OROFACIAL PAIN-1
DEFINITION
According
to
International
association for the study of pain
(IASP) pain is defined as :-
“An unpleasant sensory and
emotional
experience
associated with actual or
potential tissue damage, or
described in terms of such
damage.”
Dr.S.Karthiga Kannan
Porfessor
Oral Medicine & Radiology
SPECIFIC LEARNING OBJECTIVES
• To know the pathophysiology of orofacial pain
• To know the classification of orofacial pain
• To
know
the
clinical
characteristics
treatment of
– Trigeminal Neuralgia (TN)
– Glossopharyngeal Neuralgia (GN)
– Post Herpetic Neuralgia (PHN)
and
PAIN PATHWAYS
CLASSIFICATION OF
OROFACIAL PAIN
LOCAL DISEASES
☞ Dental causes Pulpal
Pulpitis
Dentin hypersensitivity
Cracked tooth syndrome
Apical periodontitis
Periapical Abcess
Gingivitis/Periodontitis
ANUG
Pericoronitis /pericoronal abcess
Oral ulcers
Oral Cancers
☞ ENT diseases like
sinusitis, otitis media
Pharygitis,
☞ Eye diseases – Conjunctivitis
CHORNIC OROFACIAL PAIN
☞Musculoskeletal diseases
Temporomandibular disorder(TMD)
Myofacial pain dysfunction syndrome
(MPDS)
Eagle’s syndrome
☞ Vascular diseases
Migraine
Cluster headach
Temporal or Giant cell arteritis
☞ Neurologic disorders
Trigeminal neuralgia
Glossopharyngeal neuralgia
Post herpetic neuralgia
☞ Psychogenic Pain
Atypical facial pain
Burning mouth syndrome
Atypical odontalgia
Episodic pain
☛ Trigeminal neuralgia
☛ Glossopharyngeal neuralgia
☛ Post-herpetic neuralgia
☛ Giant cell arteritis
Pattern of pain
Constant pain
☛ Burning mouth syndrome
☛ Atypical facial pain
☛ Atypical odontalgia
☛ Post-herpetic neuralgia
☛ Temporomandibular joint
dysfunction
Loss of function or sensation
☛ Facial nerve palsy
☛ Trigeminal nerve paresthesia
Category rating scale
Numeric rating scale
TRIGEMINAL NEURALGIA (TN)
Synonym –
☛ Tic douloureux,
☛ Fothergill’s neuralgia
Types
☛ Classical TN (85%) – caused by
compression of sensory root by
vascular anurysm.
☛ Secondary TN – caused by
tumors, viralinfection, trauma,
and multiple sclerosis.
☛ Is the most common of the cranial
neuralgias
☛ Age predilection - older than
50 years of age.
CLINICAL FEATURES
☛ NATURE – Unilateral, Paroxysmal
(occurs in episodes) awakes
from
sleep.
☛ QUALITY – Sharp,
stabbing,electric
piercing.
shock like,
☛ INTESITY – Severe
☛ AGGRAVATING FACTORS –
shaving, eating, washing face,
speaking, exposure to wind.
☛ DURATION – from seconds to 2
minutes.
☛ SITE – Maillary, mandibular,
Opthalmic
dermatome
in decending order, usually right
side.
Clinical features
☛ TRIGGER ZONE - Pain in TN is
precipitated
by a light
touch
on
a
“trigger
zone”(Allodynia) present on the
skin
or mucosa within the
distribution of the involved
nerve branch.
☛
Common sites for trigger zones
include the nasolabial fold and the
corner of the lip.
☛ REFRACTORY PERIOD - Just after an
attack, touching the trigger
zone will not precipitate pain.
☛
PAIN BEHAVIOR – spasm of
ipsilateral facial
muscles,
Patient protects / cover that
area.
DIFFERENTIAL DIAGNOSIS
☛ Cracked tooth Syndrome
☛ TN pain will be triggered by
touching the soft tissue
around the trigger zone,
whereas pressure on the
tooth is required to cause
pain from a cracked tooth.
INVESTIGATIONS
☛Local anesthetic blocks,
which temporarily eliminate
the trigger zone, may also
be helpful in diagnosis.
☛ CT scan,MRI of the brain is
indicated to rule out
tumors, multiple sclerosis.
☛ Magnetic
resonance
tomographic angiography
(MRTA) for vascular lesions.
MANAGEMENT OF TN
MEDICAL
☛ Carbamazepine – 100 -200 mg /
twice a day can be
increased slowly
☛ Baclofen – 5-10mg thrice a day
☛ Oxcarbamazepine – 300mg/
thrice a day
☛ Gabapentin – 200-300mg/twice a
day
☛ Phenytoin – 300 -600mg /day
☛ Lamotrigine 25mg/1-2 time
perday
SURGICAL
☛ Pheripheral Neurectomy
☛ Percutaneous Trigeminal
Rhizotomy – TN ganglion level
-Glycerol injection
-Ballon compression
-Radiofrequency rhizolysis
☛ Microvascular decompression
(MVD) – Brainstem level
☛ Gamma knife stereotactic
radiosurgery (GKS) – 70-90 Gy
radiation.
GLOSSOPHARYNGEAL NEURALGIA (GN)
☛ ETIOLOGY – compression of nerve root by
blood vessel or anurysm.
☛ TYPES
☛Pharyngeal GN
Pharynx, posterior tongue are involved
and radiate to ear, eyes, nose, maxilla,
shoulder and even tip of tongue.
☛Tymphanic GN
Ear pain radiating to pharynx
☛ NATURE OF PAIN -Paroxysmal, unilateral,
moderate to severe pain
☛ QUALITY – Sharp, stabbing, shooting or
lancinating.
☛ DURATION – Fraction of second to 2 minutes
☛ FREQUENCY – 5-12 every hour and may
occur in cluster lasting for
weeks to months.
☛ TRIGGER POINTS - Tonsillar region,
posterior pharynx.
☛ AGGRAVATING FACTORS –
swallowing, chewing, talking,
coughing and yawning, sneezing
and rubbing ear.
☛ COMPLICATIONS – GN may induce
uncontrollable coughing, seizures,
and cardiac arrythmias, bradycardia
and syncope.
☛ TREATMENT
♐MEDICAL - Carbamazepin, baclofen,
oxcarbazepin, gabapentin,
lamotrigine and phenytoin.
♐SURGICAL – Microvacular decompression
and Gamma knife stereotactic
radiosurgery
POST HERPETIC NEURALGIA (PHN)
☛ PHN- Pain of herpes zoster that
persists three or more months.
☛ AGE – common in > 50 yrs
☛ SITE - 22% - Opthalmic nerve
commonly affected.
is
☛NATURE OF PAIN - Burning
constant pain & superimposed
flashes of pain
☛QUALITY
–
burning,
sharp,
shooting, throbbing , stabbing.
☛AGGRAVATING FACTOR –
Hypo pigmented scar acts as
trigger points – Allodynia.
☛ COMPLICATION - Paresthesialoss of sensation
MANAGEMENT
☛ Prevention by use of varicella zoster
vaccine
☛ For those with active Herpes Zoster use
of antiviral drugs early in the course of the
disease
For those who develop PHN
☛ Topical therapy such as lidocaine.
☛ Topical application of Capsaicin , a
selective c-fiber neurotoxin that
deplete the substance P
☛ Acyclovir: 800 mg 5 times / day for 2
Weeks.
☛ Famcyclovir 250 mg 3 times a day
☛ Tricyclic antidepressant therapy
Amitriptyline 25-100 mg daily
divided doses.
☛ Systemic Corticosteroid
Prednisolone - 60 mg / day for 1st week
30mg / day for
for 3rd week
2nd
week and 15mg / day
Treatment should be started within 10days
and continued for three weeks
☛ Gabapentin 200-300 mg twice daily
☛ TENS - Trans Cutaneous Electrical Nerve
Stimulation
☛ Opioids, Tramadol
CLINICAL CHARARECTERISTICS
Trigeminal neuralgia
1.Site
Face
Glossopharyngeal
neuralgia
Throat, tonsillar region
Postherpetic
neuralgia
Forehead,eyes –
opthalmic
dermatome
Burning constant
pain &
superimposed
flashes of pain
2.Nature
Sharp, stabbing,
shooting
Sharp, stabbing, shooting
3.Severity
Worst pain
experienced
Worst pain
experienced
4.Initiating factors
Light touch,
washing
Swallowing, chewing
Allodynia –
light touch
5.Relieving factors
None
None
None
Moderate to
Severe
Thank you