Orofacial Pain And Neurological Disturbances

Question 1

Whats OROFACIAL PAIN?

Answer 1

An unpleasant sensation felt in the region of Mouth, Jaw & Face caused by Noxious stimulus, which is mediated through specific nerve pathway/nociceptors in CNS where it is interpreted as Pain

Question 2

What are causes of orofacial pain?

Answer 2

1.LOCAL
2.NEUROGENIC
3.VASCULAR
4.PSYCHOGENIC

Question 3

Enlist local causes of orofacial pain?

Answer 3

Diseases of Teeth
Diseases of Periodontium
Diseases of Oral mucosa
Diseases of Antrum
Diseases of Sinuses
Diseases of Jaw
Diseases of Salivary Glands
Diseases of Ears
Diseases of Eyes

Question 4

Enlist neurogenic causes of orofacial pain?

Answer 4

Trigeminal Neuralgia
Glosso pharyngeal Neuralgia
Post Herpetic Neuralgia
Causalgia
Bell’s palsy
Herpes Zoster
Ramsay Hunt Syndrome
Multiple Sclerosis
Intracranial Tumors

Question 5

Psychogenic causes of orofacial pain?

Answer 5

Atypical Odontalgia
Atypical Facial pain
Burning mouth syndrome

Question 6

Vascular causes of orofacial pain?

Answer 6

Migraine
Cluster headache
Temporal Arteritis
Paroxymal facial hemicranias
Referred pain i.e. ischemia, Angina

Question 7

Which nerves are involved in orofacial pain?

Answer 7

Trigeminal nerve (CN V & its branches V1, V2, V3)
Facial nerve (CN VII)
Glossopharyngeal nerve (CN IX)
Vagus nerve (CN X)
Cervical nerves C2, C3

Question 8

Whats somatic pain and its types?

Answer 8

Originating from the organ involved i.e. mucous membrane, bone, joint, muscles

1 superficial Somatic Pain: from Thermal, Chemical, Mechanical Stimuli. Burning/Pricking in character, generally involve Skin & Mucous membrane

2 Deep Somatic Pain: Dull aching, referred pain. It could be

Musculoskeletal: involve, muscles, bone, joints, ligaments i.e. TMJ, periodontal

Visceral: Pulp, Glands, Neurovascular, Eyes

Question 8

Explain neurogenic pain and its types?

Answer 8

Pain due to dysfunction of the peripheral or central nervous system, in the absence of nociceptor (nerve terminal), stimulated by trauma or disease.

Episodic:
Neuralgia: Pain along the course of nerves, may caused by vascular spasm
Neuro vascular

Continuous :
Neuritis: Inflammatory changes in nerves (Burning sensation)
De-eferent pain

Question 9

How to measure pain?

Answer 9

1. Visual analogue scale (VAS)
   0———————————10
   No pain worst possible pain
2. Mcgill pain Questionnaire (MPQ)

3.Qauntitative sensory testing (QST)
i.e. sensitivity to hot & cold

4. Descriptive sensory testing
   (Mild, Moderate, Severe)
5. Observable pain behavior

Question 10

Whats trigeminal neuralgia and whats its other name?

Answer 10

A self limiting disorder characterized by immediate attacks of sharp shooting lancinating pain, confined to the area of distribution of Trigeminal/cranial V Nerve, illustrated by presence of trigger zone

Tic douloureux

Question 11

Etiological factors of trigeminal neuralgia?

Answer 11

Vascular compression of trigeminal nerve

Demylinating plaque of multiple sclerosis

Trauma or infection of nerve

Tumors of cerebello-pontine angle

Meningioma of posterior cranial fossa (most frequent cause)

Idiopathic

Question 12

Most frequent cause of trigeminal neuralgia is?

Answer 12

Meningioma of posterior cranial fossa

Question 13

C/F of trigeminal neuralgia?

Answer 13

Mostly affects individuals elder than 50 yrs of age

Episodic stabbing pain for few seconds followed by period of remission

Unilateral frequently (Bilateral Rare)

Electric shock like quality of pain

Pain presents as trigger zone( in the area of distribution of trigeminal nerve) provoked by light touch

1-2 attacks per day

Common trigger zones are naso-labial fold, corner of lip
Shaving, showering, speaking, exposure to wind can trigger painful episodes

DOES NOT AFFECT SLEEP

V2 is more commonly involved

Question 14

How will you diagnose trigeminal neuralgia?

Answer 14

History

Local anesthetic blocks

Pain relieve with the Use of Tegrol (Carbamazepine)

Routine cranial nerve examination

CT scan & MRI, MRTA (magnetic resonance tomographic arteriogram) to exclude presence of brain disease

Question 15

DD of trigeminal neuralgia?

Answer 15

1. Multiple sclerosis: Occur at younger age + mainly bilateral while trigeminal neuralgia is unilateral.
2. Cluster headache: headache occurs at night + No trigger zone.
3. Post-herpetic neuralgia: After herpes zoster of the 5th cranial nerve + history of skin lesion prior to pain aids in the diagnosis.
4. Psychogenic neuralgia: the distribution of pain is unanatomical, it may cross the midline with no trigger zone it is usually deep, vague, poorly localized.
5. Neoplasia:
   - Intracranial neoplasms may cause facial pain if they irritate or compress the root or the ganglion of the trigeminal nerve.
   - This may be indistinguishable from idiopathic trigeminal neuralgia and is usually termed symptomatic trigeminal neuralgia.
6. Glossopharyngeal neuralgia: The pain is unilateral in the throat and base of the tongue on one side, sometimes radiating to the ear.
7. Pain of dental origin: e.g., pulpitis, A.D.A.A., periodontitis, pericoronitis.
8. Pain of osseous origin: (dry socket and acute osteomyelitis).
9. Pain originating in T.M.J.

Question 16

What are management strategies for trigeminal neuralgia?

Answer 16

1.Medical
2.Peripheral procedures
3.Ganglionic procedures
4. Surgical

Question 17

Explain in detail Medical,Peripheral,Ganglionic, and surgical management of trigeminal neuralgia?

Answer 17

I. Medical treatment:

1. Carbamazepine (Tegretol):
- Action as Dilantin.
- Usually begin with 200 mg, 2 times daily.

2. Second line drugs
- If the patient is unable to tolerate the side effects of carbamazepine or if the carbamazepine has been ineffective after 4 weeks → the patient should be started on the second-line drugs.
- The second line drugs are antiepileptic medicines and tricyclic antidepressants.

II. PERIPHERAL PROCEDURES

• Trigeminal neuralgia can be modulated by interruption of any part of the trigeminal pathway, from peripheral sensory nerves to the nerve root entry zone.
• Thus local anesthetic blocks of peripheral nerves can be used as an emergency measure.
• Peripheral nerve destruction usually by cryotherapy, alcohol injection, or nerve avulsion is used.
• The supraorbital, infrorbital, or mental nerves are most commonly approached.

III. GANGION PROCEDURES

• Radiofrequency Thermocoagulation.
• Glycerol Injection.
• Balloon Compression.
• Radiosurgery (Gamma knife).

IV. SURGICAL TREATMENT (Open Procedures):

1. Trigeminal Root Section:
- It is an intra-cranial surgery in which the sensory roots of gasserian ganglion are cut sparing the motor root.

2. Micro-vascular decompression “MVD”
- A loop of an artery (usually the superior cerebellar artery) which is resting on the trigeminal entry zone causing the nerve to produce the symptoms.
- In this operation, the loop of the artery is dissected, elevated, and then a small prosthesis is put to separate the artery from the nerve (called Jannetta – S operation).

Question 18

Trigger zone in glossopharngeal neuralgia?

Answer 18

Trigger zone is present in the course Cranial nerve IX (glosso pharyngeal nerve)
i.e. pharynx, posterior tongue, Ear, infra-auricular retromandibular area

Question 19

Glossopharyngealneuralgia is PROVOKED BY and also associated with?

Answer 19

Provoked by chewing, swallowing, talking
May also be associated with vasovagal reflex, followed by bradycardia, hypotension, cardiac arrest
Can occur with TN

Question 20

Etiolology Diagnoses and Treatment Of Glossopharyngeal Neuralgia?

Answer 20

Etiology: Intra/extra cranial tumors, vascular compression of IX nerve

Diagnosis: Topical anesthesia to the pharyngeal mucosa can eliminate pain

Treatment: same as TN

Question 21

Whats Nervous Intermedius/Geniculate Neuralgia?

Answer 21

Uncommon, paraoxymal neuralgia of CN VII (facial nerve)
Trigger zone is present along the course of sensory distribution of facial nerve i.e. ear, anterior tongue, soft palate
Ipsilateral
Pain is less intense than TN
Paralysis if motor root is also involved

Question 22

Etiology and treatment of geniculate neuralgia?

Answer 22

Etiology: Herpes zoster of geniculate ganglion or nervous intermedius of CN VII May called as Ramsay Hunt Syndrome
Treatment: Acyclovir, short course of high dose steroid therapy for 2-3 weeks, anticonvulsants
Surgical removal or MVD of geniculate ganglion if pt does not respond to medications

Question 23

Etiology Of Post Herpetic Neuralgia?

Answer 23

Etiology: acute herpes zoster infection of trigeminal ganglion, and its peripheral branches and cranial nerve VII

Question 24

C/F of Post herpetic neuralgia?

Answer 24

Clinical features: History of vesicle Continuous, chronic, pain Interfere with the brushing and eating affecting the dermatome supplied by nerve Pain persist longer than 1 month after the healing of vesicle Pt may feel parasthesia, hyperparasethesia

Question 25

Management Of Post herpetic neuralgia?

Answer 25

Treatment: Topical Capasaicin 0.025%, lidocaine Tricyclic antidepressants Anticonvulsants Corticosteroids Local anesthetics block at the site of pain Cryocautory Prophylaxis Vericella zoster vaccination

Question 26

Causalgia Etiology? Diagnoses? Treatment?

Answer 26

Pain arising after injury to a peripheral sensory nerve i.e. following difficult extraction Pain is due to aberrant nerve repair Constant burning pain at the site of previous trauma or surgery May mimic TN Diagnosis: History Scaring from previous surgery or trauma Treatment: Carbamazepine

Question 27

Classify Pain of psychological origin?

Answer 27

A-Atypical facial pain B-Typical Odontalgia C-Burning mouth syndrome

Question 28

Whats Atypical Facial Pain and its CF and Treatment?

Answer 28

Constant dull aching pain, deep, diffused, variable intensity, in the absence of identifiable organic cause. CF Often difficult for pts to describe their symptoms Most frequently described as deep, constant ache or burning Could be bilateral Does not disturb sleep Affects maxilla more than mandible Often complains about dry mouth & chronic pain syndrome Examination entirely normaL More common in female Middle & elderly aged patients are affected Rx: TCAs have some response in some pts 30% pts respond to Gabapentin Cognitive behavioral therapy

Question 29

Whats Atypical Odontalgia And Its Management?

Answer 29

Occurs more frequently in females in 4th & 5th decade Constant dull aching pain without any obvious cause on examination Occurs after dental extractions or endodontic treatment Pain free period after second dental management Treatment Pt re-assurance Consultation to other specialty Low dose of TCAs i.e. amitriptyline, nortriptyline (10-25mg) at night Anticonvulsants drugs

Question 30

CF of burning mouth syndrome?

Answer 30

Complain of dry mouth with altered taste Burning sensation mostly on tongue, sublingual area, anterior palate, lips May be aggravated by certain foods Usually bilateral Does not disturb sleep May occur after awakening Examination entirely normal

Question 31

Management of burning mouth syndrome?

Answer 31

Treatment: Reassurance Avoid aggravating factors Some pts may respond to TCAs (Tricyclic antidepressants:), SSRIs (selective serotonin reuptake inhibitors ) Topical clonazipam 1 mg TDS for 3 weeks Cognitive behavior therapy

Question 32

Cause of these orofacial pain is? Migraine Cluster headache Temporal Arteritis Paroxymal facial hemicranias Referred pain i.e. ischemia, Angina

Answer 32

Vascular cause

Question 33

CF and triggers of migraine ?

Answer 33

CF Migraine is a primary headache disorder , characterized by recurrent headaches,  that are moderate to severe. Typically the headaches affect one half of the head, are pulsating in nature last from 4 to 72 hours.  Associated symptoms may include  nausea, vomiting, photophobia, sensitivity to sound  The pain is generally worsen by physical activity.  Up to one-third of people have an AURA Aura is short period of visual disturbance that signals that the headache will soon occur. Females are more commonly affected than males Triggers: Depression Hunger Sleep deprivation Coffee, tea , chocolates, nuts, Pineapple, Alcohol, red wine consumption Initial constrictions of branches of external carotid artery causing aura Followed by dilatation causing headache

Question 34

Types Of Migraine?

Answer 34

Classical migraine (with Aura) Common Migraine (without Aura)

Question 35

T/F In classical migraine after AURA there is Severe throbbing ipsilateral pain involving fronto-temporal lobe

Answer 35

T

Question 36

Management therapies of migraine attack?

Answer 36

1-Prophylactic or Preventative therapy 2-Abortive therapy 3-Palliative or rescue therapy Avoid trigger factor Acute attack: Analgesics Sumatriptan (5HT agonist) Ergotamine Prophylaxis: Propanolol Other Ca+ channel blockers TCAs

Question 37

CF of cluster Headache?

Answer 37

Episodes of severe unilateral headache Occurring chiefly around the eye, like ptosis, meiosis ;accompanied by autonomic signs i.e. nasal congestion, tearing Occur without Aura and become severe within few minutes Multiple headaches/day for 4-6 weeks with or without the period of remission of months or years Mostly occurs at night causing sleep disturbance Provoked by use of nitroglycerine, alcohol Most common in men Attacks are sudden, stabbing, causing pts to cry or even strike objects Some pts may exhibit violent behavior during attack Hot metal rod pain in or around one eye (Knife Stabbing pain in eye) Symptoms most commonly affect the area supplied by V1 nerve V2 may also effected

Question 38

Main difference between migraine and cluster headache?

Answer 38

Migraine doesnt affect sleep and pt go in dark room , Cluster Headache affects sleep

Question 39

Diagnoses , DD, Treatment And Prophylaxis for cluster headache?

Answer 39

Diagnosis : Pain aborted with the use of oxygen Differential diagnosis: Migraine (does not effect sleep, pt go in dark room) Treatment: Sumatriptan Ergotamine (sublingual/inhaled) Lithium Prophylaxis: Predinisolone Ca+ channel blockers

Question 40

Explain Temporal Arteritis ?

Answer 40

Systemic Inflammatory disorder that often involved the extra cranial circulation , secondary to giant cell Granuloma (GCA) Failure to treat giant cell arteritis may lead to serious ischemic complications, including blindness, stroke and myocardial infraction

Question 41

Jaw claudication?

Answer 41

Jaw claudication refers to pain or discomfort in the jaw that occurs while chewing. It is a classic symptom of Temporal Arteritis

Question 42

cf of temporal arteritis?

Answer 42

Affects adults above the age of 50 years Dull aching or throbbing pain in temporal region accompanied by fever, malaise, anorexia Jaw claudication during mastication weight loss, fatigue ESR raised Scalp tenderness: Hair burshing , Resting over pillow, Wearing hat

Question 43

Treatment Of Temporal Arteritis?

Answer 43

Treatment: High dose of steroids predinisolone 60-100mg daily Steroids are tapered, once the signs are controlled Pts are maintained on steroids for 1-2 years after symptoms resolve.