Dental Update 2011. Differential Diagnosis for Orofacial Pain Including Sinusitis TMD Trigeminal Neuralgia – Documents

Dental Update 2011. Differential Diagnosis for Orofacial Pain Including Sinusitis TMD Trigeminal Neuralgia - Documents

This case report and literature review highlights the classical signs and symptoms of herpes zoster infection involving the trigeminal nerve. It results from the reactivation of the varicella zoster virus. There are numerous etiologies for pain symptoms, and, as with all pain conditions, the pain presentation can vary significantly. There were no direct comparisons of TNB and other interventions (such as medical management) for idiopathic trigeminal neuralgia. Device testing took place in three settings: a) laboratory testing to assess range of stimulus force intensities, b) dental chair-side to assess reliability, validity and discriminant ability in force-pain relationship; and c) MRI to evaluate magnetic compatibility and ability to evoke brain activation in painfree subjects similar to those described in the literature. . Varicella zoster virus (VZV) causes chickenpox and herpes zoster (HZ).

Her history included a description of unilateral eruptions consistent with HZ of right maxillary division of trigeminal nerve which was accompanied by spontaneous exfoliation of a tooth. The case is presented with a review of clinical data from patients with trigeminal HZ infection associated with osteonecrosis or exfoliation of teeth previously reported in the literature. The clinical presentation of chronic intraoral pain in the area of a tooth or in a site formally occupied by a tooth with no clinical or radiological signs of pathology, referred to as atypical odontalgia (AO) [6,7], is one such chronic pain condition of particular interest to dentists that is difficult to diagnose and manage. Pain may have started spontaneously (idiopathic) or due to an event, such as a traumatic injury, minor or major surgical procedure, or dental intervention (may be referred to as peripheral painful traumatic trigeminal neuropathy or chronic continuous dentoalveolar pain). include a thorough extra-oral and intra- oral examination to corroborate history findings and assist in reaching a diagnosis. Extra-oral examination should include temporomandibular joints (TMJs), regional lymph nodes, muscles of mastication and cervical muscles, salivary glands and face and eyes for any autonomic signs, such as flushing, tearing, ptosis or sweating. Cranial nerves examination may be required in some cases and, in primary care at least, a gross examination of the facial and trigeminal nerves would be expected to assess any motor or sensory abnormalities.

Pain Qualities: Burning, electric shooting, stabbing, dull ache. Limitation of mouth opening and/or deviation of the mandible on opening, TMJ tenderness, TMJ crepitus and/or click and masticatory muscle pain or tenderness may indicate temporomandibular disorders (TMD) and can be determined by palpation over the TMJs and masticatory muscles. Most patients can open comfortably to 35–45mm, equating to approximately three finger breadths, although some may open to a greater distance. Vitiligo can be diagnosed by biopsy and Wood’s… A discussion on herpes zoster, including its cause, complications, and treatment… Oral malignancy, in particular gingival or alveolar bone malignancy, may present with facial pain. Pain ensued soon afterwards.

Characteristic signs of oral HZ are the presence of unilateral vesicles that break rapidly, leaving small ulcers. Pain is initiated through noxious stimulation of primary afferent neurons at the site of injury, and the signal is carried centrally through complex neurochemical processes (Figure 12.1). One prospective case series examined the incidence of complications following bupivacaine/methylprednisolone trigeminal nerve blocks administered through the coronoid notch to patients with trigeminal neuralgia, atypical facial pain, acute herpes zoster or post-herpetic neuralgia, pain of malignant origin or cluster headache (Waldman, 1994). Resistance readings from the strain gauge attached to the intraoral probe and the amount of weight placed at the probe tip showed a linear relationship up to a “failure” point, i.e., when the probe translated. Cimetidine, a common component of heartburn medication, has been shown to lessen the severity of herpes zoster outbreaks in several different instances. The patient had no history of receiving a prescription for any medication that affects bone metabolism and had never received radiotherapy. Pain may be relieved by massaging the glands involved.

alone may lead us to the correct diagnosis. Pain ratings collected during blocked-design stimulation at dental chair-side during the full stimulus protocol (second visit) had considerable intra- and inter-subjects variation. Refer to the appropriate clinician(s), such as an oral medicine specialist and/or a multidisciplinary team including a neurologist, anesthesiologist, pain physician and pain psychologist, who are capable and ideally interested in working the patient through the diagnostic process. Simple chairside tests to confirm a dental source of pain include vitality testing using heat, cold and electric stimuli, transillumination to highlight proximal caries or a cracked tooth and use of tooth ‘slooth’ to assist localization of cracked cusps. With transillumination, a light beam is reflected where there is a change in the integrity of the tooth structure. The tooth ‘slooth’ is an instrument incorporating an indentation allowing pressure to be directed to a specific cusp to elicit pain suggestive of a cracked cusp. pain includes retro-orbital and sinus regions) pain exacerbated by drugs or occurring during sleep, pain unrelieved by diagnostic intraoral anesthetic block and pain not altered by intraoral thermal stimulation.

In giant cell arteritis, the ESR usually exceeds 50 mm/hr and sometimes 100 mm/hr. GCA can cause a sudden loss of vision due to anterior ischaemic optic neuropathy, constituting a medical emergency, therefore ESR should be checked and treatment commenced as soon as possible if GCA is suspected to prevent possible sight loss. Baseline blood tests may be useful in eliminating any possible systemic disorders which may cause or exacerbate facial pain. A variety of conditions may lead to burning sensation of the oral mucosae, including vitamin and nutritional deficiencies and, therefore, to diagnose burning mouth syndrome (BMS) correctly, it is essential to check full blood count, haematinics (iron, vitamin B12 and folate levels) and blood glucose before reaching a diagnosis of BMS. Immunological tests help to exclude connective tissue disorders which can cause trigeminal neuropathy. This case appeared to present in a classical way yet still raised diagnostic difficulties in the unwary physician, leading to delayed implementation of appropriate treatment. Intra-oral radiographs are the recommended first line investigation for diagnosing caries, periodontal and periapical pathology (Figure 1), with DPT being reserved for bony lesions and when views of the condyles are required.

Orofacial pain conditions that have been present for less than 3 months are generally ­categorized as acute conditions, while those that have persisted for at least 3 months are considered chronic pain conditions. MRI will demonstrate secondary causes of trigeminal neuralgia. These functional images have a resolution of 3 mm by 3 mm in plane (sagital, coronal) and 5.625 mm out of plane (axial). Still, you can help reduce the risk of transmitting oral herpes by not sharing objects that touch the mouth, such as eating and drinking utensils, toothbrushes, and towels. The pathologic mechanisms behind HZ-involving osteonecrosis are controversial, and several hypotheses are under debate. Headache is located over the antral area. In the presence of the key diagnostic symptoms, investigations are not required but confirmation of the diagnosis can be confirmed by maxillary sinus radiographic examination (although this is not generally advised as, apart from showing possible fluid levels in acute sinusitis, it is not of great benefit), computerized tomography (CT) or magnetic resonance imaging (MRI).

Left panels are sagittal sections, while the middle panels are coronal and the right panels axial sections. Categorization of TN into classical and atypical forms is based on symptoms and not aetiology.17 TN is being increasingly recognized with its annual incidence now being estimated around 12.8 per 100,000, with a peak incidence in 50–60-year- olds. TN symptoms arising in younger patients should alert the clinician to the possibility of an underlying cause, such as multiple sclerosis. Classical TN presents with shooting, sharp, unbearable pain in the distribution of one or more branches of the trigeminal nerve, of moderate to intense severity, lasting seconds.17,18 The right side of the face is affected in 60% of sufferers, it is unilateral in 97% of cases and rarely in first division only. It is precipitated by light touch, but may be spontaneous, and there are often associated trigger points. Patients may have periods of remission lasting days, weeks or longer. severe recurrent pain in the distribution of the glossopharyngeal nerve, GPN is very rare, with an incidence of 0.7 per 100,000, and is more common in females and those aged over 50 years.19 Classic and secondary forms are recognized.

Dental Update 2011. Differential Diagnosis for Orofacial Pain Including Sinusitis TMD Trigeminal Neuralgia - Documents
Classic GPN is severe recurrent stabbing pain in the ear, base of tongue, tonsillar fossa or below the angle of the mandible. It is precipitated by swallowing, talking or coughing. Secondary GPN presents with an additional ache that may persist between attacks and is secondary to a cranial lesion demonstrable by investigations or surgery. The pain is unilateral in location and there are no obvious motor neurological defects. On the other hand, in further paper from the same group6 it was suggested that, although vaccination results in high initial protection, full protection is lost relatively rapidly (3% per year). Although also rare, a syndrome known as Eagles syndrome should be considered in patients presenting with classical symptoms of GPN. Normal lateral and protrusive movements are at least 7 millimeters.

their pain. Dynamic pressure was the stimulus of choice since a significant number of AO patients describe increased sensitivity to touch at the intraoral pain site, mentioning that they avoid chewing around that area – a feature that it is not well described in the literature 6 7 23 24 with recent quantitative sensory testing evidence supporting this clinical finding 8 . When excluding an organic cause for BMS, a thorough, systematic soft tissue examination is important and recommended investigations include: � Haematological and biochemical investigations to assess if anaemic, low in iron, folate or vitamin B12, or if there is a raised level of glucose; � Microbiological tests for candidosis; � Baseline saliva flow rate if there is any question of hyposalivation; � Sensory testing; � Allergy testing; and � Immunological testing for conditions such as Sjögren’s syndrome or systemic lupus erythematosus. A detailed drug history will highlight any drugs that may be associated with burning oral pain. or traumatic induced neuralgia is a form of chronic facial pain arising as secondary to injury to the trigeminal nerve, such as facial trauma or a dental procedure. It is rare but increasingly recognized and the pain is described as a continuous burning sensation localized to the injured area, but may be described as constant, dull, burning with or without intermittent sharp stabbing pain. With practice, the assembly time can be decreased and with further development of our device it can be both streamlined and broaden in its scope.

The pain symptoms may be classed under the following: � Dysaesthesia (abnormal perception of pain); � Allodynia (due to a stimulus which does not normally provoke pain); or � Hyperalgesia (an increased sensitivity to pain). AO often results in repeated, and possibly unnecessary, dental treatment such as extractions, root canal therapy and apicectomies in the pursuit of pain relief.21 A patient presenting with such pain and giving a history of multiple extractions possibly preceded by root canal therapies should raise suspicions of AO. Diagnosis and management as early as possible is vital24 to avoid unnecessary invasive treatments. PHN is thought to affect 40% of patients and most patients are more than 70 years of age. Following initial exposure to the herpes zoster virus from chicken pox, the virus lies dormant in the trigeminal ganglion and, when activated, gives rise to the rash of shingles. PHN is the result of damage to the nerve by the virus. facial pain (CIFP), previously atypical facial pain, is persistent facial pain which is poorly understood, but its persistence is likely to result in psychological distress.

The pain is described as aching, heavy, nagging, sometimes throbbing or stabbing.25 It does not follow anatomical pathways and can be local or very extensive, radiating into the head and neck. The pain is often constant but with varying intensity. Psychological stresses or fatigue may worsen the symptoms and it is therefore important to take a relevant psychosocial history and record associated stress-related factors. It is questionable whether steroid therapy or an alternative antiviral agent to aciclovir could also have been useful in speeding the patient’s recovery. Exploring patients’ beliefs about their pain can be particularly enlightening. There are no specific relieving factors and the patient may also suffer irritable bowel syndrome, back and neck pain and poor sleep. tension-type headache are recognized.

For a comprehensive description of the stimulus device, see additional file 1: Appendix – Dentoalveolar Stimulus Device Description. The pathophysiology of this form of headache is not fully understood, its prevalence is quoted as 2.2% and is more common in females.27 It can mimic TMD MSK. involving cell-mediated immune damage to blood vessel walls and mainly affects blood vessels in the head and neck region. It is rare under the age of 50 years and females are about 3 times more likely than men to develop this disease. The temporal artery is commonly affected giving rise to temporal arteritis. In the third visit, that included only painfree controls, we tested its MR-compatibility by visual inspection of the images produced and the stimulus evoked-brain activation through statistical analysis of functional brain images. Patients may have features of scalp tenderness, visual changes and/or neurological changes.

Criteria stipulated by the International Headache Society (IHS) for a diagnosis of temporal arteritis is any new persistent headache in the temporal region, with either swollen tender scalp artery (Figure 3) and raised ESR or CRP, or temporal artery biopsy demonstrating giant cell arteritis.19 Major improvement or resolution of headache within 3 days of high dose steroid treatment also helps confirm the diagnosis. GCA may be associated with polymyalgia rheumatica, jaw claudication, weight loss, altered sensation or loss of vision. Owing to the high risk of early visual loss as a result of anterior ischaemic optic neuropathy, prompt diagnosis and management is essential. syndromes incorporating short lasting severe unilateral headache attacks, accompanied by cranial autonomic symptoms. TACs is included in the International Headache Society classification of headaches28 and includes cluster headache, paroxysmal hemicrania and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), all of which display trigeminal distribution pain and ipsilateral cranial autonomic features. The primary site of pain is in the distribution of the first division of the trigeminal nerve and autonomic features present. They are rare, not expected to be diagnosed in primary care and the main features are highlighted in Table 2.

causes of facial pain can be difficult for busy practitioners, but a logical approach to history-taking is important and will aid more rapid diagnoses with effective management. Although primary care clinicians would not be expected to diagnose rare pain conditions, they should be able to assess the presenting pain complaint and refer to the appropriate secondary or tertiary care centre. It is important that primary care practitioners provide sufficient detailed information of history, examination and investigation findings in their referral letters to ensure appropriate direction of the referral within the secondary/tertiary care institution. Underlying causes of orofacial pain are wide ranging and complex, but a greater understanding of a patient’s facial pain symptoms, towards establishing a diagnosis or differential diagnosis, can be achieved by obtaining a good pain history, carrying out a good clinical examination and instituting relevant investigations or referring to secondary or tertiary care when appropriate. 12. Bergstrom I, List T, Magnusson T. This blocked-design run was delivered as training, since the second visit would include 4 repetitions of this run for all subjects during which pain ratings would be collected.

Acta Odontol Scand 2008; 66: 88–92. 14. De Boever JA, Nilner M, Orthlieb JD, Steenks MH. Recommendations by the EACD for examination, diagnosis, and management of patients with temporomandibular disorders and orofacial pain by the general dental practitioner. The initial step was to position the lips and cheeks retractor in the subject. 20. Patton LL, Siegel MA, Benoliel R, De Laat A.

Management of burning mouth syndrome: systematic review and management recommendations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103 (Suppl): S13–S39. McMinn’s Color Atlas of Head and Neck Anatomy is the foremost specialist atlas of the anatomy of the head and neck. Since its first publication in 1981, the thoroughness and detail with which the anatomy of the head and neck region is covered in this high quality resource have ensured that it is required reading for dental students in the UK and worldwide. This new 4th edition retains the content and format of the 3rd edition, supplemented by additional pages on developmental and clinical topics. New material is located predominantly within chapter one. Here there is a helpful two-page spread giving an ‘at a glance’ schematic representation of the stages of tooth eruption from five months in utero to full adult dentition, a set of images produced using current methods of 3D reconstruction from CT scans to illuminate the anatomical relativities of the tooth, pulp space, bone and nerve, and a remarkable exemplar of an adult skull containing 13 sutural bones.

Clinical content has also been expanded. The essentials of several developmental and genetic abnormalities are summarized in illustrated text. A further informative section on craniosynostosis and its surgical solution could perhaps have been improved by a more extensive description of the conditions and surgical procedures which are mentioned here. There is also a new set of histological images of dental tissue, which may require reference to a histological textbook to be fully understood by the beginner. and this may create difficulty in identifying individual structures. Stimulus device assembly sequence for an fMRI session. This atlas will continue to prove an invaluable purchase for undergraduate and postgraduate dental students, dental professionals, and for all those for whom a mastery of the complex anatomy of the head and neck is a pre- requisite.

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