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Nerves supply the orofacial region, pain
N. supply the orofacial region
I. Nn. olfactorii
II. N. opticus
III. N.oculomotorius
IV. N. trochlearis
V. N. trigeminus
VI. N. abducens
VII. N. facialis
VIII. N. vestibulocochlearis
IX. N. glossopharyngeus
X. N. vagus
XI. N. accessorius
XII. N. hypoglossus
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Nervus trigeminus
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N. Trigeminus – three main branches
̶ N. ophtalmicus
̶ N. maxillaris
̶ N. mandibularis
̶ Sensitiv and motoric part
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Nervus trigeminus zones of the supply
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N. ophtalmicus
̶ Goes through fisura orbitalis superior into the orbita.
̶ It supplies: skin of: the foreahead, the upper lid, the vertex, back of
the nose as well as a part of the nasal mucosa.
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N. maxillaris
̶ Goes through f.rotundum into fossa pterygopalatina from where its
branches continue.
̶ Zones: skin of the temple, lateral part of the nose, lower lid, upper
lip, teeth in maxila, oral and nasal mucosa including maxillary
sinus. Also part of dura mater (the middle part).
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N. maxillaris branches
̶ 1. R.meningeus
̶ Nervi pterygopalatini (rr. Nasales)
̶ N palatinus major a nn palatini minores
̶ N. infraorbitalis –rr.alveolares superiores posteriores
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N. Infraorbitalis branches
̶ R. alveolaris superior medius - plexus dentalis superior
̶ Rr. alveolares superiores anteriores
̶ Rr. nasales interni
̶ Rr. cutanei
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N. maxillaris and its branches
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N.Mandibularis - branches
➢N. mylohyoideus
➢N. bucccalis (it supplies skin of the cheek, goues through m.
buccinator but this muscle is supplied by n. facialis). N. buccalis
can be also a branch of the n. infraorbitalis.
➢N. auriculotemporalis
➢R. communicans cum ganglio otico, rr.comunicantes cum nervi
faciali,rr.parotidei, rr. articulares,n.meatus acustici interni aj.
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N. mandibularis - branches
̶ N.lingualis: many branches, it terminates as rr linguales supplying the lingual
mucosa in the anterior part.
̶ N.alevolaris inferior: goes into foramen mandibulae and continues in canalis
mandibulae till the foramen mentale, from where the terminal branches goes
to the skin of the lip. Branches:
➢N.mylohyoideus
➢Plexus dentalis inferior
➢N. mentalis
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N. mandibularis – zones of supply
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Vegetative ganglia next to the n. trigeminus
̶ G. ciliare – orbita
̶ G. pterygopalatinum - fossa pterygopalatina
̶ G. oticum – next to f.ovale
̶ G. submandibulare – next to n. linguialis
Afferent branches: radix sympathica, radix parasympathica,radix
sensitiva.
Efferent branches mixed.
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N. facialis – branches
̶ N. petrosus major-parasympatic fibres for ganglion
pterygopalatinum
̶ R. communicans cum plexu tympanico
̶ N. stapedius
̶ Chorda tympani: connection with n. lingualis (parasympatic and
sensoric fibres)
̶ Nervus auricularis posterior, r- digastricus, r. stylohyoideus
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N. facialis-branches
̶ Plexus parotideus – supply of mimic muscles, r- colli m. platysma.
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N. facialis
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N. glossopharyngeus
̶ Supplie the posterior third of the tongue and pharynx.
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Pain
̶ Unpleasant, troublesome up to intolerable feeling
̶ Subjective and individual
̶ Chain of physiological reactions and psychological manifestations
̶ The stimulus affects receptors or nerves, information is led to the
central nerve system and transformed into subjective experience
and final reactions
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Receptors of pain
̶ Receptors are free nerve endings
No adaptation, feeling is so long as the duration of the stimulus is.
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Stimuli
̶ Physical
Mechanical, thermal (cold, hot), electrical
Each feeling is transformed on the pain if the intensity exceed
certain limit.
Changes of the intracranial pressure (vasodilatation), contraction of
the nuchal or scalp muscles belong also to the physical stimuli.
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Stimuli
̶ Chemical
➢ pH changes (decrease of pH – pain, around 5,8 untolerable)
➢ions (potassium)
➢Chemicals: acids, bases, hypotonic or hypertonic liquids,
Extrinsic factors: acid, bases, hypotonic or hypertonic liquids, also
stinging plants, insect poisson : changes of metabolism in cells -
pain
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Stimuli
̶ Intrinsic factors
Internal origin: hydrochlorid acid (stomach), acetylcholin, histamin,
serotonin, KCl, lactic acid.
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Inflammation - pain
̶ Reaction of cells and blood vessels on damage (irradiation,
burning, mechanical, chemical factors, infection or allergy)
Participation of histamin, serotonin, plasmakinin and others
inflammatory mediators
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Ischemia
̶ Disorders of metabolism – reduction of the supply of oxygen and
nutrients, obstruction of elimination of catabolits.
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Psychology of pain and its importance for the
human body.
̶ For the subjective feeling the status of the central nerve systém is
important.
̶ Painful stimuli cause defensive reflexes
̶ Indicator of location of the pathological process.
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Pain in the orofacial region
̶ Dental origin
Pulpitis
Periodontitis
Periodontal diseaes
Post extraction complications
Definujte zápatí – název prezentace nebo pracoviště38
Pain in the orofacial region
̶ Extradental origin
Oral mucous membrane disease
Sinusitis
Otitis media
Neurologic diseases (neuralgia, migraena)
Ophtamological diseases
Systemic diseases
Definujte zápatí – název prezentace nebo pracoviště39
Pain of dental origin
̶ Endodontics I., II.
̶ Periodontology
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̶ The neurogenic factor - activation of neural response by
environmental irritants
(mechanical, chemical, microbial)
̶ may cause
̶ immediate and transient pain perception - result of nerve fibers
irritation
̶ vasodilatation - persists = increase in capillary permeability, fluid
exudation, leucocytes infiltration= beginning of the exudative
phase
̶ increased intrapulpal pressure = result of the increased blood
volume (hyperemia) and tissue exudate
̶ secondary (spontaneous) pain response (C fibers)
̶ The pain persists - the presence of necrotic tissue
• The tissue injury factor - is due to release of
mediators by the injured odontoblasts
• chemical substances
• the same effect as the nerve factor
• prolonged vasodilatation, fluid exudation,
leucocytes infiltration, increase of intrapulpal
volume and pressure, pain
Reversible pulpitis - Hyperemia
•Capillary bed - enlargement,
vasodilatation, elevated capillary
pressure, increased vascular
permeability, potentially reversible
response
Irreversible pulpitis
Acute - hyperactivity of exudative forces
polymorphonuclear leucocytes, later macrophage
Chronic - proliferative phase
granulomatous tissue
pain is usually absent
lymphocytes, plasma cells, macrophages
limited number of PMNS
• Duration and severity
• acute
• chronic
• subacute
• Presence/absence of pain
• painful
• non painful
• Irreversible
–painful pulpitis
• acute pulpitis
• subacute pulpitis
–nonpainful pulpitis
• chronic ulcerative pulpitis (due to caries)
• chronic pulpitis (no caries)
• chronic hyperplastic pulpitis (pulp polyp)
Periodontitis
Painful pulpoperiapical pathoses
(acute apical periodontitis)
Inflammatory response - to pulpal irritants
exogenous forces become hyperactive
great increase in intraperiapical pressure
algogenic mediators released by the injured cells
Acute apical periodontitis
mild symptomatic (exudative) response
contaminants from the pulp, vasodilatation, fluid exudation,
white cells infiltration
periodontal phase - abscess in the periodontal space
enosseal phase - localized ostitis
periosteal phase - severely symptomatic
pain - throbbing character, radiating
submucous phase - periosteal inflammation - relief
Acute periapical abscess
Advanced exudative, severely symptomatic
steadily increasing amount of inflammatory exudate, leucocytic
infiltration
suppuration
Etiology
infection
injury (acute, chronic)
chemical irritation (dressings)
Recrudescent abscess
(phoenix abscess)
previously - chronic (granulomatous lesions)
contaminated (infected)
decrease in immunity
Symptoms: acute symptoms + periapical radiolucency
Subacute periapical abscess
chronic periapical abscess cycle
drainage through the stoma = the sinus tract (fistula)
parulis (gumboil) on the mucosa = swelling (gingiva, oral mucosa)
Acute periodontitis - symptoms
1. Phase
(periodont)
hyperemia in the apical periodontium
increase in pressure - elevates slightly
the tooth nerve endings are stimulated slight
pressure - mild pain
2. phase
(enosseal)
as the process advances - the tooth becomes
increasingly tender, lymph nodes sensitive, alteration
of the patient, starts pus formation, pain more
intense and steady soft vestibular tissue - painful to
palpation, patient may be febrile
Acute periodontitis - symptoms
3. phase
(periost)
the most intense pain - throbbing, steady
radiating - pus penetrates the outer plate of the bone
- raises the periosteum
swelling in the apical region
great mobility
face asymmetry, swelling
the symptoms greater in horizontal position
patient - febrile
4. phase
(submucous)
periosteum and mucosa - ruptured
RELIEF
pain subsides - but swelling
fluctuation
great asymmetry
Periodontal pain
̶ Apical
̶ Marginal
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Pain of marginal periodontal origin
- Papillitis, gingivitis
(finding on interdental papilla)
- Acute inflammation in the periodontal pocket
( the tooth is vital, BOP positive, suppuration, subgingival greatment is effective)
- Abscess in periodontal pocket
Location, percussioin in perpendicular direction, the tooth is vital
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Dentitio dificilis
̶ Finding in the retromolar area
̶ X- ray finding
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Aerodontalgia (barodontoalgia)
̶ Change of intrapuplal pressure (flight or diving)
̶ Pressure or expansion of air bubles- irritation of nerve endings
Teeth that have been treated previously, chronic inflammation…
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Referred pain -synalgia
̶ N. trigeminus many anastomoses, connection with sympathicus
and parasympathicus and other nerves.
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Synalgia dentodental
̶ The pain is localised into the other tooth. Always on the same side.
̶ Horizontal
̶ Ascendent
̶ Descendent
The reffered tooth can be more painful, the patient is not able to describe the
symptoms exactly. Careful investigation, x-ray.
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Synalgia dentocutaneous
̶ Hyperaesthesia of the cutaneous areas (see slides above)
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Synalgia dento-mucousal
̶ Various fields of mucousa
Synlagie dentonasal (maxillary incisors)
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Synalgia dento - ocular and dento -
auricular
̶ Ocular – maxillary canine, first premolar
̶ Auricular – maxillary molars
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Pain of extradental origin:
Sinusitis maxillaris
The pain is similar to pulpitis and periodontitis. Unilateral. The posterior
maxillary teeth are painful on percussion
Rhinitis can be present
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Pain of extradental origin
Ophtalmologic diseases _ iritis, iridocyclitis, glaucom :
Maxillary canine or first premolar.
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Pain of extradental origin
̶ Onemocnění vzdálených orgánů
➢Malign tumors of oesophagus and lungs
➢Angina pectoris
➢Gastroenteritis
➢Meningitis and cerebral tumors
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Pain of extradental origin
̶ Systemic diseases
➢Acute leucaemia and other oncologic diseases
➢Diabetes
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Neuralgia n. trigemini
̶ Pain can occur before the typical attack of neuralgia
̶ Primary:
Sharp short pain, vegetative (lacrimation, reddening of the skin) and motoric symptoms
(defense movement)
Trigger zone
The teeth are usually intact
The pain is very short
Usually women (age from 50)
Vasomotoric changes around g.semilunare
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Neuralgia n. trigemini
Secondary:
The pain is longer, irradiation, no trigger zone, no vegetative and
motoric symtoms, finding on the teeth (caries, filling, crown..)
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Oral membrane mucous diseases
̶ Herpes zoster
Irradiation of the pain along the nerv branche, vesicles.
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Oral mucous membrane diseases
̶ Stomatodynia a glossodynia
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Postextraction complications
̶ Alveolitis sicca
̶ History, empty socket
̶ Alveolitis purulenta
History, swelling redness, suppuration
- Nerve injury after extraction: hyperaesthesia or hypoaesthesia.
History.
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Migraena - hedeache
̶ Unilateral. Duration hours, pulsation, nauzea, vomitus, aura,
women, history.
̶ Aura 20% - one or more hours before ghe attack (ophtalmologic
symptoms, skin sensitivity, paraesthesia)
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Migraena start up factors
̶ Hormonal: Menses, pregnancy, climax
̶ Food − chocolate, alcohol, spice
̶ Stress, lack of sleep
̶ Change of environment – sudden changes of atmospheric pressues, climate
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Acute pulpitis x migraena
Character of the pain, finding on the third maxillary molars.
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Thank you!
lroubal@med.muni.cz