This document outlines various causes of pain that can originate in the oral cavity and face. It discusses pain originating from tissues like mucosa, teeth, sinuses and muscles. It also covers neurological conditions that can cause facial pain like trigeminal neuralgia or migraines. For each cause, it provides details on presentation, diagnostic factors and potential treatment approaches.

2. UNPLEASANT SENSORY OR
EMOTIONAL EXPERIENCE CAUSING
ACTUAL OR POTENTIAL TISSUE
DAMAGE

3.  Pain is usually conducted via A- delta
and the C nerve fibres
 These are usually thinly myleinated or
unmyleinated
 These carry information to the higher
cortical senses where appropriate
response is generated

4.  From mucosa
1. Ulcer(apthous, traumatic)
2. Gingivitis
 From dental origin
1. Pulpitis (reversible, irreversible)
2. Periodontitis
3. Pericoronitis
 From the maxillary sinus
1. Sinusitis
 From the muscles of mastication
1. Myofascial pain dysfunction syndrome

5.  From the Temporomandibular joint
1. Arthritis(traumatic, rheumatoid)
2. TMJ derangement and disk displacement
3. TMJ dislocation
 Fractures of the facial skeleton
All fractures of mandible and midface
 Neuralgic pain
1. Trigeminal neuralgia
2. Glossopharyngeal neuralgia
3. Post herpetic neuralgia
4. Ramsay hunt syndrome
5. Neuromas

6.  Vascular pain
1. Migraine
2. Cluster headaches
3. Temporal arteritis
4. Tension headaches
 From salivary gland
1. Parotitis (viral, bacterial)
2. Salivary stones
3. tumours
 Referred pain
1. Heart
2. Eyes
3. Nose
4. Ear
5. Throat

7.  Central origin of pain
1. Brain tumors(any space occupying
lesion)
2. Infections of the brain
3. Multiple sclerosis
 Psychosomatic pain
1. Atypical facial pain
2. Burning mouth syndrome
3. Atypical odontalgia

8. MUCOSAL PAIN:
 Visible ulcer
 Erythematous tissue can be seen
 History of trauma, repeated ulceration
in Aphthous ulcers
 Pain is directly associated with the time
of ulcer presentation
 Gingivitis is also clinically visible

9.  Pain of pulpitis is associated with hot and cold
sensitivity
 The pain is exaggerated at night and more
pronounced while lying down
 Usually a carious lesion is visible and you can
pin point the pain to that particular tooth
 The tooth is tender to percussion
 In case of periodontitis, tooth mobility may be
obvious, periodontal abscess usually drains
through the gingival crevice
 In case of pericoronitis, imapcted third olar
with limited mouth opening, pus discharge etc

10.  Since the maxillary sinus is in close
proximity to roots of upper molars and
premolars
 Sinus infections can lead to pain
mimicking pulpitis
 This type of pain is worse on bending
down and can be associated with nasal
stuffiness, headaches and foul smelling
discharge from nose

11.  The muscles of mastication can be a
cause of severe facial pain
 History of clenching, stress
 On clenching the temporalis and
masseter are painful on palpation
 The pain is relieved by pain by pain
killer
 Gets worse on mastication
 It is bilateral, diffuse, involves all
muscles of mastication

12.  More localized pain in the preauricular
area
 Made worse from opening, closing and
lateral excursions
 The clicking sound of disc can be
appreciated
 History of parafunctional habits, trauma
to the TMJ, generalized arthritis of joints
 Dislocation of the TMJ is an acute
presentation with pain and open mouth
with deviation

13. MIGRAINE
 It is a common chronic neurovascular
disorder characterized by headache,
autonomic dysfunction, aura involving
neurologic symptoms
PATHOPHYSIOLOGY
 It is neural disorder leading to dilation of
blood vessels, leading to pain
 The neural pain also involves the trigeminal
complex and specially the ophthalmic division
thus the pain distribution around the eye

14.  Episodes of severe headache, unilateral,
throbbing, associated with nausea,
vomiting and sensitivity to light and
sound
 Migraines can be with or without
aura(flashing lights, hallucination etc)
 More common in women than men
 Can be very disabling at times
 Can last from 4-72hours

15.  Non pharmacological methods
 Keeping a diary and note the aggravating
factors( lack of sleep, eating habits,
menstrual cycle, food products)
 Preventive medication like selective
serotonin reuptake inhibitors , B blockers
like propanolol, amitryptyline, other non
specific drugs like verapamil
 Acute attacks are managed by either
aspirin, NSAIDS, ergotamine ,
sumatryptans etc

16.  Most severe form of headache,
characterized by severe, unilateral pain in
the retro orbital and fronto temporal
areas.
 It is associated with signs of cranial
autonomic dysfunction ( tearing,
conjuctival injection, nasal congestion and
horner’s syndrome)
 Occurs in clusters. 15 mins to 3 hours;
once daily to eight times daily
 More common in men and associated with
alcohol use

17.  Acute attacks are treated with high
flow oxygen (12 L/min) for 15 mins
 Parenteral triptans , S/C or nasal spray
 High doses of verapamil
 Ergots, lidocaine, octreotide
 Prophylactic treatment includes
verapamil, lithium, methylsergide,
anticonvulsants (topiramate)

18.  It is a vasculitis affecting large and medium sized
vessels
 Usual age of diagnosis is 50-70 years
 More common in males
SYMPTOMS:
1. Excessive sweating
2. Disturbance in vision(blurred, double, reduced)
3. Sudden loss of vision in an eye
4. Throbbing headaches in temple area
5. Jaw claudication
6. Fever, weight loss, loss of apetite, dropping
eyelids
7. Tenderness in the temple and scalp

19.  History and examination
 Elevated ESRC- reactive protein
 Diagnostic is temporal artery biopsy.
Skip lesions may be present

TREATMENT
 Treatment should be started
immediately on suspicion
 Start steroids( orally) long term for 1-2
years

20.  Mild to moderate headache, which feels
like a tight band around the head
 Tenderness of the shoulder and neck
muscles
 They are different from migraines which
have triggering factors, nausea and
vomiting or aura
 Stress is the most triggering factor
 More common in women usually middle
aged
 Treatment is simple pain relievers,
combination medicines

21.  Parotitis or salivary gland infections
leads to painful enlarged glands with
pus discharge from the duct opening.
Accompanying systemic symptoms like
fever are also present
 Salivary gland stones can give rise to
pain on salivation that is before meals

22.  Angina can be referred to the jaw
 Infections of eyes, ear and nose can
present as facial pain but are usually
associated with other symptoms
pointing towards the specific problem

23.  It is characterized by paroxysmal pain
which is sudden electric shock like and lasts
only a few seconds
 It is triggered by touch, speaking, daily
activities like washing face or shaving
 It is characterized by trigger zones, areas
which when touched can initiate pain
 Involves the branches of trigeminal nerve
 It is always unilateral, involv
 es a known boundary of sensory nerve
 May involve more than one branch of the
trigeminal nerve
 More common in elderly women

25. 1. PRIMARY..idiopathic
2. SECONDARY… due to a space
occupying lesion or MS(young patients)
The main cause is compression of the
nerve root entry zone in the middle
cranial fossa by an atherosclerotic
cerebellar artery

27.  History is quite significant
 Patient would have had multiple extraction for
the relief of pain
 Palpate the area to locate trigger zone
 Diagnostic blocks to locate the peripheral nerve
involved. Start peripheral and proceed
proximally
 This should relieve the pain, with no response
on touching the triggering zone
 For younger patients and those with atypical
symptoms, MRI to rule out MS or space
occupying lesion

28.  PHARMACOLOGICAL
 MINIMALLY INVASIVE
 PERIPHERAL SURGERY
 CENTRAL PROCEDURES

29.  Anti epileptics work very well for TN
 Carbamazepine is the drug of choice along with
oxcarbamazepine
 We start with 100mg which will relieve pain in
2hrs but the dose range can be between 600-
1200mg per day
 Adverse effects are ataxia, drowsiness,
vertigo and thus dose adjustment is required
 Second line drugs are available: lamotrigine and
baclofen(10mg)
 Gabapentin (MS)(900-2400mg), sodium
valproate, phenytoin can also be used

30. If drug therapy starts to fail or the side
effects are increasing
1. Peripheral injections of alcohol and
phenol
2. Peripheral injection of glycerol
3. Peripheral nerve cryotherapy with
liquid nitrogen

31.  Peripheral neurectomy
 Gazzerian ganglion glycerol injection
 Gazzerian ganglion balloon compression
 Percutaneous radiofrequency
thermocoagulation

36.  Rhizotomies
 Tracotomies
 Microvascular decompression.. Jannetta
pioneered this. Most appropriate where
you remove the aberrant vessel from
the nerve root
 Gamma knife surgery using gamma
radiation.. Blood less surgery, most
effective, radiation exposure and very
expensive

39.  Neuralgia in the distribution of
glossopharyngeal nerve
 Trigger zone is at the back end of the
throat and pharynx.
 Can be caused by blood vessel pressing on
nerve, tumours of skull base
 Usually initiated on swallowing
 The medical therapy is the same as in TN
 Trans tympanic Neurectomy, microvascular
decompression is reserved for unresponsive
or severe cases

40. OVERVIEW
 Herpes Zoster is a viral infection that
presents as chicken pox in children, the
varicella virus becomes latent and resides
in the sensory nervous system in the
geniculate , trigeminal ganglion
 When the patient passes through periods
of immunocompromised state, the virus is
activated resulting in lesions or vesicles in
the distribution of the nerves
 After the condition resolves, the pain can
persist in the affected area

41. PRESENTATION
 More common in older age group> 60 yrs
 More common in women
 History of preceding rash, pain persists
for more than 3 months after resolution
 Pain is burning, gnawing
 Cutaneous scarring can be seen
 Allodynia is present
 Risk factors are advancing age, systemic
disease

42.  To reduce morbidity
 Tricyclic antidepressants…reduce uptake
of serotonin, useful for chronic pin
 Analgesic agents..capsaicin (sub P
inhibitor)
 Anticonvulsants
 Anesthetic agents,, stabilize the neuronal
membrane
 Steroids…dexamethasone used as anti
inflammatory
 Antiviral.. Shortens the clinical course,
prevent recurrences

43. OVERVIEW
 Acute peripheral facial neuropathy
associated with vesicular rash of the
skin of the ear, canal and mucous
membrane of the oropharynx
 Name was given by James Ramsay Hunt

44.  Associated with facial palsy(lower motor
neuron), skin lesions over the preauricular
area and auditory symptoms e.g tinnitis,
deafness, vertigo, nystagmus, ataxia,
cervical lymphadenopathy

46.  Caused by herpes zoster involving the
facial nerve
 VZV can be demostrated by PCR of tear
fluid of bell’s palsy patients
 MRI can demonstrate the lesion very
well
 Audiometry
 Electroneurography

47.  Corticosteroids.. Reduce inflammation
around the nerve
 oral acyclovir
 Bell palsy requires care of eyes
 Carbamazapine..helpful in neuralgic pain
 Anti histamine.. For the treatment of
vertigo

48.  Defined by the International Headache
Society as pain which cannot be attributed
to any organic disease
 It is defined as MUS

49.  More common in women
 More common in elderly people
 The pain is not electric but more of throbbing origin,
not paroxysmal
 It tends to get worse during the day, but rarely
wakes the patient at night
 The pain is not within the distribution of any nerve
 Usually bilateral
 Does not have a trigger point
 Patient may have other symptoms like muscular
aches, dysmenorrhea, backache, constipation
 Some recent bereavement in the family, stressful
life conditions

50.  Behavioral therapy: counseling, telling the
patient that the pain is actual
 Try to set goals
 Follow ups
 Tricyclic antidepressants
 Amitryptiline
 Clonazepam
 Fluoxetine
 Carbamazepine
 Gabapentin
 Capsaicin

51.  Seen in elderly post menopausal females
though no link with hormones have been
associated
 Patient has burning sensation of mucosa
 No clinically red, erythematous areas are
seen
 Patient has a gritty sensation with dry
mouth and disturbed taste
 Disease of exclusion
 Can be initiated after undergoing dental
treatment

52.  History of stress, other non specific
symptoms
 Same treatment as that for atypical
facial pain but rule out other diseases
that can cause burning mouth like lichen
planus etc

53.  Again MUS
 Pain in tooth
 No obvious cause like caries, periodontitis
 Tooth is vital
 Any treatment can aggravate the situation
 The dentist can end up doing filling to
endo- treatment followed by extraction
but pain remains
 Treatment is the same after exclusion of
other problems