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1、口颌面疼痛的分类、诊断与治疗Classification, diagnosis and treatment of orofacial painClassification of orofacial pain口颌面疼痛分类口颌面疼痛分类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
2、 neck conditions that could be associated with orofacial pain (Okeson 1996)lIntracranial pain disorders Neoplasm, aneurysm, abscess, stroke, multiple sclerosislPrimary headache disorders (neurovascular disorders) Migraine, cluster headache, tension-type headache, paroxysmal hemicrania, .lNeurogenic/
3、neuropathic pain disorders Trigeminal, glossopharyngeal, .lExtracranial pain disorders Eye, ear, nose, paranasal sinus, salivary glands,. lIntraoral pain disorders odontogenic and non-odontogenic painlTemporomandibular disorderslMental disorders Phantom bite syndromeProblems associated with orofacia
4、l pain临床上口颌面部的主要疼痛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 disorders（三叉神经痛、舌咽神经痛）uuMental disorders （Phantom bite syndrome 咬合幻觉综合症）Odontogenic pain 牙源性疼痛牙源性疼痛 l牙髓或根尖区来源l l牙周来源l l牙萌出或冠周炎l l牙科治疗后Temporomandibular disorders 颞下颌关节紊乱病颞下颌关节
5、紊乱病l lGroup 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 lGroup 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 l
6、imited opening DD without reduction, without limited openingl lGroup 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，AustralianAu
7、stralian）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 psychosoc
8、ial 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口颌面疼痛的神经生物学牙髓牙本质的神经支配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不可逆性牙髓炎存在中枢敏化l l有研究调查了约
9、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
10、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
11、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。病理性疼痛的机制病理性疼痛的机制 (Pathological pain mechanism)中枢致敏（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
12、静止型静止型 激活型激活型 活化型活化型 Substance P Excitatory Substance P Excitatory amino acid(Glutamate) NO amino acid(Glutamate) NO Arachidonic acid, Prostaglandins Arachidonic acid, Prostaglandins Cytokines NeurotrophinsCytokines NeurotrophinsPhagocytosisPhagocytosisMicroglia (Microglia (小胶质细胞小胶质细胞小胶质细胞小胶质细胞) )1.
13、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):1056-652.Li K, Fu KY, Light AR, Mao J. Systemic minocycline differentially influences changes in spinal microglial markers following formalin-induced noc
14、iception. J Neuroimmunol 2010;221(1-2):25-313.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):287-934.Fu KY, Tan YH, Sung B, Mao J. Peripheral formalin injection induces unique spinal cord microglial
15、 phenotypic changes. Neurosci Lett 2009;449(3):2342395.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):40-486.Zhang FY, Wan Y, Zhang ZK, Light AR, Fu KY.
16、Peripheral formalin injection induces long-lasting increases in cyclooxygenase 1 expression by microglia in the spinal cord. J Pain 2007;8(2):110-117Recent publications:Diagnosis of orofacial pain口颌面疼痛的诊断口颌面疼痛的诊断Key evidences for pain diagnosis诊断最重要的依据诊断最重要的依据l l疼痛的性质（疼痛的性质（pain qualitypain quality）
17、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急性或症状可逆性牙髓炎l lIntermittent Intermittent l lBrief (secon
18、ds) 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 lUsually, does not result in loss of sleep and no Usually, does not result in loss of sleep and no analgesics necessaryanalgesic
19、s necessaryl lPulp vitality tests positivePulp vitality tests positivel lNo apical change on the radiographNo apical change on the radiographPulpitis - acute or symptomatic irreversible急性或症状不可逆性牙髓炎急性或症状不可逆性牙髓炎l lProlonged pain (minutes or hours in duration)Prolonged pain (minutes or hours in duratio
20、n)l lMay arise spontaneously, tooth may be sensitive to cold, air, May arise spontaneously, tooth may be sensitive to cold, air, or heator heatl lAnalgesics 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 s
21、leepeffective), may report that pain interfered with sleepl lPulp 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 removalApical periodontiti
22、s - acute or symptomatic急性根尖周炎急性根尖周炎 l lLocalized to the area of tooth apexLocalized to the area of tooth apexl lProlonged dull or throbbingProlonged dull or throbbing一跳跳的疼acheachel lAnalgesics often have been tried with moderate Analgesics often have been tried with moderate success. Often the pati
23、ent reports loss of sleep success. Often the patient reports loss of sleep l lThe radiograph may reveal a widening of the The radiograph may reveal a widening of the periodontal ligament space periodontal ligament space l lPulp vitality tests are generally negative Pulp vitality tests are generally
24、negative 牙源性疼痛牙源性疼痛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 chang
25、es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 problemsassociated with an area where there has been previous treatmentdescribed as a constant dull ache occasional sharp exacerbations felt at the site of a tooth that is no longer p
26、resentcentral sensitization in brain stem sensory nuclear complex牙科治疗后疼痛颞下颌关节疼痛颞下颌关节疼痛Temporomandibular joint painl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。咀嚼肌疼痛咀嚼肌疼痛Masticatory muscle painl轻度到中度疼痛。l疼痛性质多为钝痛或隐痛
27、，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牙牙科科治治疗疗过过程程或或治治疗疗后后，一一些些患患者者出出现现无无法法解解释释的的主主诉诉，患患者者认认为为是是牙牙科科治治疗疗造造成成咬咬合合的的改改变变引引起起这这些些症症状状，称称之为之为“咬合幻觉综合症”（Phantom bite syndrome）。l l这这些些患患者者表表现现为为不不停停的的就就医医，不不断断的的要要求求新新的的咬咬合合治治疗疗，但都没有良好的
28、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三叉神经痛三叉神经痛Trigeminal neuralgeial 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 洗洗脸脸、漱漱口口、轻轻触触等等非非伤伤害害性性刺刺激激引引发发疼疼痛痛（板板机机点点现现象象），疼疼痛痛突突然然发发作作，也也同同样样突突然然停停止，两次发作间歇病人完全没有症状。止，两次
29、发作间歇病人完全没有症状。非典型面痛非典型面痛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
30、经病理性疼癌症疼痛表现多样，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痛、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
31、加剧，称为突破痛（breakthrough painbreakthrough pain） Management of pain疼痛的处理疼痛的处理牙科治疗牙科治疗 Dental treatmentl 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拔牙拔牙药物治疗药物治疗 Pharmacotherapyl l非甾体类抗炎药物非甾体类抗炎药物 Nonsteroidal anti-inflammatory drugs Nonsteroidal anti-inflammatory d
32、rugs 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药amitriptylineami
33、triptyline（阿（阿米替林）米替林） l l抗惊厥药抗惊厥药: Carbamazepine(: Carbamazepine(卡马西平卡马西平), gabapentin(), gabapentin(加巴喷丁加巴喷丁) ) l l-氨基丁酸氨基丁酸(GABA)(GABA)受体的阻滞剂受体的阻滞剂( (神经递质神经递质GABAGABA的一种类的一种类似物似物): Pregabalin (): Pregabalin (普瑞巴林普瑞巴林) )注射治疗注射治疗 Injection therapyl l局麻药物神经阻滞l关节腔灌洗l l皮质类固醇激素 Corticosteroidsl l透明质酸 h
34、yaluronatel肉毒毒素botulinum toxin 肌肉注射咬合治疗咬合治疗 Occlusal therapy外科手术治疗外科手术治疗 SurgeryEndoscopic surgeryEndoscopic surgeryOpen surgeryOpen surgeryqAcupuncture Biofeedback BiofeedbackqqMassage ExerciseMassage ExerciseqqMobilization Thermal treatmentMobilization Thermal treatmentqqTENS Short wave diathermyT
35、ENS Short wave diathermyqqUltrasound LaserUltrasound Laser物理治疗及其他物理治疗及其他 Physical therapy and othersCharacteristics of Orofacial Pain 口颌面疼痛的特殊性口颌面疼痛的特殊性l l发生率很高发生率很高l l包含各种类型的疼痛包含各种类型的疼痛l l牵涉痛多见牵涉痛多见l l医源性疼痛不少见医源性疼痛不少见（牙科操作后深部肌肉损伤；过长时间牙（牙科操作后深部肌肉损伤；过长时间牙科治疗致关节疼痛；正畸修复治疗后咬合问题致慢性肌肉疼痛）科治疗致关节疼痛；正畸修复治疗后咬合问题致慢性肌肉疼痛）l l牙科治疗即刻见效（牙源性）牙科治疗即刻见效（牙源性）l l治疗方式多样化治疗方式多样化Thank you !Thank you ! Thank you
