Differential diagnosis of Orofacial Pain. Prof. Yair Sharav School of Dental Medicine Hebrew University-Hadassah, Jerusalem
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1 Differential diagnosis of Orofacial Pain Prof. Yair Sharav School of Dental Medicine Hebrew University-Hadassah, Jerusalem
2 Orofacial Pain & Headache Yair Sharav & Rafael Benoliel 2008, MOSBY, Elsevir
3 Special features of orofacial pain The density of anatomical structures Mechanisms of referred pain Important psychological meaning of face and oral cavity
4 Acute & chronic pain Acute versus Chronic Pain Acute Chronic Time course Short Long (Hours to days) (months to years) Etiology Peripheral Central inflammatory neuropathic Response to: Analgesics Good Poor Psychotropics Poor Modrate - Good Behavioral Anxiety Depression gaurding illness behavior
5 Acute Orofacial Pain Intraoral pain Dental Periodontal Mucosal Related structures Maxillary sinus Salivary glands Mostly inflammatory in origin, Due to: infection, trauma, malignancy
6 Dental Dentinal Pain Pulpal Pain Evoked (cold, sweet) Short, mild Spontaneous, or evoked (cold) Paroxysmal Severe Not affected by antibiotics
7 Periapical Pain Periodontal Spontaneous, long lasting Strong Evoked by chewing No cold sensitivity Lateral periodontal Pain Spontaneous, long lasting Mild to strong Evoked by chewing Affected by antibiotics
8 Chronic Orofacial Pain Musculoskeletal Masticatory muscles Tension-type headache TMJ disorders Neurovascular Migraine Cluster headache Paroxysmal hemicrania Neurovascular orofacial pain (VOP) Neuropathic Paroxysmal Neuralgias Continuous Deafferentation
9 Musculoskeletal Masticatory muscles Tension-type headache TMJ disorders
10 Temporo mandibular pain & dysfunction (TMD) Pain is chronic, daily, does not wake Unilateral: angle of mandibule & front of ear Pain on chewing & yawning Limited mouth opening (less than 45 mm) Masticatory muscles tender to palpation (mostly unilateral)
11 TMD (n=3,428), Age and Gender Distribution Males Females Fibromyalgia: Age & gender distribution Males Females (Adapted from Howard JA 1991) Wolfe et al 1995
12 Conservative management of TMDs Medication - Amitriptyline (10 20 mg) NSAIDs Analgesics Physical Therapy Soft Diet Occlusal splint CBT
13 Migraines TACs: Neurovascular Pain Cluster Headache Paroxysmal Hemicrania SUNCT Neurovascular Orofacial Pain (NVOP)
14 Common Features of Neurovascular Pain Pain is: Periodic Severe Unilateral Pulsatile Wakes from sleep Accompanied by: a. Local autonomic signs Ocular: tearing, redness, ptosis, miosis Nasal: rhinorrhea, congestion Local swelling or redness b. systemic signs Nausea, vomiting Photo/phonophobia
15 The TACs Trigeminal Autonomic Cephalgias Cluster Headache Paroxysmal Hemicrania SUNCT
16 TACs Pain Characteristics Duration (mins.) Episodes /24h Wakes Trigger CH Alcohol PH Mechano SUNCT Mechano
17 Cluster Headache Very severe pain around the orbit Short duration ( mins) Active (cluster) and non-active periods Once a day (50% wakes) Autonomic signs: Tearing, redness of eye myosis, Ptosis, rhinorrhea
18 Cluster Headache Pain characteristics Unilateral Severe Paroxysmal Active periods: For 4-12 weeks Every 6-18 months Epidemiology Male/female (!) 5:1 Onset years Prevalence 0.24% (Migraine 10 15%)
19 Abortive treatment of CH Agent Dose Comments Oxygen Sumatriptan Dihydroergotamine 8 liters/min 6-12mg SC 20mg IN 0.5-1mg IN First line, but cumbersome Effective, fast Reduces pain severity
20 Prophylactic treatment of episodic cluster headache Agent Dose mg/d Comments Verapamil Prednisone First line Baseline ECG Initial therapy till, e.g. verapamil takes effect. Valproic Acid For patients with migraine Topiramate Increase by 25mg/d every 5 days
21 paroxysmal hemicrania Unilateral, around orbit and temple Frequent (up to 30 per day), wakes from sleep Associated signs (ipsilateral): Short attacks (15-30 min) of sharp, excruciating pain Conjunctival injection Tearing with nasal congestion and rhinorrhea
22 Paroxysmal hemicrania treatment Absolute response to Indomethacine mg / d (Abortive and Prophylactic) To avoid GI side effects: Omeprazole (Losec), mg/day
23 Neurovascular Orofacial pain (NVOP) Episodic Chronic
24 Neuropathic Orofacial Pain (NOP) : Common entities Trigeminal Neuralgia Post Herpetic Neuralgia Ramsay Hunt Syndrome Deafferentation Pain Neuritis
25 Trigeminal Neuralgia Pain is: Paroxysmal Short (seconds) Provokable (triggered) Unilateral Confined to Vth nerve No sensory deficit Tic
26 Drugs used in Trigeminal neuralgia Drug Initial dose Target dose (titerated) Dose increase Evidence Carbamazepine-CR mg/2d A Oxcarbamazepine mg/w B Baclofen mg/3d A Gabapentin mg/3d B Pregabalin mg/2-3d C
27 Pretrigeminal Neuralgia PTN has been reported in 18% of Trigeminal Neuralgia patients. Characterized by dull continues pain for months to yrs becoming more typical of TN as the process continues. PTN is highly responsive to Carbamazepine.
28 Herpetic Pain Acute herpetic Post herpetic Ramsay Hunt
29 Acute herpes zoster Affects the trigeminal nerve in 10-15% of cases Ophthalmic branch affected in 50-80% of cases Begins as localized pain followed by typical vesicular eruption within 7 days Acute herpetic
30 Acute herpes zoster Treatment Drug Dosage Times (Days) Acyclovir (Zovirax) Valaciclovir (Valtrex) Famcyclovir 250 (500 U.S.) Duration (days) Initiate drug treatment early, especially in patients >50-y-o to avoid rash duration, pain severity and PHN
31 Post Herpetic Neuralgia Pain that develops in acute HZ but persists for > 6 months Pain is burning with superimposed stabbing pain Accompanied by allodynia and hyperalgesia Typical skin changes Affects elderly > young, 60% of patients >60y will develop PHN Post herpetic
32 Post Herpetic Neuralgia Treatment Drug NNT Amitriptyline Opioids (oxycontin) Gabapentin Pregabalin Tramadol 4.7
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