Pain differential diagnosis for crrection management

1. Differential Diagnosis of
Orofacial Pain
Sailesh Kumar. R
OMFS PG Trainee
MADCH

2. • Pain: is unpleasant sensory and emotional experience associated
with actual and potential tissue damage.
• Types :
• Acute
• Chronic

3. Acute Orofacial Pain
• Intraoral pain
• Dental
• Periodontal
• Mucosal
• Related structures
• Maxillary sinus
• Salivary glands
• Mostly inflammatory in origin,
• Due to: infection, trauma, malignancy

4. Dental
• Dentinal Pain
• Evoked
• (cold, sweet)
• Short, mild
• Pulpal Pain
• Spontaneous, or evoked (cold)
• Paroxysmal
• Severe
• Not affected by antibiotics
Periodontal
• Periapical Pain
• Spontaneous, long lasting
• Strong
• Evoked by chewing
• No cold sensitivity
• Lateral periodontal Pain
• Spontaneous, long lasting
• Mild to strong
• Evoked by chewing
• Affected by antibiotics

5. Chronic Orofacial Pain
• Masticatory muscles
• Tension-type headache
• TMJ disorders
Musculoskeletal
• Migraine
• Cluster headache
• Paroxysmal hemicrania
• Neurovascular orofacial pain (VOP)
Neurovascular
• Paroxysmal
• Neuralgias
• Continuous
• Deafferentation
Neuropathic

6. Myofascial pain
• Diffuse poorly localized periauricular pain.
• May associated with parafunctional habits .
• The pain may be severe in morning.
• The pain is more severe during periods of tension and anxiety.
• The range of mandibular movement decrease .
• "trigger points," where muscles have taut, palpable band regions that
twitch when manually percussed.

7. Management of myofascial pain:
-Education of patient and explanation .
-Self care to eliminate oral habit such as gum chewing , clenching
of teeth.
-thermal therapy(U/S, laser ).
-Intraoral appliance.
-Pharmacotherapy:
-NSAID.
-Muscle relaxant drugs ,
-Antianxiety drugs.
-TCAs.
Botox injection.
Trigger point block therapies, using local anesthetic in combination
with corticosteroid.

8. Temporo mandibular pain & dysfunction
(TMD)
• Pain is chronic, daily, doesn’t wake from sleep
• Mostly seen in females
• Unilateral: angle of mandibule & front of ear
• Pain on chewing & yawning
• Limited mouth opening (less than 45 mm)
• Masticatory muscles tender to palpation (mostly unilateral)

9. Conservative management of TMDs
•Medication
Amitriptyline (10 – 20 mg)
NSAIDs
Analgesics
•Physical Therapy
•Soft Diet
•Occlusal splint
•CBT

10. NEURALGIA-INDUCING CAVITATIONAL
OSTEONECROSIS
Rare pain disorder characterized by continuous lancinating like pain
in site of previous tooth extraction.
Usually in lower 3rd molar region.
Pain not interfere with sleep.
Radiographically appear as moth eaten or soap bubbles in site of
previous extraction.
Treated by resection of bone area with pain ,

11. Neurovascular Pain
Migraines
TACs - Trigeminal Autonomic Cephalgias :
• Cluster Headache
• Paroxysmal Hemicrania
• SUNCT
• Neurovascular Orofacial Pain (NVOP)

12. Common Features of Neurovascular Pain
• Pain is:
• Periodic
• Severe
• Unilateral
• Pulsatile
• Wakes from sleep
•Accompanied by:
• Local autonomic signs
Ocular: tearing, redness, ptosis,
miosis
Nasal: rhinorrhea, congestion ,
Local swelling or redness
• Systemic signs
Nausea, vomiting
Photo/phonophobia

13. The TACs -Trigeminal Autonomic Cephalgias
• Cluster Headache
• Paroxysmal Hemicrania
• SUNCT (Short – lasting unilateral neuralgiform headache with
conjunctival injection and tearing)

14. Cluster Headache
• Very severe pain around the orbit
• Short duration (15 - 120 mins)
• Active (cluster) and non-active periods
• Once a day (50% wakes)
• Autonomic signs:
• Tearing, redness of eye
• myosis, Ptosis,
• rhinorrhea

15. Cluster Headache
• Pain characteristics
• Unilateral
• Severe
• Paroxysmal
• Active periods: For 4-12
weeks Every 6-18 months
•Epidemiology
• Male/female (!) 5:1
• Onset 30-40 years
• Prevalence 0.24%
• (Migraine 10 – 15%)

16. Abortive treatment of CH
Agent Dose Comments
• Oxygen 8 liters/min First line, but cumbersome
• Sumatriptan 6-12mg Effective, fast
• Dihydro-ergotamine 0.5-1mg Reduces pain severity

17. Prophylactic treatment of episodic cluster
headache
Agent Dose mg/d Comments
• Verapamil 160-480 First line
• Prednisone 50-80 Initial therapy till verapamil
takes effect.
• Valproic Acid 600-2000 For patients with migraine
• Topiramate 25-200 Increase by 25mg/d
every 5 days

18. Paroxysmal hemicrania
•Unilateral, around orbit and temple
•Frequent (up to 30 per day), wakes from sleep Associated signs
(ipsilateral):
•Short attacks (15 -30 min) of sharp, excruciating pain
•Conjunctival injection
•Tearing with nasal congestion and rhinorrhea

19. Paroxysmal hemicrania treatment
• Absolute response to Indomethacine 25 - 150 mg / d (Abortive and
Prophylactic)
• To avoid GI side effects:
• Omeprazole 20-40 mg/day

20. SUNCT syndrome
• A rare type of primary headache that belongs to the group of headaches
called trigeminal autonomic cephalalgia (TACs).
• TACs are caused by activation of the autonomic nervous system of the trigeminal nerve in the
face.
• Patients experience excruciating burning, stabbing, or electrical headache mainly in
the orbital area only on one side of the body.
• Each attack can last from five seconds to six minutes and may occur up to 200 times daily.
• Onset of the symptoms usually come later in life, at an average age of about 50. Although the
majority of patients are males above age 50, it is not uncommon to find SUNCT present among
other age groups, including children and infants.

21. • There is no permanent cure available.
• Though antiepileptic drugs (membrane-stabilizing drugs) such
as pregabalin, gabapentin, topiramate,and lamotrigine improve
symptoms

22. Neuropathic Orofacial Pain (NOP) : Common
entities
•Trigeminal Neuralgia
•Post Herpetic Neuralgia
•Ramsay Hunt Syndrome
•Deafferentation Pain
•Neuritis

23. Trigeminal Neuralgia
• Pain is:
• Paroxysmal
• Short (seconds)
• Provokable (triggered)
• Unilateral Confined to Vth nerve

24. Drugs used in Trigeminal neuralgia

25. Pretrigeminal Neuralgia
• PTN has been reported in 18% of Trigeminal Neuralgia patients.
• Characterized by dull continues pain for months to yrs becoming
more typical of TN as the process continues.
• PTN is highly responsive to Carbamazepine.

26. Herpetic Pain
• Acute herpetic
• Post herpetic
• Ramsay Hunt

27. Acute herpes zoster
•Affects the trigeminal nerve in 10-15% of cases
•Ophthalmic branch affected in 50-80% of cases
•Begins as localized pain followed by typical vesicular eruption within 7
days

28. Acute herpes zoster Treatment
Initiate drug treatment early, especially in patients >50-y to avoid rash
duration, pain severity and PHN

29. Post Herpetic Neuralgia
•Pain that develops in acute HZ but persists for > 6 months
•Pain is burning with superimposed stabbing pain
•Accompanied by allodynia and hyperalgesia
•Typical skin changes
•Affects elderly > young, 60% of patients >60y will develop PHN

30. Post Herpetic Neuralgia Treatment
•Drug
•Amitriptyline
•Opioids (oxycontin)
•Gabapentin
•Pregabalin
•Tramadol

31. Clinical features :
Pain similar to character of TN.
Affect tonsil ,tongue base, ear,and intra articular area.
Patient often point just to behind mandible angle.
Triggered by yawning and swallowing.
The application of a topical anesthetic to the pharyngeal mucosa eliminates
glossopharyngeal nerve pain.
Glossopharangeal neuralgia

32. Management:
-Anti convulsion drugs,carbamezipine.
-Vascular decompression.
-Intracranial or extra cranial neuroectomy.
Etiology:
The most common causes of glossopharyngeal neuralgia are intracranial
or extracranial tumors and vascular abnormalities that compress CN IX.
Glossopharangeal neuralgia

33. Occipital Neuralgia
A paroxysmal stabbing pain in the distribution of the greater or lesser occipital
nerves.
It 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 ,

34. Post -Traumatic Neuropathic Pain
Its caused by Trigeminal nerve injuries may result from facial trauma or from 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 with nerve damage may experience anesthesia , paresthesia, allodynia (from a
stimulus which normally doesn’t provoke pain) , or hyperalgesia .

35. Post -Traumatic Neuropathic Pain
Treatment:
 may be surgical ,nonsurgical, or both,
Systemic corticosteroids a when administered within the first week after a nerve
injury.
Anticonvulsant drugs, Gabapentin.
Topical capsaicin .

36. 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

37. Complex Regional Pain Syndrome
Etiology and Pathogenesis:
believed to result from changes after trauma that couples sensory nerve fibers
with sympathetic fibers.

38. Complex Regional Pain Syndrome
Treatment:
physical therapy.
block of regional sympathetic ganglia or regional intravenous blockades with
guanethidine ,reserpine, or phenoxybenzamine,
Bisphosphonates such as alendronate or pamidronate.

39. 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

40. Management:
-High dose of steroid for 2-3weeks.
-Acyclovir is significant in reduce the duration.
-Anti convulsion ,Carbamezipine.
Surgery: section of nerve intermedius.

41. CENTRAL POSTSTROKE PAIN
 Condition secondary to damage caused by a cerebrovascular
accident .
its is characterized by constant or paroxysmal pain accompanied
by sensory abnormalities ,

42. CENTRAL POSTSTROKE PAIN
Treatment:
anticonvulsant ( Lamotrigine,Gabapentine)
sodium channel blocker(Mexiletine).
Tricyclic Antidepressants (Amitriptyline).
Short-term relief may be obtained with intra venous lignocaine or
propofol .

43. Bell's palsy
 In about 50% of patient with Bell's palsy, pain occur in or near the ear
but sometimes spreading down the jaw, either precedes or develops at
the same time as the facial palsy.
Treatment: prednisolone 60-80 mg per day, acyclovir.

44. 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 .

45. Atypical facial pain
Clinical 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 irritable bowel syndrome ,dry mouth and
chronic pain syndrome .

46. Atypical facial pain
Treatment :
Often rewarded with limited response.
Tricyclic antideprssant drugs have some effect in some patients .
30% of patient respond to Gabapentine
Cognitive behavior therapy

47. occurs most frequently in women in the fourth and fifth decades of life,
 constant dull, aching pain without an apparent cause that can be
detected by examination ,
it occur after dental extraction or endodontic treatment ,
Period of pain free after secondary dental management.
Atypical odontalgia(phantom)

48. Management:
• patient reassurance ,consultation to other specialty
• T.C.A. like amitriptyline , nortriptyline at low dose. 10 -25 mg
at night
• Anti convulsant drugs.

49. 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

50. 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 .

51. Burning mouth syndrome
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.

52. 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.

53. Types of Eagles syndrome:
1-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.

54. 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.

56. Diagnosis:
(1)clinical manifestations,
(2) digital palpation of the process in the tonsillar fossa,
(3) radiological findings .
(4) lidocaine infiltration test.
Treatment:
CONSERVATIVE: involves injecting steroids or long-lasting anesthetics into
the lesser cornu of the hyoid or the inferior aspect of the tonsillar fossa
,NSAID
Surgical: intra oral or extra oral styloidectomy

57.  Before puberty , female more than male .
Aura may developed before headache in 40%.
It may be triggered by foods such as nuts,
chocolate, and red wine ; stress; sleep deprivation;
or hunger.
Migraine

58. Clinical manifestation:
A-classic migraine (start with prodromal aura occurring over 20-30
minutes )
• Flashing lights
• Scotoma (localized area of vision depression )
• Sensitivity to light
• Sensory and motor deficit
• Aura is 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

59. 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.

60. Migraine
Treatment :
Avoid trigger factors
Acute attack: analgesics, Sumatriptan (5-HT agonist) , Ergotamin.
Prophylaxis : pizotifen ,propranolol , ca channel blockers . TCAs

61. Temporal Arteritis
-Its inflammation(vasculitis) of cranial arterial tree secondary to giant cell
granulomatous.
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.

62. Temporal Arteritis
Diagnosis:
elevated ESR 50-100 .
elevated CRP.
Biopsy.
Treatment:
 high dose of steroid(prednisolone) 60 -100mg daily.
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.

63. Stress induced
• Oral parafunctions habits suppressed the stress induced expression of
Corticotropine releasing factor in paraventricular nucleus of hypothalamus
• Dysregulation of HPA axis
• There is altered cortisol function and basal hypocortisolism in stress state
• Enhanced pain sensitivity may be due to reduced release of Corticotropine
releasing hormone
*Stress and Pain (dys)regulation in Chronic Orofacial Pain By Ursula Gall,2008

64. 1-Burket,s oral medicine.
2-Neville , Oral & Maxillofacial PATHOLOGY
3-Fonseca Oral and Maxillofacial surgery.
4- Peter ward booth, Oral & Maxillofacial surgery.
5-Lecture notes in oral and maxillofacial surgery.
6- Orofacial pain ,from basic to management
References

65. THANK YOU