Pain is the most important protective sensation. Assessment and Management is the most fundamental part of the nurse’s responsibility [ 5 vital sign – temp, heart rate, pulse rate, respiratory rate, blood pressure ]. Perception of the pain is influenced by cultural, psychological, emotional factors. An unpleasant sensation and is the most primitive of all senses.

1. PAIN
DR. ARUMUGAM PM
FIRST YEAR MDS
DEPARTMENT OF PUBLIC HEALTH DENTISTRY

2. SYNOPSIS
• INTRODUCTION
• HISTROY
• DEFINITION
• BENEFITS
• COMPONENTS
• PATHWAY OF PAIN SENSATION
1. Pathway from skin and deeper structures
2. Pathway from face
3. Pathway from viscera
4. Pathway from pelvic region
• REFERRED PAIN
• ANALGESIC PATHWAY
• GATECONTROL THEORY

3. • OROFACIAL PAIN
INTRODUCTION
DEFINITION
TYPE
HOW TO DIAGNOSE
CLASSIFICATION
TEMPEROMANDIBULAR DISORDER
CLUSTER HEAD ACHE
PAROXYSMAL HEMICRANIA
SUNLT
HEMICRANIA CONTINUA
• NEUROPATHIC OROFACIAL PAIN
TRIGEMINAL NEURALGIA
GLOSSOPHARYNGGEAL NEURALGIA
BURNING MOUTH SYNDROME
PAINFUL POST TRAUMATIC TRIGEMINAL NEUROPATHY

4. • DENTOALVEOLAR ORAL MUCOSAL PAIN
INTRODUCTION
PAIN MECHANISM
ETIOLOGY
INVESTIGATION
ORAL ULCERATION
BONE AND OROFACIAL PATHOLOGY
• PUBLIC HEALTH SIGNIFICANCE
• OVER ALL VIEW
• CONCLUSION
• REFERENCE

5. INTRODUCTION
Pain is the most important protective sensation
Assessment and Management is the most fundamental part of
the nurse’s responsibility [ 5 vital sign – temp, heart rate, pulse
rate, respiratory rate, blood pressure ]
Perception of the pain is influenced by cultural, psychological,
emotional factors..
An unpleasant sensation and is the most primitive of all senses

6. HISTORY
Pain is derived from LATIN – “POENA” ( punishment from God )
 Aristotle – did not include a sense of pain when he enumerated
the five senses of considered pain to the “Passion of the Soul”
Hippocrates – Believed that pain was caused by an imbalance in
the vital fluid of a Human
Bible – its not only in relationship to injury and illness but also an
Anguish of the Soul

7. DEFINITION
Pain is defined as an unpleasant and emotional
experience associated with or without actual tissue
damage
Pain is produced by real or potential injury to the body.
. Acute pain is a sharp pain of short duration with easily
identified cause. Often it is localized in a small area
before spreading to neighboring areas
Chronic pain is the intermittent or constant pain with
different intensities. It lasts for longer periods. It is
somewhat difficult to treat chronic pain

8. TYPES OF PAIN

9. BENEFITS OF THE PAIN
Pain is an important sensory symptom. Though it is an unpleasant sensation, it has
protective or survival benefits
1. warning sign
2. creates awareness of injury
3. prevents further damage by causing reflex withdrawal
4. Pain forces the person to minimize the activities
5. urges the person to take required treatment

10. „COMPONENTS OF PAIN SENSATION
Fast pain is the first sensation whenever a pain stimulus is applied
a bright, sharp and localized pain
Slow pain, which is experienced as a dull, diffused and unpleasant pain.

11. PATHWAY OF PAIN SENSATION
Sensation from various parts of body is carried to brain by through
1. Pathway from skin and deeper structures
2. Pathway from face
3. Pathway from viscera
4. Pathway from pelvic region

12. 1. FROM SKIN AND DEEPER STRUCTURES
• RECEPTOR – Free nerve ending , which is distribute through out the body
• Fast pain sensation is carried by Aδ type afferent fibers - synapse with neurons of
marginal nucleus
• Slow pain sensation is carried by C type afferent fibers, which synapse
with neurons of substantia gelatinosa

13. SENSORY PATHWAY
FIRST ORDER NEURON - the cells in posterior nerve root ganglia - receive
the impulses of sensation from receptors through their dendrites - transmitted to
spinal cord through the axons of these neurons.

14. • SECOND ORDER NEURON - Neurons of marginal nucleus and substantia gelatinosa of
Rolando form the second order neurons – ascends in the form of lateral spinothalamic tract.
the fibers cross the midline via anterior
gray commissure, reach the lateral white
column of the opposite side and ascend
neurons of
marginal nucleus
These nerve fibers terminate in ventral
posterolateral nucleus of thalamus.
FAST PAIN FIBERS
SLOW PAIN FIBERS
neurons of substantia
gelatinosa,
cross the midline and run along
the fibers of fast pain as
paleospinothalamic fibers
in lateral spinothalamic tract.
One fifth of these fibers
terminate in ventral
posterolateral nucleus of
thalamus.
Remaining fibers : 1.Nuclei
of reticular formation in brainstem
2.Tectum of midbrain
3. Gray matter surrounding
aqueduct of Sylvius.

15. • THIRD ORDER NEURON –
i. Thalamic nucleus
ii. Reticular formation
iii. Tectum
iv. Gray matter around aqueduct of Sylvius.
• Axons from these neurons reach the sensory
area of cerebral cortex
• Some fibers from reticular formation reach
hypothalamus.

16. 2.FROM FACE
• Special sensations - the complex sensations for which the body has some specialized sense
organs.( Sensations of vision, hearing, taste and smell )
• Somatic sensations - the sensations arising from skin, muscles, tendons and joints. These
sensations have specific receptors,
1. Epicritic sensations - Epicritic sensations are the mild or light sensations.
i. Fine touch or tactile sensation
ii. Tactile localization
iii. Tactile discrimination
iv. Temperature sensation with finer range between 25°C and 40°C.
2. Protopathic sensations - Protopathic sensations are the crude sensations
i. Pressure sensation
ii. Pain sensation
iii. Temperature sensation with a wider range, i.e. above 40°C and below 25°C.

17. FROM FACE

18. 3. Deep sensations - Deep sensations are sensations arising from deeper structures
beneath the skin and visceral organs..
i. Sensation of vibration or pallesthesia
ii. Kinesthetic sensation or kinesthesia:
a. Conscious kinesthetic sensation
b. Subconscious kinesthetic
iii. Visceral sensations

19. SENSORY PATHWAY

20. SENSORY FIBERS OF TRIGEMINAL NERVE
 It’s carries somatosensory information from face, teeth,
periodontal tissues, oral cavity, nasal cavity, cranial dura
mater and major part of scalp to sensory cortex. It also
conveys proprioceptive impulses from the extrinsic muscles
of the eyeball.
ORIGIN - Sensory fibers of trigeminal nerve arise from
the trigeminal ganglion situated near temporal bone.
Peripheral processes three divisions of trigeminal
nerve, namely ophthalmic, mandibular and maxillary
divisions
Central processes from neurons of trigeminal
ganglion enter pons in the form of sensory root.

21. TERMINATION OF TRIGEMINAL NERVE
After reaching the pons, fibers of sensory root divide into two
groups, namely descending fibers and ascending fibers
Descending fibers - terminate on primary sensory nucleus and
spinal nucleus of trigeminal nerve.
Primary sensory nucleus is situated in pons.
Spinal nucleus of trigeminal nerve is situated below the primary
sensory nucleus and extends up to the upper segments of spinal cord
Ascending fibers - sensory root terminate in the mesencephalic
nucleus of trigeminal nerve, situated in brainstem above the level of
primary sensory nucleus

23. CENTRAL CONNECTION
primary sensory nucleus
spinal nucleus of trigeminal nerve trigeminal lemniscus terminate in thalamus
 From thalamus, the fibers pass via superior thalamic radiation and reach the somatosensory
areas of cerebral cortex
Primary sensory nucleus and Spinal nucleus of trigeminal nerve
sensations of touch, pressure, pain and temperature
 Fibers from mesencephalic nucleus form the trigeminocerebellar tract that enters
spinocerebellum superior cerebellar peduncle of the same side.
 This nucleus conveys proprioceptive impulses from facial muscles, muscles of mastication
and ocular muscles.

24. LEMNISCUS
Lemniscus or fillet is the prominent bundle of sensory nerves in brain.
Lemniscus is of four types:
1. Spinal lemniscus formed by spinothalamic tracts in medulla oblongata
2. Lateral lemniscus formed by sensation of hearing from cochlear nuclei to
inferior colliculus and medial geniculate body
3. Medial lemniscus formed by nucleus cuneatus, nucleus gracilis
4. Trigeminal lemniscus carries general senses from head, neck, face, mouth,
eyeballs and ears.

25. EFFECT OF
DISORDER
OF
SENSORY
PATHWAY
APPLIED
PHYSIOLOGY

26. SOMATOMOTOR SYSTEM
Motor activities are divided into two types:
1. Activities of skeletal muscles, which are involved in
posture and movement
2. Activities of smooth muscles, cardiac muscles and
other tissues, which are involved in the functions of
various visceral organs.
MOTOR ACTIVITY OF BODY
Voluntary(
skeletal)
Involuntaryt
issue/ANS
Controlled by
somatomotor nerve
fiber
Constituted by
sympathetic and
parasympathetic

27. SOMATOMOTOR SYSTEM
 Movements of the body depend upon different groups of skeletal
muscles.
1. Execution of smooth, precise and accurate voluntary movements
2. Coordination of movements responsible - skilled activities
and maintenance of posture and equilibrium
 The execution planning, coordination and adjustments of movements
of the body are under the influence of different parts of nervous system,
which are together called motor system.
Sensory system of the body also plays a vital role in the control of
movements.

28.  Coordination and control of movements initiated by
cerebral cortex depends upon two factors:
1. Feedback signals from proprioceptors in muscle
and other sensory receptors
2. Interaction of other parts of brain such as brainstem,
cerebellum and basal ganglia
 the motor system includes spinal cord and its nerves, cranial nerves, brainstem, cerebral
cortex, cerebellum and basal ganglia.

29. „3.FROM VISCERA
• Pain sensation from thoracic and abdominal viscera is transmitted by sympathetic
(thoracolumbar) nerves.
• Pain from esophagus, trachea and pharynx is carried by vagus and glossopharyngeal nerves
• Pain from visera is unpleasant, poorly localized…
• causes ; Ischemia
Chemical Stimuli
Spasm and Over distention of hollo organ
4. FROM PELVIC REGION
• Pain sensation from deeper structures of pelvic region is conveyed by sacral parasympathetic
nerves.

30. REFERRED PAIN
• Referred pain is the pain that is perceived at a site adjacent to or away from the site of origin.
• Deep pain and some visceral pain are referred
• Superficial pain is not referred
Example of referred pain;
1. Cardiac pain is felt at inner part of left arm and left shoulder
2. Pain in ovary is referred to umbilicus
3. Pain from testis is felt in abdomen
4. Pain in diaphragm is referred to shoulder
5. Pain in gallbladder is referred to epigastric region
6. Renal pain is referred to loin.

31. MECHANISM OF REFERRED PAIN
• According to dermatomal rule, pain is referred to a structure,
which is developed from the same dermatome from which the
pain producing structure is developed.
• The heart and inner aspect of left arm originate from the
same dermatome. So, the pain in heart is referred to left arm.
NEUROTRANSMITTERS INVOLVED IN PAIN
SENSATION
Glutamate and substance P are the neurotransmitters
secreted by pain nerve endings.
Aδ afferent fibers – Fast pain secrete glutamate
C type Fibers – Slow Pain secrete Substance P

32. „ANALGESIC PATHWAY
1. Its arise from frontal lobe of cerebral cortex an
hypothalamus
2. These fibers terminate in the gray matter (periaqueductal
gray matter)
Terminate on:
i. Nucleus raphe magnus, situated in reticular formation of
lower pons and upper medulla
ii. Nucleus reticularis, para gigantocellularis situated in medulla
3. Reticular nuclei descend through lateral white column of
spinal cord reach the synapses of the neurons in afferent
pain pathway situated in anterior gray horn Synapses ;
i. Aδ fiber - marginal nucleus
ii. C type fiber – substantia gelatinosa of Rolando.
4. At synaptic level, analgesic fibers release neurotransmitters
and inhibit the pain transmission before being relayed to
brain.

33. GATE CONTROL THEORY
• Melzack and Wall 1965
• Most acceptable theory
• The pain stimuli transmitted by afferent pain fibers are blocked by gate mechanism
located at the posterior gray horn of spinal cord. If the gate is opened, pain is felt.
If the gate is closed, pain is suppressed.
Briefly, Information – the presence of wound – CNS – Small peripheral nerves

34. Mechanism of Gate Control at Spinal Level
1. When pain stimulus is applied on any part of body, besides pain receptors, the receptors of
other sensations such as touch are also stimulated
2. when all this stimulus reach the spinal cord through posterior nerve root, the fibers of
sensation (posterior column fibers) send collaterals to the neurons of pain pathway, i.e. cells
of marginal nucleus and substantia gelatinosa
3. Impulses of touch sensation passing through these collaterals inhibit the release of
glutamate and substance P from the pain fibers
4. This closes the gate and the pain transmission is blocked

35. GATE CONTROL THEORY

36. Role of Brain in Gate Control Mechanism
According to Melzack and Wall, brain also plays some important role in the gate control
of the spinal cord as follows:
1. If the gates in spinal cord are not closed, pain signals reach thalamus through lateral
spinothalamic tract
2. These signals are processed in thalamus and sent to sensory cortex
3. Perception of pain occurs in cortical level in context of the person’s emotional status and
previous experiences
4. The person responds to the pain based on the integration of all these information in the
brain.
Thus, the brain determines the severity and extent of pain.
5. To minimize the severity and extent of pain, brain sends message back to spinal cord to
the gate by releasing pain relievers such as opiate peptides
6. Now the pain stimulus is blocked and the person feels less pain.

37. OROFACIAL PAIN
Orofacial pain is generally defined as pain originating below the orbitomeatal line, above the neck and
anterior to the ears..

38. OROFACIAL PAIN
Orofacial pain remains a prevalent and debilitating condition with significant social and
economic impacts. Orofacial pain (OFP) is prevalent in the general population; around 23%, of
which 7%–11% is chronic..
OROFACIAL PAIN
ACUTE
CHRONIC
TEETH
SUPPORTING
STRUCTURE
1.DENTAL CARIES
2.BEOKEN TOOTH
3.TOOTH ABRASION
PERIODONTAL
AND GINGIVAL
DENTAL
SENSITIVITY
1.MUSCULOSKELETAL
2.NEUROVASCULAR
3.NEUROPATHIC

39. HOW TO DIAGNOSE – TAKING THROUGH HISTORY
2. Medical history
– physical disorders or disease
systemic arthritis or other
musculoskeletal or rheumatologic
conditions
– Sleep disorders and sleep-related
breathing disorders
– Previous treatments, surgeries, and/
or hospitalizations
– Trauma to the head and face
– Medications
– Alcohol and other substances of
abuse
1. Chief complaint(s) and history of
present illness
– Date and event of onset
– Location
– Quality
– Intensity
– Duration
– Frequency
– Remissions or change over time
– Modifying factors (alleviating,
precipitating, or aggravating)
– Previous treatment results

40. 3. Dental history
– Current or preexisting relevant physical
disorders or diseases
– Previous treatments, including the
– History of trauma to the head and
patient’s attitude toward treatment
neck (including iatrogenic trauma)
– Parafunctional history, both awake
and asleep
4. Psychosocial history
– Social, behavioral, and
psychologic
issues
– Occupational, recreational, and
family status
– Litigation, disability, or secondary
gain issues

41. CLASSIFICATION OF
OROFACIAL PAIN
TMD – temporomandibular disorders,
TAC – trigeminal autonomic cephalalgias
SOURCE: Joanna M. Zakrzewska

42. MUSCULOSKELETAL DISORDER

43. TEMPOROMANDIBULAR DISORDER
• The TMJ is technically considered a
ginglymoarthrodial joint because each TMJ
provides for both hinging or rotation movement in
one plane (a criterion for a ginglymoid joint)
• For gliding or translation movements (a criterion
for an arthrodial joint)
DEFINITION ;
• TMDs encompass a group of musculoskeletal and
neuromuscular conditions that involve the TMJs,
the masticatory muscles, and all associated tissues,

44. • They have been identified as a major cause of nondental pain in the orofacial region.
• The most frequent presenting symptom is pain, usually localized in the muscles of mastication
or the preauricular area. Chewing or other mandibular activities usually aggravate the pain
• TMJ Sounds are most frequently popping, clicking, grating or crepitus
• Nonpainful masticatory muscle hypertrophy and abnormal occlusal wear associated with oral
parafunction such as bruxism (eg, clenching and grinding) may be related problems

46. • Factors that may cause the onset of TMDs are called initiating factors,
• Factors that increase the risk of TMDs are called predisposing factors,
• Factors that interfere with healing or enhance the progression of TMDs are called perpetuating
factors,
• Not a single etiologic factor or a unique theoretical model that can explain the onset of TMD
• Trauma to any component of the masticatory system can spontaneously initiate loss of
structural integrity and alter function, so reducing the adaptive capacity in the system

47. SYMPTOMS ;
• Clicking
• Limitation of movement – full-open locking, partial open locking,
• Momentary hesitation in opening
• Sudden inability to fully close the teeth
• Crepitus.
• TRAUMA ;
DIRECR sudden and usually isolated blow to the structures
INDIRECT a sudden blow but without direct contact To the affected structures
MICROTRAUMA the result of prolonged, repeated force over time

48. •TMJ DISORDERS
1. Joint pain ; A. Arthralgia B. Arthritis
2. Joint disorders ;
A. i. Disc displacement with reduction
ii. Disc displacement with reduction with intermittent locking
iii. Disc displacement without reduction with limited opening
iv. Disc displacement without reduction without limited opening
B. Other hypomobility
i. Adhesions/adherence
ii. Ankylosis
a. Fibrous ankylosis
b. Osseous ankylosis
C. Hypermobility disorders
i. Subluxation
ii. Luxation
a. Closed dislocation b. Recurrent dislocation c. Ligamentous laxity

49. 3. Joint diseases ;
A. Degenerative joint diseases, i. Osteoarthrosis ii. Osteoarthritis
B. Condylysis
C. Osteochondritis dissecans
D. Osteonecrosis
E. Systemic arthritides (rheumatoid arthritis)
F. Neoplasm
G. Synovial chondromatosis
4. Fractures ;
A. Closed fracture of condylar process B. Closed fracture of subcondylar process
C. Open fracture of condylar process D. Open fracture of subcondylar process
5. Congenital/developmental disorders
A. Aplasia
B. Hypoplasia
C. Hyperplasia

50. •Masticatory muscle disorders
1.Muscle pain limited to the orofacial region
A. Myalgia
i. Local myalgia
ii. Myofascial pain
iii. Myofascial pain with referral
B. Tendonitis
C. Myositis
i. Noninfective ii. Infective
2. Contracture
A. Muscle B. Tendon C. Spasm
3. Hypertrophy
4. Neoplasms
A. Jaw i. Malignant ii. Benign
B. Soft tissues of head, face, and neck i. Malignant ii. Benign

51. 5. Movement disorders
A. Orafacial dyskinesia
i. Abnormal involuntary movements
ii. Ataxia, unspecified muscular incoordination
iii. Subacute, due to drugs; oral tardive dyskinesia
B. Oromandibular dystonia
i. Acute, due to drugs
ii. Deformans, familial, idiopathic, and torsion dystonia
6. Masticatory muscle pain attributed to systemic/central disorders
A. Fibromyalgia
B. Centrally mediated myalgia
Masticatory muscle disorders 1. Headache attributed to TMDs
Associated structures 1. Coronoid hyperplasia

52. SOURCE: Joanna M. Zakrzewska

53. • Panoramic radiography is considered standard as a first stage evaluation;
• OPG - differential diagnosis of tooth pathology and other bony pathology,
• CT may be warranted if panoramic radiography positive
• MRI for disc pathology – its use should be balanced with recognition that
displacements with reduction,
• Other tests advocated for diagnosis, such as EMG and jaw movement studies, have
insufficient supporting evidence to warrant their use

54. • SELF CARE - Use of cold and hot packs
- Automassage
- Various jaw exercises
- Over the counter pain medications
- Education about parafunctional jaw activities
- General relaxation skills.
• PHARMACOLOGICAL - NSAIDs
Benzodiazepines
Cyclobenzaprine
Tricyclic antidepressants
Gabapentin

55. • Oral appliances - Hard or soft stabilization splints
• Occlusal treatments - Occlusal adjustment
• Physical medicine - Acupuncture, Low level laser, TENS ( Transcutaneous Electric Nerve
Stimulation therapy ) , ultrasound, thermal remedies,
jaw manipulation
• Surgery - Arthrocentesis, arthroscopic surgery, open joint surgery

56. CLUSTER HEADACHE

57. INTRODUCTION
• CH is the archetypal TAC with severe pain and major autonomic activation
• Autosomal dominant
• Ages of 20–29 years
• seems to affect men more than women
• Unilateral pain
• Pain in CH is usually periorbital or ocular, but varies. In “upper CH” the forehead, temporal,
and parietal regions are involved
• In “lower CH” the temporal and suboccipital regions are affected with radiation to the teeth,
jaws, neck, and cheeks
• Patients may describe pain as a “hot poker” or a “stabbing” feeling in the eye

58. • Last 15–180 min and may occur up to 8/d. Restlessness.
• Up to 4% of patients with pituitary tumors have CH.
• Pain is most usually accompanied by at least one ipsilateral autonomic
sign; conjunctival injection/lacrimation, nasal congestion/rhinorrhea,
eyelid edema, forehead/facial sweating, miosis, and ptosis.
• suffer from obstructive sleep apnea

59. MANAGEMENT OF CLUSTER HEADACHE
• Pharmacologic treatment may be abortive, transitional or preventative.
• Abortive symptomatic relief – rapidly attained oxygen inhalation
(Subcutaneous sumatriptan) medically fit
• Rapid transitional prophylaxis corticosteroids limited and selected patient
• CH, prophylaxis is usually with verapamil, and topiramate as second-line therapy

60. PAROXYSMAL HEMICRANIA
• PH is rare with an estimated prevalence of 2–20 percentage..
• Mean age of onset is usually 34–41 years
• 20% of PHs behave episodically
• PH is a unilateral, severe orbital, or periorbital pain.
• The vast majority of attacks do not change sides, but strong pain may cross the midline
and very rarely becomes bilateral.
• It may occur in temporal, periauricular, maxillary, and rarely occipital areas. Referral to
the shoulder, neck, and arm is quite common.
• Patients and has led to the term “modified cluster pattern.” About one-third of PH
patients report nocturnal attacks that wake

61. Quality is mostly sharp but may also be throbbing, stabbing, or boring and its severity
excruciating
The most common are ipsilateral lacrimation, nasal congestion, conjunctival injection, and
rhinorrhea. In patient series one “migrainous feature” was reported by nearly 90% of PH cases..
MANAGEMENT :
Indomethacin should be initiated for 3 days at 75mg followed, If needed, by 150 mg for a
further 3 days is recommended as trial therapy
Prognosis in PH is good and long-term remission has been reported

62. SHORT LASTING, UNILATERAL, NEURALGIFORM HEADACHE ATTACKS
WITH CONGENITAL INJECTION AND TEARING (SUNCT)
• SUNCT syndrome is a unilateral headache/facial pain characterized by brief paroxysmal
attacks accompanied by ipsilateral local AS, usually conjunctival injection and lacrimation
• unilateral pain, usually ocular/periocular, but may involve most head areas. Pain spreading
across the midline or changing sides is rare.
• Slightly more common in males, SUNCT occurs in siblings and has been presented as
“familial SUNCT.
• Quality is usually stabbing or pulsating

63. • These may be single attacks, groups of a number of stabs/attacks, or a “saw-tooth”
pattern with numerous stabs/attacks lasting minutes
• Pain in SUNCT triggered by light mechanical stimuli in the areas innervated by the trigeminal
nerve,
• MANAGEMENT:
Lamotrigine (currently considered drug of choice: 100–300mg/d), gabapentin (900–2700
mg/d), topiramate (50–200 mg/d)

64. HEMICRANIA CONTINUA
• Now considered a part of TAC family
• HC seems to be often misdiagnosed and mistreated; time to correct diagnosis may reach
five years.
• HC is a unilateral headache
• That has been present for >3 months and daily and continuous.
• Pain is diffuse around half the head and face primarily in the frontal, temporal, and
periorbital regions
• The most common signs present in 30%–40% of patients are photophobia, nausea,
conjunctival injection, phonophobia, and tearing.
• A sandy sensation in the eye has been reported

65. • During exacerbations up to 60% of patients display features
such as photophobia, phonophobia, nausea, and more rarely
vomiting
• Rarely (15%–18%) nasal stuffiness or rhinorrhea, vomiting, or
ptosis may also be reported
• MANAGEMENT :
Indomethacin is totally effective and relieves
pain within hours or 1–2 days..
Piroxicam-beta-cyclodextrin is a good alternative
for selected cases

66. NEUROPATHIC OROFACIAL PAIN

67. • Neuropathic pain is initiated by a primary lesion or
dysfunction of the nervous system.
• Neuropathic pain may be triggered by local trauma or
systemic disorders, such as diabetes, that affect structures
• Neuropathic OFP includes a number of clinical entities;
• The most common are TN, painful posttraumatic
neuropathies, and burning mouth syndrome (BMS).
• More rarely facial post herpetic neuropathy, central
poststroke pain, and glossopharyngeal neuralgia (GN) are
encountered.

68. TRIGEMINAL NEURALGIA
• TN is an excruciating, short-lasting, unilateral facial
pain
• The most common is the classical unrelated to
pathology and most probably caused by
neurovascular compression of the trigeminal nerve
root
• The vast majority (>85%) of TN patients are
diagnosed with classical TN (CTN). Recent evidence
suggests that most cases of CTN result from the
compression of the trigeminal nerve root by a
vascular malformation

69. • Characterized by paroxysmal, excruciating pain in trigeminal dermatomes, most
commonly in both the maxillary and mandibular branches of the trigeminal nerve
• CTN is strictly unilateral and pain radiation is generally within the dermatome of the
origin
• Bilateral cases are extremely rare and begin unilaterally preceding the onset of
contralateral pain by years
• Nature of Pain is paroxysmal, shooting, sharp, piercing, stabbing, or electrical.
• Attacks begin and end abruptly, lasting from a fraction of a second up to 2 minutes.
Longer attacks, increasing with disease duration, have been reported.

70. • Pain paroxysms are usually accompanied by spasm of the ipsilateral facial muscles (hence the
name tic douloureux).
• Typically pain is precipitated by light, innocuous touch at sites called “trigger areas.” Many
attacks are spontaneous, and trigger areas are not always clinically identifiable..
• Trigger factors such as noise, lights, and stress may also induce pain..
• Latency refers to the short period of time between stimulation of a trigger area and pain onset.
• A refractory period occurs following an attack and during this time pain may not be initiated

71. MANAGEMENT :
• Carbamazepine (100–200 mg twice daily of the slow release formulation)
• Oxcarbazepine (300 mg × 3/d )
• Baclofen (5–10 mg × 3/d )
• Gabapentin (200–300 mg × 2/d )
• Lamotrigine (25 mg × 1–2/d )
• Surgical (best prognosis in typical TN early after onset):
Peripheral level
Ganglion level
Trigeminal root level

72. GLOSSOPHARYNGEAL NEURALGIA
• GN is similar to TN and its characterized by a milder natural history with the majority of
patients going into remission.
• Due to its location and features, GN is a difficult diagnosis and adequate treatment is often
delayed for years
Two main branches;
Tympanic
( auricular )
Pharynx
Pain predominant in Ear, may radiate to
pharynx
Pharynx and posterior tongue are
involved
Inner ear, angle of the Mandible, Eye, Nose,
Mandible, Shoulder, Tip of tongue

73. • GN is a paroxysmal, unilateral, severe pain that is sharp, stabbing, shooting, or lancinating
• GN attacks are stereotyped within patients.
• Trigger areas are located in the tonsillar region and posterior pharynx, and these display a
refractory period.
• Swallowing, chewing, talking, coughing and/or yawning, sneezing, clearing the throat, and
rubbing the ear activate these areas
MANAGEMENT:
• Carbamazepine is usually successful and is the favored medication. Alternatives include
baclofen, oxcarbazepine, gabapentin, lamotrigine, and phenytoin

74. BURNING MOUTH SYNDROME
• BMS is a poorly understood pain condition that is most probably
neuropathic. The condition is also known as stomatodynia and is
characterized by a burning mucosal pain with no significant physical
signs and is common in post menopausal women.
• BMS
“Primary” or idiopathic BMS cannot be attributed to any
systemic or local cause
“Secondary BMS” (SBMS) local or systemic pathological
conditions.
• The primary location of the burning complaint is the tongue, usually
the anterior 2/3.
• Usually more than one site is involved and in addition to the tongue,
hard palate, lips, and gingivae are frequently involved.

75. • Common aggravating factors include personal stressors, fatigue, and specific foods (acidic, hot,
or spicy).
• More than two-thirds of the patients complain of altered taste sensation (dysgeusia)
accompanying the burning sensation, in many cases described as a spontaneous metallic taste..
• Local factors and diseases known to induce SBMS include oral candidiasis, lichen planus, and
allergies.
• Systemic disorders that induce SBMS include hormonal changes, deficiencies of vitamin B12,
folic acid or iron, diabetes mellitus, side effects of medications, and autoimmune diseases.
• MANAGEMENT: Topical clonazepam (1 mg; “suck and spit” 3 times daily)
Cognitive behavioral therapy
Alpha-lipoic acid (600 mg daily)
TCAs ( TRICYCLIC ANTIDEPRESSANTS )

76. PAINFUL POSTTRAUMATIC TRIGEMINAL
NEUROPATHY
• PTTN is novel and has recently been adopted by the
International Headache Society (HIS)
• Chronic pain following negligible nerve trauma such as
root canal therapy or following considerable injury to
nerve bundles, such as in fractures of the facial skeleton..
• Onset of neuropathic pain and its characteristics vary from
patient to patient

77. • Such variability is probably due to a combination of environmental, psychosocial, and genetic
factors.
• The presence and duration of pain in the tooth, tenderness to percussion, Female gender,
previous painful treatment in the orofacial region, and concomitant chronic pain issues.
• It’s are all the possible risk factors for the development of chronic pain following successful
root canal therapy
• Painful neuropathies may present with a clinical phenotype involving combinations of
spontaneous and evoked pain and of positive (e.g., dysesthesia) and negative symptomatology
(e.g., numbness).

78. • Pain is overwhelmingly unilateral and occurs in the area of injury, or at the distal dermatome of
an injured nerve.
• Most cases are continuous, but some report superimposed paroxysmal pain attacks. Less
frequently there may be short-lasting pain with associated mechanical trigger areas, mimicking
TN..
• MANAGEMENT : Topical lidocaína
TCAs
Gabapentin
Opioids

79. DENTOALVEOLAR ORAL MUCOSAL PAIN

80. KEY POINTS ;
- Dental causes of orofacial pain are common in the population
- Different pain qualities exist in the stages of dental pulpitis
- Dental causes of pain can be identified through detailed clinical examination and radiographs
- Co-existing dental pathologies are important to identify
- Acute and chronic pain states may be concurrent
- Maxillary sinusitis has several diagnostic features that enable rapid diagnosis without the need
for imaging
- Salivary gland diseases can present without chronic pain

81. INTRODUCTION
• Dental and oral disease states are recognized as the most common pathology to afflict the
general population. Dental disease such as caries is the primary cause of patients seeking
pain relief from dental practitioners
1. TEETH ( eg; dental caries, stimulation of dental pulp )
2. ADJACENT SOFT TISSUE OF GINGIVA AND ORAL MUCOSA ( eg; dental abscess and oral
ulceration
3. BONE AND OROFACIAL PATHOLOGY ( eg; jaw fracture and infection such as
osteomyelitis

82. PAIN MECHANISM OF DENTAL PAIN
Two clinical descriptions of pulpal pain;
FIRST clinical pain - short, sharp, brief pain that is induced by the rapid fluid flow within dentinal
tubules from stimuli such as cold, heat, air, drilling and osmotic changes. Typically this pain is
the physiological ‘helpful’ warning response in order to prevent on going noxious stimuli
damaging the pulp.
SECOND clinical pain - slow, dull, aching, poorly localized pain indicating the presence of
inflammatory mediators on nerve fibers and established pulpal inflammation. Pain of this type
often require the Cartesian ‘amputation’ approach to pain relief

83. • Brief, sharp pain followed by prolonged, dull ache that eventually dissipates (potentially
reversible pulpitis)
• Increased pain intensity to noxious stimuli and dull ache that is constant or recurrent over
days and weeks (potentially irreversible pulpitis)
• Constant, severe, unrelenting toothache (acute pulpitis)
• No pain response to noxious stimulus (non-vital tooth)
• Periapical infection in bone and tenderness and pain to percussion.
There is usually minor pain where adequate discharge of pus is occurring from a sinus tract, or
severe pain where there is little drainage present.

84. SPECIFIC CAUSES OF PAIN
1. Dental caries
2. Dental Abscess
3. Cracked tooth syndrome
4. Sensitivity from Dental restoration
5. Exposed cementum/ Dentin
6. Premature contact ( High bite )
7. Alveolar Osteitis ( Dry Socket )
8. Gingivitis and Periodontitis
9. Pericoronitis
10. Post endodontic surgery pain

85. INVESTIGATION OF DENTAL PATHOLOGY
1. Vitality test
2. Percussion
3. Palpation
4. Radiographs
5. Selective Anesthesia
6. Bite Testing
7. Mobility
8. Transillumination

86. ORAL ULCERATION
Traumatic
(a) Morsicatio buccarum (cheek biting)
(b) Other traumatic self induced (lip, tongue,
hot food etc)
(c) Cotton roll ulcer
(d) Factitial ulcer
Iatrogenic
(a) Traumatic (self, surgical instrument)
(b) Aspirin burn
(c) Contact stomatitis (amalgam allergy)
(d) Radiation mucositis
(e) Lichenoid drug reaction (gold,
antihypertensives)
Idiopathic
(a) Aphthous – minor, major, herpetiform

87. Autoimmune
(a) Behcet’s syndrome
(b) Erythema migrans
(c) Lupus erythematosus (discoid and systemic)
(d) Pemphigus vulgaris
(e) Mucous membrane pemphigoid
(f) Lichen planus
(g) Erythema multiforme
(h) Crohn’s disease
Infection (local and systemic)
(a) Primary herpetic gingivostomatitis
(b) Recurrent herpes stomatitis
(c) Chronic herpes simplex
(d) Herpes zoster
(e) Herpangina
(f) Tuberculosis
(g) Syphilitic chancre, gumma
(h) Histoplasmosis, blastomycosis
(i) Hand, foot and mouth disease

88. BONE AND OROFACIAL PATHOLOGY
Maxillary sinusitis
A ‘constant burning pain with zygomatic and dental tenderness from the inflammation of the
maxillary sinus’
CAUSES:
Patients with prolonged viral upper respiratory tract infection (common cold) may go on to
develop sinusitis.
Bacterial sinusitis tends to be present if symptoms have lasted more than 7 days. The most
commonly implicated bacteria are the Streptococcus pneumoniae and Hemophilus influenzae.
It can occur after a dental infection or after treatment to upper premolar or molars especially
extractions.

89. CLINICAL FEATURE
• Maxillary tooth or facial pain (especially unilateral)
• Purulent nasal discharge
• Unilateral maxillary sinus tenderness
• Worsening of symptoms after initial improvement.
INVESTIGATION
• Maxillary sinus radiography and CT scanning will be
positive in 90%
of bacterial sinusitis
EXAMINATION
• Intra-orally the upper teeth on the affected area will
be tender to
percussion.
• The sinus can be trans illuminated by putting a
torch in intra-orally.

90. MANAGEMENT This should begin with symptomatic treatments
- Decongestants
- Analgesics
- Alpha-adrenergic agents
- Mucolytic agents
- Antihistamines
- Corticosteriods
- Proteolytic agents.
The indications for antibiotic use include;
- Moderately severe symptoms and acute bacterial
sinusitis
- Symptoms lasting more than 7 days
- Pain of face or teeth
- Purulent nasal secretions
- Severe symptoms regardless of duration

91. SALIVARY GLAND PATHOLOGY
• Tumor's, duct blockage and subsequent infection also elicit pain in the trigeminal nerve.
• Salivary stones are most frequent in the submandibular gland. The pain is intermittent and
characteristically occurs just before eating.
• There may be associated tenderness of the involved salivary gland.
• Bimanual palpation will enable the
stone to be palpated, if it is in the duct
and salivary flow from the duct will be
slow or absent
MANAGEMENT:
Antimicrobial and analgesic
Decongestants
Mucolytics

92. OVER VIEW OF DENTAL AND MUSCULOSKELETAL PAIN

93. ZAKRZEWKA, J.M “ DIFFERENTIAL DIAGNOSIS OF FACIAL PAIN AND GUIDELINES
FOR MANAGEMENT”. BRITISH JOURNAL OF ANAESTHESIA 111 (1): 95–104 (2013)

94. PUBLIC HEALTH SIGNIFICANCE
• Over the past few decades, health in India is gaining less importance and oral health, the
least.
• Oral diseases are still a burden for developing countries such as India, especially among the
rural masses.
• Prevalence of oral diseases is very high in India with dental caries and periodontal disease as
the two most common oral diseases.
• It is well documented that there is an association of oral health with various systemic
conditions such as diabetes, cardiovascular disorders, pregnancy, and its impact on quality of
life.

95. • Orofacial pain and loss of sensorimotor functions limit food choices and the pleasures of
eating, restrict social contact, and inhibit intimacy.
• The main role of public health dentistry is to understand the distribution and determinants of
oral diseases and to educate, motivate, and promote oral health in diverse populations.
• Over the past decades, research and practice in dental public health (DPH) have been
concentrated upon the two major problems – dental caries and periodontal disease
• According to estimates, about 50% of school children are suffering from dental caries and
more than 90% of adults have periodontal diseases.

96. • This increase in prevalence of dental diseases is observed parallel to the rapid nutrition
transition in the recent decades and may also be one of its consequences.
• India is called as the “oral cancer capital” of the world attributed to its high intake of both
smoked and smokeless tobacco products, strongly associated with oral neoplasms.
• Most of these highly prevalent oral diseases are largely preventable and can be reduced
through various health promotion and preventive measures.
• Most of the above mentioned oral disease and conditions results in painful consequence's

97. CONCLUSION
• Patients will often visit their primary medical/DENTAL practitioner with orofacial pain
complaints.
• Hence, it is important to recognize and have an understanding of these conditions to
properly evaluate and potentially manage these disorders.
• If the practitioner is uncertain or uncomfortable with these conditions, then patient referral
to a knowledgeable health care practitioner should be considered for further evaluation and
management.

98. REFERENCE
1. Sembulingam K, Sembulingam prema. Essentials of Medical Physiology. Jaypee Brothers
Medical Publishers(P)LTD “2012” (6): 838-842.
2. Zakrzewska JM. Differential diagnosis of facial pain and guidelines for management. British
journal of anaesthesia. 2013 Jul 1;111(1):95-104.
3. Gambhir RS, Kaur A, Singh A, Sandhu AR, Dhaliwal AP
. Dental public health in India: An
insight. Journal of Family Medicine and Primary Care. 2016 Oct 5(4):747.
4. Balasubramaniam R, Klasser GD. Orofacial pain syndromes: evaluation and management.
Medical Clinics. 2014 Nov 1 98(6):1385-1405.
5. De Leeuw R, Klasser GD, editors. Orofacial pain: guidelines for assessment, diagnosis, and
management. Chicago: Quintessence; 2008.

99. 6. Michael Glick, “ Burket’s Oral Medicine”. People’s medical publishing house
“2015”(12):(309-322)
7. Leeuw D Reny, Klasser D Gary, “ Guideline for Assessment Diagnosis and
management”. The American Academy of Orofacial pain “2018”(6):(1-143)
8. Zakrzewska M Joanna “orofacial pain”. United state by oxford University press inc., New
york “2009” (1):(11-67)
9. Moule J Alex, Hicks M Lamar, “ Diagnosing Dental and Orofacial Pain: A clinical Manual”,
“2017”:(61-79)