Orofacial pain is the field of dentistry devoted to the diagnosis and management of complex facial pain and oro motor disorder Orofacial pain is the term covering any pain in the mouth , Jaw and face

1. Orofacial pain
Done by:-
Dr. Sarah Abd Al-salam
Supervisied by:-
Dr.Rabeha

2. Pain:- Is unpleasant sensory and emotional
experience associated with actual or potential
tissue damage

3. Classification of pain by its origin
 Nociceptive pain ( somatic pain):- It caused by
stimulation of peripheral nerve that respond only to the
stimuli approaching or exceeding the harmful
intensity(nociceptor) and may be classified according to
the mode noxious stimulation
The most common categories are :-
 Thermal ( heat, cold)
 Mechanical ( crushing, tearing, shearing )
 Chemical ( chemicals released during inflammation)

4.  Neuropathic pain:- It caused by damage or disease
affecting any part of the nervous system involved in the
body feeling
It often described as burning, tingling, electrical, stabbing
or pins or needles

5.  psychogenic pain:- It is pain caused increased or
prolonged by mental, emotional or behavioral factors
Headache,back pain and stomach pain are sometimes
diagnosed as psychogenic pain

6. Orofacial pain
It is a general term covering any pain which is felt in the
mouth , jaw and the face
It use to describe the pain in the region above the neck,
infront of the ears and below the orbitomental, as well as
pain in the oral cavity

7. Anatomical consideration

8. How we can feel the orofacial pain

9. The causes of orofacial pain may be :-
 Dental
 TMJ dysfunction
 Facial bone disease ( infective, traumatic and neoplastic )
 Pathology in related structures ( Salivary gland, sinus and
nasepharyngeal )
 Neurological disorder ( trigeminal neuralgia, glossopharyngeal ,
occipital and post herpetic neurologia )
 Vascular ( migraine, cluster headache and temporal arteritis )
 Psychogenic pain ( atypical facial pain , atypical odontalgia and
burning mouth syndrome )
 Refferred pain ( MI and angina )

10. Diagnosis of orofacial pain
The most important factors to facilitate reaching an
accurate diagnosis are
 Proper history taking
 Carful examination
The objective of diagnosis is to identify what, where, how
and why the patient complain

11. Pain history should cover :-
1. Onset of pain :- Whether is sudden or gradual
2. The duration of pain
3. Progression of pain
4. Exact location of pain
5. Frequency of pain
6. Time distribution of the pain ( day, night, random )
7. Description of the pain ( stabbing, burning, constant,
paroxysmal in nature)
8. Severity of pain ( according to patient’s experience )
9. Associated complain (eg nausea, vomiting,
fever…etc)
10. Stimulating factor ( stress,tiredness, certain food
product)
11. Alleviating factor ( drugs, sleep, rest )
12. Radiation of pain to other location

12. Clinical examination
The clinical examination is very important in diagnosing the
patient problem the clinician should examine odontogenic and
other related structures:-
1. Status of the teeth
2. Vitality of the pulp
3. Occlual relationship
4. The oral mucosa
5. Muscle of mastication
6. TMJ
7. Salivary gland
8. Paranasal sinus
9. Cranial nerve function

17. Causes of orofacial pain
 Dental

23.  TMJ

24.  Facial bone disease
• Osteomylities
• Paget’s disease

25.  Conjectivities
Rinities

26.  Neurological disorder :-
 Trigeminal neuralgia
 Glossopharyngeal neuralgia
 Post herpetic neuralgia
 Occipital neuralgia

27. Trigeminal neuralgia
It is a unilateral painful disorder that characterized by brief
electric shock like pains , is abrupt in onset and
termination and is limited to the distribution of one or
more division of trigeminal nerve
It provoked by talking , eating or touching specific area
called trigger zone

29. Clinical feature
Location:- The pain is unilateral with only 3% of
incidences
Character:- Electric shock like, shooting stabbing or sharp
in quality
Duration:- Each attack last between a few seconds and 2
minute but can rapidly followed by new attack

30. Investigation

32. Treatment
 Carbamazepine (Tegrol):- Is the most common used
drug and is an effective therapy for greater than 85% of
newly diagnosed patient the drug is administered in
slowly increasing dose
Up to 80% of patients are relieved partly or completely by
carbamazepine , but minor side effect are common such as
drowsiness, dryness of the mouth, diarrhea and vomiting
and all are dose related . A small dose therefore given and
gradually raised

33.  Baclofen and Gabapentin can be used for the patient
who don’t respond to carbamazepine
 Surgical treatment:- In cases in which drug therapy is
ineffective or in which the patient is unable to tolerate
the side effect surgical therapy is indicated the simplest
option is cryotherapy to the trigeminal nerve if fail
cryotherapy to the base of the skull if fail microvascular
decompression of the trigeminal ganglion may be
required

35. Glossopharyngeal neuralgia
This rare condition is characterized by pain similar to that of
trigeminal neuralgia but felt in the base of the tongue,
pharynx, ear and infra auricular retro mandibular area
The pain is sharp and transient is typically triggered by
swallowing, chewing or coughing it may be so severe that
the patient may be terrified to swallow their saliva and try to
keep the mouth and the tongue as completely immobile as
possible

36. Treatment
Treatment is similar to trigeminal neuralgia with good
response to carbamazepine and baclofen

37. Post-herpetic neuralgia (PHN)
Etiology and pathogenesis:- Herpes zoster shingles is
caused by reactivation of the latent varicella zoster virus
infection that result in both pain and vesicular lesion along
the course of the affected nerve

38. Clinical manifestations
Patient with post herpetic neuralgia experience persistent
pain, paresthesia, hyperesthesia and allodynia months to
years after the zoster lesion have healed the pain is often
accompanied of sensory deficit

39. Treatment
The best therapy of PHN is prevention
 The use of antiviral drugs particularly famciclovir along
with short course of systemic corticosteroid during the
acute phase of the disease
 The use of tricyclic antidepressant during the acute
phase of herpes zoster

40. Treatment include topical and systemic drug therapy
Topical include:- the use of topical anesthesia such as
lidocaine
Systemic include:-
 The use of tricyclic antidepressant such as amitriptyline
 Gabapentin if the patient can’t tolerate the side effect of
tricyclic antidepressant
 Carbamazepine or phenytoin for the patient who
undergo episodes of shooting pain

41. Bell’s palsy
It is a condition that causes a temporary weakness or
paralysis of the muscle in the face ,it can occur when the
facial nerve that control your facial muscles become
inflamed, swollen or compressed by blood vessel

42.  The condition causes one
side of your face to droop
or become stiff you may
have difficulty smiling or
closing your eye on the
affected side in most
cases it is temporary and
symptoms usually go
away after a few weeks

43. Etiology
Etiology is unknown ,but many medical researchers
believe its most likely triggered by viral infection
The viruses and bacteria that have linked to the
development of Bells palsy include:-
 Herpes simplex virus
 HIV which damage the immune system
 Herpes zoster virus
 Epstein Barr virus

44. Treatment
 A short course ( 2-3 week) of high dose steroid therapy
is beneficial to reduce inflammation
 A cyclovir reduce the duration of the pain
 Ibuprofen or acetaminophen can help to relieve mild
pain
 eye drop

45. Home treatment
 An eye patch (for dry eye)
 A warm ,moist towel over your face to relieve pain
 Facial message
 Physical therapy exercise to stimulate your facial
muscle

46. Occipital neuralgia
It is a rare neuralgia in the distribution of the sensory
branches of cervical plexus ( most commonly in the neck
and occipital region)
The most common causes are trauma, neoplasms and
infection in the distribution of affected nerve
Treatment:- Corticosteroid and blocking of the nerve with
local anesthesia

47.  Vascular pain:-
 Migraine
 Cluster headache
 Temporal arteritis

48. Migraine
It is an severe unilateral throbbing headache that is
frequently accompanied by nausea and vomiting which
may occasionally cause pain of the face and jaws
It may be triggered by foods such as nuts,chocolate, red
wine, stress, sleep deprivation or hunger and it is more
common in wome

49. Migraine is the most common type of the vascular
headache the patient characteristically lies down in a dark
room and tries to fall a sleep

50. Up to one third of people have an aura: typically a short
period of visual disturbance which signals that the
headache will soon occur occasionally can occur with little
or no headache following it

51. Etiology
The classic theory is that migraine is caused by
vasoconstriction of intracranial vessels( which causes the
neurologic symptoms ) followed by vasodilation ( which
result in pounding headache

52. Treatment
1. Determine common food triggers migraine
2. Minimize stress by using relaxation techniques
3. Drug therapy may used either:-
 Prophylactically to prevent migraine attack include
propranolol, verapamil . For difficult cases that not
respond for safer drugs monoamine oxidase inhibitors
such as phenelzine can be used

54.  Initial treatment for those with mild to moderate
symptoms are simple analgesic aspirin , paracetamol
and NSAID
 For those with moderate to severe pain or those with
milder symptoms who don’t respond to simple analgesic
ergotamine and sumatriptan ( are effective for both pain
and nausea can be given orally, nasally and rectally
These drugs must be use cautiously since they may cause
hypertension and other cardiovascular complication

55. Cluster headache (CH)
Is a distinct pain syndrome characterized by episodes of
severe unilateral head pain occurring chiefly around the
eye, frontal and temporal regions but may start also in the
infraorbital region ( maxilla)
80% of patients are men between age 18-40 years of age

56. The term cluster is used because the patient has multiple
headache per day for 4-6 week and then may be without
pain for months or even years

57. Clinical manifestation
The attacks are sudden, unilateral and stabbing, causing
the patient to jump, cry out or even strict object
The patient describe the pain as a hot metal in or around
the eye in contrast the behavior of migraine patient

58. Etiology
The exact causes of cluster headache is unknown , but
cluster headache , but cluster headache pattern suggest that
abnormalities in the body’s biological clock hypothalamus
play a role
Unlike migraine , cluster headache isn’t associated with
trigger such as food, hormonal change or stress
Drinking alcohol may trigger headache
Other possible triggers include the use of nitroglycerine , a
drug used to treat heart disease

59. Treatment
 An acute attack of CH can be aborted by breathing 100%
oxygen and the patients may keep an oxygen cylinder at
bedside to use at the first sign of an attack
 Injection of sumatriptan or sublingual or inhaled ergotamine
may also be effective therapy
 Lithium is effective therapy for those who can tolerate the
side effect, the patient using the long term lithium must be
monitored for renal toxicity
 other drugs are useful for preventing attack include
ergotamine, prophylactic prednisone and calcium channel
blocker

60. Temporal arteritis
It is an inflammatory disorder involving the medium sized
branches of carotid arteries the temporal artery is most
common
Etiology:- It caused by immune abnormalities that results
in inflammatory cell infiltrate in the walls of the arteries

61. Clinical manifestation
Usually affects adults above the age of 50 years .Patient
have throbbing headache accompanied by generalized
symptoms including fever, malaise and loss of appetite
Examination of the involved temporal artery reveal a
thickened pulsating tender vessel since the mandibular and
lingual arteries may involved, a throbbing pain in the jaw
or tongue may be an early sign

62.  A serious complication in untreated patient is ischemia
of the eye, which may lead to sudden blindness, these
visual problem may be prevented by early diagnosis and
quick therapy
 Laboratory abnormality include an elevated ESR and
anemia
 Most effective diagnostic test is biopsy from the
involved temporal artery

64. Treatment
Corticosteroid , typically high dose prednisone must be
started as soon as the diagnosis is suspected to prevent
irreversible blindness secondary of ophthalmic artery
occlusion
The initial prednisone dose is 40-60mg per day and the
steroid is tapered when the sign are controlled

65.  Psychogenic pain:-
 Atypical facial pain (psychogenic)
 Atypical odontalgia( psychogenic dental pain)
 Burning mouth syndrome

66. Atypical facial pain
Chronic facial pain that does not meet any diagnostic
criteria and does not respond to most treatment
 Pain is not a simple sensation, but described as
unpleasant experience
 The etiology is unknown but it could be neuropathic or
psychogenic or both

67. Clinical manifestation
 The major manifestation is a constant dull aching pain
without an apparent cause that can be detected by
examination or laboratory it occur most frequently in
women in forth and fifth decade
 The patient may report that the first onset of pain
coincided with a dental procedure or medication

68.  Patient report seeking multiple dental procedure to treat
the pain , these procedure result in temporary relief , but
the pain returns in days or weeks
 The pain may remain in one area or may migrate either
spontaneously or after surgical procedure
 Symptoms may remain unilateral or involve both
maxilla and mandibule

69. Treatment
 Patient should told the nature of disease
 Tricyclic antidepressant such as amitriptyline given in
low doses are often effective in reducing pain

70. Atypical odontalgia
 This is a less common variant of atypical facial pain
 Pain is often localized in one tooth or in a row of teeth,
which are said either to ache or to be sensitive to heat,
cold or pressure
 If no organic cause can be found and treatment is
ineffective , psychiatric assessment is needed

71. Treatment
 The symptoms should be taken seriously
 Patient should be reassured that they don’t have an
undetected life threating disease
 Consultation with other specialist such as
otolaryngologists, neurologists or psychiatrists may be
helpful
 Tricyclic anti depressant such as amitriptyline and
doxepin given in low doses
 Other recommended drug such as gabapentin
 Some clinician report benefit from topical anesthetics or
topical doxepin

72. Burning mouth syndrome
Is the term describes oral burning that has no detectable
cause ( No inflammatory or ulcerative disease of oral
mucosa )
Women experience symptoms seven times more frequently
than men particularly in postmenopausal women

74. Etiology
The cause remain unknown , but a number of factors have
been suspected including:-
 Hormonal and allergic disorder
 Anemia
 Salivary gland hypofunction
 Psychiatric abnormalities
 Depression
 Chronic low grade trauma resulting from parafunctional
habit ( Rubbing the tongue across the teeth or pressing it
on the palate

75. Clinical manifestation
 The burning symptoms don’t follow anatomic pathway
 There are no mucosal lesion or known neurologic
disorder explain the symptoms
 The tongue is the most common involvement
 The burning can be either intermittent or constant but
eating drinking or placing candy or chewing gum relief
the symptoms this in contrast with neuralgia or lesion
affect the mucosa

76. Treatment
 The patient should reassured of benign nature of the
symptoms
 Patient with severe symptoms often require drug
therapy ,tricyclic such as amitriptyline
 Burning of the tongue that result from parafunctional
habit may be relieved with the use of splint covering
the teeth or palate

77. Referred pain
 Referred pain to the mandibular region due to cardiac
ischemia MI is referred to as cardiac toothache and is
characterized by pain provocation aggravation by
physical activity
 Pain relief at rest

78. Thank you