Oral Med Revision - Facial Pain

Question 1

how to categorise pain

Answer 1

1. nociceptive = normal physiological response i.e. trauma, non healing injury
2. neuropathic = lesion or disease of the somatosensory nervous system; TN is neuropathic pain
3. nociplastic pain = increased sensitivity from altered function of pain related sensory pathways in periphery & CNS; triggered by non nociceptive stimuli

Question 2

trigeminal neuralgia

Answer 2

disorder characterised by recurrent unilateral brief electric shock like pains, abrupt in onset & termination, limited to distribution of 1 or more divisions of trigeminal nerve & triggered by innocuous stimuli. it may develop without apparent cause or be a result or another diagnosed disorder. may be concomitant continuous pain of moderate intensity within the distribution of affected nerve division

Question 3

TN classification

Answer 3

classical
secondary
idiopathic

Question 4

how would pt describe TN pain

Answer 4

stabbing
electric shock
scary
10/10 pain
severe
memorable 1st episode

Question 5

SOCRATES TN presentation

Answer 5

S - unilateral, mandib/maxillary distribution usually 1 branch
O - spontaneous, sometimes triggers but not always
C - sharp electric shock like, 10/10
R - spread along branch of TN nerve may have focused starting point
A - distress, depression
T - random, short lived up to 2mins, multiple times per day, may have constant less severe background pain
E - cold wind, washing face, shaving, brushing teeth, relief from not moving face & avoiding triggers
S - may or may not disturb sleep

Question 6

common TN triggers

Answer 6

eating, washing, face, brushing teeth, cold wind, speaking, smiling, temp change, stress
managing triggers important for some pts & not all have triggers

Question 7

red flag features of TN to ask about

Answer 7

sensory motor defects
deafness
loss of balance
optic neuritis
hx of craniofacial malignancy
bilateral TN
systemic symptoms
<30yrs

Question 8

mx of TN in GDP

Answer 8

1. obtain accurate dx, exclude dental / TMD pathology
2. consider commencing carbamazepine, liaise with GP for blood monitoring, if unsure if safe to prescribe phone OM
3. consider LA if pt in extreme pain
4. urgent referral to OMFS/OM for definitive advice

Question 9

can a GDP prescribe carbamazepine

Answer 9

yes
check BNF for interactions
care in elderly as increases fall risk
care in those operating heavy machinery / driving / childcare
requires blood monitoring with FBC/U&E/LFT - arrange with GP

Question 10

carbamazepine regime

Answer 10

carbamazepine tablets 100mg send 20 tablets x1 tab x2 daily for 10 days

Question 11

TN mx in 2ndary care

Answer 11

MRI scan for all pts
space occupying lesion, MS, neurovascular conflict, neurophysiological testing or CT if MRI contraindicated
medication optimisation (using lowest dose that controls symptoms)
carbamazepine
oxcarbazepine - generally well tolerated, less evidence of safety
consider lamotrigine baclofen gabapentin or pregabalin in refractory cases
LA in acute episodes
neurosurgery can be considered if best long term pain control outcome / meds ineffective / significant side effects of meds