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atypical facial pain
SYMPTOMS •
Facial pain, often described as burning,
aching or cramping, pulling, occurs on one
side of the face, often in the region of the
trigeminal nerve and can extend into the
upper neck or back of the scalp. Although
rarely as severe as trigeminal neuralgia,
facial pain is continuous for ATFP patients,
with few, if any periods of remission.
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DIAGNOSIS
Diagnosing atypical facial pain is not an easy task. It's
not unusual for ATFP patients to have undergone
numerous dental procedures, seen multiple doctors and
undergone many medical tests before being successfully
diagnosed and treated. A diagnosis of ATFP is usually a
process of elimination. When a patient complains of
constant facial pain restricted to one side of the face, the
physician must first rule out any other conditions. Tests
include roentgenograms of the skull, MRI and/ or CT
scan with particular attention to the skull base, careful
dental and otolaryngolgic evaluation, and thorough
neurological examination. Only after tests rule out other
factors can a diagnosis of ATFP be made.
TREATMENTS •
Treatment of ATFP can be difficult and perplexing for both doctor
and patient. Medication is usually the first course of treatment.
Surgical procedures such as microvascular decompression
generally are not successful with ATFP patients.
The following drugs are used to treat atypical facial pain: •
Amitriptyline. (Triptyl, Elavil) •
Gabapentin. (Neurontin). •
Pamelor •
Capsaicin •
Other pain relief strategies include: •
Hot and cold compresses •
Acupuncture •
Atypical odontalgia
Atypical odontalgia describes atypical facial pain •
in apparently normal teeth. Unfortunately,
dentists usually consider this diagnosis only after
the failure of invasive treatment. Atypical
odontalgia patients are typified by women in
their mid-40s who complain of persistent pain in
one or more premolar or molar teeth. They
associate pain with dental procedures or trauma
to the region, While the cause of atypical
odontalgia is uncertain.
Patients with unrelenting pain in the teeth, •
gingival, palatal or alveolar tissues often see
multiple dentists and have multiple irreversible
procedures performed and still have their pain.
Up to one-third of patients attending a chronic
facial pain clinic have undergone prior
irreversible dental procedures for their pain
without success. In these cases, if no local
source of infectious, inflammatory, or other
pathology can be found, then the differential
diagnosis must include a focal neuropathic pain
disorder.
The common diagnoses given include the terms atypical odontalgia,
persistent orodental pain, or if teeth have been extracted, phantom
tooth pain. One possibility is that these pain complaints are due to a
neuropathic alteration of the trigeminal nerve. There are several
diagnostic procedures that need to be performed in any patient
suspected of having a trigeminal neuropathic disorder including (1)
cold testing of involved teeth for pulpal nonvitality; (2) a periapical
radiograph examining the teeth for apical change; (3) a panoramic
radiograph examining for other maxillofacial disease; (4) a thorough
head and neck examination also looking for abnormality; (5) a
cranial nerve examination including anesthetic testing which
documents any increased or decreased trigeminal nerve sensitivity
and rules out other neurologic changes outside the trigeminal nerve;
and (6) MRI imaging in some cases
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Finally, when a nonobvious atypical toothache first •
presents, direct microscopic examination of the tooth for
incomplete tooth fracture is also suggested. The majority
of these patients are women over the age 30 with pain in
the posterior teeth/alveolar arch. Multiple causes exist
for sustained neuropathic pain including direct nerve
injury (e.g., associated with fracture or surgical
treatment), nerve injection injury, nerve compression
injury (e.g., implant, osseous growth, neoplastic
invasion) and infection-inflammation damage to the
nerve itself. Sustained nerve pain is commonly seen in
patients with psychiatric impairment. It may be that the
unrelenting nature of the pain itself alters the patient's
personality.
Treatment includes pharmacologic •
medications which suppress nerve activity.
The common medications used for
atypical odontalgia and phantom tooth
pain include gabapentin, tricyclics, topical
anesthetics, and opioids.. With earlier
treatment, better pain control and this
should also prevent secondary psychiatric
disease from developing and lower the
number of inappropriate treatments
What is Atypical Odontalgia?
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Atypical Odontalgia (AO) is a condition in which a tooth is
very painful but nothing can be found wrong with the tooth.
The pain is continuous, usually burning, aching and
sometimes throbbing and most often occurs in upper
premolars (bicuspids) or molars.
Since symptoms are very similar to those caused by a
"toothache", often numerous dental procedures are done.
To complicate matters, these treatments (such as pulp
extirpation, root-tip surgery or tooth extraction) may offer
temporary relief from pain, only to have the pain return.
What are the Signs & Symptoms of
Atypical Odontalgia?
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The typical clinical presentation of AO involves pain in a tooth
in the absence of any sign of pathology; the pain may spread
to areas of the face, neck, and shoulder.
Symptoms include a continuous burning, aching pain in a
tooth or in the bone / gum surrounding a tooth.
Often there in increased sensitivity to pressure over the
painful region. Often nothing shows up on diagnostic tests,
no abnormalities are found on X-rays and no obvious cause
for the “tooth pain” can be found.
Patients often have difficulty localising the pain.
All ages can be affected except for children. AO seems to
be more common in women in their mid 30 - 40’s.
Diagnosis is based primarily on symptoms and on elimination
of other possible disorders. Tests may include diagnostic
dental X-rays, CT scans and possibly MRI scans. If a nerve
block does not result in pain reduction then a diagnosis of AO should be considered
How is it treated?
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Medications such as painkillers and sedatives are not
effective in AO. Surgery and other dental interventions rarely
provide relief.
Anti-depressants medications can reduce AO pain which is
probably due to their analgesic effects (Anti-depressants
have the ability to produce low-grade pain relief at lower
strengths) and not to their anti-depressant effects. AO
patients are generally not depressed.
Topical application of capsaicin to painful tissue has also been
investigated as a treatment for AO.
The outcome is usually fair, with many patients obtaining
complete relief from pain.
Especially in the absence of overt pathology, particular
attention should be paid to avoiding any unnecessary and
potentially dangerous dental intervention on the teeth.
AO is surprisingly common, of uncertain origin and potentially
treatable.
Dysgeusia
Dysgeusia is the medical term for an altered, •
distorted or reduced ability to taste.
Specific types of taste disorders include •
hypogeusia (a reduced ability to taste) and
ageusia (an inability to detect taste). A persistent
bad taste in the mouth (parageusia) is
sometimes used interchangeably with
dysgeusia.So Distortion may include sensing a
taste that is not present in the mouth, or
misidentifying a taste (e.g., pleasant-tasting
foods now taste awful).
The sense of taste begins in the mouth. A •
person is born with approximately 10,000
taste buds, most of which are located on
or around the papillae of the tongue. Taste
buds are also located on the soft palate,
pharynx , larynx , epiglottis and the first
part of the esophagus
Each taste bud contains anywhere from 50 to •
100 taste cells. Each of these cells responds
best to one of five basic taste sensations:
Sweet (e.g., sugar) •
Sour (e.g., lemon juice) •
Salty •
Bitter (e.g., aspirin) •
Umami (sometimes spelled umame) or •
“savory”
When stimulated, a taste cell sends a nerve impulse to •
the brain, where a certain taste is identified and sensed.
New taste cells are constantly being produced by the
body, replacing existing taste cells every 10 days
throughout a person’s life. Thus, if taste cells are
destroyed by burning the mouth with a hot liquid, any
consequent taste disorder is usually temporary, until new
taste cells are produced .For complex tastes, the sense
of smell is required. Many taste disorders are actually
associated with an impaired sense of smell (dysosmia) ,
which can occur due to colds or other upper respiratory
infections. Often, people do not discover they have a
smell disorder until they notice a problem with taste.
More than 200,000 people seek help for a taste •
or smell disorder every year, according to the
National Institutes of Health. The actual
incidence of these disorders is estimated to be in
the millions because a large number of people
do not seek help for the condition. Taste
disorders can affect a person’s quality of life. It
can lead to a decreased appetite, poor nutrition
and the inability to identify potentially harmful
foods or beverages
Taste disorders can have many different causes. Various •
illnesses (e.g., colds, sore throat), lifestyle habits (e.g.,
smoking), irritants (e.g., insecticides, certain prescription
mouthwash) and other factors (e.g., medications) can
contribute to dysgeusia.
Patients are urged to contact their physician or dentist if •
they have a taste disorder that lasts two weeks or longer.
A thorough medical history may be taken, including
questions about symptoms, current medications and
medical conditions, recent illnesses, and whether the
patient’s sense of smell is affected.
. Tests that measure the extent of a person’s sense of •
taste or smell may be performed. If no underlying
medical or dental condition is identified, the patient may
be referred to a facility that specializes in taste and smell
disorders. The physician, dentist or other healthcare
provider will attempt to identify the underlying cause of a
patient’s dysgeusia. How symptoms of dysgeusia begin
can help indicate the underlying cause. For instance, a
sudden loss of taste may be due to trauma or a
severe upper respiratory infection. For dysgeusia
that occurs off and on, an allergy or exposure to
chemicals may be the cause.
Treatment of dysgeusia depends on its cause. Typically, •
treating the underlying condition will also eliminate the
patient’s dysgeusia. The prognosis for patients is
generally excellent when the cause of dysgeusia can be
identified and treated. However, long-term recovery is
more complicated when the source of dysgeusia cannot
be identified or when dysgeusia results from an
untreatable condition. For the most part, dysgeusia
cannot be prevented. However, quitting smoking,
practicing good oral hygiene, having regular dental
examinations and treating sinus problems all can
contribute to reducing the likelihood of dysgeusia.
SALIVARY GLAND ANATOMY AND
PHYSIOLOGY
There are three major salivary glands: parotid, submandibular,
and sublingual. These are paired glands that secrete a highly
modified saliva through a branching duct system. Parotid
saliva is released through Stenson’s duct, the orifice of which
is visible on the buccal mucosa adjacent to the maxillary first
molars. Sublingual saliva may enter the floor of the mouth via
a series of short independent ducts, but will empty into the
submandibular (Wharton’s) duct about half of the time. The
orifice of Wharton’s duct is located sublingually on either side
of the lingual frenum. There are also thousands of minor salivary
glands throughout the mouth, most of which are named
for their anatomic location (labial, palatal, buccal, etc). These
minor glands are located just below the mucosal surface and
communicate with the oral cavity with short ducts.
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Saliva is the product of the major and minor salivary glands •
dispersed throughout the oral cavity. It is a highly complex mixture of
water and organic and non-organic components.. The three major
salivary glands share a basic anatomic structure. they are
composed of acinar and ductal cells arranged much like
cluster of grapes on stems. The acinar cells make up the secretory •
end piece. those of the parotid gland are serous, those of the
sublingual gland are mucous, and those of the submandibular gland
are of a mixed mucous and serous type. The duct cells (the “stems”)
form a branching system that carries the saliva from the acini into
the oral cavity. The duct cell morphology changes as it progresses
from the acinar junction toward the mouth •
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proteins are produced and transported into the •
saliva through both acinar and ductal cells. The
primary saliva within the acinar endpiece is
isotonic with serum but undergoes extensive
modification within the duct system, with •
resorption of sodium and chloride and secretion
of potassium. The saliva, as it enters the oral
cavity, is a protein-rich hypotonic fluid. The
secretion of saliva is controlled by sympathetic
and parasympathetic neural input.
xerostomia
called "dry mouth," among patients who •
take medications, have certain connective
tissue or immunological disorders or have
been treated with radiation therapy. When
xerostomia is the result of a reduction in
salivary flow, significant oral complications
can occur.
Xerostomia often develops when the amount of saliva •
that bathes the oral mucous membranes is reduced.
However, symptoms may occur without a measurable
reduction in salivary gland output. The most frequently
reported cause of xerostomia is the use of xerostomic
medications. A number of commonly prescribed drugs
with a variety of pharmacological activities have been
found to produce xerostomia as a side effect.
Additionally, xerostomia often is associated with
Sjögren’s syndrome, a condition that involves dry mouth
and dry eyes and that may be accompanied by
rheumatoid arthritis or a related connective tissue
disease. Xerostomia also is a frequent complication of
radiation therapy.
Xerostomia is an uncomfortable condition •
and a common oral complaint for which
patients may seek relief from dental
practitioners. Complications of xerostomia
include dental caries, candidiasis or
difficulty with the use of dentures. The
clinician needs to identify the possible
cause(s) and provide the patient with
appropriate treatment
Xerostomia is defined as a subjective complaint •
of dry mouth that may result from a decrease in
the production of saliva. Xerostomia is estimated
to affect millions of people in the United States.
Studies have found the condition in 17 to 29
percent of sampled populations based on selfreports or measurements of salivary flow rates.
Complaints of dry mouth generally are more
prevalent in women
its diminution or absence can cause significant •
morbidity and a reduction in a patient’s
perceptions of quality of life. The primary
constituents of saliva are water, proteins and
electrolytes. These components enhance taste,
speech and swallowing and facilitate irrigation,
lubrication and protection of the mucous
membranes in the upper digestive tract
Additional physiological functions of saliva
provide antimicrobial and buffering activities that
protect the teeth from dental caries.
.Patients initially may be unaware that a •
reduction in salivary flow is occurring
unless some of its complications, such as
an increase in cervical dental caries,
becomes apparent. Only after the
development of symptoms—which may
include soreness, burning or difficulty with
swallowing—is the patient likely to seek
relief from the practitioner
physiopathology
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Saliva is produced by the parotid, submandibular and sublingual
glands, as well as by hundreds of minor salivary glands that are
distributed throughout the mouth. Daily salivary output is estimated
to be approximately one liter per day, Salivary flow is categorized as
unstimulated, or resting, and stimulated, as occurs when an
exogenous factor is acting on the secretory mechanisms
Both the parasympathetic and sympathetic nervous systems
innervate the salivary glands. Parasympathetic stimulation induces
more watery secretions, whereas the sympathetic system produces
more viscous flow. Therefore, a sensation of dryness may occur, for
example, during episodes of acute anxiety or stress, which cause
changes in salivary composition owing to predominant sympathetic
stimulation during such periods.
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causes
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Medications. Xerostomia is a common and significant side effect of
many commonly prescribed drugs.. Nevertheless, the risk for
xerostomia increases with the number of drugs being taken. Older
people, therefore, are more likely to be affected. In the geriatric
population, drug-induced xerostomia has been reported to contribute
to difficulty with chewing and swallowing; this may result in
avoidance of certain foods.
A variety of drugs that have a wide range of therapeutic activities •
have been reported to cause xerostomia in 10 percent or more of
patients. Drug-induced hyposalivation also can be an extension of
the drug’s intended action, as seen with the parasympatholytic
agents (such as atropine), or as an anticholinergic side effect with
drugs such as tricyclic antidepressants.
Sjögren’s syndrome. When xerostomia is associated •
with xerophthalmia, also known as "dry eyes," it may
represent a chronic autoimmune condition that is
recognized as Sjögren’s syndrome, which affects
predominantly women after the fourth decade of life. In
primary Sjögren’s syndrome, the disease is limited to the
eyes and salivary glands. With secondary Sjögren’s
syndrome, patients also have an autoimmune or
connective tissue disease .It is estimated that 15 percent
of patients with rheumatoid arthritis, 25 percent of those
with systemic sclerosis and 30 percent of those with
systemic lupus erythematosus may develop Sjögren’s
syndrome.
The xerostomia that is associated with primary •
and secondary Sjögren’s syndrome has been
attributed to the progressive lymphocytic
infiltration that gradually destroys the secretory
acini of the major and minor salivary glands.
Another explanation for the loss of glandular
function may be related to an inhibition of nerve
stimuli of the glands. It has been suggested that
the reduction in secretions first may affect the
minor salivary glands, which can initiate the
symptoms of xerostomia.
Radiation therapy. Radiation therapy of •
the head and neck regions is employed as
a primary, concomitant or adjuvant
treatment modality for primary and
recurrent tumors in the upper
aerodigestive tract.. Ionizing radiation can
injure the major and minor salivary glands;
this can lead to atrophy of the secretory
components and result in varying degrees
of temporary or permanent xerostomia
Other conditions. Diseases with immunological abnormalities other •
than autoimmunity may be accompanied by Sjögren’s-like
manifestations or xerostomia .Infection with HIV has been
associated with arthritis, parotid gland enlargement and xerostomia.
Xerostomia has been reported in 45 to 60 percent of patients who
did allogenic bone marrow transplantation. Loss of saliva and a
number of immunological abnormalities also have been implicated
as possible complications of silicone breast implants.
Patients undergoing hemodialysis for end-stage renal disease have •
developed dry mouth and reduced salivary gland function, but these
manifestations may be attributed in part to medications being used
to treat coexisting conditions. Anxiety, depression or stress also may
give rise to subjective symptoms of dry mouth.Patients with diabetes
mellitus, particularly those who have poor glycemic control, are more
likely to complain of xerostomia and may have decreased salivary
flow.
Clinical manifestation
A reduction of saliva may lead to complaints of a dry mouth, oral •
burning or soreness or a sensation of a loss of or altered taste.
Another manifestation may be an increased need to sip or drink
water when swallowing, difficulty with swallowing dry foods. Patients
who develop Sjögren’s syndrome secondary to a connective tissue
disease also may complain of having dry eyes, and progressive
parotid gland enlargement may become evident. These initial
manifestations may precede clinically apparent alterations of
the oral mucosa or any measurable reduction in salivary gland
function. As the xerostomia progresses, inspection of the oral cavity
may disclose an erythematous, cobblestoned or fissured tongue and
atrophy of the filiform papillae. Palpation of the oral mucosa may
result in the finger’s adhering to the mucosal surfaces instead of
readily sliding over the tissues. Application of a dry cotton swab at
the parotid and sub-mandibular duct orifices followed by external
palpation of the glands may reveal delayed or inapparent salivary
flow from the ducts.
Dental-related findings include evidence of an •
increased tendency to develop cervical caries
and denture discomfort accompanied by loss of
retention.
Lack of saliva increases susceptibility to •
infection of the oral cavity and oropharynx by the
opportunistic fungus Candida albicans, or
thrush. Manifestations of oral infection with
Candida include erythema of the oral mucosa;
white, and inflamed fissures at the corners of the
mouth, a condition called cheilitis
diagnosis
An affirmative response to at least one of •
the five following questions about
symptoms has been shown to correlate
with a decrease in saliva: "Does your
mouth usually feel dry? Does your mouth
feel dry when eating a meal? Do you have
difficulty swallowing dry foods? Do you sip
liquids to aid in swallowing dry foods? Is
the amount of saliva in your mouth too
little most of the time, or don’t you notice it
A number of supplemental tests are available that can be •
used to confirm the subjective manifestations of
xerostomia. Salivary output can be measured, and a
collected amount of less than 0.12 to 0.16 milliliters per
minute (unstimulated) has been suggested to be the
criterion for hypofunction. Imaging modalities, including
sialography and scintigraphy, also have been used to
examine salivary gland function.
Criteria for the clinical, laboratory and histopathologic •
manifestations that are consistent with a diagnosis of
Sjögren’s syndrome recently were revised
MANAGEMENT
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The general approach to treating patients with hyposalivation and
xerostomia is directed at palliative treatment for the relief of
symptoms and prevention of oral complications.
If the patient’s xerostomia is caused by the side effect of a drug, the •
dentist can recommend an alternative medication, but this course
may not be beneficial if the alternate drug has a mode of action
similar to that of the original drug. Modification of the dosage
regimen is another strategy that may increase salivary flow. The
practice of carrying and sipping bottled water throughout the day,
which has become popular, also may offer relief for affected
patients. When at home, the patient can hold ice chips in his or her
mouth to provide moisture and possibly alleviate symptoms.
A number of products that can function as saliva •
substitutes have been developed specifically for
patients with xerostomia. Available in a variety of
formulations—including rinses, aerosols,
chewing gum and dentifrices these products
also may promote salivary gland secretions.
incorporation of metal in the palate of the •
maxillary denture have been shown to be
beneficial treatment options for some patients.
MANAGEMENT OF HYPOSALIVATION AND XEROSTOMIA.
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The use of parasympathomimetic drugs such as pilocarpine
hydrochloride can stimulate salivary gland secretions and has been
shown to be effective for patients with Sjögren’s syndrome and for
those who have had irradiation therapy or bone marrow
transplantation. or cholinergic agent: cevimeline hydrochloride,
recently was approved for use in patients with Sjögren’s syndrome.
Patients using parasympathomimetic drugs, however, may
experience a number of unpleasant side effects that may limit the
efficacy of these medications.
When conventional medical interventions do not provide satisfactory •
relief, or for patients with xerostomia who prefer alternative medical
therapies, acupuncture may be beneficial.
Patients who develop candidiasis secondary to xerostomia can be •
treated with oral or systemic antifungal drugs. Increasing oral
moisture also may reduce the prevalence of this opportunistic
infection.
A number of therapeutic interventions are available for the control
and prevention of dental caries. These primarily consist of rigorous
attention to personal oral hygiene, strict adherence to a non
cariogenic diet, placement of sealants and the application of topical
fluorides. The latter may be useful if an increased incidence of
coronal caries, root caries or both becomes apparent, even when
fluoridated community water is available. This strategy may be
effective for both prevention of caries and possible reversal of
decalcification. Supplements that contain sodium fluoride, or sodium
monofluorophosphate are available for professional application as
well as for home use. These products can be applied in a variety of
vehicles, including gels, rinses, lozenges and chewable tablets.
Interest now is focused on the use of varnishes that provide
prolonged exposure to fluoride. This approach may prove to be
useful for the prevention of caries associated with xerostomia.
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Fluorides also are used for the management of dental •
caries in patients whose xerostomia has resulted from
radiation therapy to the head and neck.
Patients with complete dentures who experience •
xerostomia are more likely to develop other
complications, including pain from denture irritation and
loss of retention. The greater risk of developing
candidiasis in edentulous patients may contribute to their
discomfort. Soft denture liners or incorporation of metal
in the palate of the maxillary denture have been shown
to be beneficial treatment options for some patients
conclusion
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Xerostomia is a condition of dry mouth that is experienced by many
patients. The prevalence of this complaint and its negative effect on
the patient’s quality of life make it likely that the practitioner will
encounter this condition on a regular basis. Xerostomia results from
the loss of saliva that may develop as a side effect from the use of
medications, as a manifestation of Sjögren’s syndrome secondary to
a number of connective tissue diseases or as a complication of
radiation therapy. Treatment is primarily palliative, with emphasis on
the use of saliva substitutes. Some patients may benefit from
pharmacological stimulation of the salivary glands. The predominant
complications that result from reduced saliva are dental caries,
which requires comprehensive dental management and candidiasis,
which can be treated with antifungal agents