ORAL MED/ORAL FACIAL PAIN Flashcards
there are two main systems of orofacial pain classification, what are they?
international classification of headache disorders Edition 3 - 2018
international classification of orofacial pain, 1st edition (ICOP) 2020
the oro-facial pain classification - ICOP
is broken down to 6 groups what are they ?
- Orofacial pain attributed to disorders of dentoalveolar and anatomically related structures.
(tooth related pain, pain from the periodontium, pain from the oral mucosa, pain from salivary glands and pain from bone) - myofascial orofacial pain (pain confined in a particular area)
- temporomandibular joint (TMJ) pain
- Orofacial pain attributed to lesion or disease of the cranial nerves
- Orofacial pains resembling presentations of primary headaches
- Idiopathic orofacial pain
what is trigeminal neuralgia?
Trigeminal neuralgia is sudden, severe facial pain. It’s often described as a sharp shooting pain or like having an electric shock in the jaw, teeth or gums. It usually happens in short, unpredictable attacks that can last from a few seconds to about 2 minutes.
a patient presenting with sudden severe facial pain, describing it as a sharp shooting pain on the jaw, which lasts anywhere a few seconds to 2 minutes. what could be the most likely cause of this?
trigeminal neuralgia
trigeminal neuralgia most commonly affects how many sides?
most commonly one side of the jaw
trigeminal neuralgia usually occurs spontaneously, but is sometimes associated with?
facial trauma or dental procedures.
what causes trigeminal neuralgia?
The condition may be caused by a blood vessel pressing against the trigeminal nerve, also known as vascular compression. Over time, the pulse of an artery rubbing against the nerve can wear away the insulation, which is called myelin, leaving the nerve exposed and highly sensitive.
Multiple sclerosis or a tumor — while rare — can also cause trigeminal neuralgia.
Trigeminal neuralgia occurs more often in which gender and age group?
Trigeminal neuralgia occurs more often in women than men, is more common in older people (usually 50 and older), and occurs more on the right than the left. It doesn’t usually run in families.
symptoms of trigeminal neuralgia may include?
Episodes of sharp, intense, stabbing pain in the cheek or jaw that may feel like an electric shock. Pain episodes may be triggered by anything touching the face or teeth, including shaving, applying makeup, brushing teeth, touching a tooth or a lip with the tongue, eating, drinking or talking — or even a light breeze or water hitting the face.
Periods of relief between episodes.
Anxiety from the thought of the pain returning.
The trigeminal nerve splits off into three branches:
ophthalmic
maxillary
and mandibular.
The trigeminal nerve splits off into three branches: ophthalmic, maxillary and mandibular.
Each branch provides sensation to different areas of the face. Depending on which branch and which part of the nerve is irritated, trigeminal neuralgia pain can be felt anywhere in the face. Most commonly, it is felt in the
it is felt in the lower part of the face. The intensity of the pain is exceptional: Some people report it to be more severe than experiencing a heart attack, passing a kidney stone or even giving birth.
A flare-up of trigeminal neuralgia may begin with
tingling or numbness in the face. Pain occurs in intermittent bursts that last anywhere from a few seconds to two minutes, becoming more and more frequent until the pain is almost continuous.
Flare-ups may continue for a few weeks or months followed by a pain-free period that can last a year or more.
Although trigeminal neuralgia pain may seem to disappear, does it ever go away
it always comes back, often with more intensity.
what is “atypical trigeminal neuralgia.”
In some cases, instead of sharp, stabbing pain, trigeminal neuralgia appears as a persisting dull ache. This and other symptom variations are sometimes described as “atypical trigeminal neuralgia.”
Diagnosing trigeminal neuralgia involves a physical exam and a detailed medical history to rule out other causes of facial pain.
Your health care provider
will ask about the frequency and intensity of the pain, what seems to set it off and what makes it feel better or worse. Since there is no single test for trigeminal neuralgia, getting to the nature of the pain is key to the diagnosis.
Your provider may also recommend imaging or laboratory tests, such as a CAT scan or a high-resolution MRI of the trigeminal nerve and surrounding areas. These tests can help determine if the pain is caused by a tumor or blood vessel abnormality, or by undiagnosed multiple sclerosis. Certain advanced MRI techniques may help the doctor see where a blood vessel is pressing against a branch of the trigeminal nerve.
Many people who suffer from trigeminal neuralgia successfully manage this condition for many years with medication. Trigeminal neuralgia drug therapy uses some of the same medicines prescribed for controlling seizures, which includes
carbamazepine and gabapentin
trigeminal nerve blocks
If medication no longer controls your trigeminal neuralgia pain despite the increased dosage, or if the side effects are intolerable, there are several surgical procedures to consider. such as
Rhizotomy
Microvascular Decompression (MVD) Surgery
Stereotactic Radiosurgery
what is Rhizotomy?
performed under general anesthesia.
The surgeon inserts a long needle through the cheek on the affected side of the face and uses an electrical current (heat) or a chemical (glycerin or glycerol) to deaden the pain fibers of the trigeminal nerve.
Rhizotomy provides pain relief to about 80% of patients with trigeminal neuralgia, but it’s a temporary solution that usually lasts one to three years, until the nerve regrows.
what is microvascular decompression surgery
The goal of the MVD surgery is to separate the blood vessel from the trigeminal nerve by placing a cushion made of Teflon between them.
egarded as the most long-lasting treatment for trigeminal neuralgia caused by blood vessel compression, and it helps about 80% of people with this diagnosis. It is suitable for people in good health who can tolerate surgery and general anesthesia, and whose lifestyles can accommodate a recovery period of four to six weeks.
what is stereotactic radiosurgery (sometimes known as CyberKnife or Gamma Knife treatment)?
It involves a very concentrated and precise beam of radiation that is directed at the trigeminal nerve to relieve the pain.
what is glossopharyngeal neuralgia?
Glossopharyngeal neuralgia is a rare condition in which there are repeated episodes of severe pain in the tongue, throat, ear, and tonsils.
Orofacial pains resembling presentations of primary headaches include what type of headaches?
- migraine
- tension type headaches (TTH)
- trigeminal autonomic cephalalgias (TACs)
- other primary headache disorders
Idiopathic orofacial pain include?
burning mouth syndrome (BMS)
Persistent idiopathic facial pain (PIFP)
persistent idiopathic dentoalveolar pain
what is allodynia?
pain due to a stimulus that does not normally provoke pain.
what is innocuous stimuli
a stimuli that does not produce injury, like stroking of the face
what are the three pain characteristics of trigeminal neuralgia
- lasting from a fraction of a second to 2 minutes
- severe intensity
- electric shock-like, shooting, stabbing or sharp in quality
trigeminal neuralgia is divided in three classifications? what are they
- classical trigeminal neuralgia
- secondary trigeminal neuralgia
- idiopathic trigeminal neuralgia
what is the description of classical trigeminal neuralgia
trigeminal neuralgia developing without apparent cause other than neurovascular compression
what are the diagnostic criteria for classical trigeminal neuralgia?
- recurrent paroxysms of unilateral facial pain fulfilling criteria for trigeminal neuralgia
- demonstration on MRI or during surgery of neurovascular compression (not simply contact), with morphological changes in the trigeminal nerve root.
why is the root entry zone an area of high risk for classical trigeminal neuralgia?
point where the peripheral and central myelins of Schwann cells & astrocytes meet.
secondary trigeminal neuralgia is attributed to underlying disease, which underlying disease can cause trigeminal neuralgia?
- multiple sclerosis
- space occupying lesions
- other causes (tumour)
what is the description for idiopathic trigeminal neuralgia?
trigeminal neuralgia with neither electrophysiological tests nor MRI showing significant abnormalities
what is the diagnostic criteria for Idiopathic trigeminal neuralgia
recurrent paroxysms of unilateral facial pain fulfilling criteria for trigeminal neuralgia, either purely paroxysmal or associated with concomitant continuous or near-continuous pain.
neither classical nor secondary trigeminal neuralgia has been confirmed by adequate investigation including electrophysiological tests and MRI
what is the first line agent for the treatment of TN
Carbamazepine - can be prescribed for TN by GDPs working under NHS or in private practice.
should carbamazepine be contraindicated as a first line treatment for TN what could you prescribe?
Oxcarbazepine - not available for dentist working under the NHS
by this stage the patient should have been by secondary care by a specialist.
what is an anti-convulsant
drug used to prevent or reduce the severity of epileptic fits, bipolar disorder or other convulsions
what does carbamazepine bind on to?
binds to voltage dependent sodium channels, thus inhibiting action potential generation.
where is carbamazepine metabolized and excreted?
metabolized in the liver and predominantly excreted in urine
which enzyme group metabolizes carbamazepine in the liver
cytochrome group - CYP 3A4
Stevens-Johnson syndrome is a rare condition arising from ‘over-reaction’ of the immune system to a trigger such as a mild infection or a medicine, leading to blistering and peeling of the skin and surfaces of the eyes, mouth and throat
which ethnic group should you not prescribe carbamazepine to prevent the increase of developing Stevens-Johnsons syndrome to?
Han Chinese or Thai origin
what are the contraindications for carbamazepine?
pregnancy - congenital malformations
hepatic and renal impairment - caution and monitoring
cross sensitivity with other anticonvulsants
interactions - numerous includes herbal medicines e.g. St John’s Wort, alcohol and grapefruit
what advice must be given to a parent/carer when caring for someone who’s on carbamazepine?
how to recognize disorders of:
liver
skin
bone marrow
when on carbamazepine when is immediate medical attention required?
if rash, fever, mouth ulcers or bleeding develop
because of the adverse effects of carbamazepine on the liver, kidneys and bone marrow its important for what test to be carried out?
baseline blood tests ideally prior to commencement or as soon as possible after patient has taken medication
what is the typical dosage regime for carbamazepine
100 mg twice daily for 1-3 days
doses should be evenly spaced out throughout the day.
trigeminal neuralgia can go through periods of remission of variable duration, we don’t want to maintain a patient on carbamazepine for any longer than necessary.
after how many pain free weeks would we normally trial cautious dose reduction?
4 weeks
although there is no set regime for blood test it is recommended that blood test are taken?
weekly for first 4 weeks, 1 to 3 monthly after this
what are the second line pharmacological treatment (either alone or in combination with carbamazepine or oxcarbazepine
Lamotrigine
baclofen
gabapentin
pregabalin
carbamazepine is marketed under the manufactures name?
Tegretol
what is an anticonvulsant
a medication used for the treatment for having fits.
what is Stevens-Johnson Syndrome
Stevens-Johnson syndrome is a rare condition arising from ‘over-reaction’ of the immune system to a trigger such as a mild infection or a medicine, leading to blistering and peeling of the skin and surfaces of the eyes, mouth and throat
what is breakthrough pain
when you have pain you will be on medication for it, despite the medication there will be times when the pain breaks through
additional management of trigeminal neuralgia through pharmacological treatment include the use of lidocaine. how can these drugs be administered?
Lidocaine 10mg per dose nasal spray for maxillary pain
lidocaine 5% ointment to be applied to trigger point as requires
Lidocaine 2% 1:80 000 adrenaline as infiltration/block to trigger point
the latter can be a useful diagnostic tool and, if a long-acting local anesthetic agent is used e.g. bupivacaine, provide more prolonged relief.
people who suffer from trigeminal neuralgia require additional support why?
patients who suffer from trigeminal neuralgia can undergo the following, which impacts their lives:
severe pain
may be difficult to control
side effects of medication
negative impact on activities of daily living
negative impact on quality of life
depression
anxiety
suicidal ideation
what can we offer patients who are unable to take medications for trigeminal neuralgia or medication is ineffective
surgical management of trigeminal neuralgia
what are the indications of surgical management of trigeminal neuralgia?
- medical management ineffective
- medication not tolerated
- medication contra-indicated
- short/no pain free period
- complications
- adverse impact on quality of life
surgical management of trigeminal neuralgia can be managed in to two distinctive groups, what are they?
- palliative destructive at the level of the grasserion ganglion
- posterior cranial fossa surgery
the use of the following is used for the management of what?
- radiofrequency thermocoagulation
- gycerol rhizolysis
- balloon compression
- steriotactic radiosurgery (SRS) - gamma knife
trigeminal neuralgia surgical management with the aim of palliative destructive at the level of the grasserion ganglion.
the use of the following is used for the management of what?
- microvascular decompression
- partial sensory rhizotomy
- internal neurolysis
trigeminal neuralgia surgical management with the aim of posterior cranial fossa surgery
what is the most common surgical management for treating trigeminal neuralgia involving posterior cranial fossa surgery
microvascular decompression
what surgical management approach would you use to treat classical trigeminal neuralgia?
classical trigeminal neuralgia can only be classified as long as there is a decompression of the trigeminal nerve, thus microvascular decompression is the best management as long as it is not contra-indicated.
in cases of idiopathic TN what would be the best surgical management of TN?
a more destructive intervention is more likely to be taken.
what are the expected roles of the GDP regarding TN regarding diagnosis?
exclusion of dentoalveolar pathology
initiate medical management in conjunction with GMP
Refer if
what is glossopharyngeal neuralgia
Glossopharyngeal neuralgia is characterized by a sharp, jabbing pain deep in the throat, or in the tongue, ear, and tonsils, lasting a few seconds to a few minutes. Glossopharyngeal neuralgia is generally caused by a small blood vessel that presses on the nerves as they exit the brainstem
glossopharyngeal neuralgia can be classified as what type of lesion?
painful lesions of the cranial nerves
glossopharyngeal neuralgia is a disorder characterized by unilateral or bilateral stabbing pain?
unilateral
what similarities does glossopharyngeal neuralgia have with trigeminal neuralgia
both are unilateral in presentation, followed with a brief stabbing pain, abrupt in onset and termination.
glossopharyngeal neuralgia does not only affect the branches of the glossopharyngeal nerve but also which branches?
auricular and pharyngeal branches of the vagus nerve
where is pain experienced in glossopharyngeal neuralgia
pain is experienced in the ear, base of the tongue, tonsillar fossa and/or beneath the angle of the jaw.
glossopharyngeal neuralgia is commonly provoked by?
swallowing, talking or coughing and may remit and relapse in the fashion of trigeminal neuralgia.
glossopharyngeal neuralgia can be divided in to three categories what are they?
classical
secondary
idiopathic
how would you investigate glossopharyngeal neuralgia?
High resolution MRI of head and neck
what is the systemic management of glossopharyngeal neuralgia?
carbamazepine
painful trigeminal neuropathies all share a characteristic, what is it?
all share characteristic of neuropathic pain
the three members of the painful trigeminal neuropathies include?
- painful trigeminal neuropathy attributed to the herpes zoster virus
- trigeminal post-herpetic neuralgia (post-herpetic neuralgia)
- painful post-traumatic trigeminal neuropathy
the following are characteristics of neuropathic pain, what does allodynia mean
pain in response to a stimulus which would not normally cause pain. e.g. light pain
the following are characteristics of neuropathic pain, what does hyperalgesia mean
increased response to stimulus which would normally cause pain,
the following are characteristics of neuropathic pain, what does it mean
increased response to stimulus which would normally cause pain e.g cold in cold
what is hypoalgesia
Hypoalgesia is diminished pain in response to stimulation that typically produces pain. Individuals with hypoalgesia usually have a higher pain threshold than those without it. Hypoalgesia is different from hypoesthesia, or numbness, which is the decrease or loss of sensation to a stimulus.
what is hyperesthesia
“increased sensitivity to stimulation, excluding the special senses,” which “may refer to various modes of cutaneous sensibility including touch and thermal sensation without pain, as well as to pain.
what is dysesthesia
A condition in which a sense, especially touch, is distorted. Dysesthesia can cause an ordinary stimulus to be unpleasant or painful. It can also cause insensitivity to a stimulus.
such as burning, tingling, crawling, stinging, pain
what are the classification that applies to all three members of the trigeminal neur
- painful trigeminal neuropathy attributed to the herpes zoster virus
- trigeminal post-herpetic neuralgia (post-herpetic neuralgia)
- painful post-traumatic trigeminal neuropathy
- facial pain in one or more branches of the trigeminal nerve caused by another disorder and indicative of neural damage.
- the primary pain is usually continuous or near-continuous, and commonly described as burning or squeezing or likened to pins and needles.
- superimposed brief pain paroxysms may occur, but these are not the predominant pain type.
- there are clinically detectable sensory deficits within the trigeminal distribution, and mechanical allodynia and cold hyperalgesia are common.
what is the characteristics of painful trigeminal neuropathy attributed to the herpes zoster virus
unilateral facial pain of less than 3 months duration in the distribution(s) of one or more branches of the trigeminal nerve, caused by and associated with other symptoms and/or clinical signs of acute herpes zoster - which is commonly known as shingles
what is the characteristics of trigeminal post-herpetic neuralgia (post-herpetic neuralgia)
unilateral facial pain persisting and recurring for at least 3 months in the distribution(s) of one or more branches of the trigeminal nerve, with variable sensory changes, caused by herpes zoster
what can we do for the prevention of trigeminal post-herpatic neuralgia
antivirals up to 72 hours following appearance of lesions of shingles (herpes zoster) -aciclovir
immediate management - paracetomol and codeine may give partial relief
what came first the chickenpox or the shingles
chickenpox
what causes chicken pox
virusella zooster
what is a dermatome
an area of the skin innervated
what are the three management type for trigeminal post-herpetic neuralgia?
Management
- self management
- relaxation
- distraction
- exercise
- mindfulness
- topical
- capsaicin cream/patches
- lidocaine patches - systemic
- duloxetine
- amitriptyline
- amantadine
what is the characteristics of painful 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 of 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
- evidence of causation demonstrated by both of the following :
- pain is localized to the distribution(s) of the trigeminal nerve(s) affected by the traumatic event
- pain has developed <6 months after the taumatic event - not better accounted for by another ICHD-3 diagnosis
what is the description for Idiopathic Orofacial Pain
unilateral or bilateral intraoral or facial pain in the distribution(s) of one or more branches of the trigeminal nerve(s) for which the aetiology is unknown. the pain is usually persistent, of moderate intensity, poorly localized and described as dull, pressing or burning character.
how does idiopathic orofacial pain and neuropathic trigeminal pain differ in reference to location of the pain?
idiopathic orofacial pain - poorly localized
neuropathic trigeminal pain - well localized
what are the three members of idiopathic orofacial pain
- persistent idiopathic facial pain
- persistent idiopathic dentoalveolar pain
- burning mouth syndrome
what are the basic features common to members of this group
- persistent idiopathic facial pain
- persistent idiopathic dentoalveolar pain
- burning mouth syndrome
- daily pain
- > 2 hours duration per day
- pain >3 months
- no apparent abnormality to account for symptoms
- conventional analgesics e.g. paracetamol, NSAIDs, Opioids usually ineffective
when taking a pain history for idiopathic orofacial pain ensure that you also explore the patients?
- ideas
- concerns
- expectations
when taking a medical history what should we try and look out for?
- chronic pain elsewhere in the body
- current/past contact with pain services
- depression/anxiety
- medication - may already be taking analgesics/neuromodulators e.g.
- may be overusing over the counter analgesics, abusing tobacco, alcohol or drugs to escape from pain.
what is the GDP roles when someone presents with chronic orofacial pain?
- good pain history
- exclude dental causes
- check cranial nerves, urgent referral if any abnormalities
- reassure, suggest some self-management techniques
- refer
what are the management strategies common to all members of this group: idiopathic Orofacial pain
- explanation and reassurance
- relaxation
- exercise
- distraction
- mindfulness
cognitive behavioral therapy (CBT)
Acceptance and commitment therapy (ACT)
what determines the type of topical treatment that is used for idiopathic orofacial pain?
site dependent
what type of agents are used for systemic treatments for idiopathic orofacial pain?
neural modulating agents
persistent idiopathic facial pain was known as what nomenclature
atypical facial pain
what is the description for persistent idiopathic facial pain
persistent facial and/or oral pain, with varying presentations but recurring daily for more than 2 hours/day over more than 3 months, in the absence of clinical neurological deficit
what is the diagnostic criteria for persistent idiopathic facial pain
- facial an/or oral pain fulfilling criteria B and C
- recurring daily for >2 hours/day for >3 months
- pain has both of the following characteristics
- poorly localized, and not following the distribution of a peripheral nerve
- dull, aching or nagging quality - clinical neurological examination is normal
- a dental cause has been excluded by appropriate investigations
- not better accounted for by another ICHD-3 diagnosis
what are the clinical features of persistent idiopathic facial pain
- F>M
- 14.19% bilateral
- constantly daily pain (57-90%)
- characteristics - deep poorly localised, nagging, burning, gripping, throbbing, pressure
- 17-35% pain free months
- provoking factor - stress, cold weather, chewing, head movements, life events
- relieving factors - dental treatment, psychiatric conditions, altered sensations
- may be preceded by a minor injury, operation or dental treatment and persist after healing has occurred
what is the role of the GDP when a patient comes in with persistent idiopathic facial pain?
- exclude dental causes
- check cranial nerves - facial and trigeminal
- reassure, suggest some self-management techniques
- refer
what type of investigations may be considered with persistent idiopathic facial pain?
- MRI
- CT
- CBCT
what would be the management of persistent idiopathic facial pain in the secondary care setting
- explanation and reassurance
- relaxation
- exercise
- distraction
- mindfulness
- cognitive behavioral therapy (CBT)
- acceptance and commitment therapy (ACT)
what are the topical treatments available for persistent idiopathic facial pain?
- lidocaine ointment
- lidocaine patches - secondary care
- capsaicin cream
- levomenthol cream
gabapentin was previously used for the systemic management of persistent idiopathic facial pain, why cannot we use it anymore?
gabapentin along with pregabalin have been reclassified as controlled drugs, so cannot be used for the systemic treatment of persistent idiopathic facial pain. (NICE Guidelines)
the drugs that can be used are
- amitriptyline
- duloxetine
what is the description of painful post-traumatic trigeminal neuropathy?
unilateral facial or oral pain following trauma to the trigeminal nerve, with other symptoms and/or clinical signs of trigeminal nerve dysfunction
persistent idiopathic dentoalveolar pain, previous nomenclature was?
atypical odontalgia
persistent dentoalveolar pain disorder
what is the description for 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 agent.
what is the diagnostic criteria for persistent idiopathic dentoalveolar pain
- intraoral dentoalveolar pain fulfilling criteria B and C
- recurring daily for >2 hours/day for >3months
- pain has both of the following characteristics:
- localized to a dentoalveolar site (tooth or alveolar bone)
- deep, dull, pressure-like quality - clinical and radiographic examinations are normal and local causes have been excluded
- not better accounted for by another ICOP or ICHD-3 diagnosis
what are the clinical features of persistent idiopathic dentoalveolar pain
- characteristics - severe throbbing, aching
- provoking factor - hot and cold, dental treatment, pressure on tooth
- relieving factors - warmth, pressure, medication
- associated factors - bruxism, emotional problems, hypersensitivity to hot and cold, anxiety or depression, hypotensive therapy
- incidence 1.6% after dental treatment involving removal of a sensory nerve
what is the role of the GDP when someone presents with persistent idiopathic dentoalveolar pain?
- exclude dental cause
- avoid unnecessary pulp extirpations and extractions
- check cranial nerves
- reassure, suggest some self-management techniques
- refer
special investigations to be considered for xray for persistent idiopathic dentoalveolar pain include?
MRI
CT
CBCT
burning mouth syndrome previous nomenclature and still can be used today are?
oral dysesthesia
glossodynia (when only tongue affected)
what is the description of 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 examination and investigation.
what is diagnostic criteria for burning mouth syndrome?
- oral pain fulfilling criteria B and C
- recurring daily for >2 hours per day for >3 months
- pain has both following characteristics:
- burning quality
- felt superfically in the oral mucosa - oral mucosa is of normal appearance, and local or systemic causes have been excluded
- not better accounted for by another ICOP or ICHD-3 diagnosis
- there may be accompanying taste disturbance
what is the incidence rate for burning mouth syndrome
1-15% general population
18-33% post menopausal women
F>M 3:1
what are the most common sites affected with burning mouth syndrome?
tongue
palate
lips
what there must not be in the mucosa to diagnose urning mouth syndrome
no mucosal abnormality to account for symptoms
what must be excluded to determine that the diagnosis is burning mouth syndrome?
parafunctional habits
dry mouth
GORD - particularly if posterior part of mouth affected
candidosis - less likely if no mucosal abnormality
exclusion of which systemic causes for the diagnosis of burning mouth syndrome
- anaemia
- haematinic deficiency
- diabetes - undiagnosed or poorly controlled
- thyroid dysfunction
- medication e.g. ACE inhibitors
what is the role of the GDP to determine burning mouth syndrome
- exclude abnormality, local causes and systemic, if suspected, in collaboration with GMP
- avoid unnecessary treatment
- check cranial nerves
- reassure, suggest some self-management techniques, trail of benzydamine as mouthwash/oromucosal spray
- refer
what are the management of burning mouth syndrome
primary care - benzydamine as mouthwash or oromucosal spray (difflam)
secondary care
- capsaicin mouthwash - made up by patient using tabasco sauce in water
- clonazepam - oral rinse/tablet sucked and then spat out, not swallowed
what is xerostomia
xerostomia is a sensation of oral dryness
what is the difference between a sign and symptoms
symptoms = subjective evidence of a disease
sign = an objective physical finding
what are the symptoms of dry mouth
dry mouth
difficulty eating
difficulty swallowing
difficulty speaking
difficulty wearing dentures
mucosal surfaces stick to each other and/or to the teeth
bad taste in the mouth/altered taste
halitosis
sore mouth
deteriorating dentition
salivary gland swelling persistent/recurrent
what additional questions should you ask when taking a history for dry mouth?
When did it begin?
Any initiating factors?
Is it getting worse, better, staying the same?
Anything that makes it better (ameliorating factors) or worse
(exacerbating factors)?
Worse at any times than others?
Any dryness elsewhere?
Any treatment tried – any benefit?
Any other health care professionals seen?
thinking about the patients medical history for dry mouth what questions should you consider?
- do they suffer from type 2 diabetes and is it poorly controlled
- have they or are they currently receiving radiotherapy or chemotherapy
- are they taking in medications that correspond to dry mouth symptoms
- increase in dosage of medication related to dry mouth
thinking about the patients dental history for dry mouth what questions should you consider?
- have they or you noticed an increase in dental caries, especially in the cervical root region
- have they begun to develop difficulty wearing their dentures
- experiencing soreness in the mouth - previously symptom free
thinking about the patients social history for dry mouth what questions should you consider?
- do they smoke - more susceptible to dryness of the mouth
- do they consume excess amounts of alcohol - leads to dehydration
- stressful occupation
- family history of type 2 diabetes
- can the oral dryness be a symptom of diabetes that is yet to be diagnosed.
- family suffer from connective tissue disorder - rheumatoid arthritis or lupus - leads to secondary Sjogren’s syndrome
which scale is used to determine oral dryness
the challacombe scale
the following are criteria’s from the challacombe scale - for assessing oral dryness
each of these criteria score ten - with the patient scoring 10 at the most
Mirror sticks to buccal mucosa
Mirror sticks to tongue
Saliva frothy
No saliva pooling FOM
Tongue shows generalised shortened papillae
Altered gingival architecture (smooth)
Glossy appearance of oral mucosa especially palate
Tongue lobulated/fissured
Cervical caries (more than two teeth)
Debris on palate or sticking to teeth
a score of 1-3 on the challacombe scale will determine what?
Mild Dryness - Routine check up monitoring
treatment - may not need treatment, sugar free chewing gum, attention to hydration
a core of 4-6 on the challacombe scale will determine what?
moderate dryness - further investigations of cause not clear
treatment - sugar free gum or sialogogues. consider saliva substitutes and topical fluoride
a score of 7-10 on the challacombe scale will determine what?
severe dryness - causes needs to be determined exclude Sjogren’s refer
treatment - saliva substitutes and topical fluoride
what are the features of a tongue in a patient with dry mouth
lobulated
smooth
shiny
shortening of the papillae
wrinkling
what are the features of a palate in a patient with dry mouth
glossy appearance
glassy appearance
what type of caries is prominent in dry mouth cases
cervical caries
dry mouth signs include evidence of candidosis, which can manifest in to which conditions
angular cheilitis
erythematous mucosa
thrush
denture stomatitis
why would you see poor denture retention in patients with dry mouth
retention relies on saliva to form a suction
what pathology can dry mouth cause involving the saliva ducts
bacterial sialadenitis
what does pseudomembranous candidiasis present as?
Pseudomembranous candidiasis (thrush) is characterised by extensive white pseudomembranes consisting of desquamated epithelial cells, fibrin, and fungal hyphae (see fig 2). These white patches occur on the surface of the labial and buccal mucosa,
what is the investigations involving saliva flow
need to measure the UNSTIMULATED whole salivary flow rate
a patient is asked to allow a pool of saliva to collect at the floor of their mouth for a 15 minute period
the collected saliva will be measured
normal = >0.2 ml/min
significantly reduced rate <0.1 ml/min
why do we not ask a patient to spit when measuring a salivary flow rate
spitting induces saliva production
no talking as well as this also induces saliva production
stimulated whole salivary flow rate does not help with what?
not of diagnostic significance but of therapeutic significance, as it determines which glands will respond to sugar free gum or saliva stimulating tablets.
which gland is best to measure stimulated salivary flow rate for diagnostic significance?
parotid gland
what is the normal stimulated salivary flow rate?
0.4 ml/min
what is sarcoidosis
Sarcoidosis is an inflammatory disease in which the immune system overreacts, causing clusters of inflamed tissue called “granulomas” to form in different organs of the body.
what is chronic granulomatous disease
Chronic granulomatous disease (CGD) is a genetic disorder in which white blood cells called phagocytes are unable to kill certain types of bacteria and fungi. People with CGD are highly susceptible to frequent and sometimes life-threatening bacterial and fungal infections.
what is Graft vs Host disease
GvHD means the graft reacts against the host. The graft is the marrow or stem cells from the donor. The host is the person having the transplant. GvHD happens when particular types of white blood cell (T cells) in the donated stem cells or bone marrow attack your own body cells.
