Orofacial Pain : The New Dental Specialty
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All About Orofacial Pain

Orofacial Pain is the specialty of dentistry that includes the assessment, diagnosis & treatment of patients with orofacial pain disorders, masticatory muscles and joints disorders, jaw behaviour disorder, neuropathic pain disorders and neurovascular pain disorders. On March 31, 2020, the American Academy Of Orofacial Pain's request to recognize Orofacial Pain as a dental specialty was granted by the National Commission on Recognition of Dental Specialities.

Evaluation Of Orofacial Pain Patient

1) MEDICAL & DENTAL HISTORY

2) CHIEF COMPLAINT & PAIN HISTORY

  • Pain quality: examples include aching, throbbing, burning, shock like paroxysmal pain or some combination (quality).
  • The duration of each episode of pain.
  • The side affected: ask the patient to point to the source of the pain and/or outline the area affected by it (course).
  • Initiating factors: anything that the patient remembers occuring immediately before or at the same time at the start of their symptoms.
  • Exacerbating factors: anything that which makes the patient's symptoms worse.
  • Relieving factors: anything which relieves either partially or totally the patient's symptoms. Eg: nerve block anaesthesia, anti convulsant drugs, etc.
  • Associated signs & symptoms: eg: lacrimation, vomiting, nausea, rhinorrhea, photophobia, phonophobia, fever etc.

3) PHYSICAL EXAMINATION:

  • Vital signs.
  • Intraoral examination.
  • Head & Neck examination (lymph nodes, TMJ etc)
  • Cranial nerve examination (Evaluation of trigger zone, area of hyperesthesia, hypoesthesia and anaesthesia).

4) RADIOLOGICAL & OTHER SPECIAL INVESTIGATION:

  • Cranial nerve screening examination.
  • Laboratory blood examination.Eg :ESR
  • MRI
  • Bone Scan

Definition Of Pain & Classification Of Pain By Origin

PAIN: Pain is defined as an unpleasant sensation caused by a noxious stimulus that is mediated only along specific nerve pathway into the central nervous system where it is interpreted as pain.

On the basis of origin, pain is classified as following-

  • Somatic pain: Originating from the cells of the organ involved i.e. skin, mucous membrane, bone, joint, muscles etc.
  • Neurogenic pain: Discomfort resulting within the nervous system. Abnormality in the neural structures.
  • Psychogenic pain: Resulting from psychic causes.

SOMATIC PAIN:It involves

  • Skin
  • Mucogingiva
  • Muscles
  • TMJ
  • Bone
  • Pulp
  • Gland,Ear & Eye

NEUROPATHIC PAIN: It can be

  • EPISODIC

–Neurogenic

–Vascular

  • CONTINOUS

–Neuritis (Inflammatory change of the nerve{burning sensations}).

PSYCHOGENIC PAIN: Resulting from psychological causes.

Causes Of Orofacial Pain

I) LOCAL CAUSES (SOMATIC)

  • Diseases of teeth
  • Diseases of periodontium
  • Diseases of oral mucosa
  • Diseases of jaws
  • Diseases of antrum
  • Diseases of salivary glands
  • Diseases of TMJ
  • Diseases of ears
  • Diseases of eyes
  • Diseases of sinus & nasopharynx
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II) NEUROLOGICAL CAUSES (NEUROPATHIC)

  • Trigeminal Neuralgia
  • Glossopgaryngeal Neuralgia
  • Herpes Zoster
  • Post Herpetic Neuralgia
  • Geniculate Herpes (Ramsay Hunt Syndrome)
  • Bell's Palsy
  • Intracranial Tumors
  • Causalgia

III) PSYCHOGENIC CAUSES

  • Atypical Odontolgia
  • Atypical Facial Pain
  • Burning Mouth Syndrome

IV) VASCULAR CAUSES

  • Migraine
  • Periodic Migranous Neuralgia (sphenopalatine neuralgia,cluster headache, alarm clock headache).
  • Referred Pain

7) NEUROLOGIC PAIN

–TRIGEMINAL NEURALGIA: It is a self limiting disorder characterized by instantaneous attacks, of sharp lancinating, shooting pain confined to the area of distribution of the trigeminal nerve characterized by the presence of trigger zone. The treatment of trigeminal neuralgia involves:

I) Drugs

  • Carbamazepine (Usually begins with 200 mg twice daily)
  • 2nd line of treatment: If the patient is unable to tolerate the side affects of Carbamazepine, patient should start the 2nd line of treatment i.e anti epileptic drugs & tricyclic depressants.

II) Ganglion Procedures: Radiofrequency Thermocoagulation

  • Glycerol Injection
  • Balloon Compression
  • Radiosurgery (Gamma Knife)

III) Surgical Procedures to treat Trigeminal Neuralgia:

  • Trigeminal root section
  • Microvascular decompression

–PERI TRIGEMINAL NEURALGIA: It is an aching dental pain in a region where physical & radiograhic examination reveals no abnormality.

LA block of the tooth arrests pain.

— VAGOGLOSSOPHARYNGEAL NEURALGIA: Pain radiates from oropharynx or base of the tongue to the tonsils, larynx, soft palate, ear, the mandibular ramus or even TMJ.

Treatment of glossopharyngeal neuralgia involves

  • carbamazepine drug &
  • surgical decompression.

–HERPES ZOSTER (SHINGLES): The only non dental pain that may mimic pulpal pain. The disease is common but mainly limited to adults, often over 60 years.In trigeminal region, the ophthalmic division most commonly gets affected.

Treatment: Acyclovir may be used (5 times daily for 5 days).

–POST HERPETIC NEURALGIA: It is a neurological pain persists after reactivation of herpes zoster virus along cranial nerve V (V1,V2,V3,VII–>Ramsay Hunt Syndrome). It is caused due to acute herpes zoster infection of Trigeminal ganglion and it's branches.

Treatment involves:

  • Topical Capsacin0.025 percent.
  • Tricyclic anti depressants
  • Anticonvulsants
  • alpha 2 agonists
  • Systemic Lidocaine
  • Cryocautery

— GENICULATE HERPES (RAMSAY HUNT SYNDROME):

It is caused by Herpes zoster infection of the geniculate ganglion. Pain occurs in throat, ear, followed by vesicular eruption on the ear.

Treatment:

  • Excision of geniculate ganglion.
  • Cut of the motor portion of facial nerve.

— BELL'S PALSY: Symptoms include unilateral facial palsy.

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Treatment involves anti viral drugs such as Acyclovir.

–MULTIPLE SCLEROSIS: Its an autoimmune disease of the central nervous system (CNS) characterized by demyelination of nerves.

  • Treatment of multiple sclerosis involves anti convulsant drugs.
  • But when lower back is involved, we prescribe Carbamazepine.
  • GG Glycerolysis:If only trigeminal pain occurs alone, we prescribe tricyclic antidepressants.

–CAUSALGIA:Pain arising after injury to peripheral sensory nerve. For example: following a difficult extraction.

Treatment: Carbamazepine is prescribed.

8) PAIN OF VASCULAR ORIGIN:

–MIGRAINE: Recurrent headache combined with autonomic disturbances (aura). Women are more affected than men.

Types of migraine:

  • Classic Migraine with aura.
  • Migraine without aura.

Treatment:

  • Sumatriptan
  • NSAIDS
  • Analgesics
  • Antiemetics.

–PERIODIC MIGRANOUS NEURALGIA (SPHENOPALATINE NEURALGIA, CLUSTER HEADACHE,ALARM CLOCK HEADACHE):It affects young adults (20-40 years of age). Stress or alcohol may precipitate an attack.

Treatment: Treatment of periodic Migranous Neuralgia involves Ergotamine or anti-inflammatory indomethacin. The patient should avoid alcohol.

— GIANT CELL (TEMPORAL,CRANIAL) ARTERITIS: Pain is caused by ischemia resulting from Arteritis. Affects females more than males and is restricted to the elderly (over 60 years of age).

Symptoms include:Severe unilateral aches restricted to the temporal & frontal areas (i.e. side of head & behind the eye).

Ocular symptoms may include loss of vision in one part of the visual field.

Treatment:

Using high dose corticosteroids

If the retinal arteries are involved, then there is rapid deterioration in vision which requires urgent consultation with a retina eye specialist.

9) SOMATIC PAIN

  • MAXILLARY ANTRUM/NASOPHARYNX

SINUSITIS: Infection (usually bacterial) of the MAXILLARY sinus.

Diagnostic tests: Transillumination of the antrum or an occipitomental radiograph may show fluid level or thickening of the antral lining.

Treatment: Antibiotics eg, erythromycin , amoxicillin or ampicillin 250 mg four times per day for five days, plus nasal decongestants (xylometazoline HCl) & inhalants.

There may be somatic pain of maxillary antrum due to malignancy too. The most common malignancy of maxillary antrum is Squamous Cell Carcinoma (SCC).

  • SALIVARY GLANDS: Infection of the salivary glands and obstruction of the ducts produce dull pain & pressure sensations which correlated with eating or milking the gland.
  • ORAL MUCOSA (ZOSTER & GENICULATE HERPES)
  • JAW/MASTICATORY MUSCLES

This include temporomandibular joint disorders.

TMJ disorders include:

  • Temporomandibular joint – Myofascial pain dysfunction syndrome
  • Osteoarthritis
  • Rheumatoid arthritis
  • Trauma
  • Developmental defects
  • Ankylosis
  • Infections
  • Neoplasia

Myofascial Pain Dysfunction Syndrome or Facial Arthromyalgia: It may be unilateral or bilateral, dull pain within TMJ and/or surrounding muscles. Headaches, facial pain & neckaches are reported.

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Treatment: The treatment involves :

  • Analgesics
  • Anxiolytics
  • Antidepressants

— OSTEOARTHRITIS: Crepitation is the joint sound, crepitus denotes degenerate joint disorder.

—RHEUMATOID ARTHRITIS: Crepitation is heard when auscultated with stethoscope.

—TRAUMA: Condyle fracture, microtauma from parafunction may result in chronic symptoms.

—DEVELOPMENTAL DEFECTS: Includes hyperplasia, hypoplasia, aplasia.

— ANKYLOSIS: Following trauma, infection or other inflammatory conditions.

—INFECTIONS: Following peripheral trauma to the joint or spreading from middle ear to other structures.

—NEOPLASIA: Osteoma, Chondroma, Chondrosarcoma

V) EARS:Otitis Media (Inflammation of the middle ear).

May present to the dental surgeon as pain the region of TMJ joint. It may involve the facial (seventh cranial )nerve leading to unilateral facial paralysis.

VI) EYE:GLAUCOMA

It is pain due to rapid increase in intraocular pressure.

10) PSYCHOGENIC PAIN:

—ATYPICAL FACIAL PAIN: The pain is described as vague, constant, dull present all day. It has been associated with depression or anxiety.

More common in females,over 50 years of age.

Treatment: It involves

  • Physiotherapy
  • Anxiolytics
  • Antidepressants

—ATYPICAL ODONTALGIA: The etiology & symptomatology are same as those of atypical facial pain but the patient here attributes the pain to the teeth.

—BURNING MOUTH SYNDROME (BURNING TONGUE, GLOSSODYNIA & STOMATODYNIA):

It is more common in females. The symptoms include burning sensations in tongue, loss of taste, itching & abnormal metallic taste.

Diagnostic tests include: Hematology, thyroid function, dentures should be examined, salivary flow test, swab/smear/rinse to test for candidal infection.

Treatment: Anti -depressants and cognitive behavioral therapy may be helpful.

—TROTTER'S SYNDROME: Any pain remaining undiagnosed must be referred to exclude serious underlying pathology. Nasopharynx tumor causing pain in the lower jaw, tongue & side of head.

Acoustic neuroma (tumor of the 8th cranial nerve) may mimic other causes of facial pain.

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Dr Mriganka Sekhar Ghose
Dr Mriganka Sekhar Ghose [BDS, Paed Dent Spclty Prog (Royal College Of Surgeons, Ireland] is a dental surgeon & independent medical researcher with multiple certifications from RCS Edinburgh, Ireland & Tehran Univ Of Medical Sciences, Iran and is Community Ambassador of Mohammad Rashid Bin Univ of Medicine & Health Sciences, UAE.

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