orofacial pain

Question 1

ways to measure pain

Answer 1

visual analogue scale
hospital anxiety and depression scale
mcgill pain questionnaire
oral impacts on daily performance

Question 2

classification of orofacial pain

Answer 2

acute
chronic continuous
chronic acute

Question 3

possible etiologies of acute orofacial pain

Answer 3

tmj
facial trauma
dental and oral causes
maxillary sinusitis
salivary gland disorders

Question 4

what is most common form of non dental facial pain

Answer 4

TMD

Question 5

how to differentiate between the different forms of TMD

Answer 5

palpate the joint and muscle
if joint hurts –> arthritic
if muscle hurts –> myalgic

Question 6

in masticatory tmd, the discomfort/pain is usually located at

Answer 6

muscles of mastication
temple
retromolar pad
ear
neck
directly over TMJ area

Question 7

characteristics of tmd

Answer 7

sudden onset of pain
pain is continuous, gets worse through out the day/night, worsen with function
deep aching pain

Question 8

tmd aggravating factors

Answer 8

prolonged chewing
jaw movement
prolonged mouth opening eg at dental appointmetn

Question 9

tmd associated factors

Answer 9

parafunctional habits eg clenching, bruxing
headache
migraines
tmj disc problems

Question 10

treatment of tmd

Answer 10

Pharmacological:
NSAIDs, paracetamol, opioids
Injecting steroids/glucocorticoids into the joint (very effective if TMD due to arthritis associated with systemic inflammation)
Myalgia — diazepam, botox, TCA

Non pharmacological:
TMJ luxation — treat with manual repositioning
Jaw exercises, stretching, Occlusal correction
Arthrocentesis, discectomy with reduction, arthroscopy without reduction

Question 11

burning mouth syndrome demographics

Answer 11

only occur in women

Question 12

location for burning mouth syndrome

Answer 12

tongue (most common)
lips
palate
buccal mucosa

Question 13

nature of pain or burning mouth syndrome

Answer 13

stinging, burning
continuous
mild to severe
itchy, sore

Question 14

associated factors with burning mouth syndrome

Answer 14

depression
menopause (hormonal changes)
dry mouth
abnormal taste

Question 15

management of burning mouth syndrome

Answer 15

exclude any secondary causes eg diabetes, drugs, anemia (full blood count, hematinics eg ferritin, b12 deficiency that can cause secondary burning mouth)

alphalipoic acid with gabapentin with or without benzydamine mouthwash for symptomatic relief around meal times

cognitive behavioural therapy to help you feel better about the pain

Question 16

management of persistent idiopathic facial pain

Answer 16

this is a diagnosis of exclusion

anti depressants, cognitive behavioural therapy, acknowledge patient’s pain

Question 17

location of post herpetic neuralgia

Answer 17

at the same site as where you had herpes zoster

Question 18

presentation of post herpetic neuralgia

Answer 18

burning, tingling, itchy pain, may be sharp

moderate to severe

Question 19

aggravating factors of post herpetic neuralgia

Answer 19

(≠initiating factors, pain is there all the time
light touch
eating

Question 20

associated factors with post herpetic neuralgia

Answer 20

herpes zoster

ramsay hunt syndrome

Question 21

management of post herpetic neuralgia

Answer 21

can be reduced by early treAtment of herpes zoster with acyclovir

spontaneous resolution, about 15% remain at one year

gabapentin, carbamzepine (must take blood test to test for allergic reaction which might result in acute erythema multiforme)

Question 22

presentation of post traumatic trigeminal neuropathic pain

Answer 22

continuous burning pain
unilateral
can be sharp and very severe
up to 6 months after trauma (more severe trauma can last longer)
triggered by touch, hot , cold

Question 23

management of post traumatic trigeminal neuropathic pain

Answer 23

reassurance that pain will pass quickly
anti convulsants
gabapentin

Question 24

presentation of persistent dentoalveolar pain

Answer 24

diagnosis of exclusion
pain is localised to tooth or tooth bearing area
continuous ache, dull, throbbing
may be aggravated by touch

Question 25

management of persistent dentoalveolar pain

Answer 25

support, gabapentin, anticonvulsant

Question 26

what is giant cell arteritis

Answer 26

inflammation of lining of arteries

Question 27

giant cell arthritis may cause pain that is bilateral, or multifocal. giant cell arthritis at __ artery causes what symptom lingual, occipital, maxillary, retinal

Answer 27

lingual artery -- ischemic tongue, vascular necrosis of tongue occipital artery -- headache at back of head maxillary artery -- masticatory claudication retinal artery -- visual impairment due to giant cell infiltration in retinal arteries

Question 28

nature of pain brough on by giant cell arteritis

Answer 28

continuous, uni or bilateral sudden onset dull, throbbing claudication pain (may mimic tmj)

Question 29

diagnosis of giant cell arteritis

Answer 29

suspect if esr and crp high if suspicious, do temporal artery biopsy and look for periluminal dark halo on colour duplex ultrasonography give high dose steroids on speculation

Question 30

presentation of post stroke pain

Answer 30

``` ipsilateral side as weakness (contralateral side to cerebral hemisphere insult) whole side of face continuous burning/prickling moderate pain may be delayed onset ```

Question 31

migraine headache disorder is most common in what demographic

Answer 31

young females

Question 32

etiology of migraine

Answer 32

abnormal 5-HT activity with cerebral oedema | association with TMD

Question 33

presentation of migraine

Answer 33

unilateral Initially poorly localised, then localised (to temporal, frontal, orbital regions) may have aura episodic (attacks decrease in frequency with age)

Question 34

aggravating factors for migraine

Answer 34

hormonal (OCP can increase frequency in those predisposed) diet flashing lights stress sleep deprivation

Question 35

migraines may be associated with

Answer 35

photophobia nausea vomitnig tmj pain/tmd

Question 36

treatment for migraines

Answer 36

acute treatment: 5 HT antagonist eg ergotamine, sumatriptan prophylaxis: beta blockers, calcium channel blockers, antihistamines

Question 37

dental things to note when treating patient who is on prophylactic mediaction for migraines

Answer 37

patient may be taking propranolol which is non selective, should not give LA containing adrenaline (risk of hypertensive reaction) patient may be taking calcium channel blockrs eg verapamil which can cause gingival hypertrophy

Question 38

what are the two types of trigeminal autonomic cephalgia

Answer 38

short unilateral neuralgiform pain with cranial autonomic features eg crying, sweating short unilateral neuralgiform pain with conjunctival injection and tearing eg lacrimation, nasal suymptoms, ptosis

Question 39

presentation of trigeminal autonomic cephalgia

Answer 39

``` unilateral cluster headaches usually around the eyes (v1, v2) rapid, short lived attacks (seconds-minutes) sharp stabbing pain non refractory, frequent elicited by touch ```

Question 40

management of trigeminal autonomic cephalgia

Answer 40

anticonvulsants, iamotrigine

Question 41

the two types of trigeminal neuralgia

Answer 41

type 1: classical type episodic paroxysmal attack, short lasting (2s to minutes) usually in older patients nerve root compression at posterior cranial fossa by branch of pca type 2: longer lasting central cns aetiology eg brain tumour, demyelination disease

Question 42

location of trigeminal neuralgia

Answer 42

unilateral | usually lower divisions ie v2, v3

Question 43

nature of trigeminal neuralgia pain

Answer 43

``` episodic unilateral has refractory periods ie cannot elicit pain twice in a short period of time periods of remission electric shock with burning afterpain moderate to severe ```

Question 44

aggravating factors of trigeminal neuralgia

Answer 44

light touch cold wind brushing teeth

Question 45

treatment for trigeminal neuralgia

Answer 45

type 1 usually responds to medication. if not, neurosurgery type 2 mri to check for demyelination ``` cognitive behavioural therapy for fear steroids for demyelination antidepressants (depression due to pain) carbamazepine gabapentin with ropivacaine pregabalin ```

Question 46

what neurosurgery do you do for trigeminal neuralgia

Answer 46

microvascular decompression, rhizotomy, peripheral neurolysis

Question 47

what is the complication of carbamazepine

Answer 47

may cause acute erythema multiforme, need to take blood test to test HLA type before taking

Question 48

presentation of glossopharyngeal neuralgia

Answer 48

triggered by swallowing, coughing, touching ear unilateral in ear, tongue base, tonsils radiating pain paroxysmal, 2s to minutes electric shock patient may get syncope due to severity of pain

Question 49

management of glossopharyngeal neuralgia

Answer 49

carbamazepine gabapentin pregabalin lamotrigine

Question 50

systemic diseases with characteristic facial pain/headaches

Answer 50

``` pagets hyperthyroidism metastatic disease multiple myeloma vitamin b defiicency SLE chemotherapy folic acid and iron deficiency anemia hyperparathyroidsm ```

Question 51

red flags for orofacial pain

Answer 51

TUMOUR: spontaneous focal pain or altered sensation may indicate tumour invasion new onset headache with increasing severity, nausea, abnromal neurologic signs eg decreased sensation across face --> intra cranial tumour pregnancy + ear ache+ trismus + altered sensation in mandibular distribution --> acoustic nerve tumour CARDIAC: pain at angle of mandible esp left, brought on by exertion and relieved by rest --> cardiac ischemia SYSTEMIC: systemic signs of anorexia, fever, weight loss, malaise, sweating trigeminal neuralgia in patient under 50 years old may suggest multiple sclerosis (a type of demyelination disease) TEMPORAL ARTERITIS: suspect temporal arteritis when: - over 50 y/o, localised progressive headache, superficial temporal artery swelling and tenderness - jaw claudication, palpably tender superficial temporal arteries