Most prevalent form of orofacial pain?
Toothache, 12-14% report hx of in past 6 months
Define referred pain?
The source of pain is different from the site of pain.
Convergence hypothesis is the mechanism proposed for referred pain, describe?
Afferent sensory neurons have central terminals that converge on the same second-order sensory neuron in trigeminal nucleus
It has been estimated that about __% of all pulpal neurons converge w/ other neurons on the same trigeminal projection neurons.
What is central sensitization?
lowered threshold of central neurons due to constant barrage of nociceptive input from deep structures
Falace study findings?
A pain increases so does referred pain. 90% reporting moderate to severe pain reported referred pain.
Box 19-1. Rules to exclude primary and confirm referred pain?
1. local stim of site = no inc of pain
2. local stim of source = inc pain at source and site
3. local anes at site = no dec in pain
4. local anes at source = dec in pain at site and source
Klausen study findings?
Thermal allodynia = pulpitis vs. periodontitis (odds ratio of 9)
Mechanical allodynia = AP vs. IP (odds ratio of 6.9)
74 patients with orofacial pain
IA block 38% successful in IP mand molar
inc to 88% with IO injection
Box 19-2 Common features of odontogenic pain
- A: ability to reproduce CC
- R: relief of pain with LA inj
- E: etiologic factors (caries, trauma, fx)
- P: pain qualities (dull, aching, throbbing)
- L: localized pain
- U: unilateral pain
- S: sensitive to temp
- S: sensitive to percussion
Box 19-3 Common features of nonodontogenic pain
- B: bilateral pain or multi pain teeth
- I: inc pain assoc palp of TPs
- C: chronic pain not resp to dental tx
- P: pain that occurs with headache
- P: pain qual. burning, electric, stabbing, dull
- A: absence of etiologic factors
- I: inc pain assoc w/ emo stress, exercise, head position
- N: no consistent relief by LA inj
Myo fascial pain is a regional _______ pain with local areas of _____, __________ bands of muscle tissue known as _______ ______s.
- firm, hypersensitive
- trigger points
Myofascial pain first described by?
Travell and Rinzler, 1952
Systemic factors assoc with myofascial pain?
Trauma, hypovitaminosis, poor physical conditioning, and fatigue
Myofascial pain is often described as ____, ____, aching muscle pain.
Three masticatory muscles commonly refering pain to teeth?
Sup belly of the masseter TO max post
Inf belly of masseter TO mand post
Temporal TO max ant or post
Anterior digastric TO mand ant teeth
Wright JADA 2000 findings on myofascial pain?
- 230 pts with TMD
- 85% referred pain
- 11.6% referred pain to teeth, molars, masseter common source
Key clinical characteristics of myofascial pain?
- T: toothache inc with function of TPs muscle
- P: pain constant dull, nonpulsatile
- O: other heterotopic pain (tension headaches)
- A: LA of tooth does not alter toothache
- P: pain not altered by local stim of tooth
- P: palp or stim of TPs increases toothache
- L: LA of muscle reduces toothache
- E: exam of hypersens bands within muscles
Etiology of nonodo toothache of sinus or nasal mucosal origin?
Viral, bacterial, or allergic rhinitis, inflammation of ostium
refers to max teeth
Reduction of pain after the intranasal applicaiton of a 4% lidocaine spray is considered diagnostic.
Bacteria induced sinusitis pain caused by?
more than 70% by s. pneumoniae or h. influenzae
Head dip test?
Pain increases when the patient lies down or places head below knees
dx for sinusitis
Characteristics of toothache of sinus origin?
- P: pressure below the eyes
- A: anes of tooth partially reduces or not
- L: lowering of head inc toothache
- S: sensitive to percussion
- H: heel strike inc toothache
- A: appropriate imaging Waters view
- P: pain to pressure of sinus
Two types of tootaches of neurovascular origin?
Migraines and autonomic cephalgia
Clinical characteristics of migraine toothaches?
- P: pain is spont, variable
- I: intense pain
- T: total remission between episodes of migraine
- A: Aura
- P: photophobia, phonophobia, osmophobia
- R: remission following dent tx, but soon returns
- O: other neurovascular disorders during hx
- M: max canine or PM referred largely
- A: abortive migraine meds red toothac
- T: total remission of tootac betwn epi of migraine
What alternative meds have replaced ergotamine to treat migraines with lower adverse effects?
Sumatriptan (Imitrex) and rizatriptan (Maxalt)
Etiology of trigeminal autonomic cephalgia?
group of primary headache disorders that are short in duration but intense
Clinical signs related to autonomic activity with cluster headaches?
Lacrimation, conjunctival injection, nasal stuffiness, or rinnorhea.
Most common trigeminal autonomic cephalgia?
Cluster headaches: episodic vasodilation that activates perivascular nociceptors
up to 6-8 weeks in duration
male:female 6:1 30-50 yrs
Pain from cluster headaches can refer to max posterio teeth.
43% of subjects with cluster headaches were initially treated by a dentist
Clinical Characteristics of cluster headache toothache?
- S: spontaneous pain, resembles pulpal pain
- I: intense pain
- R: remission of toothache between episodes
- C: cluster toothache, several weeks like headache
- M: maxillary canine or PM freq referral
- A: autonomic effects mimic abscess
- T: temporal behavior of pain, similar time of day
- H: history of neurovascular disorders
Most common episodic neuropathic pain?
Trigeminal neuralgia (tic douloureux)
demylinelinization of the trigeminal nerve root by vascular compression
Most common bracnh of the trigeminal nerve for TN?
Trigger zones for paroxysmal pain in TN?
lip, chin, tongue and sometimes tooth
not paroxysmal pain, aching pain in sinus region and teeth with a duration of minutes to several hours
Key clinical characterisitcs for TN?
- B: brief episodes 5-10 seconds
- I: injection of LA at trigger zones eliminates the pain episodes
- P: PULSE pain (paroxysmal, unilateral, lancinating, severe, electric shock-like)
- A: anes of tooth (PDL) will not reduce pain
- I: innocuous peripheral stimulation is trigger zone
- N: no pain between episodes
Glossopharyngeal neuralgia is 1/10 the prevalence of TN (episodic neuropathy)
GN has less tooth pain, where does it refer?
posterior mandible, oropharynx, tonsillar fossa, ear
Characteristic differences from TN?
Pain is provoked by swallowing, chewing, or talking
IA block will not reduce toothache pain
Two types of continuous neuropathic toothache?
Neuritic: herpes zoster
Deafferentation: atypical ondotalgia
Neuritic pain or neuralgia results from?
alteration of the afferent fibers in a nerve trunk
Etiology or NP is from?
inflammation arising from traumatic, bacterial, viral, or toxic causes
Neuritis may present with other sensory alterations like? (HHPDA)
- Hyperesthesia: increased sensitivity
- Hypoesthesia: diminished sensitivity
- Paresthesia: abnormal
- Dysesthesia: unpleasant
- Anesthesia: no sensation
Clinical characteristics of toothache of neuritic origin?
- P: persistent pain, nonpulsatile, burning pain in tooth
- O: onset of toothache followed an infection or trauma
- O: other neurologic symptoms
- R: report of other teeth feeling "dead" or "strange"
- A: assoc gingival tissue pain
Deafferentation is the loss of normal afferent input from physcial, chemical, or thermal trauma to nerve.
Deafferentation commonly seen as phantom toothache
Atypical odontalgia is __ times more prevalent than TN and may include up tp _% of patients receiving pulpal extripation.
Clinical characteristics of atypical odontalgia?
- Maxillary pain
Characteristics of deafferentation toothache used to differentiate from odontogenic pain?
Diffuse pain, not always restricted to tooth (sometimes in edentulous area)
continous pain, dull, aching, throbbing, burning
lasts 4 months and is not altered by LA
Craniofacial pain reported in ~40% who experienced ischemic cardiac event, sole symptom in 6%.
Areas most frequently affected in cardiac origin toothache?
Throat82%>left mandible45%>right mandible(41%)>left TMJ ear (18%)
Symptom that is common with cardiac pain but infrequently with odontogenic pain?
complaint of pressure in tooth
If toothache is of cardiac origin, administering nitroglycerin will decrease the pain.
Axis I is a category of orofacial pain that:
includes pain conditions that have their origination from body structures
Axis II is a category of orofacial pain that:
includes pain conditions that have their origin from psychologic disorders
Somatoform pain disorder is used to describe a cognitive perception of pain that has no demonstrable physical basis
Certain systemic conditions can result in tooth pain (MDSD)
Sickle cell anemia (68% reported, may lead to pulpal necrosis)