PAIN

1. PAIN

2. Pain Common causes of oro-facial pain • Local disorders • Teeth & supporting tissues • Jaws • Maxillary antrum • Salivary glands • Pharynx • eyes • Neurological disorders • TN • Neoplasms involving the Trigeminal nerve • Glossopharyngeal neuralgia • Herpez Zoster • Multiple sclerosis • SUNCT sydrome

3. Causes • Vascular • Migraine • Migrainous Neuralgia • Giant cell arteritis • Neuralgia induced cavitationalosteonecrosis (NICO) • Psychogenic • Atypical facial pain • Burning mouth syndrome • TMPD • Referred pain

4. Analysis • Previous History • Location • Localized • Generalized • Focuses • Diffuse • Duration • Dentinal pain  transient • Pulpitis  longer • TN Brief lancinating • Migrainous Neuralgia  30-45 minutes • Migrain  hours-days • Atypical facial pain  persistent

5. Analysis • Character • Continuous • Throbbing • Severity • Ask the patient to scale it from 0-10 • Dull • Lancinating • Burning sensation • Interference with sleep

6. Analysis • Frequency & Periodicity: • Pain on laying down/bowing  Sinusitis • Disturbs sleep in the midnight (around 2am)  Migrainous neuralgia • Pain on waking  TMPDS • Provoking or relieving factors: • Temperature  dental pain • Trigger zone  TN • Stress  atypical facial pain • Alcohol  migrainous neuralgia • Biting  periapical pathology • Postural  sinusitis?

7. Analysis • Other factors: • Nausea/vomiting • Facial swelling • Nasal stuffiness • Lacrimation • Neurological signs & symptoms • Relief by analgesics • Weight loss • TMJ click • Trismus

8. Local Causes

9. Dental Pain Dentinal: • Sharp & deep • Evoked by external stimulus i.e. hot, cold, sweet, sour, salty foods/drinks • Subsides within few seconds • Poorly localized

10. Dental Pain Pulpal • Pulp Vitality test • Pain may be • Sharp & intense, elicited by change in temp. remains for 5-10 minutes, remains diminished untill stimulated again Reversible Pulpitis • Spontaneous, dull, more than 20 minutes duration, difficult to localize, affected by body position  Irreversible pulpitis

11. Pulpal Diagnostic Tools • History, nature & duration of pain • Reaction to thermal changes • Reaction to mild electrical stimulus • Reaction to tooth percussion • Radiographic examination • Visual clinical examination • Palpation of surrounding area

12. Periodontal • More localized than pulpal pain • Less severe • Associated with tenderness/pressure • Usually not aggravated by heat/cold

13. Acute peri-apical • Spontaneous • Moderate to severe • Persists for long periods • On percussion/biting on tooth • Extruded tooth in severe cases • Usually precisely located by patient • Usually associated with non-vital tooth • Swelling of the face?

14. Other Oral Causes • Lateral periodontal abscess • Food impaction • Cracked tooth • Pericoronitis • ANUG • Mucosal

15. Other oro-facial pains Jaws • Acute infections • Malignancies • Paget’s disease • Direct trauma • Cysts • Retianed roots • Infected impactions • Radiation therapy  osteo-radio necrosis  osteomyelitis

16. Other oro-facial pains TMJ • Dysfunction • Acute inflammation • Trauma • Malignancies • Muscular Pain is usually • Dull • Poorly localized • Radiates • Intensified by movement of mandible

17. Other oro-facial pains Salivary glands • In children  mumps • In adults  calculi or mucous plug • Severe pain in acute parotitis • Pain is • Localized to affected gland • Quite severe • Intensified by increased salivation

18. Other oro-facial pains Sinuses • Preceding cold • Pain & tenderness • Radio-opacity of sinuses • Upper molars/premolars become tender in maxillary sinusitis • Tumours of sinuses Pressure on Mental nerve

19. Neurologic causes • Trigeminal neuralgia • Glossopharyngeal neuralgia • Post-herpetic neuralgia • Idiopathic TN • Any lesion affecting Trigeminal n. • Traumatic • Cerebrovascular disease • Multiple sclerosis • Infections such as HIV • Inflammation • Neoplasia (Nasopharyngeal/antral ca.)

20. Vascular causes • Migraine • Migrainous neuralgia • Giant Cell Arteritis • Neuralgia Induced CavitationalOsteonecrosis

21. Oro facial pain

22. Neuralgias

23. Trigeminal Neuralgia • A disorder of trigeminal nerve that causes episodes of unilateral, intense, stabbing, electric shock like pain in the areas of face along the distribution of branches of this nerve • Areas effected may include lips, eyes, nose, scalp, forehead, upper/lower jaw • One of the most painful afflictions known

24. Trigeminal Neuralgia • Types • Classical • Symptomatic • Idiopathic

25. Trigeminal Neuralgia • Most common neurological cause of facial pain • 4 per 100000 patients • 50-70years age group • More common in females • No specific predisposing factors but emotional or physical stress, hypertension may be related

26. Trigeminal Neuralgia - Pathophysiology • Exact cause isn’t known • Compression around trigeminal root due to atherosclerotic blood vessels is the hypothesized cause • Demyelination of trigeminal nerve causing ectopic pulses • Compression by tumour • Bony compression • AV malformation • Amyloid • Pons infarct

27. Trigeminal Neuralgia

28. Trigeminal Neuralgia

29. Trigeminal Neuralgia – C/F • Mainly affects 2nd & 3rd divisions of trigeminal • Paroxysmal attacks of facial pain • Can last from few seconds to 2 minutes • Occurs mostly in the morning • Spontaneous remission may be possible • Or patients may have episodic attacks over many years

30. Trigeminal Neuralgia – C/F • Pain has atleast four characteristics • A distribution along one or more divisions of trigeminal n. • A sudden, intense, sharp, superficial, stabbing or burning pain • Intensely severe • Precipitation from trigger areas or certain daily activities such as eating, talking, washing the face, shaving or cleaning teeth • Usually asymptomatic between paroxysms but some patients report a dull ache

31. Trigeminal Neuralgia

32. Trigeminal Neuralgia – C/F • No neurological deficit • Attacks are stereotyped in individual patients Atypical TN • Less intense, constant, dull burning or aching pain with occasional electric shock like stabs

33. Diagnosis • Exclusion of other causes of pain by history, physical examination & further evaluation necessary • Exclusion of physical signs such as facial sensory or motor impairment, CVA, Multiple sclerosis, infections (HIV) or neoplasms

34. Management • Anticonvulsants  Carbamazepine • It is the main drug of choice • Prevents attacks in 60% of patients • Given continuousely & prophylactically for long periods • Used carefully & under strict medical surveillance • Contra-indicated in pregnancy

35. Dose regime • 100mg B.D for 2 weeks • Can be increased by 100mg daily every 3 days to a maximum dose of 1000mg/daily • Blood monitoring mandatory • Adverse effects • Ataxia • Drowsiness • Visual disturbances • Headache • GIT effects • Folate deficiency • Hypertension • Pancytopenia or leukopenia • Interaction with cimetidine, isoniazid, interferes with oral contraceptives

37. Monitoring • B.P: first 3 months..then 6 monthly • Blood tests: • Electrolytes (for hyponatraemia) • LFTs • RBC, WBC & Platelet counts

38. Surgical intervention • Peripheral surgery • Local cryosurgery • Injections of glycerol or streptomycin around mandibular or infra-orbital foramen • Peripheral neurectomy • Radiofrequency thermocoagulation

39. Surgical intervention • Central neurosurgery • Micro-vascular decompression • Gasserian ganglion operations • Injections around trigeminal ganglion • Radiofrequency thermocoagulationganglionolysis • Gamma knife • Trigeminal ganglion microcompression using Fogarty ballon catheter • Posterior cranial fossa procedures

40. Surgical intervention

41. Surgical intervention

42. Differential Diagnosis • Glossopharyngeal neuralgia • Giant cell arteritis • Cluster Headache • Intracranial tumour • Post-herpetic neuralgia • Multiple sclerosis • Migrain • Dental pain • TMPDS

43. Glossopharyngeal Neuralgia

44. Glossopharyngeal Neuralgia • A pain syndrome characterized by unilateral, sharp pain along the sensory distribution of ninth cranial nerve (glossopharyngeal n.)

45. Glossopharyngeal Neuralgia Pain character • Acute pain that lasts from seconds to few minutes • Lancinating, stabbing, shooting & electric shock like • Felt in the ear, throat, posterior part of tongue, soft palate & lower lateral & posterior parts of pharynx • Triggered by swallowing & speech resulting in weight loss

46. Glossopharyngeal Neuralgia • Between the attacks, patient may remain pain free or may have feeling of pressure & burning lasting for several minutes • In some patients, attack may be associated with vasomotor changes (syncope, bradycardia, hypotension or even asystole) making it potentially fatal • Differentiated from TN by distribution & triggering movements (swallowing, talking, coughing) • In 15% patients, both conditions are present & symptoms overlap

47. Glossopharyngeal Neuralgia Incidence • Less common than TN • A population bases study showed an incidence of 0.7 in 100,000 • More common in men • Incidence increases with age (> 50 years)

48. Glossopharyngeal Neuralgia Etiology Two types • Without discernable cause  idiopathic or essential GPN • With underlying pathology  secondary GPN

49. Glossopharyngeal Neuralgia Idiopathic or Essential GPN • Believed to be caused by vascular compression of ninth cranial n. (theory supported by success of MVC in elimination of symptoms) • Or central (pontine) dysfunction

50. Glossopharyngeal Neuralgia Secondary GPN • Neoplasms • Vascular malformations • Infections • Demyelination • Trauma • Elongated styloid process (eagle’s syndrome) • Other causes