IN THE NAME OF GOD Orofacial Pain Dr

IN THE NAME OF GOD

Orofacial Pain Dr. HR. Saeidi Associate Prof of Neurosurgery KUMS

Pain unpleasant sensory & emotional experience associated with actual & potential tissue damage.

Anatomic Considerations Ø Trigeminal nerve Ø Facial nerve Ø Cervical nerve 2 &3 Ø Glossopharyngeal nerve Ø Vagus nerve

v. Categories 1 - Local pain: Ø Ø Ø Dental Gingival Mucosal Salivary gland Temporomandibular joint Maxillary sinus

v. Categories of orofacial pain 2 - Neurological pain: TN Ø Glossopharyngeal neu Ø Ramsy hunt synd Ø Postherpetic neu Ø 3 - Vascular : Giant cell arteritis Ø Migraine Ø Cluster headache Ø

v. Categories of orofacial pain 4 - Psychogenic pain: Atypical facial pain Ø Atypical odontalgia Ø 5 - Referred pain: Ø Cardiac pain

Evaluation and assessment history: 1 -Chief complaint. 2 - Pain Characteristics � Onset & Intensity � Quality& location � Duration & timing of pain � Course of symptoms since onset � Activities that ↑ or ↓ pain � Associated symptoms � Previous treatments

Past medical history -Connective tissue dis. -Demyelination dis -Metastatic dis. -IHD Social history: - traumatic event prior to onset of pain. -Change in work, or problem marital state.

Physical examination: 1. head & neck skin, 2. Palpation of masticatory muscles, 3. range of mandibular movement. 4. Palpation of soft tissue. 5. Palpation of the TM joint 6. Palpation of cervical muscles 7. Cranial nerve 8. ears, nose, teeth, oropharyngeal

Diagnostic Imaging Ø - confirm diagnosis R/O serious dis Ø -Extent of an identified dis Ø -Most OFP not produce abnormality

v. TMJ DISORDERS 1 -Myofascial pain. 2 -Traumatic injuries. 3 -Arthritis &Arthrosis: infective , systemic, degenerative. 4 -Internal derangement.

v Myofascial Ø Ø Ø pain diffuse poorly localized periauricular pain may be severe in morning ↑ pain in tension & anxiety ↓ range of mandibular movemen Ø "trigger points Ø

Manage of myofascial pain -Education of patient & self care of teeth. � -thermal therapy(U/S, laser ). � � ü ü -Pharmacotherapy: -NSAID, muscle relaxant -Antianexiety&TCA Botox injection. Trigger point block therapies

INTERNAL DERANGMENT OF TMJ � Pain on palpation over TMJ. � ↓ joint range of motion. � Deviation on opening. � Joint noises with pain. � Joint crepitus

ultrasound apparatus in use Soft laser apparatus in use

v. NEURALGIA: CAVITATIONAL OSTEONECROSIS Ø Ø Ø Rare continuous lancinating in site of previous tooth extraction. Usually in lower 3 rd molar region Pain not interfere with sleep RG: mooth eaten in site of extraction Treated by resection of bone with pain

Neuralgia-inducing cavitational osteonecrosis (NICO). Periapical radiograph demonstrates an oval radiolucency in the third molar region and thin lamina dura remnants (residual socket).

v. Trigeminal neuralgia: Definition : unilateral sever brief sudden stabbing pain in distribution of 1 to 3 branches of nerve. v

v. Etiology and pathophysiology Ø primary : vascular compression of nerve near its entry into the pons (superior cerebellar artery). Ø Secondary : MS, tumors , basilar artery eneurysim.

v Clinical features Ø Ø Ø episodic , recurrent unilateral facial, sudden high intensity stabbing or electric shock pain few seconds to minutes triggered by stimulation: touching of face, washing , shaving , chewing and talking.

v. TN Clinical features It occurs mostly after 5 th decade. Ø PE of face is nearly always normal. Ø If sensory loss is present a mass lesion is more likely Ø In young pts MS should be considered. Ø

v. TN Diagnosis: history, PE. Ø A careful search for ipsilateral dental pathology Ø MRI & MRA if there is suspicion of underlying pathology. Ø

Right Trigeminal Nerve Compressing vessel

v. Medical Treatment of TN ü ü ü ü Carbamazepine(effective in 75% as first line) Oxcarbazepine in pts sensitive to Carbamazepine. Baclofen Gabapentine Lamotrigine Clonazepam Phenytoin Valproate

v. Surgical treatment of TN If medical treatment (carb) has been ineffective after 4 weeks at maximum tolerated dose. a) peripheral procedures : alcohol injection, cryosurgery , nerve avulsion a) Percutaneous ganglion procedure: RF thermocoaglation , glycerol injection , balloon compression, Gamma knife. Open operations : MVD , trigeminal root section, b)

microvascular decompression Gamma knife

v. Post-herpetic neuralgia -Pain : aching, burning, shock like. � -Potential sequela of infection with herpes zoster. � � Pain persist longer than one month after healing vesicle classified as PHN.

Management: � -Antiviral and corticosteroids after presentation of rash reduce PHN � -Anticonvulsant drugs � -Local anesthesia injected to painful site.

v. Glossopharangeal neuralgia Clinical features : Ø Ø Ø Pain similar to TN. Affect tonsil , tongue base, ear, intra articular area. Patient often point just to behind mandible angle. Triggered by yawing and swallowing. may be associated with a vasovagal reflex, The application of a topical anesthetic to the pharyngeal mucosa eliminates nerve pain.

v. Glossopharangeal neuralgia Etiology: Causes : are intra or extracranial tumors & vascular abnormalities that compress CN IX. Management: -Anti convulsion : carbamazepine. Ø -NVD Ø -Percutaneous R. F at jugular foramen. Ø Ø -Intra or extra cranial neuroectomy.

v. Occipital Neuralgia paroxysmal stabbing pain in greater or lesser occipital nerves area. Ø may be caused by trauma, Ø Palpation below the superior nuchal line may reveal a tender spot. Ø Treatment has included occipital nerve block, neurolysis, C 2 dorsal root gangionectomy , Ø

v. Post -Traumatic Neuropathic Pain Its caused by 5 th nerve injuries from facial trauma or surgical procedures, such as the removal of impacted third molars, the placement of dental implant Ø Clinical Manifestations: The pain may be persistent or occur only in response to a stimulus, such as a light touch. Ø Patients may experience anesthesia , paresthesia, allodynia , or hyperalgesia.

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

v. Complex Regional Pain Syndrome( CRPs) chronic pain conditions that develop as a result of injury. Ø patients suffer from allodynia, hyperalgesia, and spontaneous pain that extends beyond the affected nerve dermatome. Ø it accompanied by motor and sweat abnormalities, atrophic changes in muscles and skin, edema, Ø

v. Complex Regional Pain Syndrome Types of CRPs : 1 - CRPS I was previously termed reflex sympathetic dystrophy (RSD), 2 - CRPS II was previously termed causalgia. Etiology and Pathogenesis: Ø believed to result from changes after trauma that couples sensory nerve fibers with sympathetic fibers.

Complex Regional Pain Syn treatment physical therapy. Ø block of regional sympathetic ganglia or regional intravenous blockades with guanethidine , reserpine, or phenoxybenzamine, Ø Bisphonates such as alendronate or pamidronate. Ø

v. Nervous Intermedius (Geniculate) Neuralgia Paroxysmal pain of facial nerve, may result of herpes zoster of geniculate ganglion. -Clinical features: Ø -Pain at the ear, anterior tongue, soft palate. Ø -Not intense like T. N. Ø - Ramsay-hunt syndrome may develop(Facial paralysis , vesicle , tinnitus & vertigo) v

Management: � -High dose of steroid for 2 -3 weeks. � -Acyclovir significantly ↓ duration. � -Anti convulsion , Carbamezipine. � -Surgery: section of nerve intermedius.

v. Bell's palsy Ø about 50% of pts , pain occur in the ear but sometimes spreading down the jaw, either precedes or develops at the same time as the palsy. Ø Treatment: prednisolone , acyclovir.

v. Atypical facial pain Ø Constant dull aching pain , deep , diffuse variable intensity in absence of identifiable organic disease. Its more common in female. Ø Most patient middle age and elderly. Ø

v. Atypical facial pain Clinical features: Ø Ø Ø Ø Often difficult for pts to describe symptoms. described as deep , constant ache or burning. Doesn't awake patient. NO anatomical pattern and may be bilateral. Affect maxilla more than mandible. Often initiated or ↑ by dental treatment. PE entirely normal. Often have other complaints such as IBS , dry mouth and chronic pain syndrome.

v. Atypical facial pain treatment Often rewarded with limited response. Ø TAD have some effect in some pts. Ø 30% of pt. S respond to Gabapentine Ø Cognitive behavior therapy Ø

v. Atypical odontalgia (phantom) Most frequently in women in 4 TH, 5 TH of life, Ø Constant dull, aching pain without an apparent cause that can be detected by examination , Ø After dental extraction or endodontic treatment , Ø Period of pain free after 2 th dental management. Ø

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

Burning mouth syndrome 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.

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. �

v. Burning mouth syndrome Investigation: FBS , haematinics , swab for Candida. Treatment: Ø Ø Ø Reassurance. Avoidance of stimulating factors. Some patients may respond to TCA, SSRIs topical clonazepam, sucking and spitting 2 -month course alfa-lipoic acid. Cognitive behavior therapy.

v. 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.

v. Types of Eagles syndrome: 1 -Classic : the symptoms are persistent pharyngeal pain ↑ by swallowing & radiate to the ear , with sensation of foreign body within pharynx pain arise following tonsillectomy due to scar tissue around the tip of the styloid process.

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.

v. Diagnosis: (1)clinical manifestations, (2) digital palpation of the process in the tonsillar fossa, (3) radiological findings. (4) lidocaine infiltration test. v Treatment: Medical: NSAID & injecting steroids& anesthetics into the lesser cornu of the hyoid or tonsillar fossa Surgical: intra oral or extra oral styloidectomy

Migraine Before puberty , female > male. Ø Aura before headache in 40%. Ø may triggered by foods : nuts, chocolate, red wine , stress, sleep deprivation, hunger. Ø

Clinical manifestation: A-classic migraine (start with aura for 20 -30 min ) � Flashing lights Scotoma Sensitivity to light Sensory and motor deficit Aura 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 �

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. �

Migraine treatment Avoid trigger factors v Acute attack: analgesics, Sumatriptan , ergotamin. v v Prophylaxis : pizotifen , propranolol , ca channel blockers. TCAs

Cluster headache Clinical Manifestations: � � � 80%of pts with CH are men. The attacks are sudden, unilateral, stabbing , causing pts to pace, cry out, or even strike objects. Some exhibit violent behavior in attacks. pain as a hot metal rod in or around the eye. attack lasts from 15 min to 2 hrs & recurs several times daily. A majority of episodes at night, awaking the pts.

Cluster headache Clinical Manifestations: pain with nasal congestion, tearing, Sweating of the face, ptosis, ↑ salivation, edema of the eyelid. � pain in posterior maxilla that mimic dental pain. � Trigger by alcohol. �

CH treatment Ø An acute attack: 100% oxygen (its effectiveness is diagnostic), Injection of sumatriptan or sublingual or inhaled ergotamine Ø Prophylaxis : lithium, ergotamine, prednisone, and calcium channel blockers.

Chronic Paroxysmal Hemicrania Ø A form of CH that occurs predominantly in women between 30 - 40 years. Ø The episodes of pain tend be shorter, but attacks of 5 to 20 min, can occur up to 30 times daily. Ø It responds dramatically to indomethacin , which stops the attacks within 1 to 2 days.

v. Temporal Arteritis -Its inflammation(vasculitis) of cranial arteries due to to giant cell arteritis Clinical features: Ø most frequently affects adults > 50 years. Dull aching or throbbing temporal pain with generalized symptoms : fever, malaise, ↓ appetite. Ø Jaw claudication during mastication. Ø

v. Temporal Arteritis Diagnosis: Ø elevated ESR 50 -100. Ø elevated CRP. Ø Biopsy. -Treatment: Ø high dose of steroid(prednisolone) Ø the steroid is tapered once the signs of the disease are controlled. Ø Patients are maintained on systemic steroids for 1 to 2 years after symptoms resolve.

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