Orofacial pain

presented by:Dr. Muntather M. Hassan

Pain: is unpleasant sensory and emotional experience associated with actual and potential tissue damage.

Anatomic Considerations Trigeminal nerve.

Facial nerve.

Cervical nerve 2 .

Cervical nerve 3 .

Glossopharyngeal nerve.

Vagus nerve.

Categories of orofacial pain

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)

Categories of orofacial pain

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

Categories of orofacial pain

4- Psychogenic pain: Atypical facial pain Atypical odontalgia Burning mouth syndrome

5- Referred pain: Cardiac pain

Evaluation and assessment

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.

Measurement of Pain

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) .

C-diagnostic Imaging:

-Used to confirm the diagnosis or rule out serious disease.

-Extent of an identified disorder. -Most OFP not produce abnormality.

TMJ DISORDERS

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.

Management of myofascial pain:

-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.

INTERNAL DERANGMENT OF THE TMJ

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).

Mahans sign: contralateral pain suggest articular disease.

Stabilization Appliance:

Soft laser apparatus in useultrasound apparatus in use

NEURALGIA-INDUCING CAVITATIONALOSTEONECROSIS

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) .

Trigeminal neuralgia:

Definition : usually unilateral sever

brief sudden stabbing pain in distribution of one or more of branches of trigeminal nerve.

Etiology and pathophysiology

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.

Clinical features

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.

TN Clinical features

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.

TN Diagnosis:

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

Treatment of trigeminal neuralgia

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

Treatment of trigeminal neuralgia

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 b) Percutaneous ganglion procedure: include

radiofrequent thermocoaglation ,glycerol injection , balloon compression,Gamma knife.

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

Gamma knife microvascular 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

Management:

-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

Occipital 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 ,

Post -Traumatic Neuropathic Pain

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 .

Post -Traumatic Neuropathic Pain

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 .

Complex Regional Pain Syndrome( CRPs)

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,

Complex Regional Pain Syndrome

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.

Complex Regional Pain Syndrome

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.

CENTRAL POSTSTROKE PAIN

Condition secondary to damage caused by a cerebrovascular accident .

its is characterized by constant or

paroxysmal pain accompanied by sensory abnormalities ,

CENTRAL POSTSTROKE PAIN

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

Bell's palsy

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.

Atypical facial pain

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 .

Atypical facial pain

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 .

Atypical facial pain

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

Clinical features:

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 .

Burning mouth syndrome

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-lipoic

acid. Cognitive behavior therapy.

Eagle’s syndrome

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.

Types of Eagles syndrome:

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.

Diagnosis:

(1)clinical manifestations,(2) digital palpation of the process in the tonsillar

fossa, (3) radiological findings .

(4) lidocaine infiltration test. Treatment:COSERVATIVE: involves injecting steroidsor long-lasting anesthetics into the lesser cornu ofthe hyoid or the inferior aspect of the tonsillar fossaI,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

Clinical manifestation: 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

C-facial migraine(carotidynia):

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.

Migraine

Treatment : Avoid trigger factors Acute attack: analgesics, Sumatriptan (5-HT

agonist) , Ergotamin.

Prophylaxis : pizotifen ,propranolol , ca channel blockers . TCAs

Cluster headache

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.

Cluster headache

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.

Cluster headache

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

Injection of sumatriptan or sublingual or inhaled ergotamine

Prophylaxis : lithium, ergotamine, prophylacticprednisone, and calcium channel blockers.

Chronic Paroxysmal Hemicrania

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.

Temporal Arteritis

-Its inflammation(vasculitis) of cranial arterialtree.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.

Temporal Arteritis

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

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