IN THE NAME OF GOD Orofacial Pain - PowerPoint Presentation

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IN THE NAME OF GOD

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Orofacial Pain

Dr. HR.

Saeidi

Associate Prof of Neurosurgery KUMS

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Pain

unpleasant sensory

&

emotional experience associated with actual

&

potential tissue damage

.

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Anatomic Considerations

Trigeminal nerve Facial nerve Cervical nerve 2 &3Glossopharyngeal nerve Vagus nerve

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Categories

1-

Local pain

:

Dental

Gingival

Mucosal

Salivary gland

Temporomandibular

joint

Maxillary sinus

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Categories of orofacial pain

2-

Neurological pain:

T N

Glossopharyngeal

neu

Ramsy

hunt

synd

Postherpetic

neu

3-

Vascular

:

Giant cell arteritis

Migraine

Cluster headache

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Categories of orofacial pain

4-

Psychogenic pain

:

Atypical facial pain

Atypical

odontalgia

5-

Referred pain

:

Cardiac pain

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Evaluation and assessment

history

:

1-Chief complaint.

2

- Pain Characteristics

Onset & Intensity

Quality& location

Duration

&

timing of pain

Course of symptoms since onset

Activities that ↑ or ↓ pain

Associated symptoms

Previous treatments

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-Connective tissue dis.-Demyelination dis-Metastatic dis.-IHDSocial history:- traumatic event prior to onset of pain.-Change in work, or problem marital state.

Past medical history

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P

hysical examination:

1. head

&

neck skin,

2. Palpation of

masticatory

muscles,

3. range of mandibular movement.

4. Palpation of soft tissue .

5. Palpation of the TM joint

6. Palpation of cervical muscles

7. Cranial nerve

8. ears,

nose,teeth

,

oropharyngeal

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Diagnostic Imaging

- confirm diagnosis R/O serious dis

-Extent of an identified dis

-Most

OFP

not produce abnormality

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TMJ DISORDERS

1-Myofascial pain.

2-Traumatic injuries.

3-Arthritis &Arthrosis:

infective , systemic

,

degenerative.

4-Internal derangement.

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Myofascial

pain

diffuse poorly localized

periauricular

pain

pain may be severe in morning

↑

pain in tension

&

anxiety

↓

range of mandibular

movemen

"

trigger points

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Manage of myofascial pain

-Education of patient &

self care of teeth.

-thermal therapy(U/S, laser ).

-

Pharmacotherapy

:

-NSAID, muscle relaxant

-

Antianexiety&TCA

Botox injection.

Trigger point

block therapies

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INTERNAL DERANGMENT OF TMJ

Pain on palpation over TMJ.

↓

joint range of motion.

Deviation on opening.

Joint noises with pain.

Joint crepitus

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Soft laser apparatus in use

ultrasound apparatus in use

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NEURALGIA: CAVITATIONALOSTEONECROSIS

Rare continuous lancinating in site of previous tooth extraction.

Usually in lower

3

rd

molar region

Pain not interfere with sleep

RG:mooth

eaten in site of extraction

Treated by resection of bone with pain

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Neuralgia-inducing

cavitational

osteonecrosis

(NICO) .

Periapical

radiograph demonstrates an oval

radiolucency

in the third molar region and thin lamina

dura

remnants (residual socket) .

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Trigeminal neuralgia:

Definition : unilateral sever brief sudden stabbing pain in distribution of 1to 3 branches of nerve.

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Etiology and pathophysiology

primary :

vascular compression of nerve near its entry into the pons (

superior cerebellar artery

).

Secondary

:MS, tumors ,basilar artery

eneurysim

.

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Clinical features

episodic ,recurrent unilateral facial, sudden high intensity stabbing or electric shock pain

few seconds to minutes

triggered by stimulation: touching of face, washing ,shaving , chewing and talking.

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TN Clinical features

It occurs mostly after 5

th

decade.

PE of face is nearly always normal.

If sensory loss is present a mass lesion is more likely

In young

pts

MS should be considered.

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TN Diagnosis:

Diagnosis: history, PE.A careful search for ipsilateral dental pathology MRI & MRA if there is suspicion of underlying pathology.

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Right Trigeminal Nerve

Compressing vessel

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Medical Treatment of TN

Carbamazepine

(effective in 75% as first line)

Oxcarbazepine

in

pts

sensitive to Carbamazepine.

Baclofen

Gabapentine

Lamotrigine

Clonazepam

Phenytoin

Valproate

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Surgical treatment of TN

If medical treatment (carb) has been ineffective after 4 weeks at maximum tolerated dose .

peripheral procedures

:

alcohol injection, cryosurgery ,nerve avulsion

Percutaneous ganglion procedure

: RF

thermocoaglation ,glycerol injection , balloon

compression,Gamma

knife.

Open operations

:

MVD ,trigeminal root section,

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Gamma knife

microvascular

decompression

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-Pain : aching, burning, shock like.-Potential sequela of infection with herpes zoster.Pain persist longer than one month after healing vesicle classified as PHN.

Post-herpetic neuralgia

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Management:

-Antiviral and corticosteroids after presentation of rash reduce PHN

-

Anticonvulsant drugs

-Local anesthesia injected to painful site.

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Clinical features :Pain similar to TN.Affect tonsil ,tongue base, ear, intra articular area.Patient often point just to behind mandible angle.Triggered by yawing and swallowing. may be associated with a vasovagal reflex, The application of a topical anesthetic to the pharyngeal mucosa eliminates nerve pain.

Glossopharangeal neuralgia

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Management: -Anti convulsion :carbamazepine.-NVD-Percutaneous R.F at jugular foramen.-Intra or extra cranial neuroectomy.

Etiology: Causes : are intra or extracranial tumors & vascular abnormalities that compress CN IX.

Glossopharangeal neuralgia

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Occipital Neuralgia

paroxysmal stabbing pain in greater or lesser occipital nerves area

.

may be caused by trauma,

Palpation below the superior nuchal line may reveal a tender spot .

Treatment has included occipital nerve block,

neurolysis, C2 dorsal root gangionectomy ,

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Post -Traumatic Neuropathic Pain

Its caused by

5

th

nerve injuries

from facial trauma or surgical procedures, such as the removal of impacted third molars, the placement of dental implant

Clinical Manifestations:

The pain

may be persistent or occur only in response to a stimulus, such as a light touch.

Patients may experience anesthesia , paresthesia, allodynia , or hyperalgesia .

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Post -Traumatic Neuropathic Pain

Treatment:

may be surgical ,nonsurgical, or both,

Systemic corticosteroids a when administered within the

first week

after a nerve injury.

TCAs

Anticonvulsant drugs, Gabapentin.

Topical capsaicin .

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Complex Regional Pain Syndrome( CRPs)

chronic pain conditions that develop as a result of injury.

patients suffer from allodynia, hyperalgesia, and spontaneous pain that extends beyond the affected nerve dermatome.

it accompanied by motor and sweat abnormalities, atrophic changes in muscles and skin, edema,

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Complex Regional Pain Syndrome

Types of

CRPs

:

1-

CRPS I was previously termed reflex sympathetic dystrophy (RSD

),

2-

CRPS II was previously termed

causalgia

.

Etiology and Pathogenesis

:

believed to result from changes after trauma that couples sensory nerve fibers with sympathetic fibers.

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Complex Regional Pain Syn treatment

physical therapy.

block of regional sympathetic ganglia or regional intravenous blockades with guanethidine ,reserpine, or phenoxybenzamine

,

Bisphosphonates such as alendronate or pamidronate.

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Paroxysmal pain of facial nerve, may result of herpes zoster of geniculate ganglion.-Clinical features:-Pain at the ear, anterior tongue, soft palate.-Not intense like T.N.- Ramsay-hunt syndrome may develop(Facial paralysis ,vesicle ,tinnitus & vertigo)

Nervous Intermedius (Geniculate) Neuralgia

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Management

:

-High dose of steroid for 2-3weeks.

-Acyclovir significantly

↓

duration.

-Anti convulsion ,Carbamezipine.

-Surgery: section of nerve intermedius.

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Bell's palsy

about 50% of

pts

, pain occur in the ear but sometimes spreading down the jaw, either precedes or develops at the same time as the palsy.

Treatment:

prednisolone , acyclovir.

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Atypical facial pain

Constant dull aching pain , deep ,diffuse variable intensity in absence of identifiable organic disease.

Its more common in female .

Most patient middle age and elderly

.

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Atypical facial pain

Clinical features:

Often difficult for

pts

to describe symptoms .

described as deep , constant ache or burning .

Doesn't awake patient.

NO anatomical pattern and may be bilateral.

Affect maxilla more than mandible.

Often initiated or

↑

by dental treatment .

PE entirely normal .

Often have other complaints such as IBS ,dry mouth and chronic pain syndrome

.

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Atypical facial pain treatment

Often rewarded with limited response.

TAD have some effect in some

pts

.

30% of

ptS

respond to

Gabapentine

Cognitive behavior therapy

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Most frequently in women in 4TH,5TH of life, Constant dull, aching pain without an apparent cause that can be detected by examination , After dental extraction or endodontic treatment ,Period of pain free after 2th dental management.

Atypical

odontalgia

(phantom)

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-

Management

:

patient reassurance ,consultation to other specialty

-T.C.A. like amitriptyline , nortriptyline at low dose. 10 -25 mg at night

-Anti convulsant drugs.

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Burning sensation of oral mucosa , usually tongue, in absence of any identifiable clinical abnormality or cause.Epidemiology: 5 per 100,000 ,higher in middle age and elderly, affect female more than male . Causes: unknown but hormonal factors , anxiety ,and stress have been implicated.

Burning mouth syndrome

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Clinical features:

Complain of dry mouth with altered or bad taste.

Burning sensation affecting tongue , anterior palate and less common lips.

May be aggravated by certain foods.

Usually bilateral.

Doesn't awake patient . But may present at awaking

Examination entirely normal .

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Burning mouth syndrome

Investigation

:

FBS ,haematinics ,swab for Candida .

Treatment

:

Reassurance .

Avoidance of stimulating factors.

Some patients may respond to TCA, SSRIs

topical

clonazepam

, sucking and spitting

2-month course

alfa-lipoic

acid.

Cognitive behavior therapy

.

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Eagle’s syndrome

a series of symptoms caused by an elongated styloid process (more than 3 c.m) and/or the ossification of part or the entire stylohyoid Ligament.

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Types of Eagles syndrome:

1

-

Classic

:

the symptoms are persistent pharyngeal pain

↑

by swallowing

&

radiate to the ear , with sensation of foreign body within pharynx

pain arise following tonsillectomy due to scar tissue around the tip of the

styloid

process.

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2-

stylo

-carotid artery syndrome(vascular

):

Attributed to impingement of the carotid artery by the styloid process This can cause a compression when turning the head resulting in a transient ischemic accident or stroke.

3-

Traumatic Eagle syndrome

:

in which symptoms develop after fracture of a mineralized

stylohyoid

ligament.

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Diagnosis:

(1)clinical manifestations,

(2) digital palpation of the process in the

tonsillar

fossa,

(3) radiological findings .

(4)

lidocaine

infiltration test

.

Treatment:

Medical

: NSAID & injecting steroids& anesthetics into the lesser

cornu

of the hyoid or

tonsillar

fossa

Surgical:

intra oral or extra oral

styloidectomy

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Before puberty , female > male .Aura before headache in 40%. may triggered by foods : nuts, chocolate, red wine , stress, sleep deprivation, hunger.

Migraine

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Clinical manifestation:

A-classic migraine

(

start with aura for 20-30 min

)

Flashing lights

Scotoma

Sensitivity to light

Sensory and motor deficit

Aura followed by severe unilateral throbbing pain.

Headaches may last for hours or up to 2 or 3 days.

B-common migraine

(not

preceded by aura)

Severe unilateral throbbing pain

Sensitivity to light and noise

Nausea and vomiting

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C-facial migraine(carotidynia):

30-50 years

of age.

Pain last for minutes to hours and recurs several times per week.

Throbbing pain of neck and jaw.

Patients often seek dental consultation,

Tenderness of carotid artery

D-Basilar migraine :

The symptoms are primarily neurologic and include aphasia,temporary blindness, vertigo, confusion, and ataxia.

may be accompanied by an occipital headache.

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Migraine treatment

Avoid trigger factors

Acute attack:

analgesics,

Sumatriptan

,

ergotamin

.

Prophylaxis

:

pizotifen

,

propranolol

, ca channel blockers . TCAs

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Cluster headache

Clinical Manifestations:

80%of

pts

with CH are men.

The attacks are sudden, unilateral, stabbing ,causing

pts

to pace, cry out, or even strike objects. Some exhibit violent behavior in attacks

.

pain as a hot metal rod in or around the eye.

attack lasts from 15 min to 2

hrs

& recurs several times daily.

A majority of episodes at night, awaking the

pts

.

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Cluster headache

Clinical Manifestations:

pain with nasal congestion, tearing, Sweating of the face, ptosis,

↑

salivation, edema of the eyelid

.

pain in posterior maxilla that mimic dental pain.

Trigger by alcohol.

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CH treatment

An acute attack

:

100% oxygen (

its effectiveness is diagnostic

), Injection of

sumatriptan

or sublingual or inhaled ergotamine

Prophylaxis

: lithium, ergotamine,

prednisone, and calcium channel blockers.

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Chronic Paroxysmal Hemicrania

A form of CH that occurs predominantly in women between 30

-

40 years.

The episodes of pain tend be shorter, but attacks of 5 to 20 min, can occur up to 30 times daily.

It responds dramatically to

indomethacin

, which stops the attacks within 1to 2 days

.

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Temporal Arteritis

-Its inflammation(

vasculitis

) of cranial arteries due to to giant cell arteritis

Clinical features:

most frequently affects adults > 50 years.

Dull aching or throbbing temporal pain with generalized symptoms : fever, malaise,

↓

appetite.

Jaw claudication during mastication.

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Temporal Arteritis

Diagnosis:

elevated ESR 50-100 .

elevated CRP.

Biopsy.

-

Treatment

:

high dose of steroid(

prednisolone

)

the steroid is tapered once the signs of the disease are controlled.

Patients are maintained on systemic steroids for 1 to 2 years after symptoms resolve.

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Thanks for Your Attention

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