ORE Part 1 Pain Management 2 — Questions and Answers
Question 1: What is 'trigeminal neuralgia' and what are its characteristic clinical features?
- Severe unilateral lancinating (electric shock-like) pain along one or more branches of the trigeminal nerve, triggered by light touch (trigger zones), with refractory periods (Correct answer)
- A bilateral facial pain affecting the maxillary sinus
- A dull aching pain in the TMJ
- Chronic burning pain of the tongue without trigger zones
Correct answer: Severe unilateral lancinating (electric shock-like) pain along one or more branches of the trigeminal nerve, triggered by light touch (trigger zones), with refractory periods
Trigeminal neuralgia (tic douloureux) presents with severe, paroxysmal, electric shock-like pain lasting seconds, affecting one or more trigeminal nerve divisions. Trigger zones (touch, talking, eating) precipitate attacks; spontaneous refractory periods occur.
Question 2: What is 'temporomandibular disorder' (TMD) and what pain management approaches are used?
- A group of conditions affecting the TMJ and masticatory muscles — management includes self-care, reassurance, occlusal splints, physiotherapy, and analgesics (NSAIDs, low-dose TCA) (Correct answer)
- A single disease entity requiring surgical intervention
- A dental infection treated with antibiotics
- Treated only with occlusal adjustment
Correct answer: A group of conditions affecting the TMJ and masticatory muscles — management includes self-care, reassurance, occlusal splints, physiotherapy, and analgesics (NSAIDs, low-dose TCA)
TMD encompasses myalgia, arthralgia, and mixed disorders of the TMJ/masticatory muscles. First-line management is conservative: patient education, self-care (soft diet, heat), stabilisation splints, physiotherapy, and analgesics. Surgical intervention is rarely indicated.
Question 3: What is 'persistent dentoalveolar pain disorder' (PDAP) and how does it differ from routine post-extraction pain?
- A chronic neuropathic pain syndrome persisting at an extraction/endodontic site for >3 months without organic cause — previously called 'atypical odontalgia'; requires specialist management (Correct answer)
- Normal healing pain lasting 3 months after extraction
- Infection persisting after extraction
- Dry socket (alveolar osteitis) lasting 3 months
Correct answer: A chronic neuropathic pain syndrome persisting at an extraction/endodontic site for >3 months without organic cause — previously called 'atypical odontalgia'; requires specialist management
PDAP (previously atypical odontalgia/phantom tooth pain) is a chronic neuropathic pain syndrome at a previously treated dental site without radiographic or clinical pathology. Unlike normal post-extraction pain, it persists beyond healing and requires multidisciplinary management.
Question 4: What are the contraindications to prescribing ibuprofen for dental pain?
- Active peptic ulcer, severe renal impairment, third-trimester pregnancy, uncontrolled heart failure, hypersensitivity to NSAIDs/aspirin (Correct answer)
- Mild renal impairment alone
- Only relevant if the patient has diabetes
- No contraindications exist for short-term dental use
Correct answer: Active peptic ulcer, severe renal impairment, third-trimester pregnancy, uncontrolled heart failure, hypersensitivity to NSAIDs/aspirin
Ibuprofen is contraindicated in: active peptic ulceration, severe renal/hepatic impairment, third-trimester pregnancy (risk of premature ductus arteriosus closure), uncontrolled heart failure, and known NSAID hypersensitivity (including aspirin-exacerbated respiratory disease).
Question 5: What is 'peripheral sensitisation' in dental pulp pain?
- Increased excitability of peripheral nociceptors due to inflammatory mediators (bradykinin, prostaglandins, substance P), lowering their activation threshold and producing pain hypersensitivity at the site of inflammation (Correct answer)
- Central sensitisation in the trigeminal nucleus
- A process occurring only in neuropathic pain
- Sensitisation caused by local anaesthetic failure
Correct answer: Increased excitability of peripheral nociceptors due to inflammatory mediators (bradykinin, prostaglandins, substance P), lowering their activation threshold and producing pain hypersensitivity at the site of inflammation
Peripheral sensitisation occurs when inflammatory mediators released during pulpitis activate and sensitise nociceptors in the pulp. Lowered thresholds explain the disproportionate pain responses (hyperalgesia, allodynia) seen in irreversible pulpitis.
Question 6: What is 'preventive analgesia' and why is it used in oral surgery?
- Administering analgesics before painful stimuli occur (pre-operative) to reduce central sensitisation and post-operative pain intensity — e.g., ibuprofen + paracetamol 1 hour before third molar surgery (Correct answer)
- Analgesics given only after the patient reports pain
- A technique to prevent opioid prescribing entirely
- Topical anaesthesia as the only analgesic strategy
Correct answer: Administering analgesics before painful stimuli occur (pre-operative) to reduce central sensitisation and post-operative pain intensity — e.g., ibuprofen + paracetamol 1 hour before third molar surgery
Pre-emptive/preventive analgesia (e.g., oral ibuprofen and paracetamol before surgery) reduces central sensitisation and wind-up in the trigeminal pathways. Evidence supports reduced post-operative pain intensity with pre-operative analgesic administration.
ORE Part 1 Pain Management 2
What is 'trigeminal neuralgia' and what are its characteristic clinical features?