1. FACIAL PAIN-NON ODONTOGENIC CAUSES
Dr. A.V. Srinivasan
MD.,DM.,Ph.D .,
D.Sc (HON).F.I.A.N.,F.A.AN.
Emeritus professor of Tamilnadu
Dr. M.G.R Medical University.
Adjunct Professor –IIT, Chennai
Former Head, Institute of Neurology-
Madras medical college.
Ragas Dental college 07-08-2011

3. Chronic Pain
Understanding, Impact and
Awareness
We learn by thinking and the quality of the learning outcome
is determined by the quality of our thoughts
R.B. Schmeck

4. “Pain May be Inevitable, but Misery is Optional”
Dee Malchow
Pain constitutes nearly 40% of the total of patient visits to doctors. 1
“ByNature All Men/W en are alike but
om
byEducation widelydifferent”
1 Mäntyselkä et al. Pain as a reason to visit the doctor: a study in Finnish primary health care. Pain. 2001 Jan;89(2-3):175-80.
- Chinese

5.  In 2001, Barry Furrow wrote “Pain is undertreated” in the American health-care
system at all levels.2
 The term "opiophobia" has been coined to describe this remarkable clinical
aversion to the proper use of opioids to control pain.
 The possible reasons for health-care providers' failures to properly manage pain
are many;
 Occasional lack of knowledge about appropriate treatment choices for pain
management
 A reflection of a Culture hostile to drug use
 Threats of legal action.
 Worry about tolerance and addiction and other adverse drug effects
 Something as trivial as the lack of insurance cover, can lead to patients
suffering unnecessary pain as a result.
2. R.M. Marks and E.J. Sachar, "Undertreatment of Medical Inpatients with Narcotic Analgesics,"Annals of Internal Medicine, 78 (1973): 173.

6.  Despite an essentially stoic and less demanding Indian patient; the
obligation to manage pain comes to the fore not only to complete the
perfection of a clinicians management.
 But also, it is an independent entity with physical and psychological
components that in adherence to best practices can neither be ignored
nor treated such that adverse effects eclipse the malady.
 This importance of pain management is further increased when
benefits for the patient are realized,
 Early mobilization which tends to prevent the more dangerous
complication of a deep vein thrombosis;
 Shortening hospital stay
 Reducing costs

7.  In late 2000, US Congress passed into law a
provision, which the president signed , that
declared the 10 year period beginning Jan 1 st
2001, as the Decade of Pain Control and
Research.
 The American Pain Society has actively suppor ted
the Decade of Pain Control Research, and it has
been a focal point for the development of
numerous programs to advance awareness and
treatment of pain and funding for research.

8. • Pain is always a subjective experience
• Everyone learns the meaning of “pain” through experiences usually
related to injuries in early life
• As an unpleasant sensation it becomes an emotional experience
• Pain is a significant stress physically, emotionally
The International Association for the
Safety of Pain (IASP) defines pain an
unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described
in terms of such damage, or both.
(American Society of Anesthesiologists, 2002; Loeser et al, 2001; Merskey H et al, 1994; Portenoy et al, 1996)

9.  Organic vs. psychogenic
 Acute vs. chronic
 Malignant or benign
 Continuous or episodic
Perceiving Pain
• Algogenic substances – chemicals released at the site of the
injury
• Nociceptors – afferent neurons that carry pain messages
• Referred pain – pain that is perceived as if it were coming from
somewhere else in the body

10. ACUTE CHRONIC
Function To warn None (destructive)
Etiology Usually Clear Complex/obscure
Pt. Mood Anxiety/fear Depression/anger
MD impact Comforting Frustrating/draining
Role of Rx Control/cure Improve function/QOL

11. Types of Pain
Types of Pain
(Psychogenic)
(Psychogenic)
Pain arising from
Pain arising from Pain arising from
Pain arising from
pain receptors
pain receptors Pain with NO apparent cause
Pain with NO apparent cause
Nervous system
Nervous system
[Nociceptive Pain]
[Nociceptive Pain] (e.g. Low back pain or some
(e.g. Low back pain or some [Neuropathic Pain]
[Neuropathic Pain]
pelvic pain in women)
pelvic pain in women)
Peripheral
Peripheral
Central
Central
Superficical / /Somatic
Superficical Somatic Deep / /Visceral
Deep Visceral
(Brain and Spinal cord)
(Peripheral nervous
(Peripheral nervous
(Brain and Spinal cord) system)
system)
Keay, KA; Clement, CI; Bandler, R (2000). "The neuroanatomy of cardiac nociceptive pathways". in Horst, GJT. The nervous system and the heart.
Totowa, New Jersey: Humana Press. p. 304

12. Nociceptive descriptors Neuropathic descriptors
Cramping, tender Shooting
Gnawing, heavy Hot-burning
Aching Sharp
Splitting Stabbing

13. IASP (International Association for the Study of Pain) expert multi-axial classification of chronic pain
 Axis I: Anatomical location
 Axis II: Systems
 Axis III: Temporal Characteristics (intermittent, constant, etc.)
 Axis IV: Patient’s Statement of Duration/ Intensity / severity
 Axis V: Etiology
Example:
Mild post-herpetic neuralgia of T5 or T 6; 6 months ’ duration =
303.22e
Axis I: Thoracic region
Axis II: Ner vous system (central, peripheral, or autonomic); physical
disturbance/dysfunction
Axis III: Continuous or nearly continuous, fluctuating severity
Axis IV: Mild severity of 1 to 6 months
Axis V: Trauma, operation, burns, infective, parasitic (one of these)
(Loeser et al, 2001; Merskey et al, 1994)

14. Chronic pain has a
Hostility
Depression
psycho-social component
that must be dealt with
Psychological Factors before depression
Pathological Process
becomes a part of the
Loneliness
Physical Factors
Social Factors
clinical picture. Chronic
Anxiety
pain should be recognized
as a multi-factorial disease
state requiring intervention
at many levels.
A.G. Lipman, Cancer Nursing, 2:39, 1980 TIME

15.  Chronic pain has high co-morbidity
 Depression
 Anxiety disorders
 Sleep disorders
 All diminish function and quality of life
 Addressing these issues is essential to optimal pain
management
Give us the GRACE to acce pt with se re nity the thing s that canno t be chang e d the COURAGE to
chang e the thing s that sho uld be chang e d and the W ISDOM to kno w the diffe re nce

16.  Chronic pain is NOT a normal part of aging.
 Emotions play a key role in painful experience
 Pain sounds a warning, signaling damage to tissues, and has survival value so pain receptors do not
adapt to prolonged stimulation and pain sensation may intensify as pain thresholds are lowered by
continued stimulation.
 The 19th Century viewed pain as a solely physiological entity with two theories dominating – the
“specificity” & the “summation” theories. 8
 Paradigm Shift:
 Pain perception impulses are modified by ascending and by descending pain-suppressing
systems activated by various environmental and psychological factors.
 1965 Melzack & Wall: Gate Theory of Pain marked a turning point in understanding transmission
and modulation of nociceptive signals, and recognition of pain as a psychophysiological
phenomenon.
 The concept of Neuroplasticity was recognized and accepted adding dynamism to neuronal & brain
structure with neuroimaging of the central nervous system in three domains; anatomical, functional,
and chemical imaging helping measure changes in chronic pain.
 Taken together these three domains have changed our thinking on pain; now considered an altered
brain state in which there may be altered functional connections or systems and components of
degenerative aspects of the CNS. 9
8) 11. J.A. Paice, C. Toy, and S. Short, "Barriers to Cancer Pain Relief: Fear of Tolerance and Addiction," Journal of Pain and Symptom Management, 16 July 1998): 1-9.
9) Quick Reference Guide for Clinicians No. 1a. AHCPR Publication No. 92-0019: February 1993

18.  Trauma/ injury initiates immediate
nerve impulses to brain
 Injury to cells result in chemical
release
 H+
 K+
 Substance P
 Bradykinin
 5HT
 Phospholipids ⇒Prostaglandins
 Blood vessels leak resulting in
inflammation
 Stimulate C-fibres (slow response)

19. Ascending Tracts Descending Tracts
Cortex
Thalamus
Midbrain
Pons
Medulla
(Brookoff, 2000)
Spinal Cord

21.  Αδ ( A delta)
 Myelinated
 Fast conductors
 Gentle pressure and pain
 Αβ (A beta)
 Thinner – but still
myelinated
 Fast conductors
 Heavy pressure &temp
 C - very thin
 Slow conductors
 PAIN, Pressure, temp &
chemicals

22.  In chronic pain, the nervous system remodels
continuously in response to repeated pain signals
 ner ves become hypersensitive to pain
 ner ves become resistant to anti-nociceptive
system
 If untreated, pain signals will continue even after
injury resolves
 Chronic pain signals become embedded in the
central nervous system
(Marcus, 2000)

23. Pain-Sensing System in the
Malfunction in Chronic Pain
Acute pain:
Pain Pain-sensing signals are
initiated in response to a
Sensing stimulus
• They elicit a pain-
In chronic pain, relieving response
pain signals are
generated without
physiologic Chronic pain:
significance
Pain signals are generated
for no reason and may be
intensified
• Pain-relieving
mechanisms may be
defective or deactivated
(Illustration: Seward Hung, 2000)

24.  Reticulospinal fibers from raphe nuclei project to dorsal horn of spinal cord and
release serotonin which stimulates interneurons to release enkephalin
 Enkephalin inhibits transmission of pain and temperature signals in second
order neurons
 Reticulospinal fibers from locus coruleus also project to dorsal horn of spinal
cord and release norepinephrine which inhibits pain and temperature signals by
an unknown mechanism
 Mental illnesses such as depression decrease serotonin and norepinephrine
and lower pain thresholds while antidepressant drugs and therapies (e.g.,
exercise) which increase serotonin and norepinephrine levels raise pain
thresholds

25.  Inferred from characteristics, etiology or pathophysiology
 Types
 Nociceptive
 Neuropathic
 Idiopathic
 Therapeutic implications
(Portenoy et al, 1996)

26. Presumably results from ongoing activation of primary
afferent neurons responding to noxious stimuli
 Pain consistent with degree of tissue injury
 Described as aching, squeezing, stabbing, throbbing
 Subtypes:
 Somatic: related to activation of somatic af ferent
neurons
 Visceral: related to activation of visceral af ferent
neurons
(Loeser et al, 2001; Portenoy et al, 1996)

27.  Initiated by a primary lesion in the nervous system; believed to be
sustained by aberrant somatosensory processing in the peripheral or
central nervous system
 Independent of obvious ongoing nociceptive activation
 Burning, shooting, electrical quality; may be aching, throbbing, sharp
 Subtypes:
 Presumed “central generator”
 deaf ferentation pain (central pain, phantom pain)
 Sympathetically -maintained pain
 Presumed “peripheral generator”
 Polyneuropathies and mononeuropathies
(Portenoy et al, 1996)

28. Idiopathic Pain
 Usually exists in the absence of an identifiable physical or
psychologic pathology that could account for pain
 Uncommon in patients with progressive illness
Psychogenic Pain
 Presents positive evidence of a predominant psychologic
contribution and may be labeled with a specific psychiatric
diagnosis
(Loeser et al, 2001; Merskey et al, 1994; Portenoy et al, 1996)

29.  Greater understanding of the pathophysiology underlying chronic
pain syndromes
 Scientific breakthroughs in molecular biology; insight into pain at
the molecular level
 Advances in drug therapy (drug delivery technologies)
 Multimodal therapy
 Multidisciplinary teams, shared decision-making that includes
patients
 Patients’ rights movement
(JCAHO, 1999; Loeser et al, 2001)

30. Progress in Chronic Pain Management:
Therapeutic Modalities for
Chronic Pain Management
Assessment

31. “Describing pain only in terms of its
intensity is like describing music only in
terms of its loudness”
von Baeyer CL; Pain Research and Management 11(3) 2006; p.157-162

32.  Characterize the pain
 Characterize the disease, relationship between
pain and disease and potentially treatable
etiologies
 Clarify syndromes and infer pathophysiology
 Determine need for urgent therapy
 Identify other needs
 Develop a therapeutic strategy
(Portenoy et al, 1997)

33. Components
 History: temporal features, intensity, topography, quality,
exacerbating/alleviating factors
 Physical Exam: determine existence of underlying pathology
 Lab and Radiographic Tests: appropriate to pain syndrome
Assessment Tools
 Pain Intensity Scales: VAS, NAS, “faces” scale
 Multidimensional Pain Measures: Brief Pain Inventory, McGill
Pain Questionnaire
(Portenoy et al, 1997)

34. • Visual Analogue Scale (VAS)
No pain ----------------------------------- Worst pain
• Numerical Rating Scale
0 ------------------------------------- 10
Worst pain
No pain
imaginable
• Categorical Scale
None (0) Mild (1 – 4) Moderate (5 – 6) Severe (7 – 10)
• Pain Faces Scale
0 2 4 6 8 10
No Hurts just a Hurts a little Hurts even Hurts a whole Hurts as much
hurt little bit bit more more lot as you can
imagine
• Brief Pain Inventory Shade areas of worst pain. Put an X on area that hurts most
(Cleeland, 1991; Jacox et al, 1994)

35. Progress in Chronic Pain Management
Therapeutic Modalities for Chronic
Pain Management
Treatment

36.  Pharmacotherapy (Analgesics)
 Non-opioids
 Adjuvant Analgesics
 Antidepressants
 Anticonvulsants
 Opioids
 Rehabilitative Approaches
 Psychologic Interventions
 Anesthesiological Approaches
 Neurostimulatory Techniques
 Surgery
 Complementary/Alternative Approaches
 Lifestyle Changes
(Cashman, 1996; Portenoy et al, 1997; Hanks et al, 1998; Galer, 1998; Stein, 1995)

37.  Best evidence: TCAs
 Inhibit both NA and 5-HT reuptake
 TCAs are superior to SSRIs in pain management
 TCAs are superior to the anticonvulsant
 There is no consensus regarding which of the many TCA
derivatives is most effective.
 The choice of TCA is therefore dictated largely by adverse
effects
Neurologic Complications of Cancer Therapy Current Treatment Options in Neurology 1999, 1.428-437
Litsedge, A Double-Blind Comparison of Dothiepin and Amitriptyline for the Treatment of Depression with Anxiety, Psychopharmacologia (Berl.) 19, 153--162 (1971)

39.  Major reason for seeking medical care.
 90% is vasculr headache.
 10% is mixture of inflammation,traction or
dilatation of pain sensitive structure.
A true commitment is a heart felt promise to yourself from which you will not
back down
- D. Mcnally

40.  Pain
 Referred pain
 Pattern of referred pain
Success in life is a matter not so much of talent and opportunity
as of concentration and perseverance
- C.W. Wendte

41.  History
 Hx of present illness
 Past medical hx
 Family hx
 Social hx
 Physical examination
We possess by nature the factors out of which personality can be made, and to
organize them into effective personal life is every man’s primary responsibility
- Harry Emerson Fosdick

42.  Clinical features suggesting serious cause
 Crescendo
 Early morning
 Vomiting
 Fever
 Seizures & other neurological symptomes
 Worst headache in my life
 Known malignancy
 Tenderness

43. Typical Neuralgias
1) Trigeminal neuralgia
• Characterized by recurring paroxysmal
severe pain, brief duration (seconds) in the
territor y of the trigeminal ner ve,
spontaneously or initiated by chewing,
talking, touching the af fected side of the
face.
• Unknown aetiology, an ar terial loop pushing
on the sensor y root in the posterior fossa.
• Females af fected more than males
• Analgesics, surger y, destruction of the
sensor y neuron, division of ner ve root.

44. Typical Neuralgias
2) Glossophar yngeal neuralgia
• Unknown cause
• Equal both sexes
• Severe, sudden episodes of pain in
the tonsil region one side only,
ipsilateral ear.
• Pain - severe for 1-2 hours, recur
daily
• Treated like trigeminal

45. Typical Neuralgias
3) Sluder’s neuralgia and Vidian
neuralgia
• Intractable pain in the nose, eye,
cheek and lower jaw.
• Could be due to lesion of the
sphenopalatine ganglion, or vidian
ner ve.
• Analgesics, vidian neurectomy

46.  Posttraumatic neuralgia
 Neuroma
 Parietal & occipital
 90% recover y
Experience can be defined as
yesterday’s answer to today’s problems

47. Atypical facial pain
 Pain felt over the cheek, nose, upper
lip or lower jaw
 Usually bilaterally symmetrical
 Aching, shooting, burning,
accompanied by reddening of the skin
and lacrimation or watering of the nose
 Lasts for hours, days or weeks
 Psychological consultation, analgesics

48. Intracranial lesions
1) Central lesions
• Tumours of the brain stem, M.S.,
thrombotic lesions, metastasis, occult
naso-phar yngeal ca.
• No precipitant, sensor y loss.
2) Post herpetic neuralgia
• Herpes zoster may af fect trigeminal
ner ve ganglion
• Vesicular rash covers one division
commonly the 1 st with severe pain.

49. Extracranial lesions
1) Sinus disease
• Infective and neoplastic lesions of the
paranasal sinus.
• Facial pain & dental pain, loss teeth.
• Clinical suspicion.
• Treatment
2) Dental neuralgia
• Dental carries
• Dental extraction
3) Temporomandibular joint pain

50. Headache is one of the commonest
symptoms in medical practice.
Aetiology:
1) Raised intracranial pressure
 Due to tumours, abscesses, subdural
haematoma, brain haemorrhage.
2) Inflammation of the brain and
meninges
 e.g. meningitis, cerebritis, others

51. 3) Migraine
 Congenital predisposition
 Triggered by hunger, cer tain foods, sleep -
too much or too little, hormonal variations,
stress.
 Pathology-vascular dilatation
 Females af fected more than males
 ? Proceeded by aura usually visual,
paraesthesiae of hands, weakness
 Headache is unilateral or bilateral, af fects
any area of the head, aching or throbbing
of ten accompanied by nausea and
vomiting
 Diagnosis - by histor y alone
 Treatment - prevention by avoiding
precipitating factors, appropriate
medication.

52. 4) Tension headache
 More common in adult females
 Positive family histor y (40%)
 Maybe associated with migraine
 Produced by persistent contraction of
the muscles of the neck, head and face
 Caused by emotional tension,
secondar y to other headaches, posture
habit
 Treated by analgesics, muscle
relaxants, physiotherapy

53. 5) Cluster headache
 90% are men
 Age 20 - 30
 Attacks occur in groups, no aura
 Caused by vascular dilatation of
branches of external carotid
 Triggered by histamines, alcohol
 Treated by analgesics, anti-histamine,
steroids

54. Pain from temporalis muscles
 Can arise from grinding teeth at
night (bruxism), impacted wisdom
teeth, temporomandibular joint
dysfunction, anxiety when the
patient clenches the jaws too tightly
Treatment: Refer to interested
dental surgeon .

55. Pain from upper neck muscles
 Can radiate over the head
Treatment by physio-therapist or
rheumatologist
Pain from frontalis muscles
 Usually due to bad posture at work
or while driving
Treatment: physio-therapy

56. Cer vical spondylosis
 Pain mediates upwards from the neck to
the occiput or ver tex to the front of the
head, down to the shoulders
 Due to cer vical discs prolapse
 Diagnosis - x-ray
Treatment: Physio-therapy, referral to
rheumatologist

57. Temporal ar teritis
 Due to acute inflammation of the ar ter y,
the cause unknown, af fects men and
women over the age of 60
 Pain over the temples and frontal region,
intense, throbbing, tenderness over the
scalp, swelling and redness of the
overlying skin with general malaise, par tial
or complete loss of vision.
 ESR Elevated
Treatment: Cor tisone, analgesics

58. Psychologic headache
 Usually accompanied by
depression, anxiety
 No organic lesion
It is a great misfortune not to possess sufficient wit to speak well
nor sufficient judgment to keep silent
La Broyers character

59. Dedicated to my family for
making everything worthwhile

61. READ not to contradict or confute
Nor to Believe and Take for Granted
but TO WEIGH AND CONSIDER
My sincere thanks to P.Sampath