Orofacial pain
Orofacial pain
OROFACIAL PAIN
Author:
Dr. Suhail Latoo
Dept. of oral and maxillofacial pathology
Govt. Dental College & hospital, Srinagar
Dr. Khalid Amin
Dept. Conservative dentistry and Endodontics
Govt. Dental College & hospital, Srinagar
Dr. Ravinder Kumar Baghat
Dept. Conservative dentistry and Endodontics
Govt. Dental College & hospital, Srinagar
Pt come to the dental clinic complaining from:
Pain
Swelling
Bleeding
Ulcer
Discolored mucosa
Pain: unpleasant emotional experience caused by injury to the body or mind.
Pain is difficult in diagnosis because:
- Due to the difference in the nature of pain:
It varies from one individual to another & has several forms as aching, throbbing, burning
- Due to the difference in pain perception & sensation.
Neural mechanisms of pain:
Pain perception & pain reaction (arc reflex)
Any receptor in the tissue can be stimulated by painful stimuli these will generate nerve impulse that is transmitted through afferent neuron to cerebral cortex that interpret the stimuli and send a response through efferent neurons.
Pain perception: physicoanatomical process by which pain is received & transmitted to higher centers.
Pain reaction: the manifestation shown as a result of pain perception & interpretation.
Pain reaction differs according to:
Age (old, young)
Sex (male, female)
Emotional status (modify the intensity & the personal behavior response to pain).
Religious factor
Health status
N.B.
Pain receptor (necoceptors or exteroceptors).
Pain threshold (trigger of stimulus which necessary to feel pain "variable").
Sensory nerve supply to the orofacial structures:
Trigeminal
Facial
Glossopharyngeal
Vagus
Branches of cervical spinal nerve.
Hypoglossal
Types of orofacial pain:
Somatic: coetaneous or mucosal pain due to noxious stimuli to pain receptor without any abnormality or change in the neural st. (normal neural st.)
Noxious stimuli could be:
Thermal changes (impression)
Mechanical (trauma)
Pressure (denture)
Chemicals (aspirin)
Bacterial, viral, fungal infection.
Systemic disease with oral manifestation.
Somatic pain can be:
Deep or superficial
Superficial:
Sharp, easy to be localized.
E.g. skin, mucus membrane (ulcers).
Deep:
Dull, diffuse, difficult to be localized.
E.g. pulpal pain, osseous pain as (abscess), muscular pain (stress & strainischemiaspasmtresmus), ligament, & joints pain.
Vascular: pain due to changes in the blood flow (pain due to noxious stimuli that affect the vascular tissue or perivascular tissue) some classify it as deep muscular pain.
E.g. migraine, cluster headache, Milkerson Rosenthial syndrome.
Migraine:
Unilateral headache in the maxillary, frontal, occipital bone.
Female>male, start in 2nd decay of life.
Caused by contraction of the cranial blood vessels followed by dilatation causing changes in the cerebral blood flow.
It s usually associated with aura (photophobia, nausea & vomiting, fatigue).
It has familial history.
Predisposing factors:
- Allergy to food.
- Exercise.
- Stress.
- Excitation.
TXergotamineside effectshypertension & cardiovascular problem.
Cluster headache:
Unilateral headache start at evening (evening attacks).
Male>female, start in 2nd decay of life.
Chch by headache episodes for 20min in maxillary, temporal, & orbital bone followed by relief & repeat for about 1:30hour.
It s usually associated with watery discharge of the nose, nasal congestion, nostril blockage in the affected side, eye tearing, eye redness & edema of the eye led.
It has no familial history.
Can be treated with ergotamine.
Milkerson rosenthial syndrome:
Combination of:
Facial pulsy.
Bifid tongue.
Bilateral temporal headache.
Chelitis graulomatosa.
Vascular pain can be treated by analgesics.
Neurogenic: pain occurring along the course of the nerve due to abnormality in the neural st. of the nerve itself.
Chch:
- Paroxysmal.
- Very sever & sharp "like electric shook".
- Localized to the affected sensory nerve.
It may be 1ry (trigeminal, & glossopharyngeal) neuralgia, or 2ry neuralgia.
1ry neuralgia: (unknown cause)
Severe, sharp, paroxysmal pain along the course of the nerve but dose not cross the midline due to abnormality in the neural st. of the nerve it self but no pathological lesion present.
Pain resembles electric shock.
Trigeminal neuralgia:
Severe, sharp, paroxysmal pain along the course of the trigeminal nerve. (Sudden onset & disappear gradually).
Female>male, right>lift side, old>young age, maxillary > mandible >ophthalmic branch.
Etiology:
Unknown cause.
But there are 2 theories the 1st (most acceptable) says that pain is due to stretching & demylenation of the trigeminal nerve above the petrous part of the temporal bone which is larger in females, right side, old.
2nd says that pain is due to pulsation of the carotid artery above the gassarian ganglionpressure.
Trigger zone: mild sensory stimuli (shaving, touch, brushing, washing) directed to this zone will result in the neuralgial attack. Between the attacks the zone becomes refractory (pt is pain free between the attacks).
Half inch sign or frozen face.
D.D.:
Post herpetic neuralgia.
Pulpal pain.
Tumors in the orofacial st.
Atypical pain.
To differentiate:
- Presence of atypical agent.
- Continuous not in attacks.
TX:
-medically by Tegratol (anticonvulsant) 200mg /3times per day
It shouldn't exceed 800mg
Side effects (aplastic anemia, agranulocytosis, and GIT disturbance).
Or by phnytoin.
-surgically (cryosurgery, or surgical resection).
-injection of (LA, or alcohol along the coarse of the nerve).
Glossopharyngeal neuralgia:
Severe sharp paroxysmal pain along the course of the glossopharyngeal nerve.
Rare.
Trigger area:
Nasopharynix
Soft palate
Tonsil
Sides of the tongue.
Stimuli (coughing, yawning, swallowing, talking)
Pain:
- Otic.
- Pharyngeal.
- Shooting sever pain.
D.D.:
Tumors in the nasopharyngeal area.
Stone in the submandibular gland.
Eggle syndrome (elongated styloid process).
Tx:
As trigeminal neuralgia but surgical resection will change the taste sensation.
For diagnosis topical anesthesia application will relief pain.
2ry neuralgia: (well known cause) pathological changes alter the nerve st. & cause neuralgia.
e.g.
Post herpetic neuralgia: as complication of the herpes zoster infection chch by very severe knife cutting sharp pain that cannot be treated.
Antiviral & cortisones are given in these cases to prevent nerve fibrosis & scaring & the pt can be treated with tricyclic antidepressant
Paget's disease: osteoclastic activity followed by osteoblastic activity causing narrowing of the foramen, jaw & skull enlargementcompression on the nerve.
Post traumatic neuroma: due to the accidental severing of the nerve, during healing, nurolemmal sheath create a neuroma that disturb nerve impulse. This cause severe sharp pain in the lip with increased T.
Coalgia: severe sharp lancating pain in the socket due to the sectioning of the peripheral nerve during extraction.
Neuralgia 2ry to malignancy: malignant tumor can invade the nerve causing neuralgia. E.g. Trroter syndrome epidermal carcinoma in the lateral wall of the pharynx extending to the maxillary or mandibular division.
Maxillary pain in cheek.
Mandibular pain in tongue & lip parasthesia.
Eustachian tube deafness.
Referred: pain felt at a distance from the pathologically affected area.
e.g.
-coronary heart disease show a referred pain in the left shoulder & lower jaw (angle & teeth).
-pain in case of sinusitis referred to upper posterior teeth.
-pulpitis in the lower teeth referred to the upper teeth.
Psychogenic (atypical facial pain): facial pain that dose not follow anatomical pathway, & has no organic cause.
Dull pain, spread widely, bilateral, poorly localized & the pt can't determine the pain quality.
Female>male, young>old, maxilla>mandible, most common in the sides of the tongue, cross the midline.
Sometimes called psychogenic pain because it s common in pt with depression & usually seen in pt with abnormal behavior.
How to diagnose?
-Hx
-clinically & investigation (full mouth x-ray, vitality test, sensitivity test, GTT, CBC)
-pt behavior & attitude (it can be diagnosed mainly by exclusion)
Tx:
Multiple visitsPt assurance to correct the behaviorreffer to a specialist.
Mycofacial pain dysfunction syndrome (MFPD): chronic disorder chch by dull unilateral pain involving the side of the face, extending around the ear, periaurecular, frontal, occipital, sternoclidomastoid muscleetc.
Male>female, old>young.
Pain on palpation of muscle of mastication.
Pt starts with pain & chch of clicking & trismus without any pathological abnormality in TMJ.
Possible causes:
Great VDOover extension. E.g. high filling.
Short VDOover contraction.
Clenching & bruxismMuscle fatigue.
If untreated:
- After 1 yeardeviation of the jaw to one side on opening.
- These defects cause rupture of the sarcoplasmic reticulum that release the inflammatory mediators & stimulate the pain receptors.
Tx:
-cause removal.
-moist heat application for 3min.
-topical anesthesia.
-muscle exercise (tongue attach the post. Part of the palate several times during the day).
Diagnosis of tha orofacial pain: (VIP)
Clinical history:
-detailed Hx of the pain complaint:
When pain start? (Onset sudden or gradual)
Where dose it start? (Anatomical location)
How long it takes to start (duration)
How long it takes to relief (duration)
Nature of pain (throbbingabscess, dullperiodontal, sharppulpal, lancatingneurological)
Severity of pain (if interfere with sleeping, talkingsever, if notmild)
Localization
Associated symptoms
Is the pain associated with any systemic disease?
-Hx of the related disease (arthritis, muscular complaint, neurologic or psychogenic disorder).
Clinical examination of the teeth, their supporting & associated st. (vitality tests, percussion tests, x-ray, sinus x-ray).
Rapid cranial nerve evaluation:
Nerve
Test
1
Block one of the nostrils & check smell ability.
2,3
Pupil reaction to light (contraction).
4,6
Allow pupil to follow moving object without moving the head
5
Touch the skin with (sharp & blunt objects).
Check muscle of mastication.
Pt move mandible against pressure.
7
If affected the pt cannot raise his eye brow, close the eye lash, and blow his mouth on the affected side.
Also it causes dropping of the corner of the mouth.
8
Drop an object on the ground & ask about hearing.
9,10
Ask pt to say ahhhhhhhhh uvula moving, gagging reflex.
11
Check sternoclidomastoid & trapezius muscle
Ask the pt to tilt the head against pressure.
12
Tongue protrusion.
TMJ disorders (imp. In late stage MPDS):
-functional or organic TMJ disorder.
-signs & symptoms.
-radiographic evaluation.
-Management.
_
Author:
Dr. Khalid Amin
Dept. Conservative dentistry and Endodontics
Govt. Dental College & hospital, Srinagar
Pt come to the dental clinic complaining from:
Pain
Swelling
Bleeding
Ulcer
Discolored mucosa
Pain: unpleasant emotional experience caused by injury to the body or mind.
Pain is difficult in diagnosis because:
- Due to the difference in the nature of pain:
It varies from one individual to another & has several forms as aching, throbbing, burning
- Due to the difference in pain perception & sensation.
Neural mechanisms of pain:
Pain perception & pain reaction (arc reflex)
Any receptor in the tissue can be stimulated by painful stimuli these will generate nerve impulse that is transmitted through afferent neuron to cerebral cortex that interpret the stimuli and send a response through efferent neurons.
Pain perception: physicoanatomical process by which pain is received & transmitted to higher centers.
Pain reaction: the manifestation shown as a result of pain perception & interpretation.
Pain reaction differs according to:
Age (old, young)
Sex (male, female)
Emotional status (modify the intensity & the personal behavior response to pain).
Religious factor
Health status
N.B.
Pain receptor (necoceptors or exteroceptors).
Pain threshold (trigger of stimulus which necessary to feel pain "variable").
Sensory nerve supply to the orofacial structures:
Trigeminal
Facial
Glossopharyngeal
Vagus
Branches of cervical spinal nerve.
Hypoglossal
Types of orofacial pain:
Somatic: coetaneous or mucosal pain due to noxious stimuli to pain receptor without any abnormality or change in the neural st. (normal neural st.)
Noxious stimuli could be:
Thermal changes (impression)
Mechanical (trauma)
Pressure (denture)
Chemicals (aspirin)
Bacterial, viral, fungal infection.
Systemic disease with oral manifestation.
Somatic pain can be:
Deep or superficial
Superficial:
Sharp, easy to be localized.
E.g. skin, mucus membrane (ulcers).
Deep:
Dull, diffuse, difficult to be localized.
E.g. pulpal pain, osseous pain as (abscess), muscular pain (stress & strainischemiaspasmtresmus), ligament, & joints pain.
Vascular: pain due to changes in the blood flow (pain due to noxious stimuli that affect the vascular tissue or perivascular tissue) some classify it as deep muscular pain.
E.g. migraine, cluster headache, Milkerson Rosenthial syndrome.
Migraine:
Unilateral headache in the maxillary, frontal, occipital bone.
Female>male, start in 2nd decay of life.
Caused by contraction of the cranial blood vessels followed by dilatation causing changes in the cerebral blood flow.
It s usually associated with aura (photophobia, nausea & vomiting, fatigue).
It has familial history.
Predisposing factors:
- Allergy to food.
- Exercise.
- Stress.
- Excitation.
TXergotamineside effectshypertension & cardiovascular problem.
Cluster headache:
Unilateral headache start at evening (evening attacks).
Male>female, start in 2nd decay of life.
Chch by headache episodes for 20min in maxillary, temporal, & orbital bone followed by relief & repeat for about 1:30hour.
It s usually associated with watery discharge of the nose, nasal congestion, nostril blockage in the affected side, eye tearing, eye redness & edema of the eye led.
It has no familial history.
Can be treated with ergotamine.
Milkerson rosenthial syndrome:
Combination of:
Facial pulsy.
Bifid tongue.
Bilateral temporal headache.
Chelitis graulomatosa.
Vascular pain can be treated by analgesics.
Neurogenic: pain occurring along the course of the nerve due to abnormality in the neural st. of the nerve itself.
Chch:
- Paroxysmal.
- Very sever & sharp "like electric shook".
- Localized to the affected sensory nerve.
It may be 1ry (trigeminal, & glossopharyngeal) neuralgia, or 2ry neuralgia.
1ry neuralgia: (unknown cause)
Severe, sharp, paroxysmal pain along the course of the nerve but dose not cross the midline due to abnormality in the neural st. of the nerve it self but no pathological lesion present.
Pain resembles electric shock.
Trigeminal neuralgia:
Severe, sharp, paroxysmal pain along the course of the trigeminal nerve. (Sudden onset & disappear gradually).
Female>male, right>lift side, old>young age, maxillary > mandible >ophthalmic branch.
Etiology:
Unknown cause.
But there are 2 theories the 1st (most acceptable) says that pain is due to stretching & demylenation of the trigeminal nerve above the petrous part of the temporal bone which is larger in females, right side, old.
2nd says that pain is due to pulsation of the carotid artery above the gassarian ganglionpressure.
Trigger zone: mild sensory stimuli (shaving, touch, brushing, washing) directed to this zone will result in the neuralgial attack. Between the attacks the zone becomes refractory (pt is pain free between the attacks).
Half inch sign or frozen face.
D.D.:
Post herpetic neuralgia.
Pulpal pain.
Tumors in the orofacial st.
Atypical pain.
To differentiate:
- Presence of atypical agent.
- Continuous not in attacks.
TX:
-medically by Tegratol (anticonvulsant) 200mg /3times per day
It shouldn't exceed 800mg
Side effects (aplastic anemia, agranulocytosis, and GIT disturbance).
Or by phnytoin.
-surgically (cryosurgery, or surgical resection).
-injection of (LA, or alcohol along the coarse of the nerve).
Glossopharyngeal neuralgia:
Severe sharp paroxysmal pain along the course of the glossopharyngeal nerve.
Rare.
Trigger area:
Nasopharynix
Soft palate
Tonsil
Sides of the tongue.
Stimuli (coughing, yawning, swallowing, talking)
Pain:
- Otic.
- Pharyngeal.
- Shooting sever pain.
D.D.:
Tumors in the nasopharyngeal area.
Stone in the submandibular gland.
Eggle syndrome (elongated styloid process).
Tx:
As trigeminal neuralgia but surgical resection will change the taste sensation.
For diagnosis topical anesthesia application will relief pain.
2ry neuralgia: (well known cause) pathological changes alter the nerve st. & cause neuralgia.
e.g.
Post herpetic neuralgia: as complication of the herpes zoster infection chch by very severe knife cutting sharp pain that cannot be treated.
Antiviral & cortisones are given in these cases to prevent nerve fibrosis & scaring & the pt can be treated with tricyclic antidepressant
Paget's disease: osteoclastic activity followed by osteoblastic activity causing narrowing of the foramen, jaw & skull enlargementcompression on the nerve.
Post traumatic neuroma: due to the accidental severing of the nerve, during healing, nurolemmal sheath create a neuroma that disturb nerve impulse. This cause severe sharp pain in the lip with increased T.
Coalgia: severe sharp lancating pain in the socket due to the sectioning of the peripheral nerve during extraction.
Neuralgia 2ry to malignancy: malignant tumor can invade the nerve causing neuralgia. E.g. Trroter syndrome epidermal carcinoma in the lateral wall of the pharynx extending to the maxillary or mandibular division.
Maxillary pain in cheek.
Mandibular pain in tongue & lip parasthesia.
Eustachian tube deafness.
Referred: pain felt at a distance from the pathologically affected area.
e.g.
-coronary heart disease show a referred pain in the left shoulder & lower jaw (angle & teeth).
-pain in case of sinusitis referred to upper posterior teeth.
-pulpitis in the lower teeth referred to the upper teeth.
Psychogenic (atypical facial pain): facial pain that dose not follow anatomical pathway, & has no organic cause.
Dull pain, spread widely, bilateral, poorly localized & the pt can't determine the pain quality.
Female>male, young>old, maxilla>mandible, most common in the sides of the tongue, cross the midline.
Sometimes called psychogenic pain because it s common in pt with depression & usually seen in pt with abnormal behavior.
How to diagnose?
-Hx
-clinically & investigation (full mouth x-ray, vitality test, sensitivity test, GTT, CBC)
-pt behavior & attitude (it can be diagnosed mainly by exclusion)
Tx:
Multiple visitsPt assurance to correct the behaviorreffer to a specialist.
Mycofacial pain dysfunction syndrome (MFPD): chronic disorder chch by dull unilateral pain involving the side of the face, extending around the ear, periaurecular, frontal, occipital, sternoclidomastoid muscleetc.
Male>female, old>young.
Pain on palpation of muscle of mastication.
Pt starts with pain & chch of clicking & trismus without any pathological abnormality in TMJ.
Possible causes:
Great VDOover extension. E.g. high filling.
Short VDOover contraction.
Clenching & bruxismMuscle fatigue.
If untreated:
- After 1 yeardeviation of the jaw to one side on opening.
- These defects cause rupture of the sarcoplasmic reticulum that release the inflammatory mediators & stimulate the pain receptors.
Tx:
-cause removal.
-moist heat application for 3min.
-topical anesthesia.
-muscle exercise (tongue attach the post. Part of the palate several times during the day).
Diagnosis of tha orofacial pain: (VIP)
Clinical history:
-detailed Hx of the pain complaint:
When pain start? (Onset sudden or gradual)
Where dose it start? (Anatomical location)
How long it takes to start (duration)
How long it takes to relief (duration)
Nature of pain (throbbingabscess, dullperiodontal, sharppulpal, lancatingneurological)
Severity of pain (if interfere with sleeping, talkingsever, if notmild)
Localization
Associated symptoms
Is the pain associated with any systemic disease?
-Hx of the related disease (arthritis, muscular complaint, neurologic or psychogenic disorder).
Clinical examination of the teeth, their supporting & associated st. (vitality tests, percussion tests, x-ray, sinus x-ray).
Rapid cranial nerve evaluation:
Nerve
Test
1
Block one of the nostrils & check smell ability.
2,3
Pupil reaction to light (contraction).
4,6
Allow pupil to follow moving object without moving the head
5
Touch the skin with (sharp & blunt objects).
Check muscle of mastication.
Pt move mandible against pressure.
7
If affected the pt cannot raise his eye brow, close the eye lash, and blow his mouth on the affected side.
Also it causes dropping of the corner of the mouth.
8
Drop an object on the ground & ask about hearing.
9,10
Ask pt to say ahhhhhhhhh uvula moving, gagging reflex.
11
Check sternoclidomastoid & trapezius muscle
Ask the pt to tilt the head against pressure.
12
Tongue protrusion.
TMJ disorders (imp. In late stage MPDS):
-functional or organic TMJ disorder.
-signs & symptoms.
-radiographic evaluation.
-Management.
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