orofacial pain Flashcards
ways to measure pain
visual analogue scale
hospital anxiety and depression scale
mcgill pain questionnaire
oral impacts on daily performance
classification of orofacial pain
acute
chronic continuous
chronic acute
possible etiologies of acute orofacial pain
tmj facial trauma dental and oral causes maxillary sinusitis salivary gland disorders
what is most common form of non dental facial pain
TMD
how to differentiate between the different forms of TMD
palpate the joint and muscle
if joint hurts –> arthritic
if muscle hurts –> myalgic
in masticatory tmd, the discomfort/pain is usually located at
muscles of mastication temple retromolar pad ear neck directly over TMJ area
characteristics of tmd
sudden onset of pain
pain is continuous, gets worse through out the day/night, worsen with function
deep aching pain
tmd aggravating factors
prolonged chewing
jaw movement
prolonged mouth opening eg at dental appointmetn
tmd associated factors
parafunctional habits eg clenching, bruxing
headache
migraines
tmj disc problems
treatment of tmd
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
burning mouth syndrome demographics
only occur in women
location for burning mouth syndrome
tongue (most common)
lips
palate
buccal mucosa
nature of pain or burning mouth syndrome
stinging, burning
continuous
mild to severe
itchy, sore
associated factors with burning mouth syndrome
depression
menopause (hormonal changes)
dry mouth
abnormal taste
management of burning mouth syndrome
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
management of persistent idiopathic facial pain
this is a diagnosis of exclusion
anti depressants, cognitive behavioural therapy, acknowledge patient’s pain
location of post herpetic neuralgia
at the same site as where you had herpes zoster
presentation of post herpetic neuralgia
burning, tingling, itchy pain, may be sharp
moderate to severe
aggravating factors of post herpetic neuralgia
(≠initiating factors, pain is there all the time
light touch
eating
associated factors with post herpetic neuralgia
herpes zoster
ramsay hunt syndrome
management of post herpetic neuralgia
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)
presentation of post traumatic trigeminal neuropathic pain
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
management of post traumatic trigeminal neuropathic pain
reassurance that pain will pass quickly
anti convulsants
gabapentin
presentation of persistent dentoalveolar pain
diagnosis of exclusion
pain is localised to tooth or tooth bearing area
continuous ache, dull, throbbing
may be aggravated by touch
management of persistent dentoalveolar pain
support, gabapentin, anticonvulsant
what is giant cell arteritis
inflammation of lining of arteries
giant cell arthritis may cause pain that is bilateral, or multifocal.
giant cell arthritis at __ artery causes what symptom
lingual, occipital, maxillary, retinal
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
nature of pain brough on by giant cell arteritis
continuous, uni or bilateral
sudden onset
dull, throbbing
claudication pain (may mimic tmj)
diagnosis of giant cell arteritis
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
presentation of post stroke pain
ipsilateral side as weakness (contralateral side to cerebral hemisphere insult) whole side of face continuous burning/prickling moderate pain may be delayed onset
migraine headache disorder is most common in what demographic
young females
etiology of migraine
abnormal 5-HT activity with cerebral oedema
association with TMD
presentation of migraine
unilateral
Initially poorly localised, then localised (to temporal, frontal, orbital regions)
may have aura
episodic (attacks decrease in frequency with age)
aggravating factors for migraine
hormonal (OCP can increase frequency in those predisposed)
diet
flashing lights
stress
sleep deprivation
migraines may be associated with
photophobia
nausea
vomitnig
tmj pain/tmd
treatment for migraines
acute treatment: 5 HT antagonist eg ergotamine, sumatriptan
prophylaxis: beta blockers, calcium channel blockers, antihistamines
dental things to note when treating patient who is on prophylactic mediaction for migraines
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
what are the two types of trigeminal autonomic cephalgia
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
presentation of trigeminal autonomic cephalgia
unilateral cluster headaches usually around the eyes (v1, v2) rapid, short lived attacks (seconds-minutes) sharp stabbing pain non refractory, frequent elicited by touch
management of trigeminal autonomic cephalgia
anticonvulsants, iamotrigine
the two types of trigeminal neuralgia
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
location of trigeminal neuralgia
unilateral
usually lower divisions ie v2, v3
nature of trigeminal neuralgia pain
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
aggravating factors of trigeminal neuralgia
light touch
cold wind
brushing teeth
treatment for trigeminal neuralgia
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
what neurosurgery do you do for trigeminal neuralgia
microvascular decompression, rhizotomy, peripheral neurolysis
what is the complication of carbamazepine
may cause acute erythema multiforme, need to take blood test to test HLA type before taking
presentation of glossopharyngeal neuralgia
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
management of glossopharyngeal neuralgia
carbamazepine
gabapentin
pregabalin
lamotrigine
systemic diseases with characteristic facial pain/headaches
pagets hyperthyroidism metastatic disease multiple myeloma vitamin b defiicency SLE chemotherapy folic acid and iron deficiency anemia hyperparathyroidsm
red flags for orofacial pain
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
