Orofacial pain in the elderly
1. Introduction
Geriatric patients are characterized by:
- the coexistence of several chronic disabling pathologies causing physical and/or psychological dependence,
- the frequent interweaving of neurodegenerative and somatic pathologies.
- The face is the richest sensory support of the body. Anatomically; the trigeminal nerve, through its three branches, is responsible for its sensory innervation.
- Facial pain (FP), sensory exacerbations, are frequent and varied.
- The dentist is often confronted with AFs and must diagnose them.
2. Definitions
- Pain : It is defined as “an unpleasant sensory and emotional expression associated with actual or potential tissue injury, or described in terms of such injury”,
- Pain : pain in an organ or region that does not correspond to an obvious lesion.
- Neuralgia : pain located along the path of a nerve.
- Painful access : corresponds to a painful crisis.
- Salves : corresponds to periods during which the patient suffers from painful attacks.
3. Components of pain
3.1. Sensory-discriminative component
This is the physical description of the pain felt in terms of:
- Location
- Quality (burns, tingling , pins and needles, electric shocks, stab wounds, pressure, etc.)
- Duration (short, continuous, chronic, recurring, etc.) – intensity
3.2. Affective-emotional component: This is the affect that the person associates with their pain and the impact on their activity and mood: discomfort, anxiety, anguish, depression.
3.3. Behavioral component: Meaning , significance given to pain
3. 4. Cognitive component: How pain is expressed (screams, complaints, posture, withdrawal, agitation)
Pain therefore appears as a multidimensional (multifactorial) phenomenon and not as a simple reaction,
4. Diagnosis
- Clinic ++++++
- Additional examinations:
- Radiological examinations:
- Panoramic, Blondeau, Schuller, Scanner, MRI (exploration of vascular and nervous elements (vascular-nervous conflict)
- Biological examination,
- ENT examination
- Eye examination,
- Neuro-psychiatric examination.
Orofacial pain in the elderly
5. Classification
- Neurogenic pain,
- Pain of vascular origin,
- Facial pain of ENT and dental origin ,
- Facial pain in the context of DAM ,
- Idiopathic facial pain.
5.1. Neurogenic Facial Pain: Neurological: Neuralgia of the Face
They affect the sensory nerves, mainly the branches of the trigeminal nerve (V 1 = ophthalmic, V 2 = maxillary, V 3 = mandibular) and the glossopharyngeal nerve (IX). It can be:
- Essential (idiopathic)
- Symptomatic (secondary to a specific pathology).
5.1.1. Essential neuralgia (NE)
5.1.1.1. NE of the trigeminal (V) : Also described as “TROUSSEAU’s painful tic”
- Epidemiology :
- Common in women after 50 years of age
- Sex ratio 3:2
- Etio-pathogenesis :
There are several hypotheses:
- Central theory : Epileptiform character of seizures plus the effectiveness of anti-epileptics suggest a central mechanism through hyperactivity of the nucleus of the V.
- Peripheral theory:
Vasculo-nervous conflict:
Compression of the gassian ganglion
- Mixed theory :
- Clinical
- Characteristics of pain :
- Atrocious,
- In a flash,
- Dazzling,
- Intermittent,
- A sudden onset comparable to an electric shock, crushing, stabbing, tearing.
- Last a few seconds and are grouped into bursts that can last up to 1-2 minutes/day. The frequency is 1-10 bursts/day.
- Location of pain : strictly unilateral, affecting the territory of one of the branches of the V. V 2 ,++++
- Triggering factors
- the pain occurs after stimulation of a “trigger zone” which is often located in the painful area).
- During the attack, the patient becomes immobile and tense. After a painful crisis, followed by a refractory period of a few minutes. The patient is tired, anxious due to lack of sleep and food, his social life is disrupted.
- Negativity of the neurological examination: carried out outside the painful period, its aim is to verify the absence of any neurological deficit signs.
- Positive diagnosis
Elements of the Dc are:
- Patient age between 50 and 60 years old
- The pain is sudden and brief
- Existence of a trigger zone
- Presence of painful tics
- Absence of neurological manifestations
- Carbamazepine trial with NET efficacy
Differential diagnosis : it is done with
- Essential non-trigeminal facial neuralgia: same characteristics but different topography.
- Symptomatic pain (search for etiology )
- Psychalgia.
Orofacial pain in the elderly
Evolution :
In the absence of treatment, NET develops:
- in a discontinuous mode
- towards worsening with a tendency to take on a permanent character.
Treatment
1. Medical treatment
Carbamazepine (Tegretol®): first-line treatment, the dosage used varies from 400 to 1,200 mg/day.
2- surgical treatment :
Indicated in case of failure or intolerance of a well-conducted medical treatment of essential trigeminal neuralgia.
- Percutaneous retrogasserian thermocoagulation: Thermal injury is performed at the junction between the Gasserian ganglion and the trigeminal root .
- Percutaneous balloon compression of the gassian ganglion.
- Gamma radiation radiosurgery.
- Microsurgical vascular decompression.
5.1.1.2 .NE of the glossopharyngeal (IX)
- Less common than NET.
- Touches the subject +60 years.
- Pain per attack +/- long), unilateral interspersed with periods of remission.
- Pain localized to the tonsil, CAE, base of the tongue, radiating to the ear and mandibular angle.
- Trigger zone: pharyngeal mucosa and tonsillar region.
- Swallowing, coughing, turning the head, speaking and not chewing trigger the pain.
- It may be accompanied by coughing, hypersalivation, and heart rhythm disorders.
- Dc (+): is based on the location of the pain and its topography corresponding to the anatomical distribution of the (IX).
- Treatment : Same treatment regimen as NFE of V.
5.1.2. Symptomatic Facial Neuralgia: (secondary) (NS)
5.1.2.1. Trigeminal NS (V):
Etiopathogenesis
- Neuralgia (post-herpetic, herpetic).
- NS of an expansive lesion (tumor, infectious, etc.) are + rare.
- lupus erythematosus, scleroderma, Goujerot-Sjögren syndrome. Their symptoms evolve gradually; they can become bilateral.
- multiple sclerosis which is in fact the first etiology of trigeminal NS.
Clinical
- Young age of the patient +++++++++++;
- Pain with exacerbation but persistence of a painful background between attacks.
- Burning, tearing or dysesthesia-type pain.
- Absence of “trigger zone”;
- Location in several territories of the V; even bilateral;
- Presence of vasomotor signs.
- The neurological examination is abnormal
- Treatment: Etiological if the cause is accessible, otherwise neurosurgery.
Orofacial pain in the elderly
5.1.2.2. NS of the glossopharyngeal (IX)
More frequent than essential forms.
Etiologies :
- Infectious : Tonsillitis, otitis, tuberculosis
- Exocranial : ENT cancer; Styloid process syndrome
- Endocranial : Tumor of the posterior cerebral fossa, involvement of the other cranial pairs.
Clinic: it takes the same characteristics of essential neuralgia with
- Exacerbation on traction of the tongue,
- Attenuation by injection of anesthetic is a good diagnostic test,
- No trigger zone.
5.2. VASCULAR FACIAL PAIN
Etiologies
- Dissections of the cervicoencephalic arteries
- Horton’s disease or headache with giant cell arteritis:
- Reached the subject of +60 years old especially the female sex;
- Preferentially affects large caliber arteries, especially the external carotid.
- temporal headaches (sign of temporal artery damage,
- Constant pain, sometimes worsening in the morning.
- Exacerbated by hyperesthesia type contact with the scalp (rubbing from a comb, pillow, wearing glasses, etc.).
- intermittent jaw claudication
On examination : an indurated temporal artery can be found. Facial edema.
Biological examination : inflammatory syndrome, namely; increased ESR, CRP.
- Diagnosis: confirmed by temporal artery biopsy.
- Treatment: Corticosteroid therapy as soon as possible before complications occur
5.3. Stomatological, Oto-Rhino-Laryngological and Ophthalmological Facial Pain
5.3.1. Stomatological facial pain
- Tooth and gum pain
- Pulpal (less frequent): canal calcifications
- Dental cracks and fractures
- The teeth maintain satisfactory strength despite recessions
- Periodontal pain: the periodontium undergoes physiological senile atrophy with damage to the alveolar bone by osteoporosis
- Mucous membrane pain+++: Erosions and ulcerations encouraged by “oral hygiene + chronic irritations” poorly adapted prosthesis and restorations.
- Keratinization of the epithelium is accentuated, promoting the appearance of leukokeratoses.
Orofacial pain in the elderly
5.3.2. Ocular and oto-rhino-laryngological AF
5.3.2.1. Eye pain : Periorbital pain + impaired visual acuity
(acute, chronic glaucoma, intraorbital tumor)
5.3.2.2. Ear, nose and throat pain :
- Pain due to acute or chronic maxillary sinusitis increased by leaning forward, nasal obstruction or rhinorrhea.
- Radio: confirms the digest
- . Other sinusitis: frontal, ethmoid or sphenoid
- Earaches are caused by otitis media, which is throbbing, bacterial or viral in origin and are accompanied by ringing in the ears, deafness and dizziness.
5.4. FACIAL PAIN IN THE CONTEXT OF DAM
Due to a failure of the AM to adapt to an occlusion disorder or to a parafunction, increased by psychiatric and general disorders.
- Joint pain : Pain, Joint noises, OB limitation
- Muscle pain : linked to muscle spasms or their diffusion, they are accompanied by trismus and extra-manducatory signs; earache, tinnitus, neck and shoulder pain and cranio-spinal posture disorders.
Treatment :
- Medical: Drug prescriptions should be occasional during acute painful episodes 🡺
- Level 1 or 2 painkillers.
- NSAIDs in the absence of c-indications,
- Muscle relaxants; tetrazepam (Myolastan®).
- Occlusal: Balanced prosthesis
- Physical and adjuvant therapies
- Physiotherapy
- Rehabilitation with passive then active exercises of the masticatory muscles
5.5 Idiopathic facial pain:
Characterized by:
- Poorly understood pain with an imperfectly identified mechanism and difficult treatment.
- The psychological component is incriminated .
- glossodynia ++++++(>60 years).
- Risk factors
- Hormonal factors,
- Minor nervous trauma,
- Life events
Orofacial pain in the elderly
5.1. Atypical facial pain :
- Described as; burning, squeezing, constriction, movement in the bone,…
- Daytime only.
- Aggravated by chewing and speaking.
- Often preceded by accidental or surgical microtrauma.
- This pain is sometimes accompanied by dysesthesia, paresthesia, patients may report general symptoms: chronic neck pain, functional digestive disorders, etc.
- Psychological factors incriminated: depression, anxiety, cancerophobia, etc.
5.2. Atypical odontalgia :
- Corresponds to the dental location of an atypical facial pain.
- concerns a healthy tooth, most often PM and M sup.
- Absence of stimuli.
- Continuous, dull, deep daytime pain resists AL,’
- Abusive extraction and does not treat the Pain.
- If the pain persists after extractions, we speak of phantom teeth.
- A neuropathic etiology could therefore be implicated.
5.3. Stomatodynia: (glossodynia or “burning mouth syndrome”)
- Affects post-menopausal women, 60 years old.
- Pain in the oral-pharyngeal mucosa without organic cause. The patient describes continuous, chronic pain, most often bilateral, symmetrical, burning-like.
- lingual localization: Best known form.
- It is diurnal and worsens during the day, reaching its maximum when falling asleep.
- Usually spontaneous, triggered or aggravated by the ingestion of spicy or acidic foods. May be accompanied by subjective signs; feeling of thirst, taste disturbances.
Treatment:
- Reassure the patient, confirm that their condition exists and that it has been perfectly identified.
- -Advise to stop all local treatment and especially self-examination in front of the mirror
- -Convince the patient of the need for treatment by a psychiatrist.
- – Treatment with antidepressants
6. Conclusion
The dentist who is consulted to look for the etiology of an AF must be vigilant:
- Ignoring the dental origin and leaving an irritating thorn
- Wrongly blaming the teeth, forgetting the cardinal signs of any dental disease.