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PAIN 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 Causes Vascular ◦ ◦ ◦ ◦ Migraine Migrainous Neuralgia Giant cell arteritis Neuralgia induced cavitational osteonecrosis (NICO) Psychogenic ◦ Atypical facial pain ◦ Burning mouth syndrome ◦ TMPD Referred pain 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 Analysis Character ◦ Continuous ◦ Throbbing ◦ Severity Ask the patient to scale it from 0-10 ◦ ◦ ◦ ◦ Dull Lancinating Burning sensation Interference with sleep 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? Analysis Other factors: ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Nausea/vomiting Facial swelling Nasal stuffiness Lacrimation Neurological signs & symptoms Relief by analgesics Weight loss TMJ click Trismus Local Causes Dental Pain Dentinal: Sharp & deep Evoked by external stimulus i.e. hot, cold, sweet, sour, salty foods/drinks Subsides within few seconds Poorly localized 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 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 Periodontal More localized than pulpal pain Less severe Associated with tenderness/pressure Usually not aggravated by heat/cold 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? Other Oral Causes Lateral periodontal abscess Food impaction Cracked tooth Pericoronitis ANUG Mucosal Other oro-facial pains Jaws Acute infections Malignancies Paget’s disease Direct trauma Cysts Retianed roots Infected impactions Radiation therapy osteo-radio necrosis osteomyelitis Other oro-facial pains TMJ Dysfunction Acute inflammation Trauma Malignancies Muscular Pain is usually Dull Poorly localized Radiates Intensified by movement of mandible 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 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 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.) Vascular causes Migraine Migrainous neuralgia Giant Cell Arteritis Neuralgia Induced Cavitational Osteonecrosis Oro facial pain Neuralgias 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 Trigeminal Neuralgia Types ◦ Classical ◦ Symptomatic ◦ Idiopathic 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 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 Trigeminal Neuralgia Trigeminal Neuralgia 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 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 Trigeminal Neuralgia 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 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 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 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 Monitoring B.P: first 3 months..then 6 monthly Blood tests: ◦ Electrolytes (for hyponatraemia) ◦ LFTs ◦ RBC, WBC & Platelet counts Surgical intervention Peripheral surgery ◦ Local cryosurgery ◦ Injections of glycerol or streptomycin around mandibular or infra-orbital foramen ◦ Peripheral neurectomy ◦ Radiofrequency thermocoagulation Surgical intervention Central neurosurgery ◦ Micro-vascular decompression ◦ Gasserian ganglion operations Injections around trigeminal ganglion Radiofrequency thermocoagulation ganglionolysis Gamma knife Trigeminal ganglion microcompression using Fogarty ballon catheter ◦ Posterior cranial fossa procedures Surgical intervention Surgical intervention Differential Diagnosis Glossopharyngeal neuralgia Giant cell arteritis Cluster Headache Intracranial tumour Post-herpetic neuralgia Multiple sclerosis Migrain Dental pain TMPDS Glossopharyngeal Neuralgia Glossopharyngeal Neuralgia A pain syndrome characterized by unilateral, sharp pain along the sensory distribution of ninth cranial nerve (glossopharyngeal n.) 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 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 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) Glossopharyngeal Neuralgia Etiology Two types Without discernable cause idiopathic or essential GPN With underlying pathology secondary GPN 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 Glossopharyngeal Neuralgia Secondary GPN Neoplasms Vascular malformations Infections Demyelination Trauma Elongated styloid process (eagle’s syndrome) Other causes Eagle’s syndrome A painful condition first described in 1937 caused by elongated styloid process Pain in Eagle’s syndrome resembles that of GPN Pain is more constant & dull Two types ◦ Classic ◦ Carotid artery syndrome Eagle’s syndrome Classic Spasmatic, nagging pain Seen in patients with elongated styloid process (> 3-3.5cm) or ossification of stylohyoid ligament Sometimes seen in tonsillectomized patients Eagle’s syndrome Carotid artery syndrome Pain of pharyngeal distribution Becomes prominent on head turning Not related to previous surgery Caused by pressure exerted by elongated styloid process on carotid artery when the head is turned Glossopharyngeal Neuralgia Association with syncope & hypotention GPN is known to be associated with cardiac syncope, arrhythmias (bradycardia) & hypotension Cardiovascular abnormality is seen during the pain attack or immediately following it Glossopharyngeal Neuralgia Association with syncope & hypotention Two theories 1. Intense neuralgic pain activates glossopharyngeal-vagal reflex arc 2. Direct inhibition of vasomotor center peripheral vasodilation hypotention Management Carbamazepine is the drug of choice May partially effective in some patients May cause drowsiness, dizziness or itching May develop gradual tolerance with persistent high dose necessitating surgical intervention Management Other medications ◦ ◦ ◦ ◦ ◦ Baclofen Ketamine Various analgensics Lamotrigine Local anaesthesia blocks for therapeutic & diagnostic purpose Infilteration of pharyngeal area Glossopharyngeal nerve block at jugular foramen Or local application of cocaine to throat Management Injection of neurolytic substances such as phenol in glycerine 21 guage needle 0.5cm lateral to margin of anterior pillar at its lower end 0.7ml of 5% solution of phenol in glycerine Lateral margin of tongue near anterior pillar directed to its base Management Percutaneous rhizotomy Extracranial neurotomy/neurectomy Intracranial rhizotomy Microvascular decompression Atypical Facial Pain Atypical Facial Pain Constant chronic oro-facial pain defined as a “facial pain not fulfilling other criteria” Falls under the category of Medically Unexplained Symptoms (MUS) Atypical Facial Pain Characteristics Constant chronic orofacial discomfort/pain Dull, boring or burning type Ill-defined location Total lack of objective signs All investigations negative No cause detected Poor response to treatment Atypical Facial Pain 1-2% of population suffers from it Middle aged – older adults > 70% women There may be history of adverse life events, family illness, dental or oral procedures Aetiology & Pathogenesis Positron Emission Tomography in patients with AFP shows enhanced cerebral activity enhanced alerting mechanism in response to peripheral stimuli release of neuropeptides production of free radicals cell damage release of prostaglandins pain Atypical Facial Pain – C/F Cheek, nose, upper lip or sometimes lower jaw Location of pain is unrelated to anatomical distribution of trigeminal nerve May last for hours days or weeks Poorly localized May cross the midline, change its location, usually bilateral Does NOT awaken the patient from sleep Deep, dull, boring/burning sensation, may cause lacrimation & watering of nose Atypical Facial Pain – C/F May have other related problems such as ◦ ◦ ◦ ◦ ◦ ◦ Dry mouth Bad taste Headaches Chronic back pain Irritable bowl syndrome Dysmenorrhoea History of multiple consultations & attempts at treatment Pain accompanied by altered behaviour, anxiety, depression & hypochondriasis Atypical Facial Pain Examination No erythema, tenderness or swelling No odontogenic or other cause of pain Lack of objective physical signs All investigations are negative Dx Diagnosis is clinical Careful examination of oral, perioral structures, all radiographs to rule out othe causes Management Cognitive behaviour therapy (CBT) Specialist referral for psychogenic treatment Burning mouth syndrome Burning mouth syndrome Also known as glossopyrosis, glossodynia or stomatodynia Is defined as a burning sensation in the absence of identifieable organic etiology Also comes under MUS Burning mouth syndrome 5 persons/100,000 Middle aged-older adults Female predilection No precipitating cause detected in 50% patients In 20% cases, psychogenic cause can be identified In others it follow: ◦ Dental intervention ◦ Upper respiratory tract infection ◦ Drugs such as ACE or protease inhibitors Burning mouth syndrome Diagnosis depends on exclusion of other causes of burning sensation ◦ ◦ ◦ ◦ ◦ ◦ Erythema migrans Lichen planus Dry mouth Candidiasis Glossitis following nutritional deficiency Diabetes Burning mouth syndrome Exclusion of organic causes such as ◦ Haematological deficiency (iron, folic acid, vit B) ◦ Restricted tongue space due to denture ◦ Para-function such as bruxism, tongue thrusting ◦ Neuropathy ◦ Thyroid dysfunction ◦ Drugs Burning mouth syndrome – C/F Mostly affects tongue May affect palate, lips or lower alveolus Burning sensation is chronic, bilateral Often relieved by eating/drinking May accompany ◦ ◦ ◦ ◦ ◦ ◦ ◦ Dry mouth Altered taste Thirst Headaches Chronic back pain Irritable bowl syndrome dysmenorrhoea Burning mouth syndrome Diagnosis Examination to rule out other causes All investigations are negative Management Avoid anything that aggravates symptoms Avoid active dental or surgical treatment Cognitive behavioural therapy & referral to specialist
