Transcript ภาพนิ่ง 1 - Chiang Mai University

Orofacial Pain
• A relatively common symptom.
• Sources of orofacial pain include caries, periodontitis,
neuropathic, and musculoskeletal conditions.
• Symptoms of pain may represent different phases of acute
or chronic conditions.
• Based on NHIS data from 1989, survey participants
representing 39 million adults reported experiencing at least
one of five orofacial pain symptoms in the past 6 months:
– tooth pain,
– mouth sores,
– jaw joint pain,
– facial pain,
– burning mouth
(Lipton et al., 1993).
http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf
• Orofacial pain is often divided into two categories.chronic
and acute.
• The National Center for Health Statistics generally uses a
cut off point of 3 months to distinguish between acute and
chronic pain.
• Currently, there are no national data on orofacial pain for
children.
• Data sources other than the 1989 NHIS include studies on a
population of elderly adults (65+) living in 10 northern
Florida counties (Riley et al., 1998); studies of adults 45
and older, also located in northern Florida (Gilbert et al.,
1997); a survey of adults in Toronto (Locker & Grushka,
1987); and studies on temporomandibular joint disorder, or
TMD, reviewed by LeResche (1997).
http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf
What types of orofacial pain
do we see?
• Community
– Macfarlane et al 2004 – n = 125 total 1510
Dental
ML/ soft tissue
Neuro/vasc
33%
39%
28%
Prevalence orofacial pain no TMJ
Sample, Author
Sample
Type of pain
Prevalence
%
7
UK Aggarwal 2005
2299 Chronic facial
pain
UK, Macfarlane 2002
2504 Facial pain
26
45711 Facial pain
1.4
USA, Lipton 1993
Canada, Locker 1987
UK, Richards 1996
France, Munoz 1988
1014 Orofacial pain
4.9
997 Orofacial pain
3.1
1144 Head , face
2.7
Prevalence TMJ pain in adults
Sample
authors
Finland
Helkino 1974
USA
Von Korff 1988
USA
Lipton 1993
Japan
Matuska 1996
Size of
sample
Type of pain Prevalence
ranges %
600
Face and
jaw pain
12-15
1016
Muscle and
joint pain
42370
Jaw pain
3.9-6.5
672
TMJ, face
pain
5.7-15.2
12
Prevalence of selected pain conditions by poverty
status: US adults, 18 years and over
40
Percentage
30
20
10
0
Migraine
Neck Pain
Poor
Back Pain
Near Poor
Face/Jaw Pain
Not Poor
Adjusted for age
SOURCE: Lethbridge-Cejku M, Rose D, Vickerie J. Summary health statistics for US Adults: National Health
Interview Survey, 2004. National Center for Health Statistics.Vital Health Stat 10 (228). Hyattsville, MD 2006
Chronic Orofacial pain
• The cost of chronic pain is estimated to be about
$80 billion per year, 40% associated with orofacial
pain (Israel & Scrivani, 2000; Friction &
Schiffman, 1995).
• The two most prevalent sources of chronic
orofacial pain are temporomandibular joint
disorder (TMD) and burning mouth syndrome.
http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf
Chronic Orofacial pain
• TMD consists of jaw joint pain and dull facial pain
in the temporomandibular joint and the muscles of
mastication. Chronic TMD is estimated to affect
from 3% to 12% of the U.S. population (Klausner,
1995).
• Burning mouth syndrome is characterized as a
burning, tender, or annoying sensation in the
mouth with no apparent mucosal lesion.
• In 1989, the prevalence of jaw joint pain, burning
mouth, and dull facial pain in the U.S. population
was 5.3%, 0.7%, and 1.5%, respectively.
http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf
http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf
http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf
Acute orofacial pain
• Acute orofacial pain includes tooth pain and
painful sores or irritations of the mouth.
• Tooth pain is often caused by dental caries but
may also be due to periodontal disease.
• Tooth pain can interfere with work and social
activities, promote anxiety, and result in economic
costs.
Acute orofacial pain
• Data from the 1989 NHIS Orofacial Pain
Supplement indicate that the overall prevalence of
tooth pain and of mouth sores in the United States
was 13.6% and 8.4%, respectively.
• The prevalence of tooth pain was higher among
adults 20 to 64 years of age than among those 65
and older, those with lower education, poorer
people, and those who visited a dentist within the
past 12 months. (Vargas et al. 2000 and Lipton et al. 1993)
http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf
http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf
http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf
OROFACIAL PAIN
in
CANADA
Prevalence of orofacial pain in a sample of
adults in the USA during a 6-month period
(Lipton 1993)
Female
Male
14
12
10
8
6
4
2
0
toothache oral sores
jaw pain face/cheek
burning
mouth
Percentage of oral facial pain among adults in
USA and Canada (Goulet et al., 1995; Lipton et
al., 1993; & Ripley et al., 2001)
Female
Male
20
15
14
10
9.6
8.8
6.2
5
4
4.4
0
Quebec
USA
USA
Proportion of subjects with no, mild, moderate
and severe jaw pain reporting sleep problems,
difficulty in opening and joint clicking in
Quebec (Goulet et al., 1995)
Difficulty in opening
Joint clicking
Sleep porblems
70
59
60
50
32
40
30
13
20
10
1
4
24
20
14
27
31
16
7
0
None
Mild
Moderate
Severe
OROFACIAL PAIN
in
Other studies
Pain
“The subject’s conscious perception of modulated
nociceptive impulses that generate an unpleasant
sensory and emotional experience associated with
actual or potential tissue damage, or described in
terms of such damage”
(IASP definition, 1994)
History and Description of Pain
• Compliant
• Pain intensity
• Site of pain
• Quality of pain
• What starts the
pain
• When pain was first
noted
• Duration of attack
• When pain occurs
History Examination
of
Orofacial Pain
History Ex. of Orofacial Pain
1. Chief complaints
A. Location of pain
B. Onset of pain
– Association with other
factors
– Progression
C. Characteristics of pain
– Quality of pain
– Behaviour of pain
– Temporal
– Frequency
– Duration
– Intensity
– Concomitant symptoms
– Flow of pain
History Ex. of Orofacial Pain
1. Chief complaints (cont.)
D. Aggravating and
alleviating factors
– Physical modalities
– Function and
parafunction
– Sleep disturbances
– Medications
– Emotional stress
E. Past consultation
and/or treatment
F. Relationship to other
complaints
2. Past medical history
3. Review of systems
4. Psychological assessment
Clinical Examination
of
Orofacial Pain
Clinical Examination
1. General examination
E. Cervical evaluation
A. Vital signs
F. Balance and coordination
– Blood pressure
2. Muscle examination
– Pulse rate
A. Pulpation
– Respiratory rate
– Pain and tenderness
– Temperature
– Trigger points and
B. Cranial nerve evaluation
pain referal
C. Eye evaluation
D. Ear evaluation
Clinical Examination
3. Masticatory evaluation
C. Oral structures
A. Range of mandibular
– Mucogingival tissues
movement
– Teeth
– Measurement
– Periodontium
– Pain
– Occlusion
B. Temoromandibular joint 4. Other diagnostic tests
evaluation
A. Imaging
– Pain
B. Laboratory tests
– Dysfunction
C. Psychologic provocation
tests
The Erlanger/Gasser classification of
nerve fibres (1939)
Avg. 
(m)
Avg. C.V.
(m/s)
A Primary muscle-spindle afferent, motor
to skeletal muscles
15
70-120
A Cutaneous touch and pressure afferents
8
30-70
A
5
15-30
A Cultaneous temperature and pain
afferents
<3
12-30
B
Sympathetic pre-ganglionic
3
3-15
C
Cutaneous pain afferents, sympathetic
post-ganglionic(unmyelinated)
1.0
0.5-2
Type
Function
Motor to muscle spindles
Characteristics of pulpal sensory
fibres (Trowbridge and Kim, 1991)
Type Myelination
A
C
Yes
No
Location of
terminal
Pain
characteristics
Stimulation
threshold
Principally in
region of
Sharp, pricking Relatively low
pulp-dentine
junction
Probably
distributed
throughout
pulp
Burning,
aching, less
bearable than
A fibre
sensations
Relatively high,
usually
associated with
tissue injury
Stress
and
Orofacial Pain
ENVIRONMENT
BEHAVIOUR
NERVOUS SYSTEM
HOMEOSTASIS
IMMUNE SYSTEM
ENDOCRINE SYSTEM
BRAIN
IL-1
STRESS
CRH
HIPPOCAMPUS
HYPOTHALAMUS
IMMUNE
CELL
glucocorticoids
ADRENAL
GLAND
ACTH
PITUITARY
glucocorticoids
Signs and Symptoms of Stress
1. Physical Signs and Symptoms
2. Emotional Signs and Symptoms
3. Cognitive/Perceptual Signs and Symptoms
4. Behavioral Signs and Symptoms
1. Physical Signs and Symptoms of Stress
increased heart rate; pounding heart; elevated blood
pressure; sweaty palms; tightness of the chest, neck,
jaw and back muscles; headache; diarrhea;
constipation; urinary hesitancy; trembling, twitching;
1. Physical Signs and Symptoms of Stress
stuttering and other speech difficulties; nausea;
vomiting; sleep disturbances; fatigue; shallow breathing;
dryness of the mouth or throat; susceptibility to minor illness,
cold hands, itching; being easily startled; chronic pain and
dysponesis
2. Emotional Signs and Symptoms of Stress
•
•
•
•
•
irritability, angry outbursts, hostility,
depression, jealously, restlessness, withdrawal,
anxiousness, diminished initiative,
feelings of unreality or overalertness,
reduction of personal involvement with others, lack of
interest, tendency to cry,
2. Emotional Signs and Symptoms of Stress
•
•
•
•
•
•
being critical of others, self-deprecation,
nightmares, impatience,
decreased perception of positive experience opportunities,
narrowed focus, obsessive rumination,
reduced self-esteem, insomnia,
changes in eating habits and weakened positive emotional
response reflexes
3. Cognitive/Perceptual
Signs and Symptoms of Stress
•
•
•
•
•
•
forgetfulness, preoccupation, blocking,
blurred vision, errors in judging distance,
diminished or exaggerated fantasy life, reduced creativity,
lack of concentration, diminished productivity,
lack of attention to detail,
orientation to the past,
3. Cognitive/Perceptual
Signs and Symptoms of Stress
•
•
•
•
•
•
decreased psychomotor reactivity and coordination,
attention deficit, disorganization of thought,
negative self-esteem,
diminished sense of meaning in life,
lack of control/need for too much control,
negative self-statements and negative evaluation of
experiences
4. Behavioral Signs and Symptoms of
Stress
•
•
•
•
•
•
increased smoking,
aggressive behaviors (such as driving),
increased alcohol or drug use,
carelessness,
under-eating, over-eating,
withdrawal, listlessness,
4. Behavioral Signs and Symptoms of
Stress
•
•
•
•
hostility,
accident-proneness,
nervous laughter,
compulsive behavior and impatience
Memory
Sensory Arousal
Psyche
Limbic system
Respiratory control Pituitary gland Sympathetic NS GI system
Adrenal cortex
Immune-Inflam
response
Electrolyte water control
Kidney
Adrenal medulla
Adrenaline
Cardiovascular
system
Metabolism Haemostasis-fibrinolysis
Metabolic and Haemostatic changes
ความเครี ยดกับโรคทางร่ างกาย
• Stress ส่ งผลให้ มีการเพิม่ การหลัง่ ACTH, GH, PRL, betaendorphine, ADH, insulin and glucagon
ACTH --> cortisol --> NE --> E
• Stress stimulate sympathetic nervous system
Cardiac Output, Stroke Volume, systolic Blood Pressure
 blood flow to muscle, skin
 blood glucose
 rate of blood coagulation
Cardiovascular responses
• Increase Heart rate, Cardiac output, Blood pressure, muscle
blood flow
• ผ้ ปู ่ วยทีม่ ีภาวะ hypertension, obesity, high fat diet
Stress --> cortisol or epihephine --> cholesterol --> coronary
artery disease
Arteriosclerosis
Myocardial infarction
Other
Gastrointestinal responses
• อาหารติดคอ, ปวดท้ อง, diarrhea, fullness, nausea หลังอาหาร
increase gastric acid, mobility --> peptic ulcer
• Respiratory responses
Hyperventilation --> hypocapnea
Cerebral vasoconstriction
dizziness, confusion, paraesthesia, tetany
Cooling --> trigger --> asthmatic attack
Immunological responses
• Cortisol
CMI – cancer
HMI – allergy
• Metabolic – haemostatic changes
Lipolysis
Insulin hyperglycemia ระวังใน DM
Glucagon
Adrenaline
ความเครี ยด – โรคทางช่ องปาก
• โรคฟันผุ – โพรงประสาทฟัน – ปลายรากฟัน
Stress decrease saliva flow
วัยร่ ุน – salivary flow + immune ถูกกด
ความกดอากาศ – aerodontalgia
RCT --> stress --> pain from blood pressure
Experimental animal stress --> caries
• โรคปริ ทันต์
NUG = stress
ความเครี ยด – โรคทางช่ องปาก
• Clenching – bruxism –TMD
ฟันสึก, โรคปริ ทันต์ , ฟันแตก, masseter muscle เกร็ ง โต, ปวดหัว
ผ้ ปู ่ วยทีม่ ี TMD = stress ปานกลาง ถึง สูง
• Bad habit
ดูดนิ้ว
กัดแก้ม, กัดปาก, กัดเล็บ --> malocclusion
Tongue thrusting
• Aphthous – herpetic lesion
Experimental animal (stress from noise) --> herpetic lesion
Sign and symptoms of depression
Fatigue
Alcohol-substance abuse
Pessimism (มองโลกแง่ ร้าย)
Headache
Anxiety
Constipation (ท้องผกู )
Phobias
Crying episodes
Irritability
Vertigo
Paresthesias
Muscle aches
Behavioral disturbances
Marital problems
Diarrhea
Excessive perspiration
Hyperventilation
Blurred vision
Dry or flushed skin
Slurred speech
Urinary tract disturbances
Work inhibition, weakness
Thank you