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Orofacial Pain |
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Diagnosis Made on the basis of a detailed assessment of the character of the pain, including: duration, site, severity, character, frequency and periodicity, associated features, initiating factors and relieving factors.
Neurological Trigeminal Neuralgia ¨ unilateral, stabbing, electric-shock like pain in trigeminal nerve distribution – (1 or more of main branches) ¨ often trigger point identified by patient, lasts seconds ¨ pain intensity severe ¨ 50-70 years (<40 consider other cause) ¨ short duration only ¨ no neurological deficit ¨ idiopathic - ? compression around trigeminal nerve in posterior cranial fossa
Rx. - Carbamazepine used successfully for most – need regular blood tests ¨ (* hyponatraemia; suppresses WBC, RBC, Plts; induces liver enzymes) ¨ other anticonvulsants or antidepressants can be used ¨ peripheral nerve techniques eg cryosurgery, glycerol injections, thermocoagulation ¨ central neurosurgery for intractable cases (microvascular decompression)
Glossopharyngeal Neuralgia ¨ much less common than trigeminal neuralgia ¨ pain of a similar nature but affects tonsil, oropharynx and/ or ear ¨ triggered by swallowing or coughing
Rx. – Carbamazepine less effective, Gabapentin also used ¨ usually secondary to lesions in post. cranial fossa or jugular foramen
Herpes zoster (including post-herpetic neuralgia) ¨ neuralgia both precedes and accompanies shingles ¨ 10% of pts who have had recurrent VZV develop neuralgia during acute phase and persisting (post-herpetic) more than 6 months afterwards, elderly mostly ¨ post-herpetic neuralgia can be extremely resistant to Rx., pain can be intolerable, analgesics rarely effective, anti-depressants and anti-convulsants can help
Vascular Migrainous Neuralgia (Cluster Headache) ¨ oedema and dilatation of walls of internal carotid artery and possibly external also ¨ 30-50 years, more common in men ¨ retro-orbital excruciatingly severe ‘boring’ pain, lasts less than an hour ¨ pain onset and termination is sudden ¨ precipitated by alcohol, or occurs spontaneously 1-3 times/day ¨ obvious vascular changes associated: lacrimation, nasal congestion and/or rhinorrhoea ¨ no visual symptoms, nausea or vomiting associated as a migraine ¨ Prophylaxis with verapamil, lithium, nifedipine, diltiazem
Giant cell arteritis ¨ granulomatous vasculitis of vessels in head and neck ¨ over 60 years ¨ unilateral ‘headache-like’ pain (severe dull ache) in temporal/occipital region ¨ systemic upset: weight loss, muscle weakness, lethargy ¨ temporal artery frequently becomes red, swollen, firm, tender and tortuous ¨ temporal artery biopsy useful in confirming diagnosis (>3cm length as skip lesions) ¨ risk of blindness due to retinal vasculitis ¨ start oral prednisolone ASAP (60mg/day), good response if treated early
Psychogenic Atypical facial pain ¨ chronic pain of unknown aetiology ¨ 50% of pts. have anxiety or depression associated ¨ often women middle-aged or older ¨ absence of organic signs ¨ pain poorly localised, persists for many years on daily basis ¨ lack of response to analgesics, lack of triggering factors ¨ diagnosis made on basis of history and absence of dental cause for pain ¨ cranial nerve function should be assessed ¨ CT or MRI to exclude malignancy at base of skull ¨ Rx. responds well to anti-depressants
Burning mouth syndrome (oral dysaesthesia) ¨ aetiology uncertain ¨ no visible abnormality, organic disease or haematological abnormality ¨ middle-aged or older woman mainly affected ¨ burning pain, persistently sore ¨ bizarre patterns of pain inconsistent with neurological or vascular anatomy ¨ associated depression, anxiety, cancerophobic (20% of cases) ¨ obsession with symptoms may rule patients’ life ¨ Rx. involves reassurance of common nature and no serious underlying problem ¨ antidepressants help, sometimes dramatically |
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This is the main reason why patients attend a dental clinic. In most cases, an obvious dental cause of the symptoms can be identified, and appropriate treatment provided.
A wide range of diseases apart from local disorders can cause oro-facial pain, including neurological, vascular and psychogenic causes. |