PAIN

PainCommon 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

CausesVascular

◦Migraine◦Migrainous Neuralgia◦Giant cell arteritis◦Neuralgia induced cavitational

osteonecrosis (NICO)Psychogenic

◦Atypical facial pain◦Burning mouth syndrome◦TMPD

Referred pain

Analysis

Previous HistoryLocation

◦ 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

AnalysisCharacter

◦Continuous◦Throbbing◦Severity

Ask the patient to scale it from 0-10

◦Dull◦Lancinating◦Burning sensation◦Interference with sleep

AnalysisFrequency & 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 & deepEvoked by external stimulus i.e.

hot, cold, sweet, sour, salty foods/drinks

Subsides within few secondsPoorly localized

Dental Pain

PulpalPulp Vitality testPain 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 ToolsHistory, nature & duration of painReaction to thermal changesReaction to mild electrical

stimulusReaction to tooth percussionRadiographic examinationVisual clinical examinationPalpation of surrounding area

PeriodontalMore localized than pulpal painLess severeAssociated with

tenderness/pressureUsually not aggravated by

heat/cold

Acute peri-apicalSpontaneousModerate to severePersists for long periodsOn percussion/biting on toothExtruded tooth in severe casesUsually precisely located by

patientUsually associated with non-vital

toothSwelling of the face?

Other Oral CausesLateral periodontal abscessFood impactionCracked toothPericoronitisANUGMucosal

Other oro-facial painsJawsAcute infectionsMalignanciesPaget’s diseaseDirect traumaCystsRetianed rootsInfected impactionsRadiation therapy osteo-radio

necrosis osteomyelitis

Other oro-facial painsTMJDysfunctionAcute inflammationTraumaMalignanciesMuscularPain is usuallyDullPoorly localizedRadiatesIntensified by movement of mandible

Other oro-facial pains

Salivary glandsIn children mumpsIn adults calculi or mucous plugSevere pain in acute parotitisPain is

◦Localized to affected gland◦Quite severe◦Intensified by increased salivation

Other oro-facial pains

SinusesPreceding coldPain & tendernessRadio-opacity of sinusesUpper molars/premolars become

tender in maxillary sinusitisTumours of sinusesPressure on Mental nerve

Neurologic causesTrigeminal neuralgiaGlossopharyngeal neuralgiaPost-herpetic neuralgiaIdiopathic TNAny lesion affecting Trigeminal n.

◦Traumatic◦Cerebrovascular disease◦Multiple sclerosis◦ Infections such as HIV◦ Inflammation◦Neoplasia (Nasopharyngeal/antral ca.)

Vascular causesMigraineMigrainous neuralgiaGiant Cell ArteritisNeuralgia Induced Cavitational

Osteonecrosis

Oro facial pain

Neuralgias

Trigeminal NeuralgiaA 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 NeuralgiaTypes

◦Classical◦Symptomatic◦Idiopathic

Trigeminal NeuralgiaMost common neurological cause

of facial pain4 per 100000 patients50-70years age groupMore common in femalesNo specific predisposing factors

but emotional or physical stress, hypertension may be related

Trigeminal Neuralgia - PathophysiologyExact cause isn’t knownCompression around trigeminal root

due to atherosclerotic blood vessels is the hypothesized cause

Demyelination of trigeminal nerve causing ectopic pulses

Compression by tumourBony compressionAV malformationAmyloidPons infarct

Trigeminal Neuralgia

Trigeminal Neuralgia

Trigeminal Neuralgia – C/FMainly affects 2nd & 3rd divisions

of trigeminalParoxysmal attacks of facial painCan last from few seconds to 2

minutesOccurs mostly in the morningSpontaneous remission may be

possibleOr patients may have episodic

attacks over many years

Trigeminal Neuralgia – C/FPain 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/FNo neurological deficitAttacks are stereotyped in

individual patientsAtypical TNLess intense, constant, dull

burning or aching pain with occasional electric shock like stabs

DiagnosisExclusion 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

ManagementAnticonvulsants

CarbamazepineIt is the main drug of choicePrevents attacks in 60% of

patientsGiven continuousely &

prophylactically for long periodsUsed carefully & under strict

medical surveillanceContra-indicated in pregnancy

Dose regime100mg B.D for 2 weeksCan be increased by 100mg daily every 3 days

to a maximum dose of 1000mg/dailyBlood monitoring mandatoryAdverse 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

monthlyBlood tests:

◦Electrolytes (for hyponatraemia)◦LFTs◦RBC, WBC & Platelet counts

Surgical interventionPeripheral surgery

◦Local cryosurgery◦Injections of glycerol or streptomycin

around mandibular or infra-orbital foramen

◦Peripheral neurectomy◦Radiofrequency thermocoagulation

Surgical interventionCentral 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 DiagnosisGlossopharyngeal neuralgiaGiant cell arteritisCluster HeadacheIntracranial tumourPost-herpetic neuralgiaMultiple sclerosisMigrainDental painTMPDS

Glossopharyngeal Neuralgia

Glossopharyngeal NeuralgiaA pain syndrome characterized

by unilateral, sharp pain along the sensory distribution of ninth cranial nerve (glossopharyngeal n.)

Glossopharyngeal NeuralgiaPain characterAcute pain that lasts from seconds to

few minutesLancinating, stabbing, shooting &

electric shock likeFelt 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 NeuralgiaBetween 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 NeuralgiaIncidenceLess common than TNA population bases study showed

an incidence of 0.7 in 100,000More common in menIncidence increases with age (>

50 years)

Glossopharyngeal NeuralgiaEtiologyTwo typesWithout discernable cause

idiopathic or essential GPNWith underlying pathology

secondary GPN

Glossopharyngeal NeuralgiaIdiopathic or Essential GPNBelieved 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 NeuralgiaSecondary GPNNeoplasmsVascular malformationsInfectionsDemyelinationTraumaElongated styloid process (eagle’s

syndrome)Other causes

Eagle’s syndromeA painful condition first described

in 1937 caused by elongated styloid process

Pain in Eagle’s syndrome resembles that of GPN

Pain is more constant & dullTwo types

◦Classic◦Carotid artery syndrome

Eagle’s syndrome

ClassicSpasmatic, nagging painSeen in patients with elongated

styloid process (> 3-3.5cm) or ossification of stylohyoid

ligamentSometimes seen in

tonsillectomized patients

Eagle’s syndrome

Carotid artery syndromePain of pharyngeal distributionBecomes prominent on head

turningNot related to previous surgeryCaused 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 NeuralgiaAssociation with syncope &

hypotentionTwo theories1. Intense neuralgic pain activates

glossopharyngeal-vagal reflex arc

2. Direct inhibition of vasomotor center peripheral vasodilation hypotention

ManagementCarbamazepine is the drug of

choiceMay partially effective in some

patientsMay cause drowsiness, dizziness

or itchingMay 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 glycerine21 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

ManagementPercutaneous rhizotomyExtracranial

neurotomy/neurectomyIntracranial rhizotomyMicrovascular decompression

Atypical Facial Pain

Atypical Facial PainConstant 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

CharacteristicsConstant chronic orofacial

discomfort/painDull, boring or burning typeIll-defined locationTotal lack of objective signsAll investigations negativeNo cause detectedPoor response to treatment

Atypical Facial Pain1-2% of population suffers from itMiddle aged – older adults> 70% womenThere may be history of adverse

life events, family illness, dental or oral procedures

Aetiology & PathogenesisPositron 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/FCheek, nose, upper lip or sometimes lower

jawLocation of pain is unrelated to anatomical

distribution of trigeminal nerveMay last for hours days or weeksPoorly localizedMay cross the midline, change its location,

usually bilateralDoes NOT awaken the patient from sleepDeep, dull, boring/burning sensation, may

cause lacrimation & watering of nose

Atypical Facial Pain – C/FMay 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 PainExaminationNo erythema, tenderness or swellingNo odontogenic or other cause of painLack of objective physical signsAll investigations are negativeDxDiagnosis is clinicalCareful examination of oral, perioral

structures, all radiographs to rule out othe causes

ManagementCognitive 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 syndrome5 persons/100,000Middle aged-older adultsFemale predilectionNo precipitating cause detected in 50%

patientsIn 20% cases, psychogenic cause can

be identifiedIn others it follow:

◦Dental intervention◦Upper respiratory tract infection◦Drugs such as ACE or protease inhibitors

Burning mouth syndromeDiagnosis depends on exclusion

of other causes of burning sensation◦Erythema migrans◦Lichen planus◦Dry mouth◦Candidiasis◦Glossitis following nutritional

deficiency◦Diabetes

Burning mouth syndromeExclusion 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/FMostly affects tongueMay affect palate, lips or lower alveolusBurning sensation is chronic, bilateralOften relieved by eating/drinkingMay accompany

◦Dry mouth◦Altered taste◦Thirst◦Headaches◦Chronic back pain◦ Irritable bowl syndrome◦dysmenorrhoea

Burning mouth syndrome

DiagnosisExamination to rule out other

causesAll investigations are negative

Management Avoid anything that aggravates

symptomsAvoid active dental or surgical

treatmentCognitive behavioural therapy &

referral to specialist