Sign In Overview
- This is a disorder leading to excessive bone turnover due to excessive bone resorption and formation
- Begins as excessive bone resorption due to excessive osteoclast activity, followed by excessive and disorganised bone formation due to increased osteoblast activity. The result being poorly structured and malformed bone
Clinical Features
- Increased hat size (head gets larger)
- Deafness due to auditory foramen narrowing and compression of nerves
- Vision loss due to compression of nerves
Diagnosis
Radiography:
- Cotton wool appearance of the bone
- Hypercementosis of roots (excessive cementum build-up on roots)
- Loss of lamina dura
- Root resorption
- Alveolar ridges increase in size
Blood test:
- Alkaline phosphatase levels
Treatment
- Bisphosphonates – inhibits oestoclasts from resorbing bone, resulting in a decrease in net turn over
- Painkillers
- Calcium supplements
- Physiotherapy
Dental Considerations
- When Paget’s disease affects the facial bones the teeth may become mobile
- XLA may be difficult due to root hypercementosis
- There may be increased post-operative bleeding due to increase blood perfusion to the new bone
- Denture is likely to be too tight
- Can cause facial pain/neuralgia
Overview
The sinus’s are air filled spaces in the bones mainly located around the nose. When these become inflamed it is known as sinusitis.
Clinical Features
- Blocked nose
- Facial pain
– Forehead
– Top of jaw, teeth and cheeks
– Between/behind eyes
– More severe when leaning forward
- Sore throat
- Cough
- Halitosis
- Green/ yellow discharge from the nose
- Congested sinuses are often full of fluid and can put pressure on the facial structures (including TMJ)
- They also force you to mouth breath potentially causing TMJ soreness
Types
- Acute sinusitis – gets better within 12 weeks
- Chronic sinusitis – lasts longer than 12 weeks
- Recurrent sinusitis – repeated flare ups for 3+ years
Cause
- Acute sinusitis is caused by infection of the sinus lining often due to viral infection (rarely bacterial infection)
- Chronic sinusitis starts of as an acute but may also be triggered by an allergy
- Smoking
- Asthma
- Blockage of nose or sinus e.g. nasal polyps
Treatment
- Generally self-limiting condition that last up to 2-3 weeks
- local measures should be used initially:
– Steam inhalation
- Ephedrine nasal drops can be prescribed to relieve symptoms
- Antibiotics (amoxicillin or doxycycline) prescribed for persistent/ severe symptoms or purulent discharge lasting at least 7 days
- Surgery if severe
TMJD
The origin of Temperomandibular joint disorder can be broken down into 3 categories:
- Muscle disorder
- Internal derangement of the TMJ
- Joint disorder
This is where there is no pathology of the TMJ and the pain derives from the muscles of mastication.
It’s often associated with stress, unusual bite and parafunctional habits.
Symptoms
- Muscular spasms
- Limited mouth opening
- Facial pain
- Dull pain all the time that gets worse on chewing
Treatment
Would treat it like you would treat any overused muscle
- Soft diet
- Limit mouth opening
- Rest the muscles – no chewing gum, biting nails etc
- Apply heat to the outside of face
If severe, can also try:
- Analgesics
- Splints
- Jaw exercise
- Physiotherapy
This is where there is no pathology of the TMJ and the pain derives from the muscles of mastication.
It’s often associated with stress, unusual bite and parafunctional habits.
Symptoms
- Muscular spasms
- Limited mouth opening
- Facial pain
- Dull pain all the time that gets worse on chewing
Treatment
Would treat it like you would treat any overused muscle
- Soft diet
- Limit mouth opening
- Rest the muscles – no chewing gum, biting nails etc
- Apply heat to the outside of face
If severe, can also try:
- Analgesics
- Splints
- Jaw exercise
- Physiotherapy
This is when the disc is displaced and sits in front of the head of the condyle.
Disc displacement can occur with reduction or without reduction:
Features of disc displacement with reduction:
- The disc is displaced anteriorly and the condyle pops forward onto the disc and back
- There is a reproducible click
- No limited mouth opening
- Can be painful
Features of disc displacement without reduction:
- This disc is displaced anteriorly but the condyle is unable to pop into it
- No click
- There is limited mouth opening known as ‘lock jaw’
- Pain is more severe
There is currently no evidence of disc displacement with reduction progressing into disc displacement without reduction (Kononen et al 1996)
This is where the cause is due to existing joint conditions such as osteoarthritis, rheumatoid arthritis, or even simply trauma to the joint (Traumatic arthritis)
Treatment
- Treat underlying joint condition
- Traumatic arthritis:
– Self limiting– settles in 5-10 days
– Analgesics e.g. NSAID’s, Paracetamol
Vascular Pain
Pain that originates from blood vessel can lead to facial pain and the cause can vary greatly. The most common ones that will be seen in a dental setting are the following:
Overview
This is a recurrent throbbing headache, typically affecting one-side and often accompanied with nausea and blurred vision
Often warning signs precede the actual migraine known as the Aura phase. These present as:
- Zig zag flickering lights
- Opposite side sensory parathesia
- Motor limb weakness
Site:
- Unilateral
- Temporal
- Occipital
- Frontal
Symptoms
- Severe throbbing pain
- Photophobia
- Phonophobia
- Nausea/vomiting
- Can be prolonged for hours or even days
Associated factors
- Stress
- Menstruation
- Menopause
- Oral contraceptive pill
Treatment
- Avoid any associated factors
- Painkilers e.g. NSAID’s, Paracetamol
Overview
An inflammatory disease affecting the large blood vessels of the scalp, neck and arms. Inflammation causes a narrowing or blockage of the blood vessels, which interrupts blood flow. This often affects temporal arteries causing pain in temporal/frontal region.
It is commonly known as Giant cell arteritis.
Symptoms
- Unilateral throbbing in temporal region
- Painful tender temporal arteries
- Engorged and pronounced temporal artery
- Masticatory pain due to ischaemia of the muscles
- Pain exacerbated on lying down
- Double vision
- Can also affect ophthalmic artery
Transient vision loss which can become permanent if not treated
Diagnosis
Physical exam:
- Enlarged and painful arteries
Blood test:
- Elevated ESR – over 100mm in an hour. A normal reading almost certainly rules out temporal arteritis (normal range is 0-22 mm/hr for men and 0-29 mm/hr for women).
- CRP (c-reactive protein) is raised
- Liver function test – Alkaline phosphatase is usually raised
- Raised platelets levels
Biopsy (gold standard):
- Artery will often show inflammation that includes abnormally large cells, called giant cells, which give the disease its name. (this should only be done in patients with a raised ESR)
Treatment
- Referral
- High dose of corticosteroid e.g. prednisolone
Neuralgia
Neuralgia is pain that originates from damaged nerves leading to a sharp, stabbing pain. The damaged nerve pain can be anywhere in the body and can have a multitude of causes. The most common neuralgia that is relevant to dental clinicians are described below.
Overview
This is a sudden, usually unilateral, sharp recurrent pain in the distribution of one or more branches of the 5th cranial nerve (trigeminal nerve)
Trigeminal neuralgia is difficult to diagnose as the clinical features often overlap with other more common causes. Commonly it is misdiagnosed with:
- Dental pain: cracked tooth, retained root
- Sinus pain
- Post-herpetic neuralgia
- Cluster headache
- TMJ Pain dysfunction
- Multiple sclerosis
Cause
Compression of the trigeminal nerve occurs due to vascular abnormality. This leads to the demyelination of the nerve due to pressure of the tortuous blood vessel in the post cranial fossa.
The blood vessel is in close proximity to the nerve and every time blood pumps through the vessel, the nerve is hit causing demyelination and therefore pain.
Clinical Features
- Sharp unbearable short-lasting pain on one side
- Often have a trigger zone with light contact, smiling, or cold air
- May be prolonged for a matter of minutes or hours
- Rarely occurs at night – does not affect sleep
- Pain follows the distribution of one or more of the branches of the 5th cranial nerve
- More common in females
- Peak on set is 50-70 years
- Most commonly affects mandibular nerve, then maxillary, followed by ophthalmic branch
- 20% of patients will present with pre-trigeminal nerualgia – pain that precedes trigeminal neuralgia which is characterised by a dull ache (similar to tooth ache)
Diagnosis
- Most effective method of diagnosis trigeminal neuralgia is to exclude any other factors such as dental pain and tumour
- Perform CT or MRI scan
- Patients younger than 50 should be referred to neurologists for multiple sclerosis
- Often patients are immediately prescribed with carbamazepine and if symptoms alleviate then this confirms the diagnosis
Treatment
Medication:
- Carbamazepine – 100mg tablets, 1 tablet twice daily (See SDCEP guidelines)
- Other drugs that can be given are phenytoin, gabapentin, lamotrigine
Surgery:
Peripheral (performed where the nerve enters the mandible at the lingula):
- Cryotherapy – the nerve is frozen
- The peripheral nerve branch is either directly exposed or injected with alcohol or phenolunder GA
- Nerve sectioning – the nerve is cut
Central:
- Microvascular decompression – vessels lying on the trigeminal nerve are moved aside or removed. This is done by removing bone.
- Gamma knife surgery – Radiographic beams are focused onto an area destroying the cells
- Percutaneous radiofrequency rhizotomy (PRR) – Electric currents are used to sever the nerve associated with the pain and thus reduce the pain
Overview
Post-herpetic neuralgia is lasting nerve pain for greater than 6 months in an area previously affected by shingles. It is a common complication of shingles.
Clinical Features
- Pain usually comes about before, during or after an attack of herpes zoster
- Pain usually subsides within weeks but if it persists for more than 6 months then it is classified as post herpetic neuralgia
- Intense burning accompanied with stabbing sensation which is made worse by movement and thermal change
Treatment
- Difficult to treat
- Carbamazepine isn’t very effective
- Gabapentin can be a good alternative
- Tricyclic antidepressants help to deal with the pain
- Prophylaxis is the most important and effective – systemic antivirals should be given for shingles to reduce the incidence of post herpetic neuralgia (see SDCEP Guidelines)
Overview
A condition characterised by a paroxysmal, sharp, locating pain that affects one side of the throat and base of the tongue, it is usually triggered by swallowing.
Clinical features
- Similar to trigeminal neuralgia
- Unilateral shooting pain in the oropharynx
10%~ will also have the following associated symptoms:
- Bradycardia
- Fall in blood pressure
- Syncope
Treatment
- Carbamazepine
- Gabapentin often works better than carbmazepine
- Neurosurgery would be the final resort (see treatment for trigeminal neuralgia)
Psychogenic
Psychogenic pain is pain that is mainly driven emotional or mental factors. In these cases, diagnosis is extremely difficult and as there is no physical pathology treatment is also challenging.
Overview
Chronic facial pain that doesn’t fit into any other diagnosis or in the current classification system.
Clinical Features
- Most common amongst middle aged women
- Continuous dull ache
- Usually affects the maxilla (can be unilateral or bilateral)
- Doesn’t follow a specific nerve course and often crosses the midline
- Aggravated by fatigue, upset and worry
- Often chronic for numerous years
- Conventional analgesics provide no relief
Associations
Most patients suffering from atypical facial pain also suffer from:
- Headaches
- Irritable bowel syndrome (IBS)
- Dysmenorrhoea
- Chronic fatigue syndrome
Treatment
- CBT (Cognitive behavioural therapy) – therapy that helps manage your problems by changing the way you think and behave
- Antidepressants
- Anticonvulsants (carbamazepine/phenytoin/gabapentin)
Overview
Burning Mouth Syndrome (BMS) is a painful, complex condition often described as a burning, scalding, or tingling feeling in the mouth that may occur every day for months or even more.
Associations
- More likely with females
- Perimenopausal or postmenopausal
- Over the age of 50
Categories
Primary BMS – When no clinical or lab abnormalities can be identified, the condition is called primary or idiopathic burning mouth syndrome
Secondary BMS – Sometimes burning mouth syndrome is caused by an underlying medical condition. In these cases, it’s called secondary burning mouth syndrome. Examples of underlying conditions are:
- Dry mouth (xerostomia)
- Zinc deficiency
- Haematinic deficiency
- Allergies
- Medications for high blood pressure
- Diabetes
Clinical Features
- A burning or scalding sensation that most commonly affects your tongue
- Dry mouth
- Taste changes in your mouth (metallic taste)
- Loss of taste
- Tingling, stinging or numbness in your mouth
Diagnosis
Test for any underlying medical conditions such as:
- Haematinic deficiencies
- Thyroid function test
- Zinc deficiency
- Endocrine problems such as diabetes
- Investigation for Sjogren’s syndrome
Treatment
- Eliminate any systemic or local causes
- Cognitive behavioural therapy (CBT)
- Antidepressant therapy:
– Tricyclic antidepressants
Dental Uppdate: Oral Medicine – Facial Pain, https://www.dental-update.co.uk/issuesThreeArticle.asp?aKey=898
Jordan, R. and Lewis, M. (2004). A colour handbook of oral medicine. New York: Thieme.
See also Hard Tissue Swellings
