orofacial pain Flashcards
what are the common causes of acute pain?
dental TMJ maxillary sinusitis salivary gland disorders (mumps) facial trauma
how to classify chronic pain
unilateral vs bilateral
continuous vs episodic
aetiologies of chronic orofacial pain
musculoskeletal: TMD, myalgia
neuralgia: trigeminal, glossopharyngeal etc
vascular: post stroke pain, giant cell artheitis
primary headaches
unknown causes
TMD prevalence aetiology clinical presentation (onset, type, severity) management
prevalence: 5-12% of population, 20-40yr
aetiology: arthralgic, myalgic, mixed
commonly masticatory, linked with internal derangement of TMJ, disc problems,
clinical presentation:
bilateral continuous
pain in muscles of mastication, discomfort around ear, temple, mouth, retromolar, neck, tmj
sudden onset, continuous, worse through function, deep aching variable severity
clenching, headaches, migraines
assoc w back pain, fibromyalgia, depression
management:
drugs, arthroscopy, bite splint, occlusion
how to tell if patient is TMD or facial myalgia
facial myalgia no tenderness around TMJ
facial myalgia has muscle hypertrophy
what is BMS
syndrome vs symptoms
burning mouth syndrome is true neuropathy
aetiology: hormonal changes during menopause, disorder of peripheral nerve fibers
clinical presentation:
bilateral continuous
tongue (most common), lips, palate, buccal mucosa
continuous burning stinging pain occasionally itchy or sore, varying severity
dry mouth, abnormal taste, depression
management:
exclude secondary causes: drugs, candida, anaemia
avoid triggers (spicy)
ice cream relieve
poor prognosis
alpha lipoic acid (first line treatment), gabapentin, benzydamine, difflam mouth rinse at meal times,
cognitive behaviour therapy (questionable)
what is persistent idiopathic facial pain
diagnosed by exclusion
clinical presentation:
bilateral continuous
no anatomical changes
continuous dull ache with long remissions
assoc w fatigue, stress, pain, irritable bowel, sig life events
management:
acknowledge pain is real, antidepressant, cognitive behavioural therapy
post herpetic neuralgia
affects trigeminal nerve depending on which division
aetiology: herpes zoster (15% of patients)
assoc w ramsay hunt syndrome (geniculate, unilateral VII palsy, hearing disorders)
clinical presentation:
continuous unilateral burning tingling itchy vesicles, moderate / severe pain can be intraoral or extraoral, triggered by light touch or eating
management: prescribe acyclovir if you suspect anything to prevent it
spontaneous resolution (15% remain at 1 year)
gabapentin, carbamazepine (steven Johnson/ acute erythema multiforme for asians need to test first)
post traumatic trigeminal pain
aetiology: trauma in the area, dental procedures eg. lower 8s removal
presentation: neuropathic continuous unilateral burning pain, can be sharp and severe onset up to 6 months post trauma. triggered by touch, hot, cold
management: gabapentin, anticonvulsant (carbamazepine)
atypical odontalgia / persistent dentoalveolar pain
diagnosed by exclusion
aetiology:
implants (after you exclude possible complications), tooth aches post extraction
presentation: localised continuous ache, dull, throbbing, pain around tooth or tooth bearing area after tooth removed
management: gabapentin, anticonvulsant (carbamazepine)
giant cell arteritis/ temporal arteritis
prevalence: 70 yr, female>male
aetiology:
giant cell infiltration of medium size arteries, 40-40% have connective tissue disorders (polymyalgia rheumatica)
presentation:
sudden onset severe continuous temporal pain, may be bilateral, may be multifocal
worse when chewing
assoc w visual disturbance (25%), biplopia, loss of vision, fever, myalgia, malaise, weight loss
vascular necrosis, large vessels
progressive headache
palpably tender superficial temporal arteries
management: spot and treat with steroid on speculation (to prevent patients from going blind) and biopsy temporal artery
ultrasonography
ESP and CRP
post stroke pain
presentation
if brain bleed on left side, you have paralysis on right side cos nerves cross the midline and the brain stem
presentation:
pain ipsilateral to weakness, whole side of face, continuous ache or burning / prickling, moderate, may be delayed
types of headaches
tension, migraine, cluster (autonomic cephalgia)
episodic migraines
aetiology
presentation
management
prevalence: young females
aetiology: abnormal 5-HydroxyTriptamine activity with cerebral oedema
assoc w TMD
hormonal/ oral contraceptive
chocolate, banana, stress, sleep deprivation, bright flashing lights,
presentation: unilateral low class initially poorly localised then localises to temporal, frontal, orbital region accompanied with aura or motor disturbances attacks decreases in frequency with age photophobia, nausea, vomiting, TMD
management:
acute- 5-HT antagonist (sumatriptan or ergotamine)
prophylaxis- antihistamine (pizotifen), b-blocker (propranolol), calcium channel blockers (verapamil)
trigeminal autonimic cephalgias
presentation: short unilateral neuralgiform pain with autonomic features
short unilateral neuralgiform pain with conjunctival injection and tearing
unilateral mainly v1 v2 (eyes)
rapid attacks in minutes or seconds
frequent *non refractory, sharp stabbing pain elicited by touch
differentiating factor: tearing, red eyes, eye edema, rhinorrhoea, cheek redness, ear fullness
trigeminal neuralgia: type 1 vs type 2
type 1: intense episodic paroxysmal, classic cause by nerve root compression by posterior cerebral artery, older patients
management: medication or neurosurgery
carbamazepine, lamotrigine +baclofen bagapentin+ropivicane pregabalin neurosurgery: microvascular decompression (very small number mortality, hearing loss, success rate 70% in 10 yr)
type 2: longer lasting
caused by central cns aetiology, demyelination symptom (multiple sclerosis), younger
management: need to order MRI to confirm CNS pathology
give steroids
fear: CBT
depression: antidepressant
trigeminal neuralgia`
aetiology: old age, demyelination
presentation:
unilateral trigeminal (more common V2 V3), can be extraoral & intraoral
paroxysmal attacks 2s to minutes
refractory period
remissions
electric shock with burning after pain
moderate to severe
patients fearful as they don’t know what can trigger, depression
aggrevated: dk, light touch, cold wind, brushing teeth
glossopharyngeal neuralgia (sensation to back of throat)
prevalence: a lot less than trigeminal
presentation:
unilateral in ear, tongue base tonsils (radiates)
paroxysmal 2s to minutes
electric shock moderate to severe (more painful than trigeminal)
pain when swallowing, coughing, touching ears, occasionally faint from pain
management: mri to exclude CNS pathology carbamazepine, lamotrigine +baclofen bagapentin+ropivicane pregabalin
what questions to ask patient
frequency duration provoking relieving previous treatment/management strategies patient's perceived cause
examination
- inspection of swelling/asymmetry
- palpation of temporomandibular joint and masticatory muscles
assessment and measurement of range of mandibular movement
*measure so you can refer back - if you put pressure on the joint and it hurts its TMD (90% of cases of facial pain)
- palpation of cervical muscles and assessment of cervical range of motion
cranial nerve examination (difficult)
inspection of ears, nose, oropharyngeal areas
examination and palpation of intraoral soft tissue
examination of teeth, perio, occlusion to exclude dental cause of facial pain (most likely cause)
full blood count (looking for anaemias eg. BM)
haematinics (ferritin, B12, folate causing secondary bms)
-zinc levels, hypothyroidism, diabtetes, antibodys - Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) (temporal arteritis)
- DPT, MRI
distinguishing feature of TMD
pressure over joint causes pain
what systemic diseases cause facial pain/headaches
paget's metastatic malignancy (bone pain) hyperthyroidism multiple myeloma hyperparathyroidism (bone pain) vitamin b deficiency SLE vincristine and other chemotherapy folic acid and iron deficiency
spontaneous occurring focal neuropathy with pain or altered sensation
may indicate tumour invasion
pain at angle of mandible brought on by exertion relieved by rest
may indicate cardiac ischemia
older patient with progressive headaches, superficial temporal artery swelling/tenderness
temporal arteritis
new onset headache with nausea/vomiting (any abnormal neurologic sign)
intracranial tumour
pregancy, earache, trismus, altered sensation og mandibular branch distribution
suggests acoustic nerve tumour
trigeminal neuralgia in person <50 yr suspect
multiple sclerosis and demyelination
what are gabapentin and carbamizapine
reduce action potential along sensory nerve
carbamazepine works just as well as local anesthetics
Trigeminal neuralgia vs trigeminal autonomic cephalgia
neuralgia is refractory
autonomic cephalgia is non-refractory
