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
