This document discusses orofacial pain and altered sensation, focusing on trigeminal neuralgia. It defines trigeminal neuralgia as a rare condition involving sudden, very severe, brief stabbing pains in the trigeminal nerve distribution. It notes the pain is limited to one side of the face, involves a trigger zone, and does not affect sleep. Treatment involves carbamazepine, phenytoin, gabapentin, or surgical decompression of the trigeminal ganglion.

1. OROFACIAL PAIN & ALTERED
SENSATION
DR. ISHFAQ AHMAD

2. PAIN OF NON-DENTAL ORIGIN
• 1. NEUROLOGIC
• TRIGEMINAL NEURALGIA
• GLOSSOPHARYNGEAL NEURALGIA
• HERPES ZOSTER
• POST-HERPETIC NEURALGIA
• GENICULATE HERPES (RAMSAY-HUNT SYNDROME)
• BELL'S PALSY
• MULTIPLE SCLEROSIS
• HIV DISEASE (SEE CHAPTERS 8 AND 10)
• INTRACRANIAL TUMOURS
• CAUSALGIA

3. • VASCULAR ORIGIN
• MIGRAINE
• PERIODIC MIGRAINOUS NEURALGIA
• PAROXYSMAL FACIAL HEMICRANIA
• GIANT CELL ARTERITIS
• REFERRED PAIN, E.G. CARDIAC ISCHAEMIA
• 3. MAXILLARY ANTRUM/NASOPHARYNX
• SINUSITIS
• MALIGNANCY

4. • SALIVARY GLANDS
• ACUTE BACTERIAL SIALADENTITIS (SEE CHAPTER 12)
• CHRONIC BACTERIAL SIALADENTITIS (SEE CHAPTER 12)
• SJ6GREN'S SYNDROME (SEE CHAPTER 13)
• MALIGNANCY (SEE CHAPTERS 10 AND 12)
• CALCULI, STENOSIS OF DUCT, OBSTRUCTION OF DUCT ORIFICE
• HIV DISEASE (SEE CHAPTER 12)
• MUMPS (SEE CHAPTER 8)

5. • ORAL MUCOSA
• HERPES ZOSTER (SEE ABOVE)
• GENICULATE HERPES (RAMSAY-HUNT SYNDROME) (SEE ABOVE)
• HERPETIC GINGIVOSTOMATITIS (SEE CHAPTER 10)
• LATE STAGE CARCINOMA (SEE CHAPTERS 10 AND 12)
• MUCOSAL ULCERATION (SEE CHAPTER 10)

6. • JAW/ MASTICATORY MUSCLE
• TMJ DISORDER
• FRACTURE
• OSTEOMYELITIS
• INFECTED CYSTS
• MALIGNENCY

7. • EARS
• OTITIS MEDIA
• EYES
• GLAUCOMA
• PSYCHOGENIC
• ATYPICAL FACIAL PAIN
• ATYPICAL ODONTALGIA
• BURNING MOUTH SYNDROME

8. TRIGEMINAL NEURALGIA
• SUDDEN, VERY SEVERE, BRIEF ( SECONDS ONLY), RECURRENT STABING, PAIN IN THE DISTRIBUTION OF THE
TRIGEMIBNAL NERVE
• IT IS A RARE CONDITION. MAINLY LIMITED TO THE MIDDLE AGE AND ELDERLY
• IN AFFECTED PATIENT UNDER 40 YEARS SUSPECT SERIOUS UNDERLYING PATHOLOGY. TUMOUR OR MULTIPLE
SCLEROSIS
• 3°/OF PATIENTS PRESENTING WITH TRIGEMINAL NEURALGIA HAVE MULTIPLE SCLEROSIS.
• • ALL PATIENTS WITH TRIGEMINAL NEURALGIA MUST UNDERGO A DETAILED NEUROLOGICAL EXAMINATION,
PARTICULARLY OF THE CRANIAL NERVES
• • TRIGEMINAL NEURALGIA IS UP TO TWICE MORE COMIMON IN WOMEN.
• • THE RIGHT SIDE IS AFFECTED MORE THAN THE LEFT (1.7: I).
• • VERY RARELY (4%) PAIN MAY OCCUR

9. • AETIOLOGIES INCLUDE
• DEMYELINATION
• VASCULAR COMPRESSION OF THE TRIGEMINAL GANGLION
• TRAUMA OR INFECTION OF THE NERVE
• IDIOPATHIC
• MH. ASSOCIATION WITH MULTIPLE SCLEROSIS.

10. • SYMPTOMS
• (DIAGNOSIS IS MADE BY THE HISTORY).
• • UNILATERAL, SHORTLASTING (SECONDS) EXCRUCLATMG, UNBEARABLE,
• STABBING (LANCINATING), PAROXYSMAL FACE PAM, AFFECTING A
• PREDICTABLE SITE.
• • THERE ARE FEW MORE PAINFUL CONDITIONS.

11. • THE CHARACTERISTICS OF THE PAIN ARE:
• • PAIN IS TYPICALLY LIMITED TO ONE OF THE THREE DIVISIONS OF THE TRIGEMINAL NERVE, MOST
COMMONLY THE 2ND AND 3RDDIVISIONS.
• • A TRIGGER ZONE MAY BE PRESENT SOMEWHERE ALONG THE DISTRIBUTION OF THE TRIGEMINAL
NERVE. THE TRIGGER ZONE MAY BE REFRACTORY BETWEEN PAROXYSMS.
• ONLY LIGHT PRESSURE ON THE TRIGGER ZONE WILL INDUCE SEVERE PAIN. THE PATIENT MAY NOT
SHAVE ORTOUCH THE FACE IN THE REGION OF THE TRIGGER ZONE.
• FOR FEAR OF INDUCING A PAROXYSM. SPEECH AND SWALLOWING MAY BE LIMITED IF THE TRIGGER
ZONE INVOLVES THE MOUTH.
• ANY NEUROLOGICAL FINDING OTHER THAN THE PRESENCE OF A TRIGGER ZONE PUTS THE DIAGNOSIS
OF TRIGEMINAL NEURALGIA IN SERIOUS DOUBT.

12. • • THE PAIN OF TRIGEMINAL NEURALGIA NEVER CROSSES THE MIDLINE AND DOES NOT USUALLY
CROSS FROM ONE DIVISION TO ANOTHER IN THE SAME BOUT.
• • PAIN IS DESCRIBED AS SHARPAND STABBING, 'ELECTRIC SHOCK'L'RED HOT NEEDLE' TYPE. IT IS
OF RAPID ONSET. SHORT DURATION AND WITH RAPID RECOVERY.
• A SERIES OF JABS OCCUR OVER SEVERAL MINUTES. THIS IS OFTEN FOLLOWED BY A DULLACHE
WHICH MAY LAST FOR SEVERAL HOURS.
• PAROXYSMS OCCUR MOST COMMONLY IN THE FIRST HOURS AFTER AWAKENING.
• • THE PAIN OF TRIGEMINAL NEURALGIA CLUSTERS. PATIENTS HAVING PERIODS OF DAILY PAIN,
THEN PERIODS OF REMISSION. THE REMISSION MAY LAST DAYS, WEEKS. MONTHS OR YEARS.
• • OF DIAGNOSTIC SIGNIFICANCE TRIGEMINAL NEURALGIA DOES NOT AFFECT SLEEP.

13. • SIGNS
• • TIC DOULOUREUX (SPASMODIC CONTRACTION OF FACE MUSCLES DUE TO THE
PAIN OF TRIGEMINAL NEURALGIA).

14. • KEYWORDS
• VERY BRIEF
• SEVERE
• LANCINATING PAIN
• TRIGGER ZONE
• TRIGEMINAL NERVE DISTRIBUTION
• SLEEP NOT AFFECTED

15. • DIFFERENTIAL DIAGNOSIS
• NEUROPATHY
• HERPES ZOSTER
• ATYPICAL FACIAL PAIN
• MIGRAINOUS NEURALGIA
• PULPITIS
• ATYPICAL PERIODONTITIS

16. • TREATMENT
• CARBAMAZEPINE.
• PHENYTOIN,
• GABAPENTIN
• LAMOTRIGINE.
• SURGICAL TREATMENTS
• NEUROSURGICAL DECOMPRESSION OF THE TRIGEMINAL GANGLION
• GAMMA KNIFE ABLATION