Non-Odontogenic Pain

Question 1

How can pain be classified?

Answer 1

Nociceptive
Neuropathic
Nociplastic

Question 2

What is nociceptive pain?

Answer 2

Normal physiological response (trauma, non-healing injury, inflammation)
Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors

Question 3

What is neuropathic pain?

Answer 3

Lesion or disease of the somatosensory nervous system eg - TN

Question 4

What is nociplastic pain?

Answer 4

Results in the increased sensitivity from the altered function of pain-related sensory pathways in the periphery and CNS

Question 5

What is TN?

Answer 5

A disorder with recurrent unilateral brief electric shock like pains, abrupt in onset and termination, limited to distribution of one or more divisions of trigeminal nerve
May develop without cause of can be result of diagnosed disorder

Question 6

What are the types of TN?

Answer 6

Classical
Secondary
Idiopathic

Question 7

How can TN pain be described?

Answer 7

Stabbing
Electric shock
Scary
10/10
Severe
With memorable first episode

Question 8

How does TN present?

Answer 8

Unilateral, usually one branch
Spontaneous onset, sometimes triggers
Sharp electric shock pain
Spread along branch of TN nerve
Suicidal ideation, depression
Random, short lived up to two minutes, multiple times a day
May have constant less severe background pain
Exacerbating - cold wind, washing face, shaving, brushing teeth
Relieving - not moving face, avoiding triggers, medications
May or may not wake from sleep

Question 9

What are the common TN triggers?

Answer 9

Eating
Washing face
Brushing teeth
Eating
Speaking
Smiling
Cold wind
Temp changes
Stress

Question 10

What TN red flags should you ask about?

Answer 10

Sensory motor defects
Deafness
Loss of balance
Optic neuritis - swelling and inflammation
History of cranio-facial malignancy
Bilateral TN
Systemic symptoms
<30 years old

Question 11

How is TN managed as a GDP?

Answer 11

Obtain accurate diagnosis, exclude dental/TMD path
Consider carbapazepine, liaise with GP for blood monitoring - if unsure call OM for advice
Consider LA if pt is in extreme pain
Urgent referral to OM/OMFS for definitive advice

Question 12

What should you look out for when prescribing carbamazepine?

Answer 12

Check BNF for interactions
Care in elderly as increases falls risk
Care in this operating heavy machinery/driving/children
Requires blood monitoring - arrange with GP

Question 13

What is the prescription for carbamazepine?

Answer 13

100mg tablets, 20 tablets, 1 tablet twice daily

Question 14

How is TN managed in secondary care?

Answer 14

MRI for all pts
Medication optimisation - use lowest dose that controls symptoms - oxycarbazepine, lamotrigine, baclofen, gabapentin, pregabalin
Consider neurosurgery

Question 16

When can neurosurgery be considered for TN?

Answer 16

May be best long term pain control outcome
If medications ineffective
If side-effects of medicines being encountered
Is there neurovascular conflict
Is pt medically well
Does pt accept the surgical risks

Question 17

What is oral dysaesthesia?

Answer 17

Idiopathic chronic condition, characterised by persistent alteration to oral sensation received to be abnormal and/or unpleasant in the absence of an identifiable local or systemic cause

Question 19

What type of pain is an oral dysaesthesia?

Answer 19

Neuropathic

Question 20

What are the common symptoms of oral dysaesthesia?

Answer 20

Prickling
Burning
Numbness
Tingling
Shooting sensation

Question 21

What are common complaints with oral dysaesthesia?

Answer 21

Tip of tongue nips
Sandpaper on tongue
Cotton wool in mouth
Mouth feels really dry
Tingling on roof of mouth
Feels like mouth on fire
Chemical taste and smell
Mouth feels dirty and fluffy

Question 22

Describe the history of oral dysaesthesia

Answer 22

Anterior 1/3 of tongue, palate, lips, labial mucosa
Random onset
Prickling, burning, numb, tingling, shooting
No spread of pain
Dry mouth sensation, altered taste
Worse at night, less noticeable when busy
Exacerbating - worry, when unoccupied
Relieving - eating, drinking, socialising
Won’t wake from sleep but difficulty getting to sleep

Question 23

What red flags should you ask about oral dysaesthesia?

Answer 23

Objective numbness - permanently lost senation
Unilateral symptoms
Dysphagia
Odynophagia
Weight loss
Loss of balance/hearing change
Unexplained motor or other sensory change
URGENT referral in these instances

Question 24

What conditions can be excluded from oral dysaesthesia?

Answer 24

Fungal infection
Mucosal disease eg - lichen planus
Odontogenic infection
Dry mouth
Parafunctional
Tongue thrusting
Cranial nerves, E/O, I/O should be normal

Question 25

What investigations do you need for oral dysaesthesia?

Answer 25

FBC - anaemia Haematinics for deficiency Thyroid function tests HbA1c to exclude diabetes

Question 26

How should you explain oral dysaesthesia pain to a pt?

Answer 26

Take history including triggers and how it impacts life Look for other diagnoses Show empathy Recognise pain is real and tell them this Let them know they’re not alone in this Provide leaflet on BMD as an unconfirmed diagnosis

Question 27

How is oral dysaesthesia managed in secondary care?

Answer 27

Counselling and CBT Improving sleep - caffeine, alcohol, discussion with GP Exercise Explanation of chronic pain Reflect to what is impacting life Medications

Question 28

What topical medications can be used for oral dysaesthesia?

Answer 28

Saliva subs - GDP Difflam - GDP Clonazepam mouthwash - Specialist

Question 29

What systemic medications can be used for oral dysaesthesia?

Answer 29

Tricyclic antidepressants - specialist Duloxetine/venlafaxine - specialist Anticonvulsants - gabapentin, pregabalin - specialist

Question 30

How can you manage oral dysaesthesia as a GDP?

Answer 30

Exclude dental or mucosal cause for symptoms Explain no worrying features but acknowledge pt symptoms are real Refer to OM and simultaneously ask GP to consider blood investigations Consider saliva substitutes and difflam