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OROFACIAL PAIN PowerPoint Presentation

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Description : Check out this medical presentation on Orthopaedics, which is titled "OROFACIAL PAIN", to know about the Assessment, Diagnosis and Treatment of complex chronic orofacial pain and dysfunction, oromotor and jaw behaviour disorders, and chronic facial, head and neck pain.

Tags : Orthopaedics, OROFACIAL PAIN, Assessment, Diagnosis, Treatment, chronic orofacial pain, dysfunction

Published on : Aug 18, 2021 | Views : 4467 | Downloads : 18

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Slide 1-

OROFACIAL PAIN Clin A/Prof Robert Delcanho BDSc MS Cert OFP FFPMANZCA FICD FAAOP Diplomate, American Board of Orofacial Pain St John of God Hospital, Subiaco Clinic 25 McCourt Street Subiaco WA
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OROFACIAL PAIN The field of Dentistry that includes the Assessment, Diagnosis and Treatment of Complex chronic orofacial pain and dysfunction Oromotor and jaw behaviour disorders Chronic facial, head and neck pain
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OROFACIAL PAIN Dental (Odontogenic) Pain Musculoskeletal Pain – Temporomandibular disorders 3. Neurovascular Pain – Primary headaches 4. Neuropathic Pain Episodic Continuous 5. Sinus Pain 6. Psychogenic Pain 7. Intracranial 8. Cervicogenic
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Head -meninges -skull & scalp -nerves -trigeminal (V) -C2-3 (GON/LON) Orofacial -sinuses -TMJ, ear -teeth, nerves Neck & shoulders Pain generators
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Red flags T.I.N.T Tumour Temporal arteritis Intracranial pressure Infection Neurovascular Trigeminal Trauma
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Red Flag Case Presentation Female 16 years Hx of constant deep aching TMJ/jaw pain worse with chewing, extending to occiput. Initially treated with Occlusal Splint/Physio. Headaches on exertion - paroxysmal with “fainting”. Parents noted subtle personality changes. MRI - Arnold Chiari formation- surgery.
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Intracranial Pathology Diagnostic Clues Neurological type symptoms/signs. No response to peripheral therapies. Unusual or worsening symptoms despite therapy. Negative response to somatic/sympathetic blocks.
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Intracranial pathology Common manifestations of raised intracranial pressure
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Space Occupying Lesions Neoplasms Arterial dissection Aneurysms Infection/Abscess Infarction/haemorrhage Oedema Angioma
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Temporal (Giant cell) Arteritis RED FLAG Headache emergency New onset headache in >50 years Uni/bilateral dull temporal pain Claudication masticatory muscles Visual disturbance Polymyalgia-shoulder/hip, malaise Swollen, tender temporal artery Elevated ESR, CRP Positive biopsy
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Temporal Arteritis RED FLAG Headache of vascular origin Initial symptoms may resemble TMD - Pain/stiffness in jaw - Pain/fatigue of jaw when chewing - Pain may radiate to ear, teeth - Temporal headache If untreated may cause blindness, stroke and death! Generally resolves with high dose steroids
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Extracranial Sources of Orofacial Pain Teeth and oral mucosa ENT, paranasal sinuses TMJs &myofascial Tongue Salivary Glands Lymph Glands Eyes Vessels & nerves
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Odontogenic Pain – Toothache Most common cause of orofacial pain! Often missed by medical people Dental caries into dentine / pulp Pulpitis, pulp necrosis Cracked teeth Periodontal infection ASK ABOUT HOLES IN TEETH Hot/cold/bite SENSITIVITY, PAIN AT NIGHT
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Toothache Toothache - most common orofacial pain complaint 12.2% of population reported toothache in last 6M Diagnosis can be challenging and complicated Pain from one tooth may be referred from another tooth or from other orofacial structures Other craniofacial pain disorders may mimic the symptoms of toothache Proper diagnosis is critical
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Consider all pains in the mouth and face to be of dental origin until proven otherwise
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TEMPOROMANDIBULAR DISORDERS Major cause of Non Dental Pain in Orofacial Region
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TEMPOROMANDIBULAR DISORDERS Collection of medical and dental conditions affecting the temporomandibular joint and/or muscles of mastication and/or contiguous tissues resulting in pain and/or dysfunction
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TEMPOROMANDIBULAR DISORDERS Primary Clinical Features Ear ache (pre-auricular pain) Painful jaw use e.g. with chewing, yawning Tender TMJs and muscles of mastication Restriction of jaw movement Interference with jaw movement TMJ sounds e.g. clicking, cracking, popping sounds
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TEMPOROMANDIBULAR DISORDER Other Clinical Features Headache Ear symptoms eg discomfort, fullness Occlusal discomfort or change Mandibular dyskinesia Intermittent facial swelling
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TEMPOROMANDIBULAR DISORDERS The pain/dysfunction should be directly related and aggravated by jaw use (Solberg)
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Temporomandibular Disorders TMJ ARTHRALGIAS 1. Traumatic arthralgia 2. Arthromyalgia 3. Internal Derangement - painful TMJ dysfunction 4. Osteoarthritis 5. Systemic (poly)arthritis .OROFACIAL MYALGIAS - Muscle splinting/strain - Muscle spasm - Myofascial Pain +/- TPs - Myositis - Fibromyalgia
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TEMPOROMANDIBULAR DISORDERS Masticatory Muscle Disorders Protective co-contraction (splinting) Local muscle soreness (strain) Muscle spasm Myositis Myofascial pain
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Neurovascular Pain
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Case Presentation 48 year old female Intermittent dull throbbing pain in upper tooth/jaw, radiating to temple and eye. Severe attacks, last 1-3 days with constant dull pain. When severe, feels sick and prefers dark, quiet room to sleep. Attacks used to respond well to NSAIDs. Had a root canal, crown of upper premolar + splint
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Migraine
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Case Presentation Male in mid forties. Right sided face pain attacks on/off over three years Extending into right eye. Often awakened from sleep with severe throbbing pain. Would get up and pace around holding his R. eye. Face would feel sweaty, tearing of eye. Numerous dental visits – Root canals/ extractions.
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Case Presentation EXAMINATION Cranial nerve screen - Normal TMJ/Myofascial – Normal Oro-dental- Normal Medication Trial - response to oxygen/sumatriptan
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TRIGEMINAL AUTONOMIC CEPHALGIAS (TACs) CLUSTER HEADACHE CHRONIC PAROXYSMAL HEMICRANIA HEMICRANIA CONTINUA Peri-orbital or maxillary pain. Frequently leads to dental work including extractions. Unilateral, severe attacks with typical autonomic headache accompanying symptoms.
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Cluster Headache Clinical Features Attacks are severe - boring Strictly unilateraln in and around eye and/or temporal region - “hot poker” Attack duration 15-180 min Attacks occur from once every 2nd day up to 8x day. Attacks occur in series lasting weeks to months Remissions mths-yrs Autonomic features +++ Males 5-7:1 65% had dental Tx
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Chronic Paroxysmal Hemicrania Similar to Cluster but Female preponderance (3:1) Attacks are more frequent and of shorter duration 5-40 attacks per day (median 5-10) Attacks last 2-45 minutes At least one autonomic symptom on the side of pain conjunctival injection lacrimation nasal congestion rhinorrhoea, ptosis eyelid oedema
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Chronic Paroxysmal Hemicrania Always unilateral orbital, and/or temporal. Severe stabbing/boring type pain that throbs as it builds up. Episodic form occursin bouts lasting months to years with clear intervals (rare). In most cases responds rapidly and absolutely to Indomethacin (diagnostic test).
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Tension Type Headache (TTH) Previously called tension headache, muscle contraction headache, stress headache Most common primary headache (30-70% prevalence) Episodic (frequent/infrequent) and chronic forms Usually frontal /temporal location Tightness, pressure in hat-band like distribution +/- pericranial muscle tenderness Often co morbid with migraine w/o aura.
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Tension Type Headache NOT DUE TO ABNORMAL MUSCLE CONTRACTION
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Neuropathic Orofacial Pains EPISODIC Trigeminal Neuralgia Glossopharyngeal Neuralgia CONTINUOUS Painful Traumatic Trigeminal Neuropathy Post Herpetic Neuralgia Persistent Idiopathic Facial Pain (PIFP) Persistent Dento-alveolar Pain (PADP) Burning Mouth Syndrome
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Case Presentation 65 year old female Sharp shooting pains upper anterior teeth 22/23 Saw dentist - fillings, root canals, extraction, bridge, removal of bridge Inserting denture triggers sharp pain Repeated denture adjustments
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Case Presentation EXAMINATION Cervical spine - normal Cranial nerve screen - normal TMJ/MM - normal Myofascial - tender masseter. Intraoral - mucosa normal appearance trigger area palatal to 23 site.
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Orofacial Neuropathic Pain
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Trigeminal neuralgia Brief, electric shock-like, lancinating pains that affects the face unilaterally affecting one or more divisions of the trigeminal nerve tic douloureux
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Trigeminal Neuralgia Intermittent brief paroxysmal pain (secs-mins) Limited distribution: V2 and/or V3 > V1 Trigger zone –minor stimuli- touch, wind, shave Abrupt in onset and termination and may remit Remission period can spontaneously occur that lasts for weeks to years, and may return Triggerable or spontaneous No obvious local cause
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Painful Post Traumatic Trigeminal Neuropathy (AFP, PIFP) Unilateral facial and/or oral pain Usually continuous +/- sharp jolts of pain History of trauma to same V nerve branch Positive and/or negative neurosensory signs (allodynia, hyperalgesia, hypoesthesia etc) Equivocal response to LA nerve block Varying degree of central & sympathetic involvement
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Case presentation 40 yo female Complains of 3 years continuous dull aching pain in lower left quadrant. Occasional sharp pains. Problem commenced after periodontal surgery and surgical extraction of third molar. Since had RCT of 1st and 2nd molars w/o effect Aggravated by eating on that side and brushing teeth.
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Persistent Dento-Alveolar Pain Disorder (PDAP) (Atypical Odontalgia, Phantom tooth pain) Continuous variable pain Localized to dento-alveolar region – tooth/extrn sites Usually multiple (unsuccessful) dental procedures No obvious local pathology-clinical/radiography Not caused by another disease or disorder +/- Sensory abnormalities Somatic block equivocal
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Case Presentation 48 year old female 2 years continuous dull, aching, burning pain in upper right jaw Presumed pulpitis so over time 3 x root canals Extractions all upper molars, now wants premolar out Extractions only aggravated pain, which has spread Some sinus and menopausal symptoms Hx of depression - not current
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Case Presentation Cervical Spine - normal Cranial Nerve Screen - normal Stomatognathic- normal Myofascial – trigger points but not replicating pain Intraoral- Extraction sites hyperaesthetic Somatic block – negative Sympathetic block- partially positive Cone Beam CT, MRI- normal
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Persistent Dento-Alveolar Pain Disorder (PDAP) (Atypical Odontalgia, Phantom Tooth pain) Females > males – usually mid 40s on Posterior maxillary quadrant most often Hx of trauma - multiple dental procedures Somatosensory abnormalities around tooth site No evidence of psychopathology <50% responded to LA block Variable response to TCA, gabapentinoids, topicals etc Repeated dental procedures are contraindicated
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EETS Excessive Endodontic Treatment Syndrome
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THANK YOU !!!! dr@orofacialpain.com.au
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Classification of Orofacial Pains Somatic Pain Superficial Pain Mucogingival Pain Deep Pain Cutaneous Pain Muscle Pain Myospasm Central Mediated Myalgia Myofascial Pain Local Muscle Soreness Protective Co-Contraction TMJ Pain Osseous Pain Connect. Tissue Pain Periodontal Pain Visceral Pain Musculoskeletal Pain Visceral Mucosal Pain Glandular, ENT Pain Pulpal Pain Vascular Pain Neurovascular Pain Capsular Pain Arthritic Pain Retrodiscal Pain Ligamentous Pain Neuropathic Pain Episodic Pain Paroxysmal Neuralgia Continuous Pain Trigeminal Neuralgia Peripheral Mediated Pain Metabolic Polyneuropathies Central Mediated Pain Entrapment Neuropathy Deafferentation Pain Neuritic Pain Burning Mouth Disorder Atypical Odontalgia (Phantom Pain) Neurovascular Variants Other Primary Headache Cluster and other TCA Arteritis Pain Peripheral Neurits Herpes Zoster Post Herpetic Neuralgia Somatoform Disorders Conversion Disorder Pain Disorder Undifferentiated Somatoform Disorder Hypochondriasis Axis II (Psychological Conditions) Axis I (Physical Conditions) Other Neuralgias Okeson, 2003 Chronic Regional Pain Syndrome Sympathetically Maintained Pain Tension-Type Migraine Carotidynia Traumatic Neuroma Maladaptive Health Behavior Stress-Related Physiological Response Personality Traits or Coping Style Axis I Axis II Diagnosis