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TRANSCRIPT
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Orofacial Neuropathy: Diagnosis and Treatment
AIPM:Oct19,2017JosephMa9hews,DDS,MSc
Disclosure
• Nothingtodisclose.
More than 1 in 6 adults experienced orofacial pain in the past year
JADA2015146;721
OrofacialPainPainwhichisfeltinthemouth,jawsandtheface.
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Diagnos>c Categories
• Intraoral• Muscular• Temporomandibularjointdisorders• Headachedisorders• Extracranial• Intracranial• Thoracic• Neuropathic
IntraoralpainEst.95%oforofacialpainisofdentalorigin
• Dentalcaries• PulpiRs,pulpalnecrosis,andperiapicalinfecRon• Periodontaldisease• PeriodonRum• Mucogingival• PericoroniRsassociatedwitherupRngteeth
• Mucosal• MucosiRs
CrackedtoothsyndromeMimicsneuropathicpain
Cracked tooth symptoms
• Generalized facial pain or discomfort • Severe stabbing lancina>ng pain when bi>ng • Paroxysmal pain • Sensi>vity to hot and/or cold • Sensi>vity to chemical changes (sweet or acidic) • Pain may be worse immediately aKer release of bi>ng
pressure on tooth
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Cracked tooth Imaging
• DentalX-ray• HospitalCT• HighresoluRonconebeamCTwithcustomsecRons
Cracked tooth examina>on
• Clinicalevalua3on• Visualexam• Percussion• Sharppointexplora3on• Thermaltes3ng• Dye• Pulptes3ng• Transillumina3on• Chewing/bi3ngtests• Toothsleuth
• PalpaRonpainincharacterisRclocaRons:• Masseter,SCM,spleniuscapitus,uppertraps,anteriortemporalis• NegaRvelaboratoryandradiographicfindings• ClinicalpresentaRonmayresembleneuropathicpain
MusclePain
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Diagnos>c tests
• Sprayandstretchreducespain• TriggerpointinjecRons
48 year old femalewith leK side Facial Pain
Imaging• CBCT• Remodelingandlossof
corRcalbone• Subchondralcysts• OsteophyRcacRvity• Consistentwith
osteoarthriRs
RightTMjointLe^TMjoint
TMJointdisorders• ArthriditesinTMD• OsteoarthriRs• RheumatoidarthriRs• PsoriaRcarthriRs
• Internalderangements • DiscdisplacementwithorwithoutreducRon
Treatmentshouldbespecifictothedisorder
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AZTMJ
Intracranial• Vascular• Aneurism• Hemorrhage• Hematoma• Edema
• Nonvascular• Neoplasms• Edema
• Other• MSplaque• Pos9raumaRcchanges
• Meningioma
Intracranial facial pain disorders
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Extracranial Causes of Orofacial Pain and Headaches
• OsteomyeliRs• MulRplemyeloma• Sicklecelldisease,• Paget’sdisease• Osteopetrosis• Eosinophilicgranuloma• HisRocytosis• Osteoblastoma• MetastaRctumors
• CaroRdarterydissecRon• Myofascialpain• ORRs• Salivaryglanddiseases• Nasal/paranasalsinuscomplex• GiantcellarteriRs• ThyroidiRs• Autoimmunedisease:Lupus/MS• Viral/bacterialinfecRons
Other sources of facial pain
• Orofacialpainpresentin>25%ofpaRentswithinfarctorarterydissecRonMedPregl.2011;64:575
• Jawpainin27%ofwomenand18%ofmenwithmyocardialinfarcRon.AmJCritCare.2008;17:14-24
Thoracic
• OrofacialpainistheONLYpresenRngsymptomin6%ofpaRentswithcardiacischemia.JAmDentAssoc.2007;138:74
Image:Voohoo.net
OrofacialNeuropathy
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Categorizing Neuropathies
• Dysesthesia,anesthesia,hyperalgesia,allodynia• Movementdisorders• Peripheralneuropathies(outsideofCNS)• Centralneuropathies(withintheCNS)• Painful/non-painful• Episodic• ConRnuous
Orofacial Neuropathic Pain
Episodic• TrigeminalNeuralgia• GlossopharyngealNeuralgia• Ophthalmoplegia• NervusIntermediusNeuralgia• SuperiorLaryngealNeuralgia
Con3nuous• PeripheralPainfulTraumaRcTrigeminalNeuropathy• PersistentIdiopathicFacialPain• PeripheralNeuriRs• PostherpeRcNeuralgia• Burningmouthsyndrome
Diagnosis
• NeurologicaltesRng• TopicalanestheRctesRng(20%benzocaine)• AnestheRcblocks(1%lidocainewithoutvasoconstrictor)• starRngperipherallymovingcentrally
• BrainMRI• WithandwithoutcontrastwithaddiRonalsecRonsthroughtheposteriorcranialfossaespeciallythecerebelloponRneangle.
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Trigeminal neuralgia management
• Surgical• OralmedicaRon• TopicalmedicaRons• Botox
Surgical interven>ons
• Microvasculardecompression• WorldNeurosurg.2017;103:757• PercutaneousballooncompressionNeurosurgClinNAm.2017;28:429
• AblaRveprocedures• RadiofrequencyablaRon• GlycerolinjecRons• Cryotherapy
• StereotacRc• Gammaknife(Neurosurgery.2005;56:1295)• Linearaccelerator(Neurosurgery.2005;57:1193)
GavinDavis-Surgeon
Medica>on Management of neuralgias and painful neuropathies • BaselinebloodtesRng• CBC• Electrolytes• MetabolicPanel• RenalfuncRon• HepaRcfuncRon
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Medica3ons Dosage SideEffects(par3allist) Notes
Carbamazepine(Tegretol)
200-800mgbid
Stevens-JohnsonSyndromeErythemamulRformeHepatotoxicityWDseizuresifabrupt
LFtesRngHLAB1502screenBehaviorchanges
Oxcarbazepine(Trileptal)
150-1200mgRd
HyponatremiaS-JSyndromeWDseizuresifabrupt
ElectrolytetesRngHLAB1502screenBehaviorchanges
GabapenRn(NeuronRn)
300-1200mgRd
FaRgue,S-JSyndromeWeightgainWDseizuresifabrupt
CratbaselineBehaviorchanges
Pregabalin(Lyrica)
150-300mgbid
Dizziness,weightgain,WDseizuresifabrupt
CratbaselineBehaviorchanges
Other oral meds for orofacial neuropathy
• TricyclicanRdepressants• amitriptylineornortriptyline
• Phenytoin• Topiramate• MemanRne• Phentolamine• Clonazepam
78 year old female
• RouRnedentalexam18mos.ago• Tooth#30waspainlessbutdx:crackedtooth• Crown#30• ConRnuousachingpainfourmonths.normalxray• EndodonRcprocedurecompleted• Severeburningcon3nuouspain• Wants#30extracted➛OSurg:referredtoOFP
IASP:PTTNPainfulTraumaRcTrigeminalNeuropathy
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Painful post-trauma>c trigeminal neuropathy
• Phantomtoothpain• Atypicalodontalgia• Atypicalfacialpain• Persistentdentoalveolarpain• PeripheralpainfultraumaRctrigeminalneuropathy• Persistentidiopathicorofacialpain
MoreauN,etalJournaloforofacialpainandheadache2017;31:7.
Persistent severe pain aKer root canal injury from sodium hypochlorite irriga>on
• Startedduringrootcanaltherapy• WhileirrigaRngwithNaOClpaRentexperiencedsuddensharpburningpain• RapidfacialswellingandprofusebleedingfromendodonRcaccess• ForoveraweekpainconRnuedunchanged
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Six months later • Painvariesinintensity5-9/10• Morepainfula^erexposuretocold
Examina>on
Rednessofle^cheekandle^earLe^eyeisasomewhatredandeffusive80%decreaseinsensaRonofle^sideCNV1andCNV2comparedtorightside20%decreaseinsensaRonofle^sideCNV3comparedtorightside
SYNAPSE!
SilbersteinSD,etal.HeadacheinClinicalPracRce.Oxford,UK
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Addi>onal Tes>ng
• Co9onRppedapplicator• LightlytouchgingivainlabialvesRbule• LightlystokegingivainlabialvesRbule
• 20%topicalbenzocaine• ShallowinfiltraRonwith9mglidocaine2%withoutepinephrine
StaRcmechanicalallodynia
PeripheralsensiRzaRon
Dynamicmechanicalallodynia
CentralsensiRzaRon
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Anesthe>c Tes>ng
Topicalbenzocainedecreasedpainfrom8to6/10LidocaineinjecRondecreasedpainfrom6to3/10
Diagnoses • PeripheralsensiRzaRon• StaRcmechanicalallodynia• PainreducRona^eranestheRcDxtesRng
• CentralsensiRzaRon• Dynamicmechanicalallodynia• Residualpaina^eranestheRcDxtesRng
• SympatheRcallymediatedpain• Autonomicfeatures• Morepaina^erexposuretocold• Residualpaina^erlidocaineinjecRon
• Post-Trauma3cTrigeminalNeuropathy
Ma9hewsJ,MerrillR.JAmDentAssoc;145:914RentonT,YilmanZ.JOrofacPain2011;25:333-344
Plan
• Neurosensorystent• Capsaicin0.025%• Orabase(Benzocaine20%)
LewisM,Shankar,etal.OralSurgOalMedOralPatholOralRaiolEndod.2007;103(supplS32):e1-e24
PadillaM,ClarkGT,MerrillRL.JAmDentAssoc.2000Feb;131(2):184-95.
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Stent fabrica>on
Fabricated stent
Stent delivery
Ptwasinstructedtowearthestent
FullRmeandre-applymedicaRonEvery3hours
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Stent delivery
Capsaicin
h9ps://www.researchgate.net/publicaRon/51581406_Topical_capsaicin_for_pain_management_TherapeuRc_potenRal_and_mechanisms_of_acRon_of_the_new_high-concentraRon_capsaicin_8_patch[accessedJun12,2017]
• RepeatedapplicaRonofcapsaicincanproduceapersistentlocaleffectonnociceptors
• SubstancePdepleRonordefuncRonalizaRon.
• ReducesspontaneousneuronalacRvity
• LossofresponsivenesstoawiderangeofsensorysRmuli.
54 year old female with persistent gingival pain 11 months aKer implants placed
• Twoimplants-mandibularle^• ConRnuous“Burning”gingivalpain• SensiRvetotouchbetween#19implantandtooth#20(StaRcmechanicalallodynia)• DxTest:90%decreaseinpainwithtopical20%benzocaine.
Painwaseliminateda^er8weekswearingneurosensorystentandtopicalmedicaRon.
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Treatment and prognosis
• UptoonethirdofnerveinjuriesresulRngfromimplantplacementneverrecoverfully.
AgbajeJO,etal.JMaxillofacOralSurg.2016;15:321
• TopicalmedicaRons• Microsurgicalrepair• Implantremoval(whenappropriate)• OralmedicaRonmanagement
IMPLANT NEUROPATHY
Various Mechanisms and symptoms
• Anesthesia• Paresthesia• Dysesthesia• Allodynia• Hyper-orHypoalgesia
• Secondarytoneuronalinjury• MagnitudeandduraRonoftheinjury• MechanicaldeformaRon• TransecRon• ParRal• Complete
• TraumaRcNeuromaformaRon• Ischemia• Vascularcompression• Compartmentsyndrome
Neuroanatomy and gene expression
• AmandibularcanalintheinferioraspectofthemandiblemaybemorelikelytohaveextensivearborizaRonoutsidetheinferioralveolarcanal• GeneRcdimorphismincludingepigeneRcphenomena
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Other medica>ons for the NS stent
Lidocainesodiumchannelblocker
Imagecredit:CorryResearchGroup
Imagecredit:WikipediaCommons
CarbamazepineSodiumchannelBlocker• Membranestabilizer• renderstheNa+channelmoresuscepRbletoblockade
RizzoM.JNeuroSci1997:152;103
• ReducesNMDAsignaling• GABAreceptoragonistbyinhibiRonofGABA-AandGABA-Breceptors.MagnaghiV.J.Mol.Neurosci2006;28:89
GABA
Glutamate
Other medica>ons for the NS stent Chasing neuro receptors
• Gabapen3n–• IncreasesnoradrenergicdescendinginhibiRon• HirokiT.AnesthAnalg2017
• Ca++Channelblocker,α2-δsubunit• DhandA.Brain2014;137:313
• Protectsinterneurons• PengB.NeurosciLe92011;494:19
• Reducesallodyniaandhyperalgesia• Go9rupH.etal.Anesthesiology2004;101:1400.
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Other medica>ons for the NS stent Chasing receptors
• Clonidine0.01-0.02%• Alpha2receptoragonist• ImportantwherethereisevidenceofsympatheRcallymediatedpainandAlpha-2Csubtypeexpressedonc-fibers.MalmbergAB,etalBritJPharm2001;132:1827.
Other medica>ons for the NS stent Chasing receptors
• Ketamine(1-2%)• NMDAreceptorantagonist• DecreasescentralsensiRzaRonbyinhibiRngcentraltemporalsummaRon(Arendt-NielsenLetalAnesthAnalg1995;81:63)
• Decreasessecondarymechanicalhyperalgesia(KoppertW.etal.Anesthesiology2001;95:395.
• Reduceseffectsofsubstance-P(TamE.OpenNeurolJ2012;6:58)
Advantages of topicals
• Evadefirst-passmetabolism• TargeteddistribuRon• NoRtraRon,minimalsystemicdruglevels,li9leabusepotenRal
• MedicallycompromisedpaRents
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Pilot study of oral topical in neurosensory stent
• 39paRents• DeafferentaRonpain(PTTN)• TraumaRcneuroma• Trigeminalneuralgia
• Assignedintothreegroups• Topicaltreatmentonly(12)• Systemictreatmentonly(10)• Combinedtopical+systemic(17)
HeirG,etal.OralSurgOralMedOralPatholOralRadiolEndod2008;105:466
Results
Star3ngVAS ANerTreatmentVAS
WeekstoMaxbenefit
CombinedTopicalandSystemic
7.5+0.403 3.6 5.5
SystemicOnly
8.6+0.611 5.1 4
TopicalOnly
6.1+0.716 3.6 3
HeirG,etal.OralSurgOralMedOralPatholOralRadiolEndod2008;105:466
Conclusions
• TopicalmedicaRons• UsedaloneorincombinaRonwithsystemicmedicaRons• HighlyeffecRveinprovidingrapidreliefwhencomparedtosystemicmedicaRonsalone
HeirG,etal.OralSurgOralMedOralPatholOralRadiolEndod2008;105:466
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Other medica>ons for Neuro-sensory stents
5%Ketoprofen5%GabapenRn2%Carbamazepine1%Lidocaine1%Ketamine0.01%Clonidine
Thecarrieriscrucial,workwithyourcompoundingpharmacisttoachieveopRmalabsorpRonrate
BOTOX for trigeminal neuralgia
• InjecRonofbotulinumtoxintypeAintotriggerzoneoftrigeminalneuralgiaasameanstocontrolpain.NgeowWC.OralSurgOralMedOralPatholOralRadiolEndod2010;109:47.• BeneficialeffectsofbotulinumtoxintypeAintrigeminalneuralgia.ZuñigaC,etalArqNeuropsiquiatr2008;66:500.
Orofacial Pain
Thefirststeptowardsuccessfultreatmentisaccuratediagnosis