Oral Medicine Lec4

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    Facial Pain

    Is an unpleasant sensation & a subjective symptomwhich is difficult to investigate since it can not be

    seen, smell, heard, palpated or tasted unlike lump or

    ulcer which can be examined and assessed , in case

    of pain the clinician rely on the description given by

    the patient.

    Pain serves as a good purpose as it is act as threat

    signal of an abnormality in the body.

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    The clinician have to know what and how to ask the

    patient, there are many questions , which must be

    asked about any pain:

    1. Type of pain: Sharp , tenderness, dull pain

    ,throbbing, stabbing ,burning ,electric shock.

    2. Severity:

    Mildmanaged with mild analgesics (aspirin ,

    paracetamol)

    Moderateunresponsive to mild analgesicsSevere disturbs sleep.

    3. Duration : Time since onset (days ,weeks ,months,

    years)& duration of attack

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    4. Nature : Continuous in attacks or paroxysmal.

    5. Initiating factors : any potential factors.

    6. Exacerbation and relieving factors : record all and

    note especially hot and cold sensitivity or pain on

    eating which suggest a dental cause.

    7. Localization : the patient should map out the

    distribution of pain if possible. Is it well or poorly

    defined?

    8. Referral : try to determine whether the pain could

    be referred.

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    The clinician must evaluate :

    ) The nerve involved1)

    a- The trigeminal nerveb- The greater auricular nerve: area of the angle of

    mandible

    c- The glossopharngeal nerve: pain in the posterior

    part of the tongue or in the throat.

    ) Whether the pain :2(

    A. Peripheral : only one branch will be involved

    B. Proximal : more than one branch will be involvedC. Intra cranial : more than one division may be

    involved and in advanced lesion there may be

    signs of elevation in intra cranial pressure

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    Causes of pain felt in the oral cavity

    # Disease of teeth and supporting tissues

    # Oral mucosal diseases

    # Disease of the jaw# Pain in the edentulous patient

    # Postoperative pain

    # Pain trigger by mastication

    # Referred pain# Neurological diseases

    # Psychogenic (atypical ) facial Pain

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    Causes o f pain f rom the teeth o r suppo rt ing t issues

    1~Pulpitis

    an extensive acute pulp inflammationAcute pulpitis:

    ,it may originating as acute pulpitis or it may be an

    exacerbation of chronic pulpitis.

    The pain severe, unlocalized (because pulp has only

    pain fibers no proprioceptive fibers/ mechano-

    receptors), provoked by heat changes and

    sometimes tender to percussion .the patient feel illand need urgent treatment.

    pain is not a prominent feature butChronic pulpitis:

    sometimes patient feels intermittent ,dull, mild pain.

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    2~Dentine hypersensitivity cracked tooth or cracked

    cusp syndrome

    The tooth sensitive to thermal changes (cold & hot)

    3~Periapical periodontitis

    tooth is painful ,extrudedAcute Periapical abscess:

    from the socket and patient can localize the

    causative tooth because the problem affect

    periapical tissue which contain mechano-receptors

    which tell the brain the exact site of pain. Patient

    may have fever, regional L.N enlargement.

    there is no or mild pain,Chronic Periapical abscess:

    sinus may be present at the periapical area of the

    tooth.

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    4~Lateral periodontal abscessPain due gingivitis and periodontal abscess tend to

    be constant in nature.

    5~Acute ulcerative gingivitis

    Extremely painful gingiva with scattered punch-out

    ulceration and malodor and there may be gingival

    bleeding.

    6~HIV associated periodontitis

    7~PericoronitisPeriodontal pain with a swelling cheek and limitation

    of opening of mandible.

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    Painfu l Jaw Diseases:1/ Fracture

    2/Osteomylitis3/ Infected cysts

    4/ Malignant neoplasm

    Causes o f Pain in Edentu lous pat ients :1/ Denture trauma

    2/ Excessive vertical dimension3/ Diseases of denture bearing mucosa

    4/ Diseases of jaws

    5/ Teeth or tooth erupting under denture

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    Pos toperat ive Pain1/ Alveolar osteitis ( dry socket )

    2/ Fracture of jaw

    3/ Damage to the TMJ4/ Osteomlyitis

    5/ Damage to the nerve trunk or involvement of

    nerves in scar tissue

    Pain induced by Mast icat ion :1/ Disease of teeth and supporting tissues

    2/ Pain Dysfunction syndrome3/ Diseases of TMJ

    4/ Temporal arteritis

    5/ Trigeminal neuralgia

    6/ Salivary calculi

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    Referred PainPain originating from an organ which is located at a

    distance, anatomically from the face & mouth and

    referred to the head and neck causing facial pain .

    a) Cardiogenic pain : mostly referred to angle of

    mandible at left side & it simulate third molar pain,so it may misdiagnose. Pain occur and precipitated

    by exercise and stress and associated with

    substernal pain (severe stabbing pain) and

    administration of nitroglycerin relieves the pain.b) Neck lesions: refer to side of face via C2 and C3.

    c) Lesions of esophagus and cardiac end of

    stomach : which can diagnosed easily since it occur

    after certain meals ,it cause mostly heart burn.

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    we discussed in previous lectureNeuro log ical Disease:

    Psychogenic Pain ( atyp ical facial pain )Features:

    1- Women of middle age or older mainly affected.

    2- Absence of organic signs.

    3- Description of pain mainly bizarre.4- Pain often poorly localized.

    5- Delusional symptoms occasionally associated.

    6- Lack of response to analgesic.

    7- Unchanging pain persisting for many years.

    8- Lack of any triggering factors.

    9- Sometimes good response to antidepressive

    treatment.

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    Pain f rom Extra Oral Diseases :Diseases of maxillary antrum--

    .Acute sinus i t is :1

    sometimes it simulate dental pain and can be easily

    misdiagnose as toothache which arise from upper

    premolar and molar teeth but pain in sinusitisfluctuant with posture and can not stimulated by hot

    or cold may associated with uni/bilateral nasal block

    mostly preceded by common cold (especially in

    winter) ,if palpate the sinus it is painful, supra-orbitalheadache with tenderness of several upper

    posterior teeth.

    To confirm diagnosis we can take x-ray occipito-

    mental view.

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    -- Diseases o f ear

    which is mostly affecting children. Otitis media :1and young adults and the pain is acute ,severe ,

    persistent with bulging of tympanic membrane

    which is hyperemic .

    pain and when we move the. Otitis externa:2

    external ear we may see boil in the external ear.

    in the region.. Neoplasm3

    , particularly when it involve the antra.Carcinoma2

    floor, it associated with epiphora.

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    -- Diseases o f sal ivary g lands

    1. Acute parotitis2. Salivary calculi.

    3. Sjogren`s syndrome.

    4. Malignant neoplasm.

    -- Diseases o f eyes :iritis , conjunctivitis etc

    --TMJ Disease :we will discussed it in detailslater on.

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    -- Myocardial infarct ion and Angina :

    pain referred through cardiac nerve fibers of vaguswhich communicate with nucleus of trigeminal

    nerve.

    -- Neck lesions.

    -- Lesions o f esophagus and cardiac end o f

    s tomach.

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    Common causes of parasthesia or

    anaesthesia of the lip :

    1- Inferior dental block.

    2- Trauma (fracture or operative damage).3- Acute osteomylitis.

    4- Malignant tumors of mandible.

    5- Exposed mental foramene.

    6- Herpes zoster.7- Multiple sclerosis.

    8- Tetany.

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