Orofacial Pain

CLASSIFICATION OF OROFACIAL PAINS I. Neurologic origin:

1. 2. 3. 4. 5. 6.

T rigem inal neuralgia. Pretrigeminal neuralgia. G la s so p h a ry n g e a l n e u ra lg ia . H e rp s z o ste r. P o s t h e r p e t i c n e u ra l g ia . Geniculate herpes (Ramsay-hunt syndrome). M ultiple sclerosis. Intracranial tum ors. C ausalgia.

7. B e l l ' s p a l s y .
8. 9. 10.

II. Vascular origin:

1. 2.

M ig ra in e . Periodic migrainous neuralgia (Sphenopalatine Neuralgia, C l u s t e r headache, alarm clock headache). Paroxysmal facial hemicrania. Giant cell (temporal, cranial) arteritis. Referred pain, e.g. cardiac ischemia. Sinusitis.

3. 4. 5.

III. Maxillary antruminasopharynx

1.

2. Malignancy.

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IV. Salivary glands

1. Acute bacterial sialadentitis. 2. 3.

Chronic bacterial sialadentitis. Sjogren's syndrome. 4. Malignancy.

5. Calculi, stenosis of duct, obstruction of duct orifice. 6. HIV disease. 7. Mumps.

V. Oral mucosa
1. Herpes zoster. 2. Geniculate herpes (Ramsay-Hunt syndrome). 3. Herpetic gingivostomatitis. 4. Late stage carcinoma. 5. Mucosal ulceration.

VI. Jaws/masticatory muscles

1. Temporomandibular joint disorders. 2. Fractures. 3. Osteomyelitis.

4. Infected cysts.
5. Malignancy.

VII. Ears Otitis media. VIII. Eyes Glucoma. IX. Psychogenic

1. Atypical facial pain. 2. Atypical odontalgia. 3. Burning mouth syndrome.

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I. Neurologic pain 1. Trigeminal neuralgia Definition: A self limiting disorder characterized by instantaneous attacks, of sharp lancinating, shooting pain confined to the area of distribution of the trigeminal nerve and characterized by the presence of trigger zone. Etiology:
1.

Demyelination.

2. Vascular compression of the trigeminal ganglion. 3. Trauma or infection of the nerve.

4.

Idiopathic.
1. Involving areas supplied by the 2nd and 3rd divisions of trigeminal

Incidence: nerve (teeth, jaws, face and associated structures).

2.

Age: more than 40 years of age, in

affected patients under 40 years, suspect serious underlying pathology e.g. tumors or multiple sclerosis.
3.

Sex: Females are affected twice The right side is affected more Mostly Unilateral, bilateral is

more than males. 4. commonly than the left side. 5. relatively uncommon.
6. The 2nd division of trigeminal nerve (V2) is more commonly than

the 3rd division, on the other hand the ophthalmic nerve is involved only in 5% of cases.

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Clinical features: Signs

1.

Spasmodic contraction of face muscles due to the pain of

trigeminal neuralgia. Symptoms

1.

Pain is limited to one of the three divisions of the The pain of trigeminal neuralgia never crosses the midline. Pain is described as sharp and stabbing, electric shock, red

trigeminal nerve, most commonly the 2nd and 3rd divisions.

2. 3.

hot needle type. It is of rapid onset, short duration and with rapid recovery.
4.

Paroxysms occur most commonly in the first hours The pain of trigeminal neuralgia is as clusters, patients

after awakening.
5.

having periods of daily pain, then periods of remission. The remission may last days, weeks, months or years.
6.

Trigeminal neuralgia does not affect sleep. This pain could be evoked by touch or even breeze to the

7.

trigger zone on the face or mouth or it is evoked spontaneously. Trigger zone: 1. Represent primary site of origin for pain provocation.
2. Half-inch finger sign: The patient points to the trigger area with

his finger without touching it, as this may precipitate the attack.

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Differential diagnosis:
1. 2.

Presence of trigger zone and periods of remissions. Clinical examination of other cranial nerves to exclude other L.A nerve block of the trigger zone will arrest pain for the Diagnostic aids: CT & MRI are used to exclude the presence of tumor. Tegretol can be used for diagnosis. Multiple sclerosis: Occur at younger age + mainly Cluster headache: headache occurs at night + No trigger zone. Post-herpetic neuralgia: After herpes zoster of the 5th cranial

causes.
3.

duration of LA. 4.

5.

bilateral while trigeminal neuralgia is unilateral.

6. 7.

Nerve + history of skin lesion prior to pain aids in the diagnosis.

8. Psychogenic Neuralgia: the distribution of pain is unanatomical,

it may cross the midline with no trigger zone it is usually deep, vague, poorly localized.
9.

Neoplasia: Intracranial neoplasms may cause facial pain if they irritate or compress the root or the ganglion of the trigeminal nerve.

This may be indistinguishable from idiopathic

trigeminal neuralgia and is usually termed symptomatic trigeminal neuralgi.

D.D: by careful clinical examination + imaging the

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patients with facial pain of any type.

10.Glossopharyngeal neuralgia: The pain is unilateral in the throat

and base of the tongue on one side, sometimes radiating to the ear.
11.

Pain of dental origin: e.g. pulpitis, A.D.A.A. periodontitis, Pain of osseous origin (dry socket and acute osteomyelitis). Pain originating in T.M.J.

pericoronitis.
12.

13. Keywords
1. Very brief. 2. Severe.
3. 4. 5. 6.

Lancinating pain. Trigger zone. Trigeminal nerve distribution. Sleep not affected.

TREATMENT: I. Medical treatment: 1. Carbamazepine (Tegretol): 1.

2. 3.

Action as Dilantin. Usually begin with 200 mg, 2 times daily. Side effect: liver toxicity, agranulocytosis, visual

burning and dizziness. 2. Second line drugs 1. If the patient is unable to tolerate the side effects of carbamazepine or if the carbamazepine has been ineffective after 4 weeks at the maximum tolerated dose the patient should be started the second-line drugs.

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2.

The second line drugs are antiepileptic medicines gabapentin and oxcarbazepine and tricyclic

including

antidepressants including amitriptyline & imipramine. II. PERIPHERAL PROCEDURES

1.

Trigeminal neuralgia can be modulated by interruption of any part of the trigeminal pathway, from peripheral sensory nerves to the nerve root entry zone.

2.

Thus local anesthetic blocks of peripheral nerves can be used as an emergency measure.

3.

Peripheral nerve destruction usually by cryotherapy, alcohol injection, or nerve avulsion is used.

4.

The supraorbital, infraorbital, or mental nerves are most commonly approached.

5. The use of bone wax or silastic plugs at the foramen (Where the nerve has been avulsed) tends to slow down nerve regeneration with full sensation occur without return of trigeminal symptoms. Pain relief for 1-2 years. III. GANGLION PROCEDURES 1. Radiofrequency Thermocoagulation
1.

The radiofrequency needle passes into the foramen ovale to reach the trigeminal ganglion.

2.

When it is correctly placed, cerebrospinal fluid (CSF) should emerge on removal of the stylet because the ganglion contains CSF.

3.

The electrode is inserted just beyond the tip of the needle, and a low-amplitude current is applied using a lesion generator produce a temperature of 55- 60 in order to distruct the unmyelinated fibers of the ganglion.

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4.

Action: electro-coagulation of trigeminal ganglion (Based

on coagulation necrosis). 2. Glycerol Injection

1.

The injection performed in the gasserian ganglion Action: coagulation necrosis. Drugs used are: 100% glycerol. Periods of pain relief vary from 6-30 months. Ganglionic lysis: Glycerol 100% is injected in the

intracranially.
2. 3.

4.
5.

CSF of Meckel's cave to cause ganglion coagulation. It is a sensitive technique but gives reliable result of pain relief with no permant numbness. 3. Balloon Compression
1.

A 12-gauge spinal needle is advanced only just into the When inflated, the balloon should take on the shape of No more than 0.75 mL of contrast should be injected and the

foramen oval and the balloon catheter passed through it.

2.

Meckel's cave and should appear pear shaped.

3.

balloon should remain inflated for 1 minute.

4. Radiosurgery (Gamma knife):
1. 2.

It's an electromagnetic radiation with high energy. Selectively affect the affected sensory root fibers of trigeminal Disadvantages:

nerve. 3. Short period of pain relief. High recurrence.

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IV. SURGICAL TREATMENT (Open Procedures): 1. Trigeminal Root Section:

1.

It is an intra-cranial surgery in which the sensory roots of Disadvantages:

gasserian ganglion are cut sparing the motor root. 2. by cut nerves.

Produces a permanent anesthesia of the areas supplied Rendering the patient liable to keratitis, particularly Cranial nerve damage (fifth, seventh, or eighth) from Vascular damage. Postoperative hemorrhage causing cerebellar or

when the greater superficial petrosal nerve was damaged.

excessive retraction or manipulation.

brainstem compression. 2. Micro-vascular decompression "MVD" 1. A loop of an artery (usually superior cerebellar artery) which is resting on the trigeminal entry zone causing the nerve to produce the symptoms.
2. In this operation the loop of the artery is dissected, elevated and

then a small prosthesis are put to separate the artery from the nerve (called Jannetta S operation). 3. treatment. 4. Contraindications: Indications: Pt had a toxic reaction or even no response to medical

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 POSTOPERATIVE CARE
1. 2.

Poor surgical risk pt Pt had a good response to medical treatment.

All surgical procedures carry a risk of sensory loss. The affection of the first division of trigeminal nerve All patients should have an eye shield applied until they are If sensation is absent and fails to return, special glasses with

anesthesia of the cornea scarring blindness.

3.

cooperative enough for corneal sensation to be tested.

4.

side panels should be worn and the patient instructed about appropriate eye care.
5.

Postoperative care after open procedures: Observation in an intensive care unit is recommended to The patient will often have a headache or be dizzy or avoid the development of a posterior fossa hematoma.

nauseated for day or two and will not usually be discharged until the third or fourth postoperative day. 2. Pretrigeminal neuralgia.
1.

It is an aching dental pain in a region where physical and radioLocal anesthetic block of the tooth arrests pain. Pre-TN responds to similar treatments as TN, beginning with

graphic examination reveals no abnormality. 2.

3.

anticonvulsant therapy.

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3. Vago glossopharyngeal Neuralgia Definition: It is sharp, paroxysmal electric shock pain radiate from the oropharynx or base of the tongue to tonsils, larynx, soft palate, ear, the mandibular ramus or even to region of TMJ. Clinical picture: 1. 2. Pain is unilateral and of short duration. glossopharyngeal rather than the trigeminal nerve. Otic (pain related to the ear).
Pharyngeal (pain related to the angle of the jaw, throat and

3. Two distributions of pain are recognized:

neck). 4. 5. Swallowing, chewing, speaking, eating and drinking can Pain is stopped by anesthetizing the pharynx with topical trigger attacks. anesthetic where trigger point is located.
6. Vagal features sometimes occur (e.g. nausea, bradycardia)

during paroxysms. Incidence:

1.

Middle-aged and the elderly are mainly affected. Females > males.

2. Etiology: 1.

3. Left side affected more than right side. Vascular compression of the posterior inferior

cerebellar artery on the root entry at the medulla.

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D.D:
1.

Eagle syndrome: as similar pain distribution & intensity but

Eagle syndrome include dysphagia, foreign body sensation in throat, headache and pain on turning the head to the other side. Diagnosis: 1. 2. Treatment: 1. 2. Carbamazepine. Surgical decompression. 4. Herpes zoster (shingles)
The only non-dental pain that may truly mimic pulpal pain. Zoster is a viral inflammation of a posterior root ganglion,

It is difficult because of absence of skin trigger areas. The use of topical cocaine on tonsillar fossa eliminated pain

for 1-2 hrs.

affecting one or two peripheral sensory nerves.

Herpes zoster causes chicken pox in children but (like herpes

simplex) remains dormant in sensory ganglia until reactivated.

Reactivation in adults gives rise to shingles. The disease is common but mainly limited to adults, often over

60 years old.
In the trigeminal region the ophthalmic division is most

commonly affected.
The patient may present to the dentist if the 2nd or 3rd division of

the trigeminal nerve is involved.

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Symptoms
1. Severe, unilateral, deep seated, burning pain, in the prodromal

phase, a few days before the rash and vesicles develop.

2. The vesicles become weeping and crusting on the skin but

remain as shallow ulcers in the mouth.

3. The vesicles and ulcers are unilateral in distribution.

4. The patient will be feverish and feel unwell.

5. If the mouth is involved there will be pain and difficulty with

swallowing. Signs
1. If the maxillary division of the trigeminal nerve is involved, the

hard and soft palates are affected, unilaterally.

2. If the mandibular division, extensive unilateral cutaneous

lesions will be present.

3. With ophthalmic division involvement (Gasserian herpes)

serious corneal ulceration may develop.

4. The unilateral distribution of the lesions along the anatomical

distribution of the dermatome is characteristic of herpes zoster.

5. Unilateral groups of thin-walled vesicles or ulcers (intraoral)

stop sharply at the midline.

6. There may be pyrexia and regional lymph node enlargement and

tenderness.
7. A painful complication of herpes zoster infection is post-

herpetic neuralgia. Keywords

1. Unilateral distribution of lesions.

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2. Pain precedes vesicle formation.

Treatment
1. In severe cases and where health is already compromised,

aciclovir may be used (800 mg 5 times daily for 5 days).

2. Intravenous medication is indicated to avoid loss of sight.

5. Postherpetic neuralgia Definition:

1.

It is a neurological pain persists after reactivation of herpes

zoster along cranial nerve V (V1, V2, V3, VII Ramsay Hunt Syndrome).
2.

The ophthalmic division of the trigeminal nerve is most

commonly affected. Etiology:

1.

Acute herpes zoster infection of trigeminal ganglion and its

peripheral branches. Predisposing factors: 1. 2. 3. Old individual. Immunocompromised patient. Debilitated patient.

D.D from T.N: 1. 2. Vesicles erupt along distribution of nerve and not cross Pain is along all division of trigeminal nerves. midline.

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Clinically: 1.
2.

History of vesicles. Pain burning, constant, chronic and continuous (not Pain interfere with eating and brushing and affect only Overlying skin is often red as patients may scratch the skin to Geniculate ganglion involvement altered taste, salivary Motor part of facial nerve involvement Bell's palsy. Pain may be severe and persistent as it lead to suicidal

paroxysmal). 3. dermatome supplied by the affected nerve.

4.

gain temporary relief from the pain. 5. 6.

7.

secretion, lacrimation, ear and soft palate pain.

depression. Keywords 1. 2.
3. 4.

Continuous. Severe. Unilateral pain. Previous herpes zoster infection.

Treatment 1. 2. Topical: Capsaicin 0.025 % applied to the lesion. Systemic:

Tricyclic antidepressants. Anticonvulsants.

2 agonist.

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 Systemic lidocaine therapy. 3. Cryocautory.

4. Transcutaneous Rhizotomy.

6. Geniculate herpes (RamsayHunt syndrome) Signs and symptoms 1. Caused by herpes zoster infection of the geniculate ganglion.
2.

Pain occurs in the throat or ear, followed by vesicular eruption on the ear and fauces. A lower motor neurone facial palsy (see below) is evident. May be accompanied by tinnitus and vertigo. 1. 3. Excision of geniculate ganglion. Pharmacological treatment. 7. B ell's P alsy

3. 4.

Treatment: 2. Cut of the motor portion of facial nerve

Definition: Acute lower motor neurone palsy of the facial nerve. Etiology: Herpes simplexinfection, leading to oedema of the nerve in the facial canal. Clinically:
1. Affects both sexes equally, and is usually found in adults. 2. In 10% of patients recovery from facial paralysis is incomplete. 3. Unilateral facial paralysis. 4. Pain may precede or accompany thepalsy.

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Symptoms
1. Pain around the ear prior to or with the onset of paralysis, and

may radiate to the jaw.

2. Facial paralysis is usually of rapid onset. Paralysis of facial

muscles is unilateral. Signs

1. Diagnosis of the cause of pain becomes apparent when paralysis

sets in a few hours or days later.

2. On testing of the facial muscles, when paralysis has occurred,

the patient will be unable to approximate the eye lids or smile on the affected side. Keywords
1. Unilateral pain around ear 2. Followed closely by unilateral facial palsy

Treatment 1. Refer for specialist care, where prednisolone, perhaps in

2. Combination with aciclovir may be used.

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Notes:
1. The muscles of facial expression are supplied by the seventh

cranial (facial) nerve.

2. The neurones which control movement of the muscles of the

upper part of the face are innervated from both cerebral hemispheres.
3. In contrast, neurones controlling muscles of the lower face are

innervated only from the opposite hemisphere. 4. Facial nerve lesions may be:
Upper motor neurone lesion: The upper part of the face

is not involved, due to its bilateral innervation.

Lower motor neurone lesion: Both the upper and the lower

facial muscles are involved. The commonest cause is Bell's palsy.

5. Lower facial muscles are tested by asking the patient to smile or

show the teeth.

6. Upper facial muscles are tested by asking the patient to 'screw up'

the eyes or wrinkle the forehead.

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8. Multiple sclerosis Definition: 1. 2. Incidence: 1.

2. 3.

A systemic neurolgic pain associated with Auto immune disease of CNS Characterized

sclerosis & other acute pain syndromes throughout the body. by demylination or nerves. Age: 35 years. Females < males.

Mimic other causes of dental and non-dental pain, e.g. 3% patients with trigeminal neuralgia have multiple

trigeminal neuralgia.
4.

sclerosis.
Signs & symptoms:
1.

Retrobulbar neuritis may cause ocular pain. Multiple neurological lesions (e.g. paraesthesia, motor defect, Muscular weakness. Tingling or numbness of hands or feet. Loss of postural sense. Vertigo and sphincter disturbances. Facial pain usually occurs late in the disease.

2.

visual disturbance) may be present (caused by nerve demyelination).

3. 4. 5. 6.
7.

Etiology:
1.

Sensory dysfunction of spinothalamic tracts & post. Column

demyelination multiple segments of myeline loss in the pons with periventricular gray area in the forebrain.

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Diagnosis: 1.
2.

MRI reveals sclerotic plaques in multiples segment of Spinal fluid analysis for abnormal gamma globulin count &

pons & periventricular area in the forebrain. mononuclear leukocytosis. Keywords

1. Multiple neurological lesions. 2. Disseminated in time and location.

Treatment: 1.
2. 3.

Anticonvulsant drugs continues only when other pain G.G Glycerolysis if only trigeminal pain occurs alone. Tricyclic antidepressant. 9. Intracranial tumours

(lower back) is also present Carbamazepine.

In adults, the commonest intracranial neoplasms are gliomas, meningiomas, metastatic carcinoma (from lung or breast), neuroma (usually eighth nerve) and pituitary tumours.

In children, the commonest intracranial neoplasms are medulloblastoma and astrocytoma.

Symptoms:
1. Recurrent headache aggravated or precipitated by straining or

coughing.
2. Vomiting (usually associated with tumors of the posterior

fossa and due to direct involvement of the vomiting centre).

3. Progressive defects of function, both mental and physical, e.g.

deafness, visual deterioration, weakness, personality change, epilepsy.

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Signs
1. Papilloedema (bulging of the optic disc), due to obstruction of

CSF pathways. 2. Focal neurological signs (may serve to localize the tumor) e.g.:

Acoustic neuroma in the cerebello-pontine angle is the most

Sensory loss in the distribution of the trigeminal

common tumor affecting the trigeminal nerve., Leads to: nerve.

Absence of corneal reflex. Unilateral deafness. Weakness of the facial muscles if the facial nerve is

involved.
Spastic weakness of the opposite leg.

Parasagittal tumour (meningioma) compressing the olfac-

tory nerve causing anosmia. Pituitary adenoma causing bitemporal visual field defects. Diagnostic tests Cranial nerve examination. 10. Causalgia

Pain arising after injury to a peripheral sensory nerve, for example, following a difficult extraction.

Pain is due to aberrant nerve repair. Symptoms Constant, burning or boring pain at a site of previous trauma or surgery; can sometimes mimic trigeminal neuralgia. Signs

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Scarring from previous surgery or trauma. Keywords Scarring at site of pain Treatment Carbamazepine. Differential diagnosis of facial palsy 1. Neurologic:

Bell's palsy. Stroke. Cerebral tumour. Multiple sclerosis. HIV disease. Diabetes mellitus. RamsayHunt syndrome.

Surgery/trauma to facial nerve.

2. Primary muscle disease:

Myasthenia gravis. Surgery/trauma. Malignancy. Mastoiditis. Malignancy.

3. Parotid salivary gland lesions:

4. Middle ear disorder:

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II. Pain of vascular origin

1. Migraine Definition: Recurrent headache combined with autonomic disturbances (aura). Incidence and age 1. Usually starts in the second decade and diminishes with age.
2.

Women are more affected than men.

3. In 50% of cases there is a family history of migraine. Etiology Initial constriction of branches of the external carotid artery, causing the characteristic aura, followed by dilatation, causing the headache. Types:
1.

Classic migraine (with aura). Migraine without aura. Characterized by :

2. 1.

Classical migraine: Abrupt onset headache unilateral and deep throbbing. Headache may last 12 hours.

Affect frontotemporal region. Unilateral then secondary spread to the entire cranium.
2.

Headache is preceded by aura symptoms (prodromal,

preheadache stage causes lethargy).

3. Prodromal stage lasts 15-30 minutes and is followed by severe,

throbbing, temporal, frontal and orbital pain.

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4.

Aura include a reversible sensory, motor, visual and speech the face. Motor unilateral muscle weakness in the face. Visual Zig zag flickering light and blurred vision. Sensory numbness, paraesthesia and anasethesia of

disturbance:

5. The patient is obviously ill, pale, sweating and nauseous.

Vomiting may occur. Migraine without aura Headache is: Precipitating factors: 1.
2.

Unilateral. Throbbing. Moderate to sever. Accompanied by photophobia, phonophobia Aggravated by physical excretion.

and nausea and vomiting.

Stress events. Physical or psychological events. Trauma. Vasoactive foods as chocolate and bananas.

3.
4.

Keywords
1. Throbbing day-time headache lasting several hours.

2. Aura. 3. Photophobia. 4. Nausea and vomting.

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Treatment:
1. 2. 3. 4.

Sumatriptan. Non steroidal anti-inflammatory drugs (NSAIDs). Opioid analgesics. Antiemetics.

D.D:
1.

For the dentist knowledge of migraine is important, because

temporomandibular disorders may precipitate a migraine attack in a migraine-prone patient.

2.

Nausea and photophobia are not accompaniments with

masticatory musculoskeletal disorders or jaw and tooth pain of dental origin. 2. Periodic migrainous neuralgia (Sphenopalatine Neuralgia, C luster headache, alarm clock headache). Incidence and age
1. 2.
3.

affects young adults (20-40 years). Males more than females. Stress or alcohol may precipitate an attack. 1. Vascular compression of the ganglion by branches of

Etiology: internal maxillary artery. Signs and symptoms:

1.

Unilateral paroxysmal attack of pain.

2. Dull aching or burning headache.

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3. Unlike classic migraine, pain usually occurs at night.

4.

It is one of the few pain conditions that can

awaken the patient (from sleep) this observation is useful for diagnosis.
5.

Pain is of rapid onset and short duration, usually Pain is usually limited to the area around and Attacks recur at similar times of the night (alarm clock

lasting up to 30 minutes only, but occasionally up to 2 hours.

6.

behind the eye and related maxilla.

7.

waking) and are clustered (often once every 24 hours) and followed by a long period of remission for weeks, months or even years ('cluster headache').
8.

Autonomic symptoms may accompany periodic Nasal blockage (stuffy nose). Nasal d i s c h a r g e . Tearful eye. Unlike migraine, there is no:

migrainous neuralgia including:

9.

Nausea or visual disturbance. Trigger zone.

1.

Treatment: Ergotamine or anti-inflammatory drugs, e.g. IndomethaThe patient should avoid alcohol. cin may be employed.
2.

Keywords

1. 2.

Mainly males. Very severe pain.

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3.
4. 5.

Episodic (periodic). Similar time, often at night ('alarm clock awakening'). Occurs in bouts ('cluster headache'). Autonomic symptoms.

6.

Differential diagnosis
1. 2. 3.

Sinusitis. Retrobulbar neuritis. Giant cell arteritis. Acute glaucoma. Classic migraine. Trigeminal neuralgia. 3. Paroxysmal facial hemicranias

4.
5. 6.

Very similar to periodic migrainous neuralgia but without the autonomic problems. Treatment Indomethacin may be used. 4. Giant cell (temporal, cranial) arteritis

Pain is caused by ischaemia resulting from the arteritis. Affects females more than males and is restricted to the elderly (over 60 years).

Symptoms
1.

Severe, unilateral ache restricted to the temporal and frontal Pain can be brought on by eating due to ischaemia of the masti-

areas (i.e. side of head and behind the eye).

2.

catory muscles (known as masseteric claudication).

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3.

The temporal and frontal skin and scalp may be tender to the The patient feels unwell and may suffer aching and stiffness of This is one of the few pain disorders with systemic upset, e.g. Ocular symptoms include loss of vision in one part of the visual

touch.
4.

the shoulders and hips, termed `polymyalgia rheumatica'.

5.

lethargy, weight loss, weakness.

6.

field. Signs
1.

The temporal arteries may be occluded, pulseless,

thickened and tortuous. Keywords 1.

2. 3. 4.

Elderly, females Unilateral, boring pain. Masseteric claudication. Systemic upset. Temporal artery biopies. The ESR (or plasma viscosity, or C-reactive protein) is

Diagnostic tests
1. 2.

elevated. Treatment
1.

If the retinal arteries are involved rapid deterioration Acute necrosis of facial tissues may occur such as Using high-dose corticosteroids. 5. Cardiac ischaemia

in vision occurs.
2.

gangrene of the scalp, lip or tongue.

3.

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Symptoms
1.

Pain may refer to the left arm and left jaw, and may be Pain lasts a few minutes only and is relieved by rest. Attacks occur most often in cold weather.

related to exercise, eating a large -meal and emotion. 2. 3. Signs Diagnosis is by history. Treatment Refer for medical assessment and treatment. III. Maxillary antrum/nasopharynx 1. Sinusitis Infection (usually bacterial) of the maxillary sinus. Symptoms

1.

Usually unilateral, rarely bilateral,

dull/throbbing, continuous pain, limited to the upper jaw and under the eye.

2. 3. 4.

Pain is worse in the evening and with

bending or shaking of the head and lying down. Patients may experience the feeling

of fluid moving in the affected sinus. The associated stuffy nose, nasal

discharge and fullness of cheek may be described as a 'cold in the head'.

5. 6.
unwell.

Pressure over the cheek causes pain

and many upper teeth, on one side, may be painful. The patient may feel feverish and

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Signs
1.

Facial swelling may be seen with severe sinus in patients with diabetes mellitus or the

infections

immunocompromised.

2. 3.
molars). Keywords

Nasal obstruction with mucopurulent

rhinorrhoea. Tender maxillary teeth (usually

1. 2.
3. 4.

Unilateral pain under eye. Numerous maxillary teeth on one side Stuffy nose Fluid level.

may be painful.

Diagnostic tests

1.

Transillumination of the antra or an

occipitomental radiograph may show a fluid level or thickening of the antral lining. Treatment

2.
for five

Antibiotics, days, plus a

e.g. nasal

erythromycin, decongestant

amoxycillin or ampicillin 250 mg, four times per day (xylometazoline HCI) and inhalants.

3.

Antral washout or surgery may be

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recommended in severe/recurrent disease. 2. Malignancy

Any tumor arising along the intra- or extracranial course of the trigeminal nerve or within the nasopharynx or maxillary antrum may cause unilateral, dull, facial pain.

The most common malignancy affecting the maxillary antrum is squamous cell carcinoma. A tumor may spread from the antrum in any direction:

Through the anterior and infratemporal walls swelling Through the posterior wall damage the posterior

on the cheek, mimicking a dental abscess.

superior alveolar nerves anaesthesia of the teeth and gum in the maxillary molar region.

Through the floor swelling on the palate or buccal Through the roof involve the infra-orbital nerve

sulcus, mimicking a dental abscess.

facial anaesthesia + alteration of the pupillary level + preptosis (drooping of the eyelid) and diplopia.

Extension into the infratemporal fossa may involve the

sphenopalatine ganglion anaesthesia or paraesthesia of the palate.

Extension

through

recent

extraction

socket

mimicking an antral prolapse.

If the medial pterygoid muscle is involved, trismus may A tumor may extend into the nasal cavityl causing

result.

partial obstruction and nasal discharge.

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Teeth may be loosened and painful as a result of bone destruction, mimicking periodontal disease. The dental pulp may necrose as a result of disruption of the blood supply.

Symptoms and signs 1. 2. 3. diseases. Diagnostic tests 1.

2.

Occur late in the disease process. Depend upon the direction of spread (see above). May mimic those of other dental and non-dental

Lymph node examination. Drainage from the maxillary antrum is to the Lymphadenopathy may indicate metastatic spread. Transillumination. sinuscopy, radiography (occipitomental views),

submandibular and upper deep cervical nodes.

3.

4.
5.

tomography and biopsy.

3. Trotter's syndrome

Any pain remaining undiagnosed must be referred to exclude Nasopharyngeal tumor causing pain in the lower jaw, tongue and side of head, and middle ear deafness.

serious underlying pathology.

Acoustic neuroma (tumor of eighth cranial nerve) is mimicking other causes of facial pain.

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IV. Salivary glands Infection of salivary glands and obstruction of the ducts producepain dull

and pressure sensations which correlated with eating or the gland. milking Pain may be localized to the glandreferred to the teeth. or By examination the gland is tender, if duct is partially blockage pain

associated with swelling during eating. V. Oral mucosa: Zoster and geniculate herpes VI. Jaws/masticatory muscles Temporomandibular joint disorders include:
1.

Temporomandibular Osteoarthritis. Rheumatoid arthritis. Trauma. Developmental defects. Ankylosis. Infection. Neoplasia.

joint

pain-dysfunction

syndrome.
2. 3. 4. 5. 6.

7.
8.

1. Temporomandibular joint pain-dysfunction syndrome (PDS) (facial arthromyalgia) Incidence

1. 2.

Equal frequency between genders. Aged between 15 and 40 years.

Symptoms

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1.

Unilateral or bilateral, dull pain

within

the

temporomandibular joint (TMJ) and/or surrounding muscles.

2. 3.

If bilateral, one side is usually most affected. TMJ sounds, such as clicking, crunching or grating Headaches, facial pain and neck related aches Any headache is usually located in the temporal The pain is usually a dull ache. Unlike migraine, there are no associated features,

are described. 4. are reported.

5.

region.
6. 7.

such as photophobia or nausea. Signs 1.

2.

Joint clicks may occur. The masticatory muscles may be hypertrophic Mandibular movement may be limited and deviation Oral habits, such as parafunction, can be identified

(due to parafunction such as bruxism).

3.

may occur on the opening or closing cycle.

4.

in 50% of patients. Psychological considerations

1. 2.

Anxiety, depression is often accompanying PDS. The prevalence of depression in PDS is five times

greater than in the general population.

Diagnostic tests
1.

Clinical and radiographic examination usually

reveals no joint pathology.

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2.

Isolated headache or painless joint sounds are not

diagnostic of PDS. Keywords

1. 2.

More females present. Unilateral or bilateral dull ache, related surrounding Bruxism. Psychological stress. No TMJ pathology. Soft diet, elimination of chewing gum. Application of moist heat or ultrasound to painful muscles Analgesics. Anxiolytics (e.g. diazepam (muscle relaxant and

muscles.
3. 4. 5.

Treatment
1. 2.

and physiotherapy.
3. 4.

anxiolytic) 5 mg 1 hour before sleep, then 2 mg twice daily, for up to 10 days maximum). 5.
6. 7.

Antidepressants. Occlusal splints. Occlusal adjustment of the natural teeth by selective

grinding. 2. Osteoarthritis

Crepitation (crunching and grating) is the joint sound; crepitus denotes degenerative joint disease. May be accompanied by preauricular pain, but not involving the masticatory muscles. Radiographs will show degenerative joint disease.

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3. Rheumatoid arthritis 4. Trauma Condyle fracture or traumatic arthritis. Pain and trismus of traumatic arthritis resolve after one Crepitation is the joint sound.

week.

Microtrauma from parafunction may result in chronic

symptoms. 5. Developmental defects

7. Infection

Includes hyperplasia, hypoplasia, aplasia.

6. Ankylosis (rare in developed countries) Following trauma, infection or other inflammatory

condition.

8. Neoplasia

Following penetrating trauma to the joint or spreading

from middle ear or other structures.

Osteoma, chondroma, chondrosarcoma. VII. Ears

Otitis media (inflammation of the middle ear)

May present to the dentist as pain in the region of the

temporomandibular joint. May involve the facial (seventh cranial) nerve leading

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to unilateral facial paralysis.

VIII. Eyes Glaucoma Due to rapid increase in intraocular pressure. Symptoms Persistent, severe, unilateral orbital pain centred above the eye but may radiate across one side of the face. Signs The eye is stony hard, due to raised intraocular pressure. The pupil is dull, oval and dilated. The cornea is misty. IX. Psychogenic 1. Atypical facial pain Symptoms
1. The pain is described as a vague, constant, dull ache, present all

day every day.

2. It has been associated with depression or anxiety stress .

3. It is more common in females, over 50 years of age.

4. Appear as aching pain and feeling of pressure present continually for months,affect

maxilla more than mandible.

5. It may be unilateral or bilateral and cross midline.

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6. The continuous nature of the pain, often for years, the lack of

provoking and relieving factors and the inconsistency with clinical findings (no pathology identified) are characteristic.

Signs 1. No causative factor is detectable. 2. Cranial nerves are intact. K eywords

1. Mainly adult females. 2. Continuous (for months or years), unchanging pain. 3. Non-anatomical distribution. 4. Bizarre description. 5. No signs.

6. Sleep not affected Treatment 1. Psychotherapy. 2. Anxiolytics. 3. Anti-depressants. 2. Atypical odontalgia Atypical facial pain where the patient attributes the pain to the teeth. Symptoms
1. The etiology and symptomatology are the same as those of

atypical facial pain but the patient attributes the pain with the teeth.
2. Many dental treatments may have been attempted, by different

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dentists, including serial extraction, with no improvement in the pain.

3. Following extirpation of a pulp, or extraction of a suspected

tooth, the pain migrates elsewhere but usually nearby (i.e. to the next tooth). Signs None; diagnosis is by exclusion. Treatment Stop dental treatment and refer to an appropriate clinic. 3. Burning mouth syndrome (burning tongue, glossopyrosis, glossodynia, stomatodynia) Clinical presentation: 1. Sex: more common in female (postmenopausal women). 2. Age: usually over 50 years.
3. Nature: burning tongue, loss of taste, itching, and abnormal metallic taste. 4. Site: tongue, lips and hard palate or alveolar ridge.

Etiology
1. Psychological factors such as anxiety and depression.

Symptoms
1. Severe, constant, burning pain, often bilateral and present for

months or years.
2. Pain is often relieved by eating. 3. The tongue is involved most often but any mucous membranes

may be affected.
4. Sleep is not affected.

Signs

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No mucous membrane abnormalities can be seen in the area affected. Diagnostic tests (to exclude organic disease) may include:
1. Haematology. 2. Thyroid function.

3. Examine dentures.
4. Salivary flow test. 5. Examine for parafunction. 6. Swab/smear/oral rinse to test for candidal infection.

Treatment
1. When other factors have been excluded, the patient should be referred for

psychiatric assessment.
2. Antidepressants and cognitive behavioural therapy may be helpful.

Differential diagnosis of burning mouth 1. Psychogenic Burning mouth syndrome 2. Deficiency states Vitamin B Iron Folic acid 3. Infections Candidiasis 4. Other Denture discomfort Dry mouth Allergy Diabetes mellitus

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