cons presentation

8/6/2019 Cons Presentation

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AliahShivaani

Sara

AnneWilliam

Sailo

AisyahJaysonYuen

AliceHafizah

Archana


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yHeadache

PRIMARY SECONDARY

migraine

clustertensionDue to underlying

disorderin the head andneck.


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Management of primary

headachey TENSION HEADACHE

OTC medications as:

Aspirin Ibuprofen (Motrin, Advil)

Acetaminophen (Tylenol)

Naproxen (aleve)

Supportive treatment :

Massage

Biofeedback

Stress management


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y CLUSTER HEADACHE

Initial treatment include:

1) Injectionoftryptan medications, eg:

y Sumatriptan (Imitrex),

y Zolmitriptan (Zomig), and

y Rizatriptan (Maxalt)

2) Injectionoflidocaine, a local anesthetic, into thenostril;

3)Dihydroergotamine (DHE, Migranal), a medicationthat causes blood vessels to constrict;


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MIGRAINESy Non-medication therapies

for migraine

y Usingice,

y biofeedback, and

y relaxation techniques may be helpful in stopping anattack once it has started.

Sleep may be the best medicine

ifit is possible


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y MEDICATIONS:

acetaminophen(Tylenol), and

non-steroidal anti-inflammatory drugs (NSAIDs) Eg:aspirin and ibuprofen.

Triptans : sumatriptan, zolmitriptan.

Ergotamine tartarate.


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yAVOID!:

Smoking

certainfoods especially those high in tyramine such assharp cheeses or those containing sulphites (wines)ornitrates (nuts, pressed meats).


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SECONDARY HEADACHEy Headachewhich result from underlying condition; eg:

y Cerebrovascular disease

y Tumoury Blow to the head

y Infection

y Diabetes

y Thyroid disease

y Tooth, eye or ear problems

y Medications


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y Thus, management for the secondary headache isusually aimed at minimizingor eliminating the cause.

y Other supportive therapy:

oAcupunture

oAromatherapy

y

Nutritional treatment:y Lemon

y Apple

y Henna

y

Marjoramy Rosemary

y Cinnamon


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Increase in intracranial pressurey depends on the etiology

y In patientswho have high ICP it is particularly

important to ensure adequate airway, breathing,and oxygenation.

y whenit is necessary to decrease cerebral blood flow,can be lowered using common antihypertensive

agents such as calcium channel blockers.


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ICP ( cont.) CSF drainage lowers ICP immediately byreducing

intracranial volume and more long-term by allowing

edema fluid to draininto the ventricular system. Drainage ofeven a small volume ofCSF can lower ICP

significantly,.

Urgent neurosurgeryis done fromfocal causes (Eg:

haematoma ) by craniotomyor burr hole. ICP monitoris placed and monitor all time.


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Tumorsy Brain tumors are treated bymultidisciplinary teams of

highly skilled specialistswhose decisions are based on:

yresults ofdiagnostic tests

y tumor size, position, and growth pattern

y the patient's health history and current medical status

y thewishes ofthe patient and his family


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Tumors Radiation therapy

External radiotherapy, generally delivered on an

outpatient basis, directs radiation to the tumor and thearea around it.

Implant radiation therapyinvolves placing tiny piecesofradioactive material in the brain. Left in place

permanently, orfor a short time, these radioactivepellets release measured doses ofradiation each day.This technique is called brachytherapy.


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Tumors Chemotherapy

One ormore cancer-killing drugs may be taken by

mouth orinjected into a blood vessel, muscle, or thecerebrospinal fluid.

Chemotherapymay be usedwith radiation and surgeryas part ofa patient's initial treatment, or used alone totreat tumors that recurin the same place orin another

part ofthe body. The usual chemotherapyregimenfor a brain tumor is a

combination approach, most commonly usingprocarbazine, and vincristine.


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TumorsOther treatment

y analgesics torelieve pain

y anticancer drugs to limit tumorgrowthy anticonvulsants to control seizures

y steroids toreduce swellingofbrain tissue


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Intracranial venous thrombosis Neurosurgeonis required General measures appropriate to the rehabilitationofstroke

patients. Elevationofthe head at 30-40 helps toreduce

intracranial pressure. Seizures should be treatedwith anticonvulsant(eg:carbamazapine)

Specific treatment involves anticoagulationor thrombolytictreatments. Most studies report betteroutcomeswith anticoagulation. Heparin

is used and later converted to warfarin. Heparin appears to be a safe and effective treatment

Surgerymay veryrarely be requiredwhen there is markedneurological deterioration. The thrombus is removed andthrombolysis locallyis also used.


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MeningitisyAdequate airway, breathing, and oxygenation.

y Intra-cranial pressure is monitored

y SteroidsAdjuvant treatmentwith corticosteroids (usually dexamethasone) hasbeen shownin some studies toreduce rates ofmortality.


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MeningitisAntibiotics :

Ampicillin

Cefotaxime

Ceftriaxone

Gentamycin

Vancomycin

Meropenem


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Sinusitis Conservative- Nasal irrigation may helpwith

symptoms ofchronic sinusitis.

Decongestant nasal spraycontaining oxymetazoline may provide relief.

Antibiotics amoxicillin ,Fluoroquinolone,macrolides ( clarithromycin)

For chronic or recurring sinusitis, referral toan otolaryngologist specialist may be indicated orendoscopic sinus surgery can be done.


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Neuropathic Pain

Management


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General Managementy Psychologic factors such as anxiety and

depressionmust be constantly considered fromthe start oftreatment.

y Surgery to alleviate nerve compression.y NSAIDs & Opioids.y Treat the underlying condition such as diabetes

related NP.y

Electrical stimulation(via implant device)ofthe nerves involved inneuropathic paingenerationmay significantly control the painsymptoms.


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Neuropathic Orofacial Pain

Disorders Idiopathic trigeminal neuralgia (ITN)

Malignant neoplasms involving the trigeminal nerve

Glossopharyngeal neuralgia Herpes zoster(including post-herpetic neuralgia)

Multiple sclerosis


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Neurological Causes of Orofacial Pain

Sensoryinnervationofface depends on trigeminal nerve, sodiseases affecting this nerve anywhere in the course fromorofacial region to brain, can cause orofacial painorindeedsensory loss sometimeswith serious implications.

Such causes include:

trauma

cerebrovascular disease

demyelinating disease (egmultiple sclerosis)

neoplasia (egnasopharyngeal, antral or brain tumours); (orinfections such as herpes zosteror HIV/AIDS)


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Management ofTrigeminal

Neuralgiay ITN is often anintermittent disease sorecurrence is

common and usually the pain spreads toinvolve awiderarea as time goes. In the acute situation the patients

symptoms may be controlled on a short term basiswithinjectionofa regional local anaesthetic.

y Medical treatment using anticonvulsants, is successful formost patients.

y Carbamazepine is the main drug used, but it is not ananalgesic and must be given continuously prophylacticallyfor long periods, blood tests to check mainlyfor liverfunction(may become impaired for long term usage ofcarbamazepine); and bone marrowfunction.


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y Cranial nerve examination should be carried out toknow the extent ofthe disorder, not known to beinfectious, usuallyno long-term consequences,Symptoms may be controlledwith drugs, freezingthe nerve, or surgery.

yAlternative medical therapies such asacupuncture, chiropractic adjustment, self-hypnosis, are sometimes used.


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Medical and surgical treatments for

Trigeminal Neuralgiay Medical

y Carbamazepine

y Gabapentin

y Phenytoiny Lamotrigine

y Baclofen

y Surgical

y

Cryotherapyy Balloon compressionoftrigeminal ganglion

y Microvascular decompression

y Gamma knife surgery


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PSYCHOGENIC CAUSESOF

OROFACIAL PAIN

yReassurance may be effective but thepainmay also be helped bymassage,warmth, bynon-steroidal anti-inflammatory drugs (NSAIDs), or bybenzodiazepines which are bothanxiolytic and mild muscle relaxants,or by complementary therapies.


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MANAGEMENT OF PATIENTSSUFFERING

ATYPICAL FACIAL PAIN OR PAIN WITH APSYCHOGENIC BASISyAttention to anyfactors such as the dentures or

haematinic deficiencies should be done, but active

dental ororal surgical treatment, or attempts athormone replacement, or polypharmacyin theabsence ofany specific indication, should beavoided.

y Donot repeat examinations at subsequentappointments as thiswill onlyworsen abnormalillness behaviour and health fears.


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y Operative interventionis rarely successful. Activedental measures such as restorative treatment,

endodontics ororal surgical treatment that is outofspecific indication, should be avoided as theymayreinforce patients perception that the painhas anorganic basis.

y Identify and relieve factorswhich lower the painthreshold. Simple analgesics (NSAIDs) should betried initially, before using a more potent option.

y

Offerreferral to a specialist for Cognitive-behavioural therapy(CBT)or a trial ofantidepressants, explaining that these agents areaimed to treat the symptoms not depression.


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-The key tomanaging painfrommedical ordental procedures is anticipation.

-Effective painmanagement involves acombinationofpharmacologic, psychologic,cognitive-behavioral, and physicaltreatments.

-look from dentist


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y When there is painfrom the oral cavity, examplestoothaches,jaw pain, burningmouth, ulcer, etc the

best is to see a dentist

y Dental treatment should be done toreliefthesymptom

y Examples are filling, root canal treatment, andextraction


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Odotondogenic pain


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yA)Si ple meas re-Reass rance, explanati n, a calm envir nment, an gentle

an ling.-C l or ot pac s

-Cognitive-be avioral tec ni ues, suc a breat ingexercises

yB) Local anest etics an nervebloc s-use to stop t e con uction ofpain impulses t roug t e

nerves.-examples:

topical anest esia(benzocaine), LA(lidocaine)


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C)Oral analgesics

and painmedication:a)The non-steroidal anti-inflammatory agents (NSAIDs)--aspirin, ibuprofen

b)AcetaminophenTylenolc)weak opioids (codeine)codeine


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yA)Acetaminophen (Tylenol)

y blocks the central productionofprostaglandins,thus producing analgesia (painrelief)with noperipheral anti-inflammatory action and noadverse affects on platelet functionor GI tract

occur.y B)NSAID(ibuprofen)

y block the central and peripheral productionofprostaglandins resultingin analgesia aswell as

anti-inflammatory effects. NSAIDs block thecyclooxygenaseenzymes:COX-1 and COX-2

PS:NSAIDS avoid in patientswho have: asthma, bleedingdisorders, gastric ulcers, or surgical bleeding.


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y C)opioids

y activate the mu1receptor,which is responsible for

analgesia.y Activationofthe mu2receptor leads to the undesired

effects of:respiratory depression, sedation,constipation, nausea, and vomiting


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SYSTEMIC

DISEASE

MANDIBULAR

DISLOCATION

ANKYLOSIS

TETANUS

WHIPLASH

DISC

DISPLACEMENT

ORTHODONTICS

/BRACES

YAWNING

MALOCCLUSION

BRUXISM

CAUSES

Causes of TMJDisorder


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Principles of

management

Reversibletreatment

(conservative)

Selfmanagement

Behavioralmodification

Rrreversibletreatment

ComplexOcclusal

therapy

Surgery

q PainqAdverse loadingRestorationoffunctionResumptionofnormal

activitive

Physicaltherapy

medicationOrthopedicappliances


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Apply moistheat or cold

packs.

Eat softfoods.

Selfmanagement

Soft foodAvoid hard

food

Deceasechewing

StretchingexercisesExercising


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Behavioral modificationy Undergo corrective dental treatments. Replace missing

teeth; use crowns, bridges or braces to balance the bitingsurfaces ofyour teeth or to correct a bite problem.y Avoid extreme jaw movements. Keep yawning and

chewing(especiallygumorice) to a minimum and avoidextremejawmovements such as yellingor singing.

y

Don't rest your chin on your hand or hold the telephonebetween your shoulder and ear. Practice good posture toreduce neck and facial pain.

y Keep your teeth slightly apart as often as you can torelieve pressure on thejaw. To control clenchingorgrinding during the day, place your tongue between yourteeth.

y Learn relaxation techniques to help control muscletensionin thejaw. Ask your dentist about the need forphysical therapyormassage. Consider stress reductiontherapy, including biofeedback.


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Physical therapyy FAILED- When the basic treatments listed above prove

unsuccessful, suggest one ormore ofthe following:

y Transcutaneous electrical nerve stimulation (TENS) This

therapy uses low-level electrical currents to provide painreliefbyrelaxing thejawjoint and facial muscles. This treatment can bedone at the dentist's office or at home.

y Ultrasound . Ultrasound treatment is applied to the TMJ torelieve soreness orimprove mobility.

y

Trigger-point injections. Painmedicationis injected intotenderfacial muscles called "trigger points"" torelieve pain.

y Radio wave therapy. Radiowaves create a low level electricalstimulation to thejoint,which increases blood flow. The patientexperiences reliefofpainin thejoint.


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medicationy Torelieve muscle pain and swelling, trynonsteroidal

anti-inflammatory drugs (NSAIDs), suchas aspirin or ibuprofen (Advil, Motrin)

y higher doses ofthese orother NSAIDs orother drugsfor pain such as narcotic analgesics. Muscle relaxants,

especiallyfor peoplewhogrind or clench their teeth,can help relax tightjawmuscles.

yAnti-anxietymedications can help relieve stress that issometimes thought to aggravate TMD.

yAntidepressants,when used in low doses, can also helpreduce or control pain.

y Muscle relaxants, anti-anxiety drugs andantidepressants are available by prescriptiononly.


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Orthopedic appliancesy Splint

Occlusal splints (also called night guards ormouth guards)reduce nighttime clenchingin some patients,while increasingclenching activityinother patients. Thus,while occlusal splintsdo prevent loss oftooth enamel fromgrinding, use ofa splint canworsen TMJ disorder symptoms for some people.

Nighttime Biofeedbacky Nighttime EMG biofeedback (forinstance by using

a biofeedback headband) can be used toreduce bruxism andthus reduce or eliminate the ongoingnightly cycle ofdamagethat contributes to the majorityofTMJ disorder symptoms. Thistreatment is non-invasive, uses no drugs, and can be tried for upto threeweeks at no cost.


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y Elimination of para-functional habits

yAn approach to eliminating para-functional habits involvesthe takingofa detailed history and careful physicalexamination. The medical history should be designed toreveal durationofillness and symptoms, previoustreatment and effects, contributingmedical findings,

historyoffacial trauma, and a search for habits that mayhave produced or enhanced symptoms. Particular attentionshould be directed inidentifying perversejaw habits, suchas clenchingor teeth grinding, lip or cheek biting, or

positioningofthe lowerjawin an edge-to-edge bite. All ofthe above strain the muscles ofmastication(chewing) andresults injaw pain. Palpationofthese muscleswill cause apainful response.


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Complex Occlusal therapyy Restoration of the occlusal surfaces of the teethy Ifthe occlusal surfaces ofthe teeth or the supporting

structures have been altered due toinappropriate dentaltreatment, periodontal disease, or trauma, the properocclusionmayneed to be restored.

y Patientswith bridges, crowns, oronlays should be checked

for bite discrepancies. These discrepancies, ifpresent, maycause a person tomake contactwith posterior teeth duringsideways chewingmotions. These inappropriate contactsare called interferences, and ifpresent, they can cause apatient to subconsciously avoid those motions, as theywillprovoke a painful response.

y The result can be excessive strainor even spasms ofthechewingmuscles. Treatment could include adjusting therestorations orreplacing them.


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Surgeryy The surgeryis irreversible. Attempts in the last decade to

develop surgical treatments based on MRI and CAT scansnowreceive less attention. These techniques are reserved

for the most recalcitrant caseswhere other therapeuticmodalities have failed.

y Exercise protocols, habit control, and splinting should bethe first line ofapproach, leaving oral surgery as a last

resort. Certainly a focus onother possible causes offacialpain andjawimmobility and dysfunction should be theinitial considerationofthe examiningoral-facial painspecialist, oral surgeonor health professional.

f f


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3 types ofsurgeryfor TMD:

yArthrocentesis. This is a minor procedureperformed in the office undergeneral anesthesia.It is performed for sudden-onset, closed lock cases(restrictedjawopening)in patientswith nosignificant prior historyofTMJ problems. Thesurgeryinvolves insertingneedles inside theaffectedjoint andwashingout thejointwith sterilefluids. Occasionally, the procedure mayinvolveinserting a blunt instrument inside ofthejoint.The instrument is used in a sweepingmotion toremove tissue adhesion bands and to dislodge adisc that is stuck infront ofthe condyle (the partofyour TMJ consistingofthe "ball" portionofthe"ball and socket")


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y Arthroscopy. The surgeon thenmakes a smallincisioninfront ofthe ear and inserts a small, thin

instrument that contains a lens and light. Thisinstrument is hooked up to a video screen, allowingthe surgeon to examine the TMJ and surrounding area.Dependingon the cause ofthe TMD, the surgeonmay

remove inflamed tissue orrealign the disc or condyle.Comparedwith open surgery, this surgeryis lessinvasive, leaves less scarring, and is associatedwithminimal complications and a shorterrecovery time.Dependingon the cause ofthe TMD, arthroscopymaynot be possible, and open-joint surgerywill need to beconsidered.


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y Open-joint surgery. Unlike arthroscopy, the entirearea around the TMJis opened so that the surgeon can

get a full view and better access. Types ofopen-jointsurgeries. This approach is used if:

yThe bony structures that comprise thejaw

joint are deterioratingyThere are tumors inor around your TMJ

yThere is severe scarringor chips ofbone in

thejoint.


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Pharmacological treatmentPharmacologic treatment modalities for cervicogenic

headache include manymedications that are used forthe preventive orpalliative management oftension-type headache, migraine, and "neuropathic" pain

syndromes. Antidepressants

Serotonin and norepinephrine reuptake inhibitors(SNRIs) suchas venlafaxine hydrochloride

AntiepilepticDrugsModulators or stabilizers ofperipheral and central

pain transmission.


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Monthlymonitoringofliver transaminase levels andofcompleteblood cell (CBC) counts for evidence oftoxicity.

Gabapentin-postherpetic neuralgia,management ofotherneuropathicpain syndromesand migraine.

Topiramate-migraineprophylaxis,cluster headache.

Carbamazepine-trigeminal neuralgia and centralneuropathic pain.

Analgesics

Management ofacute pain.

Narcotic analgesics are not generallyrecommendedfor the long-termmanagementofcervicogenicheadache,but cautiously prescribed for temporarypainrelief.


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Migraine-specificabortive medications, ergot

derivativesor triptans mayrelieve the painofepisodic migraine attacksthat canoccurin somepatientswith cervicogenic headache.

OtherMedications

Musclerelaxants, such as tizanidinehydrochlorideand baclofen, mayprovide some analgesic efficacy.

Botulinum toxin, type Ainjected into pericranialand cervical muscles is a promising treatment for

patientswith migraineand cervicogenic headache,but further clinical and scientific studyis needed.


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Physical and manual modes of

therapyy This therapy have greater efficacywhen the treatment

modalities are combined.

y Long-term prevention and control ofheadaches involved in

ongoing exercise and physical conditioning programs.y Osteopathic manipulative techniques such as craniosacral,

strain-counter strain, and muscle energy techniqueseffective for cervicogenic headache.

y Physical treatment modalities are generally better toleratedwheninitiatedwith gentle musclestretching and manualcervical traction.

y Anesthetic blockade and neurolytic procedures can be usedfor temporarypainrelief and increase therapy efficacy.


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Psychological and Behavioral

Treatmenty Biofeedback, relaxation, and cognitive-behavioral

therapy are important adjunctive treatments in thecomprehensive management ofpain.


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Anesthetic blockade Neurolysisy Cervical epidural steroid injections may be indicated

in patientswith multilevel disc or spine degeneration.

y

Greateroccipital nerve blockade provided efficacysimilar torepeated blockade ofthe C2 and C3 nerves.

y Diagnostic blockade ofcervical nerve, medial branch,or zygapophysealjoint blockade is successful but

temporary, painrelief, the treatment algorithm canthen proceed to considerationfor a longer-actingneurolytic procedure such as radiofrequency thermalneurolysis


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Surgical treatmenty Surgical liberationoftheoccipital nerve from

"entrapment" in the trapezius muscle orsurroundingconnective tissues and surgical transection ofthegreateroccipital nerve can provide temporary painrelief.

y Surgical procedures such as neurectomy, dorsalrhizotomy, and microvascular decompressionofnerveroots or peripheral nervesare not generallyrecommendedwithout radiologicevidence.


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Axis II: Developmental Disorders and Personality

Disorders

` Axis II assessment and management of patient withorofacial pain includes behavioral, social, psychological

and adaptive components of the patients profile

` For examples, assessing the risk of suicide, presence of

major psychological or thought disorders, loss of copingability, associated findings such as number of others pain

and sleep dysfunction.

` Behavioral interview expand the understanding of factors

that modify the level of pain, trigger recurrences ormodulate the patients ability to cope with symptoms


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Medicationy in addition to behavioral therapy also advisable, which

includes

Antidepressant Tricyclic antidepressant Amitriptyline.

Selective serotonin reuptake inhibitors Fluoxetine.

Antipsychotic Phenothiazines

y If major psychopathology is diagnosed, treatment withantipsychotic medication may be necessary.


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Dental managementyVigorous dental education program.

y Saliva substitutes

y

Anticaries agents containingfluoride.y Special precautionswhen prescribingor administering

analgesics and local anesthetics.


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THANK YOU!!

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