口颌面疼痛的分类、诊断与治疗

口颌面疼痛的分类、诊断与治疗Classificationoforofacialpain口颌面疼痛分类2021/1/122TheInternationalHeadacheSociety(IHS)TheInternationalAssociationfortheStudyofPain(IASP)TheAmericanAcademyofOrofacialPain(AAOP)2021/1/123Classificationofallhead,face,andneckconditionsthatcouldbeassociatedwithorofacialpain(Okeson1996)Intracranialpaindisorders

Neoplasm,aneurysm,abscess,stroke,multiplesclerosisPrimaryheadachedisorders(neurovasculardisorders)

Migraine,clusterheadache,tension-typeheadache,paroxysmalhemicrania,….Neurogenic/neuropathicpaindisorders

Trigeminal,glossopharyngeal,….Extracranialpaindisorders

Eye,ear,nose,paranasalsinus,salivaryglands,…..Intraoralpaindisordersodontogenicandnon-odontogenicpainTemporomandibulardisordersMentaldisordersPhantombitesyndrome2021/1/124Problemsassociatedwithorofacialpain

临床上口颌面部的主要疼痛Odontogenicpain〔牙源性疼痛〕Temporomandibulardisorders

〔颞下颌关节紊乱病〕Neurogenic/neuropathicpaindisorders〔三叉神经痛、舌咽神经痛〕Mentaldisorders〔Phantombitesyndrome咬合幻觉综合症〕2021/1/125Odontogenicpain牙源性疼痛牙髓或根尖区来源牙周来源牙萌出或冠周炎牙科治疗后2021/1/126Temporomandibulardisorders

颞下颌关节紊乱病GroupI:Muscledisorders〔肌肉疾患〕MyofascialpainMyofascialpainwithlimitedopeningGroupII:Discdisplacement(DD,关节盘移位〕DDwithreductionDDwithoutreduction,withlimitedopeningDDwithoutreduction,withoutlimitedopeningGroupIII:Arthralgia,arthritis,arthrosis〔关节痛、骨关节炎、骨关节病〕2021/1/127Epidemiology

口颌面疼痛的流行病学Toothache12%〔成年，US)14.1%〔成人，Toronto〕31.8%〔12岁前，Australian〕Temporomandibulardisorderpainisthemostcommonchronicorofacialpain(9-15%forwomen;3%-10%formen〕(Riskfactors:ageandsex,otherchronicpaincondition,depressionandpsychosocialdistress,andgeneticfactors)2021/1/128Neurobiologyoforofacialpain

口颌面疼痛的神经生物学2021/1/129牙髓牙本质的神经支配神经末梢或在牙髓中终止〔多为无髓C纤维〕或穿越成牙本质细胞层一段间隔〔150~200μm〕后在牙本质小管中终止〔多为Aδ或者Aβ纤维〕。2021/1/1210

牙髓坏死是既有炎症性疼痛又有神经病理性疼痛特点的一独特的组织病理状态。2021/1/1211不可逆性牙髓炎存在中枢敏化有研究调查了约1000名在牙科治疗前的疼痛患者，其中57%不可逆性牙髓炎的患者报告在叩诊时有机械性痛觉异常。不可逆性牙髓炎所引起的痛觉异常应归因于牙髓以及根尖周机械性伤害感受初级神经元的活化，或中枢敏化。利用数字合力仪检查发现，不可逆性牙髓炎患者患侧牙的机械痛阈比对照侧牙低77%。也证实了不可逆性牙髓炎患者存在中枢敏化这一假说，因为不可逆性牙髓炎患者的对侧牙齿并没有可查的病理改变，但与安康对照组人群相比，机械痛阈降低了50%。2021/1/1212脊髓程度的痛觉传递(Paintransmissioninspinalcord)牙髓的感觉神经终末端止于三叉神经尾侧亚核、极间亚核和嘴侧亚核〔广泛性〕。解释了临床上牙髓炎病症患者不能定位患牙的现象。2021/1/1213脊髓程度的痛觉传递(Paintransmissioninspinalcord)动物实验证实，诱导牙髓炎症后三叉神经尾侧亚核发生了中枢敏化现象。临床上，中枢敏化对看似成功的牙髓治疗后疼痛的持续起到了一定的作用。2021/1/1214病理性疼痛的机制(Pathologicalpainmechanism)中枢致敏〔Centralsensitization〕2021/1/1215FuKY,LightAR,MatsushimaGK,andMaixnerW.Microglialreactionsaftersubcutaneousformalininjectionintotherathindpaw.

BrainResearch1999Apr17;825(1-2):59-67

静止型

激活型

活化型

SubstancePExcitatoryaminoacid(Glutamate)NOArachidonicacid,ProstaglandinsCytokinesNeurotrophinsPhagocytosisMicroglia(小胶质细胞)2021/1/1216LiK,LinT,CaoY,LightAR,FuKY.Peripheralformalininjuryinducestwostagesofmicroglialactivationinthespinalcord.JPain;11(11):1056-65LiK,FuKY,LightAR,MaoJ.Systemicminocyclinedifferentiallyinfluenceschangesinspinalmicroglialmarkersfollowingformalin-inducednociception.JNeuroimmunol;221(1-2):25-31CaoY,XieQF,LiK,LightAR,FuKY.Experimentalocclusalinterferenceinduceslong-termmasticatorymusclehyperalgesiainrats.Pain;144(3):287-93FuKY,TanYH,SungB,MaoJ.Peripheralformalininjectioninducesuniquespinalcordmicroglialphenotypicchanges.NeurosciLett;449(3):234–239LinT,LiK,ZhangFY,ZhangZK,LightAR,FuKY.Dissociationofspinalmicrogliamorphologicalactivationandperipheralinflammationininflammatorypainmodels.JNeuroimmunol2007;192(1-2):40-48ZhangFY,WanY,ZhangZK,LightAR,FuKY.Peripheralformalininjectioninduceslong-lastingincreasesincyclooxygenase1expressionbymicrogliainthespinalcord.JPain2007;8(2):110-117Recentpublications:2021/1/1217Diagnosisoforofacialpain

口颌面疼痛的诊断2021/1/1218Keyevidencesforpaindiagnosis

诊断最重要的根据疼痛的性质〔painquality〕疼痛的强度〔painintensity〕疼痛的部位和分布〔locationandareaofpain〕疼痛的发生和持续过程〔paininitiationandduration〕2021/1/1219Pulpitis-acuteorsymptomaticreversible

急性或病症可逆性牙髓炎IntermittentBrief(seconds)discomfortinitiatedbycoldorair,withoutlingeringorspontaneouspainUsually,doesnotresultinlossofsleepandnoanalgesicsnecessaryPulpvitalitytestspositiveNoapicalchangeontheradiograph2021/1/1220Pulpitis-acuteorsymptomaticirreversible

急性或病症不可逆性牙髓炎Prolongedpain(minutesorhoursinduration)Mayarisespontaneously,toothmaybesensitivetocold,air,orheatAnalgesicsoftenhavebeentried(mayormaynotbeeffective),mayreportthatpaininterferedwithsleepPulpvitalitytestsoftenrevealnoresponseoraheightenedresponseandalingeringpainonstimulusremoval2021/1/1221Apicalperiodontitis-acuteorsymptomatic

急性根尖周炎

LocalizedtotheareaoftoothapexProlongeddullorthrobbing一跳跳的疼

acheAnalgesicsoftenhavebeentriedwithmoderatesuccess.OftenthepatientreportslossofsleepTheradiographmayrevealawideningoftheperiodontalligamentspacePulpvitalitytestsaregenerallynegative2021/1/1222牙源性疼痛牙髓或根尖区来源牙周来源牙萌出或冠周炎牙科治疗后2021/1/1223Postendodontictreatmentdiscomfort〔根管治疗后疼痛〕approximately60%ofcasesbecausetheapicalextrusionofdebrisleadstoacuteperiapicalperiodontitismild,resolvesinafewdayspremedicationwithNSAIDsiscommonrarelyleadstosuppurativechanges牙科治疗后疼痛

2021/1/1224Atypicalodontalgia(phantomtoothpain)非典型性牙痛〔幻牙痛〕predominantlyinwomen,oftenassociatedwithemotionalproblemsassociatedwithanareawheretherehasbeenprevioustreatmentdescribedasaconstantdullacheoccasionalsharpexacerbationsfeltatthesiteofatooththatisnolongerpresentcentralsensitizationinbrainstemsensorynuclearcomplex牙科治疗后疼痛

2021/1/1225颞下颌关节疼痛

Temporomandibularjointpain多是轻度到中度疼痛，急性滑膜炎可出现强烈的疼痛。疼痛多表现为隐痛、牵扯痛、钝痛、胀痛，有时仅表现为不适感、僵硬感、或肿胀感。疼痛部位为颞下颌关节区，有时可牵涉到颞部、耳部、半侧咀嚼肌、甚至可引起半侧头痛。关节运动时疼痛或疼痛加重，一般下颌静止不活动时不痛。2021/1/1226咀嚼肌疼痛

Masticatorymusclepain轻度到中度疼痛。疼痛性质多为钝痛或隐痛，锐痛和撕裂样痛少见，肌痉挛病人有时疼痛强烈部分的或广泛的肌肉压痛。疼痛发生多表现持续性，病人常主诉咀嚼乏力、疲劳，晨起面部肌肉有胀感，活动后减轻。部分慢性疼痛病人常有全身乏力、抑郁、生活事件等心理和社会问题。2021/1/1227牙科治疗过程或治疗后，一些患者出现无法解释的主诉，患者认为是牙科治疗造成咬合的改变引起这些病症，称之为“咬合幻觉综合症〞〔Phantombitesyndrome〕。这些患者表现为不停的就医，不断的要求新的咬合治疗，但都没有良好的效果。〔DeBoeveretal.,2000〕Mentaldisorders:Phantombitesyndrome

2021/1/1228三叉神经痛

Trigeminalneuralgeia疼痛剧烈电击样、短暂的刺痛疼痛局限在三叉神经分布区，单侧疼痛洗脸、漱口、轻触等非伤害性刺激引发疼痛〔板机点现象〕，疼痛突然发作，也同样突然停顿，两次发作间歇病人完全没有病症。2021/1/1229非典型面痛

Atypicaloralandfacialpain被病人描绘为一种持续性的、烧灼样的钝痛没有不痛间歇没有临床上可以检查出的相关植物神经异常，牙齿及相关组织和副鼻窦没有病理改变，所有影像学检查均正常中年女性多见，常有心情抑郁或焦虑不安。2021/1/1230癌症疼痛(cancerpain)癌症疼痛表现多样，可以是伤害感受性疼痛，也可以是神经病理性疼痛疼痛强度，中重度剧烈疼痛多见疼痛表现为锐痛、跳痛、或压迫样疼痛。神经病理性疼痛表现为灼痛、刺痛或电击样疼痛癌症疼痛往往不限于一处，可以是局灶性或广泛性疼痛，有时表现为“牵涉痛(referralpain)〞在轻中度疼痛的根底上发生一过性的疼痛加剧，称为打破痛〔breakthroughpain〕2021/1/1231Managementofpain

疼痛的处理2021/1/1232牙科治疗Dentaltreatment牙本质小管封闭牙体治疗根管治疗根管治疗，牙冠修复牙周治疗,根管治疗拔牙2021/1/1233药物治疗Pharmacotherapy非甾体类抗炎药物Nonsteroidalanti-inflammatorydrugs阿片类镇痛药物：口腔癌疼痛;曲马多Tramadol用于关节痛硫酸氨基葡萄糖Glucosaminesulfate:早期骨关节炎抗焦虑药Anti-anxietydrugs:clonazepam〔氯硝安定〕抗抑郁药Antidepressants:三环类抗抑郁药amit