1. Clin A/Prof Robert Delcanho
OROFACIAL PAIN
Clin A/Prof Robert Delcanho
BDSc MS Cert OFP FFPMANZCA FICD FAAOP
Diplomate, American Board of Orofacial Pain
St John of God Hospital, Subiaco Clinic
25 McCourt Street
Subiaco WA

2. OROFACIAL PAIN
The field of Dentistry that includes the Assessment, Diagnosis and Treatment of
Complex chronic orofacial pain and dysfunction
Oromotor and jaw behaviour disorders
Chronic facial, head and neck pain

3. OROFACIAL PAIN Dental (Odontogenic) Pain
Musculoskeletal Pain – Temporomandibular disorders
3. Neurovascular Pain – Primary headaches
4. Neuropathic Pain
Episodic
Continuous
5. Sinus Pain
6. Psychogenic Pain
7. Intracranial
8. Cervicogenic

4. Pain generators Head -meninges Orofacial -sinuses Neck & shoulders
-skull & scalp
-nerves
-trigeminal (V)
-C2-3 (GON/LON)
Orofacial
-sinuses
-TMJ, ear
-teeth, nerves
Neck & shoulders

5. Intracranial pressure Infection Neurovascular Trigeminal Trauma
Red flags
T.I.N.T
Tumour
Temporal arteritis
Intracranial pressure
Infection
Neurovascular
Trigeminal
Trauma

6. Red Flag Case Presentation
Female 16 years
Hx of constant deep aching TMJ/jaw pain worse with chewing, extending to occiput.
Initially treated with Occlusal Splint/Physio.
Headaches on exertion - paroxysmal with “fainting”.
Parents noted subtle personality changes.
MRI - Arnold Chiari formation- surgery.

7. Intracranial Pathology Diagnostic Clues
Neurological type symptoms/signs.
No response to peripheral therapies.
Unusual or worsening symptoms despite therapy.
Negative response to somatic/sympathetic blocks.

8. Intracranial pathology
Common manifestations of raised intracranial pressure

9. Space Occupying Lesions
Neoplasms
Arterial dissection
Aneurysms
Infection/Abscess
Infarction/haemorrhage
Oedema
Angioma

10. Temporal (Giant cell) Arteritis
RED FLAG
Headache emergency
New onset headache in >50 years
Uni/bilateral dull temporal pain
Claudication masticatory muscles
Visual disturbance
Polymyalgia-shoulder/hip, malaise
Swollen, tender temporal artery
Elevated ESR, CRP
Positive biopsy

11. Temporal Arteritis RED FLAG Headache of vascular origin
Initial symptoms may resemble TMD
- Pain/stiffness in jaw
- Pain/fatigue of jaw when chewing
- Pain may radiate to ear, teeth
- Temporal headache
If untreated may cause blindness, stroke and death!
Generally resolves with high dose steroids

12. Extracranial Sources of Orofacial Pain
Teeth and oral mucosa
ENT, paranasal sinuses
TMJs &myofascial
Tongue
Salivary Glands
Lymph Glands
Eyes
Vessels & nerves

13. Odontogenic Pain – Toothache
Most common cause of orofacial pain!
Often missed by medical people
Dental caries into dentine / pulp
Pulpitis, pulp necrosis
Cracked teeth
Periodontal infection
ASK ABOUT HOLES IN TEETH
Hot/cold/bite SENSITIVITY, PAIN AT NIGHT

14. Toothache Toothache - most common orofacial pain complaint
12.2% of population reported toothache in last 6M
Diagnosis can be challenging and complicated
Pain from one tooth may be referred from another tooth or from other orofacial structures
Other craniofacial pain disorders may mimic the symptoms of toothache
Proper diagnosis is critical
45711 american households 22% in past 6 months

15. Consider all pains in the mouth and face to be of dental origin until proven otherwise

16. TEMPOROMANDIBULAR DISORDERS
Major cause of Non Dental Pain in Orofacial Region

17. TEMPOROMANDIBULAR DISORDERS
Collection of medical and dental conditions affecting the temporomandibular joint and/or muscles of mastication and/or contiguous tissues resulting in pain and/or dysfunction

18. TEMPOROMANDIBULAR DISORDERS Primary Clinical Features
Ear ache (pre-auricular pain)
Painful jaw use e.g. with chewing, yawning
Tender TMJs and muscles of mastication
Restriction of jaw movement
Interference with jaw movement
TMJ sounds e.g. clicking, cracking, popping sounds

19. TEMPOROMANDIBULAR DISORDER Other Clinical Features
Headache
Ear symptoms eg discomfort, fullness
Occlusal discomfort or change
Mandibular dyskinesia
Intermittent facial swelling

20. TEMPOROMANDIBULAR DISORDERS
The pain/dysfunction should be directly related and aggravated by jaw use (Solberg)

21. Temporomandibular Disorders
TMJ ARTHRALGIAS
1. Traumatic arthralgia
2. Arthromyalgia
3. Internal Derangement - painful TMJ dysfunction
4. Osteoarthritis
5. Systemic (poly)arthritis
.OROFACIAL MYALGIAS
- Muscle splinting/strain
- Muscle spasm
- Myofascial Pain +/- TPs
- Myositis
- Fibromyalgia

22. TEMPOROMANDIBULAR DISORDERS Masticatory Muscle Disorders
Protective co-contraction (splinting)
Local muscle soreness (strain)
Muscle spasm
Myositis
Myofascial pain

23. Neurovascular Pain

24. Case Presentation 48 year old female
Intermittent dull throbbing pain in upper tooth/jaw, radiating to temple and eye.
Severe attacks, last 1-3 days with constant dull pain.
When severe, feels sick and prefers dark, quiet room to sleep.
Attacks used to respond well to NSAIDs.
Had a root canal, crown of upper premolar + splint

25. Migraine

26. Case Presentation Male in mid forties.
Right sided face pain attacks on/off over three years
Extending into right eye.
Often awakened from sleep with severe throbbing pain.
Would get up and pace around holding his R. eye.
Face would feel sweaty, tearing of eye.
Numerous dental visits – Root canals/ extractions.

27. Case Presentation EXAMINATION Cranial nerve screen - Normal
TMJ/Myofascial – Normal
Oro-dental- Normal
Medication Trial - response to oxygen/sumatriptan

28. TRIGEMINAL AUTONOMIC CEPHALGIAS (TACs)
CLUSTER HEADACHE
CHRONIC PAROXYSMAL HEMICRANIA
HEMICRANIA CONTINUA
Unilateral, severe attacks with typical autonomic headache accompanying symptoms.
Peri-orbital or maxillary pain.
Frequently leads to dental work including extractions.

29. Cluster Headache Clinical Features
Attacks are severe - boring
Strictly unilateraln in and around eye and/or temporal region - “hot poker”
Attack duration min
Attacks occur from once every 2nd day up to 8x day.
Attacks occur in series lasting weeks to months Remissions mths-yrs
Autonomic features +++
Males 5-7:1
65% had dental Tx

30. Chronic Paroxysmal Hemicrania
Similar to Cluster but
Female preponderance (3:1)
Attacks are more frequent and of shorter duration
5-40 attacks per day (median 5-10)
Attacks last 2-45 minutes
At least one autonomic symptom on the side of pain
conjunctival injection lacrimation
nasal congestion rhinorrhoea,
ptosis eyelid oedema

31. Chronic Paroxysmal Hemicrania
Always unilateral orbital, and/or temporal.
Severe stabbing/boring type pain that throbs as it builds up.
Episodic form occursin bouts lasting months to years with clear intervals (rare).
In most cases responds rapidly and absolutely to Indomethacin (diagnostic test).

32. Tension Type Headache (TTH)
Previously called tension headache, muscle contraction headache, stress headache
Most common primary headache (30-70% prevalence)
Episodic (frequent/infrequent) and chronic forms
Usually frontal /temporal location
Tightness, pressure in hat-band like distribution
+/- pericranial muscle tenderness
Often co morbid with migraine w/o aura.

33. Tension Type Headache
NOT DUE TO ABNORMAL MUSCLE CONTRACTION

34. Neuropathic Orofacial Pains
EPISODIC
Trigeminal Neuralgia
Glossopharyngeal Neuralgia
CONTINUOUS
Painful Traumatic Trigeminal Neuropathy
Post Herpetic Neuralgia
Persistent Idiopathic Facial Pain (PIFP)
Persistent Dento-alveolar Pain (PADP)
Burning Mouth Syndrome

35. Case Presentation 65 year old female
Sharp shooting pains upper anterior teeth 22/23
Saw dentist - fillings, root canals, extraction, bridge, removal of bridge
Inserting denture triggers sharp pain
Repeated denture adjustments

36. Case Presentation EXAMINATION Cervical spine - normal
Cranial nerve screen - normal
TMJ/MM - normal
Myofascial - tender masseter.
Intraoral - mucosa normal appearance trigger area palatal to 23 site.

37. Orofacial Neuropathic Pain

38. Trigeminal neuralgia
Brief, electric shock-like, lancinating pains that affects the face unilaterally affecting one or more divisions of the trigeminal nerve
tic douloureux
seconds
Shaving , combing the hair, wind, eating

39. Trigeminal Neuralgia Intermittent brief paroxysmal pain (secs-mins)
Limited distribution: V2 and/or V3 > V1
Trigger zone –minor stimuli- touch, wind, shave
Abrupt in onset and termination and may remit
Remission period can spontaneously occur that lasts for weeks to years, and may return
Triggerable or spontaneous
No obvious local cause

40. Painful Post Traumatic Trigeminal Neuropathy (AFP, PIFP)
Unilateral facial and/or oral pain
Usually continuous +/- sharp jolts of pain
History of trauma to same V nerve branch
Positive and/or negative neurosensory signs
(allodynia, hyperalgesia, hypoesthesia etc)
Equivocal response to LA nerve block
Varying degree of central & sympathetic involvement

41. Case presentation 40 yo female
Complains of 3 years continuous dull aching pain in lower left quadrant. Occasional sharp pains.
Problem commenced after periodontal surgery and surgical extraction of third molar.
Since had RCT of 1st and 2nd molars w/o effect
Aggravated by eating on that side and brushing teeth.

42. Persistent Dento-Alveolar Pain Disorder (PDAP)
(Atypical Odontalgia, Phantom tooth pain)
Continuous variable pain
Localized to dento-alveolar region – tooth/extrn sites
Usually multiple (unsuccessful) dental procedures
No obvious local pathology-clinical/radiography
Not caused by another disease or disorder
+/- Sensory abnormalities
Somatic block equivocal

43. Case Presentation 48 year old female
2 years continuous dull, aching, burning pain in upper right jaw
Presumed pulpitis so over time 3 x root canals
Extractions all upper molars, now wants premolar out
Extractions only aggravated pain, which has spread
Some sinus and menopausal symptoms
Hx of depression - not current

44. Case Presentation Cervical Spine - normal
Cranial Nerve Screen - normal
Stomatognathic- normal
Myofascial – trigger points but not replicating pain
Intraoral- Extraction sites hyperaesthetic
Somatic block – negative
Sympathetic block- partially positive
Cone Beam CT, MRI- normal

45. Persistent Dento-Alveolar Pain Disorder (PDAP) (Atypical Odontalgia, Phantom Tooth pain)
Females > males – usually mid 40s on
Posterior maxillary quadrant most often
Hx of trauma - multiple dental procedures
Somatosensory abnormalities around tooth site
No evidence of psychopathology
<50% responded to LA block
Variable response to TCA, gabapentinoids, topicals etc
Repeated dental procedures are contraindicated

46. EETS
Excessive Endodontic Treatment Syndrome

47. THANK YOU !!!!

48. Classification of Orofacial Pains
Axis I
(Physical Conditions)
Axis II
(Psychological Conditions)
Somatic Pain
Neuropathic Pain
Superficial Pain
Deep Pain
Episodic Pain
Continuous Pain
Mood Disorders
Bipolar Disorder
a Medical Condition
Mood Disorder due to
Depressive Disorder
Anxiety Disorders
Posttraumatic Stress
Disorder
Anxiety Disorder due to
a Medical Condition
Generalized Anxiety
Cutaneous Pain
Mucogingival Pain
Musculoskeletal Pain
Visceral Pain
Paroxysmal Neuralgia
Metabolic Polyneuropathies
Peripheral Mediated Pain
Central Mediated Pain
Somatoform Disorders
Other Conditions
Affecting Med Condition
Psychological Factors
Malingering
Muscle Pain
TMJ Pain
Osseous Pain
Connect. Tissue Pain
Periodontal Pain
Glandular, ENT Pain
Visceral Mucosal Pain
Pulpal Pain
Vascular Pain
Neurovascular Pain
Other Neuralgias
Trigeminal Neuralgia
Entrapment Neuropathy
Deafferentation Pain
Neuritic Pain
Burning Mouth Disorder
Atypical Odontalgia
(Phantom Pain)
Hypochondriasis
Pain Disorder
Conversion Disorder
Somatoform Disorder
Undifferentiated
Central Mediated Myalgia
Myospasm
Myofascial Pain
Local Muscle Soreness
Protective Co-Contraction
Arthritic Pain
Capsular Pain
Retrodiscal Pain
Ligamentous Pain
Carotidynia
Arteritis Pain
Neurovascular Variants
Other Primary Headache
Cluster and other TCA
Tension-Type
Migraine
Traumatic Neuroma
Peripheral Neurits
Herpes Zoster
Post Herpetic Neuralgia
Pain Syndrome
Chronic Regional
Physiological Response
Stress-Related
Maladaptive Health
Behavior
Personality Traits
or Coping Style
Axis I Axis II
Sympathetically Maintained Pain
Diagnosis
Okeson, 2003