Orofacial Pain

This is the main reason why patients attend a dental clinic.  In most cases, an obvious dental cause of the symptoms can be identified, and appropriate treatment provided.

A wide range of diseases apart from local disorders can cause oro-facial pain, including neurological, vascular and psychogenic causes.

 

Diagnosis

Made on the basis of a detailed assessment of the character of the pain, including: duration, site, severity, character, frequency and periodicity, associated features, initiating factors and relieving factors.

 

Neurological

1. Trigeminal Neuralgia

 

  • unilateral, stabbing, electric-shock like pain in trigeminal nerve distribution – (1 or more of main branches)
  • often trigger point identified by patient, lasts seconds
  • pain intensity severe
  • 50-70 years (<40 consider other cause)
  • short duration only
  • no neurological deficit
  • idiopathic - ? compression around trigeminal nerve in posterior cranial fossa 

 

Management

 

  • Carbamazepine used successfully for most – need regular blood tests
  • (* hyponatraemia; suppresses WBC, RBC, Plts; induces liver enzymes)
  • other anticonvulsants or antidepressants can be used
  • peripheral nerve techniques eg cryosurgery, glycerol injections, thermocoagulation
  • central neurosurgery for intractable cases (microvascular decompression)

 

 

2. Glossopharyngeal Neuralgia

 

  • much less common than trigeminal neuralgia
  • pain of a similar nature but affects tonsil, oropharynx and/ or ear
  • triggered by swallowing or coughing

 

 

Management 

 

  • Carbamazepine less effective, Gabapentin also used
  • usually secondary to lesions in post. cranial fossa or jugular foramen

 

 

3. Herpes zoster (including post-herpetic neuralgia)

 

  • neuralgia both precedes and accompanies shingles
  • 10% of pts who have had recurrent VZV develop neuralgia during acute phase and persisting (post-herpetic) more than 6 months afterwards, elderly mostly
  • post-herpetic neuralgia can be extremely resistant to Rx., pain can be intolerable, analgesics rarely effective, anti-depressants and anti-convulsants can help

 

 

Vascular

4. Migrainous Neuralgia (Cluster Headache)

 

  • oedema and dilatation of walls of internal carotid artery and possibly external also
  • 30-50 years, more common in men
  • retro-orbital excruciatingly severe ‘boring’ pain, lasts less than an hour
  • pain onset and termination is sudden
  • precipitated by alcohol, or occurs spontaneously 1-3 times/day
  • obvious vascular changes associated: lacrimation, nasal congestion and/or rhinorrhoea
  • no visual symptoms, nausea or vomiting associated as a migraine
  • Rx. oxygen and sumatriptan
  • Prophylaxis with verapamil, lithium, nifedipine, diltiazem

 

 

5. Giant cell arteritis

 

  • granulomatous vasculitis of vessels in head and neck
  • over 60 years
  • unilateral ‘headache-like’ pain (severe dull ache) in temporal/occipital region
  • systemic upset: weight loss, muscle weakness, lethargy
  • temporal artery frequently becomes red, swollen, firm, tender and tortuous
  • ESR usually raised, possibly CRP also (ESR reasonable guide to disease activity)
  • temporal artery biopsy useful in confirming diagnosis (>3cm length as skip lesions)
  • risk of blindness due to retinal vasculitis
  • start oral prednisolone ASAP (60mg/day), good response if treated early

 

 

Psychogenic

6. Atypical facial pain

 

  • chronic pain of unknown aetiology
  • 50% of pts. have anxiety or depression associated
  • often women middle-aged or older
  • absence of organic signs
  • pain poorly localised, persists for many years on daily basis
  • lack of response to analgesics, lack of triggering factors
  • diagnosis made on basis of history and absence of dental cause for pain
  • cranial nerve function should be assessed
  • CT or MRI to exclude malignancy at base of skull

 

Rx. responds well to anti-depressants

 

7. Burning mouth syndrome (oral dysaesthesia)

 

  • aetiology uncertain
  • no visible abnormality, organic disease or haematological abnormality
  • middle-aged or older woman mainly affected
  • burning pain, persistently sore
  • bizarre patterns of pain inconsistent with neurological or vascular anatomy
  • associated depression, anxiety, cancerophobic (20% of cases)
  • obsession with symptoms may rule patients’ life

 

Rx. involves reassurance of common nature and no serious underlying problem

antidepressants help, sometimes dramatically