Orofacial Pain

Question 1

what is burning mouth syndrome

Answer 1

chronic, intraoral burning/dysaesthetic sensation
recurs 2hrs + / day
50% of days last 3 months
without evident causative lesions

Question 2

prevalence and diagnosis of burning mouth syndrome

Answer 2

1-7%, women, older

diagnosis of exclusion - OLP, candida, hypo salivation, tongue parafunction
anaemia, B12/9 deficient, DM, ace inhibitors

Question 3

symptoms of burning mouth syndrome

Answer 3

burning pain of mouth/tongue
bilatera;
xerostomia, dysguesia
relieved on eating, worsen with day

onset = spontaneous, trigger [dent/med procedures, new meds, illness, stressful events]
psychology - emotional distress, anxiety, depression

Question 4

pathophysiology of burning mouth syndrome

Answer 4

peripheral + central neuropathy
decreased brain dopaminergic activity with should inhibit nociceptive signals
reduction in protective neurosteroids (DHEA) reduced by hormones

hormones - menapause, prostate cancer
chronic stress -> altered HPA activity -> persistent raised cortisol -> decreased protective neurosteroids

genetics, environment

Question 5

primary vs secondary management of burning mouth syndrome

Answer 5

primary =
empathy, recogniser pain, not alone, leaflet
FBC, ferritin, folate, B12, HbA1c, DM, anaemia

secondary =
educate, reassure, distraction, CBT
amitriptyline
alpha lipoid acid
topical capsaicin
AVOID BENZYDAMINE
clonazepam 500mcg in water
nortiptyline 50mg
gabapentin
preglablin
duloxetine

Question 6

what is persistent idiopathic facial pain (PIFP)

Answer 6

persistent facial +/r oral pain, varied presentation, recurs daily 2hrs+, over 3 months, no neurological deficit
associated WITH OTHER CHRONIC PAIN

poorly localised, unilateral, maxillary, dull, throbbing, sharp exacerbations
aggravated by stress
onset via minor procedure
can be bilateral later

avoid unnecessary tx if uncertain, OM refer

2nd - notriptyline, duloxetine, CBT
physical activity, distraction, physiotherapy, relaxation

Question 7

what is persistent idiopathic dentoalveolar pain

Answer 7

persistent unilateral dentoalveolar pain, rarely multiple sites, variable, daily 2hr+ for 3 months

well-localised, mod intensity, tooth/mucosa, XLA site, pre/molar maxilla
dull, pressure-like, hard to differentiate
onset = preceding dental tx

cause = unclear, possible neuropathic [phantom limb, central modulation]

clinical / xray, pain aggravated by stress

refer OM/restorative after establishing no cause

Question 8

what is post traumatic trigeminal neuropathic pain

Answer 8

persistent 3 months, onset within 6mths injury to peripheral trigeminal nerve, association with somatosensory symptoms in area of burning, shooting pain, numbers, hyperalgesia. allodynia

burning, shooting, mod=severe, most of day, rarely crosses midline
onset = injury

risks = preceding pain of increased severity/duration, psychosocial factors, fear, older, female

preventive strategies in select pt
minimise tissue damage
refer OM
if suspect - avoid further investigations