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Pain

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A lecture to fifth stage dentistry students

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Pain

  1. 1. Dr.Mohammed Rhael Ali Maxillofacial surgeon Tikrit dentistry college
  2. 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.
  3. 3. 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.
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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.
  8. 8. 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
  9. 9. 4- Psychogenic : Atypical facial pain Atypical odontalgia Burning mouth syndrome 5- Referred pain: Cardiac pain Causes of orofacial pain
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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.
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. Treatment: An acute attack: Symptomatic treatment is with tryptan’s ergots and analgesics. Prophylaxis : lithium, ergotamine, prophylactic prednisone, and calcium channel blockers.
  21. 21. 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
  22. 22. 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
  23. 23. 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.
  24. 24. diagnosis Diagnosis depend on history and clinical examination. One should always assess cranialnerve function. MRI to detect vascular compress
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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.
  29. 29. 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.
  30. 30. 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
  31. 31. 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.
  32. 32. 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.
  33. 33. 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 .
  34. 34. 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
  35. 35. 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
  36. 36. 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.
  37. 37. 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.
  38. 38. Thank you for listening … #Rahil @Dr.Mohamed_rahil @rahil_clinic

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