PAIN - Dentistry32
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Transcript PAIN - Dentistry32
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
Referred pain
Analysis
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
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
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?
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.
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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
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
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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:
◦ 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
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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
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
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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
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
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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
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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