Dr. Rupak Sethuraman
SPECIFIC LEARNING OBJECTIVES
 Various management techniques of orofacial pain
 Management of common orofacial pain disorders
VARIOUS TREATMENT MODALITIES
 1. Cognitive behavioral therapy- attempts to alter
patterns of negative thoughts and to bring about more
healthy and adaptive thoughts, emotions, and actions.
 2. Relaxation therapy- More significant in reducing
the distress associated with pain.
 3. Drug therapy- Four categories of drugs are widely
used:
Non steroidal anti inflammatory drugs (NSAIDs)
Opioid analgesics
Adjuvants such as anti convulsants
Topical medications
Management of trigeminal
neuralgia (TN)
 Initial therapy for TN should consist of trials of drugs
that are effective in eliminating the painful attacks.
 Anticonvulsant drugs are most frequently used and are
most effective.
 Carbamazepine is the most commonly used drug and
is an effective therapy for greater than 85% of newly
diagnosed cases of TN.
 The drug is administered in slowly increasing doses
until pain relief has been achieved.
 Skin
reactions, including generalized
multiforme, are serious side effects.
erythema
 Patients receiving carbamazepine must have periodic
hematologic laboratory evaluations because serious
life threatening blood disorders may occur .
 Patients who do not respond to carbamazepine alone
may obtain relief from baclofen or by combining
carbamazepine with baclofen.
 Oxcarbamazepine
is the 10-ketoanalogue of
carbamazepine with a similar mode of action. Its
principal advantage over carbamazepine is less liver
toxicity and less risk of blood disorders.
 Other drugs that are effective for some patients
include gabapentin, phenytoin, lamotrigine, baclofen,
topiramate, and pimozide.
 Since TN
may have temporary or permanent
spontaneous remissions, drug therapy should be
slowly withdrawn if a patient remains pain free for 3
months.
Management of post herpetic
neuralgia (PHN)
 Prevention of PHN is now possible, and use of a
varicella-zoster vaccine for patients over 60 years of
age significantly reduces the incidence of herpes zoster
and the sequelae of PHN.
 For patients who develop herpes zoster, use of antiviral
drugs early in the course of the disease reduces the risk
of PHN.
 For patients who develop PHN, the method of
treatment chosen should depend on the severity of the
symptoms and the general medical status of the
patient.
 Treatment includes topical therapy, drug therapy, and
surgery.
 Topical therapy includes the use of topical anesthetic
agents, such as lidocaine, or analgesics, particularly
capsaicin.
 Capsaicin, an extract of hot chilli peppers that
depletes the neurotransmitter substance P when used
topically, has been shown to be helpful in reducing the
pain of PHN, but the side effect of a burning sensation
at the site of application limits its usefulness for many
patients.
 The use of Tricyclic Anti Depressants (TCAs) such as
amitriptyline, nortriptyline, doxepin, and desipramine
is a well-established method of reducing the chronic
burning pain that is characteristic of PHN.
Management of Burning Mouth
Syndrome (BMS)
 Once the diagnosis of BMS has been made by
eliminating the possibility of detectable lesions or
underlying medical disorders, the patient should be
reassured of the benign nature of the symptoms.
 Counseling the patient in regard to the nature of BMS
is helpful in management, particularly because many
patients will have had multiple clinical evaluations
without an explanation for the symptoms.
 Counseling
and reassurance may be adequate
management for individuals with mild burning
sensations, but patients with symptoms that are more
severe often require drug therapy.
 The drug therapies that have been found to be the
most helpful are low doses of TCAs, such as
amitriptyline and doxepin, or clonazepam (a
benzodiazepine derivative).
 It should be explained to the patient that these drugs
are being used not to manage psychiatric illness but
for their analgesic effect.
 On the other hand, application of topical clonazepam
was effective in reducing pain intensity; moreover, in
another study, the positive effect was carried over up to
6 months following 2 weeks of treatment.
 A 2-month course of 600 mg daily of alpha-lipoic acid
has been shown to reduce BMS pain, and systemic
capsaicin (0.25% capsule 3 times per day for 30 days)
demonstrated some positive effects on BMS pain
intensity.
 Any Questions??
 Thank you