systemic medication can be prescribed for RAS in secondary care?
Short course of prednisolone
Colchicine
DMARDs e.g. azathioprine, mycophenolate, mofetil
What is the management of GDP of oral lichen planus?
Explanation of diagnosis ‘
Ask re. Other site involvement and refer
Counsel re. Smoking cessation and alcohol
Advice risk of oral cancer
Consider use of symptom severity measure
What options are there for management of oral lichen planus?
Diet modification
SLS free toothpaste
Topical analgesic
Topical steroids
Regular reviews - 6 monthly as OPMD
