OROFACIAL PAIN

Presented By
Dr Samreen Younas
PGR-I (FCPS)
OMFS
 Contents
What is orofacial pain
Causes of orofacial pain
Trigeminal Neuralgia
Glossopharyngeal Neuralgia
Post Herpatic Neuralgia
Eagles Syndrome
Temporomandibular pain
Burning mouth syndrome
Atypical Facial pain
Migrain
Cluster Headache
Temporal Arteritis
Take Home Massage
 Orofacial pain
Pain localized to the region
above the neck in front of the ears, and
below the orbitomeatal line as well as
within the oral cavity
 Causes of orofacial pain

1- Local :
Dental : (pulpitis., dentine hypersensetivity
,periapical periodontitis.cracked tooth syndrome
Gingival: (e.g primary herpetic
gingivostomatitis,
Mucosal: (e,g ulceration)
Salivary gland: (acute suppurative sialadenitis)
Temporomandibular joint:
Maxillary sinus: (sinusitis,malignancy)
 Categories of orofacial
pain
2- Neurological :
Trigeminal neuralgia
Glossopharyngeal neuralgia
Ramsy hunt syndrome
Postherpetic neuralgia
3- Vascular :
Giant cell arteritis and variant
Migraine and variant
Cluster headache ,chronic paroxysmal
hemicrania
 Categories of orofacial
pain
4- Psychogenic :
Atypical facial pain
Atypical odontalgia
Burning mouth syndrome

5- Referred pain:
Cardiac pain
 Trigeminal neuralgia:

Definition :
usually unilateral severe,
brief, sudden, stabbing
recurrent pain in
distribution of one or
more of branches of
trigeminal nerve.
Etiology

Compression of trigeminal nerve root by

an aberrant loop of artry or vein.
Primary demyelinating disorders e.g
multiple sclerosis.
Non demyelinating lesions of pons or
medulla e.g infarct or angioma.
Infiltrative disorders e.g carcinomatous
deposits.
Chronic entrapment and compression
results in focal demyelination primarily
followed by axonal degeneration.
This demyelination in turn precipitates
ectopic or hyperactive discharge of the
nerve..
 Clinical features
Pain of TN is often described as sharp and
shooting like an electric shock.

Severity may vary within the same patient and

intensity may increase.

Almost always unilateral.

right> left
 lasts for a few seconds to 1 minute ,
Pain is frequently triggered by trivial
stimulation: such as touching of
face, washing ,shaving , chewing
and talking.
Pain is not provoked directly by thermal
stimuli.
 TN Clinical features
Clinical examination of face is nearly always
normal.
If sensory loss is present a mass lesion is more
likely
In young patients with TN, multiple sclerosis
should be considered.
 TN Diagnosis:
Diagnosis depend on history and
clinical examination.
One should always assess cranial
nerve function.
MRI to detect vascular
compression.
RightTrigeminalNerve

Compressingvessel
 Treatment of trigeminal
neuralgia
1- Medical treatment:
Carbamazepine
Oxcarbazepine who are sensitive to
Carbamazepine.
Baclofen
Gabapentine.
Lamotrigine
Clonazepam
Phenytoin
Treatment of trigeminal
neuralgia
2- Surgical treatment(invasive):
indicated If medical treatment (carbamazepine) has
been ineffective after 4 weeks at maximum
tolerated dose .

Microvascular decompression
Percutaneous radiofrequency
thermorizotomy
Gamma knife radiosurgery
Glycerol injections
Peripheral neurectomies
microvascular
decompression
Gamma knife
 Glossopharyngeal Neuralgia

Is an uncommon disorder characterized

by lancinating pain of oropharynx or
neck, sometimes triggerd by
swallowing, coughing or talking.
Epidemiology:
less common than TN.
arises in middle to late life.
males=females
 Clinical features

Differences from TN
Pain GN can awaken the pt from sleep
Syncope can be a feature and rarely
cardiac arrythmias caused by vagal
stimulation.
Xerostomia or exessive salivation.
Glossopharangeal neuralgia

Etiology:
An identifiable cause is rarely found.

The most common causes of glossopharyngeal

neuralgia are intracranial or extracranial tumors
and vascular abnormalities that compress CN IX.

Management:
Of GN parallels that of TN
-Anti convulsion drugs,carbamezipine.
-Vascular decompression.

-Intracranial or extra cranial neuroectomy.

 Post Herpetic Neuralgia

-Pain is typically aching,buring,or

shock like.

-Potential sequela of infection with

herpes zoster.

Acute phase is painful but subsides

within 2 to 5 weeks.
 Managment

-Antiviral and corticosteroids after

presentation of rash reduce
incidence of postherptic neuralgia.
-Anticonvulsant drugs
-Local anesthesia injected to painful
site.
 EAGLES SYNDROME

Is an uncommon disorder characterized

by the sensation of a foreign body
within the pharynx with pain on
swallowing.

Etiology:
Pain seems to arise following
tonsillectomy and is associated with
elongated ossified styloid process and
ligament.
 CLINICAL FEATURES

Pain is usually dull and nagging

Usually localized
May radiate to ear
 Types of Eagles syndrome

1-Classic :
The symptoms are persistent
pharyngeal pain aggravated by
swallowing and frequently radiate to
the ear , with sensation of foreign
body within pharynx , This pain arise
following tonsillectomy due to
development of scar tissue around
the tip of the styloid process.
2- stylo-carotid artery syndrome(vascular):

Attributed to impingement of the carotid

artery by the styloid process This can cause a
compression when turning the head resulting
in a transient ischemic accident or stroke.

3-Traumatic Eagle syndrome:

in which symptoms develop after fracture of a
mineralized stylohyoid ligament.
 Diagnosis
(1)clinical manifestations,
(2) digital palpation of the process in the tonsillar
fossa,
(3) radiological findings .
(4) lidocaine infiltration test .
Treatment:
COSERVATIVE: involves injecting steroids
or long-lasting anesthetics into the lesser cornu of
the hyoid or the inferior aspect of the tonsillar fossa
I,NSAID
Surgical: intra oral or extra oral styloidectomy
 TEMPOROMANDIBULAR
PAIN
Is defined as group of symptoms
including pain of orofacial muscles,
and/or TMJ and dysfunction of TMJ.

Epidimeology:
Affects all racial groups
2nd and 3rd decade of life
males=females
 CLINICAL FEATURES

TMD can involve the following

Muscels of mastication: Myofascial
pain(tendeness or dull aches around
TMJ including ear.
The TMJ: limited jaw opening or pain, jaw
locking, clicking sounds.
Others: Headaches, ear aches, pain
radiating to neck or shoulders,
dizziness and tinnitis.
 Etiology
o Parafunctional habits
o Occlusal anomalies
o Local trauma
o Life events and mental health
Management:
Conservative therapies
Soft diet
Limited
talking
Avoidance of wide mouth opening.
Muscle massage
Jaw exercises
Splint therapy
Psychogenic based therapies
Clonazipam
TCA
SSRI
Surgery
 Burning Mouth Syndrome

Burning sensation of oral mucosa , usually

tongue, in absence of any identifiable
clinical abnormality or cause.
Epidemiology: 5 per 100,000 ,higher in
middle age and elderly, affect female
more than male .

Causes: unknown but hormonal factors ,

anxiety ,and stress have been implicated.
 Clinical Features
Complain of dry mouth with altered or
bad taste.
Anterior tongue>hard palate>lower lip
>alveolar ridge
May be aggravated by certain foods.
Usually bilateral.
Doesn't awake patient . But may
present at awaking
Examination entirely normal .
Investigation: FBC ,haematinics ,swab for Candida .

Treatment:
Reassurance .
Avoidance of stimulating factors.
Some patients may respond to TCA, SSRIs
topical clonazepam, sucking and spitting 1 mg
three times daily for 2 weeks.
2-month course of 600 mg daily alfa-lipoic acid.
Cognitive behavior therapy.
Atypical facial pain

Constant dull aching pain , variable

intensity in absence of identifiable
organic disease.

Its more common in female .

Most patient middle age and elderly .
 Atypical facial pain
Clinical features:

Often difficult for patients to describe their symptoms .

Most frequently described as deep , constant ache or
burning .
Doesn't awake patient.
Doesn't follow anatomical pattern and may be
bilateral.
Affect maxilla more than mandible.
Often initiated or exacerbated by dental treatment .
Examination entirely normal .
Often have other complaints such as IBS ,dry mouth
and chronic pain syndrome .
Atypical facial pain

Treatment :
Treatment of atypical facial pain remains
difficult.
Analgesics are ineffective
TCA drugs have some effect in some
patients .
30% of patient respond to Gabapentine
Cognitive behavior therapy
Atypical odontalgia(phantom)
Presents as pain in a tooth or site of dental
extraction In the absence of clinical or
radiological evidence of pathological
dental condition.
Clinical features:
5th decade
Females>males
Premolar and molar area
Maxillary>mandibular
 Pain is burning or aching
History of surgical or other trauma exist
History of symptoms greater than 4-6
weeks
L.A is ineffective
-Management:
Remains unsatisfactory
Topical aplication of capsaicin and
EMLA
Antidepressants
anxiolytics
 Migraine
Is achronic neurological disorder, typically affects one
half of the head, pain is pulsating and throbbing in
nature.

Associated symptoms may include nausea vomiting

sensitivity to light, smell or noise.

Itmay be triggered by foods such as nuts, chocolate,

and red wine ; stress; sleep deprivation; or hunger.
 Clinical Features
o Duration : usually 12 to 72 hours
o Female:male ratio >2:1
o Neurologic aura : 40%
o Moderate to svere in intensity
o Usually unilateral
The mechanism although not
completely understood appears to
involve neurogenic inflamation of
intracranial blood vessels resulting from
neurotransmitter imbalance in certain
brain centers.
 Migraine

Treatment :
Avoid trigger factors
Acute attack: analgesics, Sumatriptan (5-HT
agonist) , Ergotamin.

Prophylaxis : is directed at normalizing

neurotransmitter imbalance with Antidepressants
, Anticonvulsants, beta-Blockers
 Cluster headache
Clinical manifestations
pain as a hot metal rod in or around the eye.Svere
unilateral orbital, supra orbital,or temporal pain
lasting 15 to 80min.
Pain may occur once or multiple times per day with
precise regularity.

Some component of parasympathetic over

activity is present i.e lacrimation, conjunctival
injection, ptosis or rhinorrhea.
Triggered by alcohol
Produces pain in post.maxilla
 Cluster headache

Treatment:
An acute attack:
Symptomatic treatment is with tryptans
ergots and analgesics.
Prophylaxis : lithium, ergotamine, prophylactic
prednisone, and calcium channel blockers.
Temporal Arteritis
-Is an inflammation(vasculitis) of cranial arterial
tree, secondary to giant cell granulomatous
reaction.

Clinical features:
most frequently affects adults above the age of
50 years.
Dull aching or throbbing temporal pain.
accompanied by generalized symptoms ,
including fever, malaise, and loss of appetite.
Jaw claudication during mastication.
 Temporal Arteritis

Diagnosis:
elevated ESR .
elevated CRP.
Biopsy.
-Treatment:
high dose of steroid(prednisolone) 60 -100mg
daily.
the steroid is tapered once the signs of the
disease are controlled.
Prescribe calcium and vit.D supplements.
 Take Home Message
Orofacial pains are common cause of
morbidity.
No definitive diagnostic criteria is
available and despite many
investigation tools, misdiagnosis is
common.
Many treatment modalities are in use,
but no one is definitive.
THANK YOU