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FINALS - Oral Medicine > Orofacial Pain > Flashcards

Orofacial Pain Flashcards

1
Q

What is pain?

A

An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

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2
Q

What systems can you use to assess pain?

A

Physical symptoms
PAIN scores (McGill)

Emotional symptoms
Psychological scores (HAD)

QOL scores (OHIP)

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3
Q

What systems in the body regulate pain?

A

Nociception
Peripheral Nerve Transmission
Spinal Modulation
Central Appreciation

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4
Q

Where in the embryo does the trigeminal nerve develop from?

A

The 1st pharyngeal arch.

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5
Q

Which structures are innervated by the trigeminal nerve in relation to embryonic development?

A

Any structures which develop from the first pharyngeal arch.

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6
Q

What causes trigeminal neuralgia?

A

Idiopathic:

Classical:
Vascular compression of the
trigeminal nerve

Secondary:
Multiple sclerosis
Space-occupying lesion
Others: skull-base bone deformity, connective tissue disease,
arteriovenous malformation

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7
Q

What clinical investigations would you do for suspected trigeminal neuralgia ?

A

o Trigeminal nerve reflex testing
o Full neurological examination
o OPT to rule out dental cause then MRI brain scan
o Blood tests – FBC, U&E’s. Blood glucose; LFTs
o Positive response to carbamazepine drug management confirms diagnosis

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8
Q

What 2 neurological disorders can give rise to trigeminal neuralgia?

A

o Multiple sclerosis
o Tumour compressing on trigeminal nerve

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9
Q

What is the first line drug for management of trigeminal neuralgia?

A

o Carbamazepine modified release 100mg
▪ Send: 20 tablets
▪ Label: 1 tablet twice daily

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10
Q

What blood tests must be done before starting carbamazepine?

A

o FBC – haematology
o U&Es and LFTs – biochemistry

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11
Q

What are the side effects of carbamazepine?

A

o Liver dysfunction
o Allergies
o Ataxia
o Nausea, vomiting, dizziness
o Dry mouth and swollen tongue
o Sedation
o Consistent nightmares

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12
Q

What are the 2 indications for surgery for treating trigeminal neuralgia?

A

o When medical intervention is ineffective or contraindicated
o When medication has adverse side effects
o Seriously affecting quality of life

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13
Q

What types of surgery that can be carried out for trigeminal neuralgia?

A

o Peripheral neurectomies
o Trigeminal nerve balloon compression
o Microvascular decompression (MVD)
o Radio-surgery gamma knife

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14
Q

Name and describe the two types of orofacial pain syndromes?

A

Dental:
▪ Generally gets better or worse over time
▪ Usually acute/sub-acute not chronic

Non-dental:
▪ Generally acute infective non-dental pain that gets worse or
chronic pain usually caused by a non dental condition

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15
Q

List the three types of dental pain and how they can arise.

A

Musculoskeletal = Periodontal and TMJD pain

Visceral structures = Abscesses, pulpal pair, caries

Atypical odontalgia = dental pain without detected
pathology which follows distinct pattern of pain (pain free
episodes with immense pain which settles spontaneously)

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16
Q

What are the features of non-dental neuropathic pain?

A

Constant burning/aching pain with a fixed location
and intensity

Generally occurs after injury from trauma, XLA,
herpes zoster singles, destructive treatment or
after routine treatment,

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17
Q

List four examples of non-dental neuropathic orofacial pain.

A

▪ Generally Trigeminal neuralgia
▪ Chronic regional pain syndrome (CRPS)
▪ Traumatic injury to facial nerve
▪ Surgical injury to nerves of the H&N

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18
Q

What is non-dental psychogenic orofacial pain?

A

Persistent idiopathic facial pain which poorly fits
into standard chronic pain syndromes and responds
poorly to treatment.

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19
Q

Briefly describe the mechanism by which pain occurs.

A

Tissue damage leads to prostaglandin and bradykinin production
Nociceptors receive these and send signal to spinal chord

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20
Q

Where in the nervous system do local anesthetics AND NSAIDs affect to minimize pain?

A

Nerve endings.

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21
Q

Where in the nervous system do local anesthetics work to minimize pain?

A

Nerve endings, primary afferent nerves, dorsal root ganglions.

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22
Q

Where in the nervous system do opioids, a2 agonists, TCAs and SSRIs take affect?

A

Descending noradrenergic and serotoninergic inhibitory fibers.

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23
Q

Where do opioids and ketamine take affect?

A

The dorsal horn in the spinal cord.

24
Q

What is chronic regional pain syndrome (CPRS)?

A

Delocalized pain which spreads around anatomical boundaries. This leads to a bilateral tight burning sensation.

25
What systemic agents can be given for neuropathic pain
Pregabalin Gabapentin Tricyclic Duloxetine
26
Other than medication, what alternative neuropathic pain management options are there?
Physical TENS – occasionally helpful Low frequency TENS Acupuncture – good results Psychological Distraction Correct abnormal illness behaviour Improve self esteem/positive outlook
27
What is atypical odontalgia?
Dental pain without dental pathology Distinct pattern of pain Equal sex distribution Pain free or mild between episodes Intense unbearable pain 2-3 weeks duration Settles spontaneously
28
What is the management for atypical odontalgia?
Ensure there is no causative agent (periapical pathology, abscess, soft tissue lesions, cracked teeth etc.)
29
What is dysgeusia and what causes it?
‘Bad taste’ - ‘bad smell’ - ‘Halitosis’ nothing detected by practitioner nothing found on examination ENT causes - chronic sinusitis perio/dental infection GORD
30
A patient presents with facial pain and jaw clicking, you suspect TMD. What information from you examination could lead you to this diagnosis?
Extra oral examination: Limited range of movement Deviation on opening or closing TMJ tenderness TMJ clicking on opening or closing or crepitus Muscle tenderness of the masseter +/- temporalis on palpation Muscle of mastication hypertrophy Intra oral examination: Signs of parafunctional habits – linea Alba, cheek chewing, scalloping of tongue Wear facets, high spots on occlusion interincisal opening distance measured with ruler to see extent of opening
31
What risk factors could predispose someone to TMD?
Inflammatory secondary to parafunction ▪ Chewing habits, nail biting etc. ▪ Bruxism ▪ Grinding ▪ Clenching Trauma Stress Psychogenic response Occlusal abnormalities Females>males 18-30years of age
32
What management options are there for TMD?
Conservative advices: ▪ Reassurance ▪ Stress management – relaxation, massages, lifestyle alterations, yoga, mindfulness, counselling ▪ Physiotherapy – acupuncture, TENS, muscle manipulation ▪ Limiting jaw moments – soft diet of small pieces, masticating bilaterally, limiting wide opening, no chewing gum/biting nails/ chewing pens, don’t incise on food, supporting mouth yawning ▪ Parafunctional habits – stopping clenching, bruxism, grinding with mental attitude and realization or use of splints and hot and cold compresses ▪ Jaw exercises – side to side movement ▪ Pharmacotherapy – NSAIDs, diazepam, antidepressants (amitriptyline) ▪ Splinting – soft bite guard; stabilization splint; anterior bite plane ▪ Manipulation under GA ▪ Surgery in severe cases and as last resort – arthrocentesis or arthroscopy
33
Are there any other conditions that might present with similar signs and symptoms of TDM and how might you exclude them?
o Dental cause – periapical or OPT to examine for any dental causes o Sinusitis – radiograph of the sinuses o Atypical facial pain/myofascial pain syndrome – usually doesn’t have clicking/crepitus of the TMJ o Salivary gland pathology – radiograph of the salivary glands to check for any pathologies o Trigeminal neuralgia – history of exacerbations and-increased pain at night is not typical presentation of TMD
34
You decide to construct a stabilization splint, how would you describe how this splint should be made to the technician?
Hard acrylic splint that had full occlusal coverage Upper and lower alginate with face bow registration required for occlusion Requires to be ‘ground in’ both in the lab and clinically to achieve maximum bilateral intercuspation, wear facets and sloping canine guidance plane.
35
What is artherocentesis?
Washing of the upper superior joint space of the TMJ. Carried out under LA. Solution (lactated Ringers) injected in which breaks fibrous adhesion and washes away inflammatory exudate.
36
How would you classify a patients jaw pain?
Joint degeneration (pain on use, crepitus, resting pain) Internal derangement (locking open or closed) Joint pathology
37
List five physical signs of TMD.
Clicking joint Locking with reduction Limitation of opening mouth Tenderness of masticatory muscles Tenderness of cervico-cranial muscles
38
What is linear alba?
A white line of thickened tissue on the buccal tissues between the teeth. It indicates parafunctional habit.
39
What is oral dysaesthesia?
Unpleasant sensation involving: ALL modes of oral sensation Burning or ‘nipping’ feeling Dysgeusia Paranesthesia feeling Dry mouth feeling
40
What are the predisposing factors for oral dysesthesia?
Deficiency states haematinics zinc vit B1, B6 Fungal and Viral infections Anxiety and stress Gender – more women present to OM than men
41
How do you manage oral dysesthesia?
Explain the condition to the patient ‘pins and needles’ in the taste etc Assess degree of anxiety Anxiolytic medication Clinical psychology
42
What is neuralgia?
An intense stabbing pain The pain is usually brief but may be severe. Pain extends along the course of the affected nerve. Usually caused by irritation of or damage to a nerve
43
Which nerves mediate sensation in the head?
Trigeminal Glossopharyngeal and Vagus Nervus intermedius Occipital
44
How does trigeminal neuralgia present?
Unilateral maxillary or mandibular division pain > ophthalmic division Stabbing pain 5 - 10 seconds duration Remissions and relapse
45
What are some of the red flags that may indicate a trigeminal neuralgia requires specialist treatment?
Younger patient (>40yrs) Sensory deficit in facial region hearing loss – acoustic neuroma Other Cranial nerve lesions
46
What tests should be done in patients with severe trigeminal neuralgia?
Cranial nerve testing MRI
47
What second line drugs are there for trigeminal neuralgia?
Gabapentin Pregabalin Phenytoin Baclofen
48
What is trigeminal autonomic cephalagias?
Cluster headaches, paroxysmal hemicrania, SUNCT Unilateral head pain - predominantly V1 Very severe / Excruciating Usually prominent cranial parasympathetic autonomic features (ipsilateral to the headache) Conjunctival injection / lacrimation Nasal congestion / rhinorrhea Eyelid oedema Ear fullness Miosis and ptosis (Horner’s syndrome)
49
What is the drug therapy for trigeminal autonomic cephalalgias?
During attack - subcutaneous sumatriptan Abortive - occipital depomedrone/lidocaine injection Preventative - Verapamil, lithium, merthysegride Prophylaxis - Indomethacin, COX-II inhibitors
50
What is the proper name for burning mouth syndrome?
Oral dysaesthesia
51
Who is most likely to be affected by burning mouth syndrome?
o Females > males o Mostly menopausal women o aged around 40-60
52
What are the causes of burning mouth?
o Nutritional deficiencies – b12, iron, folate o Xerostomia o Fungal infections – lichen planus or geographic tongue o Poorly fitting dentures o Allergies orally o Parafunctional habits o Endocrine disorders – diabetes, hypothyroidism o Physiological factors – stress, anxiety, depression
53
What are the signs and symptoms of burning mouth syndrome?
Severe burning or tingling in the mouth, commonly affecting tongue Sensation of dry mouth with increased thirst Taste changes such as bitter or metallic taste Loss of taste
54
What are the differential diagnosis for burning mouth?
Lichen planus Dental cause/orofacial pain Denture problems Xerostomia Diabetes Undiagnosed systemic conditions
55
What special tests would you carry out to investigate suspected burning mouth?
Blood tests: FBC; haematinics, U&E, TFT, LFT, HbA1c Salivary flow rate for xerostomia assessment Intra/extra oral examination for parafunctional habits Denture assessment Psychiatric assessment
55
How can burning mouth be managed?
Reassurance Correct any underlying causes: ▪ Nutrient replacement therapy ▪ Diabetes diagnosis and treatment ▪ Correcting poorly fitting dentures ▪ Management of parafunctional habits o Conservative advice: ▪ Staying hydrated ▪ Difflam mouthwash use o Pharmacotherapy : ▪ Gabapentin ▪ CBT

FINALS - Oral Medicine (13 decks)

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