Dento-facial pain-Odontogenic and Non Odontogenic pain

Dento-facial pain can be either odontogenic or non-odontogenic in origin

Odontogenic

Tooth
  • Pulp
  • Periodontal  - priodontitis, pericementitis
Jaw
  • Alveolitis
  • Dry socket
  • Osteomylitis
  • Non odontogenic
 
1.Tempor-mandibular joint
  • Arthritis – Arthralgia, Subluxation, Clicking
  • Neuritis – Costen’s Syndrome
  • Bruxism
2. Para nasal sinuses – Sinusitis, CA. Maxillary Antrum
3. Otalgia – Ac. External otitis, Chronic Suppurative Otitis Media (CSOM)
4. Ophthalmic
  • Iritis / Iridocyclitis
  • Herpes Zoster Ophthalmicus
  • Retrobulbar Neuritis
  • Heterophoria
  • Acute Glaucoma
  • Chronic Blind Eye
5. Inflammatory
  • Sialadenitis – Parotitis, Submandibular sialadenitis
  • Lymphadenitis – Pre auricular, Submandibular
6. Malignancy
  • CA. Tongue
  • CA. Oropharynx / Nasopharynx / Laryngopharynx
  • Ca. Maxillary Antrum
7. Spirochetes – Lymes Disease
8. Idiopathic
  • Myo-facial pain - muscular
  • Neuralgia
  • Trigeminal
  • Sphenopalatine
  • Glossopharyngeal
  • Neurovascular
  • Migraine
  • Temporal Arteritis
  • Histamine Cephalgia
  • Tension Headache
9. Psychosomatic – Psychalgia, Hysteria
10. Referred pain – Angina pectoris

Idiopathic pains and psychosomatic pains are non-organic and all the rest have an organic cause, which the treatment protocol needs to address.

Odontalgia: Odontalgia can either arise from the pulp or the periodontium. Pulpitis is the inflammation of the vessels and nerves in the pulp and it occurs when the pulp is exposed to various irritants – thermal, mechanical, chemical or bacterial. Pulpal pain is difficult to localize, as no proprioceptive fibers are present in the pulp chamber. It is only when the inflammation extends to the adjoining periodontium that localization of pain is possible. Careful clinical examination and radiography helps in differentiating pulpal pain from periodontal pain. However gingival recession, looseness of tooth, pocket formation or loss of bone points towards a periodontal disease.
               
Pupal Inflammation
Periodontal Membrane
Pain is not always localized, difficult to locate
Pain is always localized and easy to locate
Pain is sharp, lancinating and intermittent
Pain is dull, steady and continuous and throbbing
Pain is worse during fatigue and at night in day
Pain is not affected by position of body or time of reclining position               
Pulp is very sensitive to thermal changes and Other irritants        
Tooth is not affected by thermal changes and other irritants.
Tooth is not tender on percussion
In early stage pressure relieves and in later stage it intensifies pain
Tooth does not seem elongated and does not interfere I occlusion                               
The tooth is raised in its socket and strikes first in occlusion
Tooth usually shows extensive caries   
The tooth is usually sound
Regional lymphadenopathy +ve
Regional lymphadenopathy –ve
Body temperature not affected                               
Body temperature usually raised

Trigeminal Neuralgia: Trigeminal Neuralgia or tic douloureux is an intermittent pain of great severity, which commences in the 3rd. or 2nd. division and extends in time to the adjacent division, the ophthalmic division usually escaping. Occurring predominantly in females, the cause is usually unknown but considered related to he infection of the nerve by herpes simplex virus. The duration of the pain is brief to start with but gradually the pain free interval reduces, and eventually the patient has almost continuous pain and may become suicidal. The pain is described as red-hot needles searing the flesh and often has certain definite trigger zones. Spasms of pain are initiated by external stimuli like cold draughts, brushing teeth, washing, speaking, eating or drinking hot or cold substances. Treatment starts with oral analgesics like Tegretal. If pain gets incapacitating then 4-5 ml of absolute alcohol is injected into the Gasserian Ganglion. Relief from pain and anaesthesia stays from 6 months to 2 years after which the sensations return and so does the pain. 7.5% phenol in myodil injected into the ganglion under X ray control produces relief of pain without loss of sensation. Partial division of the sensory root of V cranial nerve, preserving the upper and inner 1/3 of the root, which has the fibers of ophthalmic division, by micro-neurosurgery, may bring lasting relief.

Sphenopalatine Neuralgia: Sphenopalatine Neuralgia or Sluder’s syndrome is a condition where there is pain about the eye, upper teeth and upper jaw, extending sometimes to zygoma and temple and occasionally producing earache and pain in and around the ear and mastoid. Photophobia, lachrymation, rhinorrhea, glossodynia and loss or diminished taste sensations are also frequent. Unlike Trigeminal Neuralgia the pain is more constant, lacking he severe paroxysms. The Sphenopalatine (Meckel’s) ganglion is believed to be irritated by infection or hyperplasia of sphenoid or posterior Ethmoid sinuses. The best diagnostic tool is to anaesthetize the Meckel’s ganglion and most permanent result is obtained by injecting absolute alcohol.

Glossopharyngeal Neuralgia: Severe explosion of pain either in the region of tonsils or deep in the ear with a trigger zone in the tonsillar area is characteristic. The diagnosis is clinched by the fact hat instilling or injecting local anaesthesia in this region relives the pain. In genuine cases the Glossopharyngeal nerve needs to be divided. The nerve can be approached in the tonsillar fossa after tonsillectomy, or through the posterior fossa as it enters the jugular foramen.

Paranasal sinusitis: Very hard to differentiate from odontalgia because of the close proximity of the teeth and maxillary sinuses, there is always a suggestive history of recent cold or influenza. If the pain is bilateral and improves on sitting up it is often frontal sinusitis. If the pain is unilateral and gets relieved on recumbent posture it is maxillary sinusitis. Bony tenderness over sinuses and painful tapping over more than one tooth of the upper jaw suggests a sinus lesion rather than a tooth lesion. Sinus pain is aggravated on walking and bending over. Transilluminating the sinus in a dark room clinically and cloudy sinus on radiography confirms the diagnosis. One should never be in a hurry in extracting teeth in presence of an existing allergy or cold.
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