Oral Medicine Lec 5

7/27/2019 Oral Medicine Lec 5

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Pain f rom Extra Oral Diseases

Myofacial Pain Dysfunction Syndrome--

Refers to the clinical condition characterizedby pain , fatigue and spasm of the muscles of

mastication.

Tenderness to palpation in one or more of

these muscles is the most reliable diagnostic

feature of MPDS.


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Muscle tenderness is generally most

pronounced near the origin orinsertion of an affected muscle, butthe belly is often at least mildlytender.

This tenderness is most easilydemonstrated for the temporalis and

masseter muscles by applyingfingertip pressure during extremeopening and closing movement of the

mandible.


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The symptoms complex that defines the MPDS

includes :

1/ spasm of one or more of the muscles of

mastication.

2/ tenderness to palpation of one or more muscles

of mastication.3/ diffuse head pain that similar to tension headache

and is usually most severe in the morning.

4/ pain on jaw opening.

5/ limitation of opening measured to be less than 35-

40mm between incisal edges at the midline.

6/ lateral deviation during jaw opening.


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7/ evidence of bruxism or clenching history or

presence of generalized wear facets.

8/ malocclusion or evidence of occlusal disharmony.

9/ unilateral or bilateral preauricular pain during

palpation.

10/ joint sounds such as clicking, popping and

crepitus during opening.

The patient are usually young to middle aged

females who experience constant or episodic

emotional stress.


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The symptoms of MPDS tend to occur in cycles with

asymptomatic periods interposed between acute

bouts associated with demanding emotionalsituations. Occlusal disharmony may be a

contributory factor.

Treatment1. elimination of contributory factors, if possible

2. palliative treatment during acute periods of

discomfort, include: analgesics and application

of moisture heat to the spastic muscles is

generally adequate in mild cases.


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3. elimination of occlusal disharmony by removal of

isolated interference and comprehensive

orthodontic treatment of complex malocclusionmay be appropriate.

4. bite plane to minimize the bruxism adverse effects

5. counseling to promote better adaptation by the

patient to stress and dramatic emotional episodes

may help some individuals .

Any combination of these approaches may be

necessary to achieve relief in a specific case.


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-- Eagle's Syndrome

Ossification of styloid ligament is a common

idiopathic process, which progresses gradually and

is more pronounced among older patients.

The ossification is usually revealed by panoramic

radiographs of patients.

The pain is caused by the resistance of the rigid,

ossified ligament to the mobility of surrounding soft

tissues.


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This is usually associated with history of

tonsillectomy , which ( has produced scarring and

entrapment of the ligament).Symptoms develop years after the surgery as the

ossification progressively increases the rigidity of

the structure.

The nature of pain associated with eagle's syndrome

include sharpness in throat during swallowing

associated with chronic sore throat without

erythema .These sensation describe as fish bone caught in the

throat or as obstruction and burning sensation.

Treatment is surgical removal


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-- Frey's SyndromeAs a result of TMJ surgery , injury or infection in the

parotid region causing damage to the auriculo-

temporal nerve lead to connection between post

ganglionic parasympathetic nerve fiber from otic

ganglia which supply the salivary gland with

sympathetic fibers from superior cervical gangliawhich supplies sweat glands and the vascular wall

at the auriculo-temporal region , so sweating and

flushing to the region supplied by auriculo-temporal

nerve take place when the patient eats.In this case nerve connection is going to be wrong

so orders go from brain to vascular walls and sweat

gland instead of going to the salivary glands.

Treatment by rehabilitation.


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-- Vascular painPain originating from vascular structures may cause

facial pain that can be misdiagnosed for other oral

disorders, including toothache .

Classic Migraine Headache

Migraine is an intermittent paroxysmal headachewith pre-headache phase for free intervals caused

by vascular spasm initiated by release of

endogenous vasoactive mediators such as

serotonin , bradykinin which lead tovasoconstriction followed by reflex vasodilatation.

There is positive family history and females affected

more than males.


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due tovisual auraClassic migraine starts with a

ophthalmic artery spasm that commonly precedesclassic migraine include flashing lights or a

localized area of depressed vision (scotoma).

Sensitivity to light (photophopia), hemianesthesia ,aphasia, or other neurologic symptoms may also be

part of the aura , which lasts from 20 to 30 minutes.

The aura is followed by an increasingly severeunilateral throbbing headache that is frequently

accompanied by nausea and vomiting .


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The patient characteristically lies down in dark room

and tries to fall asleep.

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

Predisposing factors

1. emotional stress and anxiety2. menstrual cycle and hormonal changes.

3. contraceptive pills.

4. certain types of food preservatives , liver, cheese

and caffeine.5. alcohol.

6. drugs like nitroglycern and reserpin.

7. hypoglycemia.


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Treatment

- Migrel (1-2mg ergotamine + 100mg caffeine).

- Pizotifen 1.5mg at night or 0.5 mg three times daily.

-- B-blockers and Ca++ Channel blockers.

Common Migraine Headache, butnot preceded by an auraCommon migraine is

patients may experience irritability or other moodchanges.

The pain of common migraine resembles the pain of

classic migraine and is usually unilateral ,pounding

and associated with sensitivity to light and noise .nausea and vomiting are also common.

The pain accompanied by altered sensation , nasal

congestion , depression of salivation and

lacrimation.


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Cluster Headache (Migrainous neuralgia)

It is caused by vascular changes at the base of theskull and abnormal hypothalamic function,

moreover it may be due to oedema and dilatation of

the wall of the internal carotid artery and probably

also the external carotid artery.Men , young adult up to age 50 mainly affected.

Attack may be precipitated by alcohol or

vasodilators or come on spontaneously 1-3 timesdaily with duration of 0.5-2 hours, sometimes recur

at the same time each day or may disturb sleep like

clock alarm.


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Cluster of Pain is localized to the region of the orbit

,temple or maxilla associated with congestion and

lacrimation of eye the nostrils may be blocked. The

skin over the cheek may become red and maybecome sweating and tachycardia.

After one to several months , there is usually

sudden and spontaneously remission and the

patient remains completely free from pain for

months or even years.

Unlike migraine ,there is neither visual symptoms

nor nausea or vomiting.

Treatment: May response to simple analgesic or to

erogatamine.


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Cranial arteritis ( Temporal arteritis ,

Giant cell arteritis )

- Caused by immune abnormalities that affect

cytokines and T lymphocytes ,resulting in

inflammatory infiltrates in the walls of arteries.

- This infiltrates in the walls of arteries ischaracterized by the formation of multinucleated

giant cell . the underlying trigger of the

inflammatory response is unknown.

- Affected adults above the age of 50 years.

- Patient have a throbbing headache accompanied

by generalized symptoms including fever, malaise

and loss of appetite.


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examination of the involved temporalDiagnosis:

artery reveals a thickened pulsating vessel.

Laboratory abnormalities include an elevatederythrocyte sedimentation rate (ESR) and anemia.

The most definitive diagnostic test is a biopsy

specimen (temporal artery biopsy).

individual with cranial arteries should beTreatment:

treated with systemic corticosteroids. Steroid may

be supplemented by adjuvant therapy withimmunsupressive drugs, such as

cyclophosphamide to reduce the complications of

long-term corticosteroid therapy.


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Headache--- Headache usually describes the pain in the region

of the cranial vault.

-The extracranial coverings and arteries are

sensitive to pain . Within the cranial cavity ,there

are few pain sensitive structures.- Pain can be evoked from venous sinuses , the

arteries and dura mater at the base of the brain.

Displacement and distortion of these structure

cause headache.The 5th , 9th, 10th cranial nerves contain pain

fibers and direct compression of these nerves

produces pain.


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Headache may be due to :

Referred Pain

Eye diseases, nasal and sinus diseases, dental and

oral conditions, cervical spondylosis.

Cranial neuralgia

Tempromandibular neuralgia arises as a result of

derangement of TMJ secondary to an alteration of

the bite caused by loss of teeth , ill-fitting dentures

or habitual over-closing of the jaw because of

tension.

Pain various from a dull ache to intense stabs ,

radiate to the temporal and frontal areas, the cheek,

lower jaw and occasionally to the neck.

M i l i it ti


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Meningeal irritation

Headache is an almost accompaniment of

encephalitis and meningitis. The pain increase by

minor movement of head , the accompanyingpyrexia and neck stiffness usually make the

diagnosis obvious.

Vascular headacheThese are almost described as throbbing in

character and are aggregated by head movements.

Headache due to traction on intracranial structures

Headache may occur in the presence of anexpanding intracranial lesion such as cerebral tumor

or due to lowered intracranial pressure due to

reduced cerebrospinal fluid (CSF) after lumbar

puncture


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Psychogenic headache

Are associated with anxiety and depression.It described as pressing, severe ,continuous and

unrelieved by analgesics.

It tend to be localized to the front of the head or to

the vertex or it may involve the whole head.

It is prominent on waking in the morning and tends

to get worse as the day wears on.


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Tension headache

The tension headache is the most common form , it

precipitated by demanding emotional situations

leading to muscle strain. The mechanism areprobably more complex, but stress , over work and

depression are definite initiating factors.

The bilateral pain is described as fullness ,pressure

or tightness with waves of superimposed aching.

Attacks may be acute with duration of few hours to a

day or in some instances the pain can be relativelyconstant for days or weeks.

by relaxation training , analgesics ,Treatment:

antianaxiety drugs

Oral Medicine Lec 5

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