PAIN

Dr Ahmed Talaat Temerek

Lecturer of OMFS
Assuit and South valley University
 P A I N
 “Pain is an unpleasant sensory and emotional experience associated with

actual or potential tissue damage, or described in terms of such damage”.

 Pain has both physical and emotional components. The physical part

of pain results from nerve stimulation.

 P A I N
FA C T S
• Most common symptom in the maxillofacial area including mouth, face and neck.

• Most common cause of emergency.

• Pain usually arise after stimulation of receptors P E R I P H E R A L L Y and is modified

C E N T R A L LY.

• Pain perception is complicated by C U L T U R A L , C O G N I T I V E A N D E M O T I O N A L

F A C T O R S and modified by P R E V I O U S D E N T A L E X P E R I E N C E .

• Pain may be of D E N T A L or N O N - D E N T A L origin.

 PAIN AND SENSATION DEFINITIONS
• Allodynia – pain from a stimulus that would not normally cause
pain
• Analgesia – absence of a pain in the presence of stimulation that
would normally be painful
• Anesthesia - absence of any sensation in the presence of
stimulation that would normally be painful
• Hyperalgesia - severe pain from a stimulus that would normally
cause only slight discomfort
• Paresthesia – an abnormal sensation that is either spontaneous or
evoked as tingling, numbness or pricking e.g. pins, needles with no
apparent stimulus.

• Dysesthesia – unpleasant abnormal sensation that is either

spontaneous or evoked. All dysesthia are a type of paresthesia but
not all paresthesia are type of paresthesia.

• Causalgia – burning pain, allodynia and hyperpathia after partial

nerve injury
 DIAGNOSIS
• Chief complaint PAIN
• History of present illness
• ■ Current symptons:
1. – Onset
2. – Location
3. – Quality
4. – Intensity
5. – Frequency
6. – Duration
7. – Aggravating and alleviating factors
8. – Concomitant or associated features
9. – Past treatments
 Questions for Pain
How would you describe your pain?
Sharp – Stabbing – Dull – Throbbing – Boring – Dull

Where is the pain most severe?

Point to the point of maximum intensity

How severe is the pain?

Does the pain prevent you from sleep or wake you up at night?

Is the pain continuous or does it come and go?

 Questions for Pain
If it come and go , how long does it last for each time?

Does any thing cause the pain to start?

Does any thing makes the pain worst?

Does any thing makes the pain better?

Are there any other problem?

 PAIN OF DENTAL ORIGIN
CHARACTER
• Unilateral (unless both sides)

• Never referred across to the other side of the face but may occur in ……………………….

• Periodontal pain (acute periodontitis, Pericoronitis) is usually well localised and patient can point to
involved tooth.

• Pulpal pain is poorly localized and may be referred to another tooth of the same side or any tissue
supplied by the ipsilateral trigeminal nerve branch.

• The commonest cause of dental pain is the dental pulp.

• P U L PA L PA I N

• P E R I O D O N TA L P A I N

• G I N G I VA L PA I N

• B O N E PA I N

• D E N T U R E B A S E PA I N
P U L PA L PA I N

• Dentine sensitivity: due to dentine exposure.

• Cracked tooth: E only, E and D only, E D and Pulp, Root and Cr
&Root.
• Pulpitis: Hyperaemia, Acute pulpitis, Supprattive pulpitis,
Chronic pulpitis and Chronic Hyperplstic Pulpitis.
• P E R I O D O N TA L P A I N
• Acute apical periodontitis of pulpal origin.
• Traumatic periodontitis.
• Chronic apical periodontitis.
• Acute periodontitis of gingival origin.
• Periodontal – endondotic lesion.
• G I N G I VA L PA I N
• Traumatic Gingivitis.
• Acute gingivitis
• A.N.U.G.
• Acute Pericoronitis.
• Third molar infection.
• Teething
• Gingivitis due to other causes e.g. Lichen Planus and Mucous
Membrane Pemphigoid.
• B O N E PA I N
• Dry socket.
• Cyst.
• Infected dental cyst.
• Osteomyelitis.
• Trauma.
• Tumor
• D E N T U R E B A S E PA I N
 PAIN OF NON-DENTAL ORIGIN
CHARACTER

• Less common than pain of dental origin

• The commonest cause temporomandibular joint disorder.

I. Neurologic
1) Trigeminal Neuralgia
2) Glossopharyngeal Neuralgia
3) H.Z.
4) Post-herpetic Neuralgia
5) Ramsay-Hunt Syndrome (Geniculate Herpes).
6) Bell`s Palsy.
7) Multiple sclerosis.
8) HIV infection
9) Intracranial Tumor.
10) Causalgia.
II. Vascular Pain
1. Migraine
2. Cluster headache
3. Giant cell artreritis.
4. Paroxysmal Facial hemicranias.
5. Referred pain.
III. Maxillary Sinus
1. Sinusitis
2. Malignancy
IV. Salivary Gland:
1. Acute sialadenitis (bacterial, viral, fungal)
2. Chronic sialdentitis
3. Sjogrene Syndrome
4. Malignancy
5. Stone, stenosis of duct, obstruction of duct orifice
6. HIV disease.
7. Mumps.
V. Oral mucosa:
I. HZ
II. Ramsay-Hunt Syndrome
III. Herpetic Gingivostomatitis
IV. Late stage Carcinoma
V. Mucosal ulcers
VI. TMJ/Masticatory muscles:
1. TMJ disorders
2. Fractures
3. Osteomyelitis
4. Infected Cyst
5. Malignancy
VII. Ears
1. Ototis media
VIII.Eye
1. Glaucoma
IX. Psychogenic
1. Atypical facial pain
2. Atypical odontalgia
3. Burning mouth syndrome
Definition:

• A self limiting disorder characterized by instantaneous attacks, of

sharp lancinating, shooting pain confined to the area of distribution
of the trigeminal nerve and characterized by the presence of trigger
zone.
• Etiology: UNKNOWN
• Demyelination.
• Vascular compression of the trigeminal ganglion in Pons region.
• Trauma or infection of the nerve.
• Idiopathic.
 C L A S S I F I C AT I O N
• Classic TN:
• the most common form
• paroxysmal attacks
• pain has at least one of the following features: intense, sharp, superficial or stabbing, or precipitated by a
trigger point or area.
• There is no clinical neurologic deficit on examination.
• Symptoms of classic TN cannot be attributed to another disorder

• Symptomatic TN: has all of the features of classic TN with the additional finding of a
causative lesion, other than vascular compression.

• Atypical TN: because it may meet most, but not all, of the diagnostic criteria of classic TN.
Incidence:
• Involving areas supplied by the 2nd and 3rd divisions of trigeminal
nerve (teeth, jaws, face and associated structures).
• Incidence: 4/100 000
• Age: more than 40 years of age, in affected patients under 40 years,
suspect serious underlying pathology e.g. tumors or multiple
sclerosis.
• Sex: Females are affected twice more than males.
• The right side is affected more commonly than the left side.
• Mostly Unilateral, bilateral is relatively uncommon.
• The 2nd division of trigeminal nerve (V2) is more commonly than the
3rd division, on the other hand the ophthalmic nerve is involved only
in 5% of cases.
Clinical features:
• Signs
• Tic Douloureux: Spasmodic contraction of face muscles due to the pain of
trigeminal neuralgia.
• Symptoms
• Pain is limited to one of the three divisions of the
trigeminal nerve, most commonly the 2nd and 3rd divisions.
• The pain of trigeminal neuralgia never crosses the midline.
• Pain is described as sharp and stabbing, electric shock, red hot needle type. It
is of rapid onset, short duration and with rapid recovery.
• Paroxysms occur most commonly in the first hours after awakening.
• The pain of trigeminal neuralgia is as clusters, patients having periods of daily
pain, then periods of remission. The remission may last days, weeks, months
or years.
• Trigeminal neuralgia does not affect sleep.
• This pain could be evoked by touch or even breeze to the trigger zone on the
face or mouth or it is evoked spontaneously.
 Trigger zone
• Represent primary site of origin for pain provocation.

• Half-inch finger sign: The patient points to the trigger area with his finger

without touching it, as this may precipitate the attack.

Differential diagnosis:
1. Presence of trigger zone and periods of remissions.
2. Clinical examination of other cranial nerves to exclude
other causes.
3. L.A nerve block of the trigger zone will arrest pain for the
duration of LA.
4. Diagnostic aids:
1. CT & MRI are used to exclude the presence of tumor.
2. Tegretol can be used for diagnosis.
5. Multiple sclerosis: Occur at younger age + mainly bilateral
while trigeminal neuralgia is unilateral.
5. Cluster headache: headache occurs at night + No trigger zone.
6. Post-herpetic neuralgia: After herpes zoster of the 5th cranial Nerve
+ history of skin lesion prior to pain aids in the diagnosis.
7. Psychogenic Neuralgia: the distribution of pain is unanatomical, it
may cross the midline with no trigger zone it is usually deep, vague,
poorly localized.
8. Neoplasia:
• Intracranial neoplasms may cause facial pain if they irritate or compress the
root or the ganglion of the trigeminal nerve.
• This may be indistinguishable from idiopathic trigeminal neuralgia and is
usually termed symptomatic trigeminal neuralgia.
• D.D: by careful clinical examination + imaging the patients with facial pain of
any type.
9. Glossopharyngeal neuralgia: The pain is unilateral in the throat and
base of the tongue on one side, sometimes radiating to the ear.
10. Pain of dental origin: e.g. pulpitis, A.D.A.A. periodontitis,
pericoronitis.
11. Pain of osseous origin (dry socket and acute osteomyelitis).
12. Pain originating in T.M.J
• Very brief.
• Severe.
• Lancinating pain.
• Trigger zone.
• Trigeminal nerve distribution.
• Sleep not affected.
I. Medical treatment:
• 1. First line drug Carbamazepine (Tegretol):
• Action as Dilantin.
• Usually begin with 200 mg, 2 times daily and maximum dose of 1200 mg/day.
• Side effect: liver toxicity, aplastic anemia, visual burning and dizziness.
• 2. Second line drugs
• If the patient is unable to tolerate the side effects of carbamazepine or if the
carbamazepine has been ineffective after 4 weeks at the maximum tolerated
dose → the patient should be started the second-line drugs.
• The second line drugs are antiepileptic medicines including gabapentin,
oxcarbazepine, baclofen, clonazepam and tricyclic antidepressants including
amitriptyline & imipramine.
II. PERIPHERAL PROCEDURES
• Trigeminal neuralgia can be modulated by interruption of any part of
the trigeminal pathway, from peripheral sensory nerves to the nerve
root entry zone.
• The supraorbital, infraorbital, or mental nerves are most commonly
approached.
1. Thus local anesthetic blocks of peripheral nerves can be used as an
emergency measure.
2. Peripheral nerve destruction usually by cryotherapy, alcohol
injection, or nerve avulsion is used.
3. The use of bone wax or silastic plugs at the foramen (Where the
nerve has been avulsed) tends to slow down nerve regeneration
with full sensation occur without return of trigeminal symptoms.
Pain relief for 1-2 years.
GANGLION PROCEDURES
• 1. Radiofrequency Thermocoagulation
• The radiofrequency needle passes into the foramen ovale to reach the trigeminal
ganglion.
• When it is correctly placed, cerebrospinal fluid (CSF) should emerge on removal
of the stylet because the ganglion contains CSF.
• The electrode is inserted just beyond the tip of the needle, and a low-amplitude
current is applied using a lesion generator → produce a temperature of 55°- 60°
in order to distruct the unmyelinated fibers of the ganglion.
• Action: electro-coagulation of trigeminal ganglion (Based on coagulation
necrosis).
•
• 2. Glycerol Injection
• The injection performed in the gasserian ganglion intracranially.
• Action: coagulation necrosis.
• Drugs used are: 100% glycerol.
• Periods of pain relief vary from 6-30 months.
• Ganglionic lysis: Glycerol 100% is injected in the CSF of Meckel's cave to cause ganglion coagulation. It is
a sensitive technique but gives reliable result of pain relief with no permant numbness.
GANGLION PROCEDURES
• 3. Balloon Decompression
• A 12-gauge spinal needle is advanced only just into the foramen oval and
the balloon catheter passed through it.
• When inflated, the balloon should take on the shape of Meckel's cave and
should appear pear shaped.
• No more than 0.75 mL of contrast should be injected and the balloon
should remain inflated for 1 minute.
• 4. Radiosurgery (Gamma knife):
• It's an electromagnetic radiation with high energy.
• Selectively affect the affected sensory root fibers of trigeminal nerve.
• Disadvantages:
• Short period of pain relief.
• High recurrence.
IV. SURGICAL TREATMENT (Open Procedures):
• 1. Trigeminal Root Section:
• It is an intra-cranial surgery in which the sensory roots of Gasserian
ganglion are cut sparing the motor root.
• Disadvantages:
• Produces a permanent anesthesia of the areas supplied by cut nerves.
• Rendering the patient liable to keratitis, particularly when the greater
superficial petrosal nerve was damaged.
• Cranial nerve damage (fifth, seventh, or eighth) from excessive
retraction or manipulation.
• Vascular damage.
• Postoperative hemorrhage causing cerebellar or brainstem compres-
sion.
IV. SURGICAL TREATMENT (Open Procedures):

• 2. Micro-vascular decompression "MVD"

• A loop of an artery (usually superior cerebellar artery) which is resting
on the trigeminal entry zone causing the nerve to produce the
symptoms.
• In this operation the loop of the artery is dissected, elevated and then
a small prosthesis are put to separate the artery from the nerve
(called Jannetta – S operation
2. Pre-trigeminal neuralgia.

• May reported by up to 20% of sufferers of TN.

• It is an aching dental pain in a region where physical and radiographic
examination reveals no abnormality.
• Local anesthetic block of the tooth arrests pain.
• Pre-TN responds to similar treatments as TN, beginning with anticonvulsant
therapy.
• Goes on to deteriorate in to TN.