OROFACIAL PAIN

Clin A/Prof Robert Delcanho

BDSc MS Cert OFP FFPMANZCA FICD FAAOP
Diplomate, American Board of Orofacial Pain

St John of God Hospital, Subiaco Clinic

25 McCourt Street
Subiaco WA
 OROFACIAL PAIN
The field of Dentistry that includes the
Assessment, Diagnosis and Treatment of

 Complex chronic orofacial pain and dysfunction

 Oromotor and jaw behaviour disorders

 Chronic facial, head and neck pain

 OROFACIAL PAIN
1. Dental (Odontogenic) Pain
2. Musculoskeletal Pain – Temporomandibular disorders
3. Neurovascular Pain – Primary headaches
4. Neuropathic Pain
• Episodic
• Continuous
5. Sinus Pain
6. Psychogenic Pain
7. Intracranial
8. Cervicogenic
 Pain
generators

o Head
-meninges
-skull & scalp
-nerves
-trigeminal (V)
-C2-3 (GON/LON)

o Orofacial
-sinuses
-TMJ, ear
-teeth, nerves

o Neck & shoulders

 Red flags
T.I.N.T

o Tumour
o Temporal arteritis
o Intracranial pressure
o Infection
o Neurovascular
o Trigeminal
o Trauma
 Red Flag Case Presentation

 Female 16 years
 Hx of constant deep aching TMJ/jaw pain worse
with chewing, extending to occiput.
 Initially treated with Occlusal Splint/Physio.
 Headaches on exertion - paroxysmal with “fainting”.
 Parents noted subtle personality changes.
 MRI - Arnold Chiari formation- surgery.
 Intracranial Pathology
Diagnostic Clues

 Neurological type symptoms/signs.

 No response to peripheral therapies.
 Unusual or worsening symptoms despite therapy.
 Negative response to somatic/sympathetic blocks.
 Intracranial pathology
Common manifestations of raised intracranial pressure
 Space Occupying Lesions
 Neoplasms
 Arterial dissection
 Aneurysms
 Infection/Abscess
 Infarction/haemorrhage
 Oedema
 Angioma
Temporal (Giant cell) Arteritis
 RED FLAG
 Headache emergency
 New onset headache in >50 years
 Uni/bilateral dull temporal pain
 Claudication masticatory muscles
 Visual disturbance
 Polymyalgia-shoulder/hip, malaise
 Swollen, tender temporal artery
 Elevated ESR, CRP
 Positive biopsy
 Temporal Arteritis
RED FLAG
 Headache of vascular origin
 Initial symptoms may resemble TMD
- Pain/stiffness in jaw
- Pain/fatigue of jaw when chewing
- Pain may radiate to ear, teeth
- Temporal headache
 If untreated may cause blindness, stroke and death!
 Generally resolves with high dose steroids
 Extracranial Sources of Orofacial Pain

 Teeth and oral mucosa

 ENT, paranasal sinuses
 TMJs &myofascial
 Tongue
 Salivary Glands
 Lymph Glands
 Eyes
 Vessels & nerves
 Odontogenic Pain – Toothache
 Most common cause of orofacial pain!
 Often missed by medical people
 Dental caries into dentine / pulp
 Pulpitis, pulp necrosis
 Cracked teeth
 Periodontal infection
 ASK ABOUT HOLES IN TEETH
 Hot/cold/bite SENSITIVITY, PAIN AT NIGHT
 TOOTHACHE
• Toothache - most common orofacial pain complaint
• 12.2% of population reported toothache in last 6M
• Diagnosis can be challenging and complicated
• Pain from one tooth may be referred from another
tooth or from other orofacial structures
• Other craniofacial pain disorders may mimic the
symptoms of toothache
• Proper diagnosis is critical
Consider all pains in the mouth and face to
be of dental origin until proven otherwise
 TEMPOROMANDIBULAR DISORDERS

Major cause of Non Dental Pain in Orofacial Region

 TEMPOROMANDIBULAR DISORDERS

Collection of medical and dental conditions

affecting the temporomandibular joint
and/or muscles of mastication and/or
contiguous tissues resulting in pain and/or
dysfunction
 TEMPOROMANDIBULAR DISORDERS
Primary Clinical Features

 Ear ache (pre-auricular pain)

 Painful jaw use e.g. with chewing, yawning
 Tender TMJs and muscles of mastication
 Restriction of jaw movement
 Interference with jaw movement
 TMJ sounds e.g. clicking, cracking, popping sounds
 TEMPOROMANDIBULAR DISORDER
Other Clinical Features

 Headache
 Ear symptoms eg discomfort, fullness
 Occlusal discomfort or change
 Mandibular dyskinesia
 Intermittent facial swelling
TEMPOROMANDIBULAR DISORDERS

The pain/dysfunction should be directly

related and aggravated by jaw use (Solberg)
Temporomandibular Disorders

TMJ ARTHRALGIAS .OROFACIAL MYALGIAS

1. Traumatic arthralgia - Muscle splinting/strain
- Muscle spasm
2. Arthromyalgia - Myofascial Pain +/- TPs
- Myositis
- Fibromyalgia
3. Internal Derangement - painful
TMJ dysfunction

4. Osteoarthritis

5. Systemic (poly)arthritis
 TEMPOROMANDIBULAR DISORDERS
Masticatory Muscle Disorders

 Protective co-contraction (splinting)

 Local muscle soreness (strain)
 Muscle spasm
 Myositis
 Myofascial pain
NEUROVASCULAR PAIN
 Case Presentation
 48 year old female
 Intermittent dull throbbing pain in upper tooth/jaw,
radiating to temple and eye.
 Severe attacks, last 1-3 days with constant dull pain.
 When severe, feels sick and prefers dark, quiet room
to sleep.
 Attacks used to respond well to NSAIDs.
 Had a root canal, crown of upper premolar + splint
Migraine
 Case Presentation
 Male in mid forties.
 Right sided face pain attacks on/off over three years
 Extending into right eye.
 Often awakened from sleep with severe throbbing
pain.
 Would get up and pace around holding his R. eye.
 Face would feel sweaty, tearing of eye.
 Numerous dental visits – Root canals/ extractions.
 Case Presentation
 EXAMINATION
Cranial nerve screen - Normal
TMJ/Myofascial – Normal
Oro-dental- Normal

 Medication Trial - response to oxygen/sumatriptan

 TRIGEMINAL AUTONOMIC
CEPHALGIAS (TACs)
 CLUSTER HEADACHE
 CHRONIC PAROXYSMAL HEMICRANIA
 HEMICRANIA CONTINUA

Unilateral, severe attacks with typical autonomic

headache accompanying symptoms.

Peri-orbital or maxillary pain.

Frequently leads to dental work including extractions.
 Cluster Headache
Clinical Features
• Attacks are severe - boring
• Strictly unilateraln in and
around eye and/or temporal
region - “hot poker”
• Attack duration 15-180 min
• Attacks occur from once
every 2nd day up to 8x day.
• Attacks occur in series
lasting weeks to months
Remissions mths-yrs

• Autonomic features +++

• Males 5-7:1

65% had dental Tx

 Chronic Paroxysmal Hemicrania
Similar to Cluster but

 Female preponderance (3:1)

 Attacks are more frequent and of shorter duration
 5-40 attacks per day (median 5-10)
 Attacks last 2-45 minutes
 At least one autonomic symptom on the side of pain
conjunctival injection lacrimation
nasal congestion rhinorrhoea,
ptosis eyelid oedema
 Chronic Paroxysmal Hemicrania

 Always unilateral orbital, and/or temporal.

 Severe stabbing/boring type pain that throbs as it builds
up.
 Episodic form occursin bouts lasting months to years
with clear intervals (rare).

 In most cases responds rapidly and absolutely to

Indomethacin (diagnostic test).
 Tension Type Headache (TTH)

 Previously called tension headache, muscle

contraction headache, stress headache
 Most common primary headache (30-70% prevalence)
 Episodic (frequent/infrequent) and chronic forms
 Usually frontal /temporal location
 Tightness, pressure in hat-band like distribution
 +/- pericranial muscle tenderness
 Often co morbid with migraine w/o aura.
 Tension Type Headache
NOT DUE TO ABNORMAL MUSCLE CONTRACTION
 Neuropathic Orofacial Pains
EPISODIC
 Trigeminal Neuralgia
 Glossopharyngeal Neuralgia

 CONTINUOUS
 Painful Traumatic Trigeminal Neuropathy
 Post Herpetic Neuralgia
 Persistent Idiopathic Facial Pain (PIFP)
 Persistent Dento-alveolar Pain (PADP)
 Burning Mouth Syndrome
 Case Presentation

 65 year old female

 Sharp shooting pains upper anterior teeth 22/23
 Saw dentist - fillings, root canals, extraction,
bridge, removal of bridge
 Inserting denture triggers sharp pain
 Repeated denture adjustments
 Case Presentation
EXAMINATION
 Cervical spine - normal
 Cranial nerve screen - normal
 TMJ/MM - normal
 Myofascial - tender masseter.
 Intraoral - mucosa normal appearance
trigger area palatal to 23 site.
Orofacial Neuropathic Pain
 Trigeminal neuralgia
Brief, electric shock-like, lancinating pains
that affects the face unilaterally affecting
one or more divisions of the trigeminal
nerve
 Trigeminal Neuralgia

 Intermittent brief paroxysmal pain (secs-mins)

 Limited distribution: V2 and/or V3 > V1
 Trigger zone –minor stimuli- touch, wind, shave
 Abrupt in onset and termination and may remit
 Remission period can spontaneously occur that lasts
for weeks to years, and may return
 Triggerable or spontaneous
 No obvious local cause
Painful Post Traumatic Trigeminal
Neuropathy (AFP, PIFP)

 Unilateral facial and/or oral pain

 Usually continuous +/- sharp jolts of pain
 History of trauma to same V nerve branch
 Positive and/or negative neurosensory signs
 (allodynia, hyperalgesia, hypoesthesia etc)
 Equivocal response to LA nerve block
 Varying degree of central & sympathetic involvement
 Case presentation

 40 yo female
 Complains of 3 years continuous dull aching pain
in lower left quadrant. Occasional sharp pains.
 Problem commenced after periodontal surgery and
surgical extraction of third molar.
 Since had RCT of 1st and 2nd molars w/o effect
 Aggravated by eating on that side and brushing
teeth.
 Persistent Dento-Alveolar Pain
Disorder (PDAP)
(Atypical Odontalgia, Phantom tooth pain)

 Continuous variable pain

 Localized to dento-alveolar region – tooth/extrn sites
 Usually multiple (unsuccessful) dental procedures
 No obvious local pathology-clinical/radiography
 Not caused by another disease or disorder
 +/- Sensory abnormalities
 Somatic block equivocal
 Case Presentation

 48 year old female

 2 years continuous dull, aching, burning pain in upper
right jaw
 Presumed pulpitis so over time 3 x root canals
 Extractions all upper molars, now wants premolar out
 Extractions only aggravated pain, which has spread
 Some sinus and menopausal symptoms
 Hx of depression - not current
 Case Presentation
 Cervical Spine - normal
 Cranial Nerve Screen - normal
 Stomatognathic- normal
 Myofascial – trigger points but not replicating pain
 Intraoral- Extraction sites hyperaesthetic
 Somatic block – negative
 Sympathetic block- partially positive
 Cone Beam CT, MRI- normal
 Persistent Dento-Alveolar Pain
Disorder (PDAP)
(Atypical Odontalgia, Phantom Tooth pain)

 Females > males – usually mid 40s on

 Posterior maxillary quadrant most often
 Hx of trauma - multiple dental procedures
 Somatosensory abnormalities around tooth site
 No evidence of psychopathology
 <50% responded to LA block
 Variable response to TCA, gabapentinoids, topicals etc
 Repeated dental procedures are contraindicated
 EETS
Excessive Endodontic Treatment Syndrome
 THANK YOU !!!!

dr@orofacialpain.com.au
 Anxiety Disorders

Personality Traits
Okeson, 2003
Other Conditions

Generalized Anxiety Malingering

Disorder or Coping Style
Posttraumatic Stress Psychological Factors Maladaptive Health
Behavior
(Psychological Conditions)

Disorder Affecting Med Condition

Anxiety Disorder due to Stress-Related
a Medical Condition
Other Conditions Physiological Response
Axis II

Axis I Axis II

Undifferentiated
Somatoform Disorders

Somatoform Disorder
Diagnosis
Mood Disorders

Depressive Disorder
Conversion Disorder
Bipolar Disorder
Pain Disorder
Mood Disorder due to
a Medical Condition
Hypochondriasis
Chronic Regional
Classification of Orofacial Pains

Sympathetically Maintained Pain

Pain Syndrome
Post Herpetic Neuralgia
Atypical Odontalgia
(Phantom Pain)
Central Mediated Pain
Continuous Pain

Burning Mouth Disorder Herpes Zoster

Peripheral Mediated Pain Neuritic Pain Peripheral Neurits
Deafferentation Pain Traumatic Neuroma
Neuropathic Pain

Metabolic Polyneuropathies
Migraine
Entrapment Neuropathy
Tension-Type
Episodic Pain

Trigeminal Neuralgia Cluster and other TCA

Paroxysmal Neuralgia
Other Neuralgias Other Primary Headache
(Physical Conditions)

Neurovascular Pain Neurovascular Variants

Axis I

Arteritis Pain
Vascular Pain
Carotidynia
Pulpal Pain
Ligamentous Pain
Deep Pain

Visceral Pain
Visceral Mucosal Pain
Retrodiscal Pain
Musculoskeletal Pain Glandular, ENT Pain
Capsular Pain
Somatic Pain

Arthritic Pain
Periodontal Pain
Superficial Pain
Protective Co-Contraction
Mucogingival Pain
Connect. Tissue Pain
Local Muscle Soreness
Cutaneous Pain Osseous Pain Myofascial Pain
TMJ Pain Myospasm
Muscle Pain Central Mediated Myalgia