presented by:Dr. Muntather M. Hassan

Pain: is unpleasant sensory and

emotional experience associated with

actual and potential tissue damage.

Trigeminal nerve.

Facial nerve.

Cervical nerve 2 .

Cervical nerve 3 .

Glossopharyngeal nerve.

Vagus nerve.

1- Local pain: Dental : (pulpitis., dentine hypersensetivity

,periapical periodontitis.cracked tooth syndrome

Gingival: (e.g primary herpetic gingivostomatitis,

Mucosal: (e,g ulceration)

Salivary gland: (acute suppurative sialadenitis)

Temporomandibular joint:

Maxillary sinus: (sinusitis,malignancy)

2- Neurological pain: Trigeminal neuralgia

Glossopharyngeal neuralgia

Ramsy hunt syndrome

Postherpetic neuralgia

3- Vascular :

Giant cell arteritis and variant

Migraine and variant

Cluster headache ,chronic paroxysmal hemicrania

4- Psychogenic pain: Atypical facial pain

Atypical odontalgia

Burning mouth syndrome

5- Referred pain:

Cardiac pain

A-history:1-Chief complaint.

2-History of present illness.

Pain Characteristics

Intensity

Quality

Location

Onset

Associated events at onset

Duration and timing of pain

Course of symptoms since onset

Activities that increase pain

Activities that decrease pain

Associated symptoms (eg, altered sensation, swelling)

Previous treatments and their effects

Referral

-Connective tissue disease.

-Demylination disorder.

-Metastatic disease.

-Ischemic heart disease.

4-Social history:

-History of traumatic event prior to onset of pain.

-Change in work, or problem regarding marital

state.

3-Past medical history

B-physical examination:

1. Inspection of the head and neck skin, 2. Palpation of masticatory muscles,

3. Assessment and measurement of the range of mandibular movement.

4. Palpation of soft tissue .

5. Palpation of the temporomandibular joint6. Palpation of cervical muscles and assessment of

cervical range of motion.

7. Cranial nerve examination.

8. General inspection of the ears, nose, and oropharyngeal areas.

9. Examination and palpation of intraoral soft tissue.

10. Examination of the teeth and periodontium (including occlusion.

Methods of pain measurement:

1-visual analog scale (VAS)

0 -----------------------------------10

no pain worst possible pain

2-Descriptive rating scales (eg, no pain, mild, moderate, severe pain).

3-Faces rating scale.

4-The McGill Pain Questionnaire (MPQ) .

-Used to confirm the diagnosis or rule out

serious disease.

-Extent of an identified disorder.

-Most OFP not produce abnormality.

1-Myofascial pain.

2-Traumatic injuries.

3-Arthritis &Arthrosis:

(a)infective .

(b) systemic.

(c) degenerative.

4-Internal derangement.

Myofascial pain

diffuse poorly localized periauricular pain.

May associated with parafunctional habits .

the pain may be severe in morning.

the pain is more severe during periods of

tension and anxiety.

the range of mandibular movement decrease .

"trigger points," where muscles have taut,

palpable band regions that twitch when

manually percussed.

-Education of patient and explanation .

-Self care to eliminate oral habit such as gum

chewing , clenching of teeth.

-thermal therapy(U/S, laser ).

-Intraoral appliance.

-Pharmacotherapy:

-NSAID.

-Muscle relaxant drugs ,

-Antianxiety drugs.

-TCAs.

Botox injection.

Trigger point block therapies, using local anesthetic in

combination with corticosteroid.

Pain on palpation directly over TMJ.

Limitation in joint range of motion.

Deviation on opening.

Joint noises consistently associated

with pain.

Joint crepitus.

Mahan sign (+ve in Wilkes II,III and IV).

Soft laser apparatus in useultrasound apparatus in use

Rare pain disorder characterized by

continuous lancinating like pain in site of

previous tooth extraction.

Usually in lower 3rd molar region.

Pain not interfere with sleep.

Radiographically appear as moth eaten or

soap bubbles in site of previous extraction.

Treated by resection of bone area with

pain ,

Neuralgia-inducing cavitational osteonecrosis

(NICO) . Periapical radiograph demonstrates an oval

radiolucency in the third molar region and thin lamina dura

remnants (residual socket) .

Definition :

usually unilateral sever

brief sudden stabbing

pain in distribution of

one or more of branches

of trigeminal nerve.

TN divided to primary and secondary(symptomatic)

the primary TN are result of vascular

compression of trigeminal nerve near its entry

into the pons (superior cerebellar artery).

Secondary TN causes include :multiple sclerosis,

tumors ,basilar artery eneurysim or actasia.

It presents as episodic ,recurrent unilateral

facial pain, described as sudden high intensity

stabbing or electric like shock.

lasts for a few seconds to minutes ,

Pain is frequently triggered by trivial stimulation:

such as touching of face, washing ,shaving ,

chewing and talking.

It occurs mostly after 5th decade.

Clinical examination of face is nearly always

normal.

If sensory loss is present a mass lesion is more likely

In young patients with TN, multiple sclerosis should

be considered.

Diagnosis depend on history and

clinical examination.

A careful search for ipsilateral

dental pathology should be

undertake

MRI and MRA and performed if

there is suspicion of underlying

pathology.

Right Trigeminal Nerve

Compressing vessel

1- Medical treatment: Carbamazepine 200 mg _ 1600mg bid .(effective

in 75% as first line of treatment)

Oxcarbazepine 600mg _3000mg It used in patients

who are sensitive to Carbamazepine.

Baclofen 15mg _80mg tid.

Gabapentine 900mg _3600mg tid.

Lamotrigine 25mg _300mg.

Clonazepam 1.5 mg _ 6mg

Phenytoin 300 mg

Valproate sodium 500mg _1500mg

2- Surgical treatment(invasive):indicated If medical treatment (carbamazepine) has

been ineffective after 4 weeks at maximum

tolerated dose .

Surgical treatment divided into 3 groups:

a) peripheral procedures :include alcohol injection, cryosurgery

,nerve avulsion

a) Percutaneous ganglion procedure: include radiofrequent

thermocoaglation ,glycerol injection , balloon

compression,Gamma knife.

b) Open operations : microvascular decompression ,trigeminal root section,

Gamma knifemicrovascular

decompression

-Pain is typically aching,buring,or shock

like.

-Potential sequela of infection with

herpes zoster.

Pain persist longer than one month after

healing vesicle classified as PHN.

Post-herpetic neuralgia

-Antiviral and corticosteroids after

presentation of rash reduce incidence of

postherptic neuralgia.

-Anticonvulsant drugs

-Local anesthesia injected to painful site.

Clinical features : Pain similar to character of TN.

Affect tonsil ,tongue base, ear,and intra articular

area.

Patient often point just to behind mandible angle.

Triggered by yawing and swallowing.

may be associated with a vasovagal reflex,

The application of a topical anesthetic to the

pharyngeal mucosa eliminates glossopharyngeal

nerve pain.

Glossopharangeal neuralgia

Management:

-Anti convulsion drugs,carbamezipine.

-Vascular decompression.

-Percutaneous R.F. at the jugular foramen.

-Intracranial or extra cranial neuroectomy.

Etiology:

The most common causes of glossopharyngeal

neuralgia areintracranial or extracranial tumors and

vascular abnormalities that compress CN IX.

Glossopharangeal neuralgia

presents as a paroxysmal stabbing pain in the

distribution of the greater or lesser occipital nerves. It may be caused by trauma,

Palpation below the superior nuchal line may

reveal a tender spot .

Treatment has included occipital nerve block,

neurolysis, C2 dorsal root gangionectomy ,

Its caused by Trigeminal nerve injuries may result

from facial trauma or from surgical procedures,

such as the removal of impacted third molars, the

placement of dental implant

Clinical Manifestations: The pain may be persistent

or occur only in response to a stimulus, such as a

light touch.

Patients with nerve damage may experience

anesthesia , paresthesia, allodynia , or

hyperalgesia .

Treatment: may be surgical ,nonsurgical, or both,

Systemic corticosteroids a when administered

within the first week after a nerve injury.

TCAs

Anticonvulsant drugs, Gabapentin.

Topical capsaicin .

chronic pain conditions that develop as a result of

injury.

patients suffer from allodynia, hyperalgesia, and

spontaneous pain that extends beyond the

affected nerve dermatome.

it accompanied by motor and sweat

abnormalities, atrophic changes in muscles and

skin, edema,

Types of CRPs :

1- CRPS I was previously termed reflex sympathetic

dystrophy (RSD),

2- CRPS II was previously termed causalgia.

Etiology and Pathogenesis:

believed to result from changes after trauma that

couples sensory nerve fibers with sympathetic

fibers.

Treatment: physical therapy.

block of regional sympathetic ganglia or regional

intravenous blockades with guanethidine

,reserpine, or phenoxybenzamine, Bisphosphonates such as alendronate or

pamidronate.

Paroxysmal pain of facial nerve, may result of

herpes zoster of geniculate ganglion.

-Clinical features:

-Pain at the ear, anterior tongue, soft palate.

-Not intense like T.N.

- Ramsay-hunt syndrome may develop(Facial

paralysis ,vesicle ,tinnitus & vertigo)

Nervous Intermedius (Geniculate) Neuralgia

Management:

-High dose of steroid for 2-3weeks.

-Acyclovir is significant in reduce the

duration.

-Anti convulsion ,Carbamezipine.

-Surgery: section of nerve intermedius.

Condition secondary to damage caused by

a cerebrovascular accident .

its is characterized by constant or paroxysmal

pain accompanied by sensory abnormalities ,

Treatment:

anticonvulsant ( Lamotrigine,Gabapentine)

sodium channel blocker(Mexiletine).

TCAs (Amitriptyline).

Short-term relief may be obtained with intra

venous lignocaine or propofol .

Note: the anticonvulsants are preferred

In about 50% of patient with Bell's palsy,

pain occur in or near the ear but sometimes

spreading down the jaw, either precedes or

develops at the same time as the facial

palsy.

Treatment: prednisolone 60-80 mg per day,

acyclovir.

Constant dull aching pain , deep ,diffuse

variable intensity in absence of identifiable

organic disease.

Its more common in female .

Most patient middle age and elderly .

Clinical features:

Often difficult for patients to describe their symptoms .

Most frequently described as deep , constant ache or

burning .

Doesn't awake patient.

Doesn't follow anatomical pattern and may be

bilateral.

Affect maxilla more than mandible.

Often initiated or exacerbated by dental treatment .

Examination entirely normal .

Often have other complaints such as IBS ,dry mouth and chronic pain syndrome .

Treatment :

Often rewarded with limited response.

Tricyclic antideprssant drugs have some

effect in some patients .

30% of patient respond to Gabapentine

Cognitive behavior therapy

occurs most frequently in women in the fourth and

fifth decades of life,

constant dull, aching pain without an apparent

cause that can be detected by examination ,

it occur after dental extraction or endodontic

treatment ,

Period of pain free after secondary dental

management.

Atypical odontalgia(phantom)

-Management:

patient reassurance ,consultation to

other specialty

-T.C.A. like amitriptyline , nortriptyline at

low dose. 10 -25 mg at night

-Anti convulsant drugs.

Burning sensation of oral mucosa , usually

tongue, in absence of any identifiable

clinical abnormality or cause.

Epidemiology: 5 per 100,000 ,higher in

middle age and elderly, affect female

more than male .

Causes: unknown but hormonal factors ,

anxiety ,and stress have been implicated.

Burning mouth syndrome

Complain of dry mouth with altered or

bad taste.

Burning sensation affecting tongue ,

anterior palate and less common lips.

May be aggravated by certain foods.

Usually bilateral.

Doesn't awake patient . But may present at

awaking

Examination entirely normal .

Investigation: FBC ,haematinics ,swab for Candida .

Treatment: Reassurance .

Avoidance of stimulating factors.

Some patients may respond to TCA, SSRIs

topical clonazepam, sucking and spitting 1 mg three times daily for 2 weeks.

2-month course of 600 mg daily alfa-lipoicacid.

Cognitive behavior therapy.

a series of symptoms caused by an elongated

styloid process (more than 3 c.m) and/or the

ossification of part or the entire stylohyoid

Ligament.

1-Classic :

the symptoms are persistent pharyngeal

pain aggravated by swallowing and

frequently radiate to the ear , with sensation

of foreign body within pharynx , This pain

arise following tonsillectomy due to

development of scar tissue around the tip of

the styloid process.

2- stylo-carotid artery syndrome(vascular):

Attributed to impingement of the carotid artery by

the styloid process This can cause a compression

when turning the head resulting in a transient

ischemic accident or stroke.

3-Traumatic Eagle syndrome:

in which symptoms develop after fracture of a

mineralized stylohyoid ligament.

(1)clinical manifestations,

(2) digital palpation of the process in the tonsillarfossa,

(3) radiological findings .

(4) lidocaine infiltration test.

Treatment:COSERVATIVE: involves injecting steroids

or long-lasting anesthetics into the lesser cornu of

the hyoid or the inferior aspect of the tonsillar fossa

I,NSAID

Surgical: intra oral or extra oral styloidectomy

Before puberty , female more than male .

Aura may developed before headache in 40%.

It may be triggered by foods such as nuts, chocolate, and red wine ; stress; sleep deprivation; or hunger.

Migraine

A-classic migraine (start with prodromal aura occurring over 20-30 minutes )

Flashing lights

Scotoma (localized area of vision depression )

Sensitivity to light

Sensory and motor deficit

Aura is followed by severe unilateral throbbing pain. Headaches may last for hours or up to 2 or 3 days.

B-common migraine (not preceded by aura)

Severe unilateral throbbing pain

Sensitivity to light and noise

Nausea and vomiting

30-50 years of age.

Pain last for minutes to hours and recurs several times per week.

Throbbing pain of neck and jaw.

Patients often seek dental consultation,

Tenderness of carotid artery

D-Basilar migraine : The symptoms are primarily neurologic and

include aphasia,temporary blindness, vertigo, confusion, and ataxia.

may be accompanied by an occipital headache.

Treatment :

Avoid trigger factors

Acute attack: analgesics, Sumatriptan (5-HT

agonist) , Ergotamin.

Prophylaxis : pizotifen ,propranolol , ca channel

blockers . TCAs

Clinical Manifestations: 80%of patients with CH are men.

The attacks are sudden, unilateral, and stabbing

,causing patients to pace, cry out, or even strike

objects. Some patients exhibit violent behavior

during attacks. pain as a hot metal rod in or around the eye.

Each attack lasts from 15 minutes to 2 hours and

recurs several times daily.

A majority of the painful episodes occur at night,

often awaking the patient from sleep.

Clinical Manifestations: The pain is associate nasal congestion and tearing

Sweating of the face, ptosis, increased salivation,

and edema of the eyelid. Cluster headache produce pain in posterior

maxilla that mimic dental pain.

Trigger by alcohol.

Treatment:

An acute attack: 100% oxygen (its effectiveness is diagnostic), Injection

of sumatriptan or sublingual or inhaled ergotamine

Prophylaxis : lithium, ergotamine, prophylactic

prednisone, and calcium channel blockers.

is believed to be a form of CH that occurs

predominantly in women between the ages of 30

and 40 years.

The episodes of pain tend be shorter, but attacks

of 5 to 20 minutes’ duration can occur up to 30

times daily.

It responds dramatically to therapy with

indomethacin , which stops the attacks within 1to 2

days.

-Its inflammation(vasculitis) of cranial arterial

tree.secondary to giant cell granulomatous.

Clinical features: most frequently affects adults above the age of

50 years.

Dull aching or throbbing temporal pain. accompanied by generalized symptoms , including fever, malaise, and loss of appetite.

Jaw claudication during mastication.

Diagnosis:

elevated ESR 50-100 .

elevated CRP.

Biopsy.

-Treatment:

high dose of steroid(prednisolone) 60 -100mg daily.

the steroid is tapered once the signs of the disease are controlled.

Patients are maintained on systemic steroids for 1 to 2 years after symptoms resolve.

1-Burket,s oral medicine.

2-Neville , Oral & Maxillofacial PATHOLOGY

3-Fonseca Oral and Maxillofacial surgery.

4- Booth Oral & Maxillofacial surgery.

5-Lecture notes in oral and maxillofacial surgery.

6- Orofacial pain ,from basic to management

References

THANK YOU