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    Oro facial pain Oro facial pain Presentation Transcript

    • Oro-Facial PainAnd its ManagementIyad Abou RabiiDDS. OMFS. MRes. PhD
    • Introduction•General medical practitioners are often called uponto manage acute dental pain in emergency situations,for example, out of hours or in rural Australia, where itmay not be possible for a dentist to provideimmediate treatment. Common acute oral problemsare usually easy to diagnose. Simple managementcan alleviate pain and further discomfort until a dentistcan be called upon.•Most problems can be identified by the history andexamination. Several dental conditions have typicalsymptoms with different types of pain.
    • Rostral Transmission of PainA delta and C fibers from the orofacial region transmit nociceptivesignals primarily via trigeminal nerves to the trigeminal nucleuscaudalis; noxious information from additional regions is conveyedby other cranial nerves.The nucleus caudalis is located in the medulla; its organization andfunction in processing pain signals are similar to the area on thedorsal aspect of the spinal cord known as the dorsal horn.The medullary and spinal dorsal horns contain four majorcomponents related to the processing of noxious stimuli: centralterminals of afferent fibers, local circuit neurons, projectionneurons, and descending neurons.
    • Rostral Transmission of Pain
    • Pain and anxiety•Pain and anxiety are two sides of the same coin.• Pain can cause a person to be anxious, and an anxiouspatient is likely to experience more pain than a patient who isnot anxious.•Therefore interventions that modulate anxiety reduce pain.•Defining anxious patient and do the necessary to reduce itsanxiety is a mean part of pain management
    • Pain and anxiety•Define anxious patient:Even the most experienced clinician is often unsure how to interpret apatient’s response to dental treatment. Is it really pain, or is the patient justjumpy? Is it painful or merely unpleasant? Why is this particular patient soupset?
    • Pain and anxietyThedentist may ask certain questions as part of the routine preoperative patienthistory or during the patient interview
    • History and examination•What are the Items that History should focus on ?
    • History and examinationWhen investigating acute dental pain, the history should focus on thepains:•location•type•frequency and duration•onset•exacerbation and remission (for example the response to heat or cold)•severity•area of radiation.•Current Medications•History of AllergiesAssociated pathology and referred pain should also be considered.
    • Current Medications•Information regarding a patient’s medications not onlyprovides insight regarding medical status but also may alertthe dentist to possible drug interactions.•Careful attention should be paid to any prescribedmedications the patient is taking currently or has taken withinthe past month.
    • History of Allergies•Patients may label any adverse drug experience as an“allergic reaction.”•Any report of allergy should be further questioned to clarifythat signs and symptoms were consistent withhypersensitivity reactions (i.e., rash, pruritus, urticaria, airwaycompromise).
    • History and examinationWhat are structures that need to be examined?
    • History and examination•The following structures need to be examined carefully in order to be surethat the pain is of dental origin:•tongue•buccal mucosa•floor of the mouth•hard palate•teeth and periodontal tissues•tonsils•temporomandibular joints•airway•ears•salivary glands•lymph nodes.
    • History and examination•Which tests can assist in diagnosis?
    • History and examinationThere are several simple tests that may assist in diagnosis of dental pain.•Pulp sensitivity testDry ice, or an ordinary ice stick (made in a plastic or glass tube), is placedon the cervical third (neck region) of the tooth crown. A response to thestimulus indicates that the pulpal tissue is capable of transmitting nerveimpulses. No response may indicate pulp necrosis.
    • History and examinationThere are several simple tests that may assist in diagnosis of dental pain.•Percussion testUsing an instrument handle, the tooth is tapped in the longitudinal axis. Apainful response suggests possible periapical inflammation.
    • History and examinationThere are several simple tests that may assist in diagnosis of dental pain.•ProbingPlacing a fine, blunt probe gently into the gingival sulcus surrounding thetooth enables the health of the gingival tissues to be assessed. Bleedingand/or sulcus depths greater than 3-4 mm indicate gum disease..
    • History and examinationThere are several simple tests that may assist in diagnosis of dental pain.•Mobility testHolding a tooth firmly on the buccal (cheek) and lingual sides between thefingers enables mobility to be assessed. All teeth have a small amount ofmobility (<0.5 mm), but visible movement suggests loss of bone supportaround the root of the tooth.
    • History and examinationThere are several simple tests that may assist in diagnosis of dental pain.•PalpationCareful palpation around the area of concern may reveal tenderness andthe type and extent of swelling.
    • History and examinationThere are several simple tests that may assist in diagnosis of dental pain.•Radiographic examinationIf it is possible to obtain a screening radiograph, such as anorthopantomograph (OPG), this may assist in the diagnosis andlocalisation of the cause of the pain. The radiograph should show clearlythe apical and periapical structures of teeth and associated tissues. Therelationship of the maxillary molars and premolars to the floor of themaxillary sinus can be examined, and radiographs may reveal recurrentcaries or periapical radiolucencies associated with an established infection.
    • History and examinationThere are several simple tests that may assist in diagnosis of dental pain.•Radiographic examinationIf it is possible to obtain a screening radiograph, such as anorthopantomograph (OPG), this may assist in the diagnosis andlocalisation of the cause of the pain. The radiograph should show clearlythe apical and periapical structures of teeth and associated tissues. Therelationship of the maxillary molars and premolars to the floor of themaxillary sinus can be examined, and radiographs may reveal recurrentcaries or periapical radiolucencies associated with an established infection.
    • History and examinationThere are several simple tests that may assist in diagnosis of dental pain.•Radiographic examination.
    • types of dental painWhat are the common types of dental pain?
    • Dentinal PainThe hydrodynamic theory of dentinal pain has strongexperimental support and postulates that movementof fluid through the dentinal tubules results in pain.
    • Dentinal PainStimuli, including air blasts, cold, and hypertonic sugars(“sweets”), can produce dentinal tubule fluid movement .Movement of this fluid results in stimulation of nociceptivenerve fibers located on the pulpal side of the dentinal tubules.
    • types of dental painCommon types of oro-facial pain likely to cause a patient to seekemergency care are categorised in this figure. The character of the paincan point to a diagnosis.
    • Short, sharp, shooting (Acute) pain•This type of pain can be generalised or confined to one region of themouth.After exposure of dentin, either by loss of enamel or by loss ofcementum and gingiva, dentinal sensitivitycan develop. Dentinal sensitivity is characterized as a sharp pain thatoccurs soon after a provoking stimulus.•The pain may be due to fluid movement through open tubules in thedentine or there may be some initial inflammatory changes in thedental pulp.•It can be caused by caries, dentine exposure on root surfaces, splitcusp, lost or fractured restoration or a fractured tooth.
    • Short, sharp, shooting (Acute) painAcute pain typically results from an injurious insult and is self-limiting.The report of pain typically stops before the precipitating injury healscompletely.Strategies for acute pain management are based on knowledge ofperipheral and central mechanisms of nociception. In general, acutepain management may involve a three-pronged approach:(1) inhibition of biochemical processes signaling tissue injury,(2) blockade of nociceptive impulses along the peripheral nerves, and(3) activation of endogenous analgesic mechanisms in the CNS.These approaches can be employed simultaneously to result in additive analgesia.
    • Short, sharp, shooting pain•Patients complain commonly of a sharp pain associated with hot, coldor sweet stimuli.•The pain is only present when a stimulus is applied.•In the case of a cracked cusp, grainy bread or hard food may create asharp pain, that may be spasmodic, on biting or chewing.
    • Short, sharp, shooting pain•With gingival recession, recent scaling, or tooth wear due to a highacid diet or gastric reflux, there may be generalised dentine sensitivity.However, with caries, fractured fillings and cracked cusps, the paintends to be localised to the affected tooth.•Intermittent sharp, shooting pains are also symptomatic of trigeminalneuralgia, so care must be taken not to mistakenly label toothache asneuralgia.
    • Short, sharp, shooting pain•Treatment •For root sensitivity the use of a desensitising toothpaste and a reduction in acid in the diet will help resolve the symptoms. •The use of a fluoride mouth-rinse may also help. •In the case of caries, a lost filling or fractured tooth, coverage of the exposed dentine with a temporary restoration with Eugenol will usually relieve the symptoms.
    • Short, sharp, shooting pain•Treatment• Traditional pharmacologic pain management usually involves the administration of opioid analgesics.Parenteral opioid analgesics are the standard of care for severe pain in hospitalized patients.• Oral form are administrated in dental climnics• Unfortunately, the oral efficacy of most opioid drugs is very poor. An additional problem with opioids relates to their propensity for nausea in ambulatory patients.• Since most dental pain situations involve ambulatory outpatients requiring oral analgesics, the usefulness of opioids is limited to an adjunctive role. In general, the combination of an aspirin-like drug with an opioid increases analgesia at the cost of an increased incidence of side effects.
    • Dull, throbbing, persistent (Chronic) pain•This type of pain may have several causes. These include toothproblems, food impaction, pericoronitis, acute necrotising ulcerativegingivitis, temporomandibular disorder, or even maxillary sinusitus.
    • Dull, throbbing, persistent pain•Painful tooth problems•The most common dental cause of dull, throbbing persistent pain iscaries. In many cases this is recurrent and associated with an existingrestoration. Where the pulp is affected irreversibly, necrosis may followwith possible development of a periapical infection.•A fractured cusp involving the pulp, or a large deep restoration mayalso be associated with this type of pain. Affected teeth may be tenderto percussion in the later stages of periapical inflammation.
    • Dull, throbbing, persistent pain•There is considerable variation in the pain reported by patients, but itcommonly starts as a sharp stabbing pain that becomes progressivelydull and throbbing. At first the pain may be caused by a stimulus, but itthen becomes spontaneous and remains for a considerable time afterremoval of the stimulus
    • Dull, throbbing, persistent pain•The pain may radiate and be referred to other areas of the mouth.•This type of pain tends to cause the patient to have difficulty sleepingand may be exacerbated by lying down.•Heat may make the pain worse whereas cold may alleviate it.•The pain may be intermittent with no regular pattern and may haveoccurred over months or years.•If there is periapical infection present, patients may no longercomplain of pain in response to a thermal stimulus, but rather ofsensitivity on biting.
    • Dull, throbbing, persistent pain•TreatmentTreatment of affected teeth will involve either root canal therapy ortooth removal. In some patients, periapical inflammation can lead to acellulitis of the face characterised by a rapid spread of bacteria andtheir breakdown products into the surrounding tissues causingextensive oedema and pain. If systemic signs of infection are present,for example, fever and malaise, as well as swelling and possiblytrismus (limitation of mouth opening), this is a surgical emergency.
    • Dull, throbbing, persistent pain•TreatmentIf pus is present, it needs to be drained, the cause eliminated, andhost defences augmented with antibiotics. The microbial spectrum ismainly gram positive including anaerobes. Appropriate antibioticswould include a penicillin or a `first generation cephalosporin,combined with metronidazole in more severe cases.Do think that other Drugs is needed ?
    • Dull, throbbing, persistent pain•Treatment•One approach with some clinical support is the use of antihistaminesas adjunctive analgesic agents. Histamine is released during mast celldegranulation.•Generalizing from animal studies, antihistamines should demonstrategreater efficacy when given before surgery, but this has yet to beestablished in the clinic.•Several clinical studies have demonstrated that antihistamines serveas effective adjunctive analgesics in the oral surgery model.•So in the case of chronic pain NSAIDs combined with antihistaminesgive good resultes
    • Oral pain and Antibiotics•Should antibiotics be prescribed?•While antibiotics are appropriate in the management of certain dentalinfections, they are not indicated if the pain results from inflammatory(non-infective) or neuropathic mechanisms. The degree of pain is nota reliable indicator of acute infection.
    • Oral pain and Antibiotics•There is evidence that dentists and doctors are using antibioticsempirically for dental pain, rather than making careful diagnoses of thecauses of the pain.1 Most dental emergency situations involvepatients with acute inflammation of the dental pulp or the periapicaltissues. Prescribing antibiotics for these conditions will not remove thecause of the problem nor destroy the bacteria within the tooth.
    • Oral pain and Antibiotics•Antibiotics should be limited to patients with malaise, fever, lymphnode involvement, a suppressed or compromised immune system,cellulitis or a spreading infection, or a rapid onset of severe infection.
    • Other Cases
    • Food impaction and pericoronitis• Soft tissue problems that may cause dull, throbbing, persistent paininclude local inflammation (acute gingivitis associated with foodimpaction) or pericoronitis.
    • Food impaction and pericoronitis•Chronic periodontitis with gradual bone loss, rarely causes pain andpatients may be unaware of the disorder until tooth mobility is evident.There is quite often bleeding from the gums and sometimes anunpleasant taste. This is usually a generalised condition, however,deep pocketing with extreme bone loss can occur around isolatedteeth. Food impaction in these areas can cause localised gingivalpain. Poor contact between adjacent teeth and the presence of anoccluding cusp forcing food into this gap can also cause a build-up offood debris and result in gingival inflammation.
    • Food impaction and pericoronitis•Acute pericoronitis involves bacterial infection around an uneruptedor partially erupted tooth and usually affects the lower third molar(wisdom tooth). The condition is often aggravated by the upper molarimpacting on the swollen flap of soft tissue covering the uneruptedtooth. There may be trismus.
    • Food impaction and pericoronitis• Treatment•Food debris should be removed and drainage established, if pus ispresent. Irrigation with chlorhexidine and rinsing the mouth with hotsalty water is recommended. Early referral to a dentist is indicated.Cellulitis can develop, requiring urgent referral to a surgeon.
    • Acute necrotising ulcerative gingivitis•Acute necrotising ulcerative gingivitis is a rapidly progressive infectionof the gingival tissues that causes ulceration of the interdental gingivalpapillae. It can lead to extensive destruction. Usually young to middle-aged people with reduced resistance to infection are affected. Malesare more likely to be affected than females, with stress, smoking andpoor oral hygiene being predisposing factors. Halitosis, spontaneousgingival bleeding, and a `punched-out appearance of the interdentalpapillae are all important signs.
    • Acute necrotising ulcerative gingivitis•The patients quite often complain of severe gingival tenderness withpain on eating and tooth brushing. The pain is dull, deep-seated andconstant. The gums can bleed spontaneously and there is also anunpleasant taste in the mouth.
    • Acute necrotising ulcerative gingivitis•TreatmentAs there is an acute infection with mainly anaerobic bacteria,treatment follows surgical principles and includes superficialdebridement, use of chlorhexidine mouthwashes and a course ofmetronidazole tablets. Treating the contributing factors should preventa recurrence..
    • Dry socket•A dull throbbing pain develops two to four days after a mandibulartooth extraction. It rarely occurs in the maxilla. Smoking is a majorpredisposing factor as it reduces the blood supply. The tissue aroundthe socket is very tender and white necrotic bone is exposed in thesocket. Halitosis is very common.
    • Dry socket•Treatment•The area should be irrigated thoroughly with warm saline solution. Ifloose bone is present, local anaesthesia may be necessary to allowthorough cleaning of the socket. Patients should be shown how toirrigate the area and told to do this regularly. Analgesics are indicated,but pain may persist for several days. Although opinion is divided as towhether or not dry socket is an infective condition, we do notrecommend the use of antibiotics in its management
    • Sinusitis• This is caused by infection of the maxillary sinus, usually following anupper respiratory tract infection. However, there can be a history ofrecent tooth extraction leading to an oro-antral fistula. Patients usuallycomplain of unilateral dull pain in all posterior upper teeth. All theseteeth may be tender to percussion, but they will respond to a pulpsensitivity test. There are usually no other dental signs.
    • Sinusitis•The pain tends to be increased on lying down or bending over. Thereis often a feeling of `fullness on the affected side. The pain is usuallyunilateral, dull, throbbing and continuous. Quite often the patient feelsunwell generally and feverish.
    • Sinusitis•The pain tends to be increased on lying down or bending over. Thereis often a feeling of `fullness on the affected side. The pain is usuallyunilateral, dull, throbbing and continuous. Quite often the patient feelsunwell generally and feverish.
    • Sinusitis•TreatmentPain originating from the sinus arises mainly from pressure.Decongestants can help sinus drainage. Antibiotics probably haveonly a minor role in mild cases. Referral to an otorhinolaryngologist forendoscopic sinus surgery may be indicated in chronic cases.3
    • Trigeminal Neuralgia• Non-analgesic drug (Carbamazepine) give excellent results in the treatment of Trigeminal Neuralgia• Dose • 100 mg twice daily • No improvement: the dose is increased to 200 mg four time a day • No improvement : Dose can be augmented until 1600 mg a day with (monitoring of plasmatic concentration of the drug should be achieved regularly)• If with such dose there is no improvement then Phenytoin is used (150 to 300 mg daily)
    • TMJ Pain• Diazepam has both sedative and muscle relaxant effects, so it is helpful if the origin of the trismus is psychotic• In other cases the use of Paracetamol 250 mg in combination with Chlorzoxzson (muscle relaxant ) 300 mg is recommended 4 times daily.
    • atypical facial pain• The use of Tricyclic antidepressant looks helpful (Amitriptyline)• Anyway the prescription of such drugs should not be done by a dentist
    • Conclusion : Therapeutics
    • Therapeutic Uses of Non-Opioid Analgesics• optimal analgesic therapy for ambulatory dental patients should be efficacious with a minimum incidence of side effects.• Nonsteroidal antiinflammatory drugs (NSAIDs) are the mainstay of therapy for the management of acute dental pain.• They have also been evaluated for chronic orofacial pain, for minimizing edema after surgical procedures, and for endodontic pain.
    • Therapeutic Uses of Non-Opioid Analgesics• Ibuprofen is superior to aspirin, acetaminophen, and combinations of aspirin or acetaminophen plus codeine 60 mg but has fewer side effects than the opioid combinations.• Marketed doses of NSAIDs are generally equally effective but vary in onset, duration of action, and adverse side effects with repeat dosing.• Parenteral ketorolac is comparable to injectable opioid drugs but has fewer side effects, especially in ambulatory patients.
    • Therapeutic Uses of OpioidAnalgesics• When managing dental pain, optimize non-opioid agents before adding an opioid to the regimen.• Limit ambulation in patients prone to nausea and vomiting.• If the patient is opioid-dependent, consult with the primary practitioner regarding appropriate drug and dosage.• Decrease doses in elderly patients or in those who have renal or hepatic compromise.
    • Therapeutic Uses of OpioidAnalgesics• Codeine and its derivatives are prodrugs. Only 10% of an administered dose is converted to the active• morphine derivative. They are less effective for patients who are taking cimetidine or theantidepressants fluoxetine and paroxetine.• Opioid agonists are equivalent in their analgesic efficacy and propensities to produce side effects.
    • Therapeutic Uses of OpioidAnalgesics• Meperidine should not be prescribed for more than 2 to 3 days because it is converted to normeperidine, a CNS stimulant with an extremely long elimination half-life.• This statement is also true for propoxyphene, which is converted to norpropoxyphene.
    • NSAID-Opioid Combinations• Combining an NSAID with an opioid results in additive analgesia but has increased side effects, especially in ambulatory patients.• A full therapeutic dose of each ingredient in the combination is needed to achieve a genuine therapeutic advantage.
    • NSAID-Opioid Combinations• One tablet of the fixed-dose combination of ibuprofen 200 mg and hydrocodone 7.5 mg should be administered with ibuprofen 200 to 400 mg to result in the normal analgesic dose of ibuprofen and an additive effect of the opioid with acceptable side effects.
    • Preventive Analgesia• Administration of NSAIDs in the perioperative period before local anesthetic offset delays the onset of postoperative pain and lowers its intensity.• Blockade of prostanoids formed by constitutive COX-1 during and immediately after surgery is less important than suppression of the products of inducible COX-2 during the first few hours after surgery.
    • Copyright noticeFeel free to use this PowerPoint presentation for your personal,educational and business.Do• Make a copy for backups on your harddrive or local network.• Use the presentation for your presentations and projects.• Print hand outs or other promotional items.Don‘t• Make it available on a website, portal or social network website for download. (Incl. groups, file sharing networks, Slideshare etc.)• Edit or modify the downloaded presentation and claim / pass off as your own work.All copyright and intellectual property rights, without limitation, are retained by Dr. Iyad Abou Rabii. By downloading and using this presentatione, you agree to this statement.Please feel free to contact me, if you do have any questions about usage.Dr Iyad Abou RabiiIyad.abou.rabii@qudent.edu.sa