Orofacial Pain Flashcards
What is pain?
An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
What systems can you use to assess pain?
Physical symptoms
PAIN scores (McGill)
Emotional symptoms
Psychological scores (HAD)
QOL scores (OHIP)
What systems in the body regulate pain?
Nociception
Peripheral Nerve Transmission
Spinal Modulation
Central Appreciation
Where in the embryo does the trigeminal nerve develop from?
The 1st pharyngeal arch.
Which structures are innervated by the trigeminal nerve in relation to embryonic development?
Any structures which develop from the first pharyngeal arch.
What causes trigeminal neuralgia?
Idiopathic:
Classical:
Vascular compression of the
trigeminal nerve
Secondary:
Multiple sclerosis
Space-occupying lesion
Others: skull-base bone deformity, connective tissue disease,
arteriovenous malformation
What clinical investigations would you do for suspected trigeminal neuralgia ?
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
What 2 neurological disorders can give rise to trigeminal neuralgia?
o Multiple sclerosis
o Tumour compressing on trigeminal nerve
What is the first line drug for management of trigeminal neuralgia?
o Carbamazepine modified release 100mg
▪ Send: 20 tablets
▪ Label: 1 tablet twice daily
What blood tests must be done before starting carbamazepine?
o FBC – haematology
o U&Es and LFTs – biochemistry
What are the side effects of carbamazepine?
o Liver dysfunction
o Allergies
o Ataxia
o Nausea, vomiting, dizziness
o Dry mouth and swollen tongue
o Sedation
o Consistent nightmares
What are the 2 indications for surgery for treating trigeminal neuralgia?
o When medical intervention is ineffective or contraindicated
o When medication has adverse side effects
o Seriously affecting quality of life
What types of surgery that can be carried out for trigeminal neuralgia?
o Peripheral neurectomies
o Trigeminal nerve balloon compression
o Microvascular decompression (MVD)
o Radio-surgery gamma knife
Name and describe the two types of orofacial pain syndromes?
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
List the three types of dental pain and how they can arise.
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)
What are the features of non-dental neuropathic pain?
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,
List four examples of non-dental neuropathic orofacial pain.
▪ Generally Trigeminal neuralgia
▪ Chronic regional pain syndrome (CRPS)
▪ Traumatic injury to facial nerve
▪ Surgical injury to nerves of the H&N
What is non-dental psychogenic orofacial pain?
Persistent idiopathic facial pain which poorly fits
into standard chronic pain syndromes and responds
poorly to treatment.
Briefly describe the mechanism by which pain occurs.
Tissue damage leads to prostaglandin and bradykinin production
Nociceptors receive these and send signal to spinal chord
Where in the nervous system do local anesthetics AND NSAIDs affect to minimize pain?
Nerve endings.
Where in the nervous system do local anesthetics work to minimize pain?
Nerve endings, primary afferent nerves, dorsal root ganglions.
Where in the nervous system do opioids, a2 agonists, TCAs and SSRIs take affect?
Descending noradrenergic and serotoninergic inhibitory fibers.
Where do opioids and ketamine take affect?
The dorsal horn in the spinal cord.
What is chronic regional pain syndrome (CPRS)?
Delocalized pain which spreads around anatomical boundaries. This leads to a bilateral tight burning sensation.
What systemic agents can be given for neuropathic pain
Pregabalin
Gabapentin
Tricyclic
Duloxetine
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
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
What is the management for atypical odontalgia?
Ensure there is no causative agent (periapical pathology, abscess, soft tissue lesions, cracked teeth etc.)
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
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
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
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
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
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.
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.
How would you classify a patients jaw pain?
Joint degeneration (pain on use, crepitus, resting pain)
Internal derangement (locking open or closed)
Joint pathology
List five physical signs of TMD.
Clicking joint
Locking with reduction
Limitation of opening mouth
Tenderness of masticatory muscles
Tenderness of cervico-cranial muscles
What is linear alba?
A white line of thickened tissue on the buccal tissues between the teeth. It indicates parafunctional habit.
What is oral dysaesthesia?
Unpleasant sensation involving:
ALL modes of oral sensation
Burning or ‘nipping’ feeling
Dysgeusia
Paranesthesia feeling
Dry mouth feeling
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
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
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
Which nerves mediate sensation in the head?
Trigeminal
Glossopharyngeal and Vagus
Nervus intermedius
Occipital
How does trigeminal neuralgia present?
Unilateral maxillary or mandibular division pain > ophthalmic division
Stabbing pain
5 - 10 seconds duration
Remissions and relapse
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
What tests should be done in patients with severe trigeminal neuralgia?
Cranial nerve testing
MRI
What second line drugs are there for trigeminal neuralgia?
Gabapentin
Pregabalin
Phenytoin
Baclofen
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)
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
What is the proper name for burning mouth syndrome?
Oral dysaesthesia
Who is most likely to be affected by burning mouth syndrome?
o Females > males
o Mostly menopausal women
o aged around 40-60
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
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
What are the differential diagnosis for burning mouth?
Lichen planus
Dental cause/orofacial pain
Denture problems
Xerostomia
Diabetes
Undiagnosed systemic conditions
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
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
