Orofacial Pain Flashcards
What is the definition of Orofacial pain?
= involves area above the neck, anterior to ears + below orbitomiatal line
-includes pain from oral cavity
- TMD most common facial non-dental (non-odontogenic) pain
List the types of CHRONIC orofacial pain?
-TMD
- Persistent idiopathic facial pain (nerve rx after tooth XLA e.g. atypical odontalgia)
- Burning mouth syndrome
- Glossopharyngeal neuralgia
- Trigeminal neuralgia
- Shingle + postherpetic neuralgia
- Headaches (including giant cell arthritis, cluster headaches etc)
How many months defines chronic / persistent pain?
pain that has been present for over 3 months
Non-pharmacological means of pain relief?
- CBT
(targets cognitive, emotional + behavioural factors
involves relaxation + behaviour techniques
decreases pain by addressing psychological aspects - Acupuncture (used for chronic TMD)
What is TMD?
Temperomandibular disorders (TMD)
What is TMJD?
Temperomandibular Joint Dysfunction Syndrome
What is the definition of TMD/TMJD?
Refers to musculoskeletal disorders involving muscles of mastication +/or TMJs
Includes:
1.Myofacial pain disorder (musclar origin)
2.TMJ disc inference disorders (disc displacement w or w/o reduction)
3. TMJ degenerative joint disease (osteoarthritic change)
What are the risk factors for TMJD?
- Depression
- Multiple pain conditions (back pain, IBS)
- Female
- Age 18-44yrs
- Bruxism
- Facial trauma
- Insomnia
- Exogenous hormone pain
What does SOCRATES for TMD look like?
Site- unilateral, bilateral, TMJ area
Character- dull, aching, throbbing
Radiation- pre/post auricular, MoM
Assoc factors- stress, clicking, tender muscles
Timing- intermittent or constant
R/E- rest, analgesics | chewing, opening wide, yawning
What’s the non- pharmacological management of TMD?
- Split therapy
- CBT
-Physiotherapy - Acupuncture
- Botox injections
- Relaxtion/ pt empowerment
- Warmth to joints
- Self-massage
-Jaw exercises - Simple analgesics (oral or topical)
- Tx of parafunctional habits
What’s the pharmacological management of TMD?
Analgesics:
NSAIDs
Paracetamol
Opoids (if severe)
Corticosteroids:
IM injections
Antidepressants
Muscle Relaxants
Sedative hypnotics
Anxiolytics
What is Glassopharyngeal neuralgia?
Severe transient STABBING pain involving ear, base of tongue, tonsillar fossa or beneath angle of jaw
How does glossopharyngeal neuralgia present?
- unilateral
- initiated by swallowing, chewing, talking or coughing
- may be pharyngeal or tympanic
- remissions may occur
- may be assoc w/ syncope or arrhythmias
(less common than trigeminal neuralgia)
Aetiology of glossopharyngeal neuralgia?
Primary reason - nerve compression
Secondary reason- congenital vascular anomalies, tumour or aneurysm
(- persistent background aching pain)
What is the management glossopharyngeal neuralgia?
- Medical management of nerve
- Nerve decompression
- Cardiac pacing
What is a KEY/COMMON differential diagnosis for Glossopharyngeal Neuralgia?
Eagle Syndrome
What is Eagle syndrome?
Throat injury where stylohyoid is elongated, pressing on glossopharyngeal, vagus +/- trigeminal cranial nerves
What are the symptoms of Eagle syndrome?
- shooting pains involving throat ear or jaw, tongue base pain
- pain when swallowing or turning head
- tinnitus
- feeling of something being stuck in throat
- sensation of hypersalivation
What is the tx for Eagle syndrome?
Styloidectomy
What is Trigeminal Neuralgia (TN)?
sudden, (mostly) unilateral, severe, brief, stabbing, recurrent pain in the distribution of 1 or more branches of the 5th cranial nerve at the root entry zone
Who does Trigeminal Neuralgia affect?
Age onset: 5-6th decade
RF: Hypertension + Multiple Sclerosis
What is the classifcation of Trigeminal Neuralgia?
- Idiopathic - typical or atypical
- Secondary:
- intrinsic pathology i.e. MS; likely bilateral + younger pt
- extrinsic pathology i.e. posterior fossils tumours or vascular lesions; constant pain
What does SOCRATES for Trigeminal Neuralgia look like?
Site- unilateral distribution of trigeminal nerve (usually right)
Character- flashing, shooting, sharp, unbearable, exhausting pain
Radiation- rarely first division
Assoc factors- trigger zones, weight loss
Timing- lasts seconds (complete remission weeks-months)
Relieving factors: avoiding touch, sleep, anticonvulsants
What investigations can be conducted for diagnosis of Trigeminal Neuralgia?
FBC
Renal profile
LFT
MRI posterior fossa - to look for nerve root compression (to rule out MS or tumour)
Use low dose carbamezipine to rule out MS if they respond to it
What is 1st line tx for Trigeminal Neuralgia?
- Carbamazepine - gold standard “tegretol”
- 300-800mg dose daily split into 4 doses daily (dose is slowly increased)
Side effects of Carbamazepine: drowsiness, tiredness, nausea, constipation, diploma + blurred vision, ataxia, rash allergy (e.g. Erythema Multiforme)
(effective in reducing pain for ~70% pts, failure rx to increased severity of pain)
- Oxcarbazepine (fewer side effects)
What is 2nd + 3rd tx for Trigeminal Neuralgia?
2nd = Lamotrigine (anticonvulsant)
3rd= Baclofen (antispasmodic i.e. muscle relaxant)
What is the final line/4th line tx for Trigeminal Neuralgia?
Posterior fossa surgery for microvascular decompression
(good for long term relief, but risks of hearing loss, facial numbness, dizziness, post-op infection + stroke)
What is Burning Mouth Syndrome? (BMS)
Idiopathic burning discomfort or pain affecting people with clinically normal oral mucosa in whom a medical or dental cause has been excluded
What does the SOCRATES for Burning Mouth Syndrome look like?
Site- Tongue, lips palate
Character- Burning, tender, tiresome feeling
Radiation: Whole mouth
Assoc factors: feeling of oral dryness, altered taste, depression, anxiety, F>60yrs
Timing: continuous, intermittent, worse PM
Relieving factors: rest, eating, distraction
Provoking factors: eating, stress
What is the most common aetiology?
Hormonal
i.e. women post menopause due to neuropathic + hormonal changes
What is the tx for Burning Mouth Syndrome?
Reassure pt it’s not cancer and the symptoms have a psychological basis
Exclude local or medical cause for symptoms
Symptomatic management:
- saliva substitutes, diluted benztdamine oral rinse
- if low mood, refer to GP
- low dose antidepressants, TCA (nortriptyline) or SSRI (flouxetine)
- other meds: gabapentin, alpha lipoic acid (food supplement)
- CBT
What is prognosis for Burning Mouth Syndrome?
Can affect pt for long time, even w/ tx
What is Persistent Idiopathic Pain?
= poorly localised pain w/ widespread radiation (hx of chromic dental pain w repeated unsuccessful dental interventions)
What are the initiating factors related to Persistent Idiopathic Facial Pain? (PIFP)
Dental interventions
Severe Dental Infections
Stress during major life event
What does SOCRATES for PIFP look like?
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