facial pain

ass. prof. dr. ali moh’d munasser abdulrab helpoop

hc. omfs jordan university.
ab. omfs-1.
jb. omfs full. jordian uiversity hospital.
 facial pain
IS THE STIMULUS TO SEEK DENTAL CARE.
ACCURATE DIAGNOSIS AND TREATMENT DEPEND ON THE
INFORMATION THAT YOU GAINED FROM THE PATIENT.
MUCH INFORMATION MUST BE COLLECTED.
BASIC INFORMATION THAT WE NEED INCLUDE:
NATURE OF THE PAIN : BY HIS OWN WORDS.
OPEN QUESTIONS: NOT TO LIST THE DISCRIPTORS.
USE THE 0-10 SCALE
0= PAIN FREE
10= THE WORST PAIN.
onset of pain.
duration of each episode of pain.
frequency of the painful episode.
sites affected:
1. point to the source of pain.
2. outline the area affected.
3. radiation to other areas.
4. confined to the distribution of particular nerves.
5. crossing the midline
initiating factors
precipitating factors: induce the patient symptoms
exacerbating factors: that make the patient symptoms worse.
ameliorating factors: nything which relieve the patient symptoms.
associated signs and symptoms.
previous investigation.
previous treatment.
releavent medical, dental, social and family history.
thourough extraoral and intraoral examination.
assessment of the cranial nerves function
 2 types.

trigeminal classical tn (ctn)

symptomatic tn (stn): strctural abnormalities.
neuralgia more than 85% is of classical trigeminal neuralgia.
definition:
is the compression of the trigeminal nerve by a blood vessel in the dorsal
root entery zone( drez) is the leading cause of classical trigeminal
neuralgia.

in symptomatic trigeminal neuralgia:

the compression is the result of structural lesion such as tumor or
vascular malformation.
demylination secondary to ms is fall within the definition of stn.
 sex:
clinical female more than male.
presentation age:
more than 50 yrs.
if in younger, is suggestion of stn.
nature:
a sharp, stabbing,episodic, electric shoch like pain.
the patient has to stop what they are doing.
duration:
usually seconds and may last upto 2 minutes.
dull pain persists in the background after the sharp pain has resolved.
episodes of pain may be so close together that they seem continuous but
this is unusual.
unpredictable recurrence.
site:
1. localized to one or more division of the tn.
2. most 2nd and 3rd division.
3. pain not cross the midline.
4. bilateral trigeminal neuralgia is unusual and this suggestive of stn.
initiating factor:
the pain may be induced if a particular area of skin or mucosa is
stimulated, this is calle dthe trigger zone.
activity: washing, shaving putting on mike up, eating and speaking.
exposure to cold.
 associated signs and symptoms
in classic trigeminal neuralgia: absence.
in symptomatic trigeminal neuralgia : sensory deficit.
special investigation:
mri is mandatory, to see the approximation of the nerve from the blood vessele.
to exclude the cranial fossa lesion and some extended ms.

medical management:
carbamazepine, start of 100 mg bd or tds and increasing slowly untill the symptoms contolled till 200 and
400 mg tds.
side effects: nausea, ataxia and dizziness.
leukopenia, thrombocytopenia and skin reaction, if occur withdraw the medication.
oxcarbazepine is the alternative.
lamotrigine is added or use as an alternative.
 microvascular decompression:

surgical gives best out come.

low rate of complication.
management sooner rather than later time.
neurectomy (peripheral destruction procedure).
percutaneous radiofrequency thermocoagulation (central
destruction procedure).
gamma knife stereotactic surgery: if the surgery is contraindicated.
retrogasserian glycerol injection
local anesthesia injection into the trigger zone.
surgical proceduress
 an extremely uncommon condition.
clinical presentation:
glossopharyngeal nature:
neuralgia
sharp, stabbing, episodic electrical shock like pain.
patient avoid swallowing.
duration: usually seconds.
spontaneous remission can occur but the remission and recurrence are
unpredictable.
site:
posterolateral tongue, fauces, within the ear of the affected side.
initiating factors:
eating, drinking,swallowing, speaking and coughing.
signs and symptoms: absence.
 special investigation
mri and ct- scan, to exclude the posterior cranial fossa and jugular
foramen lesions.
medical management: tha same as the tn.
surgical treatment:
tha same as the tn.
not possible to use local injection or cryotherapy.
surgical resection of the glossopharyngeal nerve is effective but can result
with significan side effect and complications.
 classic vesicles of herpes zoster.

preherpetic in some cases, preceded by facial pain.

neuralgia clinical presentation:

an aching or burning pain mimicking classic pulpitis.
duration: continuous.
site:
limited to the distribution of the division of the trigeminal nerve, in
which the lesions of herpez zoster subsequently develop.
patient can localize the pain to a particular tooth or teeth.
associated signs development of clinical signs of herpes zoster
and symptoms within a few days of pain onset confirm the
diagnosis.
special investigation:
vitality test.
peripheral and bite wing radiographs.
 occurs in about 10% of patients who have had herpez zoster
post herpetic infection and persists in approximately 5%.

neurlgia clinical presentation:

sex:
female more than male.
age:
more than 50 yrs.
nature:
an intense, unpleasent, burning pain.
duration:
may be continually and symptoms have been present for at least 3
monts.
site:
localized to the area of distribution of the divisions of the trigeminal
nerve involved in the preceeding episodes of herpez zoster.
 history and possibly scar of hz.

accompanying pain severity may lead to anxiety and depression.

special investigation:
symptoms
diagnosed on clinical ground alone.

medical management:
famiciclovir (prevention or ameliorating of post herpetic neuralgia.
if post herpetic neuralgia develops:
medical management is difficult.
carbamazepine can be used.
tca and gabapentine and pregabaline and topical lidocaine.
strong opoids and capsaicin.
surgical treatment:
bubivacains can be used for blockade of the stellate ganglion to produce
short-term relieve.
 pain of migraine
clinical presentation:
vascular sex: female more than male.
origin age: wide range, childhood onwards.
nature: intense, severe, persistent, aching pain.
duration: hours or days.
site:
usually unilateral.
not always affect the same side.
certain varient are centered on the eyes.
 1. choclate, banana.

initiating 2. alcohol, stress.

factors 3.
4.
hormonal changes during menstrual cycle.
contraceptive pills, noise.

associated signs and symptoms:

in classic migrain the headache is preceeding by an aura which include
(nausea, vomiting,visual disturbance (photophobia and flashing light).
other disturbance of sensory and/ or motor function.
special investigation:
ct-scan and mri use to exclude the presence of intracranial lesions.
 medical management
paracetamol, ibuprofen, aspirin: effective espcially when used in combination
with the antiemetic metoclopromide.
is the previous are ineffective: use serotonin receptors agonists (sumatriptin) is
appropriate.
for prevention:
beta-blocker, tca, gabapentin and sodium valporate.
botox:
in particular sites for injections in the forehead, temple, head back and above
shoulder.
 clinical presentation
cluster sex: male more than female.

headache
age: predominently less than 50 yrs.
nature: intense, aching pain that disturbing sleep.
attacks may occur at the same time each day.
duration:
intermittent episodes of pain between 15-180 minutes.
duration on daily basis for several weeks interspersed with pain free
periods of months rather than days.
site: on one side of the face.
cheek, orbit, forhead and temple.
not crossing the midline.
 1. alcohol
2. vasodilators.
initiating 3. high altitude.

factors associated signs and symptoms:

flushing of the cheeks.
watering of the eyes.
nasal congestion.
special invetigations:
ct-scan and mri to exclude intracranial lesions.
medical management:
subcutanous sumatriptan and intranasal zolmitriptan: effective.
for prevention: calcium channel blocker (verapamil) may be taken.
 may occur alone or as a component of polymyalgia rheumatica.

cinical presentation:
sex:female more than male.
giant cell arteritis, age: usually more than 50 yrs.
cranial arteritis, nature: severe, throbbing headache.
temporal arteritis duration: hours or days.
site: unilateral affect the temple.
initiating factrs: none.
associated signs and symotoms:
1. the temporal artery throbs and is prominent and tender to touch.
2. eating may result in pain in the muscle of mastication.
3. if a lingual artey is affected, this lead to tongue pain.
4. ulceration duo to necrosis secondary to ischemia can occur.
5. fever, general malise, wt. loss.
 if:pain and stiffness affecting the shoulder, upper arms and pelvis and

poymyalgia unilateral headache, the diagnosis of polymyalgia rheumatica should be

considered.

rheumatica special investigation:

1. esr is grossly elevated.
2. serum il-6 is grossly elevated.
3. plasma viscosity pv, crp are useful.
4. biopsy of the temporal artery:
skip lesions.
area affected the media and intima are infiltrated by inflammatory cells
ans presence of giant cells.
the lumen of the vessel is narrowed secondary to thrombosis and fibrosis.
a negative biopsy doesn’t however preclude the diagnosis.

medical management:
high dose steroids (prednisolone 40-60 mg daily).
as the inflammatory mediators fall, the dose can be slowly reduced.
relapse occur and long term therapy may be required (3-6 yrs).

complications:
blindness secondary to ischemia of the optic nerve.
 by excluding other cause of the facial pain.
peripheral clinical presentation:
idiopathic facial sex:
pain, atypical f more than m.
orofacial pain age:
usually more than 50 yrs.
nature:
a deep graping, vice like, aching poorly localised pain.
a feeling of pressure.
duration:
daily persistent pain for months or yrs.
with intermittent increase in severity.
many patient visit a lot of physician without benefit.
 poorly localised pain.
more maxilla than the andible.
site: initially unilaterally then bilaterally.
the pain crosses the mid line.
initiating / ameliorating factors: none.
analgesic: ineffective.
associated signs and symptoms.
 clinical examination
medical history:
1. irritable bowel syndrome.
2. back, pelvic pain, fibromyalgia.
3. some have hx. of depression and anxiety.

social hx:
1. the source of stress and distress should be identified ex:
2. bereavement, significant illness.
3. anxiety about family, friends.
4. job loss, relation ship breakdown.
5. unhappy home, unhappy work life.
6. fear of serious illness.
 medical management
1. reassurance.
2. tca, dothiepin, amitriptyline.
3. ssri, fluoxetine.
4. gabapentin, pregabalin, useful.
5. psychiatrist consultation.
 the patient localise the pain to tooth or a
atypical group of teeth that are clinically or
odontalgia radiographically normal.
hx. of dental treatment to alleviate their
symptoms as extraction and the pain is
persistent in the extraction site and in the
adjacent teeth.
 glossodynia, glossopyrosis, dysthaesthesia.
burning burning sensation affecting the oral mucosa.

mouth clinical presentation:

sex: f more than m
syndrome age: usually above 50 yrs.
nature: a burning sensation as scalded or sprinkled with pepper.
duration: daily burn for months or years.
increase as the day goes on.
doesnot disturb sleep.
visit many physician without benefit.
 site:
tongue, lips, hard palate.
either singly or in combination.
unusual site, throat or mouth floor.
analgesics are ineffective.
not present during eating or occupied.
noticed more durng rest.
associated symptoms:
alteration in taste sensation, dysgeusia.
subjective oral dryness.
 special investigation
1. cbc, haematinics, to diagnose anaemia.
2. iron, folate, vit.b12 deficiency.
3. excluding candidal infection.
4. sialometry for dryness of mouth.
5. blood sugar or hba1c for diabetus.
6. patch test for allergy from dental materials.
medical management:
•reassurance.
•tca.
•gabapentin and pregabalin.
•sri, paroxetine, useful.
 thanks for ur attention
ass. prof. ali moh’d munasser abdulrab helpoop