orofacial pain

2.  What is orofacial pain
 Causes of orofacial pain
 Trigeminal Neuralgia
 Glossopharyngeal Neuralgia
 Post Herpatic Neuralgia
 Eagle’s Syndrome
 Temporomandibular pain
 Burning mouth syndrome
 Atypical Facial pain
 Migrain
 Cluster Headache
 Temporal Arteritis
 Take Home Massage

4. 1- Local :
 Dental : (pulpitis., dentine hypersensetivity ,periapical
periodontitis.cracked tooth syndrome
 Gingival: (e.g primary herpetic gingivostomatitis,
 Mucosal: (e,g ulceration)
 Salivary gland: (acute suppurative sialadenitis)
 Temporomandibular joint:
 Maxillary sinus: (sinusitis,malignancy)

5. 2- Neurological :
 Trigeminal neuralgia
 Glossopharyngeal neuralgia
 Ramsy hunt syndrome
 Postherpetic neuralgia
3- Vascular :
 Giant cell arteritis and variant
 Migraine and variant
 Cluster headache ,chronic paroxysmal hemicrania

6. 4- Psychogenic :
 Atypical facial pain
 Atypical odontalgia
 Burning mouth syndrome
5- Referred pain:
 Cardiac pain

7.  Definition :
usually unilateral severe,
brief, sudden, stabbing
recurrent pain in
distribution of one or more
of branches of trigeminal
nerve.

8.  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.

9. 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..

10.  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.
 right> left

11.  lasts for a few seconds to 1 minute ,
 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.

12.  Clinical examination of face is nearly always normal.
 If sensory loss is present a mass lesion is more likely
 In young patients with TN, multiple sclerosis should be
considered.

13.  Diagnosis depend on history and
clinical examination.
 One should always assess cranial
nerve function.
 MRI to detect vascular compression.

14. Right Trigeminal Nerve
Compressing vessel

15. 1- Medical treatment:
 Carbamazepine
 Oxcarbazepine who are sensitive to Carbamazepine.
 Baclofen
 Gabapentine.
 Lamotrigine
 Clonazepam
 Phenytoin

16. 2- Surgical treatment(invasive):
indicated If medical treatment (carbamazepine) has been
ineffective after 4 weeks at maximum tolerated dose .
 Microvascular decompression
 Percutaneous radiofrequency thermorizotomy
 Gamma knife radiosurgery
 Glycerol injections
 Peripheral neurectomies

17. Gamma knife
microvascular
decompression

18. Is an uncommon disorder characterized by
lancinating pain of oropharynx or neck,
sometimes triggerd by swallowing, coughing
or talking.
Epidemiology:
less common than TN.
arises in middle to late life.
males=females

19. 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.

20. Management:
Of GN parallels that of TN
 -Anti convulsion drugs,carbamezipine.
 -Vascular decompression.
 -Intracranial or extra cranial neuroectomy.
Etiology:
An identifiable cause is rarely found.
The most common causes of glossopharyngeal neuralgia
are intracranial or extracranial tumors and vascular
abnormalities that compress CN IX.
Glossopharangeal neuralgia

21.  -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.

22.  -Antiviral and corticosteroids after
presentation of rash reduce incidence of
postherptic neuralgia.
 -Anticonvulsant drugs
 -Local anesthesia injected to painful site.

23. 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.

24.  Pain is usually dull and nagging
 Usually localized
 May radiate to ear

25. 1-Classic :
The symptoms are persistent pharyngeal
pain aggravated by swallowing and
frequently radiate to the ear , with
sensation of foreign body within pharynx ,
This pain arise following tonsillectomy due
to development of scar tissue around the
tip of the styloid process.

26. 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.

28. (1)clinical manifestations,
(2) digital palpation of the process in the tonsillar fossa,
(3) radiological findings .
(4) lidocaine infiltration test.
 Treatment:
COSERVATIVE: involves injecting steroids
or long-lasting anesthetics into the lesser cornu of
the hyoid or the inferior aspect of the tonsillar fossa
I,NSAID
Surgical: intra oral or extra oral styloidectomy

29. Is defined as group of symptoms including pain
of orofacial muscles, and/or TMJ and
dysfunction of TMJ.
Epidimeology:
Affects all racial groups
2nd and 3rd decade of life
males=females

30. TMD can involve the following
Muscels of mastication: Myofascial
pain(tendeness or dull aches around TMJ
including ear.
The TMJ: limited jaw opening or pain, jaw
locking, clicking sounds.
Others: Headaches, ear aches, pain radiating
to neck or shoulders, dizziness and tinnitis.

31. o Parafunctional habits
o Occlusal anomalies
o Local trauma
o Life events and mental health
Management:
Conservative therapies
Soft diet
Limited talking

32. Avoidance of wide mouth opening.
Muscle massage
Jaw exercises
Splint therapy
Psychogenic based therapies
Clonazipam
TCA
SSRI
Surgery

33. 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.

34.  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 .

35. Investigation: FBC ,haematinics ,swab for Candida .
Treatment:
 Reassurance .
 Avoidance of stimulating factors.
 Some patients may respond to TCA, SSRIs
 topical clonazepam, sucking and spitting 1 mg three
times daily for 2 weeks.
 2-month course of 600 mg daily alfa-lipoic acid.
 Cognitive behavior therapy.

36.  Constant dull aching pain , variable intensity in
absence of identifiable organic disease.
 Its more common in female .
 Most patient middle age and elderly .

37. Clinical features:
 Often difficult for patients to describe their symptoms .
 Most frequently described as deep , constant ache or burning
.
 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 .

38. 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

39. 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:
5th decade
Females>males
Premolar and molar area
Maxillary>mandibular
Atypical odontalgia(phantom)

40.  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

41. Is achronic neurological 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.
Migraine

42. o Duration : usually 12 to 72 hours
o Female:male ratio >2:1
o Neurologic aura :≈ 40%
o Moderate to svere in intensity
o Usually unilateral
The mechanism although not completely
understood appears to involve neurogenic
inflamation of intracranial blood vessels
resulting from neurotransmitter imbalance in
certain brain centers.

43. Treatment :
 Avoid trigger factors
 Acute attack: analgesics, Sumatriptan (5-HT agonist)
, Ergotamin.
 Prophylaxis : is directed at normalizing
neurotransmitter imbalance with Antidepressants ,
Anticonvulsants, beta-Blockers

44. Clinical manifestations
pain as a hot metal rod in or around the eye.Svere
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, conjunctival injection, ptosis or
rhinorrhea.
 Triggered by alcohol
 Produces pain in post.maxilla

45. Treatment:
 An acute attack:
Symptomatic treatment is with tryptan’s
ergots and analgesics.
 Prophylaxis : lithium, ergotamine, prophylactic
prednisone, and calcium channel blockers.

46. -Is an inflammation(vasculitis) of cranial arterial
tree, secondary to giant cell granulomatous
reaction.
Clinical features:
 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.
 Jaw claudication during mastication.

47. Diagnosis:
 elevated ESR .
 elevated CRP.
 Biopsy.
-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.

48. 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.

49. THANK YOU