ORO-FACIAL PAIN IN THE ELDERLY
- Introduction- Definition
Pain is the expression of an unpleasant sensory and emotional experience, related to an existing or potential tissue injury (or described in terms of such injury).
Orofacial pain is pain that is localized or referred to oral, perioral, or facial anatomical structures due to local, regional, or systemic clinical conditions or central nervous system dysfunctions.
- Pain is the main oral complaint of elderly subjects.
- The management of acute nociceptive pain (infectious, traumatic and post-operative) responds favorably to well-codified treatment protocols.
- However, these are not the only facial pains; some of them can be indicative of conditions that are not directly related to the oral cavity.
Classification:
Depending on the genesis of pain, three mechanisms are described:
Nociceptive pain: Example of dental pain
Neurogenic pain: In this case the pain is due to damage to the nerve itself called neuropathy, the pain is felt as:
- Electric shocks
- Throbbing pains
- A burning sensation
- A painful cold sensation
- Tingling in the area of the affected nerve
- The pain felt by amputees, particularly in the amputated limb, known as a “phantom limb”
Idiopathic and psychogenic pain:
Psychogenic pain is generated by the psyche and is felt by the patient in the absence of injury.
- Pain and the elderly:
Elderly patients have a high prevalence of pain. This varies from 60% to 80% depending on the study. The latter are at least 75 years old and are characterized by the coexistence of several chronic disabling pathologies causing physical and/or psychological dependence and by the frequent interweaving of neurodegenerative and somatic pathologies.
The specific nature of the elderly population is the source of a certain number of difficulties:
- Cognitive impairment is present in the majority of patients.
- This is all the more so since elderly patients naturally have difficulty expressing pain, whether it is experienced as inevitable or confused with suffering.
- Assessment plays an important role in the care process.
- The causes of pain are numerous and of variable nature: excess nociception, neuropathic or mixed.
- The diagnosis is sometimes difficult, the approach must be careful.
- Elderly subjects have chronic pathologies with acute decompensations.
- The practitioner is sometimes forced to establish completely opposing therapeutic strategies depending on the patients and the situation.
- Pain management in geriatrics must take all of these parameters into account.
- Pain assessment is the first objective to be respected. It favors self-assessment but quickly turns into hetero-assessment.
- Assessment of pain in the elderly 3-1- Self-assessment
The patient’s complaint remains the most accurate and reliable assessment.
The characteristics of pain and the impact on quality of life or activities of daily living can be obtained in the majority of elderly patients even with cognitive impairment. The use of a diagram or drawing can help in localizing the painful area.
-The most appropriate pain scales in the elderly are the numerical scale and the verbal scale.
It is advisable to use scales with large characters for ease of reading.
-The visual analogue scale (VAS) is widely used but is not very appropriate in the elderly.
The Visual Analogue Scale (VAS)
The digital scale
3-2- Evaluation of pain in patients with cognitive or verbal communication disorders: Heteroassessment
When self-assessment is not possible due to cognitive or verbal communication impairments; a hetero-assessment scale should be used.
Pain will be carefully sought in the modification of the patient’s behavior. In recent years, great interest has been focused on the development of heteroevaluation scales in order to overcome the difficulties of screening and managing pain in the elderly.
- Main orofacial pains in the elderly:
The oral cavity is the preferred site of expression of certain chronic disabling pains whose etiopathogenesis remains largely unknown.
These pains include several clinical entities: facial pain, atypical odontalgia, idiopathic stomatodynia and certain forms of ADAM.
These are pains that are poorly understood, poorly defined, poorly evaluated and often poorly treated.
The similarity of the clinical pictures, the fact that the entities are often present simultaneously or successively in the same patient, that they share risk factors and that their etiology and physiopathogenesis are essentially unknown suggest that they have common etiopathogenic mechanisms.
- Neuropathic pain
It is characterized by a greater intensity and duration than chronic pain without neuropathic predominance. Diabetes, shingles, cancer particularly affect the elderly and can cause this type of pain.
Pain is classified as neuropathic when there is nerve damage due to damage or dysfunction of the central or peripheral nervous system, as well as certain signs and symptoms, including impaired sensitivity.
These chronic pains are burning, stinging, compressive, vice-like, or dominated by attacks resembling electric shocks or stab wounds and are violently exacerbated, in certain cases, by a non-nociceptive stimulus, such as the simple brushing of clothing.
NEURALGIA of the face or NEUROGENIC FACIAL AGGIA (neuropathic) These are painful phenomena secondary to irritation of the sensory nerves of the face (V, IX). We distinguish:
- Idiopathic essential neuralgia
- Symptomatic neuralgia secondary to a given neurological, vascular, tumoral, or other condition (Piot 1997)
ESSENTIAL NEURALGIA OF THE V
Diagnosis is based on clinical features: characteristics of pain defined by the IASP (2003): “sudden recurring pain, generally unilateral, in the form of a stab, of short duration, affecting the territory of one or more branches of the trigeminal nerve”. Affects more women than men (3/2)
Semiology of pain
“Atrocious”, dazzling, paroxysmal
- Well described by the patient: electric shock, stabbing, crushing, tearing.
- Painful attacks last a few seconds, 1 to 2 minutes
- Frequency = 1 to 10 salvos (crises) /day especially diurnal
- Bursts = alternating with refractory periods (calm)
Pain = spontaneous but especially triggered after stimulation or touching of the mucous membrane or skin = Trigger zone
*excitation of this area occurs: function, sensory stimulation (light, noise). During the crisis: patient remains frozen, motionless, tense = “Trousseau painful tic”
* Pain = strictly unilateral, affecting 1 branch of the V, often V2, rarely V3, exceptionally V1
Etiology: + probable = cerebellar artery compresses the nerve root at the entry area at the pons
*vascular-nervous conflict at the level of the trigeminal ganglion detected during MRI angiographic sequences = pain due to vascular compression
SYMPTOMATIC NEURALGIA OF THE V
Semiology: intense pain + persistence of underlying pain
*burning, tearing or dysesthesia type pain
*no trigger zone
*presence of vasomotor signs
*neurological examination: reduction or abolition of the corneal reflex, hypoesthesia in the V territory, paresis and amyotrophy of the temporal and masseter muscles, extra-geminal neurological impairment: deafness, vestibular impairment.
Etiologies
- Central causes: bulbar lesions, protuberant: tumors, stroke, multiple sclerosis.
- Peripheral causes:
*Mononeuropathy: frequent causes: -post-herpetic or herpetic neuralgia: burning or dysesthesia persisting for more than 3 months after the rash, affects V1 (anti-virals = insufficient).
*Neuralgia symptomatic of an expansive lesion (tumor or infectious) of the petrous bone, of the Gasserian ganglion
*Painful anesthesia of the V (trunk) during facial trauma, ENT surgeries, after radiotherapy
- Dental pain and the elderly
The presence of pathologies linked to aging and the occurrence of dependency lead to a deterioration in oral health.
In the absence of prevention and appropriate care, the pain generated by the lesions, in the absence of oral hygiene, has a negative impact on the quality of oral life, on psychosocial well-being and nutrition, and therefore on general health.
In the elderly, periodontal disease is the most common and is more painful than pulp disease. The specific features of dental disease in the elderly are as follows:
- The predominance of cervical carious lesions, more commonly called root caries.
- Non-carious lesions are mainly represented by cervical abrasions, especially linked to traumatic brushing or unfavorable occlusion.
- As the dentino-pulp complex evolves over time towards an increase in mineralization, the reduction in the volume of the pulp cavity explains the rarity of inflammatory pulp involvement.
-The greater frequency and severity of periodontal diseases observed with aging would rather be the result of prolonged exposure of periodontal tissues to plaque than a direct consequence of senescence.
- Facial arthromyoalgia
With aging, the joint generally atrophies with limited functional adaptation.
Cartilage wears down at points of friction and pressure.
From the age of sixty, condylo-meniscal and meniscal morphological changes are observed, the glenoid cavity being less affected.
Joint lesions may also be related to chronic pathology such as rheumatoid arthritis, psoriatic arthritis and systemic lupus erythematosus. TMJ dysfunction is characterized by crackling or crepitating sounds, musculoskeletal orofacial pain, headaches or, in extreme cases, loss of balance. This symptomatology is exacerbated in edentulous elderly people with inadequate dentures. It is associated with the decrease in the height of the occlusion which causes excessive wear of the TMJ.
- Idiopathic stomatodynia
This condition is characterized by pain in the oral mucosa without an identifiable organic cause.
This definition excludes all pain in the lingual mucosa, and more generally oral mucosa, which can be explained by identified local or systemic pathological conditions.
Pain is the cardinal sign of stomatodynia.
It is described as a prolonged burning sensation of the oral mucosa, however, tingling and numbness sensations are also reported.
The pain usually appears spontaneously without any triggering factor.
The diagnostic criteria require continuous pain present for four to six months.
Oral pain is almost always bilateral and felt mainly on the tongue, lower lip, hard palate.
The upper lip and mandibular alveolar region may be affected while the jugal mucosa and floor of the mouth are rarely involved.
This pain is often accompanied by persistent dysguesia; this is an alteration of taste with a bitter, metallic perception or both.
Some patients with stomatodynia complain of xerostomia.
This is more of a subjective feeling than an objective salivary dysfunction.
This feeling seems to be linked to associated problems such as depression and in particular to the adverse effects of psychotropic drugs, anticholinergics, antihistamines, or diuretics taken as part of treatment.
- PAIN TREATMENTS
Treatment is etiological, when possible and reasonable, in the elderly.
- Symptomatic treatment should be associated in all cases.
It may be non-medicinal depending on the etiologies and the possibilities of the context.
It can also be medicinal: analgesics, co-analgesics, antidepressants, anticonvulsants, or even multifactorial.
There is no specific symptomatic treatment for the elderly. It is essentially based on the prescription of analgesics.
The progression of these is done in a graduated manner according to the 0.MS scale. This scale only concerns analgesics, and must be used in constant adaptation to the clinic and the etiology.
If the drugs at one level are ineffective, we move on to the next level.
Step 1 of the WHO scale concerns mild pain. For the treatment of this pain, so-called “peripheral” analgesics such as paracetamol and acid are used.
acetyl salicylic.
The use of the latter will be prudent in geriatrics due to the importance of the side effects, particularly digestive.
Step 2 of the WHO scale concerns moderate pain and includes minor morphine-based painkillers, as well as other drug classes. The leader of the step
2 is codeine. Also used are: tramadol and noramidopyrine.
Step 3 of the WHO scale concerns severe pain and uses major morphine drugs. Their leader is morphine. These treatments apply to chronic pain resistant to step 1 or 2 analgesics.
- Non-drug methods :
Other solutions exist but are poorly suited to emergencies.
- relaxation acts with varying effectiveness on muscle tension, helping to control pain and emotional stress, which in turn acts on muscle tension and pain;
- hypnosis in palliative care allows for better management of the patient’s anxiety and a significant reduction in the consumption of analgesics and psychotropic drugs;
- Physiotherapy has a special place in the overall management of pain. Gentle passive mobilization and massages help reduce painful contractions and joint stiffness; they provide a feeling of well-being;
- Analgesic radiotherapy is most commonly used in cancer-related pain, particularly in cases of bone metastases or perimedullary invasion.
- acupuncture for nociceptive pain corresponding to deep or muscular painful points or neuropathic pain;
- Mesotherapy, which consists of injecting drugs associated with procaine or xylocaine intradermally or subcutaneously, has not been the subject of any conclusive scientific publication.
Conclusion
Managing pain remains a key concern for caregivers as well as a priority. It is imperative to have scales to best quantify this pain even in non-communicative patients . The goal is to provide rapid relief in the emergency setting and to assess the effectiveness of treatments safely for the elderly person. This intensity measurement, as relevant as possible, makes it possible to adapt treatments by taking into account pharmacokinetic and dynamic changes related to aging. This involves understanding painful phenomena with their age-related specificities. No medication is contraindicated solely because of age.
ORO-FACIAL PAIN IN THE ELDERLY
Untreated cavities can lead to tooth loss.
Dental veneers restore a harmonious smile in just a few sessions.
Misaligned teeth can cause joint pain.
Dental implants are fixed into the bone for optimal stability.
Chlorhexidine mouthwashes treat gum infections.
Damaged baby teeth can affect speech and chewing.
A toothbrush replaced every three months ensures effective hygiene.