Oro-Facial Pain
By
Iain Macleod
What is Pain?
• “Pain is an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage or described in terms of such
damage”
• “- pain is always subjective -”
Int. Assoc. for the Study of Pain
Oro-Facial Pain
• The remit of the dentist?
• Patients go to dentist to get
problem fixed
– Filling, extraction etc
• Problem arises when dentist
can’t fix it!
• Patients don’t go to dentist for
medical/psychological help!
• Dentist under pressure to do
something!
• Poor inter-professional
communication between
medicine and dentistry
• Dentists often isolated
Oro-facial Pain
• Oro-facial pain can be
difficult to diagnose!
• TMD can be a great
mimic!
• Beware of referred
pain!
Causes of facial pain
• Many causes!
• May be infectious,
neurological,
vascular
oncological or
psychogenic
In the primary care setting
how much do each of the following
contribute to the diagnosis?
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History taking
>80%
Physical examination
<10%
Investigations
<10%
So why do we do so many investigations?
Why Do We Order So Many
Tests?
• "Defensive" medicine in an increasingly
litigious environment
• Loss of confidence in our abilities to
extract meaningful information from the
history and examination
Consequences of Ordering So Many
Tests
– Time delay in diagnosis as one awaits the test
results
– The patient is exposed to the risk and side
effects of tests that may not be necessary
The pain history
• Onset, location and duration of facial pain
• Alleviating or aggravating factors
• Medical, dental & social history
KEY QUESTIONS
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IS THE PAIN PRESENT EVERY DAY ?
WHAT IS A NORMAL DAY LIKE ?
HOW SEVERE IS THE PAIN ? –
(Score 0-10)
Rules of Thumb!
• Dental pain gets better or worse!
• Chronic pain is rarely dental!
• If an experienced dentist “feels” the pain is
not dental they are most often right !
5th & 7th Cranial Nerves
1. Sensory root of
trigeminal nerve
2. Pons
3. Vestibulocochlear nerve
4. Facial nerve
5. Abducent nerve
6. Medulla oblongata
7. Motor root of
trigeminal nerve
8. Basilar sulcus
Nasopharyngeal Carcinoma
(Trotter’s Syndrome)
• Maxillary pain
– With numbness!!
• Unilateral
nosebleeds
Toothache
Dental caries
Dental Pain - radiation
• Caries in mandibular
molars can produce
pain around the ear
• Caries in maxillary
teeth can produce
maxillary, orbital,
retro-orbital
Dental Pain
• Dental pain can be
difficult to diagnose!
– Tooth sleuth!
– Hot water test!
• TMD can be a great
mimic!
– Headaches, jaw pain,
toothache etc.!
• Beware of referred pain
– sinuses, cervical spine,
heart etc.!
Acute Maxillary Sinusitis
• Unilateral or bilateral
pressure, fullness or
burning pain over
cheekbone, upper teeth
and around eyes
• Exacerbated by stooping
• Usually follows an URTI
• Most cases self limiting
Chronic Maxillary Sinusitis
• Feeling of pressure
below the eyes or
toothache
• Computed Tomography
• Endoscopy
Sinusitis Management
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Decongestants
Steam inhalations
Antibiotics if indicated
Local Heat
Antihistamines if allergic component
corticosteroids
Sinus irrigation
Endoscopic surgery
TEMPOROMANDIBULAR JOINT
DISORDERS
• Common
• More has been written about this topic
than for any other joint !
• Various classifications
• Many cases are self limiting
• Surgery is indicated in very few BUT
important exceptions
Temporomandibular Dysfunction
• Pain in the joint and/or surrounding muscles
• Joint “clicking”
• Periods of limitation of joint movement (trismus)
EPIDEMIOLOGICAL DATA
• Percentage of population with signs
50-75%
• Percentage of population with symptoms
20-25%
• Percentage of population who seek
treatment 3-4%
Temporomandibular Dysfunction
• Causes
• Parafunction
– Bruxism
– Clenching
• Emotional stress
• Predisposition (F>M)
– Joint hypermobility
• Occlusal factors –
little evidence
Bruxism
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Tooth wear
Painful teeth
Cracked cusps
Mouth ulcers due to trauma
Jaws ache in the morning
Temporomandibular Dysfunction
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Pain distribution
Variable – a great mimic!!
Joint pain
Earache
Toothache
Facial pain
Headache
Can be associated with
neck and shoulder pain
Treatment of TMD
Trigeminal Neuralgia - Description
• A painful unilateral affliction of the face,
characterized by brief electric shock-like
(lancinating) pains limited to one or
more divisions of the trigeminal nerve
• Pain evoked by washing, shaving,
smoking, talking, brushing, air blowing,
or spontaneously occurring
• Pain is abrupt in onset and may remit
for varying periods
Trigeminal Neuralgia
• Subclassified into idiopathic and
symptomatic
• Idiopathic trigeminal neuralgia: due to an
interaction between trigeminal nerve and
vasculature
• Symptomatic trigeminal neuralgia: caused
by demonstrable structural lesion
Trigeminal Neuralgia
• Females > males
• Usually elderly – (if < than 40 -?MS)
• Restricted to Vth nerve
– Similar can affect IXth nerve –
glossopharyngeal neuralgia
• Trigger point – may bear no anatomical
relation to site of pain but on same side!
• Sleep often not affected
• May go into remission
Trigeminal Neuralgia
Diagnosis:
• History
• Examination
• MRI
– aberrant pontine
blood vessel?
– exclusion of other
cause (neoplasm, MS)
• (Response to trial of
carbamazepine)
Trigeminal Neuralgia
Treatment:
• Medical – anticonvulsants
( e.g. carbamazepine) –
needs medical
monitoring!
• Use of additive drugs –
e.g. baclofen
• Damage to trigger point –
alcohol injection,
cryotherapy
Trigeminal Neuralgia – Surgical
Treatment
• Radiofrequency
ganglionolysis
• Microvascular
decompression
Establishment of VZV Latency in Sensory-Nerve
Ganglia.
After a primary VZV infection (chickenpox), latent VZV
infection is established in the dorsal-root ganglia, and
zoster occurs with subsequent reactivation of the virus
N Engl J Med Vol 356(13) P1338-1343
Zoster: Clinical Features
• Usually limited to 1 or
2 adjacent, unilateral
dermatomes
• “Grape-like” lesions
clustered on an
erythematous base
• Lesions usually heal
within 4 weeks1
Post Herpetic Neuralgia
• Burning, itching, prickly pain that worsens
with contact or movement
• Persists along any of the three trigeminal
nerve distributions affected by shingles
• Difficult to treat!
• Importance of adequate treatment of
shingles – especially the elderly
• Carbamazepine, tricyclics
Giant Cell Arteritis
• Over 50yrs,women>men
• recent onset headache,scalp tenderness
• Jaw/tongue claudication (tired
tongue/jawache)
• anorexia
• visual disturbances
• Swollen disc usually
GCA Diagnosis
• ESR/CRP
• BP, CXR
• Biopsy of temporal
artery
Treatment of GCA
• Give corticosteroids immediately in all
suspected cases
• Start with 1mg/Kg prednisolone daily with
vitamin D and calcium supplements.
• Refer for Ophthalmology
Psychogenic
Somatisation Disorders
Somatisation has been defined as “the
expression of personal and social distress
in an idiom of bodily complaints with
medical help seeking”
Common !
“In general medical practice, somatisation
associated with psychiatric illness
accounts for 20 - 30% of all consultations”
DEPRESSIVE ILLNESS
Warning Signs
• Persistent low mood (> 2weeks)
• Feeling worthless, hopeless, suicidal
• Loss of interest in usual activities
– anhedonia
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Fatigue
Poor concentration
Reduced sleep
Poor appetite
Atypical Pain Conditions
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Atypical = poorly understood!
Often regarded as purely “psychogenic”!
But chronic pain will make you depressed!
Other factors may be involved!
– There may be a cause?
– Patient may just be a poor historian!
• Be careful of labels!
• Keep an open mind!
“Atypical” Facial Pain
Conditions
• Persistent idiopathic facial pain
• Persistent dento-alveolar pain (atypical
odontalgia)
• Oral dysaesthesia
• Phantom bite syndrome
• (TMD)
• Syndrome of bizarre oro-facial symptoms
Persistent Idiopathic Facial Pain
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Middle aged or older
Mainly female
Constant pain / discomfort
Poorly localised
May cross midline
Does not waken patient from sleep
Lack objective signs
Investigations (-ve)
Other symptoms (headaches,IBS,backache etc.)
Persistent Idiopathic Facial Pain
• Demand physical treatment
• Often do not accept psychological
explanation
• May have seen several
specialists/practitioners
• May be obsessed with symptoms
Psychogenic Toothache
• Patient reports that multiple teeth are often painful with
frequent change in character and location
• A general departure from normal or physiological patterns
of pain
• Patient presents with chronic pain behaviour
• Lack of response to reasonable dental treatment
• Unusual or unexpected response to therapy
• No other identifiable pain condition that can explain the
toothache
Non-Odontogenic Toothaches
Warning Symptoms- Summary
• Spontaneous multiple toothaches
• Inadequate local dental cause for the pain
• Stimulating, burning, non-pulsatile toothaches
• Constant, unremitting, non-variable toothaches
• Persistent, recurrent toothaches
• Local anesthetic blocking of the offending tooth does not
eliminate the pain
• Failure of the toothache to respond to reasonable dental
therapy
Chronic Orofacial pain
Burning mouth syndrome is characterized as a
burning, tender, or annoying sensation in the
mouth with no apparent mucosal lesion.
Descriptive symptom
Late middle age – elderly
Female>Male
Burning Mouth Syndrome
(glossodynia, glossopyrosis)
• Possible causes
• Haematinic deficiency
– Fe, B12, Folate
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Diabetes melitus
Candidosis
Dry mouth
Denture problems
Parafunctional
Psychogenic
– Anxiety
• Cancerophobia+++
– Depression
Management – What You Should Do!
• History ( what’s the story in detail )
– Exacerbants, alleviation, associated features
• Exclude organic disease
• Be aware of emotional state
– Depression / anxiety (HAD score)
- Secondary gain – what benefits does the patient get
from being unwell?
• Life events – connections with onset etc.
• Discuss with GMP (with patients consent)
• Decide on need for medication / referral
Management – What You Should Do!
• Remember the patients pain is real even if
a physical cause can not be found – tact!
• Allow the patient to express themselves
– What do you understand about your pain?
– What do you feel it represents?
– Cancer phobia?
• It can take time
• Remember most complaints are regarding
communication – or lack of it!
Management Strategies
The Pain Clinic
• Medical – drugs – alter the chemical soup!
• Surgical – nerve ablation procedures e.g. for
cancer pain
• Physiotherapy – improving activity
• Clinical Psychology – living with the problem
– Cognitative, Behavioural Therapy (CBT)
Pain Management is multidisciplinary!
Liaise closely with the GMP
Take-Home Points
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Oro-facial pain is common
Most cases are dental
Diagnosis can be very difficult
Patients are frequently frustrated & very
distressed by time they reach
secondary care
• Need a lot of listening too!
Conclusions
• Careful history taking is essential to
correctly diagnose facial pain
• Remember the anatomy of the trigeminal
nerve
• Many facial pain syndromes are wrongly
attributed to disease of the teeth or
sinuses