口颌面疼痛的分类、诊断与治疗 ppt课件

口颌面疼痛的分类、诊断与治疗 Classification, diagnosis and treatment of orofacial pain 口腔医学院 傅开元傅开元 Classification of orofacial pain 口颌面疼痛分类 lThe International Headache Society (IHS) lThe International Association for the Study of Pain (IASP) lThe American Academy of Orofacial Pain (AAOP) Classification of all head, face, and neck conditions that could be associated with orofacial pain (Okeson 1996) lIntracranial pain disorders Neoplasm, aneurysm, abscess, stroke, multiple sclerosis lPrimary headache disorders (neurovascular disorders) Migraine, cluster headache, tension-type headache, paroxysmal hemicrania, . lNeurogenic/neuropathic pain disorders Trigeminal, glossopharyngeal, . lExtracranial pain disorders Eye, ear, nose, paranasal sinus, salivary glands, lIntraoral pain disorders odontogenic and non-odontogenic pain lTemporomandibular disorders lMental disorders Phantom bite syndrome Problems associated with orofacial pain 临床上口颌面部的主要疼痛 uOdontogenic pain （牙源性疼痛） uTemporomandibular disorders （颞下颌关节紊乱病） uuNeurogenic/neuropathic pain disordersNeurogenic/neuropathic pain disorders （三叉神经痛、舌咽神经痛）、舌咽神经痛） uuMental disorders Mental disorders （Phantom bite syndrome Phantom bite syndrome 咬合幻觉综合症） Odontogenic pain 牙源性疼痛 l牙髓或根尖区来源 l l 牙周来源牙周来源 l l 牙萌出或冠周炎牙萌出或冠周炎 l l 牙科治疗后牙科治疗后 Temporomandibular disorders 颞下颌关节紊乱病 l l Group I: Muscle disordersGroup I: Muscle disorders（肌肉疾患）（肌肉疾患） Myofascial painMyofascial pain Myofascial pain with limited opening Myofascial pain with limited opening l l Group II: Disc displacement (DD,Group II: Disc displacement (DD,关节盘移位）关节盘移位） DD with reduction DD without reduction, with limited opening DD without reduction, without limited opening l l Group III: Arthralgia, arthritis, arthrosisGroup III: Arthralgia, arthritis, arthrosis（关节痛（关节痛 、骨关节炎、骨关节病）、骨关节炎、骨关节病） Epidemiology 口颌面疼痛的流行病学 lToothache 12%（成年，US) 14.1% 14.1%（成人，（成人，TorontoToronto） 31.8%31.8%（1212岁前，岁前，AustralianAustralian） lTemporomandibular disorder pain is the most common chronic orofacial pain is the most common chronic orofacial pain (9-15% for women; 3%-10% for men） (Risk factors: age and sex, other chronic pain condition, (Risk factors: age and sex, other chronic pain condition, depression and psychosocial distress, and genetic factors)depression and psychosocial distress, and genetic factors) Neurobiology of orofacial pain 口颌面疼痛的神经生物学 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 本质细胞层一段距离（150200m）后在牙本质小管中终 止（多为A或者A纤维）。 牙髓坏死是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。病理状态。 不可逆性牙髓炎存在中枢敏化 l l 有研究调查了约有研究调查了约10001000名在牙科治疗前的疼痛患者，其中名在牙科治疗前的疼痛患者，其中57%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。不可逆性牙髓炎的患者报告在叩诊时有机械性痛觉异常。 l l 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，或机械性伤害感受初级神经元的活化，或中枢敏化。 l l 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械痛阈比对照侧牙低77%77%。也证实了不可逆性牙髓炎患者存。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，但与健康对照组人群相比，机械痛并没有可查的病理改变，但与健康对照组人群相比，机械痛 阈降低了阈降低了50%50%。 脊髓水平的痛觉传递(Pain transmission in spinal cord) 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 释了临床上牙髓炎症状患者不能定位患牙的 现象。 脊髓水平的痛觉传递(Pain transmission in spinal cord) 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。 病理性疼痛的机制 (Pathological pain mechanism) 中枢致敏（Central sensitization） Fu KY, Light AR, Matsushima GK, and Maixner W. Microglial reactions after subcutaneous formalin injection into the rat hind paw. Brain Research 1999 Apr 17;825(1-2):59-67 静止型静止型 激活型激活型 活化型活化型 Substance P Substance P Excitatory amino acid(Glutamate) Excitatory amino acid(Glutamate) NO NO Arachidonic acid, Prostaglandins Arachidonic acid, Prostaglandins Cytokines Cytokines NeurotrophinsNeurotrophins PhagocytosisPhagocytosis Microglia (Microglia (小胶质细胞小胶质细胞 ) ) 1.Li K, Lin T, Cao Y, Light AR, Fu KY. Peripheral formalin injury induces two stages of microglial activation in the spinal cord. J Pain 2010;11(11):1056-65 2.Li K, Fu KY, Light AR, Mao J. Systemic minocycline differentially influences changes in spinal microglial markers following formalin-induced nociception. J Neuroimmunol 2010;221(1-2):25-31 3.Cao Y, Xie QF, Li K, Light AR, Fu KY. Experimental occlusal interference induces long-term masticatory muscle hyperalgesia in rats. Pain 2009;144(3):287- 93 4.Fu KY, Tan YH, Sung B, Mao J. Peripheral formalin injection induces unique spinal cord microglial phenotypic changes. Neurosci Lett 2009;449(3):234239 5.Lin T, Li K, Zhang FY, Zhang ZK, Light AR, Fu KY. Dissociation of spinal microglia morphological activation and peripheral inflammation in inflammatory pain models. J Neuroimmunol 2007;192(1-2):40-48 6.Zhang FY, Wan Y, Zhang ZK, Light AR, Fu KY. Peripheral formalin injection induces long-lasting increases in cyclooxygenase 1 expression by microglia in the spinal cord. J Pain 2007;8(2):110-117 Recent publications: Diagnosis of orofacial pain 口颌面疼痛的诊断 Key evidences for pain diagnosis 诊断最重要的依据 l l 疼痛的性质（疼痛的性质（pain qualitypain quality） l疼痛的强度（pain intensitypain intensity） l l 疼痛的部位和分布（疼痛的部位和分布（location and area of painlocation and area of pain） l l 疼痛的发生和持续过程（疼痛的发生和持续过程（pain initiation and pain initiation and durationduration） Pulpitis - acute or symptomatic reversible 急性或症状可逆性牙髓炎 l l Intermittent Intermittent l l Brief (seconds) discomfort initiated by cold or air, Brief (seconds) discomfort initiated by cold or air, without lingering or spontaneous pain without lingering or spontaneous pain l l Usually, does not result in loss of sleep and no Usually, does not result in loss of sleep and no analgesics necessaryanalgesics necessary l l Pulp vitality tests positivePulp vitality tests positive l l No apical change on the radiographNo apical change on the radiograph Pulpitis - acute or symptomatic irreversible 急性或症状不可逆性牙髓炎 l l Prolonged pain (minutes or hours in duration)Prolonged pain (minutes or hours in duration) l l May arise spontaneously, tooth may be sensitive to cold, air, May arise spontaneously, tooth may be sensitive to cold, air, or heator heat l l Analgesics often have been tried (may or may not be Analgesics often have been tried (may or may not be effective), may report that pain interfered with sleepeffective), may report that pain interfered with sleep l l Pulp vitality tests often reveal no response or a heightened Pulp vitality tests often reveal no response or a heightened response and a lingering pain on stimulus removalresponse and a lingering pain on stimulus removal Apical periodontitis - acute or symptomatic 急性根尖周炎 l l Localized to the area of tooth apexLocalized to the area of tooth apex l l Prolonged dull or throbbingProlonged dull or throbbing一跳跳的疼 acheache l l Analgesics often have been tried with moderate Analgesics often have been tried with moderate success. Often the patient reports loss of sleep success. Often the patient reports loss of sleep l l The radiograph may reveal a widening of the The radiograph may reveal a widening of the periodontal ligament space periodontal ligament space l l Pulp vitality tests are generally negative Pulp vitality tests are generally negative 牙源性疼痛 l牙髓或根尖区来源 l牙周来源 l l 牙萌出或冠周炎牙萌出或冠周炎 l牙科治疗后 lPostendodontic treatment discomfort （根管治疗后疼痛） approximately 60% of cases because the apical extrusion of debris leads to acute periapical periodontitis mild, resolves in a few days premedication with NSAIDs is common rarely leads to suppurative changes 牙科治疗后疼痛 lAtypical odontalgia (phantom tooth pain) 非典型性牙痛（幻牙痛） predominantly in women, often associated with emotional problems associated with an area where there has been previous treatment described as a constant dull ache occasional sharp exacerbations felt at the site of a tooth that is no longer present central sensitization in brain stem sensory nuclear complex 牙科治疗后疼痛 颞下颌关节疼痛 Temporomandibular joint pain l多是轻度到中度疼痛，急性滑膜炎可出现强烈的疼痛。 l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。 l 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。 l关节运动时疼痛或疼痛加重，一般下颌静止不活动时不 痛。 咀嚼肌疼痛 Masticatory muscle pain l轻度到中度疼痛。 l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局部的或广泛的肌肉压痛。 l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。 l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。 l l 牙科治疗过程或治疗后，一些患者出现无法解释的主诉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症状，患者认为是牙科治疗造成咬合的改变引起这些症状， 称之为称之为“咬合幻觉综合症”（Phantom bite syndrome）。 l l 这些患者表现为不停的就医，不断的要求新的咬合治疗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。，但都没有良好的效果。 （De Boever et al., 2000De Boever et al., 2000） Mental disorders: Phantom bite syndrome 三叉神经痛 Trigeminal neuralgeia l l 疼痛剧烈疼痛剧烈 l l 电击样、短暂的刺痛电击样、短暂的刺痛 l l 疼痛局限在三叉神经分布区，单侧疼痛疼痛局限在三叉神经分布区，单侧疼痛 l l 洗脸、漱口、轻触等非伤害性刺激引发疼痛（板洗脸、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，也同样突然停止，机点现象），疼痛突然发作，也同样突然停止， 两次发作间歇病人完全没有症状。两次发作间歇病人完全没有症状。 非典型面痛 Atypical oral and facial pain l l 被病人描述为一种持续性的、烧灼样的钝痛被病人描述为一种持续性的、烧灼样的钝痛 l l 没有不痛间歇没有不痛间歇 l l 没有临床上可以检查出的相关植物神经异常，牙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 学检查均正常学检查均正常 l l 中年女性多见，常有心情抑郁或焦虑不安。中年女性多见，常有心情抑郁或焦虑不安。 癌症疼痛(cancer pain) l l 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 l l 疼痛强度，中重度剧烈疼痛多见疼痛强度，中重度剧烈疼痛多见 l l 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、刺痛或电击样疼痛痛、刺痛或电击样疼痛 l l 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 为为“ “牵涉痛牵涉痛(referral pain)”(referral pain)” l l 在轻中度疼痛的基础上发生一过性的疼痛加剧，称为突破痛（在轻中度疼痛的基础上发生一过性的疼痛加剧，称为突破痛（ breakthrough painbreakthrough pain） Management of pain 疼痛的处理 牙科治疗 Dental treatment l l 牙本质小管封闭牙本质小管封闭 l l 牙体治疗牙体治疗 l l 根管治疗根管治疗 l l 根管治疗，牙冠修复根管治疗，牙冠修复 l l 牙周治疗牙周治疗, ,根管治疗根管治疗 l l 拔牙拔牙 药物治疗 Pharmacotherapy l l 非甾体类抗炎药物非甾体类抗炎药物 Nonsteroidal anti-inflammatory drugs Nonsteroidal anti-inflammatory drugs l l 阿片类镇痛药物：口腔癌疼痛阿片类镇痛药物：口腔癌疼痛; ; 曲马多曲马多TramadolTramadol用于关节痛用于关节痛 l l 硫酸氨基葡萄糖硫酸氨基葡萄糖 Glucosamine sulfate: Glucosamine sulfate: 早期骨关节炎早期骨关节炎 l l 抗焦虑药抗焦虑药Anti-anxiety drugsAnti-anxiety drugs: clonazepam: clonazepam（氯硝安定）（氯硝安定） l l 抗抑郁药抗抑郁药Antidepressants: Antidepressants: 三环类抗抑郁药三环类抗抑郁