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The Many Faces of Pain What We Don’T See/Know!!!

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The Many Faces of Pain What We Don’T See/Know!!! Anatomy of the Head and Neck Goals of Comprehensive Dentistry with • Optimum oral health Clinical Application • Anatomic harmony • Functional harmony - TM joints - musculature - occlusion Henry A. Gremillion, DDS, MAGD LSU School of Dentistry • Orthopedic stability Chief concern -bitemporal headache -pain with jaw function The Puzzle -sore teeth upon waking -neck pain Should I treat this patient? What is/are the diagnosis(es)? How should I treat this patient? What factors are important in this case? Pain Pathways What We See The Many Faces of Pain What We Don’t See/Know!!! 1 Differential Diagnosis Differential Diagnosis • Teeth The systematic consideration of the • Paranasal sinuses patient’s signs and symptoms in • Otologic order to distinguish one disease • Joint from another. •Muscle • Vascular • Neurogenous DIAGNOSIS IS THE KEY! Osteology Must Consisider: -anatomy Anatomy of the Skull - physiology - neurology - psychology Supraorbital foramen- supraorbital nerve and vessels Optic canal- optic nerve, ophthalmic artery Superior orbital fissure- nasociliary, frontal, and lacrimal branches of V1, occulomotor nerve, trochlear nerve, abducens nerve, superior and inferior ophthalmic veins Inferior orbital fissure- V2, zygomatic nerve, infraorbital vessels 2 Left Blowout Fx Maxilla Mandible Battle's sign, also called mastoid ecchymosis : consists of bruising over the mastoid process (just behind the auricle), as a result of extravasation of blood along the path of the posterior auricular artery. It is an indication of fracture of the base of the posterior portion of the skull, and may suggest underlying brain trauma Parietal Frontal Superior nuchal line Temporal Nasal Inferior nuchal line Occipital Ethmoid Sphenoid Vomer Maxilla Palatine 3 Cone Beam Computed Tomography (CBCT) LeFort I,II,III Fractures LeFort III Facial Fracture 4 CORONOID HYPERTROPHY • Limited range of motion (gradually developing) • May be painless • Most common in adolescent males EAGLE’S SYNDROME ELONGATED STYLOID PROCESS EAGLE’S SYNDROME • Pain on swallowing • Pain upon palpation of lateral pharyngeal wall • Pain on turning head (associated dizziness?) 5 Surgical Removal Of Styloid Process 6 WORRISOME HEADACHE RED FLAGS “SNOOP” Systemic symptoms (fever, weight loss) or Secondary risk factors (HIV, systemic cancer) ANATOMY OF THE Neurologic deficits lateralizing to side of pain or abnormal signs (confusion, impaired alertness, or consciousness) ORAL CAVITY and Onset: sudden, abrupt, or split-second FLOOR of MOUTH Older: new onset and progressive headache, especially in middle-age >50 (giant cell arteritis) Previous headache history: first headache or different (change in attack frequency, severity, or clinical features) Inferior alveolar Lingual nerve nerve Sublingual gland Submandibular duct Mylohyoid muscle Nerve to the myolhyoid Geniohyoid muscle Submandibular Hyoglossus gland muscle 7 Hyoglossus muscle Sublingual salivary gland Submandibular duct Lingual artery Lingual nerve Mylohyoid muscle Lingual vein Hypoglossal nerve Sublingual Gland and Submandibular Lingual nerve Duct Submandibular ganglion Superior pharyngeal constrictor Deep lingual artery Styloglossus muscle Venae comitantes Palatoglossus msucle Stylohyoid ligament Stylopharyngeus muscle Hyoglossus muscle (cut) Lingual artery Submandibular Internal jugular vein duct Sublingual External carotid artery artery & vein Hypoglossal nerve Geniohyoid muscle Lingual Nerve 8 Tongue position and its relationship to sleep-related breathing disorders such as sleep apnea… genioglossus activity Tongue Tongue Obstructed Oropharynx Oropharynx SLEEP-RELATED BREATHING Nasal Cavity & DISTURBANCES Paranasal Sinuses Enlarged & Inflamed Tonsils 9 frontal sinus cribiform plate sphenoidal sinus nasal septum choanae lateral process of septal nasal cartilage major alar cartilage nasal vestibule anterior nasal spine incisive canal oral cavity tongue soft palate 10 Mucous Retention Cyst DISPLACED ROOT / TOOTH Root Tip in Maxillary Sinus 1. Under flap 2. Sinus 3. Infratemporal Fossa 11 Third Molar Displaced into Maxillary Sinus Third Molar Displaced into Infratemporaral Foss Fractured Tuberosity with Maxillary Sinus Exposure S Sinus Lift with Iliac Bone Graft i n PARANASAL ORIGINS OF PAIN 12 Acute / Chronic Sinusitis: Paranasal Sinuses PAINFUL COMPLICATIONS . Mucosal inflammation and thickening in Headache and facial pain are commonly cases of acute sinusitis related to infection, inflammation, and/or . Partial or complete obstruction of sinus ostia obstruction of the outflow of the tracts of . Pressure sensation the paranasal sinuses. Maxillary mucoceles . Osteomyelitis Acute / Chronic Sinusitis: Sinus involved Site(s) of referral • Sphenoid sinus • Vertex, other parts of the cranium • Frontal sinus • Frontal region • Ethmoid sinus • Between the eyes • Maxillary sinus • Maxilla, dental structures • Pansinusitis • Pain may be coalescent, less localized, associated with frontal headaches, constant pressure Pansinusitis 13 Mucosal Contact Headache MUCOSAL • Dull and aching • Diffuse peri-/retro-ocular, supraorbital pain CONTACT • History of chronic maxillary sinusitis • Allergy prone HEADACHE • Associated with upper respiratory tract infection • Impedance of normal mucosal activity 14 Pharyngeal Region Plate 58 Plate 58A Plate 58B 15 EAR Eustachian tube dysfunction • Normal function – Dilatation – Primarily involves the tensor veli palatini – Swallowing causes momentary eustachian tube dilitation which equalizes pressure – Secondarily involves • Levator veli palatini • Salpingopharyngeus Plate 89 • Superior constrictor Ear Pain ( Otalgia ) • Acute Otitis Externa • Acute Otits Media – Severe ear pain often – Fluid/pressure behind the TM – Most common in children – Treatment • Antibiotics • Myringotomy ( ear tubes ) 16 Ear Symptoms and TMJ Tonic Tensor Tympani Phenomenon – Ear pain (Otalgia) • Hypertonia of medial pterygoid produces a – Hearing changes- stuffiness most concomitant reflex hypertonia of the tensor likely related to ET tympani muscle dysfunction. • Tonic tensor tympani cannot initiate the reflex – Tinnitus (ringing that increases the tonus of the tnsor veli in ear) palatini muscle – Dizziness • Failure of the eustachian tube to open during deglutition Otomandibular Syndrome 1 or more of the following without pathology in ENT exam plus 1 or more muscles symptomatic • Pain / fullness in and around ear • Hearing loss • Tinnitus • Loss of equilibrium Plate 88 Submandibular (Digastric) Triangle Digastric Triangle • Superior – Inferior border of mandible • Anterior – Superior border of anterior belly of digastric • Posterior – Superior border of posterior belly of digastric 17 Styloglossus muscle Posterior digastric muscle Masseter muscle Hyoglossus muscle Mylohyoid muscle Stylohyoid muscle Anterior digastric muscle Middle pharyngeal constrictor muscle Thyrohyoid muscle Inferior pharyngeal constrictor muscle Sternohyoid muscle Scalene muscles posterior Omohyoid muscle middle (superior belly) anterior Trapezius muscle Brachial plexus Sternocleidomastoid muscle Sternal head Omohyoid muscle Clavicular head (inferior belly) Lesser’s triangle Major Salivary Glands Patient: Betty Parotid gland • 51 year old Caucasian female -pure serous • Medical history significant for: Submandibular gland – left temporomandibular surgery X2 -primarily serous – hypothyroidism Sublingual gland -primarily mucous Patient: Betty • Chief pain concern: – “I have pain in my jaw and throat when I eat. The pain radiates to my ear. It feels like a toothache.” 18 Patient: Betty Sialolithiasis Diagnosis • Aggravating factors: – chewing and drinking • History – certain aromas – pain with salivation • Alleviating/relieving factors: • Inspection – none identified • Palpation Sialolithiasis Diagnosis • Imaging – occlusal – lateral jaw – panoramic – sialogram Temporal branches Zygomatic branches Superficial Face Posterior auricular nerve Buccal branches Nerve to the posterior belly of digastric Marginal mandibular branches Cervical branches 19 BELL’S PALSY • Cranial nerve VII paralysis • May occur post-dental procedure • Usually unilateral • Gradual or sudden onset • Viral relationship??? Patient: Juan Patient: Juan • Chief pain concern(s): • 28 year old Hispanic male – “pain on the right side of my face; headaches in the temples; clicking in my right jaw; face feels numb and • Medical history: tingles on the right side; throbbing when I eat” – unexplained intermittent facial swelling and lymphadenopathy • previously treated with Pen VK 500 mg Patient: Juan • Aggravating factors: – eating – opening wide – yawning • Alleviating/relieving factors: – antibiotics (Pen VK 500) – analgesics (Ibuprofen)-- “takes the edge off” 20 Parotido-Masseteric Hypertrophy Traumatic Occlusion Syndrome • Parotid swelling – duct obstruction Parotid duct – pain • Sialdochitis Superficial masseter muscle Buccinator – bacterial infection due to retrograde travel of organisms from the oral cavity • Traumatic occlusion Parotido-Masseteric Hypertrophy Traumatic Occlusion Syndrome Treatment • Antibiotic therapy • Analgesics • Occlusal therapy • Control parafunctional habits Patient: Bernadette Patient: Bernadette • 78 yr. old Caucasian female Chief pain concern(s): • Medical history: – “I have facial pain all over both sides of my – hypertension face. I have severe pain upon chewing. My – osteoporosis neck hurts.” – intermittent, migrating joint swelling – fatigue of recent onset – depressed mood – progressively worsening vision 21 Patient: Bernadette Temporal Arteritis Characteristics
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