Orofacial Pain Flashcards
How can pain often ‘refer’ in the head and neck?
Many nerves share a common pathway
- stimulation of one nerve can cause stimulation of common pathway, leading to referred pain
When pain is felt and a nerve stimulated, these often run to spinal cord or other nerve centres in brain
- multiple nerves can converge in these areas and synapses can induce pain stimulation in other nerves
Afferent vs efferent?
Afferent = sensory to Brain
Efferent = brain to muscle motor
How can autonomic nerve referred pain occur?
Autonomic afferent and efferent
Afferent enters CNS and goes to brain
- managed same was as efferent signals and pain induced
E.g. cardiac pain felt as somatic pain yet it has no somatic heart supply
How does an autonomic reflex arc work? Give example
Sensory afferent information transported to spinal cord
Synapse to efferent motor neurone which travels through sympathetic ganglion to effector organ which produces a response
Nasal congestion
increased blood flow - swelling and going red
How does tissue damage in the periphery produce a pain response?
Tissue damage causes chemical mediators such as
- bradykinin and prostaglandins
These produce action potential nociceptor which transmits it to CNS
How does melzac and walls gate control of pain work
‘Gate’ in spinal cord allows pain through to be sent to brain
Sensory input e.g. hot stimulus on hand
Nociceptor sends signal to spinal cord
Also touch, non nociceptive signal is sent to the spinal cord
Strong or repetitive non nocieptive input can close gate in spinal cord to prevent pain input being sent to the brain, thus distracting brain from pain, leading to reduced feeling
E.g. holding hot dinner plate but dont want to drop food
How would one take a pain assessment?
Socrates
Physical symptoms - McGill pain scores
Emotional symptoms - psychological scores
What is nociceptive vs neuropathic pain?
Nociceptive
- activity in neural pathways in response to potentially tissue damaging stimuli
Neuropathic
- initiated or caused by primary lesion or dysfunction in nervous system
What is neuropathic pain typically like?
Constant burning / aching
Fixed location and often fixed intensity
Usually following a history of ‘injury’
Give some remedies for neuropathic pain
Systemic meds
- pregabalin
- opioids
Topical meds
- capsaicin
- ketamine
Physical
- TENS
- acupuncture
Psychological
- distraction
What is atypical odontalgia?
Dental pain without dental pathology
Pain free or mild between episodes, then intense unbearable pain
What is persistent idiopathic facial pain?
Pain which poorly fits into standard chronic pain symptoms such as
- tmd
- Trigeminal neuralgia
- migraine
Often high disability level, autonomic component
Management of persistent idiopathic facial pain?
Believe patient and do not blame any associated depression
Do not increase damage with surgery
Adopt holistic strategy
- QOL
- realistic outcomes
What is oral dysaesthesia?
Some symptoms?
Abnormal sensory PERCEPTION in the ABSENCE of ABNORMAL stimulus
So basically feeling a different perception even when there is no abnormal stimulus
Burning
Dry mouth
Paraesthesia
Dysguesia - altered taste
Most common predisposing factors for oral dysaesthesia?
Haematinic deficiency
Fungal / viral infection
Women > men
Difference between burning mouth syndrome affecting the lips and tongue tip / margin vs multiple other sites around mouth
Lip and tongue tip / margin = parafunction
Multiple other sites = dysaesthesia
How might a patient with dysgeusia present?
Possible causes?
Bad taste, bas smell
Nothing detectable by practitioner
Nothing on examination
ENT - chronic sinusitis
Perio/dental infection
GORD
How might a patient with touch dysaesthesia present?
What must dentist do?
Pins and needles or tingling
- normal sensation to objective testing
Cranial nerve testing
- to rule out neurological disease
Must exclude local causes
- tumour or infection
MRI essential for demyelination / tumour
How might someone with dry mouth dysaesthesia present?
Causes?
Very common and complain of debilitating dry mouth
Eating is ok
Worse when waken at night
How could you classify a TMD patient?
Joint degeneration
- crepitus
- pain on use
- pain on rest?
Internal derangement
- locking open or closed
No pathology
What physical signs typically present with TMD?
Clicking, locking, grinding, noise in joint
Limited mouth opening / deviation on opening
Tenderness of MOM
Tenderness in cervico-cranial muscles
Frictional keratosis
NCTSL / occlusal issues
What might a patients History be if they have TMD?
Acute facial or neck pain
Any chronic head / neck / face pain
Periodicity of symptoms - worse at night / day
Parafunctional habits
Give some management techniques one could employ for a patient with TMD pain?
Information leaflet on self help, education and mindfulness
Physical therapy / Physiotherapy and exercises
CBT
Bite splints to prevent tooth surface loss
Why might a child often present with TMD?
Anxious children
Reaction to abuse
- school bullying
- home - parental disharmony or abuse
