1. Orofacial Pain Management
MJDF Study Group.
Craig Hadden

2. Definition Orofacial:
Relating to the mouth and face (Trigeminal Nerve distribution)
Pain: Feeling of distress, suffering, or agony, caused by 
stimulation of specialized nerve endings. Also includes perception and subjective interpretation.

3. Prevalence:
22% of the US population suffer orofacial pain more than once in 6 months. ¼ of population in England, only half sought help, prevalence higher in young people (18-25yo) and women. Total cost of “headache” accross 8 countries in Europe is estimated at approximately 173billion Euros annually.

4. Diagnosis:
Site Onset Character Radiating Associations Timing Exacerbating/relieving features Severity – pain scale.

5. Diagnosis: Identify inflammation – redness, swelling, heat, pain.
Loss of function – trismus, inability to bite on tooth, difficulty swallowing.

6. Diagnosis: Special Tests: Hot/cold, EPT.
Radiographs: PAs, BWs, Panoral, CBCT.
Haematological investigations.
Biopsy
Signs of sinister disease: >50yo, Painless trismus, Asymmetry, Sudden or recent acute pain.

7. Aetiology of pain:
Dental: most common Pulpal – reversible pulpitis – caries removal – irreversible pulpitis – RCT/XLA Sensitivity - Cold/Sweet/Physical - coatings/TBI/ sensitive tooth paste.

8. Aetiology of pain: Apical: Heavy bite - adjust occlusion
Apical periodontitis, leading to dental abscess – RCT/XLA
Post operatively after RCT – monitor/analgesics.

9. Aetiology of pain: Apical spread: Blocked airway,
Systemic involvement: Fever/malaise and swelling/trismus – XLA with drainage and appropriate antibiotics – SDCEP.

10. Aetiology of pain:
Pericoronitis – XLA if possible (according to paper) but antibiotics indicated if XLA not an available option.
Periodontitis - remove causative factors: plaque retentive areas. Scaling as appropriate, OHI, TBI, Smoking cessation where applicable.

11. Aetiology of pain:
ANUG – debridement, OHI, TBI, Metronidazole with review after 3 days. (see SDCEP)
Alveolar Osteitis – curettage, rinse of socket (avoiding Chlorohexidine) alvogyl.

12. Aetiology of pain: Non Odontogenic:
Maxillary sinusitis – maxillary molars, ache which worsens when lying down. Treat with decongestants, refer if chronic.
Viral infections (see previous!)
Atypical facial pain – rule out any dental causes.
Trigeminal Neuralgia – refer
TMD – Covered previously.

13. Intra and Post Operative Pain Prevention
Intra-operative:
Local Anaesthetic:
Prevents transmission of nerve impulses
Binds to sodium channels preventing polarisation and firing.

14. LA
Lidocaine 2%, 1:80k adrenaline: general use, minor oral surgery, block required for lower molars.
Prilocaine 3%, Felypressin: Medically compromised patients eg hypertension/ hyperthyroidism.
Mepivicaine 2%, 1:100k adrenaline: as lidocaine
Articaine 4%, 1:100k adrenaline: good for ‘hot’ pulps, infiltratations all round mouth.
Bupivacaine 0.5%, 1:200k adrenaline: long acting, increased toxicity comparatively.
Levobupivacaine 0.5%, 1:200k adrenaline: long acting, reduced toxicity comparatively to bupivacaine

15. LA Risks of parasthesia
Unfounded that 4% Articaine has increased risk of causing nerve damage when used as block.
Repeated insertion of needle when repeating injection after failed block more likely to traumatise nerve.
Suggestion that Articaine infiltrations for lower molars are therefore safer for lower molar anaesthesia.

16. LA Technique: depends on requirement:
Block/Infiltration.
Standard ID Block, Gow Gates or Akinosi “high block.”
Lower teeth can have additional innervation from:
Nerve to Mylohyoid
Long Buccal Nerve
Cutaneous Coli Nerve (labial periostium)
Auriculotemporal.

17. Post Operative Management
Use of analgesics can speed recovery.
Opiod/Non-opiod (NSAIDs, paracetemol)
NSAIDs – reduce pain from inflammatory reaction (Arachidonic Acid Cascade)
Opiods may affect emotional aspects of pa
in and modify transmission of pain information

18. NSAIDs Gold standard for analgesia in dentistry.
Action: inhibition of the enzyme Cyclo-oxygenase, and hence prostaglandin production.
Ibuprofen 200/400mg, tds
Diclofenac 25/50mg, tds (see SDCEP)
Contraindications: GI issues, Anticoagulant therapies, Bleeding disorders, Nephropathy, Allergy.

19. Paracetamol No significant anti-inflammatory effect
Hepatotoxic – be aware of alcoholics/patients with liver disease.
Mechanism unclear.

20. Which one when?

21. Summary Orofacial pain requires a diagnosis
Intra-operative pain can be controlled with appropriate LA delivered through an appropriate technique.
Post-operative recovery is aided by appropriate pain management.

24. References:
Acute Orofacial Pain, Khawaja N, Renton T, Dental Update, June 2015,