Oral pain Flashcards
Different types/causes of facial pain
Dental pain e.g. PAP, pulpitis, cracked tooth, hypersensitivity, post-op TMD Osteitis/myelosteitis Infections Burning mouth Myalgia Vascular e.g. temporal arteritis Neurological e.g. cluster headache, trigeminal neuralgia Trauma
Facial pain - pain history from patient
SOCRATES TMD FH, SH, MH Parafunction Recent changes to medication, lifestyle, dental work, etc.
Different types of dental pain
PAP - pain on pressure Pulpitis - pain with stimuli Cracked tooth - pain when biting stopped Bruxism - pain on multiple teeth, after waking up TMD - opening and closing, locking, clicking Hypersensitivity - cold, sweet Post-op - cold, sweet Inflammation - swelling, tender
Initial/general management of a patient in pain ???????
- Reassure
- Explain the diagnosis, treatment options
- Biopsychosocial assessment
Referred dental pain
Pain in an area triggered by something somewhere else
Burning mouth syndrome
Oral dysthaesia Burning pain in parts of or all of the mouth Unknown aetiology but can be triggered by local or systemic factors: Local - xerostomia - bacteria/viral/fungal - parafunction - geographic tongue - reflux - allergies
Systemic
- Psychological
- Vit B12/folate/iron deficiency
- Hormones/menopause
- diabetes
Management = treat the underlying cause, manage symptoms. Use antidepressants, CBT, oestrogen
Chronic pain
> 3 months
Atypical facial pain - symptoms/diagnosis
Daily
Constant
In face - can be in one area or move to different areas
Investigations are all negative - no cause
Associated features = swelling, flushing, altered sensation, lacrimation
Atypical odontalgia symptoms/diagnosis [5]
- Throbbing pain in the tooth or socket but all negative tests and no known cause
- Treatment of that tooth will not resolve the pain - it will continue or move to another tooth/area
- Sensitised nerves after RCT/XLA/infection or treatment
- Tends to be older patients + psychosocial causes
- Referral to pain services if it doesn’t improve in a week
Hyperalgesia
Excessive pain in response to a stimulus
Allodynia
Pain response to a non-pain stimulus
Spontaneous pain
Pain in the absence of a stimulus
Central sensitisation
Nerves/muscles are sensitised so excessive response and more sensitive to stimuli
Abnormal/worrying signs when doing a pain exam
Vomiting, headache, photophobia = raised ICP
Abnormal nerve responses
Trigeminal neuralgia presentations
Short Sharp Severe Stabbing Sudden Unilateral
Occurs in 1+ trigeminal nerve distributions
In older patients, gets worse with age and worse with movement and during the daytime
Trigeminal neuralgia aetiology
Trigeminal ganglion connected to pons through nerves. Demyelination of these nerves can cause electrical signals to jump between the nerves and be very painful
1) classic = vascular hypothesis - artery pressing on nerve causing demyelination
2) secondary to pathology e.g. tumour pressing on nerve, multiple sclerosis causing plaque-like demyelination, peripheral neuropathy
3) idiopathic
Management of trigeminal neuralgia
Medication
1) Sodium channel blockers e.g. carbamazepine (anti-epileptic, but SE = lupus-like reactions, rash, interacts w warfarin and other drugs)
2) Gabapentin, pregabilin, phenytoin, valproate pain meds
Surgery
- microvascular decompression (for vascular theory)
- cryotherapy (superficial nerves)
- ganglion procedure
- gamma knife/stereotactic radiosurgery
Microvascular decompression for trigeminal neuralgia
For vascular theory/classical
- Surgically reposition the artery so that it is no longer compressing the nerve
- One-time fix, great results
- But invasive so the patient needs to be young and fit
- Severe complications of surgery = meningitis, stroke, cranial nerve deficits, CSF leak.
Cryotherapy for trigeminal neuralgia
Non-invasive, simple to do.
Can cause scarring, fibrosis and sensory deficit
But can only freeze superficial/peripheral nerves
Temporary bc nerve will grow back (6 months)
Stereo-tactic radiosurgery for trigeminal neuralgia
Precision high dose radiation to a small area of the brain.
Day case procedure, using a frame to secure the head and MRI scan to locate the nerve.
Damage to the nerve causing fibrosis
One-time
But sometimes doesn’t work, can cause irritation, tingling, numbness
Ganglion procedure for trigeminal neuralgia
Less invasive but still surgery and GA
Damage the nerve fibres by injecting into the ganglion.
Use a solution, or thermally so that they can’t fire anymore
But only lasts 2-3 years
Can damage surrounding nerves too = other sensory deficits
Types of headaches
Cluster headaches
Migraines
Temporal arteritis
Temporal arteritis symptoms/signs
Unilateral or bilateral - new persistant headache
Lack of blood = necrosis.
Pain and tenderness in the temporal region on palpation
Pain and tenderness in MoM and on opening/closing
Reduced pulse in the temporal artery
If it spreads to the ocular artery it can cause blindness
Temporal arteritis aetiology
Autoimmune disorder.
Antibodies against the elastic layer of the artery, cause inflammation, fibrosis and thickening of temporal artery walls
This reduces or cuts off blood supply to the muscles and soft tissues
Temporal arteritis special investigations
Palpate
Doppler scan of the artery to see thickening
Blood tests - raised ESR and CRP
Biopsy of temporal artery = inflammation and thickening of the wall
Temporal arteritis management
Autoimmune = steroids (prednisolone). Higher dose if eye involved.
Urgent referral to ophthalmologist, rheumatologist, GMP
Cluster headaches aetiology
Unknown cause
Can be triggered by things -
Autonomic condition
Cluster headaches symptoms/signs
In ocular/temporal/frontal region
Unilateral but can switch between sides
Recurrent episodes, daily attacks for months
Alarm clock headache - severe throbbing burning pain, that wakes the patient up
Horner’s eye signs
+ Rhinorrheo, lacrimation, rash, swelling, red-eye
Management of cluster headaches
Acute attack = 100% oxygen, 10-12L/min or inject/nasal of triptan
Prevention = avoid triggers e.g. alcohol, coffee and medications like prednisolone, gabapentin, lithium, verapamil
Migraine signs/symptoms
Headache
Lasts 4-72h
Nausea, photophobia, phonophobia, throbbing
Episodic
Migraine triggers
Food Smells Stress Relaxation Hormones Oestrogen
Migraine management
Symptoms = analgesics, anti-emetics, triptan Prevention = amitriptyline, beta-blockers Educate = triggers, physcological methods
