Article
Specialist referral may be indicated if the Practitioner feels:
Pain
Pain in the teeth, mouth, face or head usually has a local cause – often the sequelae of dental caries (odontogenic pain) – but psychogenic, neurological, vascular and conditions where pain is referred from elsewhere may be responsible (Table 1).
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Local disorders
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Dental staff will be well versed in pain of local cause and therefore this article discusses mainly the conditions in which specialist help may be indicated. Many of the conditions discussed in previous articles in this series may cause pain.
The real significance to the patient of orofacial pain, apart from the pain itself, can range from the benign to potentially lethal conditions. Some orofacial pain or headaches have an obvious but relatively unimportant cause (eg a hangover – caused mainly by the acetaldehyde resulting from metabolism of alcohol); other types of pain have no obvious underlying organic pathology (and are thus termed medically unexplained symptoms (MUS), eg atypical facial pain); some can threaten important faculties such as sight (eg giant cell arteritis), or even life (eg brain tumours).
Diagnosis of orofacial pain
The history is the most important means of diagnosing orofacial pain (Figure 1).
In order to differentiate the widely disparate causes, it is essential to determine keypoints about the pain, especially:
The cause of most orofacial pain is established mainly from the history, and examination findings are also helpful, not least in excluding local pathology. However, it is important to consider the usefulness of a Specialist who can arrange additional investigations, particularly imaging of the head and neck, using CT or MRI. It is crucial not to miss detecting organic disease and thus mislabelling the patient as having psychogenic pain, and not to miss a brain tumour underlying a patient with supposed ‘idiopathic’ trigeminal neuralgia.
Local causes of orofacial pain
Odontogenic pain
Most orofacial pain is, of course, related to dental disease – odontogenic causes – and will not be described further.
Mucosal pain
Pain from oral mucosal lesions can be either localized or diffuse. Localized pain is usually associated with a mucosal break, either an erosion (a partial thickness loss of epithelium) or ulcer (a full thickness loss of epithelium), discussed in a previous article. Of course, the distinction between these painful conditions can at times be difficult or impossible and many patients have both.
Diffuse pain may also be caused by infection, or a systemic underlying deficiency state or other factors, and is usually then described as ‘soreness’ or sometimes ‘burning’.
Mucosal pain may be aggravated by sour, acidic, spicy, or salty foods, so that few affected patients can tolerate or enjoy citrus fruits or tomatoes for example. The area is usually also tender to touch.
Other local causes of orofacial pain
Jaws
Pain from the jaws can be caused by infection, direct trauma, malignancies, and rarely by Paget's disease. However, unless associated with infection or jaw fracture, retained roots and impacted teeth, and lesions such as cysts, are usually painless.
Malignant tumours usually produce deep, boring pain, sometimes associated with paraesthesia or anaesthesia, but odontogenic and other benign tumours of the bone do not normally produce pain. Lip numbness or tingling, therefore, may herald a tumour in the jaw bone.
Salivary glands
Pain from salivary gland disorders is mainly caused by duct obstruction, sometimes by infection or a tumour. The pain is usually localized to the affected gland, may be quite severe, and may be intensified by increased saliva production, such as before and with meals. Examination may reveal a swollen salivary gland, sometimes with tenderness and/or a degree of trismus.
Sinuses and pharynx
Disease of the paranasal sinuses and nasopharynx, which can cause oral and/or facial pain, include sinusitis and tumours, which can remain undetected until they have reached an advanced stage. Any suggestion of a discharge from the nose, or obstruction to breathing, cheek swelling or numbness or tingling of the upper lip should be taken seriously as they may herald an antral carcinoma.
Pressure on mental nerve
On occasions, if there is dehiscence of the mental nerve, as a result of resorption of the alveolar ridge, pain is caused by pressure from a denture.
Temporomandibular joint pain
Pain from the TMJ may result from dysfunction, trauma, inflammation and, very rarely, tumours, either in the head and neck, or even lungs.
Temporomandibular pain-dysfunction syndrome
Temporomandibular pain-dysfunction syndrome is a very common problem, characterized by pain, clicking and jaw locking or limitation of opening of the jaw. Afflicting young women mainly, factors which have been implicated include over-opening of the mouth, muscle overactivity (eg bruxism, clenching), TMJ disruption and psychiatric history (eg anxiety, stressful life events). Precipitating factors may include local trauma, wide mouth opening, or emotional upset.
Diagnosis
Diagnosis is clinical. Pain from TMJ disease is usually dull, poorly localized, may radiate widely, is usually intensified by movement of the mandible and may be associated with trismus because of spasm in the masticatory muscles. Examination may reveal a click from the joint, limited jaw movements, and tender masticatory muscles. Any suggestion of a swollen and/or warm joint suggests true arthritis.
Management
Most patients recover spontaneously and progression to arthritis is virtually unknown. Therefore reassurance and conservative measures are the main management. TMJ pain-dysfunction can usually be effectively managed in general practice. Practitioners are usually well versed with this problem but possible options for treatment in a primary care environment are summarized in Table 2 and patient guidance in Table 3.
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Recalcitrant cases may need Specialist attention, particularly if simple measures fail.
Keypoints for patients: temporomandibular (TMJ) pain-dysfunction
Websites and patient information
http://www.aaop.org
http://www.nidcr.nih.gov/OralHealth/Topics/TMJ/TMJDisorders.htm
Psychogenic causes of orofacial pain
Psychogenic (tension) headaches caused by anxiety or stress-induced muscle tension are common, especially in young adults. The pain typically affects the frontal, occipital and/or temporal regions, as a constant ache or band-like pressure, often worse by the evening, but usually abates with rest. Similar problems can affect the orofacial region.
Reassurance may be effective but the pain may also be helped by massage, warmth, non-steroidal anti-inflammatory drugs (NSAIDs), or by benzodiazepines, which are both anxiolytic and mild muscle relaxants, or by complementary therapies.
In some studies, nearly 40% of the population have reported frequent headaches and orofacial pain. The reason behind conditions with a psychogenic component, sometimes termed medically unexplained symptoms (MUS), may include:
Features common to most MUS include:
Patients may bring diaries of their symptoms to emphasize their problem. Some have termed this the ‘malady of small bits of paper’ and, though there is by no means always a psychogenic basis, such notes characterize patients with MUS. These days, this is being replaced by Internet print-outs, which are also increasingly brought by well-informed patients who have no psychogenic problems whatsoever.
Occasional patients quite deliberately induce painful oral lesions and some have Munchausen's syndrome, where they behave in such a fashion as to appear to want operative intervention.
The most common types of orofacial pain with a strong psychogenic component are:
Some clinicians also include temporomandibular pain-dysfunction in this category.
Chronic idiopathic facial pain (IFP)
Idiopathic facial pain is a constant chronic orofacial discomfort or pain, defined by the International Headache Society as facial pain not fulfilling other criteria. Therefore, like BMS, it is also a diagnosis reached only by the exclusion of organic disease; there are no physical signs, investigations are all negative and it is an MUS. Atypical facial pain is fairly common, affecting probably around 1–2% of the population. Indeed, in some studies, nearly 40% of the population have reported frequent headache and/or orofacial pain.
Keypoints: chronic idiopathic facial pain
Pain is often of a dull, boring or burning type with an ill-defined location and there is:
Patients are often middle-aged or older and 70% or more are females. Most sufferers from IFP are otherwise normal individuals who are, or have been, under extreme stress, such as bereavement, or concern about cancer. There are often recent adverse life events, such as bereavement or family illness and/or dental or oral interventional procedures.
Clinical features
History findings in IFP include pain, mainly in the upper jaw, of distribution unrelated to the anatomical distribution of the trigeminal nerve, poorly localized, and sometimes crossing the mid-line to involve the other side or moving to another site. Pain is often of a deep, dull, boring or burning, chronic discomfort, and persists for most or all of the day but does not waken the patient from sleep. However, the patient may report difficulty sleeping.
There may also be multiple oral and/or other psychogenic related complaints, such as dry mouth, bad or altered taste, thirst, headaches, chronic back pain, irritable bowel syndrome or dysmenorrhoea. Patients only uncommonly use analgesics to try to control the pain, but there is a high level of utilization of healthcare services. There have often already been multiple consultations and attempts at treatment.
Pain is accompanied by altered behaviour, anxiety or depression. Over 50% of such patients are depressed or hypochondriacal, and some have lost or been separated from parents in childhood. Many lack insight and will persist in blaming organic diseases (or healthcare professionals) for their pain.
Clinical examination is unremarkable with a total lack of objective physical (including neurological) signs. All imaging studies and blood investigations are negative.
Diagnosis of IFP
Diagnosis is clinical through careful examination of the mouth, peri-oral structures, and cranial nerves, and imaging (tooth/jaw/sinus radiography and MRI/CT scan) to exclude organic disease, such as space-occupying or demyelinating diseases (Table 4).
| Idiopathic trigeminal neuralgia | Idiopathic facial pain | Migrainous neuralgia | |
|---|---|---|---|
| Age (Years) | >50 | 30–50 | 30–50 |
| Sex | F>M | F>M | M>F |
| Site | Unilateral, mandible or maxilla | + Bilateral, maxilla | Retro-orbital |
| Associated Features | – | +/− Depression | +/− Conjunctival injection |
| Character | Lancinating | Dull | Boring |
| Duration of episode | Brief (seconds) | Continual | Few hours |
| Usual timing of pain | Daytime | Daytime | Night-time |
| Precipitating | Trigger areas | +/− Adverse life events | +/− Alcohol |
| Main treatments | Carbamazepine | Cognitive behavioural therapy, |
Oxygen, sumatriptan |
Management of patients suffering idiopathic facial pain or pain with a psychogenic basis
Few patients with IFP have spontaneous remission and thus treatment is usually indicated (Figure 2).
Reassurance and attention to any factors such as the dentures or haematinic deficiencies may be indicated, but active dental or oral surgical treatment, or attempts at ‘hormone replacement’, or polypharmacy in the absence of any specific indication, should be avoided.
However, it is important, where possible, to identify and relieve factors which lower the pain threshold (fatigue, anxiety and depression). Simple analgesics such as NSAIDs should be tried initially, before embarking on more potent preparations.
Patient information is a very important aspect in management. Cognitive-behavioural therapy (CBT) or a Specialist referral may be indicated.
It is important to acknowledge clearly the reality of the patient's symptoms and distress and never attempt to trivialize or dismiss them:
Keypoints for patients: idiopathic facial pain
Websites and patient information
http://facial-neuralgia.org/conditions/atfp.html
Burning mouth ‘syndrome’(BMS)
There may be definable organic causes of this type of complaint, often described as a burning sensation (Table 5), and a patient in such pain may well also manifest psychological reactions to the experience. However, burning mouth ‘syndrome’ (BMS: also known as glossopyrosis; glossodynia; oral dysaesthesia; or stomatodynia) is the term usually used when symptoms, described as a burning sensation, exist in the absence of identifiable organic aetiological factors. BMS is often a MUS but it must also be recognized that it may well not be a single entity. BMS is a fairly common chronic complaint, affecting up to 0.7–2.6% of the population and seen especially in middle-aged or elderly patients, particularly in females, in a ratio of more than 3:1 and even as high as 7:1. There is no specific relationship to hormonal changes, despite the fact that BMS is often seen in middle-aged or elderly peri- or post-menopausal females. BMS has been reported in 10-40% of women presenting for treatment of menopausal symptoms.
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Local causes
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Defined clinical conditions that must be excluded since they can also present with burning include:
Uncommon causes that may need to be considered include:
Organic problems which sometimes present with no detectable clinical lesions, but that can cause similar symptoms include:
No precipitating cause for BMS can be identified in over 50% of the patients but, in others, a psychogenic cause such as anxiety, depression or cancerophobia can be identified in about 20% and, in some patients, BMS appears to follow either dental intervention or an upper respiratory tract infection.
Clinical features
BMS most frequently affects the tongue, but it can also affect the palate or, less commonly, the lips or lower alveolus. The history is that the burning sensation is chronic, usually bilateral, often relieved by eating and drinking, in contrast to pain caused by organic lesions which is typically aggravated by eating. Alcohol may also relieve or reduce the symptoms.
Patients with BMS often have multiple oral and/or other psychogenic related complaints, such as dry mouth, bad or altered taste, thirst, headaches, chronic back pain, irritable bowel syndrome or dysmenorrhoea. There may be changes in sleep patterns and mood and, though patients only uncommonly use analgesics to try to control the symptoms, there have often already been multiple consultations. Interestingly, patients with BMS also have heightened ability to taste – they are ‘supertasters’.
Examination shows no clinically detectable signs of mucosal disease or tenderness or swelling of the tongue or affected area, and no neurological or other objective signs.
Keypoints; burning mouth syndrome
Diagnosis
Diagnosis of BMS is clinical and it is important to exclude organic causes such as erythema migrans (geographic tongue), candidosis, lichen planus, dry mouth, glossitis, diabetes or denture problems. Importantly, all investigations prove normal.
Investigations indicated may include:
Management is discussed above.
Keypoints for patients: burning mouth syndrome
Websites and patient information
http://www.go4hope.org
http://www.mayoclinic.com/invoke.cfm?objectid=4E7AF27F-25B0-43D0-90383E896030B033
Atypical odontalgia
Atypical odontalgia is pain and hypersensitive teeth in the absence of detectable pathology. The pain is typically indistinguishable from pulpitis or periodontitis but is aggravated by dental intervention. Probably a variant of idiopathic facial pain, it should be managed similarly.
The syndrome of oral complaints
Multiple pains and other complaints may occur simultaneously or sequentially, and relief is rarely found (or admitted). Patients may bring diaries of their symptoms to emphasize their problem. This has been termed the ‘malady of small bits of paper’, and though there is not always a psychogenic basis, such notes characterize patients with non-organic complaints or people with highly obsessional personalities.
Neurological (neuropathic) causes of orofacial pain
Sensory innervation of the mouth, face and scalp depends on the trigeminal nerve, so that diseases affecting this nerve anywhere in the course from the orofacial region to the brain can cause orofacial pain or, indeed, sensory loss, sometimes with serious implications.
Any lesion affecting the trigeminal nerve may cause pain, often with physical signs such as facial sensory or motor impairment. Such causes include:
Idiopathic trigeminal neuralgia
Idiopathic trigeminal neuralgia (ITN) is an uncommon nerve disorder that causes episodes of unilateral intense, stabbing, electric shock-like pain in the areas of the face where the branches of the nerve are distributed – lips, eyes, nose, scalp, forehead, upper jaw, or lower jaw. ITN onset is mainly in the 50–70 year age group.
The cause of ITN is unclear, but one hypothesis is that a cerebral blood vessel becomes atherosclerotic and therefore less flexible with age, then pressing on the roots of the trigeminal nerve in the posterior cranial fossa, causing neuronal discharge.
The characteristic features of ITN are summarized as:
A less common form of the disorder called ‘Atypical Trigeminal Neuralgia’ may cause less intense, constant, dull burning or aching pain, sometimes with occasional electric shock-like stabs. Both forms of the disorder most often affect one side of the face, but some patients experience pain at different times on both sides.
Diagnosis
ITN is universally considered to be one of the most painful afflictions known. Severe pain suggestive of ITN but with physical signs such as facial sensory or motor impairment can result from lesions discussed above. These serious conditions must therefore be excluded by history, examination; including neurological assessment especially of cranial nerves, and investigations; including imaging (usually MRI) to exclude space-occupying or demyelinating disease, and blood tests to exclude infections and systemic vasculitides.
Only then can the term idiopathic (benign) trigeminal neuralgia be used!
Keypoints; trigeminal neuralgia
Management
Few patients with ITN have spontaneous remission and thus treatment is usually indicated. However, ITN is often an intermittent disease with apparent remissions lasting months or years, but recurrence is common and very often the pain spreads to involve a wider area over time and the intervals between episodes tend to shorten.
Patients with supposed ITN are best seen at an early stage by a Specialist in order to confirm the diagnosis and initiate treatment. In the acute situation, the patient's symptoms may be controlled on a short-term basis with injection of a regional local anaesthetic.
Medical treatment, typically using anticonvulsants, is successful for most patients (Table 6). Carbamazepine is the main drug used, but it is not an analgesic and must be given continuously prophylactically for long periods, and under strict medical surveillance. Adverse effects must be monitored, including:
| Medical | Surgical |
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Other agents such as gabapentin, phenytoin, lamotrigine and baclofen are available and some patients also report having reduced or relieved pain by means of alternative medical therapies, such as acupuncture, chiropractic adjustment, self-hypnosis or meditation.
Should medical care become ineffective, or produce excessive undesirable side-effects, neurosurgical procedures are available to relieve pressure on the nerve or to reduce nerve sensitivity.
Keypoints for patients: trigeminal neuralgia
Websites and patient information
http://ihs-classification.org/en/02_klassifikation/04_teil3/13.01.01_facialpain.html
http:/www.mayoclinic.com/health/trigeminal-neuralgia/DS00446
Glossopharyngeal neuralgia
Glossopharyngeal neuralgia is much less common than trigeminal neuralgia. Occasionally glossopharyngeal neuralgia is secondary to tumours. The pain is of a similar nature but affects the throat and ear, and typically is triggered by swallowing or coughing. Carbamazepine is usually less effective than for trigeminal neuralgia and adequate relief of pain can be difficult. A Specialist opinion is warranted to investigate and manage these patients.
Herpetic and post-herpetic neuralgia
Herpes zoster (shingles), the recrudescence of herpes-varicella-zoster virus latent in sensory ganglia after chickenpox, is often preceded and accompanied by neuralgia, but a unilateral rash and ulceration is typical (Figure 3). Neuralgia may also persist (post-herpetic neuralgia) after the rash has resolved and can cause continuous burning pain, in contrast to the lancinating pain of trigeminal neuralgia, which also affects mainly elderly patients. A Specialist opinion is warranted to investigate and manage these patients.
Vascular causes of orofacial pain
Several disorders in which the most obvious organic feature is vascular dilatation or constriction can cause orofacial pain. The pain is usually obviously in the face or head rather than in the mouth alone but occasionally can involve both, and can be difficult to differentiate from other causes of orofacial pain (Table 1). These disorders include:
Migrainous neuralgia (cluster headache)
Migrainous neuralgia is less common than migraine but more likely to cause orofacial pain. Males are mainly affected (M:F = 4:1) and attacks often begin in about middle age (Table 4). The pain is unilateral, occurs in attacks, is burning and ‘boring’ in character, and usually localized around the eye. Generally, the attacks commence, and often awaken the patient, at the same time each night or in the early hours of the morning, hence the term ’alarm clock headache’. This pain may be associated with profuse watering and ‘congestion’ of the conjunctiva, rhinorrhoea and nasal obstruction on the affected side. The attacks usually end in less than one hour. Attacks are sometimes precipitated by alcohol.
Migrainous neuralgia is managed by a Specialist, with a variety of agents, including sumatriptan, beta-blockers, indometacin, or oxygen inhalations.
Cranial arteritis (temporal arteritis; giant-cell arteritis)
Cranial arteritis is a febrile disease, in which giant cells appear in the arteries and cause a deranged internal elastic lamina. It most commonly affects the elderly. The headache is intense, deep and aching, throbbing in nature and persistent. It is frequently made worse when the patient lies flat in bed and it may be exacerbated or reduced by digital pressure on the artery involved. Occasionally, the artery (usually the superficial temporal artery) may be enlarged and tender. It is also characterized by malaise, weakness, weight loss, anorexia, fever, and sweating.
Diagnosis is supported by a raised erythrocyte sedimentation rate and C-reactive protein (or plasma viscosity). Arterial biopsy demonstrates fragmentation of the internal elastic lamina.
Although it is a self-limiting disease, patients with cranial arteritis may be threatened with loss of vision. Accordingly, urgent specialist referral for diagnosis and early treatment with high dose systemic corticosteroids (prednisolone) is indicated.
Referred causes of orofacial pain
Pain may occasionally be referred to the mouth, face or jaws from the following:
A Specialist opinion is warranted to investigate and manage these patients.