ORE Part 1 Pain Management 4 — Questions and Answers
Question 1: What is 'central sensitisation' and how does it contribute to chronic orofacial pain?
- Increased responsiveness of the central pain-processing neurons (in the trigeminal nucleus and higher centres) following prolonged nociceptive input — leads to amplified pain processing and expansion of pain areas (Correct answer)
- A peripheral nerve phenomenon only
- A process that resolves automatically after acute pain resolves
- Sensitisation caused only by opioid medications
Correct answer: Increased responsiveness of the central pain-processing neurons (in the trigeminal nucleus and higher centres) following prolonged nociceptive input — leads to amplified pain processing and expansion of pain areas
Central sensitisation (CS) develops when sustained nociceptive input causes 'wind-up' in the trigeminal nucleus and supraspinal centres, increasing synaptic efficacy. CS contributes to chronic orofacial pain by amplifying and expanding pain beyond the original site.
Question 2: What is the role of intraosseous anaesthesia (e.g., Stabident) in managing difficult-to-anaesthetise mandibular teeth?
- Delivers anaesthetic directly into the medullary bone adjacent to the tooth, bypassing limitations of conventional blocks — effective supplement for irreversible pulpitis of lower molars where IDB is insufficient (Correct answer)
- Replaces inferior dental block for all mandibular procedures
- Used only for maxillary teeth
- Provides anaesthesia for the entire mandible from a single injection
Correct answer: Delivers anaesthetic directly into the medullary bone adjacent to the tooth, bypassing limitations of conventional blocks — effective supplement for irreversible pulpitis of lower molars where IDB is insufficient
Intraosseous injection delivers LA directly into the cancellous bone adjacent to the tooth root apex, achieving local anaesthesia even when conventional IDB fails (common in irreversible pulpitis due to lowered inflammatory pH reducing LA efficacy).
Question 3: What is 'burning mouth syndrome' (BMS) and how is it managed?
- Chronic burning oral pain without identifiable organic cause — predominantly in post-menopausal women; managed with cognitive-behavioural therapy, clonazepam, alpha-lipoic acid, and amitriptyline (Correct answer)
- A sign of oral cancer requiring biopsy
- Caused by denture pressure and managed by denture adjustment
- Treated exclusively with antifungal therapy
Correct answer: Chronic burning oral pain without identifiable organic cause — predominantly in post-menopausal women; managed with cognitive-behavioural therapy, clonazepam, alpha-lipoic acid, and amitriptyline
BMS is a chronic neuropathic pain condition with no identifiable cause, affecting tongue/lips/palate. Management includes reassurance, CBT, low-dose clonazepam topically, alpha-lipoic acid, and tricyclic antidepressants. Ruling out organic causes (candida, nutritional deficiency, diabetes) is essential.
Question 4: What is the clinical presentation of 'atypical facial pain' (chronic idiopathic facial pain)?
- Constant, dull, diffuse, poorly localised deep facial pain not following nerve distribution, not triggered by touch, not responding to dental treatment — a central sensitisation/psychosocial disorder (Correct answer)
- Severe lancinating paroxysmal pain — same as trigeminal neuralgia
- Sharp, well-localised pain in the maxillary sinus
- Referred pain from the temporomandibular joint only
Correct answer: Constant, dull, diffuse, poorly localised deep facial pain not following nerve distribution, not triggered by touch, not responding to dental treatment — a central sensitisation/psychosocial disorder
Atypical facial pain (chronic idiopathic facial pain) presents as constant, dull, non-anatomical, poorly defined pain, often with psychological comorbidity. It does not respond to standard dental or surgical treatments, indicating central rather than peripheral aetiology.
Question 5: What assessment tool is used to screen for depression and anxiety in patients with chronic orofacial pain?
- PHQ-9 (Patient Health Questionnaire) for depression; GAD-7 for anxiety — recommended in chronic pain assessment (Correct answer)
- Visual Analogue Scale for pain only
- OHIP-14 (Oral Health Impact Profile)
- DVLA driving fitness assessment
Correct answer: PHQ-9 (Patient Health Questionnaire) for depression; GAD-7 for anxiety — recommended in chronic pain assessment
Validated psychiatric screening tools (PHQ-9 for depression, GAD-7 for anxiety) are recommended in chronic orofacial pain management because psychological comorbidity significantly impacts pain experience and treatment outcomes.
Question 6: What is the role of tricyclic antidepressants (TCAs) in managing neuropathic orofacial pain?
- TCAs (e.g., amitriptyline, nortriptyline) reduce central sensitisation and modulate descending pain inhibition — effective in low doses (10–75 mg) for neuropathic pain independently of antidepressant effect (Correct answer)
- TCAs only work for pain in depressed patients
- TCAs are contraindicated in all orofacial pain management
- TCAs act by stimulating endogenous opioids only
Correct answer: TCAs (e.g., amitriptyline, nortriptyline) reduce central sensitisation and modulate descending pain inhibition — effective in low doses (10–75 mg) for neuropathic pain independently of antidepressant effect
Low-dose TCAs (amitriptyline 10–25 mg nightly) are first or second-line for neuropathic pain (PDAP, burning mouth, post-herpetic neuralgia). They modulate descending pain inhibitory pathways and reduce central sensitisation.
ORE Part 1 Pain Management 4
What is 'central sensitisation' and how does it contribute to chronic orofacial pain?