Zeroing in on the cause of your patient&#039;s facial pain

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Applied Evidence

Zeroing in on the cause of your patient's facial pain

J Fam Pract. 2015 September;64(9):524-526,528-531B

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References

1. Lipton JA, Ship JA, Larach-Robinson D. Estimated prevalence and distribution of reported orofacial pain in the United States. J Am Dent Assoc. 1993;124:115-1121.

2. Agostoni E, Frigerio R, Santoro P. Atypical facial pain: clinical considerations and differential diagnosis. Neurol Sci. 2005;26:S71-S74.

3. Bajwa Z, Ho C, Khan S, et al. Overview of craniofacial pain. UpTo-Date Web site. Available at: http://www.uptodate.com/contents/overview-of-craniofacial-pain. Accessed January 28, 2015.

4. Bendtsen L, Birk S, Kasch H, et al. Reference programme: Diagnosis and treatment of headache disorders and facial pain. Danish Headache Society, 2nd Edition, 2012. J Headache Pain. 2012;13:S1-S29.

5. Divya KS, Moran NA, Atkin PA. Numb chin syndrome: a case series and discussion. Br Dent J. 2010;208:157-160.

6. Kapur N, Kamel IR, Herlich A. Oral and craniofacial pain: diagnosis, pathophysiology, and treatment. Int Anesthesiol Clin. 2003;41:115-150.

7. Limonadi FM, McCartney S, Burchiel KJ. Design of an artificial neural network for diagnosis of facial pain syndromes. Stereotact Funct Neurosurg. 2006;84:212-220.

8. Liu F, Steinkeler A. Epidemiology, diagnosis, and treatment of temporomandibular disorders. Dent Clin North Am. 2013;57:465-479.

9. Merskey H, Bogduk N (eds). Classification of Chronic Pain. Descriptors of Chronic Pain Syndromes and Definition of Pain Terms, 2nd ed. Seattle, WA: International Association for the Study of Pain Press; 1994.

10. Nguyen CT, Wang MB. Complementary and integrative treatments: atypical facial pain. Otolaryngol Clin North Am. 2013;46:367-382.

11. Reiter S, Winocur E, Goldsmith C, et al. Giant cell arteritis misdiagnosed as temporomandibular disorder: a case report and review of the literature. J Orofac Pain. 2009;23:360-365.

12. Renton T, Adey-Viscuso D, Meechan JG, et al. Trigeminal nerve injuries in relation to local anaesthesia in mandibular injections. Br Dent J. 2010;209:E15.

13. Shephard MK, Macgregor EA, Zakrzewska JM. Orofacial pain: a guide for the headache physician. Headache. 2014;54:22-39.

14. Zakrzewska JM. Differential diagnosis of facial pain and guidelines for management. Br J Anaesth. 2013;111:95-104.

15. Zakrzewska JM. Multi-dimensionality of chronic pain of the oral cavity and face. J Headache Pain. 2013;14:37.

16. Herb K, Cho S, Stiles MA. Temporomandibular joint pain and dysfunction. Curr Pain Headache Rep. 2006;10:408-414.

17. American Society of Temporomandibular Joint Surgeons. Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. Cranio. 2003;21:68-76.

18. Benoliel R, Zadik Y, Eliav E, et al. Peripheral painful traumatic trigeminal neuropathy: clinical features in 91 cases and proposal of novel diagnostic criteria. J Orofac Pain. 2012;26:49-58.

19. Brooke RI. Atypical odontalgia. A report of twenty-two cases. Oral Surg Oral Med Oral Pathol. 1980;49:196-199.

20. Bouhassira D, Chassany O, Gaillat J, et al. Patient perspective on herpes zoster and its complications: an observational prospective study in patients aged over 50 years in general practice. Pain. 2012;153:342-349.

21. Baskaran RK, Krishnamoorthy, Smith M. Numb chin syndrome—a reflection of systemic malignancy. World J Surg Oncol. 2006;4:52.

22. Lata J, Kumar P. Numb chin syndrome: a case report and review of the literature. Indian J Dent Res. 2010;21:135-137.

23. Cornelissen P, van Kleef M, Mekhail N, et al. Evidence-based interventional pain medicine according to clinical diagnoses. 3. Persistent idiopathic facial pain. Pain Pract. 2009;9:443-448.

24. Didier H, Marchetti C, Borromeo G, et al. Persistent idiopathic facial pain: multidisciplinary approach and assumption of comorbidity. Neurol Sci. 2010;31:S189-S195.

25. Klasser G. Management of persistent idiopathic facial pain. J Can Dent Assoc. 2013;79:d71.

26. Abiko Y, Matsuoka H, Chiba I, et al. Current evidence on atypical odontalgia: diagnosis and clinical management. Int J Dent. 2012;2012:518548.

27. Sheldon CA, White VA, Holland SP. Giant cell arteritis presenting with bilateral loss of vision and jaw pain: reminder of a potentially devastating condition. J Can Dent Assoc. 2011;77:b55.

28. Rockey JG, Anand R. Tongue necrosis secondary to temporal arteritis: a case report and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94:471-473.

29. Sarlani E, Schwartz AH, Greenspan JD, et al. Facial pain as first manifestation of lung cancer: a case of lung cancer-related cluster headache and a review of the literature. J Orofac Pain. 2003;17:262-267.

30. Kumar A, Brennan MT. Differential diagnosis of orofacial pain and temporomandibular disorder. Dent Clin North Am. 2013;57:419-428.

31. Laudenbach JM, Simon Z. Common dental and periodontal diseases: evaluation and management. Med Clin North Am. 2014;98:1239-1260.

32. Napeñas JJ. Intraoral pain disorders. Dent Clin North Am. 2013;57:429-447.

33. Vickers ER, Zakrzewska JM. Dental causes of orofacial pain. In: Orofacial Pain. Zakrzewska JM, ed. Oxford, UK: Oxford University Press; 2009:69-81.

34. Pierse JE, Dym H, Clarkson E. Diagnosis and management of common postextraction complications. Dent Clin North Am. 2012;56:75-93.

35. Renton T. Dental (odontogenic) pain. Br J Pain. 2011;5:2-7.

36. Yatani H, Komiyama O, Matsuka Y, et al. Systematic review and recommendations for nonodontogenic toothache. J Oral Rehabil. 2014;41:843-852.

37. Klasser GD, Fischer DJ, Epstein JB. Burning mouth syndrome: recognition, understanding, and management. Oral Maxillofac Surg Clin North Am. 2008;20:255-271.

38. Balasubramaniam R, Turner LN, Fischer D, et al. Non-odontogenic toothache revisited. Open Journal of Stomatology. 2011;1:92-102.

39. Patton LL, Siegel MA, Benoliel R, et al. Management of burning mouth syndrome: systematic review and management recommendations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103:S39.e1-e13.

40. Cascarini L, McGurk M. Epidemiology of salivary gland infections. Oral Maxillofac Surg Clin North Am. 2009;21:353-357.

41. Hegarty AM, Zakrzewska JM. Differential diagnosis for orofacial pain, including sinusitis, TMD, trigeminal neuralgia. Dent Update. 2011;38:396-400,402-403,405-406.

Atypical pain

Persistent idiopathic facial pain (PIFP), previously known as atypical facial pain, is a persistent facial pain that does not have the classical characteristics of cranial neuralgias and for which there is no obvious cause.^2,10,23 PIFP is not triggered by any of the factors that typically precipitate neuralgias.² The onset may be spontaneous or associated with dental intervention or facial injury, but it usually does not have a demonstrable local cause.^24,25

Diagnosis of trigeminal neuralgia can be tricky; more than half of patients experience less severe pain after the main sharp attack.

Neuropathic mechanisms that might be at work in PIFP include nociceptor sensitization, phenotypic changes and ectopic activity from the nociceptors, central sensitization possibly maintained by ongoing activity from initially damaged peripheral tissues, sympathetic abnormal activity, alteration of segmental inhibitory control, or hyperactivity or hypoactivity of descending controls.²

PIFP is most frequently reported in women in their 40s and 50s.²⁵ The history of a patient with PIFP often include mood disorders, chronic pain, or poor coping skills.¹⁴ Patients complain of a steady, unilateral, poorly localized pain that is deep, constant, aching, pulling, or crushing. It is usually present all day, every day. The constancy of the pain is its distinguishing feature. In the beginning, this pain may be in a limited area on one side of the face, usually the nasolabial folds or the angle of the mandible. Later, it may affect both sides of the face and extend to the neck and upper limbs.^23,24 Most patients with PIFP report other symptoms, including headache, neck and backache, dermatitis, pruritus, irritable bowel, and dysfunctional uterine bleeding.²⁶

Making the diagnosis. A targeted history and accurate clinical examination are essential.^2,10 Although there are no formal diagnostic criteria, a patient can be assumed to have PIFP if:^2,10• There is pain in the face for most of the day or all day, every day.
• Initially, the pain may be confined to a portion of the face, but it is poorly localized and deep.
• The pain is not associated with other physical signs or loss of sensation.
• Imaging does not reveal an obvious anatomic or structural cause.

Treatment. Treatment of PIFP can be difficult and unsatisfactory.²³ Counseling to educate patients about the chronic and nonmalignant nature of the illness is the mainstay of treatment, followed by pharmacotherapy.²³ TCAs have shown a moderate effect in several trials. Gabapentin, topiramate, carbamazepine, and pregabalin also have shown limited to modest benefit in some patients. Surgical therapies appear to be of little or no use.²³ Experimental treatments such as pulsed radiofrequency, low-energy level diode laser have shown success in small studies.^10,23

Vascular pain

Giant cell arteritis (GCA) is a systemic, chronic vasculitis involving the large and medium-sized vessels, mainly the extracranial branches of the carotid artery.^6,11 It predominantly affects people older than age 50 and is more common among women and those of Scandinavian ethnicity.²⁷

A distinguishing feature of persistent idiopathic facial pain is that the pain is present all day, every day.

The cause of GCA is unclear. Genetic predisposition linked to humoral and cellmediated immunity is believed to play a role.²⁸ Familial aggregation and predominance of the HLA-DR4 allele has been reported in patients with GCA.⁶

What you’ll see. The most common signs and symptoms of GCA are temporal headache (seen in two-thirds of patients), jaw claudication and tenderness, and swelling of the temporal artery.^6,11 The headache of GCA usually is unilateral, severe, boring or lancinating, and localized to the temporal or occipital regions of the scalp.⁶ Other orofacial manifestations include trismus, throat pain that develops while chewing, changes in tongue sensation and tongue claudication, tooth pain, dysphagia, dysarthria, submandibular mass, lip and chin numbness, macroglossia, glossitis, lip and tongue necrosis, and facial swelling.¹¹

Visual symptoms include diplopia, ptosis, and possibly blindness if treatment is not instituted at first suspicion. Ocular symptoms result from anterior ischemic optic neuropathy, posterior ischemic optic neuropathy, or central retinal or cilioretinal artery occlusion.^6,28 Patients have also reported low-grade fever, asthenia, anorexia, weight loss, and generalized aches.^11,28

Making the diagnosis. Arterial biopsy is the gold standard for diagnosis of GCA. It is usually performed on the temporal artery and is positive in 80% to 95% of people with the condition.²⁸ Other useful lab tests include erythrocyte sedimentation rate (ESR; elevated), white blood cell count (mildly elevated), and C-reactive protein (elevated).

Treatment. Prednisone is used to treat GCA, in initial doses ranging from 30 to 80 mg. A maintenance dose may be required for up to 2 years, with close follow-up and periodic ESR measurements.²⁸