oral medicine lec 5
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Pain f rom Extra Oral Diseases
Myofacial Pain Dysfunction Syndrome--
Refers to the clinical condition characterizedby pain , fatigue and spasm of the muscles of
mastication.
Tenderness to palpation in one or more of
these muscles is the most reliable diagnostic
feature of MPDS.
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Muscle tenderness is generally most
pronounced near the origin orinsertion of an affected muscle, butthe belly is often at least mildlytender.
This tenderness is most easilydemonstrated for the temporalis and
masseter muscles by applyingfingertip pressure during extremeopening and closing movement of the
mandible.
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The symptoms complex that defines the MPDS
includes :
1/ spasm of one or more of the muscles of
mastication.
2/ tenderness to palpation of one or more muscles
of mastication.3/ diffuse head pain that similar to tension headache
and is usually most severe in the morning.
4/ pain on jaw opening.
5/ limitation of opening measured to be less than 35-
40mm between incisal edges at the midline.
6/ lateral deviation during jaw opening.
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7/ evidence of bruxism or clenching history or
presence of generalized wear facets.
8/ malocclusion or evidence of occlusal disharmony.
9/ unilateral or bilateral preauricular pain during
palpation.
10/ joint sounds such as clicking, popping and
crepitus during opening.
The patient are usually young to middle aged
females who experience constant or episodic
emotional stress.
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The symptoms of MPDS tend to occur in cycles with
asymptomatic periods interposed between acute
bouts associated with demanding emotionalsituations. Occlusal disharmony may be a
contributory factor.
Treatment1. elimination of contributory factors, if possible
2. palliative treatment during acute periods of
discomfort, include: analgesics and application
of moisture heat to the spastic muscles is
generally adequate in mild cases.
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3. elimination of occlusal disharmony by removal of
isolated interference and comprehensive
orthodontic treatment of complex malocclusionmay be appropriate.
4. bite plane to minimize the bruxism adverse effects
5. counseling to promote better adaptation by the
patient to stress and dramatic emotional episodes
may help some individuals .
Any combination of these approaches may be
necessary to achieve relief in a specific case.
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-- Eagle's Syndrome
Ossification of styloid ligament is a common
idiopathic process, which progresses gradually and
is more pronounced among older patients.
The ossification is usually revealed by panoramic
radiographs of patients.
The pain is caused by the resistance of the rigid,
ossified ligament to the mobility of surrounding soft
tissues.
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This is usually associated with history of
tonsillectomy , which ( has produced scarring and
entrapment of the ligament).Symptoms develop years after the surgery as the
ossification progressively increases the rigidity of
the structure.
The nature of pain associated with eagle's syndrome
include sharpness in throat during swallowing
associated with chronic sore throat without
erythema .These sensation describe as fish bone caught in the
throat or as obstruction and burning sensation.
Treatment is surgical removal
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-- Frey's SyndromeAs a result of TMJ surgery , injury or infection in the
parotid region causing damage to the auriculo-
temporal nerve lead to connection between post
ganglionic parasympathetic nerve fiber from otic
ganglia which supply the salivary gland with
sympathetic fibers from superior cervical gangliawhich supplies sweat glands and the vascular wall
at the auriculo-temporal region , so sweating and
flushing to the region supplied by auriculo-temporal
nerve take place when the patient eats.In this case nerve connection is going to be wrong
so orders go from brain to vascular walls and sweat
gland instead of going to the salivary glands.
Treatment by rehabilitation.
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-- Vascular painPain originating from vascular structures may cause
facial pain that can be misdiagnosed for other oral
disorders, including toothache .
Classic Migraine Headache
Migraine is an intermittent paroxysmal headachewith pre-headache phase for free intervals caused
by vascular spasm initiated by release of
endogenous vasoactive mediators such as
serotonin , bradykinin which lead tovasoconstriction followed by reflex vasodilatation.
There is positive family history and females affected
more than males.
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due tovisual auraClassic migraine starts with a
ophthalmic artery spasm that commonly precedesclassic migraine include flashing lights or a
localized area of depressed vision (scotoma).
Sensitivity to light (photophopia), hemianesthesia ,aphasia, or other neurologic symptoms may also be
part of the aura , which lasts from 20 to 30 minutes.
The aura is followed by an increasingly severeunilateral throbbing headache that is frequently
accompanied by nausea and vomiting .
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The patient characteristically lies down in dark room
and tries to fall asleep.
Headaches characteristically last for hours up to 2or 3 days.
Predisposing factors
1. emotional stress and anxiety2. menstrual cycle and hormonal changes.
3. contraceptive pills.
4. certain types of food preservatives , liver, cheese
and caffeine.5. alcohol.
6. drugs like nitroglycern and reserpin.
7. hypoglycemia.
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Treatment
- Migrel (1-2mg ergotamine + 100mg caffeine).
- Pizotifen 1.5mg at night or 0.5 mg three times daily.
-- B-blockers and Ca++ Channel blockers.
Common Migraine Headache, butnot preceded by an auraCommon migraine is
patients may experience irritability or other moodchanges.
The pain of common migraine resembles the pain of
classic migraine and is usually unilateral ,pounding
and associated with sensitivity to light and noise .nausea and vomiting are also common.
The pain accompanied by altered sensation , nasal
congestion , depression of salivation and
lacrimation.
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Cluster Headache (Migrainous neuralgia)
It is caused by vascular changes at the base of theskull and abnormal hypothalamic function,
moreover it may be due to oedema and dilatation of
the wall of the internal carotid artery and probably
also the external carotid artery.Men , young adult up to age 50 mainly affected.
Attack may be precipitated by alcohol or
vasodilators or come on spontaneously 1-3 timesdaily with duration of 0.5-2 hours, sometimes recur
at the same time each day or may disturb sleep like
clock alarm.
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Cluster of Pain is localized to the region of the orbit
,temple or maxilla associated with congestion and
lacrimation of eye the nostrils may be blocked. The
skin over the cheek may become red and maybecome sweating and tachycardia.
After one to several months , there is usually
sudden and spontaneously remission and the
patient remains completely free from pain for
months or even years.
Unlike migraine ,there is neither visual symptoms
nor nausea or vomiting.
Treatment: May response to simple analgesic or to
erogatamine.
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Cranial arteritis ( Temporal arteritis ,
Giant cell arteritis )
- Caused by immune abnormalities that affect
cytokines and T lymphocytes ,resulting in
inflammatory infiltrates in the walls of arteries.
- This infiltrates in the walls of arteries ischaracterized by the formation of multinucleated
giant cell . the underlying trigger of the
inflammatory response is unknown.
- Affected adults above the age of 50 years.
- Patient have a throbbing headache accompanied
by generalized symptoms including fever, malaise
and loss of appetite.
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examination of the involved temporalDiagnosis:
artery reveals a thickened pulsating vessel.
Laboratory abnormalities include an elevatederythrocyte sedimentation rate (ESR) and anemia.
The most definitive diagnostic test is a biopsy
specimen (temporal artery biopsy).
individual with cranial arteries should beTreatment:
treated with systemic corticosteroids. Steroid may
be supplemented by adjuvant therapy withimmunsupressive drugs, such as
cyclophosphamide to reduce the complications of
long-term corticosteroid therapy.
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Headache--- Headache usually describes the pain in the region
of the cranial vault.
-The extracranial coverings and arteries are
sensitive to pain . Within the cranial cavity ,there
are few pain sensitive structures.- Pain can be evoked from venous sinuses , the
arteries and dura mater at the base of the brain.
Displacement and distortion of these structure
cause headache.The 5th , 9th, 10th cranial nerves contain pain
fibers and direct compression of these nerves
produces pain.
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Headache may be due to :
Referred Pain
Eye diseases, nasal and sinus diseases, dental and
oral conditions, cervical spondylosis.
Cranial neuralgia
Tempromandibular neuralgia arises as a result of
derangement of TMJ secondary to an alteration of
the bite caused by loss of teeth , ill-fitting dentures
or habitual over-closing of the jaw because of
tension.
Pain various from a dull ache to intense stabs ,
radiate to the temporal and frontal areas, the cheek,
lower jaw and occasionally to the neck.
M i l i it ti
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Meningeal irritation
Headache is an almost accompaniment of
encephalitis and meningitis. The pain increase by
minor movement of head , the accompanyingpyrexia and neck stiffness usually make the
diagnosis obvious.
Vascular headacheThese are almost described as throbbing in
character and are aggregated by head movements.
Headache due to traction on intracranial structures
Headache may occur in the presence of anexpanding intracranial lesion such as cerebral tumor
or due to lowered intracranial pressure due to
reduced cerebrospinal fluid (CSF) after lumbar
puncture
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Psychogenic headache
Are associated with anxiety and depression.It described as pressing, severe ,continuous and
unrelieved by analgesics.
It tend to be localized to the front of the head or to
the vertex or it may involve the whole head.
It is prominent on waking in the morning and tends
to get worse as the day wears on.
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Tension headache
The tension headache is the most common form , it
precipitated by demanding emotional situations
leading to muscle strain. The mechanism areprobably more complex, but stress , over work and
depression are definite initiating factors.
The bilateral pain is described as fullness ,pressure
or tightness with waves of superimposed aching.
Attacks may be acute with duration of few hours to a
day or in some instances the pain can be relativelyconstant for days or weeks.
by relaxation training , analgesics ,Treatment:
antianaxiety drugs
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