OROFACIAL PAIN

Presented By Dr Samreen Younas

PGR-I (FCPS)OMFS

Contents What is orofacial pain Causes of orofacial pain Trigeminal Neuralgia Glossopharyngeal Neuralgia Post Herpatic Neuralgia Eagle’s Syndrome Temporomandibular pain Burning mouth syndrome Atypical Facial pain Migrain Cluster Headache Temporal Arteritis Take Home Massage

Orofacial pain Pain localized to the region above the neck in front of the ears, and below the orbitomeatal line as well as within the oral cavity…

Causes of orofacial pain

1- Local : Dental : (pulpitis., dentine

hypersensetivity ,periapical periodontitis.cracked tooth syndrome

Gingival: (e.g primary herpetic gingivostomatitis,

Mucosal: (e,g ulceration) Salivary gland: (acute suppurative sialadenitis) Temporomandibular joint: Maxillary sinus: (sinusitis,malignancy)

Categories of orofacial pain

2- Neurological : Trigeminal neuralgia Glossopharyngeal neuralgia Ramsy hunt syndrome Postherpetic neuralgia3- Vascular : Giant cell arteritis and variant Migraine and variant Cluster headache ,chronic paroxysmal

hemicrania

Categories of orofacial pain

4- Psychogenic : Atypical facial pain Atypical odontalgia Burning mouth syndrome

5- Referred pain: Cardiac pain

Trigeminal neuralgia: Definition : usually unilateral severe,

brief, sudden, stabbing recurrent pain in distribution of one or more of branches of trigeminal nerve.

Etiology

Compression of trigeminal nerve root by an aberrant loop of artry or vein.

Primary demyelinating disorders e.g multiple sclerosis.

Non demyelinating lesions of pons or medulla e.g infarct or angioma.

Infiltrative disorders e.g carcinomatous deposits.

Chronic entrapment and compression results in focal demyelination primarily followed by axonal degeneration.

This demyelination in turn precipitates ectopic or hyperactive discharge of the nerve..

Clinical features Pain of TN is often described as sharp and

shooting like an electric shock.

Severity may vary within the same patient and intensity may increase.

Almost always unilateral. right> left

lasts for a few seconds to 1 minute , Pain is frequently triggered by trivial

stimulation: such as touching of face, washing ,shaving , chewing and talking.

Pain is not provoked directly by thermal stimuli.

TN Clinical features Clinical examination of face is nearly always

normal. If sensory loss is present a mass lesion is more

likely In young patients with TN, multiple sclerosis

should be considered.

TN Diagnosis: Diagnosis depend on history and

clinical examination. One should always assess cranial

nerve function. MRI to detect vascular

compression.

Right Trigeminal Nerve

Compressing vessel

Treatment of trigeminal neuralgia

1- Medical treatment: Carbamazepine Oxcarbazepine who are sensitive to

Carbamazepine. Baclofen Gabapentine. Lamotrigine Clonazepam Phenytoin

Treatment of trigeminal neuralgia

2- Surgical treatment(invasive):indicated If medical treatment (carbamazepine) has

been ineffective after 4 weeks at maximum tolerated dose .

Microvascular decompression Percutaneous radiofrequency

thermorizotomy Gamma knife radiosurgery Glycerol injections Peripheral neurectomies

Gamma knife microvascular decompression

Glossopharyngeal NeuralgiaIs an uncommon disorder characterized

by lancinating pain of oropharynx or neck, sometimes triggerd by swallowing, coughing or talking.

Epidemiology: less common than TN. arises in middle to late life. males=females

Clinical featuresDifferences from TN Pain GN can awaken the pt from sleep Syncope can be a feature and rarely

cardiac arrythmias caused by vagal stimulation.

Xerostomia or exessive salivation.

Management: Of GN parallels that of TN -Anti convulsion drugs,carbamezipine. -Vascular decompression. -Intracranial or extra cranial neuroectomy.

Etiology: An identifiable cause is rarely found.

The most common causes of glossopharyngeal neuralgia are intracranial or extracranial tumors and vascular abnormalities that compress CN IX.

Glossopharangeal neuralgia

Post Herpetic Neuralgia -Pain is typically aching,buring,or

shock like.

-Potential sequela of infection with herpes zoster.

Acute phase is painful but subsides within 2 to 5 weeks.

Managment -Antiviral and corticosteroids after

presentation of rash reduce incidence of postherptic neuralgia.

-Anticonvulsant drugs -Local anesthesia injected to painful

site.

EAGLE’S SYNDROMEIs an uncommon disorder characterized

by the sensation of a foreign body within the pharynx with pain on swallowing.

Etiology: Pain seems to arise following

tonsillectomy and is associated with elongated ossified styloid process and ligament.

CLINICAL FEATURES Pain is usually dull and nagging Usually localized May radiate to ear

Types of Eagle’s syndrome1-Classic : The symptoms are persistent

pharyngeal pain aggravated by swallowing and frequently radiate to the ear , with sensation of foreign body within pharynx , This pain arise following tonsillectomy due to development of scar tissue around the tip of the styloid process.

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.

Diagnosis(1)clinical manifestations,(2) digital palpation of the process in the tonsillar

fossa, (3) radiological findings . (4) lidocaine infiltration test. Treatment:COSERVATIVE: involves injecting steroidsor long-lasting anesthetics into the lesser cornu ofthe hyoid or the inferior aspect of the tonsillar fossaI,NSAIDSurgical: intra oral or extra oral styloidectomy

TEMPOROMANDIBULAR PAIN

Is defined as group of symptoms including pain of orofacial muscles, and/or TMJ and dysfunction of TMJ.

Epidimeology: Affects all racial groups 2nd and 3rd decade of life males=females

CLINICAL FEATURESTMD can involve the followingMuscels of mastication: Myofascial

pain(tendeness or dull aches around TMJ including ear.

The TMJ: limited jaw opening or pain, jaw locking, clicking sounds.

Others: Headaches, ear aches, pain radiating to neck or shoulders, dizziness and tinnitis.

Etiologyo Parafunctional habitso Occlusal anomalieso Local traumao Life events and mental healthManagement: Conservative therapies Soft diet Limited

talking

Avoidance of wide mouth opening.Muscle massageJaw exercisesSplint therapyPsychogenic based therapies Clonazipam TCA SSRISurgery

Burning Mouth SyndromeBurning 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.

Clinical Features Complain of dry mouth with altered or

bad taste. Anterior tongue>hard palate>lower lip >alveolar ridge May be aggravated by certain foods. Usually bilateral. Doesn't awake patient . But may

present at awaking Examination entirely normal .

Investigation: FBC ,haematinics ,swab for Candida .

Treatment: Reassurance . Avoidance of stimulating factors. Some patients may respond to TCA, SSRIs topical clonazepam, sucking and spitting 1 mg

three times daily for 2 weeks. 2-month course of 600 mg daily alfa-lipoic acid. Cognitive behavior therapy.

Atypical facial pain

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

Its more common in female . Most patient middle age and elderly .

Atypical facial painClinical features:

Often difficult for patients to describe their symptoms . Most frequently described as deep , constant ache or

burning . Doesn't awake patient. Doesn't follow anatomical pattern and may be

bilateral. Affect maxilla more than mandible. Often initiated or exacerbated by dental treatment . Examination entirely normal . Often have other complaints such as IBS ,dry mouth

and chronic pain syndrome .

Atypical facial pain

Treatment : Treatment of atypical facial pain remains

difficult. Analgesics are ineffective TCA drugs have some effect in some

patients . 30% of patient respond to Gabapentine Cognitive behavior therapy

Presents as pain in a tooth or site of dental extraction In the absence of clinical or radiological evidence of pathological dental condition.

Clinical features: 5th decade Females>males Premolar and molar area Maxillary>mandibular

Atypical odontalgia(phantom)

Pain is burning or aching History of surgical or other trauma exist History of symptoms greater than 4-6

weeks L.A is ineffective-Management:Remains unsatisfactory Topical aplication of capsaicin and

EMLA Antidepressants anxiolytics

Is achronic neurological disorder, typically affects one half of the head, pain is pulsating and throbbing in nature.

Associated symptoms may include nausea vomiting sensitivity to light, smell or noise.

It may be triggered by foods such as nuts, chocolate, and red wine ; stress; sleep deprivation; or hunger.

Migraine

Clinical Featureso Duration : usually 12 to 72 hourso Female:male ratio >2:1o Neurologic aura :≈ 40%o Moderate to svere in intensityo Usually unilateral The mechanism although not

completely understood appears to involve neurogenic inflamation of intracranial blood vessels resulting from neurotransmitter imbalance in certain brain centers.

Migraine

Treatment : Avoid trigger factors Acute attack: analgesics, Sumatriptan (5-HT

agonist) , Ergotamin.

Prophylaxis : is directed at normalizing neurotransmitter imbalance with Antidepressants , Anticonvulsants, beta-Blockers

Cluster headacheClinical manifestationspain as a hot metal rod in or around the eye.Svere

unilateral orbital, supra orbital,or temporal pain lasting 15 to 80min.

Pain may occur once or multiple times per day with precise regularity.

Some component of parasympathetic over activity is present i.e lacrimation, conjunctival injection, ptosis or rhinorrhea.

Triggered by alcohol Produces pain in post.maxilla

Cluster headache

Treatment: An acute attack: Symptomatic treatment is with tryptan’s ergots and analgesics. Prophylaxis : lithium, ergotamine, prophylacticprednisone, and calcium channel blockers.

Temporal Arteritis -Is an inflammation(vasculitis) of cranial arterial

tree, secondary to giant cell granulomatous reaction.

Clinical features: most frequently affects adults above the age of

50 years. Dull aching or throbbing temporal pain.

accompanied by generalized symptoms , including fever, malaise, and loss of appetite.

Jaw claudication during mastication.

Temporal Arteritis

Diagnosis: elevated ESR . elevated CRP. Biopsy.-Treatment: high dose of steroid(prednisolone) 60 -100mg

daily. the steroid is tapered once the signs of the

disease are controlled. Prescribe calcium and vit.D supplements.

Take Home Message Orofacial pains are common cause of

morbidity. No definitive diagnostic criteria is

available and despite many investigation tools, misdiagnosis is common.

Many treatment modalities are in use, but no one is definitive.

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