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Oro-Facial Pain (dental perspective) Dr. Fung Siu Chung Dept of Dentistry & Maxillofacial Surgery, UCH 12 May 2014.

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Presentation on theme: "Oro-Facial Pain (dental perspective) Dr. Fung Siu Chung Dept of Dentistry & Maxillofacial Surgery, UCH 12 May 2014."— Presentation transcript:

1 Oro-Facial Pain (dental perspective) Dr. Fung Siu Chung Dept of Dentistry & Maxillofacial Surgery, UCH 12 May 2014

2 Pain ‘unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’ International Association for the Study of Pain. Subcommittee on taxonomy of pain teams: a list with definitions and notes on usage. Pain 1979;6:249–52 pain is the number one reason people seeking health care is deemed the ‘ 5 th vital sign ’, to mark its importance as health status indicator Lanser P, Gesell S. Pain management: the fifth vital sign. Health & Benchmarks 2001;8(6): 68–70.

3 Pain head and neck region is the most common site of the human body to be involved in a chronic pain condition Donaldson D, Kroening R. Recognition and treatment of patients with chronic orofacial pain. J Am Dent Assoc 1979;99:961–6.

4 Orofacial Pain orofacial region is plagued by a number of acute, chronic, and recurrent painful maladies

5 Characteristics of Orofacial Pain (1) High Degree of Prevalence a population-based survey of 45,711 households revealed that 22% of the United States population experienced orofacial pain on more than one occasion in a 6-month period Lipton JA et al. Estimated prevalence and distribution of orofacial pain in the United States. J Am Dent Assoc 1994; 124: other population-based surveys conducted in the United Kingdom, Germany, or regional pain care centers in the United States report similar occurrence rates

6 Characteristics of Orofacial Pain (1) High Degree of Prevalence affected by age & gender ~ 10% of adults and up to 50% of the elderly Madland G, Newton-John T, Feinmann C. Chronic idiopathic orofacial pain: I: What is the evidence base? Br Dent J 2001;191(1):22–4. female of reproductive age & concentration of women in their 40s, seek treatment for orofacial pain more frequently compared to men by a 2:1 ratio Dao TT, LeResche L. Gender differences in pain. J Orofac Pain 2000;14(3):169–84. Fillingim RB. Sex, gender and pain: women and men really are different. Curr Rev Pain 2000;4:24–30.

7 Characteristics of Orofacial Pain (2) High Intensities various orofacial pain conditions intensities are similar to that observed with those of spinal pain disorders McGill Total Pain Rank Index ( PRI(T)) 0-78

8 Characteristics of Orofacial Pain (3) Diagnosis is sometimes challenging orofacial pain is derived from many unique target tissues, such as the meninges, cornea, tooth pulp, oral/nasal mucosa, and TMJ hence accurate Dx & Tx represents a significant health care problem

9 Dental ( Odontogenic ) Pain most (>95%) orofacial pain are of local cause; arises from diseases of the teeth & associated structures ( disease / defects ---) Tooth and Gum (diseases: mainly but not exclusively odontogenic infection) ( defects: neuralgic type of pain)

10 Dental ( Tooth + Gum) Structure

11 dental pulp as a model system to illustrate peripheral pain mechanisms associated with the trigeminal system

12 Dental ( Odontogenic ) Pain Originate from Tooth ( pulpal pain) Dentinal Pain: tooth hypersensitivity ( defect of tooth --- neuralgic pain DDx ) ( cervical hypersensitivity / non-carious tooth loss: abrasion/ attrition / erosion)

13 Dental ( Odontogenic ) Pain Originate from Tooth ( pulpal pain) Dental caries

14 Dental ( Odontogenic ) Pain Originate from Tooth ( pulpal pain) Dental caries Pulpitis: reversible / irreversible

15 Dental ( Odontogenic ) Pain Originate from Tooth ( pulpal pain) Dental caries Pulpitis: reversible / irreversible

16 Dental ( Odontogenic ) Pain Originate from Tooth ( pulpal pain) Dental caries Pulpitis: reversible / irreversible Apical peridontitis ( dental abscess of pulpal origin --- draining sinus)

17 Dental ( Odontogenic ) Pain Root canal Therapy ( RCT) Irreversible Pulpitis: Apical peridontitis ( dental abscess of pulpal origin )

18 Dental ( Odontogenic ) Pain Originate from Gum ( periodontal disease) Gingivitis / Peridontitis (dental abscess, no draining sinus)

19 Dental ( Odontogenic ) Pain Originate from Gum ( periodontal disease) Gingivitis / Peridontitis (dental abscess, no draining sinus)

20 Dental ( Odontogenic ) Pain Originate from both Pulp & Gum ( Prio-Endo Lesion)

21 Dental ( Odontogenic ) Pain Originate from both Pulp & Gum ( Cracked Tooth Syndrome)

22 Dental ( Odontogenic ) Pain Originate from Gum & Mucosa Pericoronitis ( acute/ sub-acute /chronic) cf gingivitis

23 Oral Pain ( Mucosal Pain) Tongue, Cheek, others (Oral Mucosal Diseases) Pathology ( autoimmune etiology) Cheek ( bilateral): atrophic / erosive oral lichen plaus Non-keratinzed epithelium: recurrent aphthous stomatitis ( minor / major / herptiform)

24 Oral Pain ( Mucosal Pain) Tongue, Cheek, others (Oral Mucosal Diseases) Infectious Candidosis: C. albicans strictly opportunistic pathogenes ( disease of the diseased) Tongue: median rhomboid glossitis, geographic tongue ( migratory glossitis) ----

25 Oral Pain ( Mucosal Pain) Tongue, Cheek, others (Oral Mucosal Diseases) Oral Dysaesthesia Burning Mouth Syndrome (glossodynia, glossopyrosis) cf. atypical ( idiopathic) facial pain / atypical odontalgia International Association for the Study of Pain as burning pain in the tongue or other oral mucous membrane associated with normal signs and laboratory findings lasting at least 4 to 6 months

26 Facial Pain ( TMJ associated)

27 TMDs ( temporo-mandibular disorders) Pain + Dysfunction of the TMJ & associated structures refer to a large group of musculoskeletal disorders that originate from the masticatory structures Okeson J. Orofacial pain: guidelines for classification, assessment, and management. 3rd edition. Chicago: Quintessence; 1996.

28 TMDs ( temporo-mandibular disorders) Very Common !! TMDs may occur in 10% of the population Glass EG, McGlynn FD, Glaros AG, et al. Prevalence of temporomandibular disorder symptoms in a major metropolitan area. Cranio 1993;11:217–20. TMDs have been reported in 46.1% of the United States population Le Resche L. Epidemiology of temporomandibular disorders: implications for the investigation of etiologic factors. Crit Rev Oral Biol Med 1997;8:291–305.

29 TMDs ( temporo-mandibular disorders) two broad types of TMDs: (A) those primarily involving the masticatory muscles myogenous TMDs (masticatory myalgia) (B) those primarily involving the TMJ complex arthrogenous TMDs myogenous TMDs (masticatory myalgia) myofascial pain / myositis / muscle spasm/ muscle contracture arthrogenous TMDs Disc derangement (DD) --- DDwR DDwoR ( ADP) / structural incompatibility of the articular surfaces / degenerative change

30 Myogenous TMDs Subtypes: myofascial pain / myositis / muscle spasm/ muscle contracture more common: > 90% in our practice, associated with stress, shopping around cf neck / back pain trigger sites --- tenderness on palpation (eg temporalis insertion on the coronoid process): reproducible diffuse pain management: non-surgical approach

31 Arthrogenous TMDs change in the structure of the condyle–disc complex altering the normal biomechanics Sub- types: disc derangement (DD) --- DDwR DDwoR ( ADP) / structural incompatibility of the articular surfaces / degenerative change

32 DDwR vs DDWoR ( cf ADP)

33

34 Arthrogenous TMDs clinical signs & symptoms vs biomechanical change ? association DDx: localized pain vs diffuse pain ( LA) joint sound +/- imaging of MRI Tx: Non-surgical Minimal invasive surgical ( arthrocentesis) remove the pain mediator of substance P, serotonin, prostaglandins, leucotrienes, bradykinins ----

35 Neuropathic Pain Neuralgic pain Idiopathic trigeminal neuralgia DDx: dentinal hypersensitivity Tx: peripheral management of LA injection / neurolysis / cryotherapy

36 Idiopathic Chronic Orofacial Pain (Malcolm Harris)  other terms--- TMJ dysfunction syndrome myofascial pain dysfunction syndrome craniomandibular dysfunction syndrome temporomandibular disorder (TMD) facial arthromyalgia(consistent w/ fibromyalgia)  umbrella term for atypical facial pain ( persistent idiopathic facial pain PIFP) atypical odontalgia facial arthromyalgia oral dysaesthesia (mainly tongue burning mouth syndrome)

37 Idiopathic Chronic Orofacial Pain (Malcolm Harris)  Definition 1. duration > 3 Ms / recurrent 2. continuous during the day 3. not paroxysmal 4. rarely disturbs sleep 5. no neuroanatomical pattern 6. standard clinical, radio & lab exam --- -ve Idiopathic pain of other parts of the body tension headache / neck pain / back pain / pelvic pain / irritable bowel etc

38 Idiopathic Chronic Orofacial Pain (Malcolm Harris)  Management medical management NSAID --- no value systemically, some support for topical gel Opioids --- for severe pain, intra-articular opioids has no value eg dothiepin mg nocte---60% pain free, but also 40% pain free for placebo! Antidepressants --- tricyclics---RCT support

39 Idiopathic Chronic Orofacial Pain (Malcolm Harris) atypical facial pain ( PIFP) / headache ( migraine, tension-type) /NPC --- TMDs atypical odontalgia --- crack tooth syndrome facial arthromyalgia --- joint complex vs masticatory muscle oral dysaesthesia(mainly tongue burning mouth syndrome --- Candidosis

40 Team Management

41 Thank You! Comment & Questions


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