Orofacial pain

Oral medicine

1. Orofacial Painpain

2. Definition
An unpleasant sensation
caused by a noxious stimulus
that is mediated only along
specific nerve pathway into
the central nervous system,
where it is interpreted as
pain.

3. Anatomic considerations
Pain of the face and
mouth is conducted
along the:
Trigeminal nerve ( CN
V)
Facial nerve (CN VII )
Glossopharingeal
nerve (CN IX)

Vagus (CN X)
Cervical nerves 2 & 3
(C2&C3)

4. Pain classification by
origin
Somatic pain Originating from the cells of
the organ involved i.e. skin, mucous
membrane, bone, joint, muscles, etc…
Neurogenic pain Discomfort resulting
within the nervous system. Abnormality
in the neural structures. No noxious
stimulus
Psychogenic pain Resulting from psychic
causes, No noxious stimulus, No
abnormality in neural structure

5. 5
Somatic pain Neuropathic pain
Superficial
somatic
Deep
somatic
MusculoskeletalVisceral
Episodic
Continuous
Muscle
TMJ
Osseous
Periodontal
Pulp
Vascular
Neurovascular
Visceral
mucosa
Gland, ear, eye
Neuralgia
Neuro-
vascular
Neuritis
Sympathetically
maintained
Deafferent
n
pain
SkinMuco-gingival

6. A- SOMATIC
Somatic pain is usually acute and
localized, it also may be :
Superficial from the skin or mucous
membrane due to noxious stimuli e.g.
thermal or chemical burns, mechanical,
ulcerations, infection: ANUG (bacterial)
AHGS (viral) Candidiasis (fungal)
Character: Burning, Pricking, Localized.

7. Deep from bone, muscles, joints and
ligaments (Eagle’s syndrome which is due to
calcification of the stylohyoid ligament)
Character: dull aching, referred.
Inflammatory from collection of infected
fluid e.g. Abscess, infected cyst,
pericoronitis.
Character: throbbing with tenderness tends
to be localized.
Referred from paraoral structures e.g.
maxillary sinus, ear, eyes
Character: deep

8. B-NEUROGENIC
Neuropathy : functional abnormality of
nerves, that may be :
Neuritis: inflammatory change of the
nerves. (burning sensation)
Neuralgia: pain along the course of the
nerve caused by vascular spasm and
CNS diseases
It’s usually poorly localized, chronic,
preceded by minor electric shock like
pain

9. CAUSES OF OROFACIAL PAIN
I- Local causes (somatic):
Diseases of teeth
Diseases of the periodontium
Diseases of oral mucosa
Disease of jaws
Diseases of the antrum
Diseases of the salivary glands
Diseases of the TMJ
Disease of the ears
Diseases of the eyes
Diseases of the sinuses and nasopharynx.

10. II-Neurological causes (Neuropathic)
May be paroxysmal or non-paroxysmal
Paroxysmal Trigeminal Neuralgia
Glossopharyngeal Neuralgia
Gerniculate ganglion Neuralgia
Post Herpetic Neuralgia
Ramsy Hunt Syndrome
Bell’s Palsy
Tumors

11. III-Psychogenic causes
No stimuli, No abnormal neural
structures
Atypical facial pain
Myo-fascial pain dysfunction syndrome
Burning Mouth
IV-Vascular Causes
Migraine
Periodic migrainous neuralgia
Vasculitis-Giant cell arteritis
Wegner’s disease

12. Diseases of teet h
•Caries, pulpitis
•Abscesses
•Hypersensitivity
•Attrition- Abrasion- Erosions
•Fracture
•Pericoronitis

14. Causes of orofacial pain

15. -Diseases of the periodontium
Periodontal Abscess
Periodontitis

16. Occlusal trauma.
Dental
impaction.
Cysts & tumours.
Osteitis.

17. Diseases of the oral mucosa
Ulcers
Erosions
Burns
Acute herpetic
gingivostomatitis
Acute necrotizing
ulcerative gingivitis
Candidiasis

18. 4-Diseases of the Jaws
Dry socket
Fractures
Osteomyelitis
Cysts
Tumors

19. Disease of the sinuses
Sinusitis: usually
following a cold.
Maxillary sinusitis pain
is felt in relation to the
upper molars which may
be tender to percussion.
Frontal sinusitis
Tumors of maxillary
sinus

20. 6-Diseases of the salivary glands
a- Sialadenitis
Due to salivary gland obstruction (stones,
fibrosis)
Characterized by pain, swelling associated
usually with eating

21. b- Acute bacterial parotitis
Pain and swelling of the affected
gland, pus discharging from the
ductal orifice.
c- Viral conditions (Mumps)
Unilateral or bilateral

22. TMJ pain dysfunction
syndrome
Aching pain around the joint
Clicking of the joint
Limitation of mouth opening
Arthritis
Acute painful spasm of the
facial muscles due to acute
inflammatory conditions or
tetany
7-Diseases of the TMJ

23. 8-Diseases of the eyes
Conjunctivitis
Glaucoma (raised intra ocular
pressure).
Errors of refraction
Headache and pain in the face

24. Diseases of the
ears (Otitis
Media)
Leading to facial
pain, also oral
diseases can cause
pain referred to
the ear.

25. II- Neuropathic (neurologic) orofacial
pain
Characterized by paroxysmal pain along
the distribution of one or more of cranial
nerves.
Described as sharp, stabbing and
lancinating, simulating electrical shock,
episodic, the pain episodes are often
initiated by minor sensory stimuli to the
skin or mucous membrane referred to as
trigger zone (diagnostic). It affects either
deep or superficial structures

26. 1- MAJOR NEURALGIAS
•Trigeminal Neuralgia (Tic Douloureux)

•Severe, sharp, paroxysmal shocking pain
related to the distribution of the trigeminal
nerve it may be :
•Primary. i.e. idiopathic
•Secondary due to trauma or CNS lesions
•It affects the maxillary and mandibular
divisions of the trigeminal nerve
Sex: female > male (2:1).
Side: right > left.
Site: 2
nd
& 3
rd
division CN
Age: 60-70 years.

27. Pathogenesis

28. Etiology of Idiopathic Trigeminal
Neuralgia:
unknown, may be due to:
Vascular compression of the trigeminal
ganglion by nearby vessels. (cerebral
arteries)
Progressive degeneration of the
trigeminal ganglion
Stretching of the nerve over the
petrous part of temporal bone which is
larger on the right side

29. Sharp, lancinating, unilateral electric shock
like pain, along the course of the nerve.
Lasts from few seconds to few minutes
Appears and disappears suddenly
Episodic attacks ranges from several per day
to few per year.
Between the intervals the patient is
completely free
Stimulated by shaving, washing, smoking
and eating
After each episode, there is a refractory
period where stimulation of trigger zone will
not induce pain

30. Clinical features

31. Trigger zone (area)
The patient points to the area (trigger
area) with his forefinger without
touching it “half an inch finger sign” to
avoid initiation of pain.
Diagnosis
Local anesthetic block will identify the
specific nerve involved.
Neurologic examination to rule out
tumors or multiple sclerosis

32. Clinical features

33. 
2ry Trigeminal Neuralgia
•Results from intracranial trauma,
peripheral nerve injury or CNS tumors

34. Medical management
Carbamazepine
 Baclofen
Phenytoin.
Surgery: done in cases
refractory to medications.
Alcohol injection in nerve
or ganglion
Cryosurgery for peripheral
nerve.
Sectioning of part of the
nerve

35. Surgical treatment of TN

36. Glossopharingeal neuralgia

37. Clinical features

38. Rare condition, paroxysmal pain
less severe than trigeminal neuralgia,
affecting the Glossopharyngeal nerve.
(9th C.N.)
Affects the throat and ears and the post
1/3 of the tongue and pharynx.
Provoked by swallowing or talking,
chewing

39. Post herpetic Neuralgia

40. Post Herpetic Neuralgia
A complication of HZ (Shingles) which
follows it, mainly in elderly patients
Persistence of neuralgic pain after
resolution of the rash for weeks or
months results from inflammation and
fibrosis of the affected nerve,
continuous burning severe pain.

54. 2-Bell’s Palsy
Unilateral dysfunction of facial nerve
and rapid onset which results in
paralysis of facial muscles.
The patient may wake up with fully
developed facial palsy
Sometimes preceded by facial pain
especially at the angle of the jaw
Unilateral talking & smiling and
deviation of the face to the unaffected
side

55. Food retention in upper and lower
buccal and labial vestibules
Weakness of buccinator muscle
The patient is unable to raise the eye
brow or close the eye unable to whistle
or retract the angle of the mouth
Change in facial expressions
Drop of the angle of the mouth and
drooling of saliva

56. Etiology
Idiopathic
Trauma
Herpes simplex
Vasospasm occurs in the bony canal of
the nerve causing ischemia and edema
that compresses the nerve decreasing
blood supply to the nerve leading to
necrosis and fibrosis of the nerve

57. Clinical features

61. Treatment
High doses of systemic steroids for 5
days then tailed off in another 5 days
ACTH IM injection for 10 days
Analgesics if needed

62. 3- Ramsy Hunt Syndrome
Special form of Herpes Zoster affecting
the facial nerve via infection of the
Gerniculate ganglion
Starts by prodrome of fever, headache,
malaise, ear pain
Appearance of crops of vesicles on the
tragus of the ear external auditory
meatus and tympanic membrane
“Herpetic Oticus”
Deafness, tinnitus and vertigo on the
affected side

63. Unilateral pain affecting the anterior 2/3 of
the tongue & soft palate
Appearance of vesicles which rupture giving
ulcers
Xerostomia (due to parotid secretion and
loss of taste )
Loss of taste sensation
Facial palsy
Self limiting disease resolve within 7-10 days
Permanent paralysis may occur

70. Psychogenic Causes of Facial Pain
Atypical Facial Pain (Psychogenic
Facial Pain)
"Persistent facial pain that does not have
the characteristics of the neuralgias and is
not associated with physical signs
Present daily and persists most of the day.
It is confined at onset to a limited area on
one side of the face and may spread to the
upper and lower jaws or other areas of the
face or neck.
 It is deep and poorly localized.


71. Clinical picture
It affects females more than males
19:1.
Its common sites are the maxilla and
the tongue.
Character of pain: Chronic,
intermittent dull aching, and poorly
localized so that the patient is unable
to define location of pain.

72. It gets worse with fatigue and
stress, but doesn't interfere with
eating or sleeping.
Responds poorly to analgesics.
Emotional breakdown, tears,
hysteria are common.

73. Diagnosis
It is diagnosed by exclusion of other causes of
Orofacial pain.
1. Case history
2.Clinical examination
3.Diagnostic aids
Vitality test and radiographs
Through examination of the nose and pharynx.
Oral examination.
Careful examination of the cranial nerves and
parotid gland.

74. Pain of Musculoskeletal Origin
1.Myo-facial pain dysfunction
Syndrome
It is a chronic disorder characterized by
unilateral dull pain in front of the ear
that is worst on awakening, clicking
and limitation of mouth opening in
absence of pathological abnormality in
TMJ

75. Etiology
1.Muscle over-
extension:
Due to ­
intermaxillary
space <e.g. high
filling, prosthetic
restoration or
denture>.

76. Etiology
Muscle over-
contraction:
Due to over-
closure of mouth
<e.g. bilateral
loss of posterior
teeth, improper
prosthetic
restoration>.

77. Etiology
Bilateral loss of posterior teeth
or improper prosthetic
appliance leads to over closure
of the mouth and muscle over
contraction ® muscle fatigue

78. Clinical features
Unilateral dull pain in the ear or
preauricular area which is worse on
awakening, and there may be vague
pain affecting the whole side of the
face.
Tenderness of muscles of mastication
on palpation.
Limitation or deviation of mandible on
opening to the affected side.
Clicking in TMJ.

79. Radiating pain to masseter muscle,
occipitally, cervically to the neck or to the
angle of the mandible
Trismus (locking or inability to open the
mouth).
Patients frequently grind or clench their
teeth or develop other Para functional
habits e.g. pencil chewing and so on
clinical examination there are:
Wear facets on teeth.
Ridging of tongue margins and buccal
mucosa at the occlusal line.

80. Trigger point
It is an area of muscle that is tender on
palpation it may occur in:
•Muscles of mastication.
•Cervical muscle (sterno-mastoid).

81. Management of MFPDS
1.Elimination of cause e.g.:
high filling ® occlusal
adjustments.
2.Occlusal splints (Bite raiser
– night guard) ® if no local
factor can be detected.
3.Patient reassurance .

85. Vascular Lesions

86. Migraine
Migraine is a recurrent headache.
It is due to arterial dilatation. Attacks are
precipitated by alcohol, drugs as
nitroglycerin, stress & environmental
factors e.g smoke & noise .
It is characterized by unilateral headache,
nausea, vomiting & photophobia .
It is treated by drugs & avoidance of
precipitating factors.

87. Periodic migranous neuralgia

88. Periodic migranous neuralgia
It is usually idiopathic, less common than
migraine & it causes unilateral facial pain

89. -Giant cell arteritis
It is an immunologically mediated disease
characterized by inflammation of the wall of
medium size arteries, with prominent giant
cells, there is obliteration of the artery
lumen and ischemia of the part supplied by
involved artery.
Giant cell arteritis may affect the
craniofacial region e.g. temporal arteritis.

91. Temporal arteritis
Is characterized by unilateral or
bilateral deep throbbing pain of
acute onset over the temporal
region and prominent tortuous
tender temporal artery.
Pain may radiate to mandible or
maxilla.
Definitive diagnosis is based on
temporal artery biopsy ® giant cell
arteritis.
Treatment: corticosteroids.

92. Temporal arteritis

93. Other Causes Of Headache & Facial Pain
(Miscellaneous Causes)
Orofacial pain may be referred from the chest
as in ischemic heart disease and lung cancer .
Raised intracranial pressure may cause
headache. It may be due to malignant
hypertension, tumour or hematoma .
Diseases of the skull such as bone metastasis or
Paget's disease may cause headache .
Trotter's syndrome: it is orofacial pain caused by
carcinoma affecting lateral wall of pharynx.

94. Atypical Odontalgia
Also called Idiopathic, Phantom tooth
pain
Clinical features
Tooth ache with no detectable cause
Pain is unaffected by endodontic therapy
or even extraction of the tooth
Persistent pain in a single tooth or a group
of teeth that exhibits no abnormality on
percussion or pulp testing