1、atypical facial pain,SYMPTOMS Facial pain, often described as burning, aching or cramping, pulling, occurs on one side of the face, often in the region of the trigeminal nerve and can extend into the upper neck or back of the scalp. Although rarely as severe as trigeminal neuralgia, facial pain is c
2、ontinuous for ATFP patients, with few, if any periods of remission.,DIAGNOSIS Diagnosing atypical facial pain is not an easy task. Its not unusual for ATFP patients to have undergone numerous dental procedures, seen multiple doctors and undergone many medical tests before being successfully diagnose
3、d and treated. A diagnosis of ATFP is usually a process of elimination. When a patient complains of constant facial pain restricted to one side of the face, the physician must first rule out any other conditions. Tests include roentgenograms of the skull, MRI and/ or CT scan with particular attentio
4、n to the skull base, careful dental and otolaryngolgic evaluation, and thorough neurological examination. Only after tests rule out other factors can a diagnosis of ATFP be made.,TREATMENTS Treatment of ATFP can be difficult and perplexing for both doctor and patient. Medication is usually the first
5、 course of treatment. Surgical procedures such as microvascular decompression generally are not successful with ATFP patients. The following drugs are used to treat atypical facial pain: Amitriptyline. (Triptyl, Elavil)Gabapentin. (Neurontin).PamelorCapsaicinOther pain relief strategies include: Hot
6、 and cold compresses Acupuncture,Atypical odontalgia,Atypical odontalgia describes atypical facial pain in apparently normal teeth. Unfortunately, dentists usually consider this diagnosis only after the failure of invasive treatment. Atypical odontalgia patients are typified by women in their mid-40
7、s who complain of persistent pain in one or more premolar or molar teeth. They associate pain with dental procedures or trauma to the region, While the cause of atypical odontalgia is uncertain.,Patients with unrelenting pain in the teeth, gingival, palatal or alveolar tissues often see multiple den
8、tists and have multiple irreversible procedures performed and still have their pain. Up to one-third of patients attending a chronic facial pain clinic have undergone prior irreversible dental procedures for their pain without success. In these cases, if no local source of infectious, inflammatory,
9、or other pathology can be found, then the differential diagnosis must include a focal neuropathic pain disorder.,The common diagnoses given include the terms atypical odontalgia, persistent orodental pain, or if teeth have been extracted, phantom tooth pain. One possibility is that these pain compla
10、ints are due to a neuropathic alteration of the trigeminal nerve. There are several diagnostic procedures that need to be performed in any patient suspected of having a trigeminal neuropathic disorder including (1) cold testing of involved teeth for pulpal nonvitality; (2) a periapical radiograph ex
11、amining the teeth for apical change; (3) a panoramic radiograph examining for other maxillofacial disease; (4) a thorough head and neck examination also looking for abnormality; (5) a cranial nerve examination including anesthetic testing which documents any increased or decreased trigeminal nerve s
12、ensitivity and rules out other neurologic changes outside the trigeminal nerve; and (6) MRI imaging in some cases,Finally, when a nonobvious atypical toothache first presents, direct microscopic examination of the tooth for incomplete tooth fracture is also suggested. The majority of these patients
13、are women over the age 30 with pain in the posterior teeth/alveolar arch. Multiple causes exist for sustained neuropathic pain including direct nerve injury (e.g., associated with fracture or surgical treatment), nerve injection injury, nerve compression injury (e.g., implant, osseous growth, neopla
14、stic invasion) and infection-inflammation damage to the nerve itself. Sustained nerve pain is commonly seen in patients with psychiatric impairment. It may be that the unrelenting nature of the pain itself alters the patients personality.,Treatment includes pharmacologic medications which suppress n
15、erve activity. The common medications used for atypical odontalgia and phantom tooth pain include gabapentin, tricyclics, topical anesthetics, and opioids With earlier treatment, better pain control and this should also prevent secondary psychiatric disease from developing and lower the number of in
16、appropriate treatments,What is Atypical Odontalgia?,Atypical Odontalgia (AO) is a condition in which a tooth is very painful but nothing can be found wrong with the tooth. The pain is continuous, usually burning, aching and sometimes throbbing and most often occurs in upper premolars (bicuspids) or
17、molars. Since symptoms are very similar to those caused by a “toothache“, often numerous dental procedures are done. To complicate matters, these treatments (such as pulp extirpation, root-tip surgery or tooth extraction) may offer temporary relief from pain, only to have the pain return.,What are t
18、he Signs & Symptoms of Atypical Odontalgia?,The typical clinical presentation of AO involves pain in a tooth in the absence of any sign of pathology; the pain may spread to areas of the face, neck, and shoulder. Symptoms include a continuous burning, aching pain in a tooth or in the bone / gum surro
19、unding a tooth. Often there in increased sensitivity to pressure over the painful region. Often nothing shows up on diagnostic tests, no abnormalities are found on X-rays and no obvious cause for the “tooth pain” can be found. Patients often have difficulty localising the pain. All ages can be affec
20、ted except for children. AO seems to be more common in women in their mid 30 - 40s. Diagnosis is based primarily on symptoms and on elimination of other possible disorders. Tests may include diagnostic dental X-rays, CT scans and possibly MRI scans. If a nerve block does not result in pain reduction
21、 then a diagnosis of AO should be considered,How is it treated?,Medications such as painkillers and sedatives are not effective in AO. Surgery and other dental interventions rarely provide relief. Anti-depressants medications can reduce AO pain which is probably due to their analgesic effects (Anti-
22、depressants have the ability to produce low-grade pain relief at lower strengths) and not to their anti-depressant effects. AO patients are generally not depressed. Topical application of capsaicin to painful tissue has also been investigated as a treatment for AO. The outcome is usually fair, with
23、many patients obtaining complete relief from pain. Especially in the absence of overt pathology, particular attention should be paid to avoiding any unnecessary and potentially dangerous dental intervention on the teeth. AO is surprisingly common, of uncertain origin and potentially treatable.,Dysge
24、usia,Dysgeusia is the medical term for an altered, distorted or reduced ability to taste. Specific types of taste disorders include hypogeusia (a reduced ability to taste) and ageusia (an inability to detect taste). A persistent bad taste in the mouth (parageusia) is sometimes used interchangeably w
25、ith dysgeusia.So Distortion may include sensing a taste that is not present in the mouth, or misidentifying a taste (e.g., pleasant-tasting foods now taste awful).,The sense of taste begins in the mouth. A person is born with approximately 10,000 taste buds, most of which are located on or around th
26、e papillae of the tongue. Taste buds are also located on the soft palate, pharynx , larynx , epiglottis and the first part of the esophagus,Each taste bud contains anywhere from 50 to 100 taste cells. Each of these cells responds best to one of five basic taste sensations: Sweet (e.g., sugar) Sour (
27、e.g., lemon juice) Salty Bitter (e.g., aspirin) Umami (sometimes spelled umame) or “savory”,When stimulated, a taste cell sends a nerve impulse to the brain, where a certain taste is identified and sensed. New taste cells are constantly being produced by the body, replacing existing taste cells ever
28、y 10 days throughout a persons life. Thus, if taste cells are destroyed by burning the mouth with a hot liquid, any consequent taste disorder is usually temporary, until new taste cells are produced .For complex tastes, the sense of smell is required. Many taste disorders are actually associated wit
29、h an impaired sense of smell (dysosmia) , which can occur due to colds or other upper respiratory infections. Often, people do not discover they have a smell disorder until they notice a problem with taste.,More than 200,000 people seek help for a taste or smell disorder every year, according to the
30、 National Institutes of Health. The actual incidence of these disorders is estimated to be in the millions because a large number of people do not seek help for the condition. Taste disorders can affect a persons quality of life. It can lead to a decreased appetite, poor nutrition and the inability
31、to identify potentially harmful foods or beverages,Taste disorders can have many different causes. Various illnesses (e.g., colds, sore throat), lifestyle habits (e.g., smoking), irritants (e.g., insecticides, certain prescription mouthwash) and other factors (e.g., medications) can contribute to dy
32、sgeusia. Patients are urged to contact their physician or dentist if they have a taste disorder that lasts two weeks or longer. A thorough medical history may be taken, including questions about symptoms, current medications and medical conditions, recent illnesses, and whether the patients sense of
33、 smell is affected.,. Tests that measure the extent of a persons sense of taste or smell may be performed. If no underlying medical or dental condition is identified, the patient may be referred to a facility that specializes in taste and smell disorders. The physician, dentist or other healthcare p
34、rovider will attempt to identify the underlying cause of a patients dysgeusia. How symptoms of dysgeusia begin can help indicate the underlying cause. For instance, a sudden loss of taste may be due to trauma or a severe upper respiratory infection. For dysgeusia that occurs off and on, an allergy o
35、r exposure to chemicals may be the cause.,Treatment of dysgeusia depends on its cause. Typically, treating the underlying condition will also eliminate the patients dysgeusia. The prognosis for patients is generally excellent when the cause of dysgeusia can be identified and treated. However, long-t
36、erm recovery is more complicated when the source of dysgeusia cannot be identified or when dysgeusia results from an untreatable condition. For the most part, dysgeusia cannot be prevented. However, quitting smoking, practicing good oral hygiene, having regular dental examinations and treating sinus
37、 problems all can contribute to reducing the likelihood of dysgeusia.,SALIVARY GLAND ANATOMY AND PHYSIOLOGY,There are three major salivary glands: parotid, submandibular, and sublingual. These are paired glands that secrete a highly modified saliva through a branching duct system. Parotid saliva is
38、released through Stensons duct, the orifice of which is visible on the buccal mucosa adjacent to the maxillary first molars. Sublingual saliva may enter the floor of the mouth via a series of short independent ducts, but will empty into the submandibular (Whartons) duct about half of the time. The o
39、rifice of Whartons duct is located sublingually on either side of the lingual frenum. There are also thousands of minor salivary glands throughout the mouth, most of which are named for their anatomic location (labial, palatal, buccal, etc). These minor glands are located just below the mucosal surf
40、ace and communicate with the oral cavity with short ducts.,Saliva is the product of the major and minor salivary glands dispersed throughout the oral cavity. It is a highly complex mixture of water and organic and non-organic components The three major salivary glands share a basic anatomic structur
41、e. they are composed of acinar and ductal cells arranged much like cluster of grapes on stems. The acinar cells make up the secretory end piece. those of the parotid gland are serous, those of the sublingual gland are mucous, and those of the submandibular gland are of a mixed mucous and serous type
42、. The duct cells (the “stems”) form a branching system that carries the saliva from the acini into the oral cavity. The duct cell morphology changes as it progresses from the acinar junction toward the mouth .,proteins are produced and transported into the saliva through both acinar and ductal cells
43、. The primary saliva within the acinar endpiece is isotonic with serum but undergoes extensive modification within the duct system, with resorption of sodium and chloride and secretion of potassium. The saliva, as it enters the oral cavity, is a protein-rich hypotonic fluid. The secretion of saliva
44、is controlled by sympathetic and parasympathetic neural input.,xerostomia,called “dry mouth,“ among patients who take medications, have certain connective tissue or immunological disorders or have been treated with radiation therapy. When xerostomia is the result of a reduction in salivary flow, sig
45、nificant oral complications can occur.,Xerostomia often develops when the amount of saliva that bathes the oral mucous membranes is reduced. However, symptoms may occur without a measurable reduction in salivary gland output. The most frequently reported cause of xerostomia is the use of xerostomic
46、medications. A number of commonly prescribed drugs with a variety of pharmacological activities have been found to produce xerostomia as a side effect. Additionally, xerostomia often is associated with Sjgrens syndrome, a condition that involves dry mouth and dry eyes and that may be accompanied by
47、rheumatoid arthritis or a related connective tissue disease. Xerostomia also is a frequent complication of radiation therapy.,Xerostomia is an uncomfortable condition and a common oral complaint for which patients may seek relief from dental practitioners. Complications of xerostomia include dental
48、caries, candidiasis or difficulty with the use of dentures. The clinician needs to identify the possible cause(s) and provide the patient with appropriate treatment,Xerostomia is defined as a subjective complaint of dry mouth that may result from a decrease in the production of saliva. Xerostomia is
49、 estimated to affect millions of people in the United States. Studies have found the condition in 17 to 29 percent of sampled populations based on self-reports or measurements of salivary flow rates. Complaints of dry mouth generally are more prevalent in women,its diminution or absence can cause si
50、gnificant morbidity and a reduction in a patients perceptions of quality of life. The primary constituents of saliva are water, proteins and electrolytes. These components enhance taste, speech and swallowing and facilitate irrigation, lubrication and protection of the mucous membranes in the upper digestive tract Additional physiological functions of saliva provide antimicrobial and buffering activities that protect the teeth from dental caries.,
