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Oro-Facial Pain Differential Diagnosis Guide
- 1. Oro-Facial Pain Differential Diagnosis Dr . Moazami
- 2. References: • Pathways of the pulp • Chapter 3
- 3. What is Pain? • Unpleasant sensory & emotional experience associated with actual or potential tissue damage .
- 4. Origin of orofacial pain • Non dental • Dental pulp periapical
- 5. Possible causes of Facial Pain Dental pain TMD /eruption pain/sinusitis/periodontal dx Neuropathic pain (neuralgias) Pathology in related structures (salivary glands, sinuses, eyes, cervical spin, nasopharyns, etc… Vascular disorders (headaches) Intracranial lesions (neoplasms, MS) Referred pain (angina pectoris) Psychogenic facial pain
- 6. “Listen to your patient”
- 7. Consider all pains in the mouth and face to be of dental origin until proved otherwise
- 8. The Experience of Pain Depends on: 1. Emotional state (varies in one person at different times) 2. Pain threshold (age , sex ) 3. Immediate environment (culture) 4. Previous experience of pain
- 9. How do we feel pain? • Specialized receptors = free nerve endings • Stimulation – Mechanical damage – Extreme temperature – Chemical irritation • Two types of neurons – A-delta: first pain, sharp – C: second pain, dull
- 10. • Orofacial pain of dental origin requires a careful examination and diagnosis Endodontic emergency: 33% Endodontic pain: 90% one tooth
- 11. “LISTEN TO YOUR PATIENT” “”
- 13. Types of Pain • Projected Pain: – Pain felt at peripheral ends of nerve, while stimulus occurred along the course of that nerve. – Example: pain in TMJ sensed as pain in ear • Referred pain: – Pain felt in an area distant from that in which the causative pathology is located – Example: angina pectoris sensed as pain over the left side of the mandible / pain in lower teeth felt in upper teeth • Phantom pain: – Pain coming from a body part that's no longer exist – Used to be considered a psychological problem, but now is recognized as real sensations originate in the spinal cord & brain
- 14. The five questions 1. Is the pain spontaneous or present all the time?
- 15. The five questions 2. What recreates or reliefes the pain?
- 16. The five questions 3. What drugs have you taken for the pain?
- 17. The five questions 4. Does pain awaken the patient?
- 18. The five questions 5. Where does it hurt, and where does the pain radiate to?
- 20. Pulpal and periapical tests: • Thermal tests • EPT • Percussion • Palpation
- 21. Duration of Pain • Acute Odontogenic pain , severe, inflamed pulp ,spontaneous ,referred , drug , sleep , RCT • Chronic Odontogenic pain, 6 months, periodontal, systemic,psychogenic pulp cap, leaky restoration , crack , caries
- 22. Pulpal pain • Sharp / aching pain • Difficult to localize • Irrelevant to masticatory function • Local anesthesia eliminates the pain • Exposed dentin / cementom Dentinal sensivity Pulpal disease
- 23. Pulpal pain tends to get better or worse but rarely stays the same overtime
- 24. Dentin sensivity • Nerve ending in dentin • Movement of dentinal fluid • Direct effect on mechanoreceptors in pulp • Treatment : Block the dentinal tubules oxalate salts / potasium oxalate
- 25. Dentin sensivity
- 27. Periapical pain • Dull or sharp / throbbing / boring • Related to masticatory function • Localization • Etiology: Irreversible pulpitis Periapical dx / TMJ Sinusitis / Headache / occlusal trauma Parafunctional habit /food impaction
- 29. Occlusal trauma
- 31. Food impaction
- 32. pericoronitis
- 33. Odontogenic pain : Review • Etiologic factors • Reproduce chief complaint during exam • Pain reduction by local anesthetics • Unilateral pain • Pain quality: sharp or dull, aching, throbbing • Localized pain • Sensivity to tempreture • Sensivity to percussion
- 36. Site of pain vs Source of pain • The location where the patient feels the pain by asking • That area of the body from which the pain actually originates Site =source cut the finger Site # source cardiac pain
- 37. Successful therapy is achived by treating the source of pain not the site of pain
- 39. Characteristics of non odontogenic toothache •Spontaneous multiple toothache , bilateral pain •Inadequete local dental cause for the pain •Constant , electric shooting , burning, dull ache •Recurrent toothache , persistant •Local anesthetic does not arrest the pain •Failure to respond dental therapy •Pain that occurs with a headache •Increased pain associated with palpation of trigger point or muscles
- 40. Origins of non odontogenic toothache •Myofascial toothache •Nourovascular toothache •Cardiac toothache •Nouropatic toothache •Sinus toothache •Psychogenic toothache
- 41. Myofacial toothache TMJ dysfunction Masseter max/man post teeth Temporalis ant/ post maxillary Digasteric ant / mandibular
- 43. Neuralgia • Pain • Localized to an area supplied by a single sensory nerve • Severe • Trigger point • Sharp stabbing pain
- 44. Neuropathic pain Post-Herpetic Neuralgia • Persistent neuritic pain for > 2 months after acute eruption • Affect elderly & immunocompromised patients • Treatment – Anticonvulsants (Gabapentin) – TCAs – Antiviral in combination with TCA • All patients with HZ infection should be vigorously treated with acyclovir to reduce risk of PHN
- 45. Nourovascular toothache Migraine Diffused pain Throbbing unilateral dull pain
- 46. Headache Migraine Cause: • Vascular instability (vascular theory) • Dysregulation of neuronal function (neuronal theory) Treatment: • NSAIDs (first line management) – Aspirin + caffeine combination • 5-HT (5-hydroxytryptamine, serotonin) Prophylactic (for recurrent cases) • 5-HT • Beta-blockers (mechanism unknown)
- 47. Headache Migraine Clinical presentation: • Affects any age • Females more commonly affected • Usually unilateral • Intermittent, each attack last for 3h - days • Usually accompanied by nausea, vomiting and photophobia • With or without aura (visual disturbances, numbness) • Precipitating factors – Stress – Some foodstuff
- 48. Sinus toothache Inflamatory condition Infection Allergy Multiple teeth Vitality
- 49. Cardiac toothache Aching pain is cyclic (LF post man.) Toothache is increased with exercise Toothache is associated with chest pain Toothache is decreased with Nitroglycerin Local anesthetic does not arrest the pain
- 51. Diagnosis of different pains
- 52. History • The most important part – First occurrence – Timing – Quality – Treatments – Associated symptoms – Precipitating factors
- 53. Past Medical History • Head injuries, infections, surgeries • Psychiatric diagnoses • Medications • Alcohol, tobacco, drugs
- 54. Diagnostic Tests Which test to select is guided by history & physical examination: – CT and/or MRI (to rule out intracranial pathology) – TMJ radiography – Diagnostic occlusal appliance – Labs (ESR, autoimmune dx ) – consult
Editor's Notes
- Pain Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Process Transduction: Noxious stimuli translated into electrical activity at the sensory endings of nerves. Transmission: Propagation of impulses throughout the sensory nervous system. Components Primary sensory afferents - to spinal cord. Ascending relay neurons - spinal cord to brain stem / thalamus. Thalamocortical projections Modulation: Nociceptive transmission is modified. Perception: Transduction, transmission, modulation interact to create subjective emotional experience of pain affective / motivational aspect - pain always carries unpleasantness and desire to escape.
- Herpetic skin eruption is caused by the reactivation of latent varicella-zoster virus from the sensory nerve ganglia. The reactivated virus is carried via the axons distally to the skin where it produces a painful rash with crusting vesicles in a dermatomal distribution. The trigeminal nerve is the second most commonly affected after nerves in the thoracic region. Steroids are often used for the acute eruption in otherwise healthy individuals, while antivirals, NSAIDs and opiates are often used in immunocompromised patients. Pain that persists 2 or more months after the acute eruption is known as post-herpetic neuralgia. NSAIDs and opiates are of little use in the treatment of the neuralgia. Anticonvulsants in conjunction with TCA or baclofen are most useful for the control of shooting neuritic pains.
- Migraines are perhaps the most studied of the headache syndromes. This is due in part to the high incidence and significant loss of productivity and limitation on quality of life suffered by those with the syndrome. It is estimated that 17% of females and 6% of males have migraine headaches. Onset is usually in the second or third decade. Migraines are characterized by headaches of moderate to severe intensity located unilaterally with a pulsating quality. Attacks last from 4-72 hours (2-48 hours in children less than 15 years old) and are aggravated by routine physical activities. In order to meet diagnostic criteria, there must be nausea, vomiting, photophobia or phonophobia. Migraines may occur with or without aura. Migraine with aura is less common. Vision complaints are the most common manifestation of aura, but patients may experience paresthesia, aphasia, nausea and vomiting prior to the onset of headache. These findings are completely reversible and precede the headache by no more than 60 minutes. Migraines seem to have a triggering event that precipitates a sterile inflammatory response around intracranial vessels that is mediated by the trigeminovascular system. Triggering factors may include stress, menses, pregnancy and oral contraceptive pills, infection in the head and neck, trauma or surgery, red wine, aged cheeses, vasodilating medications, strong odors, irregular diet or sleep and bright sunlight or flickering lights. Recent studies have discovered serotonin receptor subtypes in the central nervous system that play significant roles in the neurologic changes and intracranial blood vessel change. Newly available treatments such as sumatriptan target these receptors. Several other neuropeptides have been identified as pro-inflammatory and are believed to play a significant role in migraine development. Further investigation is hoped to provide treatment alternatives with fewer side effects.
- The most important information in the accurate diagnosis of headache and facial pain comes from the patient’s history. This may require a redirected or more targeted history after more common causes are excluded. Indeed, the otolaryngologist frequently must first reverse a self-diagnosis of “sinus headache” reached by the patient before a more thorough history can be attained and more accurate diagnosis reached. As Acquadro and Montgomery point out, the evaluation of headaches can be quite time-intensive, requiring diagnostic and treatment modalities foreign to most otolaryngologists. In fact, there is a growing number of physicians who focus their practice on the diagnosis and treatment of headache. For many diagnoses however, the otolaryngologist may elect to treat the patient himself, remain a consultant with recommendations to the primary care physician or refer the patient to a headache specialist. Regardless of who eventually leads the patient’s healthcare team, there is an increasing emphasis on a multidisciplinary approach. The more experience a clinician gains in obtaining a history for headache, focusing on pertinent symptoms, the more skilled the clinician will become in diagnosis. A complete history begins with determining the age when the patient first experienced the headache. The events occurring to the present should be recorded as well. The rate of onset and offset, intensity, quality, location, duration and response to treatments should be recorded. The frequency and timing of attacks may hold important information. The patient’s own description of the quality of the pain may aid determining its source. Pressure-like pain is common in viscous or chamber-derived pain, while sharp and shooting pains are more characteristic of neuritic pain. Throbbing pain is typical in vascular headaches. Burning and aching suggests muscular pain. Any associated symptoms – nausea and vomiting, fever, diplopia, syncope, hiccoughing, lacrimation, nasal congestion, photophobia, phonophobia, diarrhea, polyuria – should be noted. Does the patient experience any warning or aura prior to the attack? Any precipitating factors such as head movements, eating, relation to sleep, foods, stress, menses, weather, medications or alcohol should be recorded. Factors providing relief may not only guide diagnosis, but treatment as well.
- A thorough past medical history should include inquiries as to prior head injuries, intracranial infections or processes and past surgeries. Any past or present medical and psychiatric illnesses should be documented. Inquiry should be made as to current medications including the type and frequency of use of over-the-counter analgesics, oral contraceptives, herbal medicines and topical agents used on the head and face. Special attention should be paid to antihypertensives and vasodilators. A complete family and social history with amount and duration of tobacco, alcohol and recreational drug use should be noted. Life stressors should be assessed. A complete review of systems is mandatory in the complete evaluation of head and face pain.
- After the complete history and physical examination, laboratory tests may be ordered. The necessary and sufficient evaluation of the headache and facial pain patient is the matter of some debate. In general, the tests requested should be guided by the history and physical examination findings. In the patient with recent onset headache of moderate to severe intensity and findings on the neurologic examination, EEG may be the test of first choice. EEG is also helpful in the patient with muscle contractions in whom epilepsy is suspected. Radiographic studies (CT and MRI) are useful to evaluate new onset moderate to severe headaches, or to rule out intracranial pathology in patients with long-standing, chronic headache or facial pain. Lab tests directed to rule out autoimmune disease or other systemic disease should be ordered if the history suggests a generalized process. EMG (electromyogram) may be useful if a diagnosis of primary muscle disease or neuropathy is suspected. Tenderness of the TMJ may be further evaluated by radiographic imaging of the joint. Postural disorders with muscle pain and trigger points in the neck and shoulder should be evaluated with cervical spine radiographs. Psychometric testing may be of benefit in the evaluation and treatment of the patient with headache and facial pain. Many tests have been applied, but probably the most widely used is the Minnesota Multiple Personality Inventory (MMPI). While especially useful in the evaluation of the chronic headache and facial pain patient, a thorough discussion of psychometric testing is beyond the scope of this discussion and mentioned here only for completeness.