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Facial pain

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Facial pain

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Dental-Usually acute presentation Unilateral Located within the mouth but sometimes may be difficult to localise More than 90 % of orofacial pain is dental in origin Usually severe and throbbing in nature Made worse by hot or cold food or drink or by biting on the affected side

Dental caries- common cause which can progress to infection of the pulp , apical abscess or periodontal disease
 Pulpitis / Pulpal
Reversible- pulp healthy and inflammation is mild 
○ pain does not linger after a stimulus
○ vague , sharp pain that cannot be located to any particular tooth

Irreversible- severe and pulp cannot be saved
○ spontaneous severe pain- throbbing or shooting or both
○ lasts longer even after the stimulus is removed
○ can be localised to a tooth
○ often worsened by heat and relieved by cold
 Peridontal disorders – pathology of structures surrounding the teeth- gum and bone support 
( peridontal tissues )
Commonest- gingivitis and periodontitis
 Dentoalveolar abscess – pus in structures that surround the teeth
 Pericoronitis- related to wisdom teeth
 Cracked tooth syndrome- tooth has a crack that is too small to show up on X-Rays or is under the gum and challenging to identify
○ sharp pain on biting, usually worse on release of pressure
 Dry Socket ( alveolar osteitis ) -localised small scale infection of the bone of a socket ( after a dental extraction ) , the more difficulty the extraction , higher the chances of dry socket developing
 Apical odontalgia- chronic form of dental pain without signs of pathology


Non-dental- salivary gland problems-Parotitis- parotid gland is the most commonly affected among the salivary glands by an inflammatory process
○ infection can be caused by viruses as paramyxovirus ( see below mumps ) , EBV , coxsackievirus , infuenza and para influenza virus
○ acute suppurative parotitis is commonly caused by staphylococcus aureus , streptococcus species and rarely gram negative bacteria
 Mumps -caused by paramyxovirus and is characterized by b/l parotid swelling
○ usually one gland is affected first followed closely by other
○ swollen gland may deflect the ear lobe upward and outward and angle of mandible may be obscured
 Tumour 85 % happen in the parotid gland followed by submandibular and minor salivary glands
○ most are benign commonest being a pleomorphic adenoma ( mixed tumour )
○ Mucoepidermoid carcinoma is the commonest malignant tumour
 Stones
○ pain with meals
○ most cases involve the submandibular gland
○ the gland involved may be tender

rhinosinusitis , malignancy-For e.g salivary gland tumours , nasopharyngeal carcinoma , carcinoma of the maxillary antrum , sinuses , brain

Neuralgias – Trigeminal neuralgia-Most common and most intense of the cranial neuralgias Sudden usually unilateral , severe , brief , stabbing , recurrent pain in the distribution of the one or more branches of the Vth cranial nerve ( IASP ) Sharp or electrical paroxysms last seconds to minutes and may occur in rapid succession About 5 % cases can be B/L Sensitive trigger zone- touching can unleash excruciating pain during routine daily activities Mandibular and maxillary branches most commonly affected Mostly idiopathic but sometimes may be associated with
○ compression- vascular or neoplastic ( MRI is indicated )
○ multiple sclerosis
○ skull base abnormalities Neurological examination usually normal

Glossopharyngeal neuralgia-Similar in quality to the pain of trigeminal neuralgia but less severe – may coexist with trigeminal neuralgia Glossopharyngeal and fibres of the vagus N supply sensation to the post 3rd of the tongue and oropharynx U/L pain deep in the pharynx , posterior aspect of tongue or the ear that is triggered by swallowing Can last up to 2sec to 2 minutes recurrent throughout the day 
( may disappear for weeks or months )

Other neuralgias-Headache associated with Optic neuritis – pain behind both eyes which may be worse with eye movement accompanies by impaired visual acuity Paratrigeminal oculosympathetic syndrome ( Raeder syndrome )- constant U/L pain along the dist of ophthalmic division of the trigeminal N along with ipsilateral ptosis and miosis ( Horners synd ) Herpes zoster- can affect trigeminal N ophthalmic division ( herpes zoster ophthalmicus ) in addition to pain it can cause ptosis, keratitis, uveitis , iritis , conjunctivitis or acute retinal necrosis
 ( sight threatening ) Nervus intermedius neuralgia- rare pain arises from sensory branch of the facial nerve Persistent idiopathic facial pain ( formerly called atypical facial pain ) syndrome of cont or daily recurring facial or oral pain without clinical neurological deficit Burning Mouth Syndrome- affects tongue usually b/l tip, lips, palate, buccal mucosa ( rare condition ) Occipital neuralgia Headache with ophthalmoplegia

Vascular- temporal arteritis-Chronic vasculitis charecterized by granulomatous inflammation in the walls of medium and large arteries Left untreated it can lead to blindness ie neuro-ophthamic emergency Rare below age of 50 Presentation can be with claudication when chewing , together with a constant U/L headache and diffuse pain around the ear

Trigeminal autonomic cephalgias-Group of neuralgias which typically cause recurrent lancinating pain over the ophthalmic br of the trigeminal nerve + nearly always with autonomic symptoms including ipsilateral tearing , nasal discharge , ptosis and miosis Three types – cluster headache , paroxysmal hemicrania , SUNCT syndrome

Others – Facial migraine Carotid artery dissection
○ life threatening
○ can be traumatic or spontaneous
○ major cause of ischaemic stroke in all age groups
○ presentation can be non-specific Post stroke pain

Temperomandibular joint disorder-Commonest non-dental cause of facial pain Complex heterogenous group of musculoskeletal and neuromuscular conditions Seen more in females Aetiology is unknown Diagnosed if presentation is with
○ pain in and around the TMJt if and/ or muscle of mastication which may radiate to other structure
○ reproducible jt noise of the RMJ on any jaw movements , with or without restricted movement or locking of the TMJ
○ headache limited to the temporal region
○ otalgia and / or tinnitus without ear disease Several diagnostic/ classification criteria exist for TMD eg the International Research Diagnostic Criteria for Temperomandibular Dysfunction Consortium Network ( 2013 )

Key questions –When did the pain start , how long it has 
been present and periodicity Frequency Location , intensity As about factors which make or trigger the pain and relieving factors as
○ hot , cold , sweet foods , chewing, eating , brushing
○ touching of face , wind
○ physical activity
○ posture
○ stress , tiredness Pain distribution – Uni-bilateral Headache ? What kind of pain ?
dull , throbbing , burning , aching or
 pressure Sinunasal symptoms -nasal blockage , congestion , discharge , bleeding Migraine pointers – nausea , photophobia , phonophobia Hearing loss, tinnitus, vertigo Impact of the pain on quality of life

The review here does not cover all aspects or causes of facial pain but addresses the most common presentations .The classification is to help the clinician approach the matter in a structured way. For eg you may hear term from ENT specialists – Midfacial segment pain which is considered to be a category of tension headache and is often a diagnosis of exclusion ( Orofacial pain BMJ 2018 )

References Differential diagnosis of facial pain and guidelines for management BJA : British Journal of Anaesthesia , Volume 111, July 2013 , Pages 95-104 Facial pain : the differential diagnosis in an ENT clinic ent and audiology news July/ August 2016 / Vol 25 No3 www.antaudiologynews.com Zakrzewska JM FACIAL PAIN: NEUROLOGICAL AND NON-NEUROLOGICAL Journal of Neurology, Neurosurgery & Psychiatry 2002;72:ii27-ii32. Colgate oral care centre via https://www.colgate.com/en-gb/oral-health Cranial Neuralgias William P. Cheshire et al Continuum Review Article American Academy of Neurology August 2015 Facial pain- red flag symptoms Dr Rupesh Amin GP Online February 2018 CKS NHS Giant cell arteritis July 2014 ,Mumps Diagnosis and management of parotitis Arch Otolaryngol Head and Neck surg . 1992 may ; 118 (5):469-71
( Abstract ) Facial pain – A diagnostic challenge Volume 44 , AFP No12, December 2015

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