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Always a symptom of a problem (injury, infection)
Acute pain
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Not a symptom of another disease, it is a disease itself.
- Chronic pain
- Chronic pain from any source has the potential to become memorized event. Therefore, patient may experience pain even after the initial causative lesion is resolved. In cases of chronic pain, success of “palliative” treatment proves that pain itself is an illness
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This pain is a Pathologic “BAD PAIN” with no beneficial role to the host, No obvious sign of injury* Site of pain ≠ source of pain*
- Neuropathic (the source does not coincide with the site sometimes)
- Cause: pathologic excitability
- Disinhibitory process is that NS has lost its ability to inhibit excitation, Hyperexcitatory process is NS is overactivated
- - Tx obj: reduce neuronal excitability
- Types
- Traumatic trigeminal
- neuropathic pain: IANB, lingual n. injury, Trigeminal neuropathic, pain of unknown origin: crown prep
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Most common non- odontogenic, chronic facial pain (esp TMD)***
Musculoskeletal Pain
- Types
- - Myofascial pain
- - TMD: Disorders
- involving the joint, masticatory m., and cervical m.
- - Subtypes: Myofascial Pain, Articular Pain Internal derangements.
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This pain is a Physiologic “GOOD PAIN”: promotes tissue healing by avoiding its use
- Sign of injury always present
- Site of pain = Source of pain
- Somatic (inflammatory, nociceptive) Pain
- Cause: local inflammation sensitizes nociceptors and reduce pain threshold
- - Tx obj: reduce inflammation and reduce pain perception
- o NSAIDS: reduce pain signal
- o Opiates: reduce pain symptom
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A Combination of nociceptive and neuropathic pain
Headache (Neurovascular pain)
- Types
- - Migraine
- - Tension Type
- Headache
- - Cluster headache/ trigeminal autonomic cephalgias (TAC)
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Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. What are the three components?
- Pain
- 3 components of pain in Biopsychosocial model
- Affective (emotional) component: “how does the pain MAKE you feel?”
- Sensory (Discriminative) component: “how does the pain feel?”
- Function: what cant you do?
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what is central sensitization?
- When tissue around the initial injury site is "changed" and is now sensitive after the injury. This does not happen if there was anesthesia because the CNA never perceived
- the injury and the nerves were not changed.
- - preinjury local anesthesia blocks secondary hyperalgesia by reducing neuronal activation, but has NO affect on primary hyperalgesia
- Primary hyperalgesia - inflammation
- secondary hyperalgesia- cns excitability
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CNS dysregulation has 2 components
- Excessive excitation = foot stuck on gas
- Diminished inhibition = brakes dont work
- DNIC (decreased Noxious inhibitory control)
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The pulp is mostly this type of nerve fiber
C-fiber
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The main feature of TN is...
- Intervals of pain free episodes
- - Shocking, lancinating pain that comes and goes completely unpredictable (paroxysmal), with an identifiable trigger.
- More common over age of 50, V2 most common, V1 less common, Unilateral, site doesn't move
- Allodynia: light touch with exaggerated pain response (nociceptor not involved because its a neuropathic pain)
- Primary TN is the most common 90%, sometimes attributed to blood vessel pressing on nerve
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Most likely case of secondary TN
- Younger patients
- Pain that is not responding to traditional treatment
- Multiple sclerosis (more common), demyelination is expressed as TN
- Intracranial mass (tumor, nerve/aneurysm) that presses on nerve
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Medications used for Neuropathic pain
- Anticonvulsant
- TCA
- Benzodiazepines
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Procedures used to treat neuropathic pain
- Non-ablative : microvascular decompression (MVD) and transposition
- Ablative: alcohol block, alcohol neurolysis, etc...
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Type of neuropathic pain caused by Varicella zoster virus
- Post herpetic neuralgia (from the shingles virus). hyperalgesia and allodynia
- Risk factor is raised when there has been a history of shingles. 20% of cases of shingles are at V1
- Treatment: within 48 hours with acyclovir and valacyclovir has the best results
- Prevent: TCA -tryptoline reduces the risk by 50% along with -cyclovir
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Phantom tooth pain is known as
- Persistent dento-alveolar pain
- Trigeminal neuropathic pain of undetermined origin
- Often follows routine dental treatment
- - Pre-operative pain/history of chronic pain is a a big predictor
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Burning mouth syndrome is known as...
- Neuropathic Stomatodynia (gender equal, most common 1% of pop.)
- Most common in the anterior 2/4 of tongue
- Can be seen with taste diminishing
- Secondary stomatodynia caused by other condition (lichen planus, candidiasis, anemia)
- Benzodiazepine and TCA are first line of treatment (anticonvulsant are 2nd line)
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Any patient suspected of TGN must have this
- 1. cranial exam
- 2. Brain imaging (to rule out tumor)
- If the patient is young , it is VERY important to consider MS and Brain tumor because it is uncommon in younger
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What is the first line of medication for cranial neuralgias?
Anticonvulsant
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In order to treat a patient with TMD you need these 2 things
- TCA and Benzodiazepines are the best for traumatic injuries and burning pain
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In order to treat a patient with TMD you need these 2 things
- 1. Pain (burning, aching)
- 2. Altered function (limited motion)
- Most common type of TMD is myofacial
- less common is articular subtype
- Sometimes both types are present, best treatment is conservative and minor, Occlusion has NOTHING to do with TMD
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Normal opening range
30-60, less than 30 is limited
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- anterior disk displacement without reduction
- Without reduction acts like a door stop
- Much more symptomatic and inflammation occurs
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- Anterior disk displacement with reduction.
- The disk sits in front of the condyle but upon opening it looks normal, clicking is observed usually, does not cause problem and is common.
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In an MRI T1 and T2 see what?
- T1 sees anatomy
- T2 sees pathology
- MRI shows tissues opposite of CT or Xray
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TMJ arthritidites
- Degenerative DJD
- Inflammatory (RA, immune mediated)
- Traumatic
- Can present with condyle worn down
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Most common cause of acute closed lock, unilateral facial pain with limited opening
- Acute regional myofacial pain - pain causing muscle guarding /splinting and LROM
- Painful acute non-obstructive internal derangement ADDwR
- Painful acute obstructive internal derangement ADDwoR
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