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PAIN
Pain
Common causes of oro-facial pain
 Local disorders
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Teeth & supporting tissues
Jaws
Maxillary antrum
Salivary glands
Pharynx
eyes
Neurological disorders
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TN
Neoplasms involving the Trigeminal nerve
Glossopharyngeal neuralgia
Herpez Zoster
Multiple sclerosis
SUNCT sydrome
Causes

Vascular
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Migraine
Migrainous Neuralgia
Giant cell arteritis
Neuralgia induced cavitational osteonecrosis
(NICO)
Psychogenic
◦ Atypical facial pain
◦ Burning mouth syndrome
◦ TMPD
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Referred pain
Analysis
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Previous History
Location
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Localized
Generalized
Focuses
Diffuse
Duration
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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
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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
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Provoking or relieving factors:
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Temperature  dental pain
Trigger zone  TN
Stress  atypical facial pain
Alcohol  migrainous neuralgia
Biting  periapical pathology
Postural  sinusitis?
Analysis
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Other factors:
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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?
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Other Oral Causes
Lateral periodontal abscess
 Food impaction
 Cracked tooth
 Pericoronitis
 ANUG
 Mucosal
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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.
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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
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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
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Trigeminal Neuralgia
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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
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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
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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
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Trigeminal Neuralgia – C/F
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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
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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
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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
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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
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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:
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◦ Electrolytes (for hyponatraemia)
◦ LFTs
◦ RBC, WBC & Platelet counts
Surgical intervention
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Peripheral surgery
◦ Local cryosurgery
◦ Injections of glycerol or streptomycin around
mandibular or infra-orbital foramen
◦ Peripheral neurectomy
◦ Radiofrequency thermocoagulation
Surgical intervention
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Central neurosurgery
◦ Micro-vascular decompression
◦ Gasserian ganglion operations
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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
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Glossopharyngeal Neuralgia
Glossopharyngeal Neuralgia
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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
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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
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◦ 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
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Management
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Other medications
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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
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Management
Percutaneous rhizotomy
 Extracranial neurotomy/neurectomy
 Intracranial rhizotomy
 Microvascular decompression
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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)
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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
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Aetiology & Pathogenesis
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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
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Atypical Facial Pain – C/F
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May have other related problems such as
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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
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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
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Diagnosis depends on exclusion of other
causes of burning sensation
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Erythema migrans
Lichen planus
Dry mouth
Candidiasis
Glossitis following nutritional deficiency
Diabetes
Burning mouth syndrome
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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
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Mostly affects tongue
May affect palate, lips or lower alveolus
Burning sensation is chronic, bilateral
Often relieved by eating/drinking
May accompany
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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
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