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Oral Disease > Pain and Neurological Disorders > Flashcards

Pain and Neurological Disorders Flashcards

1
Q

Which nerves are most commonly damaged during treatment?

How long are they affected for?

A
  • Inferior alveolar nerve
  • Lingual nerve
  • During surgical removal lower 8s, implant placement, endodontic irrigation with hypochlorite
  • 3/4 lingual nerve injuries resolve spontaneously in 2-3 months
  • IAN effects are usually persistent, and surgical exploration should be considered within 3 months for best effect
  • Prevention is key:
    avoid unnecessary extractions, identify teeth close to nerve, use alternate techniques e.g. coronectomy
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2
Q

What can cause pain from salivary glands?

Why does pain occur immediately?

A
  • mealtime syndrome
  • acute and chronic parotitis (mumps)
  • salivary obstruction (calculi, strictures)
  • painful condition of intraparotid lymph nodes
  • inflammatory disease of parenchyma
  • malignant neoplasms with perineurial spread
  • Parotid and submandibular glands cause pain immediately as there is little space for expansion and a tight capsule
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3
Q

What can cause TMJ pain?

A
  1. intra-capsular: degenerative conditions, neoplasia, trauma, inflammatory
  2. capsular: trauma including joint dysfunction
  3. muscles of mastication: joint dysfunction, arthromyalgia
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4
Q

What is primary neuralgia?

A
  • Pain corresponds to the anatomical distribution of the nerve
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5
Q

What is the difference between neuropathy of sensory vs motor nerves?

A
  • Sensory: pain, hyperalgesia, paraesthesia, analgesia, burning, altered sensation
  • Motor: palsies, muscle fasciculation (twitch) and weakness
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6
Q

Examples of sensory and motor neuralgias and neuropathies

A 
- Sensory:
Trigeminal neuralgia 
MS
Pain of herpes zoster
Postherpetic neuralgia
Intracranial tumours
BMS
Psychogenic pain (atypical facial pain)
- Motor:
Bell's palsy
Stroke
Epilespy
Intracranial tumours
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7
Q

Aetiology and characteristics of trigeminal neuralgia

A
  • Believed to be the compression of nerve by adjacent artery - either 2nd or 3rd division of trigeminal nerve usually
  • Affects older pts (50+)
  • Unilateral - confined to one or more divisions
  • Sudden, severe, stabbing, electric pain lasting 1-2mins
  • Trigger zones within distribution of nerve
  • No sensory or motor impairment
  • Never at sleep
  • Long intervals of remission (weeks/months)
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8
Q

Diagnosis of trigeminal neuralgia?

What is the most common differential diagnosis?

A
  • Made from features described
  • Dental disease can mimic
  • Diff diagnosis: MS and intracranial tumours compressing the nerve - take MRI
  • MS: suspect if pt younger than normal, has sensory loss, bilateral pain or pain extending beyond trigeminal area
  • Intracranial tumours (rare): associated sensory loss especially if associated with cranial nerve palsies
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9
Q

Treatment of trigeminal neuralgia

A
  • Reassurance
  • Carbamazepine (anticonvulsant) most effective
  • Combination therapy
  • Surgical tx: decompression, cryotherapy, gamma knife ablation (radiation)
  • Alcohol/phenol injection
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10
Q

Characteristics of trigeminal neuropathy

A
  • Unlike trigeminal neuralgia, sensation is affected
  • Causes pain, burning, paraesthesia, anaesthesia of part of skin in distribution of trigeminal nerve
  • Usually continuous pain and may be unilateral
  • No trigger zones
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11
Q

Aetiology and treatment of trigeminal neuropathy

A
  • Can follow nerve ablation as a treatment for trigeminal neuralgia
  • Trauma
  • Intracranial neoplasms
  • Metabolic/inflammatory disorders
  • tx: long term analgesic nerve blocks, anticonvulsant or tricyclic antidepressants
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12
Q

Characteristics, aetiology and treatment of glossopharyngeal neuralgia

A
  • Pain of same character as trigeminal neuralgia, but it felt in the distribution of glossopharyngeal (base of tongue, faces and ear on one side only)
  • Triggered by swallowing, chewing or coughing
  • Pressure on nerve such as intracranial tumour
  • Carbamazepine (but less reliably)
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13
Q

Characteristics, diagnosis and treatment of postherpetic neuralgia

A
  • Develops in pts who have had trigeminal herpes zoster (aggressive antiviral tx of acute infection reduces risk of developing this)
  • Persistent pain limited to dermatome affected by zoster attack (burning, itchy, hypersensitive to touch/temp)
  • History of facial zoster or presence of scars from rash for diagnosis
  • Resistance to tx (poor response to surgery/carbamazepine)
  • Application of transcutaneous electric stimulation to affected area by pt
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14
Q

Atypical facial pain features and management?

A
  • poorly localised pain persisting for many years
  • Common site: maxillary region/upper teeth
  • Neurologically impossible distributions: bilateral or crossing dermatomes
  • Bizarre description of pain
  • No triggers
  • Emotional disturbance e.g. depression
  • Management tailored to any underlying mental illness
  • Tricyclic antidepressant e.g. prothiaden, nortyptilline
  • Phenothiazines (antipsychotic) e.g. flupenthixol, fluphenazi
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15
Q

What needs to be excluded before diagnosing atypical facial pain?

A
  • Primary or secondary neuropathy
  • Referred pain
  • TMD muscular
  • Migraine
  • TAC
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16
Q

What is atypical odontalgia?

A
  • Less common variant of atypical facial pain
  • Pain localised to one tooth or row of teeth
  • If dental disease is found, tx has no effect
  • If tooth removed or root filled - pain moves to next tooth
  • Early diagnosis is essential to avoid over treatment and dental morbidity
  • neuralgic elements to this pain
17
Q

What are the main causes of paraesthesia and anaesthesia of the lower lip (10)

A
  1. Inferior dental blocks
  2. Surgical damage on removal of 8s
  3. Fracture of mandible - nerve becomes stretched
  4. Acute osteomyelitis
  5. Malignant tumours of mandible usually metastatic
  6. Exposed mental foremen
    - due to excessive resorption of bone in edentulous
    - denture then presses on nerve
    - solution: implants or relieve denture
  7. Herpes zoster
  8. MS
  9. Tetany (muscle spasms)
    - results of hypocalcaemic status causing heightened neuromuscular excitability
    - Can be due to over breathing - usually anxiety
    - paraesthesia is bilateral and also affects extremities
  10. Postherpectic neuralgia (rarely lower lip alone)
18
Q

What do lips signs accompanied by involvement of tongue or skin of the side of the head indicate

A
  • Indicate a more proximal lesion affecting the posterior division of the mandibular nerve
  • Further proximal lesions involve motor supply to the muscles of mastication
19
Q

Causes of facial palsy?

extracranial vs intracranial

A
  1. Extracranial causes
    Bell’s palsy, malignant parotid neoplasms, parotid surgery, sarcoidosis, misplaced LA, Melkersson-Rosenthal syndrome
  2. Intracranial causes
    Strokes, cerebral tumours, MS, HIV, lyme infection, Ramsay Hunt syndrome, trauma to base of skull
20
Q

Damage to what nerve causes facial palsy

A
  • Muscles of face supplied by facial nerve, so facial palsy will be caused by damage to either upper or lower motor neurones
21
Q

Where do the lower facial nerve neurones pass from? LMN damage causes impairment of which facial muscles?

A

motor nucleus in the pons
to facial muscles

  • In LMN lesions such as Bell’s palsy, there is impairment of contraction of all facial muscles
22
Q

Where do the upper facial nerve neurones pass from? UMN damage causes impairment of which facial muscles?

A

primary motor cortex in frontal lobe
to the pons
to facial muscles

  • Muscles of upper part of face receive stimuli from both sides of the brain whereas muscles in lower portion of face activated by contralateral cortex
  • So UMN damage - lower face is more affected
23
Q

What is the cause of Bell’s palsy and what are the clinical features?

A
  • idiopathic aetiology
  • Suspected to be caused by inflammation and swelling around the ganglion caused by viral infection (herpes zoster)
  • Rapid onset
  • Pain in jaw sometimes precedes paralysis
  • Facial paralysis
  • Speech and taste are affected
  • Saliva may drool at rest from mouth
24
Q

What facial movement can you ask the pt to do to test for Bell’s palsy

A
  • ask pt to close eyes: lids on affected side cannot be brought together
  • ask pt to smoke: corner of mouth on affected side does not rise and normal lines of expression are absent
    wrinkling around the eyes not seen indicating LMN lesion
25
Q

What is the management of Bell’s palsy

A
  • Majority ervoer fully or partially without tx
  • Prednisolone orally may be given for 5-10 days and then tapered off over the following 4 days: effective if given within 24 hours of onset
  • If eye cannot close fully then must be protected
  • More than half fail to recover:
    disfiguring
    persistent denervation develop muscle atrophy
    watering of the eye due to impaired drainage of tears
  • Avoid exercise to help speed recovery
26
Q

Dental aspects affected in pts with Bell’s palsy

A
  • Paralysis reduces oral clearance of food, debris can accumulate
  • If tx fails, sagging of affected side of the face may be limited by intramural prosthesis
  • early referral important to prevent permanent disability
27
Q

What is the difference between primary and secondary headaches?

A
  • Primary headaches are a condition such as common tension headaches or migraine without underlying disease
  • Secondary headaches are caused by separate disease process, such as intracranial tumour or haemorrhage
28
Q

What are the signs of a secondary headache?

A
  • Sudden onset
  • Onset after trauma
  • Not experienced before
  • Increased frequency/severity
  • Systemic symptoms
  • Fever or rash
  • Stiff neck
29
Q

Migraine features and management

A
  • Precipitating factos: stress, hunger, certain foods, menstruation
  • Features: irregular, begins day or night and lasts 24h, intense throbbing pain, photophobia, visual disturbances, sometimes nausea and vomiting
  • Management: good response to 5HT agonists, Ergotamine
30
Q

Migrainous neuralgia aetiology, features and management

A
  • Aetiology: oedema or dilation of the wall of the internal carotid
  • Precipitating factors: alcohol
  • Features: cluster headaches: intense unilateral orbital and temporal pain, episodic (same time every day), lasts 60mins, usually attacks recur for several days then remit for months, no photophobia
  • Management: Ergotamine, analgesics, MRI to exclude other causes
31
Q

Features and management of (or giant cell arteritis)

A
  • Features: Severe persistent pain, pain in masseter, systemic features: weight loss, joint pain, visual loss
  • Management: corticosteroids

Oral Disease (43 decks)

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