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    Orofacial Pain

    Uploaded by

    許長生

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Orofacial Pain

    Uploaded by

    許長生
    7 views8 pages

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    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    7 views8 pages

    Orofacial Pain

    Uploaded by

    許長生

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 8

    Orofacial Pain

    ● Orofacial pain:
    ○ Unpleasant sensation
    ■ Indicated risk of inorganic or tissue lesion
    ○ Accompanied by psychological connotations意思 and personified painful
    threshold.
    ○ Pain was the most common symptoms that patients seek for help.
    ○ Diagnosis​:
    1. Perform an appropriate PAIN anamnesis
    2. Select the specific complementary test
    ○ Classification​:
    1. Somatic Pain
    a. Local: mucosal, periodontal, glandular...
    b. Vascular orofacial pain
    i. Migraine/ Cluster headache
    ii. Facial migraine
    iii. Inflammatory vascular Headache
    iv. Other Vascular algias
    v. Atypical odontalgia牙痛
    vi. Referred pain
    c. Masticatory pain

    2. Neurogenic Pain
    a. Trigeminal neuralgia
    b. Facial neuralgia
    c. Glossopharygeal neuralgia

    3. Psycogenic Pain
    ● Migraine 偏頭痛
    Migraine
    ● Severe headache with nausea噁心 and photophobia畏光
    ● Uncommon
    ● Adult, 女性較多
    ● 20 years (+- 10 years)

    Aetiology ● Arterial dilatation動脈擴張


    ● Predisposal factors: ​Alcohol​, S
    ​ tress​, foods contain tyramine酪
    銨: banana, chocolate ... contraceptive pill避孕藥

    Clinical ✓ Recurrent, severe, ​Unilateral​, headache that last for hours or


    features days (​4-72 hours​)
    ✓ Increases with physical activity or with head movement
    ✓ Preceding warning symptoms of visual, sensory, motor or
    speech disturbances
    ✓ Photophobia
    ✓ Nauseaor vomiting

    Diagnosis ➢ Clinical features


    ➢ Discard and organic diseases

    Treatment ● Control predisposal factors


    ● Acute attack:
    ○ Salicylic acid 900mg
    ○ Paracetamol 1000mg
    ○ Ergotamine 2 mg + Cafeine 200 mg
    ○ Sumatriptan 50-100 mg orally max 300 /mg d o 6 mg
    subcutaneous max12 mg day

    ● Migrainous neuralgia無預兆偏頭痛 or Cluster headache

    Migrainous neuralgia無預兆偏頭痛 or Cluster headache 叢集性頭痛


    ● Horton’s headache
    ● Severe, ​One-sided pain
    ● Location: eye/periocular
    ● Short duration
    ● Autonomic ​homolateral同側​ signs
    ● Pain usually occurs at the same time of the day
    ● 10 to 25 cases per 100000 inhabitants per year
    ● 20-30 years
    ● 男性較多(3.6:1)

    Pathogenesis ● Unknown
    ● Related to vascular changes
    ● Alcohol, Cocaine

    Clinical Pain typically:


    features ✓ Around the eyes
    ✓ Unilateral
    ✓ Occurs in ​cyclic attacks​, which last less than an hour
    ✓ Often awake patient at night
    ✓ Burning in character
    ✓ Watering of eye, nasal discharge and obstruction in the affected
    side

    Period of ● Recurrences in outbreak


    crises ● Two main types:
    1. ECH: Episodic Cluster Headache
    ■ Pain last for 4-8 weeks
    ■ Episodes發作 15 days pain-free
    2. CRH: Chronic Cluster Headache
    ■ Daily crisis of pain > a year
    ■ 1-3 daily attacks

    Diagnosis ➢ Clinical and neurologic examination


    ➢ Diagnosis tests
    ○ CT/MRI: non pathological findings

    Vascular disorders

    Treatment ● Patient education and ​trigger avoid


    (Cluster 1. During a crisis
    headache) ○ umatriptan 6 mg subcutaneously
    ○ Ergotamine 2mg oral
    ○ Oxygen inhalations 7l/min for 15 minutes

    2. Prophylactic treatment
    ○ One daily crisis
    ■ Ergotamine 2 mg , 2 hours before the expected
    crisis
    ○ Night crisis
    ■ Ergotamine 2mg , before going to bed
    ○ Two or more daily crisis
    ■ Ergotamine 1mg/8h/2 month
    ■ Verapamil 80mg/8h
    ■ Indomethacin 25mg/8h
    ■ Propanolol 40mg/12h

    Classification
    Neurogenic Pain

    1. Trigeminal neuralgia: 2. Facial 3. Glossopharyngea


    a. Essential (Classical): neuralgia l neuralgia
    i. Typical
    ii. Atypical
    b. With known cause:
    i. Post-traumatic
    neuralgia
    ii. Herpetic皰疹性
    and post neuralgia
    iii. Mulitiple sclerosis
    iv. Benign trigeminal
    neuralgia

    ● Trigeminal neuralgia

    Trigeminal neuralgia

    Clinical types
    ● Classical or Essential​: With not known cause
    ○ Typical: with classic features
    ○ Atypical: with atypical features
    ● Symptomatic
    ○ Due to trauma, viruses, drugs…

    ⭑ ​Classical Trigeminal neuralgia


    Clinical features ✓ Unilateral​ pain
    ✓ Electric shock-like pain of abrupt onset and
    termination
    ✓ Pain periods between 2 second and 2 minutes
    ✓ Periods of time with no pain, that varies from
    person to person
    ✓ Restricted to the trigeminal nerve, one or more
    branches
    ✓ In some patients triggered by chewing, talking,
    swallowing, smiling or exposure to
    temperatures change
    ✓ Normal sensory examination
    ✓ No pathological findings in complementary test

    Pain characteristics ✓ Paroxysmal陣發性, electric shock-like pain


    ✓ Sudden onset
    ✓ High intensity
    ✓ The pain last between 2 second and 2 minutes
    time
    ✓ When the pain disappears, the patient is with
    no pain during the intercrisis periods隔離期間.

    Triggers area ✓ Area of face, slight touch triggers pain


    ✓ Trigger areas are not always presented
    ✓ When triggered area is presented, usually an
    area of a few millimetres in diameter and
    located either in the infraorbital or menton area.

    Pain location ✓ Restricted to the trigeminal nerve,


    ✓ The most common site: ​mandibular branch
    ✓ Trigger areas: gums, teeth
    ✓ Unilateral, never crosses the midline

    Individual Pain characteristics ✓ Each patient has charcteristics pattern


    ✓ Painful crises are similar in intensity, location...

    Sensory examination No pathological finding

    Classical (Essential) Trigeminal neuralgia

    Typical Atypical

    Frecuency Seconds Minutes, Hours

    Pain characteristics Intense Burning

    Intensity Acute Moderate

    Intercrises Not pain Without intercrises


    Trigger areas Increase in pain ??

    Sleep time NO YES

    ⭑Symptomatic trigeminal neuralgia


    ● Clinical features = classical trigeminal neuralgia
    ● Sweet ́ s criteria
    ● Other associated diseases:
    ○ Herpes viruses
    ○ Multiple sclerosis
    ○ Traumatism
    ○ Tumors

    ● Trigeminal neuralgia diagnosis


    ○ Clinical and neurologic examination
    ○ Additional tests.
    ■ CT/MRI: multiple sclerosis, tumors
    ■ Blood analysis: autoimmune process
    ■ Lumbar puncture
    ■ Evoked potentials: records of brain potential by stimuli
    ● Treatment
    ○ Drug treatment
    ○ Carbamacepine (Tegretol ®): start with 100mg/12 h, increasing by
    100mg every three days until 400-1200mg/daily
    → Good results
    ○ Amitriptyline (Tryptizol ®, Norbitol ®, Deprelio ®): 30-75mg/d in three
    doses
    → It causes dryness of mouth and urinary retention
    ○ Hydontoins ( Phenytoin ®): 300- 500 mg/d
    ○ Clonacepan ( Rivotril ®): 1,5 – 6 mg/d in three doses
    ○ Baclofen (Lioseral ®): start with 5mg/d increasing 5-10 mg/d every
    three days up to 60 mg/d
    Cluster headache Trigeminal headache

    Age of onset 18-40 >= 40

    Sex Men Men/Women

    Attack duration 20-60 mins Seconds

    Frequency 1-2 daily Many times per day

    Location Periocular眼周 Lip & Jaws

    Daily distribution Night time Day time

    Trigger Alcohol/Cocaine Trigger areas

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