DR FATHIMATH ZAHRA,MDS SENIOR LECTURER ORAL MEDICINE & RADIOLOGY MALABAR DENTAL COLLEGE & RESEARCH CENTRE, MANOOR

1. Oral psychosomatic disorders

2. CLASSIFICATION
1.CHRONIC OROFACIAL PAIN
 Atypical facial pain
 Atypical odontalgia
 Oral dysaesthesia
• 2.TASTE & SALIVATION
DISTURBANCES
3. DELUSIONAL SYMPTOMS
• Delusional halitosis
• Phantom bite syndrome
4.DYSMORPHOPHOBIA
• Delusional & body dysmorphic
syndrome
5.SELF INJURIOUS BEHAVIOUR
6.EATING DISORDER
• Anorexia nervosa
• Bulimia nervosa
TYLDESLEY’S ORAL MEDICINE 5th ed.

3. Classification:
1.Pain related
disorders:
• Myofascial pain
dysfunction syndrome
• Atypical facial pain
• Atypical odontogenic
pain
• Phantom pain
2.Disorders related to
altered oral sensation:
• Burning mouth syndrome
• Idiopathic xerostomia
• Idiopathic dysgeusia
• Glossodynia
• Glossopyrosis
Shamim T. The Psychosomatic Disorders Pertaining to Dental Practice
with Revised Working Type Classification. Korean J Pain 2014 January; Vol. 27, No. 1: 16-
22

4. 3.Disorders induced by
neurotic habits
• Dental and
periodontal diseases
caused by bruxism
• Biting of oral mucosa
(self mutilation)
4.Autoimmune disorders
• Oral lichen planus
• Recurrent aphthous
stomatitis
• Psoriasis
• Mucous membrane
pemphigoid
• Erythema multiforme

5. 5.Disorder caused by
altered perception of
dentofacial form and
function
• Body dysmorphic
disorder
6.Miscellaneous disorders
• Recurrent herpes labialis
• Necrotizing ulcerative
gingivostomatitis
• Chronic periodontal
diseases
• Cancerophobia
• Delusional halitosis

6. • Atypical pain characterized by continuous dull ache that
can be bilateral/unilateral but frequently affects maxilla.
• Atypical facial pain (AFP) was first described by Frazier
and Russell (1924)
Chronic orofacial pain
ATYPICAL FACIAL PAIN

7. • The word pain is derived from the Latin word Peone
and
the Greek word Poine meaning penalty or punishment.

8. Definition
An unpleasant sensory and emotional experience
associated with actual or potential tissue damage,
or described in terms of such damage.
Task Force on Taxonomy of the International Association
for the Study of Pain (IASP)
PAIN DEFINITION:

11. • Orofacial pain may be defined as
pain and dysfunction affecting motor and
sensory transmission in the trigeminal nerve system.

12. Nociception

18. • AFP defined more by what it is not than what it is.
• Non muscular/ joint pain that has nor any
detectable neurologic cause.
• Truelove & colleagues defined as
• condition characterized by absence of other
diagnosis and causing continuous variable intensity,
migrating, nagging, deep and diffuse pain.
Atypical facial pain

19. FEATURES:
• Dull, nagging nature but pain descriptors maynot be consistent.
• Emotive adjectives may be used to describe pain.
• Pain intensity vary.
• Location may change with time.
• Not related to anatomical distribution of nerve.
• Simple analgesics usually ineffective.
• Pain exacerbate with stress / dental treatment.
• 80% of patients with other chronic pain.
• No obvious organic cause.
• History of extensive restoration/surgical therapy to resolve pain is common.
• Consultation of several specialist.

20. • IHS included atypical facial pain under “central cause
of head and facial pain”.
• (anesthesia dolorosa/ central post stroke pain,
multiple sclerosis, BMS, persistent idiopathic facial
pain)

21. • A: Pain in face are present daily and almost all or most of
day.
• B: confined to onset to limited area on one side ; deep and
poorly localised.
• C: pain not associate with any sensory loss or other
physical signs.
• D: investigations including radiography are negative.
Classification of idiopathic orofacial pain (
committee on headache classification, HIS)

22. • AO: chronic pain localized to teeth or gingiva.
• Variant of AFP.
• Phantom tooth pain: persistent pain in endodontically
treated or edentate area for which no explanation
found by physical or radiologic examination.
• Considered to be deafferentation pain.
Atypical odontalgia

23. • AAOP classified under “facial pain not fulfilling
other criteria”
• IASP “ lesions of ear, nose, oral cavity”( severe
throbbing pain in the absence of pathology)
• DSM IV : Use the term “ not otherwise
specified”

24. ATYPICAL ODONTALGIA
• Idiopathic odontalgia.
• One tooth / multiple teeth clinically & radiologically sound.
• Repeated restorations root canal therapy offending tooth treated
extraction
Adjacent tooth
extraction
Pain on alveolus
Exploratory surgery,
ridge smoothening Atypical
odontalgia

25. Examination & assessment of
patient:
• No specific biologic markers / validated diagnostic
criteria/ no gold standard.

26. • History:
HOPI/ medical history/ family/ social/ occupational

29. • What events follow and precede increased episodes of
pain?
• How is time spent during day & evening?
• What activities are performed after onset of pain?
• What all activities are modified/ eliminated?
• Do you characterize yourself as
depressed/anxious/tense?
• Any changes in sleep/food/sexual desire?(vegetative signs
of depression)
• Any diagnosed/ underdiagnosed pain else where in the
body?
Questions to consider for screening
assessment

30. • Inspection of head/neck/skin/topographic anatomy/
swelling/ assymmetry.
• Masticatory muscle examination
• Assessment of mandibular movement
• Palpation of cervical muscles
• Cranial nerve examination.
• General examination of ears/nose/ oropharyngeal
areas.
• Intra oral examination
• Rule out suspected tumour /infection / ongoing
inflammations
Physical examination

31. DIAGNOSTIC NERVE BLOCK
• False positive results.
• Due to technical or anatomical factors.
• Topical/ intra ligament/ infiltration/ regional block.
• Complete resolution of pain: local cause.
• Change in symptoms: central cause of pain.

32. Confused with:
• TN
• Cluster head ache
• Maxillary sinusitis.
• Myofacial pain of masticatory muscles.
• Serious illness:
• Cardiac ischemia( pain at angle of mandible, brought on by exertion and relieved on rest)
• Temporal arteritis(ESR elevated)
• Intra cranial tumor.
• Ca. infra temporal region.
• Multiple sclerosis.( TN in patients< 50 yrs)
• Any neurogenic disorder/ tumor

34. MANAGEMENT OF CHRONIC OROFACIAL PAIN

35. Treatment goal:
• To eliminate pain
• To modify pain behaviour
• To restore activity.
• To manage misuse/ abuse of medications.
• MPCs( MULTIDISCIPLINARY PAIN CLINICS)
• Interdisciplinary therapy.

36. General consideration In managing Orofacial
pains
Therapeutic
modalities
Pharmacologic
therapy
Physical
therapy
Psychological
therapy

37. Pharmacologic therapya. Analgesic agents
b. Anesthetic agents
c. Anti – inflammatory agents
d. Muscle relaxants
e. Antidepressants
f. Antianxiety agents
g. Vasoactive agents
h. Norepinephrine blockers
i. Antimicrobial agents
j. Antihistamine agents
k. Anticonvulsive agents
l. Neurolytic agents
m. Uricosuric agents
n. Dietary consideration
a. Non opiod analgesics
b. Opiods
c. Adjuvant drugs
Antidepressants
Antianxiety agents
Anticonvulsive agents
a. Analgesic agents
b. Anesthetic agents
• Analgesic agents
• Anesthetic agents
• Anti – inflammatory agents
• Muscle relaxants
• Antidepressants
• Antianxiety agents
• Vasoactive agents
• Norepinephrine blockers
• Antimicrobial agents
• Antihistamine agents
• Anticonvulsive agents
• Neurolytic agents
• Uricosuric agents
• Dietary consideration

38. • Different MOA for different drugs.
• Smaller doses reduces side effects.
• Synergistic action and plasma half life
taken in to care.
polypharmacy

39. • Morphine isolated from opium( papaver somniferum)
• Opiod receptors: mu/ delta/ kappa
opiods

41. • Effects at membrane level: openong potassium channel;
inhibit voltage gated calcium channels: leads to decrease
in excitability.
• Increase descending inhibiting pathways activity.
• Spinal level: inhibit transmission of nociceptive impulses
through dorsal horns.

46. Tricyclic antidepressants:
• Chronic pain can cause reactinary
depression.
• Benefits: analgesic effects/ improved
sleep / mood elevation
• Side effects: sedation/ dry mouth/
constipation/ blurred vision/ urinary
retension.
Antidepressants

47. Selective serotonin re uptake inhibitors:
fewer side effects :
• GIT disturbances(nausea/dyspepsia/ vomiting/
abdominal pain/diarrhoea/constipation)
• Headache
• Sexual dysfunction.
• Hyponatremia(drowsiness/confusions/convulsion
• Abrupt cessation: headache/paresthesia/dizziness/
anxiety

48. • tricyclic antidepressants (TCAs), serotonin-norepinephrine
reuptake inhibitors(SNRIs), selective serotonin reuptake
inhibitors(SSRIs), and other antidepressants (e.g., mirtazapine)".
• Antianxiety drugs–Benzodiazepines like Diazepam (5 to 10
mg/day), Alprazolam. (0.25 to 0.5 mg/day)
• Antidepressants–Monoaminoxidase inhibitors: Phenelzine (15 to
90mg/day), Isocarboxazid (10 to 40 mg/day)
• Tricyclic Antidepressants – Amitriptyline (10 to 100 mg/day),
Nortriptyline (25 mg/day)
• Sedatives/Hypontics–Barbiturate (15 to 20 mg)

49. • Antianxiety drugs–Benzodiazepines like Diazepam
(5 to 10 mg/day), Alprazolam. (0.25 to 0.5 mg/day)
• With exception of clonazepam, benzodiazepines
are not thought to be analgesic for long term
chronic pain management.
• For muscle spasm

50. Physical therapy
 Modalities
- sensory stimulation
- ultrasound
- electrogalvanic stimulation
- deep heat
 Manual techniques
- massage
- spray & stretch techniques
- exercise
- physical activity

51. Psychological therapy
 Counseling
 Cognitive therapy
 Behavioral modification training
- stress reduction training
- relaxation training
-Biofeed back
-hypnosis

52. • Technique termed ‘reattribution’ which involves
demonstrating an understanding of the complaints by
taking a history of related physical, mood and social
factors. It may help explain that
depression/tiredness lowers the pain threshold and
that muscle over activity and spasm (being uptight’)
causes pain

53. • Based on theory that individual’s affect and behaviour
largely determined by the manner he/she structure the
world.
Cognitive behavioural therapy (CBT):

54. • Allergy / undiscovered low grade infection persist
which causes chronic OFP.
• Life threatening cause existence.
• Possibility of further increase in pain with activity
leads to limiting functions.
• Not accept if psychogenic influence being part of
orofacial pain.
Faulty assumptions:

55. • Cognitive behavioural therapy (CBT):
Attempts to alter negative thoughts and dysfunctional attitudes to
foster more healthy and adaptive thoughts, emotions and actions.
STEP 1
ASSESSMENT
STEP 2
DERIVE
FORMULATION
STEP 3
COGNITIVE
RESTRUCTURING
STEP 4
BEHAVIOURAL
CHANGES

56. 4 components:
• Education
• Skill acquisition
• Cognitive and behavioural rehersal
• maintenance

57. • Used for non directed calming rather
than for achieving a specific
therapeutic goal.
• Reduce distress associate with pain.
• Improved sleep.
• Reduced skeletal muscle tension.
• Decreased fatigue.
Relaxation therapy

58. • Guided imagery: to recall peaceful / pleasant experience.
• Progressive relaxation of muscles in a specific order.
• Patient need to reassure that these are not done as pain is imaginery but to
reduce associated stress arises from chronic pain.
• Benefits:
Physiologic effects( slower HR, increased peripheral blood flow, decrease muscle
spasm

59. • Pain levels: intensity/ frequency/ duration/
quality/signal of pain episode or attenuation
• Emotional reaction to pain:
worry/anxiety/depression/anger & hostility
• Cognitions & beliefs: self efficacy/ locus of control/
expectations of pain
• Behaviour: medications/ activity levels/ avoiding
painful areas/ encourage empathy from others
Assessment:

60. • As a part of evaluation.
• Arrange appointments at the same time patient is in the
clinic which will facilitate the process.
• Provide patient with information regarding consultation.
• Follow ups.
Psychiatric referrel

61. ——
Click here to add the text, the text is the refinement of your
thought, and please try to explain the point of view as succinctly
as possle.
P A R T 3 : O T H E R O R A L P S Y C H O S O M A T I C
D I S O R D E R S