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7/27/2019 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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