Pain as Chief Complaint - Second Lectures PDF

Pain as chief complaint: Pain as chief complaint: Pain is the most common symptom for which patients seek help. Causes of oral or maxillofacial pain: 1. Diseases of teeth and supporting tissues. 2. Oral mucosal diseases. 3. Diseases of the jaw....

Pain as chief complaint: Pain as chief complaint: Pain is the most common symptom for which patients seek help. Causes of oral or maxillofacial pain: 1. Diseases of teeth and supporting tissues. 2. Oral mucosal diseases. 3. Diseases of the jaw. 4. Pain in the edentulous patient. 5. Postoperative pain. 6. Pain induced by mastication. 7. Referred pain. 8. Neurological diseases. 9. Muscular pain 10. Psychogenic (atypical) facial pain. 1. Pain from teeth or supporting tissues: May be due to: a) Pulpal disease. b) Pulpo-periapical disease. c) Gingival and periodontal disease. a) Pulpal disease: Pulpitis is usually the cause when hot or cold food or drinks trigger the pain. It is also the main cause of spasmodic, poorly localized attacks of pain which may be mistaken for a variety of other possible causes. Acute pulpitis: sharp lancinating character peculiar to itself, impossible to describe but unforgettable once experienced. Chronic pulpitis: recurrent attacks of less severe, often apparently spontaneous, suggest a diseased and dying pulp. b) Acute periapical periodontitis: Pain from acute periapical periodontitis should be readily identifiable as there is precisely localized tenderness of the tooth in its socket. Radiographs in early stage not value, late stage show loss of definition of the periapical lamina dura, due to sufficient distruction.in other cases, acute inflammation may supervene on chronic, and a rounded area of radiolucency is seen. c) Lateral periodontal abscess: The tooth is tender in its socket, but is usually vital and there is deep localized pocketing. Occasionally both a periodontal and periapical abscess may from together on a non-vital tooth with severe periodontal disease, or a periodontal abscess may be precipitated by endodontic treatment when a reamer perforates the side of the root. 2. Pain from mucosal lesions: Ulcers generally causes soreness no pain, however, deep ulceration may cause severe aching pain. e.g. Carcinoma causes severe pain when nerve fibers become involved. Herpes zoster causes severe aching that may be mistaken for toothache. Prepared by: Ass.PhD. Dr.Sana Aghbari 1  Pain as chief complaint: 3. Painful jaw diseases: Fractures Osteomyelitis Infected cysts Malignant neoplasms Sickle cell infarcts 4. Pain in edentulous patients: Denture trauma Excessive vertical dimension Diseases (enumerated earlier) of the denture bearing mucosa Diseases of the jaws Teeth or roots erupting under a denture 5. Postoperative pain: Alveolar osteitis (dry socket) Fracture of the jaw Damage to the TMJ. Osteomyelitis Damage to nerve trunks or involvement of nerves in scar tissue. 6. Pain induced by mastication: Diseases of the teeth and supporting tissues Diseases of TMJ Pain dysfunction syndrome Temporal arteritis Trigeminal neuralgia (rarely) Salivary calculi 7. Pain from extra- oral disease (referred pain): Diseases of the maxillary antrum - Acute sinusitis - Carcinoma, particularly when it involves the antral floor Diseases of salivary glands - Acute parotitis - Salivary calculi - Sjogren’s syndrome - Malignant neoplasms Diseases of the ears - Otitis media - Neoplasms - Myocardial infarction Prepared by: Ass.PhD. Dr.Sana Aghbari 2  Pain as chief complaint: 8. Neurological diseases: a) Trigeminal neuralgia: Typical features of trigeminal neuralgia: Pain confined to the distribution of one or more division of the trigeminal nerve. Pain is paroxysmal and severe. Trigger zone. The pain is paroxysmal, severe, sharp and stabbing in character but lasts only seconds or minutes and may be described as like lightning. However, attacks may sometimes be quickly recurrent at short intervals. Stimuli to an area (trigger zone) within the distribution of the trigeminal nerve can provoke an attack. Common stimuli are touching, draughts of cold air or tooth-brushing. Occasionally, mastication induces the pain. b) Glossopharyngeal neuralgia: This rare condition is characterized by pain similar to that of trigeminal neuralgia but felt in the base of the tongue and fauces on one side. It may also radiate deeply into the ear. The pain which is sharp, lancinating and transient, is typically triggered by swallowing, chewing, or coughing. It may be so severe that patients may be terrified to swallow their saliva and try to keep the mouth and tongue as completely immobile as possible. c) Post herpetic neuralgia: Up to 10% of patients who have trigeminal herpes zoster, particularly if elderly, may develop persistent neuralgia. The pain is more variable in character and severity than trigeminal neuralgia. It is typically persistent rather than paroxysmal. The diagnosis is straightforward if there is a history of facial zoster or if scars from the rash are present. d) Intracranial tumors: Pain resembling trigeminal neuralgia can rarely be caused by intracranial tumors. Features suggesting an intracranial lesion are associated sensory loss especially if associated with cranial nerve palsies. e) Bell’s palsy: Bell’s palsy is a common cause of facial paralysis. Causes: it probably results from compression of the facial nerve in its canal as a result of inflammation and swelling. Or due to a viral infection, particularly herpes zoster. Both sex may be affected usually between the ages of 20- 50yrs. Pain in the jaw sometimes precedes the paralysis or there may be numbness in the side of the tongue. Diagnosis clinically: Function of the facial nerve is tested by asking the patient to perform facial movements. When asked to close the eyes, the lids on the affected side cannot be brought together but the eyeball rolls up normally, since the oculomotor nerve are unaffected. When the patient is asked to smile, the corner of the mouth on the affected side is not pulled upwards and the normal lines of expression are absent. The wrinkling around the eyes which accompanies smiling is also not seen on the affected side and the eye remains staring. The patient cannot blow his mouth. The affected part of the face sometimes also contracts involuntarily in association with movement of another part. There may, for example, be twitching of the mouth when the patient blinks. More uncommon is unilateral lacrimation (crocodile tears) when eating. The majority of patients with persistent denervation develop contracture of the affected Prepared by: Ass.PhD. Dr.Sana Aghbari 3  Pain as chief complaint: side of the face. Watering of the eye (epiphora) due to impaired drainage of tears, or occasionally to excessive and erratic lacrimal secretion, may remain particularly troublesome. 9. Muscular pain: Myofascial pain dysfunction (MFD), TMJ pain dysfunction (TMPD), Facial arthromyalgia (FAM) Refer to a common triad of joint symptoms: Ø Jaw clicking Ø Jaw locking (or limitation of movements) Ø Orofacial pain. A common complaint, it appears to be related to muscles spasm and subsequent ischemic pain arising from stress, joint damage or habits (eg: tooth clenching or glinding). Etiopathogenesis: trauma, stress appears to predispose through increasing tension in the masticatory muscles. Gender predominance: female Age: teens and up to 40years. Extraoral: headache, neck aches and lower back pain, associated with psychogenic disorders. Differential diagnosis: referred pain, rheumatoid arthritis, osteoarthritis or other TMJ pathology. Main diagnostic criteria: history, clinical (crepitus from TMJ, limited or deviated opening, clicking, diffuse tenderness or spasm on palpation of masseter, temporalis, medial/ lateral pterygoid muscles) Investigation: none, radiography if TMJ pathology suspected. 10. Psychogenic diseases: a) Psychogenic (atypical) facial pain: Features suggestive of psychogenic (atypical) facial pain: Women of middle age or older mainly affected. Absence of organic signs. Pain often poorly localized. Description of pain may be bizarre. Delusional symptoms occasionally associated. Lack of response to analgesics. Unchanging pain persisting for many years. Lack of any triggering factors. Sometimes good response to anti-depressive treatment It must be emphasized that the diagnosis of psychogenic facial pain is a diagnosis by exclusion but it is important to try to recognize the condition, however limited diagnostic methods may be. The symptoms cause real enough suffering to the patient and should, if possible, be relieved. It is also important to avoid unnecessary surgery. Prepared by: Ass.PhD. Dr.Sana Aghbari 4  Pain as chief complaint: Pain is usually not provoked by any recognizable stimulus such as hot or cold foods or by mastication. Despite the fact that the pain may be said to be continuous as unbearable, the patient’s sleeping or even eating may be unaffected. Analgesics are often said to be completely ineffective, but some patients have not even tried them, despite the stated severity of the pain. Objective signs of disease are absent. Although teeth have often been extracted and diseased teeth may be present, none of these can be related to the pain. As a consequence, treatment of diseased teeth does not relieve the symptoms. Other signs of emotional disturbance are highly variable. Some patients are more or less obviously depressed some of them mention, in passing difficulties they have had, for instance, at work with their colleagues. Others may complain how miserable the pain makes them. Others may complain of bizarre symptoms such as slime in the mouth or power coming out of the jaw. b) Burning mouth syndrome: Features suggestive of burning mouth syndrome: Middle aged or older women are mainly affected No visible abnormality or evidence of organic disease, no hematological abnormality Pain typically described as burning Persistent and unremitting soreness without aggravating or relieving factors, often of months or years duration no response to analgesics Bizarre patterns of pain radiation inconsistent with neurological or vascular anatomy Sometime bitter or metallic taste associated Associated depression, anxiety or stressful life situation Obsession with symptoms which may rule the patient’s life Constant search for reassurance and treatment by different practitioners. Occasionally dramatic improvement with anti -depressant treatment and vit.B In this distressing and troublesome condition symptom may affect the whole mouth or only the tongue may be sore. This complaint has many features in common with atypical facial pain and may be a variant of it. Clinical features may suggest psychological factors. c) Psychogenic dental pain (atypical odontalgia): This is a less common variant of atypical facial pain. Pain is often precisely localized in one tooth or in a row of teeth. Which are said either to ache or to be exquisitely sensitive to heat, cold, or pressure. If dental disease is found treatment has no effect, or if, as a last resort, the tooth is removed, the pain moves to an adjacent tooth. Again, if no organic cause can be found and treatment is ineffective, psychiatric assessment is needed. Early diagnosis is essential to avoid over treatment and serious dental morbidity. According to origin: pain may be: 1. Somatic pain: due to noxious stimulation of normal neural structure that innervate body tissue. 2. Neurogenic pain: due to pathology or abnormality in the neural structures themselves (within the nervous system), i.e. neuropathy Prepared by: Ass.PhD. Dr.Sana Aghbari 5  Pain as chief complaint: 3. Psychogenic pain: due to psychic stress. Somatic pain Neurogenic pain Psychogenic pain Usually acute Usually chronic --- Cause is apparent No cause is usually No apparent (usually inflammation) apparent (except with causes neuorotropic viruses’ infection e.g. herpes zoster) Throbbing, aching, Lancinating, electric shock No specific sharp, mild, moderate like, stabbing character May be progressive in Constant in severity Bizarre pattern severity (variable in severity) Localized at affected Localized to affected nerve No localized; region and may cross distribution and not vague, crossing mid line crossing mid line anatomical boundaries May be referred to Not refereed Referred to neighboring or opposing abnormal structure (same side) location No trigger zone There may be trigger zones No trigger zone (½ inch sign of trigeminal neuralgia) -- --- History of psychic stress or antidepressant drug Prepared by: Ass.PhD. Dr.Sana Aghbari 6