Orofacial pain and sedation in the elderly
Orofacial pain = more frequent, affecting highly stressed functions = immediately disabling = main reason for consultation. They pose serious diagnostic and therapeutic problems: due to their very varied etiologies:
- their great clinical similarity – due to their anatomical intricacy – to this is added a component that is difficult to evaluate: psychological component. It is the responsibility of the dentist to diagnose them when the clinical picture is sufficiently suggestive and above all to properly direct patients towards the relevant specialties if necessary (avoiding the prescription of unnecessary examinations). A good diagnosis implies good therapy.
DEFINITIONS
Several classifications are given supported by: The International Headache Society (IHS) and the International Association for the Study of Pain (IASP).
- Pain = “unpleasant sensory and emotional experience associated with actual or potential tissue injury, or described in terms of injury”
Oro-facial pain, as in any painful experience, we identify at least two components:
- – sensory-discriminative component: linked to the perception of the attributes of the nociceptive stimulus: nature, intensity, duration, location
- – emotional component: represents the unpleasant or aversive nature of this experience and thereby makes it intolerable.
This aspect may contribute to promoting the evolution of pain towards chronicity (Chapman and Gavrin 1999; Price 2000; Lavigne et al. 2005).
Reducing the emotional component of pain has a dual therapeutic interest: – relieving acute pain – preventing the onset of chronic pain (illness).
CLINICAL STUDY OF OROFACIAL PAIN:
- NEURALGIA of the face or NEUROGENIC FACIAL PAIN (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)
1-1-ESSENTIAL NEURALGIA OF THE V
The diagnosis is based on the clinical picture: characteristics of the pain Neuralgia of the V defined by the IASP (2003): “sudden recurrent pain, generally unilateral, in the form of a stab, of short duration concerning the territory of one or more branches of the Trigeminal nerve”.
Touch more women than men (3/2)
Semiology of pain
“Atrocious”, fulminating, paroxysmal • Well described by the patient: electric shock, stabbing, crushing, tearing. • Painful attacks last a few seconds, to 1 to 2 minutes • Frequency
= 1 to 10 bursts (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 zone 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 zone at the level of the pons *vascular-nervous conflict at the level of the trigeminal ganglion detected during MRI angiographic sequences = pain due to vascular compression
- Treatment *Carbamazepine = diagnostic and therapeutic test (tested 1996, 2003, 2004), effective in 80% of cases (short term) (Tégrétol®)
Note: it should be noted that the longer the neuralgia has been present, the more the symptoms may change:
-The attacks are more numerous -The period of calm is shorter and sometimes it disappears -The treatment becomes insufficient despite the high doses…
- SYMPTOMATIC NEURALGIA OF THE V
- Semiology : intense pain + persistent underlying pain *burning, tearing or dysesthesia-like pain *no trigger zone *presence of vasomotor signs *neurological examination: reduction or abolition of the corneal reflex, hypoesthesia in the V area, paresis and amyotrophy of the temporal and masseter muscles, extra-geminal neurological impairment: deafness, vestibular impairment.
- Etiologies • Central causes: bulbar, protuberant lesions: tumors, stroke, multiple sclerosis. • Peripheral causes: *Mononeuropathy: of frequent causes: -post-herpetic or herpetic neuralgia: burns or dysesthesias persisting more than 3 months after the skin rash, affects the 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
- Diagnosis and treatment * Diagnosis +: continuous pain, no “trigger zone”, neurological abnormality *TTT = etiological (accessible) or neurosurgery
- ESSENTIAL NEURALGIA OF THE IX GLOSSOPHARYNGEAL FACE
- Epidemiology
Less common than NFE • 1 case in 70 to 100 cases of NFE • Affects adults over 60 years old
- Semiology Very similar to NFE, only the topography changes *pain in attacks *unilateral, most often left • location: tonsil, base of the tongue irradiation in the ear and angle
mandibular, CAE. *isolated otalgic form confused with the otitis form • “trigger zone”: base of the tongue, pharyngeal mucosa, tonsillar region (CA, pinna = rare)
- Triggers: swallowing, coughing, head rotation (not chewing = NFE) •
- Accompanying signs : cough, hypersalivation, rhythm disturbance (hypotension, syncope) • Pain in the back of the throat when swallowing + syncope indicate the diagnosis •
- Treatment *same regimen as NFE: Carbamazepine *infiltration and alcoholization of the IX
*endocranial or cervical neurotomy.
- FACIAL PAIN Dental- ENT- Ophthalmic “specialists”
- Stomatological Facial Pain Very few elderly people still have their natural teeth already replaced by old and poorly fitting prosthetic restorations. However, when the teeth still persist, we can observe:
- Dental and gum pain: pulp pain: mild (pulp calcification and enamel abrasion) **dental cracks (fractures) *teeth maintain satisfactory strength despite recessions exposing roots and furcations.
- Stomatological Facial Pain Very few elderly people still have their natural teeth already replaced by old and poorly fitting prosthetic restorations. However, when the teeth still persist, we can observe:
2-1-2-periodontal pain: the periodontium undergoes physiological senile atrophy: the bone is osteoporotic. desmodontitis: rare in the elderly because physiological sclerosis makes it insensitive except in the apical region (granuloma ++)
2-1-3-mucosal pain: erosions or ulcerations caused by neglected oral hygiene or irritations caused by old prosthetic or conservative restorations (amalgam). Keratinization of the gingival epithelium is accentuated, which promotes the appearance of leukokeratotic lesions. Ulcerations from viral infections (shingles, herpes) are particularly painful. Mycotic infections are often encountered. If the etiology is not found, a biopsy is necessary. – lesions related to general pathologies with an oral component: erythema multiforme, pemphigus, post-RX mucositis, diabetes, gastroesophageal reflux, dry mouth, etc.
2-1-4- Pain from oral cancers – Patient aged 50+, alcoholic and smoker, typical infiltrating ulceration with induration at the base…..
- Iatrogenic pain All oral care can cause localized or radiating pain (OCE, Surgery), alveolitis.
- Salivary pain Lithiasis, inflammation, tumors of the salivary glands favored by the changes undergone by the glandular parenchyma and saliva. Gougerot-Sjögren syndrome is often observed.
- Bone pain senile osteoporosis makes the maxillary bone more vulnerable: – fractures (even if the subject is less exposed than the young person), osteitis due to obliteration of the vascularization the bone defends itself poorly and its regeneration capacities are reduced, tumors, ORN if history of radiotherapy.
- Facial pain of ENT origin *Acute maxillary sinusitis clinical, topography of pain (cheekbone), NMP X-ray confirms the diagnosis. *other sinusitis: frontal, ethmoidal, sphenoidal.*
- Oro-facial ophthalmic pain Periorbital pain with impaired visual acuity, photophobia, other ophthalmic conditions (optic neuritis, glaucoma, etc.)
- Orofacial pain in the context of DAM = failure of the masticatory system to adapt to an occlusion or parafunction disorder aggravated by a psychological disorder. = polymorphic clinical entity certainly affecting young subjects between 20 and 40 years old, but is not exceptional in the elderly with a notable female predominance.
Clinical
*joint pain: disc displacement (noises) – The TMJs undergo changes related to general diseases (rheumatism, osteoporosis and other degenerative lesions). – These affect the articular surfaces (condyles) and the disc apparatus. – Bone and muscle senescence – Alteration of dental occlusion, reduction of the vertical dimension
*muscle pain: muscle atrophy and hypotonia ==) project into the muscle projection area. Projection to the teeth leads to extractions aggravating the DAM by loss of posterior alignment. 27 *extra-manducatory signs: by diffusion of spasms – neck and shoulder pain **otological signs: tinnitus, sensation of blocked ear – cranio-spinal posture disorders (etiology increasingly incriminated: cervical posture defect, scoliosis, posture during sleep
Treatment :
* painful episode: analgesics (level 1, 2) NSAIDs if no CI, muscle relaxants (tetrazepam, Coltramyl, mydocalm, etc.). * Etiological treatment, adequate prosthetic restoration. 28
*psychological support – educational session: reassure the patient by explaining the etiopathogenesis – patient involvement = therapeutic success. – eliminate bad habits (onychophagia) – limit mandibular kinesis – self-massage of the muscles – mandible in resting position avoiding dental contact: pronounce “N” by putting the tongue behind the upper INC, by interposing an object: pen. – correction of the closing path – correction of postural anomalies.
- IDIOPATHIC ORO-FACIAL PAIN
Mechanism imperfectly identified therefore treatment difficult Woda and Pionchon (2001) classify in this framework of idiopathic orofacial pain: Atypical facial pain, atypical odontalgia, glossodynia, idiopathic orofacial myalgia.
*psychological profile of these misunderstood patients, in urgent need of relief and the inability of the practitioner to respond to it leads to a “medical nomadism” complicating the situation even more.
*dominant female prevalence (anxiety, stress, nail biting).
- Atypical Facial Pain – affects the mouth, jaw and face – called “horrible” by the patient – type of burning, tightening, constriction, movement in the bone – only diurnal, no trigger zone – in the long run the pain spreads without respecting the V – becomes bilateral – Dysesthesia,
paresthesia – Preceded by accidental or surgical micro-trauma (dental, ENT, maxillofacial)
– Psychological factors: depression, anxiety, cancer phobia.
- Atypical Toothache – corresponds to the dental location of an atypical pain – the pain affects healthy teeth (PM, M sup) – continuous, dull, deep pain – not triggered by thermal or chemical stimuli – resists local anesthesia – migrates to another tooth if it is extracted – concept of “phantom tooth”: persistence of pain after avulsion – neuropathic etiology
= possible (not confirmed).
- Stomatodynia and Glossogynia
“Burning mouth syndrome” – patient: woman + 60 years (post menopause) or 50-70 years = abnormal sensation of burning or tingling of psychogenic functional origin limited to the tongue = glossodynia (2/3) or gum, lips, palate = stomatodynia. = oral paresthesia (Demange1996). *description is done with great detail: tingling, swelling, itching, burning… *permanent, dull discomfort preventing any professional activity
*chronic, continuous, bilateral, without organic cause *dry mouth, taste disorders *onset = linked to dental care, emotional context *analgesics = no effect.
- Atypical Orofacial Myalgia
-myofacial pain (all face) especially in the masticatory muscles
*2 clinical pictures: -idiopathic headaches = tension headaches -idiopathic arthromyalgia. – Remission phases = frequent – Examination finds tension cords and trigger points – Probable etiopathogenesis: ischemia by sustained effort by the masticatory muscles would induce desensitization of the vasodilator system, reduction of blood perfusion, metabolic and tissue alterations of the muscles.
- Treatment – multidisciplinary care : neurologist, psychologist, psychiatrist – classic analgesics: no effect – listen to the patient, stop their “medical nomadism” – suggest behavioral therapies: relaxation techniques, leisure activities – selective serotonin reuptake inhibitor antidepressants = effective – anticonvulsants – neuroleptics, anxiolytics, analgesics = useless – currently: local topicals: Clonazepam = effective – antihistamines: some effectiveness for glossodynia.
Diagnostic Approach
Clinical examination
- ANAMNESIS : listen to the patient tell their “painful story” and clarify the symptoms of the pain
*note: age, psychological profile, profession, general history, stomatological (abusive exo) “nomadism”
*pain: date of onset, onset mode: sudden, progressive, spontaneous, provoked, -evolution: acute, chronic (6 months = chronic pain = illness) -semiology: electric shock, “flash”, pulsatile, paresthetic, burning -continuous, in bursts with or without lull -recent worsening -duration of the attack: second, min, hour 38 -topography: trunk, endings, several territories -triggering causes: functions, insomnia, anxiety, stress -existence of “Trigger Zone” -presence of warning prodromes: instability, mood disorders (aura of migraines) -signs
accompanying: vasomotor and secretory phenomena, digestive signs (nausea, vomiting)
-Therapies already instituted, effectiveness? – Impact of pain on the patient’s life ++
- Clinical examination : thorough, good lighting -inspection: look for any facial abnormalities, erythema, rash, swelling -palpation: gentle, precise: of the face and neck following the bony contours, ATM, facial muscles, neck, shoulders, etc. -sensitivity: V, IX, VII -adenopathies
– arterial and venous structures – endo-oral examination: mouth opening (trismus), closure path, hygiene, dento-periodontal state, tongue, palate, mucous folds, oropharynx. – Cavities: sinuses, nasal cavities, orbits. ==) a diagnosis of high probability is established.
Additional examinations – Orthopantomogram, retro-alveolar, bite: dental etiology – CT, MRI: more precise details – AngioMRI: vascular pain – ultrasound – Essential specialty examinations (pain): Neuro++, ENT, Ophthalmology and others on request – Neurological assessment scales: *VAS: visual analog scale *Sensory exploration: prick / touch, hot / cold
*taste tests IX: sweet / salty
Therapeutic means:
Progress in understanding the neurobiology of pain contrasts with drug management, which is still based on pharmacological concepts based on three types of analgesic molecules. The WHO has classified analgesics
in 3 levels or tiers to allow a prioritization of these drugs according to their level of effectiveness and their benefit/risk ratio:
Level 1 represented by non-morphine analgesics (peripheral or minor analgesics) having an action on peripheral nociceptors: paracetamol, aspirin and
nonsteroidal anti-inflammatory drugs.
Level 2 : Combinations of level 1 analgesics with weak morphine analgesics or minor opiate derivatives (codeine, dextroproxyphene) to achieve a synergistic effect. Level 3 is represented by strong morphine agonists that belong to the class of narcotics or centrally acting analgesics.
Co-analgesics: they are often useful and sometimes essential in therapeutic management:
- Antidepressants : Amitriptyline (Laroxyl) prescribed for certain stubborn pains at a dosage lower than the antidepressant dosage: 25 to 75 mg/day;
Muscle relaxants (reduce polysynaptic spinal reflexes that generate reflex muscle contractions)
- Corticosteroids (action on gene expression, among others, of mediators involved in the control of nociceptive messages)
- Anti-epileptics :
- Carbamazepine (Tegretol) as first- line treatment for essential neuralgia, it also constitutes a diagnostic test since it is effective in the short term in 70 to 80% of cases, the effective dosage is on average 600 to 1200mg/day which are the threshold doses, treatment introduced gradually to allow better tolerance
;
- Pregabalin (Lyrica): Gaba analogue (inhibitory neurotransmitter) prescribed for peripheral neuropathic pain at 150 mg/day, the dose is increased according to response and tolerance
- Antispasmodics
- Anxiolytics (amnesic effect, benzodiazepines do not modify the perception of painful stimuli but they reduce their emotional impact)
- Vitamin B1-B6 prescribed as an adjuvant, has an essential metabolic role in cellular functioning and the transmission of nerve impulses.
Neurosurgery and physical medicine techniques:
- Neurostimulation (using electrodes generating an electric current):
- Transcutaneously used in deafferentation pain, it stimulates the large myelinated fibers which conduct tactile sensitivity, reinforces gatecontrol.
- Medulla reinforces the inhibitory action of the posterior cord pathways, the electrodes are placed subcutaneously, used after failure of the transcutaneous.
- Ablative techniques used for pain due to excess nociception involve intervention on the cranial nerves (thermocoagulation selectively destroying the small nociceptive fibers while respecting the large fibers of the GASSER ganglion) and the peripheral nerves.
- In essential facial neuralgia, resistance to medical treatments leads to the practice of:
- Infiltration of the nerve with a local anesthetic product at the trigger zone (immediate but temporary sedation)
- Alcoholization of the affected terminal branch with 60° alcohol after local anesthesia (relief for approximately 1 year)
- Percutaneous thermocoagulation provides sedation while preserving tactile sensitivity as much as possible (a high-frequency generator destroys poorly or unmyelinated fibers)
- Microsurgical vascular decompression (separating the nerve from the vessel)
- Peripheral neurotomy (section of the nerve corresponding to the painful area provides permanent anesthesia)
- Retrogasserian neurotomy (section of the sensory root at its exit from the ganglion via the temporal and extradural route)
- Cervical or endocranial neurotomy for the IX.
- Massage therapy combines physical medicine and rehabilitation techniques: hydrotherapy, cryotherapy, electrotherapy, infrared, vibrations.
- Other means: Psychotherapeutic approaches, acupuncture, mesotherapy.
CONCLUSION
Although orofacial pain is a very common reason for consultation, it is a clinical element of many etiologies. Often the dentist is the first point of contact when faced with facial pain. As they are located in the V area, they are confused with dental pain. Any pain requires a stereotypical clinical examination, both exorbital and intraoral, which will best guide an appropriate paraclinical assessment, avoiding the launch of unjustified care (extractions) that does not provide any relief to the patient. Knowledge of the various classic semiologies allows for the rapid management of these pains. Any suspicious lesion of the oral cavity must be biopsied to eliminate a malignant process. BLIDA University Faculty of Medicine
Department of Dentistry
Orofacial pain and sedation in the elderly
4th year dental medicine course
Module: Geriatric Dentistry
Course prepared by: Dr. Ayoune.S
INTRODUCTION
Orofacial pain = more frequent, affecting highly stressed functions = immediately disabling = main reason for consultation. They pose serious diagnostic and therapeutic problems: due to their very varied etiologies:
- their great clinical similarity – due to their anatomical intricacy – to this is added a component that is difficult to evaluate: psychological component. It is the responsibility of the dentist to diagnose them when the clinical picture is sufficiently suggestive and above all to properly direct patients towards the relevant specialties if necessary (avoiding the prescription of unnecessary examinations). A good diagnosis implies good therapy.
DEFINITIONS
Several classifications are given supported by: The International Headache Society (IHS) and the International Association for the Study of Pain (IASP).
- Pain = “unpleasant sensory and emotional experience associated with actual or potential tissue injury, or described in terms of injury”
Oro-facial pain, as in any painful experience, we identify at least two components:
- – sensory-discriminative component: linked to the perception of the attributes of the nociceptive stimulus: nature, intensity, duration, location
- – emotional component: represents the unpleasant or aversive nature of this experience and thereby makes it intolerable.
This aspect may contribute to promoting the evolution of pain towards chronicity (Chapman and Gavrin 1999; Price 2000; Lavigne et al. 2005).
Reducing the emotional component of pain has a dual therapeutic interest: – relieving acute pain – preventing the onset of chronic pain (illness).
CLINICAL STUDY OF OROFACIAL PAIN:
- NEURALGIA of the face or NEUROGENIC FACIAL PAIN (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)
1-1-ESSENTIAL NEURALGIA OF THE V
The diagnosis is based on the clinical picture: characteristics of the pain Neuralgia of the V defined by the IASP (2003): “sudden recurrent pain, generally unilateral, in the form of a stab, of short duration concerning the territory of one or more branches of the Trigeminal nerve”.
Touch more women than men (3/2)
Semiology of pain
“Atrocious”, fulminating, paroxysmal • Well described by the patient: electric shock, stabbing, crushing, tearing. • Painful attacks last a few seconds, to 1 to 2 minutes • Frequency
= 1 to 10 bursts (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 zone 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 zone at the level of the pons *vascular-nervous conflict at the level of the trigeminal ganglion detected during MRI angiographic sequences = pain due to vascular compression
- Treatment *Carbamazepine = diagnostic and therapeutic test (tested 1996, 2003, 2004), effective in 80% of cases (short term) (Tégrétol®)
Note: it should be noted that the longer the neuralgia has been present, the more the symptoms may change:
-The attacks are more numerous -The period of calm is shorter and sometimes it disappears -The treatment becomes insufficient despite the high doses…
- SYMPTOMATIC NEURALGIA OF THE V
- Semiology : intense pain + persistent underlying pain *burning, tearing or dysesthesia-like pain *no trigger zone *presence of vasomotor signs *neurological examination: reduction or abolition of the corneal reflex, hypoesthesia in the V area, paresis and amyotrophy of the temporal and masseter muscles, extra-geminal neurological impairment: deafness, vestibular impairment.
- Etiologies • Central causes: bulbar, protuberant lesions: tumors, stroke, multiple sclerosis. • Peripheral causes: *Mononeuropathy: of frequent causes: -post-herpetic or herpetic neuralgia: burns or dysesthesias persisting more than 3 months after the skin rash, affects the 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
- Diagnosis and treatment * Diagnosis +: continuous pain, no “trigger zone”, neurological abnormality *TTT = etiological (accessible) or neurosurgery
- ESSENTIAL NEURALGIA OF THE IX GLOSSOPHARYNGEAL FACE
- Epidemiology
Less common than NFE • 1 case in 70 to 100 cases of NFE • Affects adults over 60 years old
- Semiology Very similar to NFE, only the topography changes *pain in attacks *unilateral, most often left • location: tonsil, base of the tongue irradiation in the ear and angle
mandibular, CAE. *isolated otalgic form confused with the otitis form • “trigger zone”: base of the tongue, pharyngeal mucosa, tonsillar region (CA, pinna = rare)
- Triggers: swallowing, coughing, head rotation (not chewing = NFE) •
- Accompanying signs : cough, hypersalivation, rhythm disturbance (hypotension, syncope) • Pain in the back of the throat when swallowing + syncope indicate the diagnosis •
- Treatment *same regimen as NFE: Carbamazepine *infiltration and alcoholization of the IX
*endocranial or cervical neurotomy.
- FACIAL PAIN Dental- ENT- Ophthalmic “specialists”
- Stomatological Facial Pain Very few elderly people still have their natural teeth already replaced by old and poorly fitting prosthetic restorations. However, when the teeth still persist, we can observe:
- Dental and gum pain: pulp pain: mild (pulp calcification and enamel abrasion) **dental cracks (fractures) *teeth maintain satisfactory strength despite recessions exposing roots and furcations.
- Stomatological Facial Pain Very few elderly people still have their natural teeth already replaced by old and poorly fitting prosthetic restorations. However, when the teeth still persist, we can observe:
2-1-2-periodontal pain: the periodontium undergoes physiological senile atrophy: the bone is osteoporotic. desmodontitis: rare in the elderly because physiological sclerosis makes it insensitive except in the apical region (granuloma ++)
2-1-3-mucosal pain: erosions or ulcerations caused by neglected oral hygiene or irritations caused by old prosthetic or conservative restorations (amalgam). Keratinization of the gingival epithelium is accentuated, which promotes the appearance of leukokeratotic lesions. Ulcerations from viral infections (shingles, herpes) are particularly painful. Mycotic infections are often encountered. If the etiology is not found, a biopsy is necessary. – lesions related to general pathologies with an oral component: erythema multiforme, pemphigus, post-RX mucositis, diabetes, gastroesophageal reflux, dry mouth, etc.
2-1-4- Pain from oral cancers – Patient aged 50+, alcoholic and smoker, typical infiltrating ulceration with induration at the base…..
- Iatrogenic pain All oral care can cause localized or radiating pain (OCE, Surgery), alveolitis.
- Salivary pain Lithiasis, inflammation, tumors of the salivary glands favored by the changes undergone by the glandular parenchyma and saliva. Gougerot-Sjögren syndrome is often observed.
- Bone pain senile osteoporosis makes the maxillary bone more vulnerable: – fractures (even if the subject is less exposed than the young person), osteitis due to obliteration of the vascularization the bone defends itself poorly and its regeneration capacities are reduced, tumors, ORN if history of radiotherapy.
- Facial pain of ENT origin *Acute maxillary sinusitis clinical, topography of pain (cheekbone), NMP X-ray confirms the diagnosis. *other sinusitis: frontal, ethmoidal, sphenoidal.*
- Oro-facial ophthalmic pain Periorbital pain with impaired visual acuity, photophobia, other ophthalmic conditions (optic neuritis, glaucoma, etc.)
- Orofacial pain in the context of DAM = failure of the masticatory system to adapt to an occlusion or parafunction disorder aggravated by a psychological disorder. = polymorphic clinical entity certainly affecting young subjects between 20 and 40 years old, but is not exceptional in the elderly with a notable female predominance.
Clinical
*joint pain: disc displacement (noises) – The TMJs undergo changes related to general diseases (rheumatism, osteoporosis and other degenerative lesions). – These affect the articular surfaces (condyles) and the disc apparatus. – Bone and muscle senescence – Alteration of dental occlusion, reduction of the vertical dimension
*muscle pain: muscle atrophy and hypotonia ==) project into the muscle projection area. Projection to the teeth leads to extractions aggravating the DAM by loss of posterior alignment. 27 *extra-manducatory signs: by diffusion of spasms – neck and shoulder pain **otological signs: tinnitus, sensation of blocked ear – cranio-spinal posture disorders (etiology increasingly incriminated: cervical posture defect, scoliosis, posture during sleep
Treatment :
* painful episode: analgesics (level 1, 2) NSAIDs if no CI, muscle relaxants (tetrazepam, Coltramyl, mydocalm, etc.). * Etiological treatment, adequate prosthetic restoration. 28
*psychological support – educational session: reassure the patient by explaining the etiopathogenesis – patient involvement = therapeutic success. – eliminate bad habits (onychophagia) – limit mandibular kinesis – self-massage of the muscles – mandible in resting position avoiding dental contact: pronounce “N” by putting the tongue behind the upper INC, by interposing an object: pen. – correction of the closing path – correction of postural anomalies.
- IDIOPATHIC ORO-FACIAL PAIN
Mechanism imperfectly identified therefore treatment difficult Woda and Pionchon (2001) classify in this framework of idiopathic orofacial pain: Atypical facial pain, atypical odontalgia, glossodynia, idiopathic orofacial myalgia.
*psychological profile of these misunderstood patients, in urgent need of relief and the inability of the practitioner to respond to it leads to a “medical nomadism” complicating the situation even more.
*dominant female prevalence (anxiety, stress, nail biting).
- Atypical Facial Pain – affects the mouth, jaw and face – called “horrible” by the patient – type of burning, tightening, constriction, movement in the bone – only diurnal, no trigger zone – in the long run the pain spreads without respecting the V – becomes bilateral – Dysesthesia,
paresthesia – Preceded by accidental or surgical micro-trauma (dental, ENT, maxillofacial)
– Psychological factors: depression, anxiety, cancer phobia.
- Atypical Toothache – corresponds to the dental location of an atypical pain – the pain affects healthy teeth (PM, M sup) – continuous, dull, deep pain – not triggered by thermal or chemical stimuli – resists local anesthesia – migrates to another tooth if it is extracted – concept of “phantom tooth”: persistence of pain after avulsion – neuropathic etiology
= possible (not confirmed).
- Stomatodynia and Glossogynia
“Burning mouth syndrome” – patient: woman + 60 years (post menopause) or 50-70 years = abnormal sensation of burning or tingling of psychogenic functional origin limited to the tongue = glossodynia (2/3) or gum, lips, palate = stomatodynia. = oral paresthesia (Demange1996). *description is done with great detail: tingling, swelling, itching, burning… *permanent, dull discomfort preventing any professional activity
*chronic, continuous, bilateral, without organic cause *dry mouth, taste disorders *onset = linked to dental care, emotional context *analgesics = no effect.
- Atypical Orofacial Myalgia
-myofacial pain (all face) especially in the masticatory muscles
*2 clinical pictures: -idiopathic headaches = tension headaches -idiopathic arthromyalgia. – Remission phases = frequent – Examination finds tension cords and trigger points – Probable etiopathogenesis: ischemia by sustained effort by the masticatory muscles would induce desensitization of the vasodilator system, reduction of blood perfusion, metabolic and tissue alterations of the muscles.
- Treatment – multidisciplinary care : neurologist, psychologist, psychiatrist – classic analgesics: no effect – listen to the patient, stop their “medical nomadism” – suggest behavioral therapies: relaxation techniques, leisure activities – selective serotonin reuptake inhibitor antidepressants = effective – anticonvulsants – neuroleptics, anxiolytics, analgesics = useless – currently: local topicals: Clonazepam = effective – antihistamines: some effectiveness for glossodynia.
Diagnostic Approach
Clinical examination
- ANAMNESIS : listen to the patient tell their “painful story” and clarify the symptoms of the pain
*note: age, psychological profile, profession, general history, stomatological (abusive exo) “nomadism”
*pain: date of onset, onset mode: sudden, progressive, spontaneous, provoked, -evolution: acute, chronic (6 months = chronic pain = illness) -semiology: electric shock, “flash”, pulsatile, paresthetic, burning -continuous, in bursts with or without lull -recent worsening -duration of the attack: second, min, hour 38 -topography: trunk, endings, several territories -triggering causes: functions, insomnia, anxiety, stress -existence of “Trigger Zone” -presence of warning prodromes: instability, mood disorders (aura of migraines) -signs
accompanying: vasomotor and secretory phenomena, digestive signs (nausea, vomiting)
-Therapies already instituted, effectiveness? – Impact of pain on the patient’s life ++
- Clinical examination : thorough, good lighting -inspection: look for any facial abnormalities, erythema, rash, swelling -palpation: gentle, precise: of the face and neck following the bony contours, ATM, facial muscles, neck, shoulders, etc. -sensitivity: V, IX, VII -adenopathies
– arterial and venous structures – endo-oral examination: mouth opening (trismus), closure path, hygiene, dento-periodontal state, tongue, palate, mucous folds, oropharynx. – Cavities: sinuses, nasal cavities, orbits. ==) a diagnosis of high probability is established.
Additional examinations – Orthopantomogram, retro-alveolar, bite: dental etiology – CT, MRI: more precise details – AngioMRI: vascular pain – ultrasound – Essential specialty examinations (pain): Neuro++, ENT, Ophthalmology and others on request – Neurological assessment scales: *VAS: visual analog scale *Sensory exploration: prick / touch, hot / cold
*taste tests IX: sweet / salty
Therapeutic means:
Progress in understanding the neurobiology of pain contrasts with drug management, which is still based on pharmacological concepts based on three types of analgesic molecules. The WHO has classified analgesics
in 3 levels or tiers to allow a prioritization of these drugs according to their level of effectiveness and their benefit/risk ratio:
Level 1 represented by non-morphine analgesics (peripheral or minor analgesics) having an action on peripheral nociceptors: paracetamol, aspirin and
nonsteroidal anti-inflammatory drugs.
Level 2 : Combinations of level 1 analgesics with weak morphine analgesics or minor opiate derivatives (codeine, dextroproxyphene) to achieve a synergistic effect. Level 3 is represented by strong morphine agonists that belong to the class of narcotics or centrally acting analgesics.
Co-analgesics: they are often useful and sometimes essential in therapeutic management:
- Antidepressants : Amitriptyline (Laroxyl) prescribed for certain stubborn pains at a dosage lower than the antidepressant dosage: 25 to 75 mg/day;
Muscle relaxants (reduce polysynaptic spinal reflexes that generate reflex muscle contractions)
- Corticosteroids (action on gene expression, among others, of mediators involved in the control of nociceptive messages)
- Anti-epileptics :
- Carbamazepine (Tegretol) as first- line treatment for essential neuralgia, it also constitutes a diagnostic test since it is effective in the short term in 70 to 80% of cases, the effective dosage is on average 600 to 1200mg/day which are the threshold doses, treatment introduced gradually to allow better tolerance
;
- Pregabalin (Lyrica): Gaba analogue (inhibitory neurotransmitter) prescribed for peripheral neuropathic pain at 150 mg/day, the dose is increased according to response and tolerance
- Antispasmodics
- Anxiolytics (amnesic effect, benzodiazepines do not modify the perception of painful stimuli but they reduce their emotional impact)
- Vitamin B1-B6 prescribed as an adjuvant, has an essential metabolic role in cellular functioning and the transmission of nerve impulses.
Neurosurgery and physical medicine techniques:
- Neurostimulation (using electrodes generating an electric current):
- Transcutaneously used in deafferentation pain, it stimulates the large myelinated fibers which conduct tactile sensitivity, reinforces gatecontrol.
- Medulla reinforces the inhibitory action of the posterior cord pathways, the electrodes are placed subcutaneously, used after failure of the transcutaneous.
- Ablative techniques used for pain due to excess nociception involve intervention on the cranial nerves (thermocoagulation selectively destroying the small nociceptive fibers while respecting the large fibers of the GASSER ganglion) and the peripheral nerves.
- In essential facial neuralgia, resistance to medical treatments leads to the practice of:
- Infiltration of the nerve with a local anesthetic product at the trigger zone (immediate but temporary sedation)
- Alcoholization of the affected terminal branch with 60° alcohol after local anesthesia (relief for approximately 1 year)
- Percutaneous thermocoagulation provides sedation while preserving tactile sensitivity as much as possible (a high-frequency generator destroys poorly or unmyelinated fibers)
- Microsurgical vascular decompression (separating the nerve from the vessel)
- Peripheral neurotomy (section of the nerve corresponding to the painful area provides permanent anesthesia)
- Retrogasserian neurotomy (section of the sensory root at its exit from the ganglion via the temporal and extradural route)
- Cervical or endocranial neurotomy for the IX.
- Massage therapy combines physical medicine and rehabilitation techniques: hydrotherapy, cryotherapy, electrotherapy, infrared, vibrations.
- Other means: Psychotherapeutic approaches, acupuncture, mesotherapy.
CONCLUSION
Although orofacial pain is a very common reason for consultation, it is a clinical element of many etiologies. Often the dentist is the first point of contact when faced with facial pain. As they are located in the V area, they are confused with dental pain. Any pain requires a stereotypical clinical examination, both exorbital and intraoral, which will best guide an appropriate paraclinical assessment, avoiding the launch of unjustified care (extractions) that does not provide any relief to the patient. Knowledge of the various classic semiologies allows for the rapid management of these pains. Any suspicious lesion of the oral cavity must be biopsied to eliminate a malignant process.
Orofacial pain and sedation in the elderly
Wisdom teeth can cause pain if they erupt crooked.
Ceramic crowns offer a natural appearance and great strength.
Bleeding gums when brushing may indicate gingivitis.
Short orthodontic treatments quickly correct minor misalignments.
Composite dental fillings are discreet and long-lasting.
Interdental brushes are essential for cleaning narrow spaces.
A vitamin-rich diet strengthens teeth and gums.