A lecture to fifth stage dentistry students

1. Dr.Mohammed Rhael Ali
Maxillofacial surgeon
Tikrit dentistry college

2. Definition
AN UNPLEASANT SENSATION CAUSED BY A NOXIOUS STIMULUS THAT IS
MEDIATED ALONG SPECIFIC NERVE PATHWAY INTO THE CENTRAL NERVOUS
SYSTEM, WHERE IT IS INTERPRETED AS PAIN.

4. Criteria for history taken in cases of
orofacial pain
0 character of pain : sharp,dull,throbbing,stabing..
0.severity of pain : mild, moderate, sever
0.site at which it felt and radiated ,etc
0.timing :frequency ,duration of attacks,etc.
0.provoking factors : hot ,cold,sweet,bruxism ,etc .
0.relieving factors :analgesia ,application of heat , etc.
0.associated clinical features : swelling. Ulcer,trismus ,etc.
0.other pain elsewhere in the body :abdominal ,cervical pain, etc.
0.general medical history
0.patients emotional history :anxiety ,depression, etc.
0.family history :ill health,death of parents ,brothers, etc.

5. Pain classification by origin :
Somatic pain Originating from the cells of the organ involved i.e. skin,
mucous membrane, bone, joint, muscles, etc…
Neurogenic pain Discomfort resulting within the nervous system.
Abnormality in the neural structures. No noxious stimulus
Psychogenic pain Resulting from psychic causes, No noxious
stimulus, No abnormality in neural structure

6. A- SOMATIC pain
Somatic pain is usually acute and localized, it also may be :
Superficial from the skin or mucous membrane due to noxious stimuli e.g.
thermal or chemical burns, mechanical, ulcerations, infection: ANUG
(bacterial) AHGS (viral) Candidiasis (fungal)
Character: Burning, Pricking, Localized.
Deep from bone, muscles, joints and ligaments (Eagle’s syndrome which is
due to calcification of the stylohyoid ligament)
Character: dull aching, referred
Inflammatory from collection of infected fluid e.g. Abscess, infected cyst,
pericoronitis.
Character: throbbing with tenderness tends to be localized.
Referred from paraoral structures e.g.maxillary sinus, ear, eyes
Character: deep

7. B-NEUROGENIC
Neuropathy : functional abnormality of nerves, that may be :
Neuritis: inflammatory change of the nerves. (burning sensation)
Neuralgia: pain along the course of the nerve caused by vascular
spasm and CNS diseases

8. 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: (sialoliths, sialadenitis) Characterized by pain, swelling
associated usually with eating , pus discharging from the ductal orifice.
Temporomandibular joint: Aching pain around the joint , Clicking of the
joint , Limitation of mouth opening
Maxillary sinus: (sinusitis,malignancy) Maxillary sinusitis pain is felt in relation to the
upper molars which may be tender to percussion , usually following a cold, increased with
bending
Bone : ( Dry socket, Fractures ,Osteomyelitis )
Ear ; Diseases of the ears (Otitis Media) Leading to facial pain, also oral
diseases can cause pain referred to the ear.

9. 2. Neurological :
Trigeminal neuralgia
Glossopharyngeal neuralgia
Postherpetic neuralgia
3- Vascular :
Giant cell arteritis and variant
Migraine and its variant
Cluster headache
Causes of orofacial pain

10. 4- Psychogenic :
Atypical facial pain
Atypical odontalgia
Burning mouth syndrome
5- Referred pain:
Cardiac pain
Causes of orofacial pain

12. Is defined as group of symptoms including pain of orofacial muscles,
and/or TMJ and dysfunction of TMJ.
Clinicl features :
TMD can involve the following :
1.Muscels of mastication: Myofascial pain(tendeness or dull aches around TMJ
including ear.
2.The TMJ: limited jaw opening or pain, jaw locking, clicking sounds.
3.Others: Headaches, ear aches, pain radiating to neck or shoulders, dizziness
and tinnitis.
1. Tempromandibular joint disorders (TMD)
Pain of Musculoskeletal Origin

13. Etiology :
o Parafunctional habits
o Occlusal disturbacne
o Local trauma
o Life events and mental health
Management:
Conservative therapies : Soft diet ,Limited talking
Mediations : NSAI , muscle relaxants
Avoidance of wide mouth opening.
Muscle massage (warm back , laser therapy )
Splint therapy :(night guide, bite raising appliance )
Botox injection to masticatory muscles
Surgery

15. Eagles syndrome
Is 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 feature
Pain is usually dull and nagging
Usually localized
May radiate to ear

16. diagnosis
(1)clinical manifestations,
(2) digital palpation of the process in the tonsillar fossa,
(3) radiological findings .
Treatment:
COSERVATIVE: involves injecting steroids,,NSAID
Surgical: intra oral or extra oral styloidectomy

17. Pain of vascular origin
Giant cell arteritis
It is an immunologically mediated disease characterized by
inflammation of the wall of medium size arteries, with prominent
giant cells, there is obliteration of the artery lumen and ischemia of
the part supplied by involved artery.
Giant cell arteritis may affect the craniofacial region e.g.
temporal arteritis

18. Temporal arteritis
Is characterized by unilateral or bilateral deep throbbing pain of
acute onset over the temporal region and prominent tortuous
tender temporal artery.
Pain may radiate to mandible or maxilla.
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.
Pain of vascular origin

19. Diagnosis:
elevated ESR .
elevated CRP.
Definitive diagnosis is based on temporal artery biopsy ® giant cell
arteritis.
-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.

20. migraine
Is a chronic 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.
o Duration : usually 12 to 72 hours
o Female:male ratio >2:1
o Neurologic aura :≈ 40%
o Usually unilateral
The mechanism although not completely understood
Pain of vascular origin

21. Treatment :
Avoid trigger factors
Acute attack: analgesics, Sumatriptan (5-HT agonist)
, Ergotamin.
Prophylaxis : is directed at normalizing neurotransmitter imbalance
with Antidepressants ,Anticonvulsants, beta-Blockers
Botox injection
Pain of vascular origin

22. Cluster head ache
Clinical manifestations
pain as a hot metal rod in or around the eye.Sever 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, ptosis or rhinorrhea.
Triggered by alcohol
Produces pain in post.maxilla
Pain of vascular origin

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

24. Trigeminal neuralgia
Definition :
usually unilateral severe, brief, sudden, stabbing recurrent pain in
distribution of one or more of branches of trigeminalnerve.
Pain of neurogenic origin

25. 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

26. 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. lasts for a few seconds to 1 minute
right> left
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.
Clinical examination of face is nearly always normal.
In young patients with TN, multiple sclerosis should be considered.

27. diagnosis
Diagnosis depend on history and clinical examination.
One should always assess cranialnerve function.
MRI to detect vascular compress

28. treatment
1- Medical treatment:
Anti convulsion drugs : carbamezipine, Phenytoin
Some cases respond to Gabapentine.
Surgical treatment(invasive):
indicated If medical treatment (carbamazepine) has been ineffective after 4 weeks at
maximum tolerated dose .
Glycerol or cohole injections
Peripheral neurectomies
Microvascular decompression
Percutaneous radiofrequency thermorizotomy
Gamma knife radiosurgery

30. Glossopharyngeal neuralgia
Is an uncommon disorder characterized by lancinating pain of
oropharynx or neck, sometimes triggerd by swallowing, coughing
or talking.
less common than TN.
arises in middle to late life.
males=females
Differences 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 same as that for trigeminal neuralgia
Pain of neurogenic origin

31. 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.
Antiviral and corticosteroids after presentation of rash
reduce incidence of postherptic neuralgia.
-Anticonvulsant drugs
-Local anesthesia injected to painful site.
managment
Pain of neurogenic origin

32. Atypical Facial Pain (Psychogenic Facial Pain)
"Persistent facial pain that does not have the characteristics of the
neuralgias and is not associated with physical signs Present daily and
persists most of the day.
It is confined at onset to a limited area on one side of the face and
may spread to the upper and lower jaws or other areas of the
face or neck.
It is deep and poorly localized.
Psychogenic Causes of Facial Pain
Clinical picture
It affects females more than males
Its common sites are the maxilla and the tongue.
Character of pain: Chronic, intermittent dull aching, and poorly localized so
that the patient is unable to define location of pain.

33. Psychogenic Causes of Facial Pain
It gets worse with fatigue and stress, but doesn't interfere with
eating or sleeping.
Responds poorly to analgesics.
Emotional breakdown, tears,hysteria are common.
Diagnosis
It is diagnosed by exclusion of other causes of Orofacial pain :
1. Case history
2.Clinical examination
3.Diagnostic aids
Vitality test and radiographs
Through examination of the nose and pharynx.
Oral examination.
Careful examination of the cranial nerves and parotid gland.

34. Atypical Odontalgia
Also called Idiopathic, Phantom tooth pain
Clinical features
Tooth ache with no detectable cause
Pain is unaffected by endodontic therapy or even extraction of the
tooth
Persistent pain in a single tooth or a group of teeth that exhibits no
abnormality on percussion or pulp testing

35. Burning mouth synd
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.

36. 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,
Cognitive behavior therapy.

37. 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 .
Clinical features:
Often difficult for patients to describe their symptoms .
Most frequently described as deep , constant ache or burning sensation
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 .

38. 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
Atypical facial pain

39. Atypical odontalgia
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:
Most common site Premolar and molar area , Maxillary>mandibular
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

40. Other Causes Of Headache & Facial Pain
(Miscellaneous Causes)
Orofacial pain may be referred from the chestas in ischemic heart
disease and lung cancer .
Raised intracranial pressure may cause headache. It may be due to
malignant hypertension, tumour or hematoma .
Diseases of the skull such as bone metastasis or Paget's disease may
cause headache .
Trotter's syndrome: it is orofacial pain caused bycarcinoma
affecting lateral wall of pharynx.

41. summary
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.

43. Thank you for listening …
#Rahil @Dr.Mohamed_rahil @rahil_clinic