ORAL SURGERY

GROUP C
FACIAL
NEUROPATH
Y
CHAPTER 30
TOPICS
TO
COVER
 Basics of Pain Neurophysiology
 Classification of Orofacial Pains
 Neuropathic Facial Pains
 Chronic Headache
 Other Chronic Head Pains of Dental
Interest
 Evaluation of Patient With Orofacial
Pain
BASICS OF PAIN
NEURO-
PHYSIOLOGY
BASICS OF PAIN NEUROPHYSIOLOGY
Pain is a complex human psycho-physiologic experience.
This experience is influenced by factors such as :-
* Past pain experiences.
* Cultural behaviors .
* Emotional and medical states.

Pain experience has physiological aspect and psychological aspect.

As,
Physiological aspect:
Involve several process such as,
Transduction: Refers to the activation of specialized nerves,
namely, A-delta (Aδ) and C-fibers, that transmit information to the
spinal cord.
Transmission: Relay functions by which message is carried from
the site of tissue injury to the brain regions.
Modulation: Neural process that acts to reduce activity in the
transmission system.
Psychological aspect:
 Psychological influences are particularly important in
determining:
- perceived pain intensity
- patient response to pain.
 In some patients, the sound of the dental drill evokes
true pain perception despite the fact that the bur has
not yet touched the tooth.
 When pain becomes chronic, generally defined as
greater than 4 to 6 months induration, attention to
psychological influences can become particularly
important.
BOX 30.1 Relationship Between Sensory Nerve Fiber Size
(Diameter) and Conduction Velocity
Fiber Type Diameter (µm) Velocity
(m/s)
A 13–22 70–120
Aβ 8–13 40–70
Aγ 4–8 15–40
Aδ 1–4 5–15
B 1–3 3–14
CLASSIFICATION
OF OROFACIAL
PAIN
CLASSIFICATION OF
OROFACIAL PAIN
Numerous classification systems exist for orofacial pain
conditions.
At the most basic level, it is appropriate to classify orofacial pains
as
- Primarily somatic
- Neuropathic or Psychological
1. Somatic pain
Arises from musculoskeletal or visceral structures interpreted
through an intact pain transmission and modulation system.
- Examples of msk pain are temporomandibular joint (TMJ)
disorders or periodontal pain.
- Examples of visceral Oro facial pains include salivary gland
pain and pain caused by dental pulpitis.
2. Neuropathic pain
arises from damage or alteration to the pain pathways, most
commonly a peripheral nerve injury due to surgery or trauma.

Malingering, a term used to identify behavior in which a

patient consciously feigns illness or the extent of illness for
personal gain.

For those undiagnosed facial pains, the appropriate term should

be facial pain of unknown cause until a definitive diagnosis
has been established.
NEUROPATHIC
FACIAL PAIN
 Trigeminal Neuralgia
 Pre-trigeminal Neuralgia
 Odontalgia Resulting From
Deafferentation (Atypical
Odontalgia)
 Post-herpetic Neuralgia
 Neuroma
 Burning Mouth Syndrome
 Other Cranial Neuralgias
NEUROPATHIC FACIAL
PAIN
Neuropathic Facial Pain:
Arise from an injured pain transmission or modulation system
Cause:
•Surgical intervention
•Trauma
Examples:
•Trauma to infra orbital region may lead to numbness or pain in
distribution of infra orbital nerve
•In dental surgery, extraction of impacted third molar carries a risk
of damage to mandibular and lingual nerve
Neuropathic pain may also give rise to sensation of tooth pain
which is often a diagnostic dilemma for dentists
Management:
Referral of patient for management of these disorders to dentist
focusing on orofacial pain diagnosis and management or to
patient's personal physician or neurologist is customary.
BOX 30.1 GLOSSARY OF PAIN TERMS

Allodynia: Pain caused by stimulus that does not normally provoke

pain
Analgesia: Absence of pain in response to painful stimulus
Anesthesia: Absence of all sensation
Deafferentation pain: Pain caused by loss of sensory input into the
CNS
Dysesthesia: Unpleasant abnormal sensation, whether spontaneous
or evoked
Hyperalgesia: Increased sensitivity to noxious stimulation
Hyperesthesia: Increased sensitivity to all stimulation, excluding
special senses
Hypoalgesia: Diminished sensitivity to noxious stimulation
Hypoesthesia: Diminished sensitivity to all stimulation, excluding
the special senses
Neuralgia: Pain in the distribution of a nerve or nerves
Neuropathy: Disturbance of function or pathologic change in a
nerve
Paresthesia: Abnormal sensation, whether spontaneous or evoked
TRIGEMINAL
NEURALGIA
TRIGEMINAL
NEURALGIA
Neuropathic pain of Trigeminal nerve of origin occurring most
frequently in patients older than 50 years

BOX 30.2 Trigeminal Neuralgia:

Clinical Characteristics
• Severe paroxysmal pain
• Unilateral location (96%); right > left
• Mild superficial stimulation provokes
pain
• V2 and V3 dermatomes most
commonly affected
• Frequently pain free between attacks
• No neurologic deficits
• No dento-alveolar cause found
• Local anesthesia of trigger zone
temporarily arrests pain
TRIGEMINAL
NEURALGIA
Trigger Zone:
Usually a trigger zone is present, where mechanical stimuli such as
soft touch may provoke an attack.
Common trigger zones include Intra oral triggers
may include:
- corner of the lips - teeth
- cheek - tongue
- ala of the nose or lateral brow - gingiva
Trigger zones in the V2 and V3 distributions are most common.

Cause of TN:
The cause of TN is not entirely clear, but the consensus is that
pressure on the root entry zone of the trigeminal nerve by a
vascular loop leads to focal demyelination. This demyelination, in
turn, precipitates ectopic or hyperactive discharge of the nerve
TRIGEMINAL
NEURALGIA
Differential diagnosis:
•Multiple Sclerosis
•Lyme disease
•Tumour

Management:
The treatment of TN is medical or surgical.
•Medical treatment is with anticonvulsants. The classic medication
for the condition is carbamazepine.
•Surgical treatment includes:
- microvascular decompression
- Gamma Knife radio- surgery,
- percutaneous needle thermal rhizotomy
- balloon compression of the root entry zone.
PRE-
TRIGEMINAL
NEURALGIA
PRE-TRIGEMINAL
NEURALGIA
- A rare condition
- The condition is typically an aching dental pain in a region
where clinical and radiographic exam reveal no abnormality.
- Local anesthetic block of the tooth arrests pain for the
duration of anesthetic’s action.

A number of patients with this condition have been

demonstrated to go on to have typical TN symptoms (i.e., sharp
electric shock pains in the area).

Management:
Pre-TN responds to similar treatments as TN, beginning with
anticonvulsant therapy.
ODONTALGIA
RESULTING
FROM DE-
AFFERENTATIO
N
(ATYPICAL
ODONTALGIA)
ODONTALGIA
Pain resulting from deafferentation refers to pain that occurs when
damage to the afferent pain transmission system has occurred.
Cause:
- trauma or
- surgery, including extraction and endodontic treatment (because
of involvement of amputation of tissue that contains nerves)
These pains may be maintained by various mechanisms—some
readily appreciated and others not yet completely understood.

BOX 30.4 Odontalgia Resulting From Deafferentation

• Burning or aching pain is continuous or almost continuous.
• Sharp paroxysms may occur.
• Allodynia, hyperesthesia, or hypoesthesia may be present.
• No dentoalveolar cause is found.
• History of surgical or other trauma exists.
• History of symptoms greater than 4–6 months exists.
• Local anesthetic block is equivocal.
POST
HERPETIC
NEURALGIA
POST HERPETIC
NEURALGIA
 PHN is a clinical manifestation of reactivation of a lifelong
latent infection with VZV, usually contracted after period of
chicken pox in early life.
 Occurs later in life (immunocompromised patients).
 PHN occurs after reactivation of the virus, which can lay
dormant in the ganglia of peripheral nerve.
 Most commonly a thoracic nerve is involved. In 10 to 15%
cases trigeminal nerve is involved with the V1 dermatome
affected in 80% of trigeminal cases.
 V1 dermatome is outlined by rash, V2 and V3 intraoral and
cutaneous expression is seen.
 The pain related to HZ appears before any rash.
 The pain is typically burning, aching, or shock-like.
POST HERPETIC
NEURALGIA
TREATMENT:
• Anticonvulsants
• Tricyclic or other antidepressants
• Tramadol a mild opioid

RAMSAY HUNT SYNDROME

HZ infection of sensory and motor branches of facial nerve (CN
Vll) and in some cases the auditory nerve (CN Vlll).
Symptoms
- facial palsy,
- vertigo,
- deafness
- herpetic eruption of external auditory meatus.
The tongue can also be involved via the chorda tympani.
NEUROMA
NEUROMA
Neuroma:
Neuroma is a benign tumor of nerve tissue that is often
associated with pain or specific types of various other
symptoms.
• After peripheral nerve trans-section, proximal portion of
nerve forms sprouts in an effort to regain communication
with the severed distal component.
• When sprouting occurs without distal segment
communication, a stump of neuronal tissue, Schwann cells,
and other neural elements can form.
• The pain is commonly burning or shock-like.
• Frequently a positive Tinel sign is present.
• In this test, tapping over the suspected neuroma produces
sharp, shooting, electric shock-like pain.
• Damage to the mandibular or lingual nerve after third molar
surgery is a source for neuroma formation that a dentist
might see
BURNING
MOUTH
SYNDROME
BURNING MOUTH
SYNDROME
BMS:
In this condition, the patient perceives a burning or aching
sensation in all or part of the oral cavity.
Common Site:
- tongue
Perceived by:
- dry mouth
- altered taste
Cause:
- unknown
- a defect in pain modulation may
be the most promising theory.
Treatment:
- anticonvulsants
- antidepressants
OTHER
CRANIAL
NEURALGIAS
OTHER CRANIAL
NEURALGIAS
Glossopharyngeal Neuralgia:
- most common of the other CNs.
- The presenting symptom is typically sharp, electric shocklike
pain on swallowing with a trigger zone in the oropharynx or the
base of the tongue.
- Pain is usually experienced in the throat or tongue, but may be
referred to the lower jaw.
The facial nerve (CN VII)
- has a small somatic component on the anterior wall of the
external auditory meatus in which shock-like pains are
experienced
-symptoms of tinnitus, dysgeusia, and dysequilibrium
The vagus nerve (CN X)
-neuralgic activity manifesting as pain in the laryngeal region
shooting deep to the mandibular ramus or even to the region of
the TMJ.
Treatment
- involves the use of anticonvulsants
- in some cases intracranial surgery is necessary
CHRONIC
HEADACHE
 Migraine
 Tension Type Headache
 Cluster Headache
MIGRAINE
MIGRAINE
- Greek word "HEMICRANIA" which means half head.
- Neurological disease
- Very common type of chronic headache.
- Affects 18% Women and 8% Men.
- Occurs mostly in teenage or young adults
- Can also affect children.
- After puberty it Affects women twice as compared to men.
Mechanism:
Not completely understood, may involve neurogenic inflammation
of intracranial blood vessels resulting from neurotransmitter
imbalance in certain brainstem centers.
Location: 40% Unilateral
Duration: 4 - 72 hours
Triggering Factors:
- Menstruation
- Stress
- Certain vasoactive foods
- Drugs
- Musculoskeletal disorder (e.g., TMJ disorders)
MIGRAINE
AURA:
- Transient focal neurological phenomenon that occurs before or
during headache.
- It develops several minutes to 1 hour before headache onset
- Affects approximately 40% of patients.
- Expressed as flashing or shimmering lights or partial loss of
vision.
- Complicated aura may produce transient hemiparesis, aphasia
or blindness.
- 80% of people suffering from migraine have nausea and
photophobia
Clinical Features:
- Severe, throbbing, pulsating, continuous pain
- May or may not be followed by aura
- Mostly at day time
MIGRAINE
BOX 30.6 International Headache Society Criteria for
Migraine With Aura
A. At least two attacks fulfilling criteria B through D
B. Aura consisting of ≥1 of the following, but no motor weakness:
1. Fully reversible visual symptoms including positive and/or
negative features
2. Fully reversible sensory symptoms including positive and/or
negative features
3. Fully reversible dysphasic speech disturbance
C. At least two of the following:
1. Homonymous visual symptoms and/or unilateral sensory
symptoms
2. At least one aura symptom develops gradually over ≥5 min
and/or different aura symptoms occur in succession over ≥5 min
3. Each symptom lasts ≥5 and ≤60 min
D. Headache fulfilling criteria B through D for 1.1 Migraine without
aura begins during the aura or follows aura within 60 min
E. Not attributed to another disorder
MIGRAINE
BOX 30.5 International Headache Society Criteria for
Migraine Without Aura
A. At least five attacks fulfilling criteria B through D
B. Headache attacks lasting 4–72 h (untreated or unsuccessfully
treated)
C. Headache has two or more of the following characteristics:
1. Unilateral location
2. Pulsating quality
3. Moderate or severe pain intensity
4. Aggravation by or causing avoidance of routine physical activity
(e.g., walking, climbing stairs)
D. During headache ≥1 of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia
E. Not attributed to another disorder
MIGRAINE
Treatment:
- Antidepressants
- Anticonvulsant
- Beta-Blockers
- Botulinum toxin
- 5 HT1 Antagonist
- Cyproheptadine
Treatment of acute attacks:
- Triptans (sumatriptan, zolitriptan, etc)
- Ergots
- NSAID's
- Opioid analgesic
- Antiemetic
Dental Importance:
- TMJ disorders
- cervical spine and cervical muscular disorders
- masticatory muscle hyperactivity
TENSION TYPE
HEADACHE
TENSION-TYPE
HEADACHE
TTH:
- Referred to as muscle contraction headache, stress headache,
or psychomyogenic headache.
- Common in the general population
Incidence:
- More common in women than in men.
- Generally bilateral.
Characteristic:
- Pain is frequently bi-temporal or frontal-temporal
in distribution.
- Patients described as though the head is "in a vice"
or a "squeezing hatband" is around the head.
- These headaches can occur with or without
"pericranial muscle tenderness“.
TENSION-TYPE
HEADACHE
BOX 30.7 International Headache Society Criteria for
Episodic Tension-Type Headache
A. At least 10 episodes occurring on <1 day/month (<12
day/year) and
fulfilling criteria B through D
B. Headache lasting from 30 min to 7 days
C. Headache has two or more of the following characteristics:
1. bilateral location
2. pressing/tightening (nonpulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. no nausea or vomiting (anorexia may occur)
2. no more than one of photophobia or phonophobia
E. Not attributed to another disorder
TENSION-TYPE
HEADACHE
Treatment:
- tricyclic or other antidepressants
- cognitive-behavioral and other psychological therapies
- regular aerobic exercise

In Dentistry:
- it is important to distinguish tension-type headache from
masticatory myofascial pain.
- This can be confusing because both conditions have similar
symptoms.
- It is significant that in myofascial pain, pressure to various
head or neck muscles refers to the site of head pain, whereas
in tension-type headaches, pressure identifies the site of pain.
CLUSTER
HEADACHE
CLUSTER HEADACHE
Cluster Headache:
- It is unilateral head pain
- Mostly around eye and temporal regions
- Pain is intense , described as stabbing sensation
- Parasympathetic overactivity present
- Conjunctival injection
- Rhinorrhea
- Ptosis
- Lacrimation
- Headaches tend to occur in cyclic patterns
- Last for usually 15 to 180 minutes
- Occur once or multiple times a day, mostly in precise
regularity
BOX 30.8 Common Cluster Headache
Trigger Factors: Features
- Tobacco Smoking
- Alcohol Ingestion Sex: Mainly male
Frequency: Up to 8 per day
Quality: Throbbing or stabbing
Intensity: Severe
CLUSTER HEADACHE
Preventive Treatment:
• Verapamil • Lithium salts
• Anti-convulsants • Corticosteroids
• Certain ergot compounds
Symptomatic Treatment:
• triptans • ergots &
• analgesics
- Oxygen Inhalation at 7 to 10 L/min may be an effective abortive treatment.

For pain Local Anaesthesia can be used.

In Dentistry:
- Cluster headache produces pain in the posterior maxilla.
- Pain is frequently stabbing and intense (background aching may occur).
Features which distinguish toothache by cluster headache from a
toothache by a dental problem:
• Rapid emergence and discontinuation of symptoms unlike typical
toothache
• Toothache precipitated by alcohol ingestion
• Toothache accompanied by unilateral rhinorrhea or other parasympathetic
symptoms
OTHER CHRONIC HEAD
PAINS OF DENTAL
INTEREST

 Temporal Arteritis (Giant Cell Arteritis)

 Indomethacin-Responsive Headaches
TEMPORAL
ARTERITIS (GIANT
CELL ARTERITIS)
TEMPORAL ARTERITIS
Temporal arteritis also termed giant cell arteritis:
An inflammation of the cranial arterial tree that can affect any or all
vessels of the aortic arch and its branches.
Etiology:
The inflammation results from a giant cell granulomatous
reaction.
Characteristics:
 Onset: Acute or chronic
 Location: Localized
 Associated symptoms:
- Weight loss - polymyalgia rheumatica
- fever - decreased vision
- jaw claudication
 Pain character: Severe throbbing over area affected
 Duration: Prolonged
 Age: Over 50 years

TEMPORAL ARTERITIS
Diagnosis:
- erythrocyte sedimentation rate or cross-reactive protein
testing
- temporal artery biopsy
Treatment:
- high-dose corticosteroids
- early treatment is necessary to avoid blindness
INDOMETHACI
N- RESPONSIVE
HEADACHES
IND-RESPONSIVE
HEADACHES
A number of head pains respond primarily or exclusively to the
NSAID indomethacin. i-e, chronic paroxysmal hemi-crania, Hypnic
headache etc.
Presentation:
- a toothache may be the initial presentation.
- Exertional headaches, as in weight lifting or during sexual
intercourse.
Chronic paroxysmal hemicrania:
- Similar in presentation to cluster headache.
- Attacks are short-lived.
- Attacks occur many times a day.
- Women are more affected .
Hypnic headache:
- Seen in older patients.
- wake patient from sleep generally within 2 to 4 hours of sleep
onset and last 15 minutes to 3 hours.
- These are frequently indomethacin responsive.
- Headache is not accompanied by symptoms of parasympathetic
over activity.
EVALUATION OF
PATIENT WITH
OROFACIAL PAIN
EVALUATION
It comprises two components:
1- History 2- Physical evaluation
(1) History:
Components of pain history:
The pain history should include the chief complain, including:
- the current description of pain quality
- intensity
- when it occurs
- how long it lasts
- if it changes in character over time
- precipitating factors
- alleviating factors.
History of the present illness
- date of onset
- circumstances surrounding onset
- how the pain evolved over time
- diagnostic tests obtained
- diagnoses rendered
- what treatments were instituted in the past
- response to those treatments.
TABLE 30.3 DIFFERENTIAL DIAGNOSIS OF
COMMON HEADACHES
Temporal Migraine Cluster Tension
Arteritis
Onset Acute or chronic Acute Acute Chronic

Location Localized Unilateral Unilateral Global,

unilateral
Symptoms Weight loss, Nausea, Rhinorrhea, Multi-somatic
polymyalgia vomiting, Lacrimation complaints
rheumatica, photophobia of ipsilateral
fever side
Pain Severe Throbbing Sharp Aching
throbbing over stabbing
affected area
Duration Prolonged Prolonged 30 min to 12 Daily
h
Prior - + + +
History
Diagnostic ESR + None - None - history None - history
Test history
Physical Myalgias, fever Nausea, Unilateral,
EVALUATION
Physical evaluation should include:
- Vital signs determination
- Intraoral examination with oral cancer screening
- Head and neck examination
- Evaluation of temporal and carotid arteries, lymph nodes, skin, head, and
neck
- Myofascial and TMJ examination
Purpose of TMJ examination: Detect areas of hyperesthesia or
hyperalgesia, allodynia, trigger zone for TN, or an area of decreased
sensation.
Diagnostic anesthetic testing with vasoconstrictor-free solution helps
define neuropathic pain condition.
Local anesthesia may arrest pain temporarily.
Imaging is appropriate to rule out odontogenic, sinus, or bony pathologic
conditions.
OPG and dental periapical radiographs are helpful for dental disorders.
Intracranial imaging is important for neuropathic and headache disorders
to rule out CNS demyelinating process, vascular malformation, tumor, or
other abnormality.
Specialized studies like magnetic resonance arteriography, bone scan,
THANKYO
U