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Clinical Knowledge 2 > Orofacial Pain > Flashcards

Orofacial Pain Flashcards

1
Q

What are the common causes of toothache?

A
  • sensitive teeth
  • gum disease
  • impacted tooth
  • inflammation of tooth pulp
  • tooth decay
  • abscess
  • cracked tooth
  • (non dental causes e.g. sinus infection or congestion)
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2
Q

What is pain?

A

unpleasant sensory and emotional experience associated with an attack or potential tissue damage or described in terms of tissue damage

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3
Q

What is the clinicians role with pain?

A
  • diagnose and trate common conditions
  • diagnose uncommon conditions and if they are beyond experience, refer
  • if unable to diagnose, refer
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4
Q

Who can we refer more complex/uncommon cases to?

A
  • GMP
  • local maxillofacial surgery department
  • oral medicine department
  • directly to a specialist e.g. neurology, ENT or specialist pain clinics
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5
Q

What should you do if you fail to diagnose a patients pain problem?

A
  • refer
  • do not provide treatment
  • do not perform irreversible treatment
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6
Q

Outline the classifications of orofacial pain

A
  • intraoral
  • extraoral
  • musculoskeletal
  • neuropathic
  • neurovascular
  • psychological
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7
Q

Give the sources of intraoral pain

A

teeth
periodontum

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8
Q

Give potential sources of extra oral pain

A

salivary
sinus
lymphatic
cardiac

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9
Q

Give sources of musculo-skeletal orofacial pain

A
  • TMJ
  • MoM - musculature
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10
Q

Outline the progression of dental pain

A

stimulus related (cold/hot) –> reversible pulpitits –> irreversible pulpitits –> acute periapical periodontitis –> pulp necrosis –> acute periapical periodontitis –> acute apical abscess /chronic apical abscess

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11
Q

Neuropathic pain can be classified as either ______ or _______

A

episodic
or
continuous

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12
Q

Give an example of episodic neuropathic pain

A

trigeminal neuralgia

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13
Q

Give examples of continuous neuropathic pain

A
  • trigeminal neuropathy
  • atypical odontalgia
  • post-herpetic neuralgia
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14
Q

Give examples of neurovascular sources of orofacial pain

A
  • tension type headaches (muscle headaches)
  • migraine
  • cluster migrain
  • giant cell arteritis/temporal arteritis
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15
Q

What causes headaches?

A

vasodilaton

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16
Q

Migraines do not respond to pain relief in the same way that headaches respond. True or false

A

true

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17
Q

What are some red flags that may indicate oro-facial pain to look out for?

A
  • 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
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18
Q

There is often a high incidence of dental treatment before the diagnosis of trigeminal neuralgia. True or false

A

true

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19
Q

What infotmation should we know about the pain?

A
  • location
  • duration
  • intensity
  • speed of onset
  • aggravating factors
  • interference with sleep
  • frequency
  • periodicity
  • alleviating factors
  • associated factors
  • radiaton
  • effect of any previous treatment
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20
Q

Briefly describe the presentation of a traumatic ulcer

A
  • aphthous
  • rolled edge
  • circular
  • slothing in the middle- a sign of healing
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21
Q

What must you rule out in the presence of a traumatic ulcer?

A

signs of squamous cell carcinoma
must monitor and review for 2 weeks, if no healings is present, an appropriate referal must be made

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22
Q

Ulcers can result from …

A

burning
trauma

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23
Q

Ulcers are aggravated by…

A

spicy, acidic and salty foods

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24
Q

How would you go about treating an ulcer?

A

treat with local measures:
* remove source of trauma
* caboxymethyl-cellulose paste
* benzydamine hydrochloride (NSAID), (Difflam)
* warm salt water rinses

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25
Q

TMD is more common in …

A

younger people
female > male

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26
Q

What are some signs of TMD?

A
  • pain
  • clicking
  • crepitus (cracking sound)
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27
Q

Give examples of precipitating factor fo TMD

A
  • chewing gum- repetitive strain
  • wide opening
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28
Q

What time of the day is significant for pain experience by TMD sufferers? Why is this?

A

morning
pain on waking

Due to night grinding or clenching

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29
Q

Describe the pain often reported by TMD sufferers

A
  • dull
  • poorly localised
  • may radiate
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30
Q

What clinical signs of TMD may be present on examination ?

A
  • 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)
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31
Q

What test can be performed to aid diagnosis of TMD?

A

resistance test

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32
Q

What is the potential consequence of a lack of posterior teeth?

A

Anterior tooth wear due to load

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33
Q

What is trismus ?

A

describes a difficulty opening the mouth

pain and limitation on mouth opening
can be linked to infection

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34
Q

What test can be used to aid diagnosis of trismus?

A

3 finger test
with the patients own fingers

give an indication of normal width of opening

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35
Q

What approach is used to treat TMD?

A

staged approach

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36
Q

Outline the initial conservative treatment guidelines for TMD

A
  • 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
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37
Q

Following a lack of improvement with conservative treatment approaches, what treatment can you offer for suspected TMD?

A

Occlusal splint therapy

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38
Q

What type of emergency splint is provided to a TMD patient?

A

De-programming splint
Lucia Jig

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39
Q

What is the purpose of an emergency splint ?

A
  • encourage patient to relax
  • encourage muscle relaxation
    *opens patient up and prevents them from biting down too hard
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40
Q

Following on from an emergency splint, what kind of splint can you provide to a TMD patient?

A

soft splint (night bite guard)
made of vinyl

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41
Q

How should soft splints be designed?

A

they must be designed to cover all posterior teeth to prevent the potential for over-eruption

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42
Q

If a soft splint is unsuccessful, what other type of splint can be provided?

A

hard acrylic splint- mandibular stabilisation splint
(Tanner splint)

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43
Q

What is the objective of the tanner splint?

A

puts patient in a different occlusion
opens patient up more

Bite plande added on a tanner splint

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44
Q

What do the blue spots on a tanner splint indicate?

A

ICP - intercuspal position

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45
Q

What do the red lines on the tanner splint indicate?

A

what the patient does in protrusion and on left and right lateral excursion

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46
Q

Give other examples of a hard acrylic splint

A

Mandibular repositioning split
also known as a Gleb appliance

Local occlusal interference splint (LOIS)

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47
Q

If a TMD patient remains unresponsive to splint therapy, what other options can you consider?

A
  • restoration of posterior teeth (acrylics)
  • drugs such as diazepam (muscle relaxant)
  • surgery- arthroscopy, manipulation under GA
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48
Q

What is sinusitis?

A

constant burning pain with zygomatic and dental tenderness from inflammation in the maxillary sinus. May also have ethmoid and frontal sinus involvement

49
Q

Outline the sinuses

A

Frontal
Sphenoid
Ethmoid
Maxillary

50
Q

What are the symptoms of sinusitis?

A
  • 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)
51
Q

What are the signs of sinusitis?

A
  • maxillary teeth TTP
  • may be purulent nasal discharge
  • tenderness, erythema over maxilla (redness of mucosa due to increased blood flow)
52
Q

What is the clinicians role in diagnosis of sinusitis?

A
  • 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
53
Q

What special investigations can be executed for a sinusitis diagnosis?

A
  • bitewing
  • PA
    To exclude dental cause
54
Q

What may the radiograph in a sinusitis patient reveal?

A

fluid levels in the maxillary antrum

55
Q

What treatment can be offered to a patient with sinusitis?

A
  • 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
56
Q

What are the types of trigeminal neuralgia?

A
  • classic/idiopathic
  • symptomatic/secondary
57
Q

What causes secondary trigeminal neuralgia?

A

response to CNS lesion e.g tumour, MS or local facial fracture

58
Q

Trigeminal Neuralgia is diagnosed in 1-5% of patients with MS. True ot false

A

true

59
Q

GIve examples of paroxymal (comes and goes) neuralgias

A

glossopharyngeal neuralgia
nervus intermedius neuralgia
occipital neuralgia
post herpetic neuralgia

60
Q

Where can the pain orignate from in glossopharyngeal neuralgia?

A
  • ear
  • base of tongue
  • tonsillar regions
61
Q

Where can the pain orignate from in nervus intermedius neuralgia?

A

deep in ear canal

62
Q

Where can the pain orignate from in occipital neuralgia?

A

distribution of greater and lesser occipital nerve

63
Q

Where can the pain orignate from in post herpetic neuralgia?

A

following herpes zoster, shingles

distribution along the opthalamic branch

64
Q

Trigeminal neuralgias are ususally unilateral. True or false

A

true

65
Q

Outline possible hypotheses for the causes of trigeminal neuralgia

A
  • atherosclerosis of cerebral blood vessels presses on the trigeminal nerve root causes neuronal discharge
  • demyelination of the nerve
66
Q

What are the symptoms of trigeminal neuralgia?

A

sudden intense, sharp, stabbing, burning pain

67
Q

What are some triggering factors for trigeminal neuralgia?

A
  • 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
68
Q

What is the dental treatment for trigeminal neuralgia?

A
  • prescribe short course of carbamazepine (100-200mg daily)
  • refer to GMP or specialise
69
Q

What is the medical treatment for trigeminal neuralgia?

A
  • carbamazepine is drug of choice
    *gabapentin, phenytoin, baclofen, lamotrigine may be used

anti-epileptic drugs

70
Q

What is the surgical treatment for trigeminal neuralgia?

A
  • cryotherapy
  • gamma knife
  • microvascular decompression
71
Q

Carbamazepine dose for TGN can be titrated to a max of____ daily

A

1200mg

72
Q

What are the side effects of cabamazepine?

A
  • nausea
  • folic acid deficiency
  • megaloblastic anaemia
  • dry mouth
73
Q

What is a common drug interaction of carbamazepine?

A

warfarin

74
Q

What are some causes of secondary TGN?

A
  • tumours
  • aneurism
  • infarction
  • MS
75
Q

In secondary TGN, what impairments are often present?

A
  • facial sensory impairment
  • motor impairment
76
Q

What are the predominant locations of secondary TGN?

A

forehead
Orbit

77
Q

Secondary TGN may be…

A

bilateral

78
Q

What is the dentists role in TGN?

A
  • exclude dental causes of pain
  • advisable to GP first
  • diagnositic carbamazepine and review
  • arrange prompt referral to specialist
79
Q

How can you arrive at a definitive diagnosis of TGN with a differential diagnosis of pulpitis?

A
  • 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
80
Q

Local disorders of orofacial pain can stem from…

A
  • teeth and supporting tissues
  • jaws
  • maxillary antrum e.g. sinusitis
  • salivary glands
  • pharynx
  • eyes
81
Q

What is glossopharyngeal neuralgia?

A

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

82
Q

How can glossopharyngeal neuralgia be triggered?

A

coughing
swallowing

83
Q

10% of glossopharyngeal neuralgia sufferers also have…

A

trigeminal neuralgia

84
Q

What is the clincal presentation of shingles?

A
  • painful vesicles that do not ulcerate
    *vesicles do not cross the midline (dermatomes)
  • severe lancing pain occurs before vesicles are present
85
Q

What is post-herpetic neuralgia?

A
  • pain that persists after a shingles outbreak
86
Q

The severity and prevalence of post-herpetic neuralgia increases with …

A

age

87
Q

What is the treatment for post-herpetic neuralgia?

A

antidepressants
along side pain relief

88
Q

Give examples of psychogenic disorders

A

disorders affected by state of mind?
* * TMD
* atypical odontalgia
* burning mouth syndrome
* munchausane syndrome/munchausen by proxy

89
Q

What is munchausen syndrome?

A
  • 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
90
Q

What is atypical facial pain?

A

chronic oro-facial discomfort or pain that does not fulfill other criteria
no physical signs and investigations are negative

91
Q

What are the potential causes of atypical facial pain?

A

extreme stress
e.g. bereavement, family illness

92
Q

What are the characteristics of atypical facial pain?

A
  • 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
93
Q

What are the treatment options for atypical facial pain?

A
  • antidepressants- amitriptyline, fluoxetine (SSRI)
  • CBT
94
Q

What are the characteristics atypical odontalgia?

A
  • 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
95
Q

What is a classic sign of atypical odontalgia?

A

mutliple restored teeth
pain unresolved

96
Q

What is burning mouth syndrome?

A

localised or generalised burning or soreness of the mouth

often affects the tongue

97
Q

Burning mouth syndrome is also known as …

A

glossodynia

98
Q

The oral mucosa in burning mouth syndrome appears normal. True or false

A

true

99
Q

What are some causes of burning mouth syndrome?

A
  • geographic tongue
  • lichen planus (wickham striae)
  • xerostomia
  • candidosis
  • glossitis associated with vitamin deficiency (Fe, folic, B12)
  • diabetes
100
Q

What is the characteristic appearance of glossitis?

A
  • shiny appearance of the tongue
  • papillae have been lost
101
Q

What investigations can help you diagnose burning mouth syndrome?

A
  • blood, urine, thyroid function
  • microbiology (candida)
  • salivary flow rate
  • psychological screening
102
Q

If all your tests results are negative for burning mouth syndrome what should you do?

A
  • refer
  • manage as atypical facial pain
103
Q

What are the side effects of tricyclic antidepressants?

A
  • sedation
  • xerostomia
  • constipation
  • blurred vision
  • urinary retention
104
Q

What are the side effects of SSRI antidepressants like citalopram?

A
  • nausea
  • xerostomia
  • dyspepsia
  • vomiting
  • abdominal pain
  • diarrhoea
  • constipation
  • headaches
105
Q

Give examples of vascular disorders

A
  • migraine
  • migraineous neuralgia/cluster headaches
  • giant cell arteritis/temporal arteritis
106
Q

What is the aetiology of migraines?

A

arterial vasoconstriction/dilation

107
Q

Migraines can be confused with …

A

TMJ

108
Q

What are the symptoms of migraines?

A
  • severe unilateral headache
  • lasts for hours/days
  • nausea/vomiting
  • photophobia
    *triggers; diet, stress
    aura: visual, sensory or motor disturbance
109
Q

What are symptom of cluster headaches (migraineous neuralgia)?

A
  • unilateral boring pain
  • can keep patient awake at night
  • localised around the eye
  • can be associated with a watering eye
  • nasal discharge unilaterally
110
Q

What is temporal artertitis?

A
  • unilateral or bilateral headache, mainly continuous with aching or throbbing pain, sometimes very intense, usually in elderly with signs of temporal artery involvement
111
Q

What are the symptoms of temporal arteritis?

A
  • unilateral deep throbbing pain in temple
  • worse when lying flat
  • malaise, fever, weight loss
112
Q

What are the signs of temporal arteritis ?

A

tenderness of temporal arteries - tenderness over the temporalis muscle

113
Q

What are the criteria for temporal arteritis?

A
  • 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
114
Q

What are the special investigations to be carried out for temporal arteritis?

A
  • raised ESR
  • temporal artery biopsy
  • giant cells in internal elastic lamina
115
Q

What is the treatment for temporat arteritis?

A

urgent referal- corticosteroids due to sight risk

116
Q

Where might “referred pain” originate from?

A
  • ears, eyes
  • cardiorespiratory system e.g. angina
  • lesions in neck or check e.g. lung tumour
  • styloid process- eagles syndrome
117
Q

What should you do when you have referred orofacial pain?

A

refer as they are medical problems

118
Q

What is eagles syndrome?

A

calcification of the styloid process

Clinical Knowledge 2 (40 decks)

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