5th Class

Lec 3
Dr. Kareem M Alghanim
BDS , MSc (oral surg.) , PhD
(oral med.)

FACIAL PAIN
Pain is a subjective unpleasant
sensation and unlike a lump or
ulcer, which can be examined
and assessed, in the case of a
pain the clinician must rely on
the description given by the
patient.
CLASSIFICATION OF PAIN
Somatic (Nociceptive) Pain:- this arises from-1
musculoskeletal or visceral structures and
interpreted through an intact pain transmission
.and modulation system
Neuropathic Pain:- arises from damage or-2
alteration to the pain pathways, most commonly,
a peripheral nerve injury from surgery or trauma,
.or central nervous system trauma as in stroke
Psychogenic Pain:- resulting from psychic-3
causes and not from noxious stimulation or
.neural abnormalities
 The
Neurochemicals
of Pain
• Glutamate
Pain • Substance P
• Bradykinin
Initiators
• Prostaglandins

• Serotonin
Pain • Endorphins
• Enkephalins
Inhibitors
• Dynorphin
 Pain

receptors
Aδ – fast, sensitive to mechanical noxious
stimuli. – small, myelinated. High conductance
speed
 C – slow, sensitive to many noxious stimuli
(chemical, etc.) – small, unmyelinated. Slow
conductance speed
 CHRONIC PAIN
pain that persists past the normal time of 

healing, but this may not be an easy

determination. Alternatively, chronic pain has
been related to duration (ie, pain that lasts
.longer than 6 months)
 Recently

pain lasting longer than 3 months has been

used to define chronic pain The term
“chronic pain syndrome” has been used to
describe a condition that may have started
because of an organic cause but is now
compounded by psychological and social
problems.
 Pathophysiolo


pain
gy
The proposed explanation for the persistence of
after healing relates to changes
(neuroplasticity) in the central nervous system
 This sensitization does not require ongoing
peripheral input but is a consequence of changes in
the sensitivity of neurons in the spinal cord.
 CONTRIBUTORY
FACTORS
● Trauma or overuse of the craniomandibular region
while biting into a large apple or during tooth
extraction
● Prone sleepers have more chance of problems in
the craniocervical and craniomandibular regions than
non-prone sleepers, possibly due to the increased
long-term stress on these regions in this position
● Facial asymmetry and dysgnathia predispose to
craniomandibular dysfunction
● Stress and parafunctions can be seen as a
maintaining influence.
The most common pain-
related terms are
defined as follows
 Allodynia: is pain due to a stimulus that
does not normally produce pain.
 Hyperalgesia: is an increased response to a
stimulus that is usually painful.
 Hyperesthesia: is an increased sensitivity
to stimulation & does not imply a painful
sensation, but rather an augmented
response to a specific sensory mode (e.g.
touch, vibration, temperature).
 Causalgia: is a syndrome of burning pain,
allodynia after a traumatic nerve lesion & is
often combined with sweat secretion.
 Hypoaesthesia:is a decreased sensitivity to
stimulation .
 Hypoalgesia: is a special case of
hypoesthesia in which pain response to a
normally painful stimulus is diminished.
 Neuralgia: is pain in the distribution of a nerve.
 Neuropathy: is a disturbance of function or
pathologic change in a nerve.
 Paraesthesia: is an abnormal (but not
unpleasant) sensation, whether spontaneous
or evoked.
 Central pain: is pain associated with a lesion of
the central nervous system.
 Orofacial Disorders That
May Be Confused
withToothache
 Trigeminal neuralgia
 Trigeminal neuropathy (due to trauma or tumor
invasion of nerves)
 Atypical facial pain and atypical odontalgia
 Cluster headache
 Acute and chronic maxillary sinusitis
 Myofascial pain of masticatory muscles
 ’Trigeminal neuralgia‘

’Facial arthromyalgia
Posterior fossa:
entry of trigeminal
nerve to the brain

’Atypical facial pain‘

Burning mouth syndrome‘

16
QUESTIONS WHICH MUST BE ASKED ABOUT
ANY PAIN

 The character of pain:- pain may be

described as: Dull, Sharp, Throbbing,
Burning.
 The severity of the pain( mild ,
moderate or severe ).
 Date of onset (durations) :- days, weeks,

months or years.
 Is the pain continuous? Or have there

been remissions?
 Is the pain increasing or decreasing
in severity?
 Area to which pain radiates
 Area to which pain referred

Ex. the pain of coronary thrombosis

is substernal but it refers down to
the left arm and lower part of the
mandible.
 What makes the pain worse? Ex:-
Trigeminal neuralgia triggered by light touch
on the face (brushing, shaving)
The pain of dental origin produced when hot
or cold drinks .
The pain of acute maxillary sinusitis is
exacerbated by biting, bending, and lifting
straining.
 Are there other signs & symptoms?
( swelling, discharge, dysphagia )
:OROFACIAL PAIN

Orofacial pain is a complaint that

constitutes any symptom
occurs from a large number of
disorders and diseases that
result in a sensation of
discomfort or pain felt in the
region of the face, mouth, nose,
ears, eyes, neck, and head.
POSSIBLE CAUSES OF FACIAL
PAIN

 Dental pain.
 TMJ diseases.
 Neuropathic pain(neuralgias).
 Pathology in related structures(salivary gland, sinus,
eyes, cervical spine).
 Vascular disorder(headaches.)
 Intracranial lesions(neoplasm).
 Referred pain(angina pectoris).
 Psychogenic facial pain.
 Syndromes
TRIGEMINAL NEURALGIA
 It is severe recurrent electric shooting, sharp,
stabbing pain that lasting seconds or minutes
and provoked by talking, eating or touching
specific areas called the "trigger zone“
 Pain in the area supplied by one or more
branches of trigeminal nerve(The most
common sites are the mandibular mental area
and the maxillary canine area).
 Usually affecting the middle aged and elderly
and often women are more affected than men.
ETIOLOGY

The etiology of neuralgia is unclear

and 10% of cases have detectable
underlying pathology such as :-
1- Tumor of the cerebellar pontine angle.
2- Demyelination
3- Vascular malformation.
The remainder of cases of trigeminal
neuralgia is classified as idiopathic. A
majority of cases of idiopathic TN are
caused by an blood vessels (usually
the superior cerebellar artery) that
normally pressing on and grooving the
root of the trigeminal nerve. This
pressure results in focal demyelination
and hyper excitability of nerve fibers.
MANAGEMENT
Treatment
l- Anticonvulsant; Carbamazepine(Tegretol) 100-400mg.
Patients receiving carbamazepine must have periodic
hematologic laboratory evaluations because serious life
threatening blood dyscrasias occur, also monitoring of
hepatic and renal function is also recommended.
2- Injection of 1 ml 60% or 90% Alcohol taking care to
avoid entering a blood vessel by aspirating before the
injection, relief of pain for 6-9 months.
3- Peripheral surgery includes cryosurgery of the nerve
branch that triggers the painful attacks.
4- Microvascular decompression of the nerve root at the
brainstem.
:GLOSSOPHARYNGEAL NEURALGIA

 The location of the trigger zone and pain

sensation follows the distribution of the
glossopharyngeal nerve, namely, the posterior
tongue, ear, and retromandibular area.
 Pain is triggered by stimulating the pharyngeal
mucosa during chewing, talking, and swallowing
 The most common causes are intracranial or extra
cranial tumors and vascular abnormalities that
compress CNIX.
 Treatment is similar to that for TN, with a good
response to carbamazepine.
POST HERPETIC NEURALGIA

Herpes zoster (shingles) is caused by the

reactivation of latent varicella-zoster
virus infection that results in both pain
and vesicular lesions along the course
of the affected nerve.
Approximately 15 to 20% of cases of
herpes zoster involve the trigeminal
nerve although the majority of these
cases affect the ophthalmic division
resulting in pain and lesions in the
region of the eyes and forehead.
Herpes zoster of the maxillary and
mandibular divisions is a cause of facial
and oral pain as well as the lesions
Patients with PHN experience
persistent pain, paresthesia
and hyperesthesia months to
years after the zoster lesions
have healed. PHN may occur at
any age, but the major risk
factor is increasing age.
MANAGEMENT

 Antiviral (famcyclovir 500 mg 3 times

daily for 7-10 days or Acyclovir 800mg
5times 7-10 days)
 Short course of systemic corticosteroid

during the active phase of the disease.

 Topical therapy includes the use of

topical anesthetic agents, such a

lidocaine, or analgesics.
MYOFACIAL PAIN DYSFUNCTION SYNDROME

It refers to the clinical

condition characterized by
pain, and spasm of the
muscles of mastication,
tenderness to palpation of
one or more of these muscles
THE SYMPTOM COMPLEX THAT DEFINES THE MPDS INCLUDES

 Spasm and tenderness of one or more of

the muscles of mastication
 Diffuse head pain that is similar to tension

headache and is usually more severe in the

morning.
 Pain and limitation on jaw opening.

 Lateral deviation during jaw opening.

 Evidence of bruxism or clenching by history

or presence of generalized teeth wear.

 Malocclusion or evidence of occlusal
disharmony.
 Unilateral or bilateral preauricular pain

during palpation.
 Joint sounds such as clicking and
popping during jaw opening.
 The patients are usually young to
middle aged woman who experience
constant or episodic emotional stress.
MANAGEMENT
 Analgesics and application of
moist, heat to the spastic muscles
is generally adequate in mild
cases.
 Elimination of occlusal disharmony

by prosthetic or orthodontic
treatment.
 Bite splint to minimize the adverse

effect of bruxism.
TENSION HEADACHE

 The bilateral pain is described as fullness,

pressure or tightness with waves of
superimposed aching
 Attacks may be acute with duration of few

hours to a day or in some instances the

pain can be relatively constant for days or
weeks.
 Damaging emotional situations stress
overwork, and depression are definite
initiating factors.
CLUSTER HEADACHE ( MIGRAINOUS
NEURALGIA, ALARM CLOCK
HEADACHE )
 The attacks occur in periods, clusters
lasting for 4-6 weeks followed by long
attack-free intervals.
 It is caused by vascular changes at the

base of the skull & abnormal

hypothalamic function, in addition to
edema and dilation of the wall of
internal carotid artery and probably the
external carotid artery.
 Eighty percent of patients with CH are
men between ages of 20-50 years.
 The attacks are sudden unilateral, and
stabbing around the eye
 The pain attacks is particularly
associated with nasal congestion and
tearing. Sweating of the face ptosis and
increased salivation are also common.
Each attack lasts from 15
minutes to 2 hours and
recurs several times daily
usually at night and at the
same time each day that
may disturb sleep just like
ringing of clock (clock
alarm).
MANAGEMENT

 An acute attack of CH can

be aborted by breathing
100% oxygen.
 Injection of sumatriptan or

sublingual or inhaled
ergotamine may also be
effective therapy.
MIGRAINE

Migraine is the most common

of the vascular headaches,
which may also cause pain
of the face and jaws and
more common in woman.
-:IT MAY BE TRIGGERED BY

 Foods such as nuts, chocolate, caffeine,

liver and red wine
 Stress and sleep deprivation.

 Decreased blood sugar level

( hypoglycemia ).
 Menstruation and hormonal disturbance .

 Drugs such as vasodilator.

 Contraceptive pills .
ETIOLOGY AND PATHOGENESIS

The classic theory is that migraine is

caused by vasoconstriction of
intracranial vessels that initiated
by endogenous vasoactive
mediators such as bradykinin
(which causes the neurological
symptoms), followed by reflex
vasodilatation (which results in
pounding headache).
CLASSIC MIGRAINE
 The pain is usually unilateral pulsating
moderate to severe, characteristically
last for hours up to two or three days,
which is aggravated by physical activity.
 Associated by nausea and vomiting as

well as photophobia and/or phonophobia

( sensitivity to light and sounds ).
 The patient characteristically lies down

in a dark room and tries to fall asleep.

 The headache is preceded by
aura ( visual disturbance
described as a temporary blind
spot which obscure part of the
visual field ) and other
symptoms including numbness
and weakness along one side of
the face and speech
COMMON MIGRAINE
 Isnot preceded by an aura.
 The pain resembles the pain of

classic migraine and is usually

unilateral, pounding, and
associated with nausea and
vomiting, sensitivity to light and
noise, nasal congestion and
depression of salivation and
lacrimation .
TREATMENT OF MIGRAINE

 NSAIDs
 Ergotamine in combination with
caffeine ( Cafergot ).
 Sumatriptan.
 Beta blockers and calcium channel

blockers.
MAXILLARY SINUSITIS

Inflammation of the maxillary sinuses, in

this disease the patient may complain
from headache, pain and pressure below
the eyes that worsen by bending down,
fever, malaise, sound alteration coughing,
sneezing and nasal congestion.
 Associated with dull or throbbing pain

and tenderness of upper posterior teeth.

FREY'S SYNDROME

 This condition arises following parotid gland or rarely TMJ surgery

or trauma that create or lead to damage and interaction between
to the Auriculo-temporal nerve PSNF (Para sympathetic Nerve
Fibers) from O.G. (otic Ganglia) which supply the salivary gland
and from S.C.G Superior Cervical Ganglia) which supply the
sweat gland and vascular wall of the auriculo-temporal region.
 The patient may complain of burning sensation in the temporal
or facial region associated with flushing , profuse sweating and
lacrimation during eating while salivary secretion, flashing of the
face and sweating during crying.
 Medical treatments include:
Topical anticholinergic ointments (scopolamine)
Topical anti-perspirants (deodorant)
Botulinum toxin injections
RAMSAY HUNT SYNDROME
 Ramsay Hunt syndrome is the reactivation
of herpes zoster in the geniculate ganglion
which may include a lower motor neuron
lesion of the facial nerve, deafness, vertigo,
and pain.
 A triad of ipsilateral facial paralysis, ear
pain, and vesicles on the face, on the ear,
or in the ear is the typical presentation.
 Corticosteroids and oral acyclovir are
commonly used
EAGLE'S SYNDROME

 Ossification of the stylohyoid ligament more pronounced

among older patients.
 The pain is caused by the resistance of the rigid, ossified
ligament to the mobility of surrounding soft tissues.
 This is usually associated with a history of tonsillectomy
(which has produced scarring of the ligament).
 The complaints related to Eagle's syndrome include
sharpness in the throat during swallowing or a chronic
sore throat without erythemia. The sensation may be
described as that of a fish bone caught in the throat or
as obstruction.
 Definitive treatment is surgical removal.
ATYPICAL FACIAL PAIN AFP
PERSISTENT IDIOPATHIC FACIAL PAIN (PIFP)
 is a type of chronic facial pain which does not fulfill any other
diagnosis
 The main features of AFP are: no objective signs, negative
results with all investigations/ tests, no obvious explanation
for the cause of the pain, and a poor response to attempted
treatments. AFP has been described variably as a
medically unexplained symptom , adiagnosis of exclusion, a
psychogenic cause of pain and as a neuropathy.
 AFP is usually burning and continuous in nature, and may last
for many years. Depression and anxiety are either described
as a contributing cause of the pain, or the emotional
consequences of suffering with unrelieved, chronic pain.
 AFP is significantly more common in middle aged or elderly
people, and in females.
 ATYPICAL ODONTALGIA AO

 Atypical odontalgia (AO) is very similar in many respects

to AFP, with some sources treating them as the same entity,
considered as a sub-type of AFP. Generally, the term AO may
be used where the pain is confined to the teeth or gums,
 continuous pain in the teeth or in a tooth socket after
extraction in the absence of any identifiable dental cause
 the pain is often poorly localized, but is usually located in the
region of the maxilla (upper jaw), which is affected more than
the mandibular region,
 Usually present continuously for months or years, with
intermittent periods of increased pain,
 Usually described as dull, aching pain. Sometimes the pain is
hard to describe
MANAGEMENT OF AFP & AO
 Psychosocial interventions include
behavioral therapy
 Medication : Analgesics , Antidepressants , Centrally
acting muscle relaxants Anticonvulsants
 Surgical removal of a portion of the affected branch
of the trigeminal nerve, or direct injections of a
caustic substance (e.g. phenol, glycerol, alcohol) into
the nerve have been reported.
 "Neuralgia inducing cavitational necrosis" suggest
surgical exploration of the bone marrow surrounding
the intra-bony course of the affected nerve to
discover diseased marrow
 Burning mouth
syndrome
is a burning sensation in the mouth with no underlying dental or
medical cause. No signs of disease are found in the
mouth. People with burning mouth syndrome may also have

a dry mouth sensation where no cause can be found such as

reduced salivary flow,

tingling in the mouth,

or an altered taste or smell

Usually bilaterally located on the tongue or less commonly the

palate, lips or lower alveolar mucosa

BMS has been traditionally treated by reassurance and with

antidepressants, anxiolytics or anticonvulsants.
THANK
YOU