口颌面疼痛的分类诊断与治疗.ppt

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,Classification of orofacial pain 口颌面疼痛分类,The International Headache Society (IHS) The International Association for the Study of Pain (IASP) The American Academy of Orofacial Pain (AAOP),Classification of all head, face, and neck conditions that could be associated with orofacial pain (Okeson 1996),Intracranial pain disorders Neoplasm, aneurysm, abscess, stroke, multiple sclerosis Primary headache disorders (neurovascular disorders) Migraine, cluster headache, tension-type headache, paroxysmal hemicrania, …. Neurogenic/neuropathic pain disorders Trigeminal, glossopharyngeal, …. Extracranial pain disorders Eye, ear, nose, paranasal sinus, salivary glands,… Intraoral pain disorders odontogenic and non-odontogenic pain Temporomandibular disorders Mental disorders Phantom bite syndrome,Problems associated with orofacial pain 临床上口颌面部的主要疼痛,Odontogenic pain （牙源性疼痛） Temporomandibular disorders （颞下颌关节紊乱病） Neurogenic/neuropathic pain disorders （三叉神经痛、舌咽神经痛） Mental disorders （Phantom bite syndrome 咬合幻觉综合症）,Odontogenic pain 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,Temporomandibular disorders 颞下颌关节紊乱病,Group I: Muscle disorders（肌肉疾患） Myofascial pain Myofascial pain with limited opening Group II: Disc displacement (DD,关节盘移位） DD with reduction DD without reduction, with limited opening DD without reduction, without limited opening Group III: Arthralgia, arthritis, arthrosis（关节痛、骨关节炎、骨关节病）,Epidemiology 口颌面疼痛的流行病学,Toothache 12%（成年，US) 14.1%（成人，Toronto） 31.8%（12岁前，Australian） Temporomandibular disorder 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, 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（150~200μm）后在牙本质小管中终止（多为Aδ或者Aβ纤维）。

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，但与健康对照组人群相比，机械痛阈降低了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,激活型,活化型,Substance P Excitatory amino acid(Glutamate) NO Arachidonic acid, Prostaglandins Cytokines Neurotrophins,,,,Phagocytosis,Microglia (小胶质细胞),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 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 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 Fu KY, Tan YH, Sung B, Mao J. Peripheral formalin injection induces unique spinal cord microglial phenotypic changes. Neurosci Lett 2009;449(3):234–239 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 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,疼痛的性质（pain quality） 疼痛的强度（pain intensity） 疼痛的部位和分布（location and area of pain） 疼痛的发生和持续过程（pain initiation and duration）,Pulpitis - acute or symptomatic reversible 急性或症状可逆性牙髓炎,Intermittent Brief (seconds) discomfort initiated by cold or air, without lingering or spontaneous pain Usually, does not result in loss of sleep and no analgesics necessary Pulp vitality tests positive No apical change on the radiograph,Pulpitis - acute or symptomatic irreversible 急性或症状不可逆性牙髓炎,Prolonged pain (minutes or hours in duration) May arise spontaneously, tooth may be sensitive to cold, air, or heat Analgesics often have been tried (may or may not be effective), may report that pain interfered with sleep Pulp vitality tests often reveal no response or a heightened response and a lingering pain on stimulus removal,Apical periodontitis - acute or symptomatic 急性根尖周炎,Localized to the area of tooth apex Prolonged dull or throbbing一跳跳的疼 ache Analgesics often have been tried with moderate success. Often the patient reports l。