oral med facial pain Flashcards
1
Q
what are some oro-facial pain conditions
A
TN, burning mouth , PIFP, PIDP, PTTNP
2
Q
how long for pain to be diagnosed as chronic
A
3 months
3
Q
what is burning mouth disorder
A
a chonic orofacial pain with an intraoral burning or dysaesthetic sensation that recurs more than 2 hrs per day on 50% of the days over more than 3 months, without evident causative lesion on investigation and examination
4
Q
what is the demographic of burning mouth
A
- less than 2%
- women more prevalent
- usually older
5
Q
what are some symptoms of burning mouth
A
- pain of burning quality affecting mouth
- multiple sites
-bilateral presentation - often relieved with eating
- worse as day progresses
- associated with xerostomia or dysgeusia
- tongue is focus
6
Q
what is onset of burning mouth (give examples of triggers)
A
- half spontaneous
- half trigger
common triggers
- new meds
- illness
-stressful life events
-dental or medical procedures
7
Q
link between pyschology and BMD
A
- not CAUSAL considered predisposing and perpetuating
- not more pronounced than it is in any other chronic pain entities
- noting ; anxiety, depression and emotional distress
8
Q
what should a dentist do for BMD
A
- take a history - includes questions on potential trigger and how it impacts on day to day life
- look for other diagnoses
- show empathy - it makes difference
- recognise that the pain is real and tell them this
- provide BISOM leaflet as a uncomfirmed diagnosis
9
Q
secondary care management of BMD
A
- education and reassurance
- CBT /distraction technique
- benzydamine
- gabapentin/amytyrptyline
-clonazepam - 500mg tablet crushed with water - alpha lipoic acid
-capsaicin
10
Q
is imaging used in BMD
A
- NO
-unless unilaterally
11
Q
what things need to be excluded in BMD diagnosis
A
- oromucosal diseases such as OLP or candidal colonisation acting pathologically
- hyposalivation
- tongue parafunction
- anaemia
- vitamin B12 and B9 deficiency
- diabetes mellitus
- use of ACE inhibitors
12
Q
mechanisms of BMD
A
combination
- peripheral or central or peripheral/central neuropathy
- &
- reduced brain dopaminergic activity which normally inhibits nociceptive signalling
13
Q
what causes neuropathy in BMD
A
-reduction in protective neurosteroid
- which is due to reduction of precursors such as testosterone and gonadal
14
Q
explain hormones role in BMD
A
- reduced gonadal hormones in menopause
- reduced testosterone in anti-prostatic treatment
- chronic stress or a post traumatic stress → altered HPA activity → persistent raised cortisol → reduced protective neurosteroids
15
Q
what is PIDP
A
persistant unilateral intraoral dentoalveolar pain, rarely occuring 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 preceeding causative event
16
Q
symptoms of PIDP
A
- well localised moderate intensity pain
- ant tooth or mucosa of extraction site
- more commonly premolar or molar regions of maxilla
- character - dull, pressure like
- difficult to distinguish from odontogenic pain
17
Q
onset of PIDP
A
- usually after dental Tx
- RCT, XLA, pros
18
Q
cause of PIDP
A
- unclear
- prossibly a neuropathic pain - specifically deafferentiation pain due to sensory loss (phantom limb)
- occurs in susceptible individuals following dental Tx
- central modulation
19
Q
how to distinguish from odontogenic pain
A
- normal clincal and radiographic exam
- continuous pain reported unlike pulpal pain which tends to either worsen or improve over times
- does not wake patient from sleep
- previous dental treatment without improvement to pain
- pain may affect adjacent teeth following dental treatment
- pain aggrevated by stress
- potential involvement of multiple sites in diff quadrants
20
Q
what does dentist do in PIDP
A
- history taking
- investigate odontogenic cause with radiographs and sensibility testing
- avoid futher dental intervention
- refer to OM or restorative if unsure re odontogenic cause
- what if patient keeps coming back requesting extraction ?
- need good record keeping
- explain why to patient you dont think extraction is appropriate if the tooth is healthy
21
Q
what is PPTNP
A
- persisting over 3 monhs
- onset within 6 months of injury to the peripheral trigeminal nerve
- associated with somatosensory symptoms in the area of burning, shooting pain or numbness
- associated with hyperalgesia and allodynia
22
Q
onset of PPTNP
A
typically precipitating injuries
- 3rd molar surgery
- XLA
- endo
- implant placement
- administration of LA
23
Q
symptoms of PTTNP
A
- burning or shooting pain
- mod to severe intensity
- usually continous , lasting most of day
- rarely crosses midline
24
Q
risk factors for developing PTTNP
A
- preceding pain of greater severity
- preceding pain of greater duration
- psychosocial factors, particularly fear and past events/memories
- older age
- female
25
what should dentist do in PTTNP
- consider preventative strategies in selected patients/procedures
- pre-op use of analgesic and antiinflammatory
- post op anaglesic
- minimising tissue damage
- avoid further intervention
- refer to OM
26
what is PIFP
ICHD defines as perisistant facial and/or oral pain with varying presentations but recurring daily for more than 2 hours per day over more than 3 months , in the absence of clinical neurological deficit
26
prevalence of PIFP
- mid forties
- female:male - 2:1
- orofacial pain clinics -10-21%
- psychosocial disability and chronic pain elsewhere appear to be associated
27
symptoms of PIFP
- poorly localised unilateral pain
- however can present bilaterally - usually later in course of condition
- usually maxillary region affected
- described as - dull, nagging, aching, throbbing
- there can be sharp exacerbations
- aggravated by stress
- persistant and daily
28
onset of PIFP
- frequently follows minor procedures - dental or sinus
- often patients cant remember sequence of events
- ++ confusion where dentist has just treated an odontogenic pain
- further intervention by dentist can aggravate pain
29
cause of PIFP
- unknown
- there may be subclinical neuropathic component
- a disproportionate response to mild injury
- ? a heterogenous entity
- varying input from sensitized peripheral nerves and dysfunctional CNS pain processing
30
dentist management of PIFP
- avoid unnecessary dental treatment where diagnosis uncertain
- consider PIFP differential if
- pt has other chronic pain conditions, sleep
- sleep not affected
- little variability in severity
- poorly localised
- sometimes bilateral
- refer to oral med
31
secondary care management of PIFP
- nortriptyline
- duloxetine
- CBT
- recent study <15% found medications helpful
- 45% found non medical interventions helpful
- physical activity
- distraction
- physiotherapy
- relaxation
32
3 categories of pain
- **Nociceptive** – Normal physiological response (trauma, non-healing injury, inflammation. ‘pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors
- **Neuropathic –** Lesion or disease of the somatosensory nervous system – TN is a NEUROPATHIC PAIN
- **Nociplastic pain–** It results in increased sensitivity from the altered function of pain-related sensory pathways in the periphery and central nervous system (CNS).
- Triggered by non-nociceptive stimuli
33
what is TN
A disorder characterized 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. It may develop without apparent cause or be a result of another diagnosed disorder. Additionally, there may be concomitant continuous pain of moderate intensity within the distribution(s) of the affected nerve division(s).
34
importance of TN
- high suicide/depression
- decreased overall wellness
- unnecessary medical/dental Tx
35
demographics of TN
- incidence 8 in 100,000 UK
- usually 50-60
- slightly more females
36
distribution of TN
- unilateral
- if bilateral, possible of MS
- follows distribution of trigeminal nerve strictly
- mostly V2 and V3
- rare to see V1 alone
- doesnt affect angle of mandible
- common trigger point - alla of nose , unilaterally , radiating up to eye , canine region
- can present intra-orally - issue is if it is odontogenic pain
37
classifications of TN
-classic
-secondary
-idiopathic
38
what is classical TN
- trigeminal neuralgia developing without apparent cause other than neurovascular compression
- purely paroxysmal
- with concomitant continuous pain
39
what is secondary TN
- trigeminal neuralgia caused by an underlying disease
- MS
- space occupying lesion
- other cause
- skull-base bone deformity
- connective tissue disease
- arteriovenous malformation
- dural arteriovenous fistula
- genetic cause of neuropathy or nerve hyperexcitability
40
what is idiopathic TN
- unilateral or bilaterla pain in the distribution of one or more branches of the trigeminal nerves, indicative of neural damage but of unknown aetiology
- purely paroxysmal
- with concomitant continous pain
41
what is the pathophysiology of TN for classical , secondary and idiopathic
**Classical TN –** Neurovascular conflict of the superior cerebellar artery, compression leads to demyelination, resulting in ectopic firing – no issue with the extra-cranial course of the nerve – can be observed in asymptomatic patients.
**Idiopathic –** No conflict but unregulated sodium ion inflow resulting in depolarisation
**Secondary –** pathological process resulting in a reduction in glial/myelin coverage at the pons
42
presentation of TN
sharp
shock like
severe
short lasting <2mins
memorable first episode
43
triggers of TN
- Eating
- Washing face
- Brushing teeth
- Eating
- Speaking
- Smiling
- Cold wind
- Temperature change
- Stress
44
red flags of TN
- sensory motor defects
-deafness
-loss of balance
-optic neuritis
-history of crania-facial malignancy
-bilateral TN
-systemic symptoms
-<30 years
45
GDP management of TN
- history
- rule out odontogenic pain cause
- refer to OM
- liaise with GMP
-start carbamazepine (100mg 2 tablets daily)
- blood testing GMP
46
secondary care management of TN
- MRI
- carbamazepine
-oxcarbazepine
- LA in affected area
- medical optimisation
- neurosurgery
- baclofen and gabapentin
47
what doses of carbamazepine and oxcarbazepine for TN
- carb : 800-1200 mg - 4 doses
- oxcart ; 1200-1800mg - 4 doses
48
what does MRI in TN outrage
- space occupying lesion
- MS
- neurovascular conflict
49
surgical approaches for dealing with TN
- microvascular decompression
- neuroablative procedure - balloon compression
-stereotactic radio surgery
50
what is Trigeminal autonomic cephalagias
- group of headache disorders
- similar to TN but autonomic features
51
types of TAC
- Cluster Headache
- SUNCT/SUNA
- Hemicrania continua
- Paroxysmal hemicrania
52
what is cluster headache and treatment
- Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites
- lasting 15-180 minutes and occurring from once every other day to eight times a day.
- The pain is associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and/or eyelid oedema, and/or with restlessness or agitation
management
- Acutely: Oxygen, triptans, lidocaine
- Prophylaxis: Corticosteroids (short term), Verapamil, lithium, Indomethacin
53
what is paroxysmal hemicrania and management
- Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites
- Lasting 2-30 minutes and occurring several or many times a day.
- The attacks are usually associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and/or eyelid oedema.
- They respond absolutely to indomethacin.
54
what is SUNCT/SUNA and management
- **(S)hort Acting (U)nilateral (N)euralgiform headache attacks with (C)onjunctival injection and (T)earing**
- **(S)hort Acting (U)nilateral (N)euralgiform headache attacks with cranial (A)utonomic symptoms**
- Attacks of moderate or severe, strictly unilateral head pain
- lasting seconds to minutes, occurring at least once a day and usually associated with prominent lacrimation and redness of the ipsilateral eye.
SUNCT/SUNA: IV lidocaine, lamotrigine topiramate, Gabapentin
55
what is hemicranial continua and management
- Persistent, strictly unilateral headache, associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and/or eyelid oedema, and/or with restlessness or agitation.
- The headache is absolutely sensitive to indomethacin.
- May have a migrainous component
56
what are 3 categories of pain
nociceptive
‘pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors
neuropathic
Lesion or disease of the somatosensory nervous system
nociplastic pain
it results in increased sensitivity from the altered function of pain-related sensory pathways in the periphery and central nervous system (CNS).
