Orofacial Pain Flashcards
What are the common causes of toothache?
- sensitive teeth
- gum disease
- impacted tooth
- inflammation of tooth pulp
- tooth decay
- abscess
- cracked tooth
- (non dental causes e.g. sinus infection or congestion)
What is pain?
unpleasant sensory and emotional experience associated with an attack or potential tissue damage or described in terms of tissue damage
What is the clinicians role with pain?
- diagnose and trate common conditions
- diagnose uncommon conditions and if they are beyond experience, refer
- if unable to diagnose, refer
Who can we refer more complex/uncommon cases to?
- GMP
- local maxillofacial surgery department
- oral medicine department
- directly to a specialist e.g. neurology, ENT or specialist pain clinics
What should you do if you fail to diagnose a patients pain problem?
- refer
- do not provide treatment
- do not perform irreversible treatment
Outline the classifications of orofacial pain
- intraoral
- extraoral
- musculoskeletal
- neuropathic
- neurovascular
- psychological
Give the sources of intraoral pain
teeth
periodontum
Give potential sources of extra oral pain
salivary
sinus
lymphatic
cardiac
Give sources of musculo-skeletal orofacial pain
- TMJ
- MoM - musculature
Outline the progression of dental pain
stimulus related (cold/hot) –> reversible pulpitits –> irreversible pulpitits –> acute periapical periodontitis –> pulp necrosis –> acute periapical periodontitis –> acute apical abscess /chronic apical abscess
Neuropathic pain can be classified as either ______ or _______
episodic
or
continuous
Give an example of episodic neuropathic pain
trigeminal neuralgia
Give examples of continuous neuropathic pain
- trigeminal neuropathy
- atypical odontalgia
- post-herpetic neuralgia
Give examples of neurovascular sources of orofacial pain
- tension type headaches (muscle headaches)
- migraine
- cluster migrain
- giant cell arteritis/temporal arteritis
What causes headaches?
vasodilaton
Migraines do not respond to pain relief in the same way that headaches respond. True or false
true
What are some red flags that may indicate oro-facial pain to look out for?
- bilateral facial pain described as toothache
- toothache with absence of dental pathology
- pain radiating to the forehead, temple or cervical regions (neck/behind ear)
- persistent pain with repeated dental interventions
- toothache with hearing changes, vertigo, tinnitus facial weakness, altered facial sensation
- dental pain cannot be blocked
There is often a high incidence of dental treatment before the diagnosis of trigeminal neuralgia. True or false
true
What infotmation should we know about the pain?
- location
- duration
- intensity
- speed of onset
- aggravating factors
- interference with sleep
- frequency
- periodicity
- alleviating factors
- associated factors
- radiaton
- effect of any previous treatment
Briefly describe the presentation of a traumatic ulcer
- aphthous
- rolled edge
- circular
- slothing in the middle- a sign of healing
What must you rule out in the presence of a traumatic ulcer?
signs of squamous cell carcinoma
must monitor and review for 2 weeks, if no healings is present, an appropriate referal must be made
Ulcers can result from …
burning
trauma
Ulcers are aggravated by…
spicy, acidic and salty foods
How would you go about treating an ulcer?
treat with local measures:
* remove source of trauma
* caboxymethyl-cellulose paste
* benzydamine hydrochloride (NSAID), (Difflam)
* warm salt water rinses
TMD is more common in …
younger people
female > male
What are some signs of TMD?
- pain
- clicking
- crepitus (cracking sound)
Give examples of precipitating factor fo TMD
- chewing gum- repetitive strain
- wide opening
What time of the day is significant for pain experience by TMD sufferers? Why is this?
morning
pain on waking
Due to night grinding or clenching
Describe the pain often reported by TMD sufferers
- dull
- poorly localised
- may radiate
What clinical signs of TMD may be present on examination ?
- joint clicking or crepitus
- MoM e.g. temoralis, masseter hypertrophy, pterygoid is difficult to palpate; MoM tenderness
- Pie crust tongue (scalloped tongue)
- Linea Alba (buccal keratosis)
- lateral movement
- deviation/deflection on opening
- wear facets on canine (if patient has canine guidance)
What test can be performed to aid diagnosis of TMD?
resistance test
What is the potential consequence of a lack of posterior teeth?
Anterior tooth wear due to load
What is trismus ?
describes a difficulty opening the mouth
pain and limitation on mouth opening
can be linked to infection
What test can be used to aid diagnosis of trismus?
3 finger test
with the patients own fingers
give an indication of normal width of opening
What approach is used to treat TMD?
staged approach
Outline the initial conservative treatment guidelines for TMD
- reassure and explain aetiology
- rets and soft diet- chew with limp
- anti-inflammatory analgesis- ibuprofren 400mg 3x daily
- physiotherapy and exercises
- heat pack if TMJ/muscle injured
- reduce stress
- alternative therapies (mindfulness)
- REVIEW
Following a lack of improvement with conservative treatment approaches, what treatment can you offer for suspected TMD?
Occlusal splint therapy
What type of emergency splint is provided to a TMD patient?
De-programming splint
Lucia Jig
What is the purpose of an emergency splint ?
- encourage patient to relax
- encourage muscle relaxation
*opens patient up and prevents them from biting down too hard
Following on from an emergency splint, what kind of splint can you provide to a TMD patient?
soft splint (night bite guard)
made of vinyl
How should soft splints be designed?
they must be designed to cover all posterior teeth to prevent the potential for over-eruption
If a soft splint is unsuccessful, what other type of splint can be provided?
hard acrylic splint- mandibular stabilisation splint
(Tanner splint)
What is the objective of the tanner splint?
puts patient in a different occlusion
opens patient up more
Bite plande added on a tanner splint
What do the blue spots on a tanner splint indicate?
ICP - intercuspal position
What do the red lines on the tanner splint indicate?
what the patient does in protrusion and on left and right lateral excursion
Give other examples of a hard acrylic splint
Mandibular repositioning split
also known as a Gleb appliance
Local occlusal interference splint (LOIS)
If a TMD patient remains unresponsive to splint therapy, what other options can you consider?
- restoration of posterior teeth (acrylics)
- drugs such as diazepam (muscle relaxant)
- surgery- arthroscopy, manipulation under GA
What is sinusitis?
constant burning pain with zygomatic and dental tenderness from inflammation in the maxillary sinus. May also have ethmoid and frontal sinus involvement
Outline the sinuses
Frontal
Sphenoid
Ethmoid
Maxillary
What are the symptoms of sinusitis?
- mostly unilater pain over the upper cheek, may be bilateral, patient may complain of toothache
- worse when bending forward
- history of URT infection (bad cold)
What are the signs of sinusitis?
- maxillary teeth TTP
- may be purulent nasal discharge
- tenderness, erythema over maxilla (redness of mucosa due to increased blood flow)
What is the clinicians role in diagnosis of sinusitis?
- exclude dental cause
- no symptoms of pulpitis
- no primary or secondary caries
- no non-vital teeth
- no periodontal problems
- no fractured cusp
- bitewing/PA with nothing abnormal detected
What special investigations can be executed for a sinusitis diagnosis?
- bitewing
- PA
To exclude dental cause
What may the radiograph in a sinusitis patient reveal?
fluid levels in the maxillary antrum
What treatment can be offered to a patient with sinusitis?
- reassurance- often self limiting
- symptomatic- decongestant, steam inhalation, analgesics, antihistamines, adrenergic drops
- antibiotics as a last resort- doxycline, amoxicillin
- if unresponsive refer to GMP/ENT
What are the types of trigeminal neuralgia?
- classic/idiopathic
- symptomatic/secondary
What causes secondary trigeminal neuralgia?
response to CNS lesion e.g tumour, MS or local facial fracture
Trigeminal Neuralgia is diagnosed in 1-5% of patients with MS. True ot false
true
GIve examples of paroxymal (comes and goes) neuralgias
glossopharyngeal neuralgia
nervus intermedius neuralgia
occipital neuralgia
post herpetic neuralgia
Where can the pain orignate from in glossopharyngeal neuralgia?
- ear
- base of tongue
- tonsillar regions
Where can the pain orignate from in nervus intermedius neuralgia?
deep in ear canal
Where can the pain orignate from in occipital neuralgia?
distribution of greater and lesser occipital nerve
Where can the pain orignate from in post herpetic neuralgia?
following herpes zoster, shingles
distribution along the opthalamic branch
Trigeminal neuralgias are ususally unilateral. True or false
true
Outline possible hypotheses for the causes of trigeminal neuralgia
- atherosclerosis of cerebral blood vessels presses on the trigeminal nerve root causes neuronal discharge
- demyelination of the nerve
What are the symptoms of trigeminal neuralgia?
sudden intense, sharp, stabbing, burning pain
What are some triggering factors for trigeminal neuralgia?
- kissing and touching
- tilting your head
- stress and tiredness
- weather: head, cold, wind, rain
- eating, chewing, swallowing
- talking, smiling, laughing
- hair brushing and teeth cleaning
What is the dental treatment for trigeminal neuralgia?
- prescribe short course of carbamazepine (100-200mg daily)
- refer to GMP or specialise
What is the medical treatment for trigeminal neuralgia?
- carbamazepine is drug of choice
*gabapentin, phenytoin, baclofen, lamotrigine may be used
anti-epileptic drugs
What is the surgical treatment for trigeminal neuralgia?
- cryotherapy
- gamma knife
- microvascular decompression
Carbamazepine dose for TGN can be titrated to a max of____ daily
1200mg
What are the side effects of cabamazepine?
- nausea
- folic acid deficiency
- megaloblastic anaemia
- dry mouth
What is a common drug interaction of carbamazepine?
warfarin
What are some causes of secondary TGN?
- tumours
- aneurism
- infarction
- MS
In secondary TGN, what impairments are often present?
- facial sensory impairment
- motor impairment
What are the predominant locations of secondary TGN?
forehead
Orbit
Secondary TGN may be…
bilateral
What is the dentists role in TGN?
- exclude dental causes of pain
- advisable to GP first
- diagnositic carbamazepine and review
- arrange prompt referral to specialist
How can you arrive at a definitive diagnosis of TGN with a differential diagnosis of pulpitis?
- no local cause (no dental pathology)
- shooting, lacerating, burning pain
- food temperature has no effect
- LA may not block the pain
- No effect on sleep
- often several prior dental interventions
- severe episodes and remissions (pain progression observed in pulpitis)
- common trigger zones- perioral, perinasal regions- no trigger zone in pulpitis
Local disorders of orofacial pain can stem from…
- teeth and supporting tissues
- jaws
- maxillary antrum e.g. sinusitis
- salivary glands
- pharynx
- eyes
What is glossopharyngeal neuralgia?
sudden, brief, severe, recurrent pain in the distribution o fthe glossopharyngeal nerve
unilateral pain in throat and ear
sharp stabbing pain
last a few seconds or minutes
How can glossopharyngeal neuralgia be triggered?
coughing
swallowing
10% of glossopharyngeal neuralgia sufferers also have…
trigeminal neuralgia
What is the clincal presentation of shingles?
- painful vesicles that do not ulcerate
*vesicles do not cross the midline (dermatomes) - severe lancing pain occurs before vesicles are present
What is post-herpetic neuralgia?
- pain that persists after a shingles outbreak
The severity and prevalence of post-herpetic neuralgia increases with …
age
What is the treatment for post-herpetic neuralgia?
antidepressants
along side pain relief
Give examples of psychogenic disorders
disorders affected by state of mind?
* * TMD
* atypical odontalgia
* burning mouth syndrome
* munchausane syndrome/munchausen by proxy
What is munchausen syndrome?
- psychological disorder where someone pretends to be ill or deliberately produces symptoms of illness themselves
- main intention is to assume the sick role so that people will take care of then and put them at the centre of attention
What is atypical facial pain?
chronic oro-facial discomfort or pain that does not fulfill other criteria
no physical signs and investigations are negative
What are the potential causes of atypical facial pain?
extreme stress
e.g. bereavement, family illness
What are the characteristics of atypical facial pain?
- dull boring or gnawing ache
- maxillary pain > mandibular pain
- present all day everyday
- does not follow anatomical nerve distribution
- other complaints: dry mouth, altered taste, thirst, IBS, chronic back pain, multiple unsatisfactory consultations and attempted treatments
What are the treatment options for atypical facial pain?
- antidepressants- amitriptyline, fluoxetine (SSRI)
- CBT
What are the characteristics atypical odontalgia?
- variant of atypical facial pain
- pain is localised to tooth/teeth
- symptoms mimic pulpitis or periodontitis
- dental treatment can aggravate the pain
- extraction may lead to transfer of pain to other teeth or alveolus
What is a classic sign of atypical odontalgia?
mutliple restored teeth
pain unresolved
What is burning mouth syndrome?
localised or generalised burning or soreness of the mouth
often affects the tongue
Burning mouth syndrome is also known as …
glossodynia
The oral mucosa in burning mouth syndrome appears normal. True or false
true
What are some causes of burning mouth syndrome?
- geographic tongue
- lichen planus (wickham striae)
- xerostomia
- candidosis
- glossitis associated with vitamin deficiency (Fe, folic, B12)
- diabetes
What is the characteristic appearance of glossitis?
- shiny appearance of the tongue
- papillae have been lost
What investigations can help you diagnose burning mouth syndrome?
- blood, urine, thyroid function
- microbiology (candida)
- salivary flow rate
- psychological screening
If all your tests results are negative for burning mouth syndrome what should you do?
- refer
- manage as atypical facial pain
What are the side effects of tricyclic antidepressants?
- sedation
- xerostomia
- constipation
- blurred vision
- urinary retention
What are the side effects of SSRI antidepressants like citalopram?
- nausea
- xerostomia
- dyspepsia
- vomiting
- abdominal pain
- diarrhoea
- constipation
- headaches
Give examples of vascular disorders
- migraine
- migraineous neuralgia/cluster headaches
- giant cell arteritis/temporal arteritis
What is the aetiology of migraines?
arterial vasoconstriction/dilation
Migraines can be confused with …
TMJ
What are the symptoms of migraines?
- severe unilateral headache
- lasts for hours/days
- nausea/vomiting
- photophobia
*triggers; diet, stress
aura: visual, sensory or motor disturbance
What are symptom of cluster headaches (migraineous neuralgia)?
- unilateral boring pain
- can keep patient awake at night
- localised around the eye
- can be associated with a watering eye
- nasal discharge unilaterally
What is temporal artertitis?
- unilateral or bilateral headache, mainly continuous with aching or throbbing pain, sometimes very intense, usually in elderly with signs of temporal artery involvement
What are the symptoms of temporal arteritis?
- unilateral deep throbbing pain in temple
- worse when lying flat
- malaise, fever, weight loss
What are the signs of temporal arteritis ?
tenderness of temporal arteries - tenderness over the temporalis muscle
What are the criteria for temporal arteritis?
- age 50+ years
- new onset of localised headache
- tenderness or decreased pulse from temporal artery
- elevated erythrocyte sedimentation rate (50+)
- temporal artery biopsy showing multinucleate giant cells
What are the special investigations to be carried out for temporal arteritis?
- raised ESR
- temporal artery biopsy
- giant cells in internal elastic lamina
What is the treatment for temporat arteritis?
urgent referal- corticosteroids due to sight risk
Where might “referred pain” originate from?
- ears, eyes
- cardiorespiratory system e.g. angina
- lesions in neck or check e.g. lung tumour
- styloid process- eagles syndrome
What should you do when you have referred orofacial pain?
refer as they are medical problems
What is eagles syndrome?
calcification of the styloid process
