2. DEFINITION
• An unpleasant sensation caused by a noxious
stimulus that is mediated only along specific
nerve pathway into the central nervous system,
where it is interpreted as pain.
4. 1. MEDICAL AND DENTAL HISTORY.
2. CHIEF COMPLAINT AND PAIN HISTORY
Pain quality: e.g. aching, throbbing, burning, shock
like, paroxysmal or some combination (quality).
The duration of each episode of pain (duration).
The site affected: ask the patient to point to source of
pain and/or outline the area affected by it. (Course).
5. Contd..
• Initiating factors: anything that patient
remembers occurring immediately before or at
the same time as start of their symptoms.
• Exacerbating factors: anything which makes
patient's symptoms worse.
• Relieving factors: Anything which relieves
either partially or totally patient's symptoms e.g.
nerve block anesthesia, anticonvulsant drug.
7. 3. PHYSICAL
EXAMINATION
• Vital signs.
• Intra-oral examination with oral cancer
screening.
• Head & neck examination (lymph node, T.M.J,
skin and myofacial examination).
• Cranial nerve examination (evaluate trigger
zone, area of hyperesthesia, and area of
hypoesthesia or anaesthesia).
• Diagnostic anaesthetic testing → if pain is due
to peripheral cause → anaesthesia will arrest
pain.
9. PAIN
CLASSIFICATION
BY ORIGIN
• Somatic pain: Originating from cells of the
organ involved i.e. skin, mucous membrane,
bone, joint, muscles, etc.
• Neurogenic pain: Discomfort resulting within
the nervous system. Abnormality in neural
structures. No noxious stimulus.
• Psychogenic pain: Resulting from psychic
causes, no noxious stimulus, no abnormality in
neural structure.
12. SOMATIC
PAIN
Superficial from the skin or mucous membrane due to noxious
stimuli e.g. thermal or chemical burns, mechanical, ulcerations,
infection: bacterial, viral or 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.
13. Contd..
Inflammatory from collection of infected
fluid e.g. Abscess, infected cyst, pericoronitis.
Character: throbbing with tenderness tends to
be localized.
Referred from para-oral structures e.g.
maxillary sinus, ear, eyes.
Character: deep
14. NEUROGENIC
PAIN
• Neuritis: inflammatory change of nerves.
(burning sensation)
• Neuralgia: pain along the course of nerve
caused by vascular spasm and CNS diseases.
• Vascular:
It’s usually poorly localized, chronic, preceded
by minor electric shock like pain
15. CAUSES OF
OROFACIAL
PAIN
I- LOCAL CAUSES (SOMATIC):
Diseases of teeth.
Diseases of the periodontium.
Diseases of oral mucosa.
Disease of jaws.
Diseases of the antrum. Diseases of salivary glands.
Diseases of TMJ.
Disease of ears.
Diseases of eyes.
Diseases of sinuses and nasopharynx.
18. NEUROLOGIC
PAIN
TRIGEMINAL NEURALGIA
• A self limiting disorder characterized by
instantaneous attacks, of sharp
lancinating/ shooting pain confined to
the area of distribution of trigeminal
nerve and characterized by presence of
trigger zone.
• Etiology:
• Demyelination.
• Vascular compression of trigeminal
ganglion.
• Trauma or infection of nerve.
• Idiopathic.
19. INCIDENCE
• Involving areas supplied by the 2nd and 3rd
divisions of trigeminal nerve (teeth, jaws, face
and associated structures).
• Age: more than 40 years of age
• In affected patients under 40 years, suspect
serious underlying pathology e.g. tumors or
multiple sclerosis.
• Females:males :: 2:1.
• Right side > left side.
20. Contd..
• Mostly Unilateral, bilateral is relatively
uncommon.
• The 2nd division of trigeminal nerve (V2) is
more commonly than the 3rd division, on the
other hand the ophthalmic nerve is involved
only in 5% of cases.
21. CLINICAL
FEATURES
Signs
• Spasmodic contraction of face muscles.
Symptoms
• Pain is limited to one of the three divisions of
the trigeminal nerve, most commonly the 2nd
and 3rd divisions.
• The pain of trigeminal neuralgia never crosses
the midline.
22. Contd..
• Pain is described as sharp and stabbing, electric shock, red hot needle type. It is of
rapid onset, short duration and with rapid recovery.
• Paroxysms occur most commonly in the first hours after awakening.
• The pain of trigeminal neuralgia is as clusters, patients having periods of daily
pain, then periods of remission. The remission may last days, weeks, months or
years.
• Trigeminal neuralgia does not affect sleep.
• This pain could be evoked by touch or even breeze to the trigger zone on the face
or mouth or it is evoked spontaneously.
23. TRIGGER ZONE
• Represent primary site of origin for
pain provocation.
• Half-inch finger signs: The patient
points to the trigger area with his/her
finger without touching it, as this
may precipitate the attack.
24. DIFFERENTIAL
DIAGNOSIS
Presence of trigger zone and periods of
remissions.
Clinical examination of other cranial nerves to
exclude other causes.
L.A. nerve block of the trigger zone will arrest
pain for the duration of L.A.
Diagnostic aids:
CT & MRI are used to exclude the presence of
tumor.
Carbamazepine can be used for diagnosis.
25. Contd..
1.Multiple sclerosis: Occur at younger age + mainly
bilateral while trigeminal neuralgia is unilateral.
2.Cluster headache: headache occurs at night + No
trigger zone.
3.Post-herpetic neuralgia: After herpes zoster of the
5th cranial Nerve + history of skin lesion prior to pain
aids in the diagnosis.
4.Psychogenic Neuralgia: the distribution of pain is
unanatomical, it may cross the midline with no trigger
zone it is usually deep, vague, poorly localized
26. Contd..
5.Neoplasia:
Intracranial neoplasms may cause facial pain if they
irritate or compress the root or ganglion of
trigeminal nerve.
This may be indistinguishable from idiopathic
trigeminal neuralgia and is usually termed
symptomatic trigeminal neuralgia.
6.Glossopharyngeal neuralgia: The pain is
unilateral in throat and base of the tongue on one
side, sometimes radiating to the ear.
27. Contd..
7. Pain of dental origin: e.g. pulpitis,
periodontitis, pericoronitis.
8. Pain of osseous origin (dry socket and acute
osteomyelitis).
9. Pain originating in T.M.J
29. Contd..
The second line drugs are antiepileptic medicines and tricyclic
antidepressants.
If the patient is unable to tolerate side effects of carbamazepine or if
carbamazepine has been ineffective after 4 weeks → patient should
be started second-line drugs.
Second line drugs
30. 2.PERIPHERAL
PROCEDURES
Trigeminal neuralgia can be modulated by interruption of any part of
trigeminal pathway, from peripheral sensory nerves to the nerve root
entry zone.
Thus local anesthetic blocks of peripheral nerves can be used as an
emergency measure.
Peripheral nerve destruction usually by cryotherapy, alcohol
injection, or nerve avulsion is used.
The supraorbital, infraorbital, or mental nerves are most commonly
approached.
32. 4.SURGICAL
TREATMENT
1.Trigeminal Root Section:
It is an intra-cranial surgery in which the sensory roots of gasserian
ganglion are cut sparing the motor root.
2.Micro-vascular decompression "MVD"
A loop of an artery (usually superior cerebellar artery) which is
resting on the trigeminal entry zone causing the nerve to produce
symptoms.
33. Contd..
• In this operation, the loop of artery is dissected,
elevated and then a small prosthesis are put to separate
the artery from nerve (called Jannetta – S operation).
34. PRETRIGEMINAL
NEURALGIA
It is an aching dental pain in a
region where physical and
radiographic examination
reveals no abnormality.
Local anesthetic block of tooth
arrests pain.
Pre-TN responds to similar
treatments as TN, beginning
with anticonvulsant therapy.
35. GLOSSOPHARYNGEAL
NEURALGIA
Sharp, paroxysmal electric shock like pain
radiating from oropharynx or base of the tongue
to tonsils, larynx, soft palate, ear, mandibular
ramus or even to region of TMJ.
Clinical picture
• Pain is unilateral and of short duration.
• Swallowing, chewing, speaking, eating and
drinking can trigger attacks.
• Pain is stopped by anesthetizing the pharynx
with topical anesthetic where trigger point is
located.
36. Incidence
Middle-aged and the elderly are mainly affected.
Females > males.
Left side affected more than right side.
Etiology
Vascular compression of the posterior inferior
cerebellar artery on the root entry at the medulla.
37. Differential
diagnosis
• Eagle syndrome: as similar pain
distribution & intensity but this include
dysphagia, foreign body sensation in
throat, headache and pain on turning the
head to the other side.
Treatment:
• 1. Carbamazepine.
• 2. Surgical decompression.
39. 1.ATYPICAL
FACIAL
PAIN
SYMPTOMS
The pain is described as a vague, constant, dull ache,
present all day every day.
It has been associated with depression or anxiety
stress.
Females, >50 years of age.
It may be unilateral or bilateral and cross midline.
41. 2.ATYPICAL
ODONTALGIA
Symptoms:
The etiology and symptomatology are the same as those
of atypical facial pain but patient attributes the pain with
teeth.
Many dental treatments may have been attempted, by
different dentists, including serial extraction, with no
improvement in the pain.
Signs:
None; diagnosis is by exclusion.
43. MIGRAINE
Recurrent headache combined with
autonomic disturbances (aura).
Incidence and age
• Usually starts in the second decade and
diminishes with age.
• Women > men.
• In 50% of cases, there is a family
history of migraine.
Etiology
• Initial constriction of branches of the
external carotid artery, causing the
characteristic aura, followed by
dilatation, causing the headache.
44. Types
1. Classic migraine (with aura).
2. Migraine without aura.
CLASSICAL MIGRAINE
• Characterized by:
• Abrupt onset headache → unilateral
and deep throbbing.
• Headache may last 12 hours.
Affects frontotemporal region.
Unilateral then secondary spread to the
entire cranium.
45. Contd..
• Headache is preceded by aura
symptoms (prodromal, preheadache
stage causes lethargy).
• Aura include a reversible sensory,
motor, visual and speech disturbance:
Visual → Zig zag flickering light and
blurred vision.
Sensory → numbness, paraesthesia and
aneasthesia of the face.
Motor → unilateral muscle weakness in
the face.
47. Precipitating
factors
• Stress events.
• Physical or psychological events.
• Trauma.
• Vasoactive foods as chocolate and
bananas.
Treatment:
• Sumatriptan.
• Non steroidal anti-inflammatory drugs
(NSAIDs).
• Opioid analgesics.
• Antiemetics.
48. Differential
Diagnosis
• For the dentist, knowledge of migraine
is important because
temporomandibular disorders may
precipitate a migraine attack in a
migraine-prone patient.
• Nausea and photophobia are not
accompaniments with masticatory
musculoskeletal disorders or jaw and
tooth pain of dental origin.
49. PERIODIC MIGRAINOUS
NEURALGIA
Incidence and age:
• Young adults (20-40 years).
• Males more than females.
• Stress or alcohol may precipitate an
attack.
Etiology:
• Vascular compression of the ganglion
by branches of internal maxillary
artery.
50. Signs and symptoms
• Unilateral paroxysmal attack of pain.
• Dull aching or burning headache.
• Unlike classic migraine, pain usually
occurs at night.
• It is one of the few pain conditions
that can awaken the patient (from
sleep), this observation is useful for
diagnosis.
• Pain is of rapid onset and short
duration, usually lasting up to 30
minutes only, but occasionally up to 2
hours.
• Pain is usually limited to the area
around and behind the eye and related
maxilla.
51. Contd..
Attacks recur at similar times of the
night (alarm clock waking) and are
clustered (often once every 24 hours)
and followed by a long period of
remission for weeks, months or even
years ('cluster headache').
Autonomic symptoms may
accompany periodic migrainous
neuralgia including:
• Nasal blockage (stuffy nose).
• Nasal discharge.
• Tearful eye.
Unlike migraine, there is no:
Nausea or visual disturbance.
Trigger zone.
52. Treatment
• Ergotamine or anti-inflammatory
drugs, e.g. Indomethacin may be
employed.
• The patient should avoid alcohol.
