Facial pain Flashcards
(133 cards)
1
Q
What percentage of the population have signs and symptoms of TMJ disorders?
A
- Signs at some point in their life 50-75%
- Symptoms at some point in their life 20-25%
- Percentage of population who seek treatment 3-4%
- Women are more likely to seek treatment
2
Q
What is the TMJ?
A
It is made up from the condyle fitting into the fossa. There is a fibrous articular capsule which envelops the joint. The articular disc divides the joint into upper and lower compartments and it is biconcave.
The masseter muscle passes over the angle of the mandible and the temporalis attaches to the coronoid process.
3
Q
What are the parts of the temporal bone?
A
The mastoid process is just behind the ear and the sternocleidomastoid and digastric muscle attach to this. The zygomatic arch has the masseter muscle attaching to the top border. The external auditory meatus is behind the TMJ which is why you can hear the joint clicking.
4
Q
How does the TMJ move?
A
It is a hinge joint with a moveable socket. There is the lower compartment which is where the condyle rotates below the disc (hinge like motion) and the condyle stays in the fossa for this movement. The upper compartment is when the condyle and disc translate along the eminence (gliding) which is held in place by the posterior ligament. Normal opening is 35-50mm. The first half of opening is mainly hinging (rotation of the condyle in the fossa) and the second half is mainly forward translation of the condyle along the eminence.
5
Q
How do the muscles cause opening of the mouth?
A
A combination of muscle action facilitates this rotation and translation. The geniohyoid and digastric pull the chin down and backwards. The lateral pterygoid facilitates forward translation of condyles and discs. When closing the temporalis (posterior fibres) facilitate backward translation of the condyles. The temporalis, masseter and medial pterygoid elevate the mandible.
6
Q
How do the muscles cause protrusion of the jaw?
A
Protrusion is symmetrical forward translation of both condyles. Both lateral pterygoids pull the condyles (and discs) forward. This is 10mm. Retrusion is the return to rest position from the protrusion position. Both temporalis muscles (posterior fibres) pull the condyles back. Lateral excursion can be 10mm. The condyle on the opposite side if pulled forward. The condyle on the same side performs minimal rotation around the vertical axis. This is caused by contraction of the lateral pterygoid muscles on the opposite side combined with temporalis muscle on the same side contracting to hold the rest position of the condyle.
7
Q
What is the diagnostic classification for pain from TMD?
A
- Non-TMDs (other facial pains including dental, salivary gland, pharynx etc)
- Uncommon TMDs (specific) - inflammatory arthritis, neoplasms, growth disturbance etc
- Common TMDs which can be acute or chronic (>3 months)
8
Q
What are the common TMDs?
A
Common temporomandibular disorders account for over 95% of all referrals. Diagnosis is made on the basis of history and examination. Temporomandibular disorder has been defined as: a collective term embracing a number of clinical problems that involve the masticatory muscles, the temporomandibular joint and associated structures or both. The types of common TMD:
- Muscular
- Articular
- Disc displacement
- Degenerative joint disease
- Subluxation
- Mixed diagnosis
9
Q
How are common TMDs further classified?
A
Masseter muscle disorders (mainly affect masseter and temporalis): - Myalgia - Local myalgia - Myofascial pain - Myofascial pain with referral Temporomandibular joint disorders: - Arthralgia - Disc disorders - DD+R - DD+R with intermittent locking - DD-R with limited opening - DD-R without limited opening - Degenerative joint disease - Subluxation Headache: - Headache attributed to TMD
10
Q
What are masticatory muscle disorders?
A
The related muscles are the masseter and the temporalis. The signs and symptoms are familiar pain in the muscles on jaw function/parafunction, palpation and movement tests. In myofascial pain with referral there will be report of pain at a site beyond the boundary of the muscle being palpated. It may present as toothache, headache or earache. Referral patterns can cause confusion and awareness helps with differential diagnosis.
11
Q
What are the signs and symptoms of TMJ arthralgia?
A
There is familiar pain in the TMJ on jaw function/parafunction, palpation or movement tests.
12
Q
What is disc displacement with reduction (DD+R)?
A
The disc position is no longer maintained on the condyle throughout the range of motion. The normal position of the disc is between the fossa and the condyle, but in this the disc is anteriorly displaced. Through the opening cycle the disc reduces (goes back) to its normal position. This is when you hear the click when it reduces or moves anteriorly again.
13
Q
What are the signs and symptoms of DD+R?
A
- TMJ clicking on function and movement tests e.g. opening
- Familiar pain in TMJ on function, palpation and movement tests
- Intermittent TMJ locking/sticking
- A manoeuvre may be required to open the mouth
The movement pattern is ipsilateral deviation with opening (which corrects).
14
Q
What is DD-R (disc displacement without reduction)?
A
DD-R without reduction is a progression of disc displacement with reduction but here the disc no longer relocates. The disc simply folds in front of the condyle on forward movement.
15
Q
What are the signs and symptoms of DD-R?
A
Acute/subacute - closed lock:
- Limited mouth opening <25mm - interferes with ability to eat
- Limited contralateral excursion
- Familiar pain on TMJ on function, palpation or movement tests
There will often be ipsilateral deviation with opening which doesn’t correct.
Chronic:
- Joint can become stretched to allow nearly full range of movement
- This is disc displacement without reduction without limited opening
16
Q
What can be seen on an OPG/CT in degenerative joint disease?
A
CT is the gold standard.
- Joint space narrowing
- Osteophytes
- Subchondral sclerosis (increased opacity)
- Subchondral cysts and erosions
This is very common and may be an added source of pain and limited range of movement (may not be reason for pain).
17
Q
What are the signs and symptoms of degenerative joint disease?
A
- Crepitus on function and movement tests
- Familiar pain in TMJ on function, palpation or movement tests
- Limited mouth opening
18
Q
What is hypermobility and subluxation?
A
TMJ hypermobility can result in recurrent condyle subluxation – where the condyle comes off the end of the eminence. The signs and symptoms are:
- TMJ clicking and locking in a wide open position ( patient may yawn and jaw locks)
- Excessive mouth opening >50mm
- Familiar pain on function, palpation and movement tests
If the patient is able to reduce this dislocation it is termed subluxation and if the dislocation requires an intervention it is termed luxation.
19
Q
What is a headache attributed to TMD and the signs and symptoms?
A
It is a headache affecting temporalis. The signs and symptoms are a familiar headache in the temporal area on function, palpation of temporalis muscle and movement tests. A combination of disorders is very common (all three groups).
20
Q
What history of presenting complaint questions should you ask with TMD?
A
- Pain - SOCRATES
- Clicking - on opening or closing, aggravating/relieving, timing, temporary or persistent, associated with pain
- Other joint noises
- Limitation of opening/trismus - duration, aggravating/relieving, associated with pain
- Locking - on opening or closing, timing, temporary or persistent, associated with pain
- Altered occlusion - lateral open bite due to increased joint space
- Sensory disturbance - wouldn’t be expected with TMD, may say face feels tingly due to muscles working, usually comes and goes if associated with TMD, if tumour it would be progressive
- History of trauma
- Parafunctional activity - clenching/grinding, nail biting, lip biting
21
Q
What can chronic pain from TMD lead to?
A
If over a considerable amount of time it can lead to substantial psychological distress and behavioural reactions. For example not working, restricted social pattern, depression. This is then termed dysfunctional pain.
22
Q
What are the risk factors for chronic pain?
A
- Predisposing - trauma
- Initiating - microtrauma and strain
- Perpetuating - psychological and parafunctional
23
Q
What past medical history can link to TMD?
A
- Systemic arthritis
- Previous malignancy
- Mental health (depression/anxiety)
- Fibromyalgia
- Hypermobility syndrome
Fibromyalgia is widespread pain and sensitivity to palpation at multiple anatomically defined tissue sites. It is often accompanied by depression and insomnia. It is thought to be due to CNS neurosensory amplification.
24
Q
What are the red flags?
A
- History of cancer (may suggest metastasis)
- Pain that is abrupt in onset, severe or precipitated by exertion, coughing or sneezing or that interrupts sleep (may suggest intracranial pathology or cardiac ischaemia)
- Weight loss (may suggest cancer)
- Fever (may suggest septic arthritis, osteomyelitis, intracranial abscess, tooth abscess or mastoiditis)
- Neurological symptoms or signs (may suggest a tumour or other intracranial pathology)
- Swelling of the temporomandibular joint, mandible or parotid gland (may suggest tumour, infection or inflammatory arthropathy)
- Facial asymmetry (may indicate a tumour)
- Unilateral headache or scalp tenderness, jaw claudication or visual symptoms (suggests giant cell arteritis)
- Nasal symptoms – persistent loss of smell (anosmia), purulent discharge, nasal blockage, or epistaxis (may suggest a nasopharyngeal tumour)
- Neck mass or persistent cervical lymphadenopathy (may suggest infection or tumour)
- Change in occlusion (how the teeth meet together when the jaws are closed) this may suggest a tumour or bone growth (for example acromegaly) around the temporo-mandibular joint, or inflammatory arthritis; but can also be seen in other temporomandibular disorders
- Decreased hearing on the ipsilateral side (may suggest a nasopharyngeal tumour)
- Increasing pain or limitation in function despite initial management (may suggest a tumour)
25
What are the contributing factors to TMDs?
- Trauma - macrotrauma, parafunctional activity, third molar removal
- Systemic condition - hypermobility, fibromyalgia
- Parafunctional activity - nail biting, grinding/clenching, stress, anxiety
- Abnormal position - overclosed, occlusal interference
26
What should you look at during an extraoral exam for TMD?
- Masseter muscle hypertrophy
- Protrusive habit
- Clenching habit
- Poor neck postural habit
- Asymmetry/lumps/swelling
- Lymph nodes (infection, inflammation, neoplasm)
- Vascular/arteries (anyone over age of 50) - superficial temporal artery, temporal arteritis
- Neurological - check cranial nerves
27
What should you look at intraorally for TMD?
- Signs of clenching/grinding such as tongue scalloping/buccal mucosa ridging, attrition/wear facets, hypertrophic masseter muscles
- Occlusal assessment - interfering contacts, recent changes in occlusal scheme, skeletal pattern - class II posturing (for aesthetics and eating)
28
What should you look at in a musculoskeletal examination for TMD?
- Observation
- Range of movement ROM
- Local palpation of muscles - masseter (intraoral and extraoral) and temporalis and lateral pterygoid intraorally. Palpate TMJ over condyle or just behind and look for pain.
29
How do you measure ROM and lateral excursions?
Ask patient to open as wide as possible and this should be more than 40mm. Lateral excursions are measured by using the gap between 2 upper and 2 lower incisors as the reference point. Measure the gap. Expect about 10mm. if there is a significant difference between the two joints there is a problem. You can also use overpressure (assisted opening). If they can open more with assisted pressure it indicates a muscular problem rather than a joint problem. If joint problem they wouldn’t be able to open more. Palpate joint sounds as the patient opens the mouth. You can also observe deviations but this is no longer in classification.
30
What do TMD investigations help with?
Most patients do not require investigation. It will only help with joint related problems and not muscular. Do a sectional OPT.
31
What are the types of joint related problems seen on an OPT and other investigations that can be done?
Type I-IV (see notes for images). For more information on the bone and the disc you can do an MRI in function. You can see the movement of the disc relative to the condyle. CT scan would show bone and not in function so often not used.
32
What are the treatment options for TMD?
- Education - crucial, takes time, some patients are very receptive, includes information, principles of treatment and reassurance
- Physical therapy
- Splint therapy
- Medication
- Psychological
- Occlusal adjustments
- Botulinum toxin
- Arthrocentesis
- Surgery
- Review
33
What are the aims of intervention?
- Decrease pain
- Increase jaw function
- Increase psychological status
- Self manage
- Be safe
34
What are the guidelines for safe and effective management?
- Early diagnosis and intervention helps prevent development of chronic symptoms
- Use of conservative, reversible and evidence based interventions
- E.g. education, physical therapy, splints, medication and psychological support
- Don’t produce irreversible changes/less risk of harm
- Even longstanding and severe symptoms don’t usually require invasive treatment
- Failure of conservative interventions does not indicate a need to progress to irreversible treatment e.g. occlusal adjustments or surgery
- TMD is a dental specialism
- In secondary care, physiotherapy referrals are usually from dental and maxillofacial specialists
- For referrals to physiotherapy from non-dental health professionals we advise patient to see their GDP for intraoral screening and to consider modalities e.g. splint therapy
35
What should you inform the patient in TMD education?
Education is crucial for addressing psychological driving factors. There is an information leaflet to give patients at CCDH. When explaining use skull and images to help reinforce understanding. Tell patient how pain can be referred. How joint and muscles work, where the disc is, how it moves. Inform patient how common disorder is and that it is not a serious medical problem. Patient education helps to make sense of disorder. Reinforce benign diagnosis. Reduces threat of symptoms. Give rationale for treatment. Tell patient how they can reduce stress and strain on joint and muscles by avoiding oral habits.
36
What are oral habits?
Oral habits are well established patterns of inappropriate muscle activity. They increase strain on TMJ and muscles and may contribute to symptoms and act as barrier to recovery. They include:
- Tooth contact, clenching, grinding
- Nail biting
- Chewing gum
- Pen chewing
- Lip sucking
- Habitual protrusion - movement of lower jaw forwards
Ask patient to monitor the oral habit. Show patient how to check relaxed jaw rest position. Avoid forward head posture as this causes muscle and joint loading. Eat a soft diet, chew slowly on both sides, avoid caffeine – increased muscle activity, avoid repeated wide mouth opening e.g. yawning, avoid sleeping on front.
Read notes from now
37
What is poor sleep an indicator of?
Advise on sleep hygiene. Increasingly poor sleep over time is a substantial predictor of new onset TMDs. Sleep hygiene – things to avoid and try before bed.
38
How can physiotherapy and acupuncture be used?
Physiotherapy involves soft tissue techniques to facilitate muscle relaxation and reduce pain and then gives patient a handout so they can continue themselves. Acupuncture can be used as an adjunct and can reduce pain and facilitate muscle relaxation.
39
What is done for muscle overactivity, reduced control and hypomobility?
For muscle over-activity we can give jaw relaxation techniques. For reduced control e.g. subluxation we can give patient jaw control exercises. For joint hypomobility (stiff joints) there are manipulative therapies for TMJ to help restore mobility. Patients can do active assisted stretch at home. None of these techniques should be painful.
40
Why should the neck also be assessed?
TMJ interacts with other areas. Patients with neck disorders and TMD often have similar signs and symptoms therefore neck should be assessed in patients with facial pain.
41
What is an occlusal splint and how do they work?
An occlusal splint is a removable device usually made of acrylic resin, which fits between the maxillary and mandibular teeth. They work by:
- Occlusal disengagement
- Maxilla-mandibular realignment
- Restored vertical dimension
- TMJ repositioning
- Cognitive awareness
- Placebo effect
42
What are the types of splint?
- Directive - anterior repositioning splints ARPS
- Permissive
- Soft bite guard
- Anterior bite plane - lucia jig
- Stabilisation splint (Michigan, Tanner)
43
What is an anterior repositioning splint and the indications?
An anterior repositioning splint is used to direct the mandible more anterior to ICP. It provides a better condyle disc relationship to allow time for the tissues to adapt or repair. Indications:
- Disc derangement disorders (especially anterior disc displacement with reduction)
- Can be useful for intermittent/chronic locking of the joint (often caused by disc displacement)
44
What are the advantages and disadvantages of soft splints?
```
Advantages:
- Sometimes tolerated better by patients
- Easily constructed
- Cheap
Disadvantages:
- Difficult to adjust
- Can encourage patient to brux
- In some cases muscle pain either does not change or occasionally increases
```
45
What are lucia jigs and the uses?
Lucia jigs are used to disclude posterior teeth and allow relaxation of the muscles of mastication. Patients ‘forget’ their ICP position (neuromuscular deprogramming). Uses:
- To help locate centric relation
- As a diagnostic tool for patients with TMD symptoms
- As a quick fix for patients with acute symptoms prior to constructing a more definitive appliance (a few days)
46
What are the types of stabilisation splint (hard splint)?
- Michigan splint (upper)
- Tanner appliance (lower)
- Interocclusal appliance
- Occlusal splint
- Ramfjord appliance
47
What are the features of a stabilisation splint? (upper)
- Heat cured acrylic
- Full coverage to prevent over-eruption
- Uniform contact in centric relation canine guidance to separate posterior teeth in eccentric excursions
- Anterior guidance to separate posterior teeth in protrusion
- i.e. the splint creates an artificial ideal occlusion
48
What are the clinical stages of splint construction?
```
Visit 1:
- Upper and lower alginate impressions
- Jaw registration in centric relation
- Facebox
Visit 2:
- Fit splints - can be tedious, seat splint and adjust fitting surface as necessary
Subsequent visits
- Review and adjust as necessary
```
49
When should TMD patients wear the splint?
- Every night
- During periods of increased muscular activity/stress
- For patients with severe symptoms as often as possible during day also
50
What are the features of a Tanner appliance?
- Mandibular appliance
- Heat cured acrylic resin
- Full occlusal coverage
- Simultaneous even contacts with all opposing teeth in RCP
- Appropriate anterior guidance
- Absence of posterior interferences
51
What should be done following splint therapy?
If splint therapy is successful in reducing/eliminating symptoms consider long-term splint wear. Do not assume that further intervention e.g. occlusal adjustment will provide the same benefit. Provision of an inter-occlusal appliance (usually an upper hard acrylic splint) should be considered one of the first line treatments for patients with TMD. Full occlusal coverage is important for splints.
52
What medications can be used for TMD?
Analgesia:
- Paracetamol
- NSAID - ibuprofen
- Anxiolytics
such as:
- Tricyclic antidepressants (muscle relaxation, analgesia, a low dose of this is useful for facial pain)
- Benzodiazepines (addictive and will work so patient will want more when pain recurs, not to be given long term - caution)
53
How can the botulinum toxin be used for TMD?
Botox is given to reduce muscular activity. It will reduce activity in muscles and take away pain. It carries risk – injecting over nerve stops the nerve working, injecting into vein can cause problems as it goes elsewhere. After 6 months it will wear off so is not good for long term. It is a temporary removal of symptoms. It is expensive. If you keep injecting you can get muscle wasting. This can be useful in some cases but not used routinely.
54
How does botox work?
BTX-A binds to acceptors on cholinergic terminals. There is internalisation. There is release of light chain, cleavage of SNAP-25 and blockage of ACH release. SNAP 25 is a presynaptic membrane protein required for fusion of neurotransmitter containing vesicles.
55
What are the surgical techniques for TMDs?
Surgical techniques may be considered. Arthrocentesis can be used which is the least invasive. You wash the joint space out and inject some steroids into the upper joint space. This will settle acute inflammation. You can only do this twice in the lifetime of the joint as the steroids cause osteoporosis so the condylar head will get smaller if you do it a third time. Arthroscopy is used to have a look round the joint: adhesiolysis, lavage, biopsy, miniscal plication. If there is an acute closed lock from trauma then steroids can be useful.
56
What are the advantages and disadvantages of arthroscopy?
```
Advantages:
- Minimally invasive
- Diagnostic information
Disadvantages:
- High level of operator skill required
- Limited scope for reconstructive surgery
```
57
When is surgery considered?
- Condylar hyperplasia
- Trauma
- Ankylosis
- Tumours
- Internal derangement and severe chronic pain that is refractory to non-surgical treatment
58
What are the risks of surgery?
Auriculotemporal nerve and facial nerve (zygomatic: temporal branches).
59
What are the types of surgery?
- Diskoplasty - disc repositioning (plication)
| - Discectomy - disc removal +/- alloplastic material/temporalis muscle flap
60
What are the uncommon disorders?
- Trauma and dislocation (traumatic arthritic/effusion - lateral open bite, dislocation, fracture of TMJ/condylar head
- Osteoarthritis
- Infective arthritis
- Ankylosis and limited opening (trismus)
61
What is osteoarthritis and the treatment?
Osteoarthritis is also known as degenerative arthritis or degenerative joint disease or osteoarthritis is a group of mechanical abnormalities involving degradation of joints including articular cartilage and subchondral bone. Osteoarthritis is a painful inflammatory erosive phase lasting three years followed by a period of resolution. Treatment is symptomatic with splints, BRA, NSAIDs and arthrocentesis.
62
What are the clinical features of osteoarthritis?
- Pain centred on joint
- Tender joint
- Crepitus
- Limitation of mouth opening
- Limitation of translatory movement
- Radiological signs (erosion, spurs)
63
What is infective arthritis and the treatment?
Infective arthritis is rare and may spread to middle cranial fossa therefore must be treated urgently. Treat with drainage and antibiotics (IV). This affecting the TMJ is very rare.
64
What are the clinical features of infective arthritis?
- Pyrexia
- Very restricted opening
- Suppuration
- Erythema
- Swelling
- Long term ankylosis
65
What are the types of ankylosis and limited opening?
- Extracapsular (outside the joint) trismus
- Intracapsular
- Pseudo-ankylosis
66
What is extracapsular ankylosis?
- Trauma – fibrosis (burns, trauma, lacerations)
- Infection
- Tumours e.g. fibrosarcomas
- Periarticular fibrosis (radiation, prolonged immobilisation)
- Inflammation (dental, other)
67
What is intracapsular ankylosis?
- Trauma – fracture (forceps delivery at bone) – true bony ankylosis
- Infection
- Systemic arthritis
- Tumours
- Synovial chrondromatosis (multiple cartilaginous nodules within the TMJ) – very rare
68
What is pseudo-ankylosis?
Mechanical interference with mouth opening e.g. zygomatic fracture
Read notes
69
What is the treatment of dislocation?
Benzodiazepine is used and then it is relocated by pressing down on mandible. For recurrent dislocations:
- Physiotherapy
- Botulinum toxin - lateral pterygoid
- Fibrosis of tissues
- Surgical
70
What is inflammatory arthritis?
- Rheumatoid (also juvenile)
- Psoriatic
- SLE
- Ankylosing spondylitis
- Gout
Treat with specialist clinic and symptomatic treatment.
71
What are TMJ replacements made of?
TMJ replacements are made of two parts – ball and socket system. Reserved for cases where all other treatment modalities have failed.
72
What are the causes of dental pain in teeth, gingiva and bone?
```
Teeth:
- Caries/exposed dentine
- Pulpal pain
- Periapical pain
- Cracked tooth syndrome (worsened by biting)
Gingiva:
- Periodontitis
- Pericoronitis
- Malignancy
Bone:
- Osteomyelitis
Dental pain is the most common facial pain. It can be post-operative pain or referred dental pain.
Read notes on history.
```
73
What questions can be asked about the character of the pain?
```
Character type:
- Sharp
- Shooting
- Throbbing
- Aching
- Burning
- Nagging
- Intensity/severity - mild/moderate/severe, intensity score 1-10
Character frequency:
- Constant
- Intermittent
- Now and then
- Paroxysms - an uncontrollable outburst, a sudden attack
Character - associated symptoms:
- Clicking/noise of jaw
- Tearing
- Facial flushing
- Swelling
```
74
What is the epidemiology of chronic facial pain?
7-14% of the population may have it.
75
What are the common consequences of chronic pain?
- Reduced activity
- Unhelpful beliefs and thoughts
- Repeated treatment failures
- Long term use of analgesics and sedatives
- Loss of job, financial and family stress
- Physical deterioration e.g. muscle wasting, joint stiffness
- Feelings of depression, helplessness, irritability
- Side effects e.g. stomach problems, lethargy, constipation
- Excessive suffering (all leading to)
76
How should you examine a patient with chronic facial pain?
It is determined by the history.
EO - symmetry, lymph nodes, TMJ, cranial nerves
- IO - soft tissues, teeth
- ST - imaging, vitality testing, laboratory
In an examination do a careful visual inspection. Ensure that the view is goof enough. Palpate and percuss. Establish a diagnosis from history, exam and special tests and come up with treatment options.
77
What is the difference between acute pulpitis and periapical periodontitis?
Acute pulpitis is difficult to localise, changes with time, hypersensitive to stimuli, poor response to analgesics and vital.
Periapical periodontitis is localised, painful to bite and non-vital.
78
What are other periodontal pains?
- Periodontal abscess
- Lateral periodontal lesions
- Trauma - direct trauma, ortho treatment, bruxism - several teeth
79
What are the symptoms of bone pain?
There will be a deep throbbing pain, difficulty sleeping, frequent bad taste and foul odour. Often there may be paraesthesia but less so with BRONJ/MRONJ.
80
What is post-operative pain and how can it be prevented and managed?
It is inflammatory pain. It is mediated by the AA pathway. A good surgical technique can minimise this. NSAIDs are good for managing this. Tell the patient to buy ibuprofen prior to tooth extraction so they can take some once the LA has worn off.
81
What are the symptoms of maxillary sinusitis?
Maxillary sinusitis is a constant burning pain with zygomatic and dental tenderness from the inflammation of the maxillary sinus. The complaint is often purulent rhinorhea. There may be recovery from a nasal cold and then a worsening of symptoms. On examination there will be purulent secretions in the nasal cavity. ESR above 10mm per hour. Normal sinus functioning depends on patent ostia, satisfactory ciliary functioning and appropriate amount of secretions.
82
What is oral dysaesthesia?
The aetiology is unknown. It is painful burning of the mouth /tongue caused by nerve damage. Burning mouth is caused for no known reason. We need to exclude all the causes before arriving at burning mouth syndrome as a diagnosis. Management is with CBT (improves over 6 months) and increased oestrogen to increase taste. The prognosis is unknown as it is difficult to get studies.
83
What is trigeminal neuralgia?
Trigeminal neuralgia is a sudden, usually unilateral, severe, brief, stabbing, recurrent pain in the distribution of one or more branches of the fifth cranial nerve.
84
What is atypical facial pain?
Atypical facial pain is present daily and persists for most of the day. It should be confined at onset to a limited area of one or both sides of the face but may spread to the upper or lower jaws and a wider area of the face and neck. It should not be associated with sensory loss or other physical signs. Laboratory investigations should not demonstrate relevant abnormalities. The pain may be initiated by trauma but persist without any demonstrable local cause.
85
Why might there be TMJ pain?
- Costens syndrome
- TMJ dysfunction syndrome TMD
- Myofascial pain syndrome
- Facial arthromyalgia
- oromandibular pain
TMJ pain is pain in the TMJ and muscles of mastication which may worsen upon chewing possibly leading to restricted jaw movement.
86
How is chronic pain managed?
- Assessment and diagnosis - ensure no cause for concern
- Explanation and reassurance
- Discuss/suggest treatment options
87
What are the types of facial pain
- TMJ
- Neuralgic
- Atypical
- Vascular
88
What are the signs and treatment for TMJ pain?
It is in the temple, ear, jaws and teeth. Localisation is poor but usually unilateral. The duration is weeks-years. The character is dull and continuous and it is worse with chewing and yawning. There can be limited mouth opening and a click. The cause is stress and parafunction. Treatment is physiotherapy, behavioural and antidepressants.
89
What are the signs and treatment for neuralgic pain?
The location is along the nerve distribution. Localisation is fair to good. The duration is seconds and it is lancinating and paroxysmal. Precipitating factors are touch, wind, vibration. The cause is idiopathic or MS. Treatment is tegretol, nerve block and neurosurgery.
90
What are the signs and treatment for atypical facial pain?
It is diffuse, deep and can be across the midline, localisation is poor. The duration is weeks to years and the character is dull, boring and continuous, it can be throbbing, aching like toothache. Precipitating factors are stress and fatigue and the aetiology is nerve injury and stress. Treatment is antidepressants, behavioural (CBT). LA block does not help.
91
What are the signs and treatment for vascular pain?
The location is the orbit or the upper face and localisation is usually good. The duration is minutes to hours and the character is throbbing and deep. Precipitating factors are alcohol. Signs are lacrimation and eye infected. The aetiology is vasomotor, allergic? Treatment is triptans.
92
What are the three parts to pain in a biopsychosocial assessment?
- Biological
- Psychological - anxiety, depression
- Social context - work, finances, family
93
What are the local causes of burning mouth?
Primary burning mouth syndrome is idiopathic and the cause is unknown. Secondary burning mouth syndrome can be due to underlying medical problems
- Bacterial – oral swabs
- Fungal – oral rinse for candida
- Allergy – patch test
- Geographic tongue – observe over time
- Parafunction – dental examination
- Oeseophageal reflux – tooth erosion
- Xerostomia – salivary flow rates
94
What are the systemic causes of burning mouth?
- Decreased iron folate B12
- Diabetes
- Menopause
- Psychogenic
- Cancerphobia
95
What is the management of burning mouth?
The management is to correct deficiencies, alter medications and manage symptoms. Several controlled trials exist regarding pain improvement. Not all are placebo controlled. Topical, systemic and psychological therapies have been tried but a placebo is difficult. Often we are using expert opinion evidence.
96
What have the positive trials been for burning mouth?
- Topical clonazepam - anticonvulsant
- Antidepressants
- Alpha-lipoic acid
- Capasaicin capsule - pain reliever
- CBT
97
What is atypical odontalgia?
It is severe throbbing pain in the tooth without major pathology. It is pain associated with a tooth or tooth socket. It is precipitated by dental procedures. If the tooth is extracted the pain often recurs after a few weeks at a new site. It can also be called phantom tooth pain. It is a constant throb or ache. Dental treatment makes no difference or may cause improvement for a week.
98
What will happen after removal of a tooth with atypical pain?
- Pain remains the same (with no tooth)
- Pain moves to adjacent teeth
- Pain in gingival tissue that previously surrounded tooth
99
What is the aetiology of atypical odontalgia?
- Sensitisation of nerves may occur after infection, extraction or RCT
- Changes within the CNS and possibly ongoing neural activity
- Female prevalence
- Tends to be older patients
- Psychosocial factors
100
What are the types of abnormal pain responses?
- Hyperalgesia - stimulation is more painful
- Allodynia - non-painful stimuli are painful
- Spontaneous pain - pain in absence of stimulus
101
Why can there be central sensitisation/secondary hyperalgiesia?
It is changes in the behaviour of central (SC) cells. It is induced by tissue injury. There is increased spontaneous background firing. There is hyperexcitability to other low threshold input and increased size of receptive fields. Pain enhancement is central, enhanced responsiveness and increased AP firing rate leading to increased perceived pain intensity. Chronic stress induces transient spinal neuroinflammation and long lasting hypersensitivity.
102
What are the possible types of therapy for atypical facial pain?
- Stress management – through GMP
- Relaxation/hypnosis
- Cognitive behaviour therapy CBT
- Psychological help for other problems including talking therapy
Dont take teeth out as unable to wear dentures.
103
What does CBT involve?
CBT is a way of talking about:
- How you think about yourself, the world and other people
- How what you do affects your thoughts and feelings
- CBT can help you to change how you think (cognitive) and what you do (behaviour), these changes can help you to feel better
From a situation follows thoughts, emotions, physical feelings and actions.
104
What are the analgesic antidepressant drugs?
- As helpful with chronic pain with known pathology as with unknown pathology or aetiology e.g. chronic arthritis, post herpetic neuralgia
- Mainstay of management of AFP/AO
- Amitriptyline/nortitriptyline 10-100mg nocte
105
What are the abnormal signs?
- Abnormal cranial nerve testing results - abnormal sensations and responses
- Vomiting/headache increased ICP
106
What is the epidemiology of trigeminal neuralgia?
Trigeminal neuralgia is a sudden unilateral severe brief stabbing recurrent pain in the distribution of one or more branches of the fifth cranial nerve. The point prevalence is 0.001. The incidence is approx. 3-5 per 100000 of the population. It occurs more in women than men. It usually occurs over the age of 50. It is unilateral. Idiopathic, secondary.
107
What are the symptoms of trigeminal neuralgia?
It is a unilateral sharp shooting pain and the severity is 10/10. It may be described as like lightening, knife being twisted, electric shock. It is often triggered by eating, talking, washing. Patients often have a trigger area on the face which stimulates the pain. Often in two divisions of the trigeminal nerve e.g. not in ophthalmic. Paroxysms – individual stabs close together. It is worse in the day than at night as they are not doing anything at night. It is a very small sensitive trigger. The pain often goes into remission, particularly early on. It may go away for a few months but will then come back for longer. As the patient gets older it will be more frequent and painful.
108
What can trigeminal neuralgia lead to?
Depression, suicidal feelings and isolation.
109
What is the vascular hypothesis for trigeminal neuralgia?
There is local demyelination of the trigeminal root between ganglion and pons. The signal jumps from one area of demyelination to another and sets off pain fibres. Some patients may get a blood vessel pressing on the nerve leading to demyelination.
110
What are the types that can be diagnosed from an MRI?
- Classical - blood vessel pressing on nerve
- Secondary underlying pathology in brain
- Idiopathic
111
What are the causes of secondary trigeminal neuralgia?
Secondary trigeminal neuralgia may be due to multiple sclerosis, tumour e.g. acoustic neuroma at cerebellarpontine angle. Other rare secondary causes are peripheral neuropathy (Charcot Marie tooth), skull base deformity in Pagets disease.
112
What is the management of trigeminal neuralgia?
- Medical - if medicines fail we move onto surgical
| - Surgical - microvascular decompression, ganglion procedures, stereotactic radiosurgery, cryoanalgesia
113
What medication can be used to manage trigeminal neuralgia?
- Carbamazepine (sodium channel blocker)
- Oxycarbazepine (sodium channel blocker)
- Lamotrigine (sodium channel blocker)
- Gabapentin/pregabalin
- Baclofen
- Valproate
- Phenytoin
- Top three are most important, all medications are anti-epileptics
114
What is the dosage and side effects of carbamazepine (Tegretol)?
```
Dosage:
- Twice daily
- Increase dose gradually
Side effects:
- Rash 8%
- Ataxia and somnolence - given to old people so risk of falls
- Dyscrasia - stops marrow working properly
- Drug interactions - warfarin
```
115
How does carbamazepine work?
It is a strong inducer of a liver enzyme which is cytochrome P450. This enzyme also metabolises many other drugs including warfarin, OCP and calcium channel blockers. Carbamazepine is teratogenic. Given alongside oral contraceptive pill it will make it less effective. It induces its own metabolism so we gradually increase the dose. There is variability between patients. If you see a patient with trigeminal neuralgia contact the doctor and ask them to consider prescribing this – do not prescribe yourself. If patient is getting mild side effects try oxcarbazepine as this is similar – don’t try if patient allergic.
116
What is lamotrigine?
Lamotrigine has relatively few side effects. You increase the dose very very slowly so it takes too long for a lot of patients.
117
What is microvascular decompression?
Microvascular decompression causes more than 80% of complete pain relief and it is often lifelong. It is major neurosurgery to find the blood vessel. Morbidity – CSF leaks, meningitis, cranial nerve deficits. These are risks of the surgery. Risk of a major problem is 0.5%. Young, fit, healthy patients are pushed towards this, not elderly.
118
What is a ganglion procedure?
Ganglion procedure is when the needle is inserted through the foramen ovale into the ganglion. They then try cause C fibres (pain fibres) to die and leave the sensory fibres intact. Options:
- Compression balloon
- Glycerol injection
- Thermocoagulation
You always get some sensory loss from this. If around the cornea then this will affect blinking, tears and can lead to ulceration. This is done under general anaesthesia and it only gives pain release for 3 or 4 years so there may be repeated GA. Risk of sensory deficit.
119
What is cryoanalgesia?
Cryoanalgesia is freezing the nerve which is a temporary way of treating trigeminal neuralgia. There will be recovery and recurrence of the pain. It is 4-6 months of pain relief whilst looking for a different treatment. If you keep freezing the same area the tissue becomes scarred leading to fibrosis. There is a risk of sensory deficit.
120
What is stereotactic radiosurgery?
Stereotactic radiosurgery uses gamma rays from 201 Co60 (1.2 MeV) isotope sources. It is a high precision beam delivery system. There is localisation with stereotactic frame and MRI. There is crossfire on a small area of the brain. It is a one off treatment. It is used to treat some tumours of the brain and a few patients with trigeminal neuralgia. This is good for the elderly as there is no risk from GA, good for patients with MS as not risk to blood vessel.
121
Why do some patients not like stereotactic radiosurgery?
- Delay in pain relief - not immediate, 3 months or longer to gradually get pain relief
- Failure of treatment - works for 80%
- 20-30% of patients get some paraesthesia, some may get tingling - chronic
- Recurrence of pain
- We can repeat the treatment but the risk of numbness increases
122
Who can patients with TN be referred to?
Consider referring to oral surgery, oral medicine. Consider LA. Trigeminal neuralgia association UK is helpful for patients as they can be suicidal.
123
What is temporal arteritis?
Temporal arteritis (giant cell arteritis) is a unilateral or bilateral headache, mainly continuous or throbbing, usually in the elderly with temporal artery signs. It is an autoimmune condition. It is an intense inflammatory response centred around the arterial internal elastic lamina – primary antibody, possibly to elastin itself. The lumen of the artery becomes occluded with minimal blood flow and lots of inflammation. You cant get enough blood through the artery to organs. So if it occurs in an artery supply muscles such as muscles of mastication you get the build of lactic acid leading to pain - ischaemia and claudication. It is associated with polymyalgia rheumatica – another autoimmune condition). These patients typically get pain in shoulders and hips but there is an association.
124
What are the signs of temporal arteritis?
- A new persisting headache (often go to doctor rather than dentist)
- At least one of the following: swollen scalp artery (at temples) with elevated ESR or CRP (inflammatory markers so do a blood test) and often can't feel pulse due to inflammation OR temporal artery biopsy demonstrating arteritis
- Major improvement within three days of steroid therapy
125
What is the presentation of temporal arteritis?
- Elderly
- New onset headache (70%)
- Pain on mastication (40%)
- Scalp tenderness – painful to brush hair
- Can get necrosis on the scalp where there is loss of blood flow
- Generally unwell
- Tenderness or decreased pulsation of temporal vessels
- Elevated ESR >50mm/h
- Biopsy – skip lesions (artery will be fine in some places so large biopsy needed)
- Doppler scanning
126
What is the management of temporal arteritis?
- 50% have involvement of ophthalmic artery which may lead to blindness
- Steroids (prednisolone) - visual symptoms initially 80mg daily, no visual symptoms initially 60mg daily
- Urgent referral to either GMP, rheumatology or ophthalmology (12 hours)
127
What is cluster headache?
Cluster headache is part of trigeminal autonomic cephalalgias (TAC) which includes cluster headaches, paroxysmal hemicrania, SUNCT. Cluster headache is unilateral pain principally in the ocular, frontal and temporal areas recurring in severe bouts with daily attacks for several months and usually with rhinorrhoea and lacrimation – IASP. The pain is constant for the period of time. There will be autonomic features (rhinorrhoea and lacrimation).
128
What is the presentation of a cluster headache?
- Prevalence 1%
- Males (5:1) aged 18-40 years
- Unilateral
- Throbbing, burning, severe pain. May wake patient from their sleep (alarm clock headache)
- Often occurs at the same time every day – may be due to hypothalamus
- Severity comparable with trigeminal neuralgia
- Associated factors – lacrimation, rhinorrhoea, conjunctival injection, Horner’s syndrome
129
What is the management of an acute attack of cluster headache?
Oxygen 100% 10-12 litres/minute through a mask often takes the pain away.
Sumatriptan (5HT1 agonist) can be used subcutaneous or intranasal.
130
What is the management of cluster headache?
Prevention
- Avoid precipitating factors – alcohol, caffeine
- Verapamil – high dose but affects rhythm of heart
- Lithium
- Prednisolone
- Methylsergide
- Gabapentin
- GON
- All above drugs are not pleasant for patient
131
What is a migraine?
It is an episodic headache usually accompanied by nausea, photophobia and don't like noise. The duration is 4-72 hours. It is pulsating. There is an aura in 15% of patients. The triggers are hormonal, relaxation, perfusion, stress, oestrogen. A facial migraine affects the jaws not the head.
132
What is the treatment of a migraine?
- Simple analgesia - ibuprofen, paracetanol
- 5HT1 agonist - triptan
- Antiemetic (metoclopramide)
133
How can migraines be prevented?
- Over two per week
- Interferes with daily function
- Medications do not control the pain - amitriptyline, B blockers, pizotifen
- Patient education of triggers
- Psychological
- TENS/acupuncture, intraoral splints etc
