3. Pain is usually conducted via A- delta
and the C nerve fibres
These are usually thinly myleinated or
unmyleinated
These carry information to the higher
cortical senses where appropriate
response is generated
4. From mucosa
1. Ulcer(apthous, traumatic)
2. Gingivitis
From dental origin
1. Pulpitis (reversible, irreversible)
2. Periodontitis
3. Pericoronitis
From the maxillary sinus
1. Sinusitis
From the muscles of mastication
1. Myofascial pain dysfunction syndrome
5. From the Temporomandibular joint
1. Arthritis(traumatic, rheumatoid)
2. TMJ derangement and disk displacement
3. TMJ dislocation
Fractures of the facial skeleton
All fractures of mandible and midface
Neuralgic pain
1. Trigeminal neuralgia
2. Glossopharyngeal neuralgia
3. Post herpetic neuralgia
4. Ramsay hunt syndrome
5. Neuromas
7. Central origin of pain
1. Brain tumors(any space occupying
lesion)
2. Infections of the brain
3. Multiple sclerosis
Psychosomatic pain
1. Atypical facial pain
2. Burning mouth syndrome
3. Atypical odontalgia
8. MUCOSAL PAIN:
Visible ulcer
Erythematous tissue can be seen
History of trauma, repeated ulceration
in Aphthous ulcers
Pain is directly associated with the time
of ulcer presentation
Gingivitis is also clinically visible
9. Pain of pulpitis is associated with hot and cold
sensitivity
The pain is exaggerated at night and more
pronounced while lying down
Usually a carious lesion is visible and you can
pin point the pain to that particular tooth
The tooth is tender to percussion
In case of periodontitis, tooth mobility may be
obvious, periodontal abscess usually drains
through the gingival crevice
In case of pericoronitis, imapcted third olar
with limited mouth opening, pus discharge etc
10. Since the maxillary sinus is in close
proximity to roots of upper molars and
premolars
Sinus infections can lead to pain
mimicking pulpitis
This type of pain is worse on bending
down and can be associated with nasal
stuffiness, headaches and foul smelling
discharge from nose
11. The muscles of mastication can be a
cause of severe facial pain
History of clenching, stress
On clenching the temporalis and
masseter are painful on palpation
The pain is relieved by pain by pain
killer
Gets worse on mastication
It is bilateral, diffuse, involves all
muscles of mastication
12. More localized pain in the preauricular
area
Made worse from opening, closing and
lateral excursions
The clicking sound of disc can be
appreciated
History of parafunctional habits, trauma
to the TMJ, generalized arthritis of joints
Dislocation of the TMJ is an acute
presentation with pain and open mouth
with deviation
13. MIGRAINE
It is a common chronic neurovascular
disorder characterized by headache,
autonomic dysfunction, aura involving
neurologic symptoms
PATHOPHYSIOLOGY
It is neural disorder leading to dilation of
blood vessels, leading to pain
The neural pain also involves the trigeminal
complex and specially the ophthalmic division
thus the pain distribution around the eye
14. Episodes of severe headache, unilateral,
throbbing, associated with nausea,
vomiting and sensitivity to light and
sound
Migraines can be with or without
aura(flashing lights, hallucination etc)
More common in women than men
Can be very disabling at times
Can last from 4-72hours
15. Non pharmacological methods
Keeping a diary and note the aggravating
factors( lack of sleep, eating habits,
menstrual cycle, food products)
Preventive medication like selective
serotonin reuptake inhibitors , B blockers
like propanolol, amitryptyline, other non
specific drugs like verapamil
Acute attacks are managed by either
aspirin, NSAIDS, ergotamine ,
sumatryptans etc
16. Most severe form of headache,
characterized by severe, unilateral pain in
the retro orbital and fronto temporal
areas.
It is associated with signs of cranial
autonomic dysfunction ( tearing,
conjuctival injection, nasal congestion and
horner’s syndrome)
Occurs in clusters. 15 mins to 3 hours;
once daily to eight times daily
More common in men and associated with
alcohol use
17. Acute attacks are treated with high
flow oxygen (12 L/min) for 15 mins
Parenteral triptans , S/C or nasal spray
High doses of verapamil
Ergots, lidocaine, octreotide
Prophylactic treatment includes
verapamil, lithium, methylsergide,
anticonvulsants (topiramate)
18. It is a vasculitis affecting large and medium sized
vessels
Usual age of diagnosis is 50-70 years
More common in males
SYMPTOMS:
1. Excessive sweating
2. Disturbance in vision(blurred, double, reduced)
3. Sudden loss of vision in an eye
4. Throbbing headaches in temple area
5. Jaw claudication
6. Fever, weight loss, loss of apetite, dropping
eyelids
7. Tenderness in the temple and scalp
19. History and examination
Elevated ESRC- reactive protein
Diagnostic is temporal artery biopsy.
Skip lesions may be present
TREATMENT
Treatment should be started
immediately on suspicion
Start steroids( orally) long term for 1-2
years
20. Mild to moderate headache, which feels
like a tight band around the head
Tenderness of the shoulder and neck
muscles
They are different from migraines which
have triggering factors, nausea and
vomiting or aura
Stress is the most triggering factor
More common in women usually middle
aged
Treatment is simple pain relievers,
combination medicines
21. Parotitis or salivary gland infections
leads to painful enlarged glands with
pus discharge from the duct opening.
Accompanying systemic symptoms like
fever are also present
Salivary gland stones can give rise to
pain on salivation that is before meals
22. Angina can be referred to the jaw
Infections of eyes, ear and nose can
present as facial pain but are usually
associated with other symptoms
pointing towards the specific problem
23. It is characterized by paroxysmal pain
which is sudden electric shock like and lasts
only a few seconds
It is triggered by touch, speaking, daily
activities like washing face or shaving
It is characterized by trigger zones, areas
which when touched can initiate pain
Involves the branches of trigeminal nerve
It is always unilateral, involv
es a known boundary of sensory nerve
May involve more than one branch of the
trigeminal nerve
More common in elderly women
24.
25. 1. PRIMARY..idiopathic
2. SECONDARY… due to a space
occupying lesion or MS(young patients)
The main cause is compression of the
nerve root entry zone in the middle
cranial fossa by an atherosclerotic
cerebellar artery
26.
27. History is quite significant
Patient would have had multiple extraction for
the relief of pain
Palpate the area to locate trigger zone
Diagnostic blocks to locate the peripheral nerve
involved. Start peripheral and proceed
proximally
This should relieve the pain, with no response
on touching the triggering zone
For younger patients and those with atypical
symptoms, MRI to rule out MS or space
occupying lesion
29. Anti epileptics work very well for TN
Carbamazepine is the drug of choice along with
oxcarbamazepine
We start with 100mg which will relieve pain in
2hrs but the dose range can be between 600-
1200mg per day
Adverse effects are ataxia, drowsiness,
vertigo and thus dose adjustment is required
Second line drugs are available: lamotrigine and
baclofen(10mg)
Gabapentin (MS)(900-2400mg), sodium
valproate, phenytoin can also be used
30. If drug therapy starts to fail or the side
effects are increasing
1. Peripheral injections of alcohol and
phenol
2. Peripheral injection of glycerol
3. Peripheral nerve cryotherapy with
liquid nitrogen
36. Rhizotomies
Tracotomies
Microvascular decompression.. Jannetta
pioneered this. Most appropriate where
you remove the aberrant vessel from
the nerve root
Gamma knife surgery using gamma
radiation.. Blood less surgery, most
effective, radiation exposure and very
expensive
37.
38.
39. Neuralgia in the distribution of
glossopharyngeal nerve
Trigger zone is at the back end of the
throat and pharynx.
Can be caused by blood vessel pressing on
nerve, tumours of skull base
Usually initiated on swallowing
The medical therapy is the same as in TN
Trans tympanic Neurectomy, microvascular
decompression is reserved for unresponsive
or severe cases
40. OVERVIEW
Herpes Zoster is a viral infection that
presents as chicken pox in children, the
varicella virus becomes latent and resides
in the sensory nervous system in the
geniculate , trigeminal ganglion
When the patient passes through periods
of immunocompromised state, the virus is
activated resulting in lesions or vesicles in
the distribution of the nerves
After the condition resolves, the pain can
persist in the affected area
41. PRESENTATION
More common in older age group> 60 yrs
More common in women
History of preceding rash, pain persists
for more than 3 months after resolution
Pain is burning, gnawing
Cutaneous scarring can be seen
Allodynia is present
Risk factors are advancing age, systemic
disease
42. To reduce morbidity
Tricyclic antidepressants…reduce uptake
of serotonin, useful for chronic pin
Analgesic agents..capsaicin (sub P
inhibitor)
Anticonvulsants
Anesthetic agents,, stabilize the neuronal
membrane
Steroids…dexamethasone used as anti
inflammatory
Antiviral.. Shortens the clinical course,
prevent recurrences
43. OVERVIEW
Acute peripheral facial neuropathy
associated with vesicular rash of the
skin of the ear, canal and mucous
membrane of the oropharynx
Name was given by James Ramsay Hunt
44. Associated with facial palsy(lower motor
neuron), skin lesions over the preauricular
area and auditory symptoms e.g tinnitis,
deafness, vertigo, nystagmus, ataxia,
cervical lymphadenopathy
45.
46. Caused by herpes zoster involving the
facial nerve
VZV can be demostrated by PCR of tear
fluid of bell’s palsy patients
MRI can demonstrate the lesion very
well
Audiometry
Electroneurography
47. Corticosteroids.. Reduce inflammation
around the nerve
oral acyclovir
Bell palsy requires care of eyes
Carbamazapine..helpful in neuralgic pain
Anti histamine.. For the treatment of
vertigo
48. Defined by the International Headache
Society as pain which cannot be attributed
to any organic disease
It is defined as MUS
49. More common in women
More common in elderly people
The pain is not electric but more of throbbing origin,
not paroxysmal
It tends to get worse during the day, but rarely
wakes the patient at night
The pain is not within the distribution of any nerve
Usually bilateral
Does not have a trigger point
Patient may have other symptoms like muscular
aches, dysmenorrhea, backache, constipation
Some recent bereavement in the family, stressful
life conditions
50. Behavioral therapy: counseling, telling the
patient that the pain is actual
Try to set goals
Follow ups
Tricyclic antidepressants
Amitryptiline
Clonazepam
Fluoxetine
Carbamazepine
Gabapentin
Capsaicin
51. Seen in elderly post menopausal females
though no link with hormones have been
associated
Patient has burning sensation of mucosa
No clinically red, erythematous areas are
seen
Patient has a gritty sensation with dry
mouth and disturbed taste
Disease of exclusion
Can be initiated after undergoing dental
treatment
52. History of stress, other non specific
symptoms
Same treatment as that for atypical
facial pain but rule out other diseases
that can cause burning mouth like lichen
planus etc
53. Again MUS
Pain in tooth
No obvious cause like caries, periodontitis
Tooth is vital
Any treatment can aggravate the situation
The dentist can end up doing filling to
endo- treatment followed by extraction
but pain remains
Treatment is the same after exclusion of
other problems
