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Oral med > Chronic facial pain > Flashcards

Chronic facial pain Flashcards

1
Q

What are the three dimensions of pain?

A

Sensory

Motivational

Cognitive

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2
Q

What does allodynia mean?

A

Pain due to a stimulus that does not normally provoke pain.

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3
Q

What does hyperalgesia mean?

A

heightened pain from a stimulus that does usually produce pain

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4
Q

What is paresthesia?

A

An abnormal sensation, whether spontaneous or evoked.

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5
Q

What is dysthesia?

A

an unpleasant abnormal sensation

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6
Q

what is neuralgia?

A

A paroxysmal and often severe pain in the distribution of a sensory nerve or nerves.

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7
Q

What is neuropathic pain?

A

Pain caused by a lesion or disease of the somatosensory nervous system.

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8
Q

What is neuropathy?

A

A disturbance of function or pathological change in a nerve: in one nerve, mononeuropathy; in several nerves, mononeuropathy multiplex; if diffuse and bilateral, polyneuropathy.

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9
Q

What is the definition of chronic pain?

A

Longer than 3 months

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10
Q

Which sub group of people is chronic pain more commen in?

A

Pain with prominent psychosocial dysfunction:  Mood disorders. Affective disorders eg. Depression

 Anxiety disorders. Disorders in which a certain situation or place triggers excessive fear and/or anxiety symptoms eg. generalized anxiety disorders.

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11
Q

What is somatization?

A

Somatization is the presentation of physical symptoms as a manifestation of psychological distress.

Symptoms are usually unexplained or

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12
Q

What the main neuralgias of the head and neck which cause pain?

A

Trigeminal neuralgia

Post herpetic neuralgia

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13
Q

What are the primary headache syndroms,vascular disorders and cerebrospinal fluid syndromes that cause pain?

A

Classic Migraine (Migraine with Aura)

 Common Migraine (Migraine without

Aura)

 Migraine Variants

 Carotidynia

 Mixed Headache

 Cluster Headache

 Paroxysmal Hemicrania

 Temporal Arteritis (Giant Cell Arteritis)

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14
Q

What types of pain is associated with physchosocial cause?

A

Chronic pain

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15
Q

What is primary trigeminal neuralgia?

A

Sudden, severe, recurrent stabbing pains in the distribution of one or more branches of the Vth cranial nerve.

Always effects the primary afferant neurone

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16
Q

What type of pain is associated with trigeminal neuralgia?

A

Sharp, agonizing electric shock-like stabs or pain felt superficially in the skin or buccal mucosa.

usually there are triggers

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17
Q

What is the time pattern of trigeminal neuralgia?

A

Only for a couple of seconds but can happen every couple of mins for a period

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18
Q

What is the site of the pain caused in trigeminal neuralgia?

A

Unilateral (95% of the time)

Path of 5th cranial nerve

Often only affects one of the 3 divisions but occasional two.

The most common divisions that it affects are Maxillary, then mandibular then opthalmic

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19
Q

What are the differential diagnosis of trigeminal nerualgia?

A

Secondary trigeminal neuralgia- tumour,anuerysm

Multiple sclerosis

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20
Q

What is the treatment for trigeminal nerualgia?

A

 Carbamazepine

 Oxcarbazepine

 Gabapentin
 Lamotrigine

 Phenytoin

 Baclofen

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21
Q

What is the surgical treatment for trigmeminal neuralgia?

A

Glycerol nerve blocks

 Partial sensory

rhizotomy

 Radiofrequency ablation of the trigeminal ganglion

 Microvascular decompression

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22
Q

What is glossopharyngeal neuralgia?

A

Paroxysmal bursts of sharp, lancinating pain felt in the distribution of CNIX, particularly the throat, tonsillar fossa and adjacent area of fauces.

Spontaneous or evoked, often by coughing or swallowing.

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23
Q

How can you treat glossopharyngeal neuralgia?

A

application of local anaesthetic to

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24
Q

What is this? what is the pain characterised by?

A

Post herpatic nerualgia.

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25
Q

What type of pain does post herpatic nerualgia cause?

A

Constant pain of moderate intensity but the constant nature makes it intolerable and consquently depression can ensue.

26
Q

How can you prevent primary herpatic neuralgia?

A

high-dose aciclovir during initial Herpes Zoster (shingles) episode.

27
Q

How can you treat post herpatic neuralgia?

A

Amitriptyline, Pregabalin, topical lignocaine or capsaicin patches. Success rates of treatment are low.

28
Q

What pain is associated with TMJDS?

A

Aching in the muscles of mastication, sometimes with an occasional brief severe pain on chewing, often associated with restricted jaw movement and clicking or popping sounds.

unilateral

dull and achy but can be constant

29
Q

What are the signs of TMJDS?

A

Restricted mandibular opening with or without deviation of the jawto the affected side on opening
Tenderness to palpation of the muscles of mastication
Clicking or popping at the joint on auscultation or palpation  Changes in the ability to occlude the teeth fully.

30
Q

What imaging can be used for patients with TMJDS?

A

plain film or MRI.

On the plain film you may see degenerative changes.

On an MRI you may see disk displacement

31
Q

How do you manage TMJ disorders?

A

 Occlusal splints
 Heat packs
 TMJ exercises and massage

Medications

  • NSAIDs (topical/systemic)
  • Anxiolytics, TCAs

 Psychotherapy
 Surgical options

32
Q

What are the exacerabating factors of a tension headache

A

 Emotional stress

 Anxiety and depression
 Physical exercise
 Alcohol (which may also have the opposite effect).

33
Q

What is the managment of tension headaches?

A

 Relaxation techniques

 Analgesics

 Anxiolytics may help but should generally be avoided since some patients become depressed and others develop dependence.

 Tricyclic antidepressants e.g. amitriptyline.

34
Q

What is Atypical facial pain?

A

A chronic facial pain of unknown aetiology.

35
Q

How to manage atypical facial pain?

A

 Reassurance

 Topical measures:

 Difflam, lignocaine and capsaicin patches

 TCAs, other antidepressant meds

 Gabapentin, pregabalin

 Alternative therapies

 Pain team involvement

 Psychotherapies

36
Q

What is atypical odontalgia?

A

Pain from a tooth with no associated pathology

Throbbing pain, may be moderate to severe but constant

Can change location from tooth to tooth.

37
Q

What are the associated factors with atypical odontalgia?

A

TMJDS, oral dysaesthesia, and pains of psychological origin. Often excessive concern with oral hygiene.

38
Q

How do you manage atypical odontalgia?

A

Same as atypical facial pain

39
Q

What is oral dysthesia?

A

Unpleasant abnormal sensation of oral tissues. Burning Mouth Syndrome is a burning pain in the tongue or other oral mucous membranes.

Most often tip and lateral surface of the tongue but can occur in all of the mucosal areas.

40
Q

what are the associated symptoms with oral dysthesia? what investigations should be done?

A

 Dry mouth

 Persistent dysgeusic taste, altered taste perception, thirst

 Burning increased with tension, fatigue, speaking, and hot food, and decreased with sleeping

 Denture intolerance

Bloods – anaemia, haematinic deficiency, diabetes, CT disease

Swab – candidal infection

41
Q

How do you manage oral dysthesia?

A

 Correction of any underlying pathology

 Topical rinses – Difflam, Zinc sulphate  Vitamin B Co-Strong
 TCAs
 Gabapentin, pregabalin

 Alternative therapies  Psychotherapies

42
Q

What are the three types of migraine?

A

Classic migraine
 Common migraine
 Complicated migraine

43
Q

What are the symptoms of a classi migraine?

A

Attacks of throbbing head pain preceded by an aura.

The aura is often visual disturbances

Pain is typically unilateral, starting in the fronto-temporal

unaltered by medications and can last upto 75 hours

44
Q

What are the precipitating factos of a classic migraine? what are the signs and symptoms?

A

Stress, mood changes, relaxation, dietary causes (chocolate, alcohol, cheese, citrus fruits, etc.), flashing lights, atmospheric changes i.e. noise/smoke

nausea, anorexia, photophobia

45
Q

How to manage migraines?

A

 NSAIDS/Paracetamol
 Anti-emetics
 Ergot preparations
 Prophylactic Beta-blocking agents i.e. propranolol or seretonin antagonists i.e. pizotifen  Serotonin 1D receptor agonists like sumatriptan

46
Q

What is a cluster headache?

A

Excruciatingly severe attacks of unilateral headache, principally in the ocular, frontal and temporal areas, recurring in separate bouts with daily, or almost daily, attacks for weeks to months, usually with autonomic symptoms and signs on the symptomatic side.

80-90% male

The pain is constant, stabbing, burning, or even throbbing.

A cluster period usually occurs every 6-18 months

47
Q

What are the associated signs and symtoms with cluster headaches

A

ipsilateral ptosis

A reduction in heart rate

Runny nose

48
Q

How do you manage cluster headaches?

A

 Ergot preparations
 Oxygen inhalation
 Intranasal lignocaine
 Corticosteroids, Verapamil, Lithium or Pizotifen prophylaxis
 Serotonin 1D receptor agonists

i.e. Sumatriptan (S/C)

49
Q

What is temporal arteritis?

A

A vasculitis affecting branches of the External Carotid Artery with resulting obliteration of the vessel lumen and ischaemia of the part supplied.

unilateral or bilateral

Continuous aching or throbbing

can be associated with polymyalgia rheumatica

50
Q

Associated signs and symptoms with temporal arteritis?

A

The temporal artery on the symptomatic side may be pulseless, tender to palpation, bulging and irregular in its appearance.

Involvement of the Cenral Retinal Artery can lead to reduced visual acuity - an “alarm” situation needed immediate therapy (corticosteroid therapy) to prevent permanent blindness.

Chewing can become deficient towards the end of the meal, masticatory ischemia. can get gangrene

51
Q

How do you manage and investigate temporal arteritis?

A

A temporal artery biopsy may reveal giant cell arteritis (unreliable)

 Raised ESR. (erthyrocyte sedimentation rate)

Treat-

 Corticosteroids

 Immunosuppressive therapy e.g. azathioprine therapy

52
Q

Carbemazepine is a commom medication used for chronic facial pain. What dosage should be given?

A

Initially 100-200mg od- bd

Max dose 1.6g/24hrs

Side-effects:

 N&V, Dizziness, Ataxia

 Headache, confusion

 Blood dyscrasias,hyponatraemia

 Rash, Stevens-Johnson Syndrome, TEN

 Hepatitis, Acute renal failure

53
Q

what is the dosage and the side effects of oxcarbazepine?

A

300mg bd

 Max dose

46mg/kg/24hrs

Side-effects:

Similar however usually better tolerated than Carbamazepine

54
Q

what is the side effects and dosage of gabapentin?

A

Day 1: 300mg od

Day 2: 300mg bd

Day 3: 300mg tds

Max dose 3.6g/24hrs

Side-effcts:

 D&N&V, abdo pain

 Weight gain, HTN, Hyperlipidaemia

 Dizziness, confusion, headaches, peripheral oedema

55
Q

Dose and side effects of pregabalin?

A

 75mg bd

** Max dose**

600mg/24hrs

Side-effects: As gabapentin however generally better tolerated.

56
Q

Dose and side effects of lamotrigine?

A

25mg od

Max dose 500mg daily

Side-effects:

 Rash, hypersensitivity

 Stevens-Johnson Syndrome, TEN

 Hepatic dysfuction  Blood dyscrasias

57
Q

Dose and side effects of Baclofen?

A

5mg bd-tds

Max dose

100mg/24hrs

** Side-effects:**

 GI upset

 Hypotension

 Dry mouth

 Drowsiness, sedation, dizziness, confusion, muscular hypotonia

58
Q

what are the two types of antidepressants used for chronic facial pain?

A

Tricyclic antidepressant’s or Selective serotonin reuptake inhibitors (SSRIs)

59
Q

What are the types of TCA’s, the dose and side effects?

A

 Amitriptyline

 Nortriptyline

 10mg on, increased to 70mg on as needed

 Side-effects:

 Sedation, dizziness, ataxia

 Dry mouth, constipation, urinary retention, blurred vision

 Cardiac arrhythmias

60
Q

what are the main SSRI’s, dose and side effects?

A

Citalopram 20mg od

 Max dose 60mg/24hrs

 Side-effects:

  • GI upset
  • Hypersensitivity
  • Generally well-tolerated and less sedating that the TCAs
61
Q

What are the difficulties in managing chronic facial pain patients?

A

 Difficulties explaining non organic pathology
 Fear of missing organic disease
 Overwhelmed by pain behaviour exhibited by patient.

 Managing co existent organic pathology

62
Q

How cna you predict the patients which are not going to respond well to treatment?

A

Defensive patients
Use of terms of endearment to report disease Excessive focus upon symptoms
Overt and hostile criticism of previous treatment History of repeated episodes of inadequate treatment

Oral med (18 decks)

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