面部疼痛的鉴别诊断和治疗指南（五）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Zakrzewska JM. Differential diagnosis of facial pain and guidelines for management. Br J Anaesth. 2013;111(1):95-104.本次学习由杨聪娴副主任医师主讲。

Neuropathic pain

Neuropathic pain often presents on the face in the territoryof the trigeminal nerve (see Table 2).

神经病理性疼痛

神经病理性疼痛常表现在三叉神经支配区域的面部(见表2)。

Trigeminal post herpetic neuralgia

Trigeminal post-herpetic neuralgia (PHN) has the same clinical features as other neuralgias presenting elsewhere; management should follow guidelines for neuropathic pain.

三叉神经痛区域的疱疹后神经痛

三叉神经疱疹后神经痛(PHN)与其他部位的带状疱疹后神经痛有相同的临床表现；治疗应遵循带状疱疹后神经痛的治疗指南。

Post traumatic trigeminal pain/trigeminalneuropathic pain/atypical odontalgia

It is being increasingly recognized that it is not just injuries such as trauma to the facial skeleton that can result in neuropathic pain of the trigeminal nerve but also various dental procedures ranging from root canal therapy andextractions to dental implants. Diagnostic criteria are being proposed. In cases of dentally induced injuries, there is often a history of poor analgesia at the time of the procedure when the symptoms often start. In other instances, no clear trauma can be identifified and yet the pain is very clearly localized in the dental area; this has been called atypical odontalgia. Currently, management is as for otherneuropathic pain but there is a high percentage of failures.

创伤后三叉神经痛/三叉神经神经病理性痛/非典型牙痛

人们越来越认识到，不仅面部的创伤会导致三叉神经痛，口腔科的各种治疗，从根管治疗到拔牙和种植牙，也会导致神经病理性疼痛。目前已有了诊断标准。在牙源性疼痛的患者，疼痛始于口腔科的治疗，并且在治疗时，会有镇痛欠佳的表现。部分患者，没有明显的创伤史，但疼痛固定于牙齿区域，被称为非典型牙痛。目前，治疗与其他神经病理性疼痛相似，但失败率很高。

Burning mouth syndrome

Burning mouth syndrome (BMS) is a rare chronic condition characterized by burning of the tongue and other parts of the oral mucosa in which no dental or medical causes are found. It is seen predominantly in peri- and postmenopausal women. This condition is most commonly seen by the dental profession and the oral mucosa is normal in appearance (Table 2). Neurophysiological testing, biopsies and functional MRI suggest that it is a disorder of peripheral nerve fifibres with central brain changes. The prognosis is poor with only a small number resolving fully; however,patients can be reassured that it will not get worse and this is often crucial. Secondary causes of BMS (local and systemic) include oral candidiasis, mucosal lesions, haematological disorders, auto-immune disorders, and pharmacological side-effects.

灼口综合征

灼口综合征(BMS)是一种罕见的慢性疾病，表现为舌头和其他部位口腔黏膜的烧灼感，不伴有口腔科或其他原因。主要见于围绝经期和绝经后女性。这种疾病通常在由口腔科就诊，口腔黏膜外观正常(表2)。神经生理学检查、活检和功能MRI提示为外周神经纤维功能障碍，伴有颅脑功能改变。预后较差，只有少数患者得以充分解决;对病人表示安慰非常重要，可以阻止症状加重。继发性灼口综合征的原因(局部和

全身)包括口腔念珠菌病、黏膜病变、血液疾病、自身免疫疾病和药物副作用。

RCTs with respect to BMS are often of poor quality. CBT may be effective. There have been several RCTs evaluating the role of alpha lipoic acid (antioxidant), but the evidence is conflflicting.One study combining alpha lipoic acid with gabapentin 300 mg reported the best outcome. Topical clonazepam and capsaicin were shown to have some effect in a single short-term trial. Systemic capsaicin for 1 month gave good results but resulted in signifificant gastric problems.Topical benzydamine,trazadone, hypericum perforatum, and lafutidine have all been shown to have limited effificacy.

目前关于灼口综合征的随机对照试验的质量一般。认知行为治疗可能有效。目前已经有几项随机对照试验评估了α硫辛酸(抗氧化剂)的作用，但结论是有争议的。一项α硫辛酸与加巴喷丁300mg联合治疗的方案报告了最佳结果。一项研究表明局部氯硝西泮联合辣椒素短期内有效。全身应用辣椒素1个月效果较好，但导致严重的胃肠道问题。局部苄达明、曲唑酮、贯叶连翘、和拉夫替丁都有有限的功效。