OROFACIAL PAIN Flashcards
Biopsychosocial factors of pain:
1) Patient characteristics eg. genetics, sex, depression, cognition
2) Environment eg. upbringing, lifestyle socialisation
3) Disease eg. history or present disease
Types of orofacial pain
Temperomandibular disorders (TMD) or temperomandibular joint dysfunction syndrome (TMJDS) Persistent idiopathic facial pain (PIFP) Atypical odontalgia Burning mouth syndrome Glossopharyngeal neuralgia (9) trigeminal neuralgia (5) Shingles Headaches
what does chronic/persistent mean
> 3 months
TemperoMandibularDisorder meaning+examples
TMD means musculoskeletal disorder of the TMJ+MOM eg. myofascial pain disorder TMJ disc interference disorder TMJ degenerative joint disease
risk factors of TMJD
- depression/psychological distress
- multiple pain conditions eg. RA, chronic back pain, irritable bowl syndrome
- female
- bruxism
- facial trauma
- sleep problems
- exogenous hormone use eg. OCP
Pain history of TMJD
Site/radiation: uni/bilateral TMJ, MOM, pre/post auricular
Character: dull, aching, throbbing
Associations: clicking, stress, tender muscles
Relive: rest+analgesics
Provoke: chewing, yawning, opening wide
Duration: intermitent/constant
Severity: mild-moderate
TMJ disc problems cause:
trismus/reduced opening
deviation on opening
Indications of a DEGENERATIVE disease eg. TMJ degenerative joint disease are a combination of:
clicking crepitus limitation of movement-locking sudden inability to fully close teeth momentary hesitation during movement
TREATMENT FOR TMJD (self care, drug, adjuncts)
SELF CARE
- warmth to joints
- jaw massages+exercises
- attention to parafunctional habits eg. bruxism
- relaxation
- empowerment
DRUGS:
- analgesics: NSAIDs, paracetamol, opioids
- Corticosteroids
- Anxiolytics
- Anti-depressants
- Sedative eg. BDZ sedative and anxiety
- Muscle relaxants
AJUNCTS
- acupuncture
- CBT
- Physiotherapy
- Splint therapy
- Botox injection
cognitive-behavioural therapy and best candidates for it
- proved to help with depression
- decreases maladaptive response and increases adaptive response
- how to challenge negative thoughts about pain
BEST CANDIDATES:
- motivated
- catastophize
- highly distressed
- somatization- have physical response
- self-efficacy
Acupuncture
-Stomach 7 point inferior to zygomatic arch anterior to condyle TENDER point of masseter high density of nerve endings
Overview of managing TMJD
1) Conservative measure eg. aware of parafunctional habits/no sticky toffees
2) pain with neuropathic/atypical component= Tricyclic antidepressants
3) Mucoskeletal pain=NSAIDs/BDZ=sedative+anxiety
3) Pain+psychosocial dysfunction= CBT antidepressants and psychosocial assessment
Persistent idiopathic facial pain (PIFP)
Atypical facial pain
- Diagnosis of exclusion
- widely radiated + poor localisation
- history of chronic prolonged dental pain+ unsuccessful interventions
- may lead to multiple extractions and pain not resolving
- severe dental infections
- stress during a major life event
Features associated with persistent idiopathic facial pain
risk factors
Inflammatory bowl syndrome-IBS
Neck and back ache
dysmenorrhea
risk factors:
genetic
female
passive coping traits
Pain history of PIFP
Site/radiation: no anatomical area, widespread and poorly localised, h&n and down the arms
Character: dull throbbing aching
Associated: IBS, neck and back pain, major stress life event
Duration: intermittent/constant
Alleviating factors: relaxing and rest (NOT ANALGESICS)
Provoking: chewing, stress, cold water, dental stress
Severity: mild-severe
Atypical odontalgia
- pain in tooth/edentulous alveolar ridge with no radiographic/clinical signs
- overlap with PIFP but more localised
- dental intervention seems to have initiated this atypical odontalgia
Atypical odontalgia symptoms
persistent, intense oral pain
initiation seems to be due to dental intervention
overlap with PIFP but more localised
any tooth/extraction site but pain seems to move to neighbouring teeth
maxillary molars and premolars are most common
Management of atypical odontalgia
convince the pt nothing is wrong
stop ongoing dental interventions+XLA bc pain can move from tooth to tooth and noth is wrong
topical lidocaine 5%
Systemic tricyclic antidepressants eg. amytriptylline
When do we use tricyclic antidepressants and give an example
eg. amitriptylline
- atypical odontalgia
- TMD with pain with neuropathic/atypical components
Burning mouth syndrome
idiopathic burning pain/discomfort sensation of the mouth with NORMAL oral mucosa and all other medical/dental diagnosis have been excluded
BMS vs SYMPTOMS
Syndrome= every medical/dental diagnosis has been excluded
symptoms
local-> mucosal diseases (LP,LR,DLE,GVHD) blisters (PV,MMP,HSV)
Systemic-> Haematinic deficiencies, GIT crohns/coeliac, medication eg. ACE/b-blockers
BMS pain history
Site/radiation: tongue/lips/gingiva/palate
Character: burning smarting annoying
Associated: xerostomia, altered taste, tongue thrusting, anxiety
Relieves: distraction, rest, eating yogurt
Provokes: stress some foods
Duration: Continuous/intermittent worse pm
Severity: mild-moderate
Key associations to BMS
Xerostomia
altered taste
tongue thrusting
common in women w menopause
Reasons for BMS
1) hormonal
- menopause reduces: gonadal+neuroactive steroids
- anxiety/stress can impair HPA axis reducing adrenal steroid levels
- loss of neuroprotective effects
- oral nerve terminal neurodegenerative changes
Reasons for dysgeusia in BMS
- neuropathic changes effects gustatory nervous system - partic chorda tympani
- Removes inhibitory control of somatic small fibre nerve afferents responsible for burning sensation
- Release of inhibition of glossopharyngeal nerve resulting in taste phantoms and alterations in touch and pain
- more likely to be supertasters
Management of BMS
- exclude all medical/dental possible diagnosis
- strongly reassure that its not cancer
- symptomatic- salivary substitutes eg. carboxymethyl cellulose and difflam 0.15%
- tricyclic antidepressants eg. amytriptylline/ antidepressants eg. SSRI eg. fluoxetine
- CBT
- Alphalipoicacid,gabapentin,clonazepam
Glossopharyngeal neuralgia
CN 9
unilateral
severe transient stabbing pain at EAR, base of tongue, beneath angle of jaw
initiated by chewing/talking/swallowing/coughing
Aetiology of glossopharyngeal neuralgia
- compression of cranial nerve 9
- congenital vascular anomalys/tumor/aneurysm
Eagle syndrome
differential of glossopharyngeal neuralgia
elongated styloid process
symptoms: shooting pain involving ear, jaw, base of tongue
treatment: styloidectomy
Management of glossopharyngeal neuralgia
- decompression of nerve
- medication like trigeminal neuralgia
Trigeminal neuralgia
sudden unilateral severe stabbing recurrent pain in one or more branches of the trigeminal nerve (5th CN)
Risk factors of trigeminal neuralgia is
multiple sclerosis
hypertension
trigeminal neuralgia classification
IDIOPATHIC
typical
atypical
SECONDARY
intrinsic brainstem pathology -MS
Extrinsic cerebellopontine angle pathology- posterior fossa tumors
Pain history of trigeminal neuralgia
Site/Radiation: Trigeminal nerve distribution, normally unilateral (if its bilateral consider MS) normally V2/3
Character: sharp shooting terrifying
Associated: MS, hypertension, TRIGGER ZONES
Eleviating: avoiding touch, sleeping, anti-convulsants
Provoking: touching esp trigger zones, eating, talking, spontaneous
Duration: bouts lasts for seconds- complete remission weeks/months
Severity- moderate-severe
Trigeminal neuralgia investigations
- FBC
- MRI posterior fossa (check for a tumor)
- CT scan if nothings on the MRI to detect MS+tumors
- LFT
Aetiology of trigeminal neuralgia
idiopathic cerebellar artery compressing nerve root at root entry zone compression of the nerve at the REZ: tumor cerebellar artery demyelination plaques
Trigeminal neuralgia and multiple sclerosis
bilateral
Treatment of trigeminal neuralgia
CARBAMEZIPINE- anticonvulsant
300-800mg 1-4 times a day
trigeminal nerve surgery
Carbamezipine side effects
tired
zombie feeling
diplopia
nausea
Summary of aetiology of trigeminal neuralgia
idiopathic compression at the root entry zone due to: trauma cerebellar artery plaque demyelination
Trigeminal neuralgia progression
beginning more periods of remission and less exacerbation
middle less remission
end no remission only exacerbation
