35: Atypical (idiopathic) facial pain

Atypical (idiopathic) facial pain

Atypical facial pain (AFP) is a constant chronic orofacial discomfort or pain, for which no organic cause can be found

Patients are often older women

The pain is poorly localized; pain persists for much or all of the day, and is often of a deep, dull boring or burning type

There are often multiple oral and/or other psychogenic related complaints and consultations

Cognitive behavioural therapy or psychoactive medication may be needed

INTRODUCTION

Atypical or idiopathic facial pain (IFP) is a constant chronic orofacial discomfort or pain, which is defined by the International Headache Society as ‘facial pain not fulfilling other criteria’. Therefore, it is a diagnosis that can be difficult to make since it is reached only by the exclusion of organic disease. The organic disease that might cause similar chronic orofacial pain is typically in the local region but may be anywhere in the head and neck, or even in the chest; hence the difficulty in making this diagnosis safely.

IFP falls into the category of medically unexplained symptoms (MUS), most of which appear to have a psychogenic basis. It must be recognized, however, that a patient in pain may well also manifest psychological reactions to the experience.

Characteristics that define IFP are that:

it is a dull boring or burning continuous type of pain of ill-defined location with few, if any, periods of remission

objective signs are lacking

investigations all produce a negative result

there is no clear explanation as to the cause

there is poor response to treatment

there are often multiple consultations.

INCIDENCE

IFP is fairly common, possibly affecting around 1–2% of the population.

AGE

Patients are usually middle-aged or older; IFP is rare in children.

GENDER

Patients are often women (∼ 70%).

GEOGRAPHIC

There are no geographic factors implicated.

PREDISPOSING FACTORS

There are often recent adverse life events, such as bereavement or family illness and/or dental or oral interventive procedures.

AETIOLOGY AND PATHOGENESIS

The mouth and para-oral tissues have among the richest sensory innervation in the body. Furthermore, a large part of the sensory homunculus on the cerebral cortex receives information from orofacial structures. Right from infancy the mouth is concerned intimately with the psychological development of the individual, and disorders of structures such as the lips, teeth and oral mucosa can hold enormous emotional significance. It is hardly surprising, therefore, that orofacial disorders can result in considerable stress and that there are a range of psychogenic types of orofacial pain, including IFP.

Most sufferers from IFP are otherwise normal individuals who are, or have been, under extreme stress, such as bereavement or concern about cancer or an infection. Positron emission tomography in persons with IFP shows enhanced cerebral activity, suggesting an enhanced alerting mechanism in response to peripheral stimuli. This may lead to the release of neuropeptides and the production of free radicals, causing cell damage and the release of pain-inducing eicosanoids, such as prostaglandins. There may be a neuromuscular component.

Some patients have personality traits, such as hypochondriasis or neuroses (often depression), and a very few have psychoses.

CLINICAL FEATURES

HISTORY

The location of the pain is mainly in the upper jaw, unrelated to the anatomical distribution of trigeminal nerve innervation, poorly localized, and sometimes crosses the midline to involve the other side, or moves to another site.

The pain is chronic and often of a deep, dull boring or burning type, persisting for much or all of the day, but does not waken the patient from sleep.

Patients only uncommonly use analgesics to try and control the pain.

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.

There are often multiple oral and/or other psychogenic related complaints, such as:

chronic back pain

irritable bowel syndrome

The chronic pain may lead the patients to seek dental intervention, but to little avail. Patients may seek conservative dentistry, but this is rarely helpful – often rather to the contrary. The saga of pain may lead the clinician eventually to undertake endodontics or exodontics.

There is a high level of utilization of healthcare services: there have often already been multiple consultations and unsuccessful attempts at treatment. Many sufferers persist in blaming organic diseases (or the clinician!) for their pain.

DIAGNOSIS

Making this diagnosis is not simple and follows a process of elimination of other potential causes of orofacial pain (Table 35.1). IFP occurs in the trigeminal nerve territory, and the pain may sometimes be as sever/>

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Tags: Oral and Maxillofacial Medicine The Basis of Diagnosis and Treatment 3e

Jan 9, 2015 | Posted by mrzezo in Oral and Maxillofacial Pathology | Comments Off

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