Orofacial pain
February 5, 2012 No Comments
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 argumentative from:
Pain
Swelling
Bleeding
Ulcer
Discolored mucosa
Pain: unlikable emotional experience caused by injury to the late or mind.
Pain is hard in diagnosis because:
- Due to the difference in the nature of pain:
It varies from one individual to another & has several forms as aching, hurting, 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 with the intention of is transmitted through afferent neuron to cerebral cortex with the intention of interpret the stimuli and send a rejoinder through efferent neurons.
Pain perception: physicoanatomical process by which pain is received & transmitted to higher centers.
Pain reaction: the manifestation shown as a consequence of pain perception & interpretation.
Pain reaction differs according to:
Age (ancient, childish)
Sex (male, female)
Emotional status à(adjust the intensity & the personal behavior rejoinder to pain).
Religious thing
Shape 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. (habitual neural st.)
Noxious stimuli could be:
Thermal changes (impression)
Mechanical (shock)
Pressure (denture)
Chemicals (aspirin)
Bacterial, viral, fungal infection.
Systemic disease with oral manifestation.
Somatic pain can be:
Profound or superficial
Superficial:
Astute, simple to be localized.
E.g. skin, mucus membrane (ulcers).
Profound:
Dull, diffuse, hard to be localized.
E.g. pulpal pain, osseous pain as (abscess), strong pain (stress & strainàischemiaàrippleàtresmus), ligament, & joints pain.
Vascular: pain due to changes in the blood flow (pain due to noxious stimuli with the intention of affect the vascular tissue or perivascular tissue) some classify it as profound strong pain.
E.g. migraine, cluster headache, Milkerson Rosenthial syndrome.
Migraine:
Unilateral headache in the maxillary, forward, 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.
TXàergotamineàside thingsàhypertension & 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, mundane, & orbital bone followed by relief & repeat for about 1:30hour.
It s usually associated with watered-down discharge of the nose, nasal congestion, nostril blockage in the affected side, eye tearing, eye flush & 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 mundane headache.
Chelitis graulomatosa.
Vascular pain can be treated by analgesics.
Neurogenic: pain occurring along the way of the nerve due to abnormality in the neural st. of the nerve itself.
Chch:
- Paroxysmal.
- Very sever & astute “like electric shook”.
- Localized to the affected sensory nerve.
It may be 1ry (trigeminal, & glossopharyngeal) neuralgia, or 2ry neuralgia.
1ry neuralgia: (unknown cause)
Severe, astute, paroxysmal pain along the way of the nerve but dose not cross the midline due to abnormality in the neural st. of the nerve it self but no pathological abrasion present.
Pain resembles electric shock.
Trigeminal neuralgia:
Severe, astute, paroxysmal pain along the way of the trigeminal nerve. (Sudden onset & disappear increasingly).
Female>male, right>rescind side, ancient>childish age, maxillary > mandible >ophthalmic branch.
Etiology:
Unknown cause.
But there are 2 theories the 1st (most conventional) says with the intention of pain is due to stretching & demylenation of the trigeminal nerve above the petrous section of the mundane bone which is larger in females, right side, ancient.
2nd says with the intention of pain is due to pulsation of the carotid artery above the gassarian ganglionàpressure.
Trigger zone: mild sensory stimuli (chip, touch, brushing, washing) directed to this zone will consequence in the neuralgial attack. Linking the attacks the zone becomes refractory (pt is pain free linking the attacks).
Half inch road sign or frozen face.
D.D.:
Post herpetic neuralgia.
Pulpal pain.
Tumors in the orofacial st.
Scarce pain.
To differentiate:
- Presence of scarce agent.
- Continuous not in attacks.
TX:
-medically by Tegratol (anticonvulsant) 200mg /3times per day
It shouldn’t exceed 800mg
Side things (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 astute paroxysmal pain along the way of the glossopharyngeal nerve.
Erratic.
Trigger area:
Nasopharynix
Gentle palate
Tonsil
Sides of the tongue.
Stimuli (coughing, vast, 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 go sensation.
For diagnosis topical anesthesia application will relief pain.
2ry neuralgia: (well known cause) pathological changes adjust the nerve st. & cause neuralgia.
e.g.
Post herpetic neuralgia: as complication of the herpes zoster infection chch by very severe knife cutting astute pain with the intention of cannot be treated.
Antiviral & cortisones are given in these cases to preclude 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 enlargementàcompression on the nerve.
Post distressing neuroma: due to the accidental severing of the nerve, all through healing, nurolemmal scabbard make a neuroma with the intention of scare nerve impulse. This cause severe astute pain in the lip with increased T.
Coalgia: severe astute lancating pain in the socket due to the sectioning of the peripheral nerve all through extraction.
Neuralgia 2ry to malignancy: malignant tumor can invade the nerve causing neuralgia. E.g. Trroter syndrome àepidermal carcinoma in the lateral wall of the pharynx extending to the maxillary or mandibular division.
Maxillary àpain in cheek.
Mandibular àpain in tongue & lip parasthesia.
Eustachian tube àdeafness.
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 latter teeth.
-pulpitis in the lower teeth referred to the upper teeth.
Psychogenic (scarce facial pain): facial pain with the intention of dose not follow anatomical pathway, & has no organic cause.
Dull pain, apply widely, bilateral, poorly localized & the pt can’t determine the pain feature.
Female>male, childish>ancient, maxilla>mandible, most run of the mill in the sides of the tongue, cross the midline.
Sometimes called psychogenic pain because it s run of the mill in pt with depression & usually seen in pt with abnormal behavior.
How to diagnose?
-Hx
-clinically & investigation (satiated mouth x-ray, vitality test, sensitivity test, GTT, CBC)
-pt behavior & attitude (it can be diagnosed mainly by exclusion)
Tx:
Manifold visitsàPt assuranceà to right the behavioràreffer to a specialist.
Mycofacial pain dysfunction syndrome (MFPD): chronic disorder chch by dull unilateral pain concerning the side of the face, extending around the ear, periaurecular, forward, occipital, sternoclidomastoid muscle…etc.
Male>female, ancient>childish.
Pain on palpation of muscle of mastication.
Pt starts with pain & chch of clicking & trismus without any pathological abnormality in TMJ.
Possible causes:
Fantastic VDOàfinished extension. E.g. high filling.
Small VDOàfinished contraction.
Clenching & bruxismàMuscle fatigue.
If untreated:
- After 1 yearàdeviation of the jaw to one side on opening.
- These defects cause rupture of the sarcoplasmic reticulum with the intention of release the inflammatory mediators & stimulate the pain receptors.
Tx:
-cause removal.
-moist heat application for 3min.
-topical anesthesia.
-muscle exercise (tongue glue the post. Section of the palate several times all through the day).
Diagnosis of tha orofacial pain: (VIP)
Clinical history:
-meticulous Hx of the pain complaint:
When pain start? (Onset sudden or gradual)
Where dose it start? (Anatomical house)
How lingering it takes to start (duration)
How lingering it takes to relief (duration)
Nature of pain (hurtingàabscess, dullàperiodontal, astuteàpulpal, lancatingàneurological)
Severity of pain (if interfere with sleeping, talkingàsever, if notàmild)
Localization
Associated symptoms
Is the pain associated with any systemic disease?
-Hx of the related disease (arthritis, strong complaint, neurologic or psychogenic disorder).
Clinical examination of the teeth, their supporting & associated st. (vitality tests, hitting tests, x-ray, sinus x-ray).
Rapid cranial nerve evaluation:
Nerve
Test
1
Check one of the nostrils & check smell skill.
2,3
Pupil reaction to light (contraction).
4,6
Allow pupil to follow tender differ without tender the head
5
Touch the skin with (astute & blunt objects).
Check muscle of mastication.
Pt go mandible hostile to pressure.
7
If affected the pt cannot raise his eye top, close the eye lash, and blow his mouth on the affected side.
Also it causes dropping of the confront of the mouth.
8
Drop an differ on the ground & question about hearing.
9,10
Question pt to say ahhhhhhhhhà uvula tender, gagging reflex.
11
Check sternoclidomastoid & trapezius muscle
Question the pt to tilt the head hostile to 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 argumentative from:
Pain
Swelling
Bleeding
Ulcer
Discolored mucosa
Pain: unlikable emotional experience caused by injury to the late or mind.
Pain is hard in diagnosis because:
- Due to the difference in the nature of pain:
It varies from one individual to another & has several forms as aching, hurting, 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 with the intention of is transmitted through afferent neuron to cerebral cortex with the intention of interpret the stimuli and send a rejoinder through efferent neurons.
Pain perception: physicoanatomical process by which pain is received & transmitted to higher centers.
Pain reaction: the manifestation shown as a consequence of pain perception & interpretation.
Pain reaction differs according to:
Age (ancient, childish)
Sex (male, female)
Emotional status à(adjust the intensity & the personal behavior rejoinder to pain).
Religious thing
Shape 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. (habitual neural st.)
Noxious stimuli could be:
Thermal changes (impression)
Mechanical (shock)
Pressure (denture)
Chemicals (aspirin)
Bacterial, viral, fungal infection.
Systemic disease with oral manifestation.
Somatic pain can be:
Profound or superficial
Superficial:
Astute, simple to be localized.
E.g. skin, mucus membrane (ulcers).
Profound:
Dull, diffuse, hard to be localized.
E.g. pulpal pain, osseous pain as (abscess), strong pain (stress & strainàischemiaàrippleàtresmus), ligament, & joints pain.
Vascular: pain due to changes in the blood flow (pain due to noxious stimuli with the intention of affect the vascular tissue or perivascular tissue) some classify it as profound strong pain.
E.g. migraine, cluster headache, Milkerson Rosenthial syndrome.
Migraine:
Unilateral headache in the maxillary, forward, 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.
TXàergotamineàside thingsàhypertension & 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, mundane, & orbital bone followed by relief & repeat for about 1:30hour.
It s usually associated with watered-down discharge of the nose, nasal congestion, nostril blockage in the affected side, eye tearing, eye flush & 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 mundane headache.
Chelitis graulomatosa.
Vascular pain can be treated by analgesics.
Neurogenic: pain occurring along the way of the nerve due to abnormality in the neural st. of the nerve itself.
Chch:
- Paroxysmal.
- Very sever & astute “like electric shook”.
- Localized to the affected sensory nerve.
It may be 1ry (trigeminal, & glossopharyngeal) neuralgia, or 2ry neuralgia.
1ry neuralgia: (unknown cause)
Severe, astute, paroxysmal pain along the way of the nerve but dose not cross the midline due to abnormality in the neural st. of the nerve it self but no pathological abrasion present.
Pain resembles electric shock.
Trigeminal neuralgia:
Severe, astute, paroxysmal pain along the way of the trigeminal nerve. (Sudden onset & disappear increasingly).
Female>male, right>rescind side, ancient>childish age, maxillary > mandible >ophthalmic branch.
Etiology:
Unknown cause.
But there are 2 theories the 1st (most conventional) says with the intention of pain is due to stretching & demylenation of the trigeminal nerve above the petrous section of the mundane bone which is larger in females, right side, ancient.
2nd says with the intention of pain is due to pulsation of the carotid artery above the gassarian ganglionàpressure.
Trigger zone: mild sensory stimuli (chip, touch, brushing, washing) directed to this zone will consequence in the neuralgial attack. Linking the attacks the zone becomes refractory (pt is pain free linking the attacks).
Half inch road sign or frozen face.
D.D.:
Post herpetic neuralgia.
Pulpal pain.
Tumors in the orofacial st.
Scarce pain.
To differentiate:
- Presence of scarce agent.
- Continuous not in attacks.
TX:
-medically by Tegratol (anticonvulsant) 200mg /3times per day
It shouldn’t exceed 800mg
Side things (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 astute paroxysmal pain along the way of the glossopharyngeal nerve.
Erratic.
Trigger area:
Nasopharynix
Gentle palate
Tonsil
Sides of the tongue.
Stimuli (coughing, vast, 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 go sensation.
For diagnosis topical anesthesia application will relief pain.
2ry neuralgia: (well known cause) pathological changes adjust the nerve st. & cause neuralgia.
e.g.
Post herpetic neuralgia: as complication of the herpes zoster infection chch by very severe knife cutting astute pain with the intention of cannot be treated.
Antiviral & cortisones are given in these cases to preclude 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 enlargementàcompression on the nerve.
Post distressing neuroma: due to the accidental severing of the nerve, all through healing, nurolemmal scabbard make a neuroma with the intention of scare nerve impulse. This cause severe astute pain in the lip with increased T.
Coalgia: severe astute lancating pain in the socket due to the sectioning of the peripheral nerve all through extraction.
Neuralgia 2ry to malignancy: malignant tumor can invade the nerve causing neuralgia. E.g. Trroter syndrome àepidermal carcinoma in the lateral wall of the pharynx extending to the maxillary or mandibular division.
Maxillary àpain in cheek.
Mandibular àpain in tongue & lip parasthesia.
Eustachian tube àdeafness.
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 latter teeth.
-pulpitis in the lower teeth referred to the upper teeth.
Psychogenic (scarce facial pain): facial pain with the intention of dose not follow anatomical pathway, & has no organic cause.
Dull pain, apply widely, bilateral, poorly localized & the pt can’t determine the pain feature.
Female>male, childish>ancient, maxilla>mandible, most run of the mill in the sides of the tongue, cross the midline.
Sometimes called psychogenic pain because it s run of the mill in pt with depression & usually seen in pt with abnormal behavior.
How to diagnose?
-Hx
-clinically & investigation (satiated mouth x-ray, vitality test, sensitivity test, GTT, CBC)
-pt behavior & attitude (it can be diagnosed mainly by exclusion)
Tx:
Manifold visitsàPt assuranceà to right the behavioràreffer to a specialist.
Mycofacial pain dysfunction syndrome (MFPD): chronic disorder chch by dull unilateral pain concerning the side of the face, extending around the ear, periaurecular, forward, occipital, sternoclidomastoid muscle…etc.
Male>female, ancient>childish.
Pain on palpation of muscle of mastication.
Pt starts with pain & chch of clicking & trismus without any pathological abnormality in TMJ.
Possible causes:
Fantastic VDOàfinished extension. E.g. high filling.
Small VDOàfinished contraction.
Clenching & bruxismàMuscle fatigue.
If untreated:
- After 1 yearàdeviation of the jaw to one side on opening.
- These defects cause rupture of the sarcoplasmic reticulum with the intention of release the inflammatory mediators & stimulate the pain receptors.
Tx:
-cause removal.
-moist heat application for 3min.
-topical anesthesia.
-muscle exercise (tongue glue the post. Section of the palate several times all through the day).
Diagnosis of tha orofacial pain: (VIP)
Clinical history:
-meticulous Hx of the pain complaint:
When pain start? (Onset sudden or gradual)
Where dose it start? (Anatomical house)
How lingering it takes to start (duration)
How lingering it takes to relief (duration)
Nature of pain (hurtingàabscess, dullàperiodontal, astuteàpulpal, lancatingàneurological)
Severity of pain (if interfere with sleeping, talkingàsever, if notàmild)
Localization
Associated symptoms
Is the pain associated with any systemic disease?
-Hx of the related disease (arthritis, strong complaint, neurologic or psychogenic disorder).
Clinical examination of the teeth, their supporting & associated st. (vitality tests, hitting tests, x-ray, sinus x-ray).
Rapid cranial nerve evaluation:
Nerve
Test
1
Check one of the nostrils & check smell skill.
2,3
Pupil reaction to light (contraction).
4,6
Allow pupil to follow tender differ without tender the head
5
Touch the skin with (astute & blunt objects).
Check muscle of mastication.
Pt go mandible hostile to pressure.
7
If affected the pt cannot raise his eye top, close the eye lash, and blow his mouth on the affected side.
Also it causes dropping of the confront of the mouth.
8
Drop an differ on the ground & question about hearing.
9,10
Question pt to say ahhhhhhhhhà uvula tender, gagging reflex.
11
Check sternoclidomastoid & trapezius muscle
Question the pt to tilt the head hostile to pressure.
12
Tongue protrusion.
TMJ disorders (imp. In late stage MPDS):
-functional or organic TMJ disorder.
-signs & symptoms.
-radiographic evaluation.
-Management.
Oral And Maxillofacial Pathologist
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