FACIAL PAIN-NON ODONTOGENIC CAUSES

Dr. A.V. SrinivasanMD.,DM.,Ph.D .,D.Sc (HON).F.I.A.N.,F.A.AN.Emeritus professor of Tamilnadu Dr. M.G.R Medical University.Adjunct Professor –IIT, ChennaiFormer Head, Institute of Neurology- Madras medical college.Ragas Dental college 07-08-2011

Understanding, Impact and Understanding, Impact and AwarenessAwareness

Chronic PainChronic Pain

We learn by thinking and the quality of the learning outcome is determined by the quality of our thoughts

R.B. Schmeck

“Pain May be Inevitable, but Misery is Optional”

Dee Malchow

Pain constitutes nearly 40% of the total of patient visits to doctors.1

1 Mäntyselkä et al. Pain as a reason to visit the doctor: a study in Finnish primary health care. Pain. 2001 Jan;89(2-3):175-80.

“By Nature All Men/ Women are alike butby Education widely different”

- Chinese

In 2001, Barry Furrow wrote “Pain is undertreated” in the American health-care system at all levels.2

The term "opiophobia" has been coined to describe this remarkable clinical aversion to the proper use of opioids to control pain.

The possible reasons for health-care providers' failures to properly manage pain are many; Occasional lack of knowledge about appropriate treatment choices

for pain management A reflection of a Culture hostile to drug use Threats of legal action. Worry about tolerance and addiction and other adverse drug

effects Something as trivial as the lack of insurance cover, can lead to

patients suffering unnecessary pain as a result.

Every thing should be made as simple as possible; but not simpler

Despite an essentially stoic and less demanding Indian patient; the obligation to manage pain comes to the fore not only to complete the perfection of a clinicians management.

But also, it is an independent entity with physical and psychological components that in adherence to best practices can neither be ignored nor treated such that adverse effects eclipse the malady.

This importance of pain management is further increased when benefits for the patient are realized, Early mobilization which tends to prevent the more

dangerous complication of a deep vein thrombosis; Shortening hospital stay Reducing costs

Speak obligingly even if you cannot oblige

In late 2000, US Congress passed into law a provision, which the president signed , that declared the 10 year period beginning Jan 1st 2001, as the Decade of Pain Control and Research.

The American Pain Society has actively supported the Decade of Pain Control Research, and it has been a focal point for the development of numerous programs to advance awareness and treatment of pain and funding for research.Neuronal damage, including that

of neuronal cell membrane

• Pain is always a subjective experience

• Everyone learns the meaning of “pain” through experiences usually related to injuries in early life

• As an unpleasant sensation it becomes an emotional experience

• Pain is a significant stress physically, emotionally

The International Association for the Safety of Pain (IASP) defines pain an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, or both.

Develop the heart; art comes automatically

Organic vs. psychogenic Acute vs. chronic Malignant or benign Continuous or episodic

Perceiving Pain• Algogenic substances – chemicals released at the site of

the injury• Nociceptors – afferent neurons that carry pain messages• Referred pain – pain that is perceived as if it were

coming from somewhere else in the body

Symptoms vary depending on the location of occlusion and the extent

of the spared collateral flow

ACUTE CHRONIC

Function To warn None (destructive)

Etiology Usually Clear Complex/obscure

Pt. Mood Anxiety/fear Depression/anger

MD impact Comforting Frustrating/draining

Role of Rx Control/cure Improve function/QOL

Knowledge without action is useless;

Action without knowledge is foolish

Types of PainTypes of Pain

Pain arising from pain receptors

[Nociceptive Pain]

Pain arising from pain receptors

[Nociceptive Pain]

(Psychogenic)

Pain with NO apparent cause(e.g. Low back pain or some

pelvic pain in women)

(Psychogenic)

Pain with NO apparent cause(e.g. Low back pain or some

pelvic pain in women)

Pain arising from Nervous system[Neuropathic Pain]

Pain arising from Nervous system[Neuropathic Pain]

Central(Brain and Spinal cord)

Central(Brain and Spinal cord)

Peripheral (Peripheral nervous

system)

Peripheral (Peripheral nervous

system)

Superficical / SomaticSuperficical / Somatic Deep / VisceralDeep / Visceral

Love is selfishness and selfishness is lovelessness

Nociceptive descriptors Neuropathic descriptors

Cramping, tender Shooting

Gnawing, heavy Hot-burning

Aching Sharp

Splitting Stabbing

Teachers are reservoirs from which, through the process of education, the students draw the water of life

IASP (International Association for the Study of Pain) expert multi-axial classification of chronic pain

Axis I: Anatomical location Axis II: Systems Axis III: Temporal Characteristics (intermittent, constant, etc.) Axis IV: Patient’s Statement of Duration/ Intensity / severity Axis V: Etiology Example:

Mild post-herpetic neuralgia of T5 or T 6; 6 months’ duration = 303.22e

Axis I: Thoracic regionAxis II: Nervous system (central, peripheral, or autonomic); physical

disturbance/dysfunctionAxis III: Continuous or nearly continuous, fluctuating severityAxis IV: Mild severity of 1 to 6 monthsAxis V: Trauma, operation, burns, infective, parasitic (one of these)Learn to adapt, adjust and accommodate

Learn to give, not to take and learn to serve not to rule

Loneliness Hostility

Social Factors

Anxiety Depression

Psychological Factors

Pathological Process

Physical Factors

TIM

E

Chronic pain has a psycho-social component that must be dealt with before depression becomes a part of the clinical picture. Chronic pain should be recognized as a multi-factorial disease state requiring intervention at many levels.

Science is below the mind; Spirituality is beyond the mind

Chronic pain has high co-morbidity Depression Anxiety disorders Sleep disorders

All diminish function and quality of life Addressing these issues is essential to optimal

pain management

Give us the GRACE to accept with serenity the things that cannot be changed the COURAGE to change the things that should be changed

and the WISDOM to know the difference

Chronic pain is NOT a normal part of aging. Emotions play a key role in painful experience Pain sounds a warning, signaling damage to tissues, and has survival value so pain

receptors do not adapt to prolonged stimulation and pain sensation may intensify as pain thresholds are lowered by continued stimulation.

The 19th Century viewed pain as a solely physiological entity with two theories dominating – the “specificity” & the “summation” theories. 8

Paradigm Shift: Pain perception impulses are modified by ascending and by descending pain-

suppressing systems activated by various environmental and psychological factors.

1965 Melzack & Wall: Gate Theory of Pain marked a turning point in understanding transmission and modulation of nociceptive signals, and recognition of pain as a psychophysiological phenomenon.

The concept of Neuroplasticity was recognized and accepted adding dynamism to neuronal & brain structure with neuroimaging of the central nervous system in three domains; anatomical, functional, and chemical imaging helping measure changes in chronic pain.

Taken together these three domains have changed our thinking on pain; now considered an altered brain state in which there may be altered functional connections or systems and components of degenerative aspects of the CNS. 9

Hate screeches, fear squeals; conceits trumpets

but love since lullabies

A bad teacher complains;

A good teacher explains;

The best teacher inspires;

Trauma/ injury initiates immediate nerve impulses to brain

Injury to cells result in chemical release

H+

K+

Substance P Bradykinin 5HT Phospholipids

Prostaglandins Blood vessels leak resulting in

inflammation Stimulate C-fibres (slow

response)

Reputation is made in a moment; character is built in a life time

Ascending TractsAscending Tracts Descending TractsDescending Tracts

Cortex

Midbrain

Medulla

Spinal Cord

Thalamus

Pons

(Brookoff, 2000)

( A delta) Myelinated Fast conductors Gentle pressure and

pain (A beta)

Thinner – but still myelinated

Fast conductors Heavy pressure

&temp C - very thin

Slow conductors PAIN, Pressure, temp

& chemicals

Character gets you out of bed commitment moves you to action faith, hope and Discipline follow through to completion

In chronic pain, the nervous system remodels continuously in response to repeated pain signals

nerves become hypersensitive to pain

nerves become resistant to anti-nociceptive system

If untreated, pain signals will continue even after injury resolves

Chronic pain signals become embedded in the central nervous system

It is the providence of the knowledge to speak and it is the privilege of the wisdom to listen - Hodly’s

Pain-Sensing System in the Malfunction in Chronic Pain

)

Acute pain:Pain-sensing signals are initiated in response to a stimulus

•They elicit a pain-relieving response

Chronic pain:Pain signals are generated for no reason and may be intensified

•Pain-relieving mechanisms may be defective or deactivated

Pain Sensing

In chronic pain, pain signals are generated without physiologic significance

Opinion is ultimately determined by the feelings

and not by the intellect

Reticulospinal fibers from raphe nuclei project to dorsal horn of spinal cord and release serotonin which stimulates interneurons to release enkephalin

Enkephalin inhibits transmission of pain and temperature signals in second order neurons

Reticulospinal fibers from locus coruleus also project to dorsal horn of spinal cord and release norepinephrine which inhibits pain and temperature signals by an unknown mechanism

Mental illnesses such as depression decrease serotonin and norepinephrine and lower pain thresholds while antidepressant drugs and therapies (e.g., exercise) which increase serotonin and norepinephrine levels raise pain thresholds

A great many people think they are thinking when they are merely re arranging their prejudices

W. James

Inferred from characteristics, etiology or pathophysiology

Types

Nociceptive

Neuropathic

Idiopathic

Therapeutic implications

Opinion is ultimately determined by the feelings

and not by the intellect

Presumably results from ongoing activation of primary afferent neurons responding to noxious stimuli Pain consistent with degree of tissue injury Described as aching, squeezing, stabbing, throbbing Subtypes:

Somatic: related to activation of somatic afferent neurons

Visceral: related to activation of visceral afferent neurons

The Truth is fear and immorality are two of the greatest inhibitors of Performance to progress

Initiated by a primary lesion in the nervous system; believed to be sustained by aberrant somatosensory processing in the peripheral or central nervous system

Independent of obvious ongoing nociceptive activation

Burning, shooting, electrical quality; may be aching, throbbing, sharp

Subtypes: Presumed “central generator”

deafferentation pain (central pain, phantom pain) Sympathetically-maintained pain

Presumed “peripheral generator” Polyneuropathies and mononeuropathiesA true commitment is a heart felt promise to yourself from which

you will not back down -

D. Mcnally

Idiopathic Pain

Usually exists in the absence of an identifiable physical or psychologic pathology that could account for pain

Uncommon in patients with progressive illness

Psychogenic Pain

Presents positive evidence of a predominant psychologic contribution and may be labeled with a specific psychiatric diagnosis

Serious, sincere, systematic studies,

surely secure supreme success

Greater understanding of the pathophysiology underlying chronic pain syndromes

Scientific breakthroughs in molecular biology; insight into pain at the molecular level

Advances in drug therapy (drug delivery technologies) Multimodal therapy Multidisciplinary teams, shared decision-making that

includes patients Patients’ rights movement

Why is thought, being the secretion of the brain,

more wonderful than gravity, a property of matter?

Therapeutic Modalities for

Chronic Pain Management

Assessment

Progress in Chronic Pain Management:Progress in Chronic Pain Management:

God is a comedian performing before an audience

that is afraid to laugh

“Describing pain only in terms of its

intensity is like describing music

only in terms of its loudness”

“Men of Genius Admired: Men of Wealth envied

women of power feared but only women of character are trusted”

A- Friedman

Characterize the pain

Characterize the disease, relationship between pain and disease and potentially treatable etiologies

Clarify syndromes and infer pathophysiology

Determine need for urgent therapy

Identify other needs

Develop a therapeutic strategy

The word shall perish not for lack of wonders but lack of wonder

Components History: temporal features, intensity, topography,

quality, exacerbating/alleviating factors

Physical Exam: determine existence of underlying pathology

Lab and Radiographic Tests: appropriate to pain syndrome

Assessment Tools Pain Intensity Scales: VAS, NAS, “faces” scale Multidimensional Pain Measures: Brief Pain Inventory,

McGill Pain QuestionnaireIn any field, find the strangest thing and explore it

• Visual Analogue Scale (VAS) No painNo pain ----------------------------------- ----------------------------------- Worst painWorst pain

•Categorical Scale None (0) Mild (1 – 4) Moderate (5 – 6) Severe (7 – 10) None (0) Mild (1 – 4) Moderate (5 – 6) Severe (7 – 10)

• Numerical Rating Scale0 0 -------------------------------------------------------------------------- 10 10

No painNo painWorst pain Worst pain imaginableimaginable

00

No No hurthurt

22

Hurts just a Hurts just a little bitlittle bit

44

Hurts a little Hurts a little bit morebit more

66

Hurts even Hurts even moremore

88

Hurts a whole Hurts a whole lotlot

1010

Hurts as much Hurts as much as you can as you can

imagineimagine

• Pain Faces Scale

• Brief Pain Inventory Shade areas of worst pain. Put an X on area that hurts mostShade areas of worst pain. Put an X on area that hurts most

There are sixty trillion cells in the human body

Progress in Chronic Pain Management

Therapeutic Modalities for Chronic Therapeutic Modalities for Chronic

Pain ManagementPain Management

TreatmentTreatment

Pharmacotherapy (Analgesics) Non-opioids Adjuvant Analgesics

Antidepressants Anticonvulsants

Opioids Rehabilitative Approaches Psychologic Interventions Anesthesiological Approaches Neurostimulatory Techniques Surgery Complementary/Alternative Approaches Lifestyle Changes

Baby hears 30,000 cycles / sec, teenage boy hears 20,000 and

old hears 4,000 cycles / sec

Best evidence: TCAs Inhibit both NA and 5-HT reuptake

TCAs are superior to SSRIs in pain management

TCAs are superior to the anticonvulsant

There is no consensus regarding which of the many TCA derivatives is most effective.

The choice of TCA is therefore dictated largely by adverse effects

There are sixty trillion cells in the human body

“Motivation is the Spark that lights

the Fire of Knowledge and

fuels the engine of Accomplishment”

Major reason for seeking medical care.

90% is vasculr headache.

10% is mixture of inflammation,traction or dilatation of pain sensitive structure.

A true commitment is a heart felt promise to yourself from which you will not back down

- D. Mcnally

Pain Referred pain

Pattern of referred pain

Success in life is a matter not so much of talent and opportunity

as of concentration and perseverance

- C.W. Wendte

History Hx of present illness Past medical hx Family hx Social hx

Physical examination

We possess by nature the factors out of which personality can be made, and to organize them into effective personal life is every man’s primary

responsibility

- Harry Emerson Fosdick

Clinical features suggesting serious cause Crescendo Early morning Vomiting Fever Seizures & other neurological symptomes Worst headache in my life Known malignancy Tenderness

Typical Neuralgias1) Trigeminal neuralgia

• Characterized by recurring paroxysmal severe pain, brief duration (seconds) in the territory of the trigeminal nerve, spontaneously or initiated by chewing, talking, touching the affected side of the face.

• Unknown aetiology, an arterial loop pushing on the sensory root in the posterior fossa.

• Females affected more than males• Analgesics, surgery, destruction of the

sensory neuron, division of nerve root.

“ He who cannot forgive others destroys the bridge over which he himself must pass” - Annoy

Typical Neuralgias2) Glossopharyngeal neuralgia

• Unknown cause• Equal both sexes• Severe, sudden episodes of pain in

the tonsil region one side only, ipsilateral ear.

• Pain - severe for 1-2 hours, recur daily

• Treated like trigeminal

In all of us, even in good men, there is a wild - beast nature which peers out in sleep

Typical Neuralgias3) Sluder’s neuralgia and Vidian

neuralgia • Intractable pain in the nose, eye,

cheek and lower jaw.• Could be due to lesion of the

sphenopalatine ganglion, or vidian nerve.

• Analgesics, vidian neurectomy

The art of medicine is caring for the heart of the patient

Posttraumatic neuralgia Neuroma Parietal & occipital 90% recovery

Experience can be defined as

yesterday’s answer to today’s problems

Atypical facial pain Pain felt over the cheek, nose, upper

lip or lower jaw Usually bilaterally symmetrical Aching, shooting, burning,

accompanied by reddening of the skin and lacrimation or watering of the nose

Lasts for hours, days or weeks Psychological consultation, analgesics

The sign wasn’t placed there

By the Big Printer in the sky

Intracranial lesions1) Central lesions

• Tumours of the brain stem, M.S., thrombotic lesions, metastasis, occult naso-pharyngeal ca.

• No precipitant, sensory loss.2) Post herpetic neuralgia

• Herpes zoster may affect trigeminal nerve ganglion

• Vesicular rash covers one division commonly the 1st with severe pain.

It is the disease of not listening, the malady of not marking,

that I am troubled withal - Shakespeare

Extracranial lesions1) Sinus disease

• Infective and neoplastic lesions of the paranasal sinus.

• Facial pain & dental pain, loss teeth.• Clinical suspicion.• Treatment

2) Dental neuralgia• Dental carries• Dental extraction

3) Temporomandibular joint pain

Memory, Pity and Beauty are short lived in life; But tinged with emotion persist in life

Headache is one of the commonest symptoms in medical practice.

Aetiology:

1) Raised intracranial pressure Due to tumours, abscesses, subdural

haematoma, brain haemorrhage.

2) Inflammation of the brain and

meninges e.g. meningitis, cerebritis, others

It is the disease of not listening, the malady of not marking,

that I am troubled withal - Shakespeare

3) Migraine Congenital predisposition Triggered by hunger, certain foods, sleep - too

much or too little, hormonal variations, stress. Pathology-vascular dilatation Females affected more than males ? Proceeded by aura usually visual,

paraesthesiae of hands, weakness Headache is unilateral or bilateral, affects any

area of the head, aching or throbbing often accompanied by nausea and vomiting

Diagnosis - by history alone Treatment - prevention by avoiding

precipitating factors, appropriate medication.

The sign wasn’t placed there

By the Big Printer in the sky

4) Tension headache More common in adult females Positive family history (40%) Maybe associated with migraine Produced by persistent contraction

of the muscles of the neck, head and face

Caused by emotional tension, secondary to other headaches, posture habit

Treated by analgesics, muscle relaxants, physiotherapy

NATURE, TIME AND PATIENCE are the 3 great physicians

5) Cluster headache 90% are men Age 20 - 30 Attacks occur in groups, no aura Caused by vascular dilatation of

branches of external carotid Triggered by histamines, alcohol Treated by analgesics, anti-

histamine, steroids

Success is a prize to be won. Action is the road to it. Chance is what may lurk in the shadows at the road side.

Pain from temporalis muscles Can arise from grinding teeth at

night (bruxism), impacted wisdom teeth, temporomandibular joint dysfunction, anxiety when the patient clenches the jaws too tightly

Treatment: Refer to interested dental surgeon.

Science is below the mind; Spirituality is beyond the mind

Pain from upper neck muscles Can radiate over the head

Treatment by physio-therapist or rheumatologist

Pain from frontalis muscles Usually due to bad posture at

work or while drivingTreatment: physio-therapy

Memory, the daughter of attention, is the teeming mother of knowledge -

Martin Tupper

Cervical spondylosis Pain mediates upwards from the neck

to the occiput or vertex to the front of the head, down to the shoulders

Due to cervical discs prolapse Diagnosis - x-ray

Treatment: Physio-therapy, referral to rheumatologist

Experience can be defined as

yesterday’s answer to today’s problems

Temporal arteritis Due to acute inflammation of the artery,

the cause unknown, affects men and women over the age of 60

Pain over the temples and frontal region, intense, throbbing, tenderness over the scalp, swelling and redness of the overlying skin with general malaise, partial or complete loss of vision.

ESR Elevated

Treatment: Cortisone, analgesics

“By Nature All Men/ Women are alike butby Education widely different”

Psychologic headache Usually accompanied by

depression, anxiety

No organic lesion

It is a great misfortune not to possess sufficient wit to speak well

nor sufficient judgment to keep silent

La Broyers character

Dedicated to my family for making everything worthwhile

My sincere thanks to P.Sampath

READ not to contradict or confuteNor to Believe and Take for

Grantedbut TO WEIGH AND CONSIDER