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Oro-Facial Pain

Oro-Facial Pain. By Iain Macleod. What is Pain?. “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” “- pain is always subjective -”. Int. Assoc. for the Study of Pain. Oro-Facial Pain.

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Oro-Facial Pain

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  1. Oro-Facial Pain By Iain Macleod

  2. What is Pain? • “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” • “- pain is always subjective -” Int. Assoc. for the Study of Pain

  3. Oro-Facial Pain • The remit of the dentist? • Patients go to dentist to get problem fixed • Filling, extraction etc • Problem arises when dentist can’t fix it! • Patients don’t go to dentist for medical/psychological help! • Dentist under pressure to do something! • Poor inter-professional communication between medicine and dentistry • Dentists often isolated

  4. Oro-facial Pain • Oro-facial pain can be difficult to diagnose! • TMD can be a great mimic! • Beware of referred pain!

  5. Causes of facial pain • Many causes! • May be infectious, neurological, vascular oncological or psychogenic

  6. In the primary care settinghow much do each of the following contribute to the diagnosis? • History taking • >80% • Physical examination • <10% • Investigations • <10% • So why do we do so many investigations?

  7. Why Do We Order So Many Tests? • "Defensive" medicine in an increasingly litigious environment • Loss of confidence in our abilities to extract meaningful information from the history and examination

  8. Consequences of Ordering So Many Tests • Time delay in diagnosis as one awaits the test results • The patient is exposed to the risk and side effects of tests that may not be necessary

  9. The pain history • Onset, location and duration of facial pain • Alleviating or aggravating factors • Medical, dental & social history

  10. KEY QUESTIONS • IS THE PAIN PRESENT EVERY DAY ? • WHAT IS A NORMAL DAY LIKE ? • HOW SEVERE IS THE PAIN ? – • (Score 0-10)

  11. Rules of Thumb! • Dental pain gets better or worse! • Chronic pain is rarely dental! • If an experienced dentist “feels” the pain isnot dental they are most often right !

  12. 5th & 7th Cranial Nerves • Sensory root oftrigeminal nerve • Pons • Vestibulocochlear nerve • Facial nerve • Abducent nerve • Medulla oblongata • Motor root of trigeminalnerve • Basilar sulcus

  13. Nasopharyngeal Carcinoma(Trotter’s Syndrome) • Maxillary pain • With numbness!! • Unilateral nosebleeds

  14. Toothache

  15. Dental caries

  16. Dental Pain - radiation • Caries in mandibular molars can produce pain around the ear • Caries in maxillary teeth can produce maxillary, orbital, retro-orbital

  17. Dental Pain • Dental pain can be difficult to diagnose! • Tooth sleuth! • Hot water test! • TMD can be a great mimic! • Headaches, jaw pain, toothache etc.! • Beware of referred pain • sinuses, cervical spine, heart etc.!

  18. Acute Maxillary Sinusitis • Unilateral or bilateral pressure, fullness or burning pain over cheekbone, upper teeth and around eyes • Exacerbated by stooping • Usually follows an URTI • Most cases self limiting

  19. Chronic Maxillary Sinusitis • Feeling of pressure below the eyes or toothache • Computed Tomography • Endoscopy

  20. Sinusitis Management • Decongestants • Steam inhalations • Antibiotics if indicated • Local Heat • Antihistamines if allergic component • corticosteroids • Sinus irrigation • Endoscopic surgery

  21. TEMPOROMANDIBULAR JOINT DISORDERS • Common • More has been written about this topic than for any other joint ! • Various classifications • Many cases are self limiting • Surgery is indicated in very few BUT important exceptions

  22. Temporomandibular Dysfunction • Pain in the joint and/or surrounding muscles • Joint “clicking” • Periods of limitation of joint movement (trismus)

  23. EPIDEMIOLOGICAL DATA • Percentage of population with signs 50-75% • Percentage of population with symptoms 20-25% • Percentage of population who seek treatment 3-4%

  24. Temporomandibular Dysfunction • Causes • Parafunction • Bruxism • Clenching • Emotional stress • Predisposition (F>M) • Joint hypermobility • Occlusal factors – little evidence

  25. Bruxism • Tooth wear • Painful teeth • Cracked cusps • Mouth ulcers due to trauma • Jaws ache in the morning

  26. Temporomandibular Dysfunction • Pain distribution • Variable – a great mimic!! • Joint pain • Earache • Toothache • Facial pain • Headache • Can be associated with neck and shoulder pain

  27. Treatment of TMD

  28. Trigeminal Neuralgia - Description • A painful unilateral affliction of the face, characterized by brief electric shock-like (lancinating) pains limited to one or more divisions of the trigeminal nerve • Pain evoked by washing, shaving, smoking, talking, brushing, air blowing, or spontaneously occurring • Pain is abrupt in onset and may remit for varying periods

  29. Trigeminal Neuralgia • Subclassified into idiopathic and symptomatic • Idiopathic trigeminal neuralgia: due to an interaction between trigeminal nerve and vasculature • Symptomatic trigeminal neuralgia: caused by demonstrable structural lesion

  30. Trigeminal Neuralgia • Females > males • Usually elderly – (if < than 40 -?MS) • Restricted to Vth nerve • Similar can affect IXth nerve – glossopharyngeal neuralgia • Trigger point – may bear no anatomical relation to site of pain but on same side! • Sleep often not affected • May go into remission

  31. Trigeminal Neuralgia Diagnosis: • History • Examination • MRI • aberrant pontine blood vessel? • exclusion of other cause (neoplasm, MS) • (Response to trial of carbamazepine)

  32. Trigeminal Neuralgia Treatment: • Medical – anticonvulsants ( e.g. carbamazepine) – needs medical monitoring! • Use of additive drugs – e.g. baclofen • Damage to trigger point – alcohol injection, cryotherapy

  33. Trigeminal Neuralgia – Surgical Treatment • Radiofrequency ganglionolysis • Microvascular decompression

  34. Establishment of VZV Latency in Sensory-Nerve Ganglia. After a primary VZV infection (chickenpox), latent VZV infection is established in the dorsal-root ganglia, and zoster occurs with subsequent reactivation of the virus N Engl J Med Vol 356(13) P1338-1343

  35. Zoster: Clinical Features • Usually limited to 1 or 2 adjacent, unilateral dermatomes • “Grape-like” lesions clustered on an erythematous base • Lesions usually heal within 4 weeks1

  36. Post Herpetic Neuralgia • Burning, itching, prickly pain that worsens with contact or movement • Persists along any of the three trigeminal nerve distributions affected by shingles • Difficult to treat! • Importance of adequate treatment of shingles – especially the elderly • Carbamazepine, tricyclics

  37. GiantCell Arteritis • Over 50yrs,women>men • recent onset headache,scalp tenderness   • Jaw/tongue claudication (tired tongue/jawache)      • anorexia • visual disturbances • Swollen disc usually

  38. GCA Diagnosis • ESR/CRP • BP, CXR • Biopsy of temporal artery

  39. Treatment of GCA • Give corticosteroids immediately in all suspected cases   • Start with 1mg/Kg prednisolone daily with vitamin D and calcium supplements. • Refer for Ophthalmology 

  40. PsychogenicSomatisation Disorders Somatisation has been defined as “the expression of personal and social distress in an idiom of bodily complaints with medical help seeking”

  41. Common ! “In general medical practice, somatisation associated with psychiatric illness accounts for 20 - 30% of all consultations”

  42. DEPRESSIVE ILLNESS • Persistent low mood (> 2weeks) • Feeling worthless, hopeless, suicidal • Loss of interest in usual activities • anhedonia • Fatigue • Poor concentration • Reduced sleep • Poor appetite Warning Signs

  43. Atypical Pain Conditions • Atypical = poorly understood! • Often regarded as purely “psychogenic”! • But chronic pain will make you depressed! • Other factors may be involved! • There may be a cause? • Patient may just be a poor historian! • Be careful of labels! • Keep an open mind!

  44. “Atypical” Facial Pain Conditions • Persistent idiopathic facial pain • Persistent dento-alveolar pain (atypical odontalgia) • Oral dysaesthesia • Phantom bite syndrome • (TMD) • Syndrome of bizarre oro-facial symptoms

  45. Persistent Idiopathic Facial Pain • Middle aged or older • Mainly female • Constant pain / discomfort • Poorly localised • May cross midline • Does not waken patient from sleep • Lack objective signs • Investigations (-ve) • Other symptoms (headaches,IBS,backache etc.)

  46. Persistent Idiopathic Facial Pain • Demand physical treatment • Often do not accept psychological explanation • May have seen several specialists/practitioners • May be obsessed with symptoms

  47. Psychogenic Toothache • Patient reports that multiple teeth are often painful with frequent change in character and location • A general departure from normal or physiological patterns of pain • Patient presents with chronic pain behaviour • Lack of response to reasonable dental treatment • Unusual or unexpected response to therapy • No other identifiable pain condition that can explain the toothache

  48. Non-Odontogenic ToothachesWarning Symptoms- Summary • Spontaneous multiple toothaches • Inadequate local dental cause for the pain • Stimulating, burning, non-pulsatile toothaches • Constant, unremitting, non-variable toothaches • Persistent, recurrent toothaches • Local anesthetic blocking of the offending tooth does not eliminate the pain • Failure of the toothache to respond to reasonable dental therapy

  49. Chronic Orofacial pain Burning mouth syndrome is characterized as a burning, tender, or annoying sensation in the mouth with no apparent mucosal lesion. Descriptive symptom Late middle age – elderly Female>Male

  50. Burning Mouth Syndrome(glossodynia, glossopyrosis) • Possible causes • Haematinic deficiency • Fe, B12, Folate • Diabetes melitus • Candidosis • Dry mouth • Denture problems • Parafunctional • Psychogenic • Anxiety • Cancerophobia+++ • Depression

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