This document provides an overview of orofacial pain, including definitions, classifications, causes, and theories of pain. It discusses the classification of orofacial pain as neuropathic or non-neuropathic and lists various causes such as dental issues, musculoskeletal disorders, and neurovascular conditions. The document also outlines pain pathways in the facial region and theories of pain transmission such as the gate control theory. Key topics covered include referred pain, different types of pain based on factors like intensity, duration and localization.

1. GOOD
MORNING

2. OROFACIAL
PAIN
GUIDED BY
DR. NITIN MIRDHA
DR. BOBBIN GILL
DR. NIRMLA
DR. VAISHAK
PRESENTED BY
DR. MANISH SUNDESHA
PG 1 YEAR

3. CONTENT
• INTRODUCTION . REFERRED PAIN
• DEFINITION . PAIN ASSESSMENT TOOLS
• CLASSIFICATION OF OROFACIAL PAIN . CAUSES OF OROFACIAL PAIN
• PAIN PATHWAYS IN FACIAL REGION . NON ODONTOGENIC PAIN
• TYPES AND NATURE OF PAIN . THEORIES OF PAIN

4. INTRODUCTION OF PAIN
• OROFACIAL PAIN IS THE PRESENTING SYMPTOM
OF A BROAD SPECTRUM OF DISEASES.
• AS A SYMPTOM , IT MAY BE DUE TO MANY
CAUSES . IT MAY ALSO OCCUR IN THE ABSENCE
OF DETECTABLE PHYSICAL , IMAGING ,OR
LABORATORY ABNORMALITIES.

5. DEFINITION
• BY IASP : IT IS AN UNPLEASANT SENSORY AND
EMOTIONAL EXPERIENCE ASSOCIATED WITH
ACTUAL OR POTENTIAL TISSUE DAMAGE OR
DESCRIBED IN TERMS OF SUCH DAMAGE .

6. CLASSIFICATION OF OROFACIAL
PAIN
• NEUROPATHIC PAIN :
A. PAROXYSMAL PAIN
- TRIGEMINAL NEURALGIA
- GENICULATE NEURALGIA
- GLOSSOPHARYNGEAL NEURALGIA
B. NON - PAROXYSMAL PAIN
- TRAUMA
- VIRAL
- NEOPLASMA

7. • Non – neuropathic pain :
a. central origin
- neuronal damage
- phantom limb
- brain tumor and central lesion
- other cause :- like thalamic syndrome
of dejerine and multiple sclerosis

8. • Extraneural origin
- dental pain eg. Dental caries , pulpal and periapical
disease.
- alveolar and adjacent tissue origin eg. Dry socket ,
sinusitis
- musculoskeletal eg. TMJ arthritis , MPDS , trismus
- vascular eg. Migraine , cluster headache
- pain referred from outside the orofacial area
• Pain of unknowns nature : pain that arises outside the
peripheral nerve and only
affects the nerve and their receptors secondary.

9. AMERICAN ACADEMY OF OROFACIAL
PAIN
• 1.INTRACRANIAL STRUCTURES
• -NEOPLASM
• -ANEURYSM
• -HEMATOMA
• -ABSCESS
• -EDEMA

10. 2.Extracranial structures
-Teeth
- Ears
-Eyes
-Nose
-Throat
-Sinuses
-Tongue
-Glands

11. 3.Musculoskeletal
disorders
-TMJ disorders
- Masticatory muscle
disorders
-Fibromyalgia
-Cervical disorders
-Generalised
polyarthritides
4.Neurovascular disorders
-Migraine headaches
-Cluster headaches
-Tension type
headaches
- Cranial arteritis

12. AXIS I
(PHYSICAL CONDITIONS)
1.SOMATIC PAIN
-SUPERFICIAL SOMATIC PAIN(CUTANEOUS,MUCOGINGIVAL)
-DEEP SOMATIC PAIN
-MUSCULOSKELETAL PAIN(MUSCLE,TMJ,OSSEOUS
ANDPERIOSTEAL,SOFT CONNECTIVE TISSUE,PERIODONTAL)
- VISCERAL PAIN(PULPAL,VASCULAR,
NEUROVASCULAR,VISCERAL
MUCOSAL,GLANDULAR,OCULAR AND AURICULAR)

13. 2. Neuropathic pain
-Episodic(trigeminal,glossopharyngeal,
geniculate,nervous intermedius
neuralgias &neurovascular pains)
-Continuous(neuritis,deafferentation
pain & sympathetically maintained pain)

14. AXIS II
(PSYCHOLOGIC CONDITIONS)
1.MOOD DISORDERS
2.ANXIETY DISORDERS
3.SOMATOFORM DISORDERS
4.OTHER CONDITIONS

15. PAIN PATHWAYS IN FACIAL
REGION

16. • Sensory input from orofacial region is carried through
these 1st order neurons of Trigeminal nerve into brain
stem in the region of pons to synapse in the various
sensory nuclei of V nerve.
• Main sensory nucleus : receives periodontal and some
pulpal afferents Spinal tract
-pars caudalis (homologous to substantia gelatinosa)
-pars interpolaris
-pars oralis

17. • Second order neuron/Transmission neuron : To thalamus
- 1st order neuron synapses with 2nd order in the dorsal horn of
spinal cord or pars caudalis of V nerve .
-3 specific types
a) Low threshold mechanosensitive neurons (LTM)
light touch, pressure, proprioception
b) Nociceptive specific neurons (NS)
noxious stimulation
c) Wide dynamic range (WDR)
wide range of stimulus from noxious – non-noxious
• WDR and NS comprise trigeminal nociceptive pathways
• LTM normally non nociceptive
• Spinal tract nucleus also receives input from nerves IX, X,C1,
C2, C3

19. • 2nd order neuron may carry nociceptive impulses by
one of the two tracts-
• neospinothalamic tract
• paleospinothalamic tract.
• Faster Aδ 1⁰ fibers synapse in lamina I of pars
caudalis. From here 2⁰ NS neuron carry these by way
of neospinothalamic tract directly to the thalamus.
Mainly carry mechanical & thermal pain
Said to carry Fast Pain as ascends directly to
thalamus

20. • 1⁰ afferent C fibers synapse in laminae II, III
(substansia gelatinosa) & V.
NS neuron carry these impulses by way of
paleospinothalamic tract.
 PST doesn’t ascend directly to thalamus but
instead projects numerous interneurons into
reticular formation of brain stem.
 Reticular formation changes or modulates
(excites or inhibits) these impulses before
they reach thalamus via bulboreticular
facilitatory area or reticular inhibitory area.
• Takes longer to reach thalamus so called Slow

21. • Fast tract - 3rd order neuron carry the impulse from the
thalamus to the cerebral cortex for evaluation and
response.
• Slow tract - impulse sent not only to cortex but also to
limbic structures and hypothalamus .
• Cortex : Recognition of pain, recollects any prior
experience of such pain, suffering associated with it,
thus draw necessary attention towards it.
• Limbic system : control instincts and behaviour;
influence the affective nature i.e. whether pleasant or
unpleasant, reward/punishment, satisfaction/aversion .

22. • The oral and masticatory region is innervated by at
least 6 major sensory somatic N trunks other than
Trigeminal N –
a) Facial
b) Glossopharyngeal
c) Vagus
d) C1
e) C2
f) C3
• Visceral N actively participte in mediation of pain
.
• All sympathetic afferents and atleast the sacral
parasympathetic afferents mediate pain at

23. TYPES AND NATURE OF PAIN
• ACCORDING TO PAIN INTENSITY
• ACCORDING TO TEMPORAL RELATIONSHIP AND DURATION
• ACCORDING TO QUALITIES OF PAIN
• ACCORDING TO ONSET
• ACCORDING TO PAIN LOCALIZATION
• ACUTE PAIN
• CHRONIC PAIN

24. ACCORDING TO PAIN
INTENSITY
• MILD PAIN : IT CAN BE CONTROLLED BY THE USE OF
SIMPLE ANALGESICS
• MODERATE PAIN: IT CAN BE CONTROLLED WITH
NARCOTIC ANALGESICS
• SEVERE PAIN : IT CANNOT BE CONTROLLED BY
ANALGESICS , BUT REQUIRES EITHER ELIMINATION
OF THE CAUSE OR INTERRUPTION OF THE PAIN
PATHWAY.

25. ACCORDING TO TEMPORAL
RELATIONSHIP AND DURATION
• INTERMITTENT : PAIN OF SHORT DURATION AND SEPARATED BY WHOLLY
PAIN-FREE PERIOD.
• CONTINUOUS : PAIN OF LONGER DURATION.
• PROTRACTED : A PAINFUL EPISODE THAT THAT LASTS FOR SEVERAL DAYS
IS USUALLY DESCRIBED AS PROTRACTED.
• INTRACTABLE : PAIN THAT DOES NOT RESPOND TO THERAPY.
• RECURRENT : TWO OR MORE SIMILAR EPISODE OF PAIN.
• REMISSION : THE PAIN-FREE INTERVAL BETWEEN RECURRING EPISODES IS
CALLED AS REMISSION.
• PERIODIC : PAIN THAT IS CHARACTERIZED BY REGULARLY RECURRING
EPISODES IS SAID TO BE PERIODIC.

26. ACCORDING TO QUALITIES OF
PAIN
• STEADY PAIN : IT FLOWS AS AN UNPLEASANT SENSATION.
• PAROXYSMAL PAIN : SUDDEN ATTACK OR OUTBURST OF PAIN.
• BRIGHT PAIN : STIMULATING QUALITY.
• DULL PAIN : IT HAS GOT DEPRESSING QUALITY .
• ITCHING : IT IS A SUB-THRESHOLD PAIN AND USUALLY IS NOT DESCRIBED AS PAIN
AT ALL.
• PRICKING : IT HAS A SHARP INTERMITTENT CHARACTER OF SHORT DURATION LIKE
PIN PRICKING THE SKIN.
• STINGING : IT IS MORE CONTINUOUS AND OF HIGHER INTENSITY AND QUALITY
• BURNING : IT GIVES A FEELING OF WARMTH OR HEAT ;WHEN SHORT AND INTENSE,
IT MAY HAVE ELECTRIC SHOCK LIKE FEELING.
• THROBBING : PULSATILE PAIN IS TIMED TO CARDIAC SYSTOLE.
• ACHING : IT THE DESCRIPTIVE TERM MOST FREQUENTLY USED UNLESS THE PAIN IS
OVERSHADOWED BY ONE OF THE OTHER CHARACTERISTIC SENSATION.

27. ACCORDING TO ONSET
• SPONTANEOUS : IF THE PAIN OCCURS WITHOUT
BEING PROVOKED
• INDUCED : WHEN SOME PROVOCATION CAUSE
THE PAINFUL SENSATION
• TRIGGERED : WHEN EVOKED RESPONSE IS OUT OF
PROPORTION TO THE STIMULUS.

28. ACCORDING TO PAIN
LOCALIZATION
• LOCALIZED : IF THE PATIENT IS ABLE TO CLEARLY AND PRECISELY
DEFINE THE PAIN TO AN EXACT ANATOMICAL LOCATION.
• DIFFUSE : IT IS LESS WELL DEFINED AND SOMEWHAT VAGUE AND
VARIABLE ANATOMICALLY .
• RADIATING : RAPIDLY CHANGING PAIN.
• LANCINATING : A MOMENTARY CUTTING EXACERBATION .
• SPREADING : GRADUALLY CHANGING PAIN
• ENLARGING : IF PAIN PROGRESSIVELY INVOLVES ADJACENT
ANATOMICAL AREA, IT IS CALLED AS ENLARGING.
• MIGRATING : IF IT CHANGE FROM ONE LOCATION TO ANOTHER, THE
PAIN IS DESCRIBED AS MIGRATING .

29. ACUTE PAIN
ACUTE PAIN-
• IT IS GENERALLY A PHYSIOLOGIC RESPONSE TO AN
INJURY.
• PERSISTS AS LONG AS THE NOXIOUS STIMULUS IS
PRESENT.
• ALMOST ALWAYS SUBSIDES WITHIN THE TIME
PERIOD REQUIRED FOR THE PROCESS OF NORMAL
HEALING.

30. CHRONIC PAIN
CHRONIC PAIN-
MERSKEY AND BOGDUK(1994) DESCRIBED CHRONIC PAIN
AS A PERSISTENT PAIN THAT IS NOT AMENABLE , AS A
RULE, TO TREATMENTS BASED ON SPECIFIC REMEDIES,OR
TO THE ROUTINE METHODS OF PAIN CONTROL SUCH AS
NON-NARCOTIC ANALGESICS.

31. THEORIES OF PAIN
• SPECIFICITY THEORY
• PATTERN THEORY
• SENSORY INTERACTION THEORY
• GATE CONTROL THEORY

32. SPECIFICITY THEORY
• IN 1644, DESCARTES POSTULATED THIS THEORY
THAT PAIN SYSTEM IS A STRAIGHT CHANNEL FROM
THE SKIN TO BRAIN.
• IT WAS THOUGHT THAT THIS SPECIFIC PAIN
SYSTEM CARRIED MESSAGE FROM THE RECEPTORS
TO PAIN CENTER IN THE BRAIN.

33. PATTERN THEORY
• IT WAS PROPOSED BY GOLDSCHEIDERS.
• HE PROPOSED THAT STIMULUS INTENSITY AND
CENTRAL SUMMATION ARE THE CRITICAL
DETERMINANTS OF PAIN.
• THE THEORY SUGGESTED THAT THE PARTICULAR
PATTERNS OF NERVE IMPULSES THAT EVOKE
PAIN ARE PRODUCED BY THE SUMMATION OF
SENSORY INPUT WITHIN THE DORSAL HORN OF
THE SPINAL COLUMN.

34. SENSORY INTERACTION
THEORY
• IT IS STATED BY NOORDENBOS AND IT STATES
THE LARGE FIBER- PAIN INHIBITORY AND SMALL
FIBER – PAIN CONTRIBUTORY CONCEPTS WITH
THE TWO SYSTEM BEING IN BALANCE WITH ONE
ANOTHER .
• A DECREASE IN THE RATIO OF LARGE TO SMALL
FIBER ACTIVITY RESULT IN CENTRAL SUMMATION
AND AN INCREASE IN PAIN.

35. GATE CONTROL THEORY
• THIS THEORY IS PROPOSED BY MELZACK AND WALL GATE IN 1965 .
• ACCORDING TO THEM , THE PAIN STIMULI TRANSMITTED BY AFFERENT PAIN
FIBER ARE BLOCKED BY GATE MECHANISM.
MECHANISM :-
• WHEN PAIN STIMULUS IS APPLIED ON ANY PART OF BODY .
• ALL PAIN IMPULSE REACH THE SPINAL CORD THROUGH POSTERIOR NERVE ROOT
.
• THE FIBER OF TOUCH SENSATION SEND COLLATERALS TO THE NEURONS OF
PAIN PATHWAY.

37. • THE IMPULSE OF TOUCH SENSATION PASSING THROUGH
THESE COLLALTERALS INHIBIT THE RELEASE OF
GLUTAMATE AND SUBSTANCE P FROM THE PAIN FIBER .
• THIS CLOSES THE GATE AND THE PAIN TRANSMISSION IS
BLOCKED.
• IF THE GATES IN SPINAL CORD ARE NOT CLOSED , THE
PAIN SIGNALS REACH THE THALAMUS THROUGH LATERAL
SPINOTHALAMIC TRACK .
• BRAIN SEND MESSAGE BACK TO SPINAL CORD TO CLOSE
THE GATE BY RELEASING PAIN RELIEVERS SUCH AS OPIATE
PEPTIDES.
• NOW THE PAIN STIMULUS IS BLOCKED AND THE PERSON

38. REFERRED PAIN
:-It is a spontaneous heterotopic pain that is felt in an
area innervated by a different nerve from the one that
mediates the primary pain.
Characteristics of Referred Pain
1.Referred pain usually occurs within a single nerve root , passing
from one branch to the other.
2.Referred pain in the trigeminal area rarely crosses the midline
unless it originates at the midline.

39. REFERRED PAIN FROM REMOTE
:-
• ANGINA PECTORIS :-
• SEVER PAIN OF CARDIAC ORIGIN CAN BE REFERRED TO THE MANDIBLE AND
MAXILLARY REGION .
• THE OPPOSITE PAIN REFERENCE HAS ALSO BEEN REPORTED – PAIN FROM
PULPALGIA REFERRING DOWN THE HOMOLATERAL NECK , SHOULDER , AND
ARMS .
• THESE SYMPTOMS MAY RADIATE UPWARD FROM THE EPIGASTRIUM TO
MANDIBLE – THE LEFT MORE FREQUENTLY THAN RIGHT .

40. Myocardial infarction :-
• Thus myocardial infarct pain is similar to angina but is more
pronounced , long – lasting and does not resolve with rest .
• Usually , the patient has a rather unusual story to tell, with a
fairly severe pain that began rather suddenly in the left jaw
and grew in intensity .
• The symptoms may sound very much like a pulpitis.
Thyroid:-
• A throat with pain radiating up the side of the neck and into
the lower jaws, ears, or occiput.

41. Carotid artery :-
• Carotidynia is a symptom of unilateral vascular neck pain and
various parts of the carotid artery pain in the region of the
bifurcation was shows to cause pain in the ipsilateral jaw ,
maxilla , teeth , gums , scalp , eyes , or nose .
• The pain may also involve the temple and TMJ region and
radiate for ward into the masseter muscle with occasional
concomitant tenderness and fullness.

42. Cervical spine :-
• The cervical spine must be recognized as potential source of
dermatomal and referred pain into the head and the orofacial region.
Cervical joint dysfunction :-
• Local symptoms of cervical dysfunction may include stiffness , pain ,
and a limited range of motion of head and neck.
• The patient may also complain of throat tightness and difficulty in
swallowing
Muscular pains :-
• Pain of muscular origin is generally described as a continuous , deep ,
dull , ache or as tightness or pressure.
• It is undoubtedly the most prevalent cause of pain in the head and
neck region.

43. • Sinus –related Pain:-
• Pain of maxillary sinus will be usually felt as a
constant , dull non-pulsatile ache in the maxillary teeth
of the affected side and sometimes on the face.
• There may be accompanying ear pain , malaise , nasal
congestion and nasal discharge.
• If the teeth are secondarily involved by extension of
prior sinus disease , the dental pain will be of
periodontal type due to the effect on the periodontal
ligament with almost no features of pulpal pain .

44. PAIN ASSESSMENT TOOLS :-
• QUANTIFYING THE PAIN EXPERIENCE:-
A. VISUAL ANALOG SCALES
B. MCGILL PAIN QUESTIONNAIRE
C. DISABLITY STSATUS
D. VERBAL COMMUNICATION
E. QUANTITATIVE SENSORY TESTING

45. A. VISUAL ANALOG SCALES:-
• PAIN INTENSITY CAN BE MEASURED BY VISUAL ANALOGE SCAL.
• THIS SCAL CONSIST OF 10CM LINE .
• NUMERIC RATING SCALES, WHERE “0” IS NO PAIN AND “10” IS WORST PAIN
IMAGINABLE , ARE ALSO VERY USEFUL AND PREFERRED BY ADULT WITHOUT
CONGNITIVE IMPAIRMENT .
• PATIENT IS ASKED TO MARK THE LINE WHICH REPRESENT PAIN.

46. B. MCGILL PAIN QUESTIONNAIRE:-
• THE MCGILL PAIN QUWSTIONNAIRE IS VARBLE PAIN SCAL THAT USE A VAST
ARRAY OF WORDS COMMNLY USED DESCRIBE A PAIN EXPERIENCE.
• THIS QUESATIONNARIE CONSIST OF 20 GROUP WITH 78 TYPE OF PAIN.
• IN THESE GROUP, 1 TO 10 IS DESIGEND FOR THE ASSESSMENT OF SENSORY
CHARACTER, GROUP 11 TO 15 TO ASSESS EFFECTIVE CHARACTER AND FROM
GROUP 16 TO 20 ASSESS EVALUATIVE CHARACTER OF PAIN.

48. C. DISABLITY STSATUS:-
• THIS IS VERY IMPORTANT IN ASSESSING THE PAIN.
• DISABILITY IS LACK OF ABILITY TO FUNCTION NORMALLY ,
PHYSICALLY AND MENTALLY .
D. VERBAL COMMUNICATION :-
• THIS IS COMMUNICATED TO YOU FROM THE PATIENT .
E. QUANTITATIVE SENSORY TESTING :-
• QUANTITATIVE TESTING MODALITIES INCLUDE THERMAL,
MECHANICAL AND ELECTRICAL STIMULI.

49. CAUSES OF OROFACIAL PAIN

50. Location of pain
Buccal/Lingual?
Apical tenderness
Pain localized to 1 tooth or
more
Pain in tooth or gingiva
Not localizable
History of Pain

51. Character of
pain/ Nature of
pain
Sharp
Dull
Electric shock type pain
Onset
Sudden
Gradual

52. Duration of pain
During stimulus only
Prolonged beyond stimulus
Seconds/minutes/hours
Aggravating
factors
Temperature of fluid
Pressure of eating
Contact with hard objects
Mouth opening /closing

53. Relieving factors
Relieved by hot or cold
Analgesics
Relieved by pressure
Radiation of
pain
Does the pain radiate
Radiates to which region

54. Associated
symptoms
Swelling
Fever
Pus discharge

55. NON ODONTOGENIC PAIN
• TRIGEMINAL NEURALGIA
• GLOSSOPHARYNGEAL NEURALGIA
• CLUSTER HEADACHE
• MYOFASCIAL PAIN
• MIGRAINE
• BURNING MOUTH SYNDROME
(BMS)

56. TRIGEMINAL NEURALGIA
IT IS ALSO CALLED
• TIC DOULOUREUX,
• TRIFACIAL NEURALGIA
• FOTHERGILL’S DISEASE.
• TRIGEMINAL NEURALGIA IS AN EXTREMELY PAINFUL CONDITION AS
IT IS UNIQUE TO HUMANS.

57. Etiology:
1. Demyelination.
2. Vascular compression of the trigeminal
ganglion.
3. Trauma or infection of the nerve.
4. Idiopathic.
Clinical Features
Age and sex distribution: It usually occurs in
middle and
old age, the disease seldom occurs before 35 years
of age.Site: It is more common on the right side and the
lower
portion of the face is more frequently affected.
The pain is
confined to the trigeminal zone, nearly always

58. Pretrigeminal neuralgia: There is dull,
continuous, aching
type of jaw pain which may persist for days prior to
onset
of characteristic occurrence of paroxysmal pain in the
same
region of the jaw.
Nature of pain:The pain is paroxysmal, lasting only a
few seconds to a few minutes and is usually of extreme
intensity. It may be described by the patient as resembling
knife like stabs lightening, electric shock, stabbing or
lancinating type of pain. During the intervals between
these violent experiences, there is usually no pain or a
mild
or dull ache.

59. Triggers zones: Trigger zones which
precipitate an attack
when touched, are common on the vermilion
border of
the lips, the ala of the nose, the cheeks, and
around the
eyes.
Aggravating factors: The pain is provoked by
obvious
stimuli to the face. A touch, a draft of air, any
movement of
the face as in talking, chewing, yawning or
swallowing may
evoke a lancinating attack.

60. GLOSSOPHARYNGEAL
NEURALGIA
• IT IS ALSO CALLED VAGOGLOSSOPHARYNGEAL NEURALGIA. IT
IS A VARIANT OF TIC DOULOUREUX THAT CAN MIMIC ORAL
PATHOLOGIC CONDITION IN WHICH PAIN IS CONFINED TO THE
DISTRIBUTION OF THE NINTH CRANIAL NERVE.
•CLINICAL FEATURES:
• AGE AND SEX DISTRIBUTION: THIS NEURALGIA OCCURS WITHOUT
ANY SEX PREDILECTION IN THE MIDDLE AGED OR OLDER PERSONS.
• NATURE OF PAIN: IT MANIFESTS AS SHARP EXCRUCIATING, ELECTRIC LIKE,
LANCINATING PAROXYSMS OF PAIN IN THE EAR, PHARYNX, NASOPHARYNX, TONSILS OR
THE POSTERIOR PORTION OF THE TONGUE.

61. The pain is generally unilateral. Pain free intervals
of
seconds, minutes, hours, days, and years are
common.
Trigger zones: The patient usually has a trigger
zone in the
posterior oropharynx or tonsillar fossa. An
important and
frequent trigger is the initiation of the act of
swallowing.

62. CLUSTER HEADACHE
• IT IS A DISTINCT PAIN SYNDROME CHARACTERISED BY
EPISODES OF SEVERE UNILATERAL HEAD PAIN
OCCURRING CHIEFLY AROUND THE EYE AND
ACCOMPANIED BY A NUMBER OF AUTONOMIC SIGNS.
• THE TERM CLUSTER IS USED BECAUSE INDIVIDUALS
WHO ARE SUSCEPTIBLE TO C. H. EXPERIENCE MULTIPLE
HEADACHES PER DAY FOR 4 TO 6 WEEKS AND THEN
MAY BE WITHOUT PAIN FOR MONTHS OR EVEN YEARS.

63. Clinical Features
• 80% of patients are men.
• The attacks are sudden, unilateral, and stabbing , pain is often
described as a hot metal rod in or around the eye.
• Patients exhibit violent behaviour during attacks . this contrasts
with the behaviour of migraine patients.
• Severe painful episodes begin without an aura and become
excruciating within a few minutes . Each attack lasts from 15
minutes to 2 hours and recurs several times daily.
• Sweating of the face , ptosis, increased salivation , and edema of
the eyelid are common signs.

64. MYOFASCIAL PAIN
• THE PAIN ORIGINATING FROM THE SKELETAL MUSCLES , TENDONS AND FASCIA
SURROUNDING THESE CONSTITUTE THE TERM MYOFASCIAL PAIN.
• MYOFASCIAL PAIN IS A REGIONAL MUSCLE PAIN DISORDER THAT MANIFESTS
CHARACTERISTIC LOCAL AREAS OF HYPERSENSITIVE BANDS OF MUSCLE TISSUE
KNOWN AS ‘TRIGGER POINTS.’
• THE TRIGGER POINT HAS AN ABILITY TO CAUSE REFERRED PAIN IN A DEFINITE
ANATOMICAL AREA WHEN STIMULATED .
• EACH TRIGGER POINT IS THOUGHT TO BE LESS THAN 1-2 MM IN DIAMETER.

65. • When a trigger point is detected and palpated
the patient gives a typical behavioural
reaction , acknowledging the tenderness felt
in the area of pain reference , known as the
’jump sign’.
• Laskin’s 4 cardinal features
a . Clicking or popping noise in the TMJ
b . Limitation of jaw function or deviation
of the mandible on opening.
c. Unilateral pain-

66. MIGRAINE
MIGRAINE IS THE MOST COMMON OF THE VASCULAR HEADACHES ,
WHICH MAY OCCASIONALLY ALSO CAUSE PAIN OF THE FACE AND JAWS.
IT IS A DOMINANTLY INHERITED DISORDER CHARACTERISED BY
VARYING DEGREES OF RECURRENT VASCULAR HEADACHE ,
PHOTOPHOBIA, SLEEP DISRUPTION, AND DEPRESSION.-SHAFERS
 IT MAY BE TRIGGERED BY FOODS SUCH AS NUTS , CHOCOLATE , AND
RED WINE; STRESS; SLEEP DEPRIVATION OR HUNGER.

67. Clinical Features
• Usually begins during the second decade of life and
is especially common in professional persons.
• Affects women more than men.
• The frequency of attacks is extremely variable . they
may occur at frequent intervals over a period of years
or on only a few occasions during the life time of the
patient.
• Migraine is of several types;
Classic,Common,Basilar, and facial migraine(also
referred to as carotidynia)

68. BURNING MOUTH SYNDROME
(BMS)
 BURNING MOUTH SYNDROME IS A BURNING OR STINGING OF THE
MUCOSA , LIPS , AND OR TONGUE , IN THE ABSENCE OF VISIBLE
MUCOSAL LESIONS- SHAFERS
 BURNING MOUTH SYNDROME IS A COMMON DYSESTHESIA ( EG. ,
DISTORTION OF A SENSE)TYPICALLY DESCRIBED BY THE PATIENT AS
A BURNING SENSATION OF THE ORAL MUCOSA IN THE ABSENCE OF
CLINICALLY APPARENT MUCOSAL ALTERATIONS . NEVILLE

69. Burning mouth syndrome not related to organic oral
disease:
• Most frequently affects the tongue, sometimes
the palate or less commonly the lips or lower
alveolus;
• is usually bilateral;
• is associated with no clinical signs of disease.
• is often relieved by eating and drinking, in
contrast to pain caused by organic lesions which is
typically made worse by food.
BMS usually does not interfere with sleeping.
Clinical Features

70. • There is a strong predilection for
women(4-7 times more),with most
female patients being
postmenopausal (onset occurs
within 3-12 years after
menopause)and the age of onset
being approx 50 years.