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BDS 4: Oral Medicine > Facial pain > Flashcards

Facial pain Flashcards

1
Q

What are the risk factors of persistent idiopathic facial pain?

A

● History of widespread pain
● Genetic susceptibility
● Female
● Stress

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2
Q

What would a typical SOCRATES look like for a patient with Glossopharyngeal Neuralgia?

A

S – Unilateral & involving ear, base of tongue, tonsillar fossa or angle of mandible
O – Initiated by swallowing, chewing, talking or coughing
C – Severe stabbing pain
R – N/A
A – Syncope or Arrhythmias (due to Vagal nerve involvement)
T – Transient
E – Alleviating (sometimes pulling on earlobe)
S – Severe

Arrhythmias - Irregular heart beat

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3
Q

What are the 3 biopsychosocial factors affecting pain?

A

1) Disease – History & Presenting disease
2) Environment – Lifestyle, Culture, Upbringing & Trauma
3) Patient Characteristics – Genetics, Gender, Etc

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4
Q

What is the aetiology of trigeminal neuralgia?

A
  1. Trigeminal nerve compression at Root Entry Zone (REZ) by tumours/blood vessels
  2. Which lead to Nerve damage
  3. Which lead to Abnormal nerve firing
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5
Q

What type of disease is chronic/persistent pain?

A

Disease of neuromatrix

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6
Q

Define HYPOALGESIA

A

Diminished pain response to a normally painful stimulus
E.g. In MS (Multiple Sclerosis)

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7
Q

Define atypical odontalgia

A

Pain in a tooth or edentulous alveolar ridge but NO clinical or radiological abnormalities can be detected

(80% pts relate with dental treatment)

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8
Q

Define HYPERALGESIA

A

Increased response to stimulus which is normally painful

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9
Q

What is giant cell arteritis?

A

Granulomatous arteritis affecting large/medium sized arteries
Most frequently the Temporal arteries

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10
Q

Define burning mouth syndrome

A

An idiopathic burning discomfort or pain affecting people with clinically normal oral mucosa in whom a medical or dental cause has been excluded

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11
Q

What are some associated symptoms of cluster headaches?

A

Same side lacrimation
Nasal stuffiness
Restlessness
Nausea

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12
Q

What topical and sytemic tx can be given to pts with atypical odontalagia?

A

Topical Treatment
* Capsaicin or Lidocaine

Systemic Treatment
* Tricyclic Antidepressants (Amitriptyline or Nortryptilline)
* Anti-epileptics (Gabapentin or Pregabalin)

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13
Q

Define DYSAESTHESIA

A

Unpleasant sensation whether spontaneous or evoked

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14
Q

How do you manage a pt with burning mouth syndrome?

A

Strong reassurance to Px
Consider cognitive behaviour therapy if moods are causing issue

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15
Q

What are the risk factors of trigeminal neuralgia?

A

Multiple sclerosis and hypertension

MS - lifelong condition that affects the brain and nerves

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16
Q

Define ANALGESIA

A

Absence of pain in response to a normally painful stimulus

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17
Q

What are some systemic causes of burning mouth syndrome?

A

● Systemic disease (e.g. Diabetes)
● Medications (e.g. ACE inhibitors)
● Hormone & Vitamin deficiencies

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18
Q

What is the most common non-dental facial pain?

A

Temporomandibular Disorders (TMD)

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19
Q

What affected anatomy contributes to orofacial pain?

A

Pain involving area above the neck, anterior to ears & below the orbitomeatal line (including pain from oral cavity)

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20
Q

How do you diagnose Persistent Idiopathic Facial Pain?

A

Diagnosis is via Exclusion of other causes

(due to non-specific symptoms – “poorly localised pain with widespread radiation” OR no help after several dental interventions - Ie several XLAs and still pain)

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21
Q

What are the pharmalogical tx options for TMD?

A

● Analgesics – NSAIDs, Paracetamol or Opioids
● Corticosteroids – Iontophoresis or Intra-capsular injections
● Antidepressants
● Anxiolytics
● Sedative-Hypnotics
● Muscle relaxants

Think that a patient with TMD is normally stressed/anxious/depressed

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22
Q

How do you manage pts with atypical odontalagia?

A

Reassure Px no dental cause & stop on-going cycle of dental interventions
Consider congitive behaviour therapy

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23
Q

How do you manage a pt with persistent idiopathic facial pain?

A

Hold off on unnecessary dental treatments till pain resolved (assure Px unrelated to dental and explain likely cause ie stress)

Consider congitive behaviour therapy or use of antidepressants

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24
Q

How do you mange giant cell arteritis?

A

Corticosteroids (40-60mg/day Prednisolone)
Calcium or Vit D supplements

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25
Q

How long does pain need to be present for it to be considered chronic or persistent?

A

Over 3 months

26
Q

How long can cluster headaches last for?

A

Pain builds up over 5-10 mins & can last hours (average 45 mins)

27
Q

What do the words;
Chronic
Persistent
Imply about the pain itself?

A

Chronic implies may never go
Persistent suggests able to live with

28
Q

What are the conserative tx options for TMD?

A

● Behavioural changes (parafunctional habits)
● Relaxation
● Diet advise – avoid hard/brittle foods
● Jaw exercises
● Massage
● Warmth to joints

29
Q

What is the aetiology of Glossopharyngeal Neuralgia?

A

1) Primary = Nerve compression
2) Secondary = Congenital vascular anomalies, Tumour or Aneurysm

30
Q

How do you diagnose burning mouth syndrome?

A

Diagnosis is via Exclusion of Actual causes of Burning mouth (e.g. Vit B/Folate deficiency anaemia)

31
Q

Define Temporomandibular Disorders (TMD)

A

Collective term – Mucoskeletal disorders involving muscles of mastication and/or TMJ

32
Q

What would a typical SOCRATES look like for a patient with Trigeminal Neuralgia?

A

S – Normally UNILATERAL (60% right side)
O – Anytime
C – Flashing, Sharp, Shooting, Unbearable, Terrifying
R – Distributions of the Trigeminal Nerve (first division rare)
A – Weight loss
T – Intermittent (Bouts last seconds, followed by pain free periods weeks-months)
E – Provoking (Light touch, Eating or Talking)
S – Moderate to Severe

33
Q

What would a typical SOCRATES look for a patient with TMJD?

A

S – TMJ may be uni or bilateral
O - Any
C – Dull/Aching/Throbbing pain
R – Pre/Post ear or Muscles of mastication
A – Stress, Clicking, Tender muscles, Headache/Migraine
T – Intermittent or constant
E – Provoking (Chewing, Yawning or Opening wide)
S – Mild to Moderate

34
Q

What would a typical SOCRATES look like for a patient with Burning Mouth Syndrome?

A

S – Tongue, Lips, Palate (can radiate to whole mouth)
O – Anytime
C – Burning, Tender & “Irritating”/”Tiring”
R – Whole mouth
A – Feeling of Oral Dryness, Altered Taste, Depression/Anxiety
T – Intermittent or constant (worse in evening)
E – Provoking (Eating or Tension)
S – Mild to Moderate

35
Q

What special investigations need to be carried out for trigeminal neurlagia?

A

FBC
MRI scan of posterior fossa to detect compression and rule out tumours and MS

36
Q

Define PARAESTHESIA

A

Abnormal (not unpleasant) sensation whether spontaneous or evoked

37
Q

What is the likely age of onset for giant cell arteritis?

A

Above 50 y/o
Consider this diagnosis in any elderly Px with recent onset headache or facial pain

38
Q

What are cluster headaches?

A

Unilateral excruciating attacks of pain principally involving orbital, frontal and temporal regions

39
Q

What are different disorders included in TMD?

A

Myofascial pain disorder
TMJ disc interference disorders
TMJ degenerative joint disease

40
Q

Define ALLODYNIA

A

Pain due to a stimulus that would not normally provoke pain

E.g. VZV Post-Herpetic Trigeminal Neuralgia can lead to pain touching skin or clothes

41
Q

Define trigeminal neuralgia

A

Sudden, usually unilateral, severe, brief, recurring, stabbing pain in the distribution of one or more branches of the trigeminal nerve

42
Q

What would a typical SOCRATES look like for a patient with Atypical Odontalgia?

A

S – Well localised (Max molars and premolars most affected)
O – In conjunction with dental interventions
C – Persistent Dull/Ache/Throbbing pain
R – N/A
A – N/A
T – Intermittent or constant
E – Provoking (Chewing)
S – Moderate

43
Q

What are some complocations associated with giant cell arteritis?

A

Visual ischaemic complications
Irreversible visual loss
Increased risk of mortality from cardiovascualr disease

44
Q

What are the adjunctive tx options for TMD?

Alongside conserative and pharmalogical tx

A

● Splint therapy
● Cognitive Behavioural Therapy
● Physiotherapy
● Acupuncture
● Botox injections

45
Q

What would a typical SOCRATES look like for a patient with persistent idiopathic facial pain?

A

S - Poorly localised pain w/ widespread radiation
O - Any
C - Nagging, Dull, Throbbing, Sharp or Aching
R - Widespread (Can go anywhere)
A – Pain in other areas (headaches, neck or back)
T – Intermittent or constant
E – Provoking (Chewing, Stress, Cold weather or Dental Stress)
S – Mild to Severe

46
Q

How do you manage Glossopharyngeal Neuralgia?

A

Medication such as Carbamazepine
Cardiac pacing may be required (if heart involvement)
Surgical nerve decompression

47
Q

What age and gender has the highest prevalence of trigeminal neuralgia

A

50-60 years, more common in men
RARE CONDITION

48
Q

What may patients with persistent idiopathic facial pain also complain about that they experience in their everyday life?

A

50% complain of chronic fatigue
50-70% complain of sleep disturbance

49
Q

What are the five potential indicators of degenerative change in TMD?

How many changes need to be observed to suggest that it is becoming degenerative?

A

● Clicking
● Crepitus (sand paper like feeling on palpation)
● Limitation of movement – Locking
● Momentary hesitation/pause in movement
● Sudden inability to fully close teeth

50
Q

What hormonal changes can cause burning mouth syndrome and how?

A

Menopause = Reduction in gonadal & neuroactive steroids
Chronic stress = Impaired HPA axis leads to reduced adrenal steroid levels
Loss of hormones = Loss of their neuroprotective effect

HPA Axis - hypothalamic-pituitary-adrenal axis

51
Q

What are the risk factors of TMJD?

A

Depression (or other psychological distress)
Multiple pain conditions
Females
18-44 y/o
Bruxism
Sleep problems
Facial trauma
Contraceptive pill

Think females and their problems

52
Q

As tigeminal neurlagia progresses how are periods of exacerbation and remission affected?

A

As disease progresses, periods of exacerbation increase and periods of remission decrease

53
Q

What ages do cluster headaches normally start between?

A

28-30

54
Q

What are the 3 main symptoms of burning mouth syndrome?

A

1) Px complains of Oral Dryness BUT THIS IS NOT THE CASE ON EXAMINATION
2) Px complains of Altered Taste
3) Tongue thrusting (pushing forward)

55
Q

What is the ratio of M to F for cluster headaches?

A

M>F ratio 5:1

56
Q

What may you see in blood reports of pts with giant cell arteritis?

A

ESR (Erythrocyte Sedimentation Rate) above 50mm/min

57
Q

What is the local and systemic tx options for burning mouth syndrome?

A

Symptomatic management
* Saliva substitutes
* Benzydamine oral rinse

Systemic Treatment
* Tricylicantidepssants (Nortriptyline/Amitriptyline)
* SSRIs (Fluoxetine)

SSRIs Selective serotonin reuptake inhibitors

58
Q

What are the different classifcations of trigeminal neuralgia?

A

Idiopathic
– Typical
– Atypical

Secondary
– Intrinsic brainstem pathology (eg MS, Stroke)
– Extrinsic cerebellopontine angle pathology (e.g. aneurysms)§

59
Q

What are some side effects to warn a pt about when taking carbamazepine?

A

Drowsiness
Dizziness
Diplopia (double vision)
Ataxia (lack of voluntary movement)
Allergic Reactions

60
Q

What are some local causes of burning mouth syndrome?

A

● Mucosal diseases
● Infection
● Parafunctional habits (e.g. bruxism)
● Ill-fitting dentures
● Hypersensitivity reactions

61
Q

What should be avoided in pts experiencing cluster headaches?

A

Avoid alcohol (major trigger)

62
Q

What can be prescribed to a patient with trigeminal neuralgia?

A

Carbamazepine (GOLD STANDARD)
Oxcarbamezepine (less drug interactions & less side effects)
Lamotrigene
Baclofen
Phenytoin

BDS 4: Oral Medicine (15 decks)

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