Nonsurgical Management of Facial Pain

Facial pain syndromes are common in clinical practice. Many of these syndromes are also unique, given the complex anatomy and specialized sensory innervation of the head, face, and neck, and thus can pose diagnostic challenges.

The common descriptive terms for craniofacial pain complaints are frequently misleading. To avoid confusion, clinicians should be familiar with the Diagnostic Classification for Head, Face, and Neck Pain Disorders of the International Headache Society (IHS), the “International Classification of Headache Disorders II” ( Boxes 31-1 to 31-3 ). Clinicians need to be able to distinguish among painful conditions that arise as a result of structural pathology of the oral and facial structures, temporomandibular joint (TMJ) disorders, myofascial pain disorders (MPDs), headache syndromes, and primary cranial neuralgias.

BOX 31-1
International Classification of Headache Disorders II

14 Categories

  • Primary headaches: 1-4

  • Secondary headaches: 5-12

  • Cranial neuralgias, central and primary facial pain, and other headache disorders: 13-14

From Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders: 2nd edition, Cephalalgia 24(Suppl 1):9-160, 2004.

BOX 31-2
Headache or Facial Pain Attributed to Disorders of the Cranium, Neck, Eyes, Ears, Nose, Sinuses, Teeth, Mouth, or Other Facial or Cranial Structures (11.1-11.8)

  • 11.1—Cranial bones

  • 11.2—Neck

  • 11.3—Eyes

  • 11.4—Ears

  • 11.5—Rhinosinusitis (sinus disorders)

  • 11.6—Teeth, jaws, or related structures

  • 11.7—TMJ disorders (TMD)

  • 11.8—Other

TMD, temporomandibular disorder; TMJ, temporomandibular joint.

From Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders: 2nd edition, Cephalalgia 24(Suppl 1):9-160, 2004.

BOX 31-3
Cranial Neuralgias, Central and Primary Facial Pain, and Other Headaches (13.1-13.19)

  • 13.1—Trigeminal neuralgia

  • 13.2—Glossopharyngeal neuralgia

  • 13.8—Occipital neuralgia

  • 13.12—Constant pain caused by compression, irritation, or distortion of cranial nerves or upper cervical roots by structural lesions

  • 13.15—Head or facial pain attributed to herpes zoster

    • Post-herpetic neuralgia

  • 13.18—Central causes of facial pain

    • Anesthesia dolorosa

    • Central post-stroke pain

      • Facial pain attributed to multiple sclerosis

      • Persistent idiopathic facial pain

      • Burning mouth syndrome

From Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders: 2nd edition, Cephalalgia 24(Suppl 1):9-160, 2004.

Diagnostic Evaluation

Pain in the mouth or face is one of the most common symptoms seen in clinical practice. The majority of symptoms are related to dental disease, and in most cases the cause can readily be established, the problem dealt with expeditiously, and the pain eliminated. However, in a few patients, pain may be persistent and defy attempts at treatment. Intractable oral and facial pain can be diagnostically challenging, given the many potential causes of pain, the anatomic complexity of the region, and the psychosocial importance of the face and mouth. A rigorous protocol for evaluating these patients includes a thorough history and an appropriate clinical examination.

A detailed history should always be obtained before examining the patient or ordering special tests or imaging studies because the history will establish a diagnosis in the majority of cases.

Chief Complaint

The patient’s description of the pain may provide clues to its cause. Primary neuralgias are frequently described as sharp and lancinating, secondary neuralgias have a burning quality, vascular headaches are throbbing, and muscle pain is described as a deep, dull ache. The patient may not be able to give all these descriptions at the first interview, and corroborating information from relatives and friends may be needed to build a general picture of the pain as it affects the patient. Each pain complaint should be listed in order of severity.

History of Present Complaint

The intensity of the pain needs to be measured against the patient’s own experience of pain, need for medication, and effect on lifestyle. For example, does the pain interfere with work, sleep, or social activities? How severe is it on a 10-point scale? Does it fluctuate over time? The origin of the pain should be determined by asking the patient to indicate the site of the pain or the site of its maximum intensity. Its anatomic distribution should be accurately traced in terms of local anatomy.

The patient should be encouraged to recall the events surrounding onset of the pain, even if it was several years ago. Any other instances of similar pain should be ascertained, even though the patient may not associate these events with the present problem. The time relationships of the pain should be clarified in terms of duration and frequency of attacks, as well as possible remissions.

Aggravating factors should be determined. Is the pain aggravated by the ingestion of specific foods or beverages; by lying down; during times of stress, talking, brushing the teeth, shaving, or applying make-up; or by other identifiable factors? In addition, relieving factors (e.g., lying down, sleeping, heat, and cold) are important clues.

The effects of previous treatments need to be clarified. Which medications have helped? Has surgery altered the nature of the pain? Has endodontic treatment or extraction affected the pain? Finally, the presence or absence of associated factors (e.g., swelling of the face, flushing, tearing, nasal congestion, or facial weakness) needs to be ascertained.

Medical History

A careful medical history and detailed history of the pain should be taken. In particular, any trauma to the head, face, and mouth should be noted. Current and past medications, relevant family history, and the use of over-the-counter medications, supplements, and alternative or complementary therapies should be identified. Any jaw habits such as clenching, grinding, posturing the jaw, or gum chewing, including occupational or vocational habits (e.g., playing a wind instrument, scuba diving, and so on), need to be identified. A comprehensive psychosocial history is imperative for all patients with chronic pain disorders. The details of any pending or planned disability claims or litigation should be ascertained.

Physical Examination

The purpose of the physical examination is to discover any possible anatomic or physiologic basis for the pain; therefore, it is important to proceed systematically. Patients with facial pain should undergo a complete head and neck examination, not an examination directed by a presumed diagnosis.

Neurologic Function

The most important evaluations involve cranial nerves V (trigeminal) and VII (facial) and the upper cervical nerves (C2-4). The three divisions of the trigeminal nerve—supraorbital, infraorbital, and inferior alveolar nerves—supply the majority of sensation to the mouth and face. The skin distribution of all three divisions should be examined, as well as the intraoral distribution of the second and third divisions. Directional sense, two-point discrimination, and sensory perception with von Frey hairs (Semmes-Weinstein microfilaments) may help in making the diagnosis. Hot and cold sensitivity and taste may need to be tested in certain situations. Pain with pressure over the six foramina may indicate trigeminal involvement. The corneal and gag reflexes should be assessed. The size and strength of the masticatory muscles reflect the motor division of cranial nerve V. Facial nerve function can be assessed by asking the patient to whistle, purse the lips, smile, close the eyes, and frown.

Upper cervical nerve sensation can be assessed on the scalp for C2 and at the angle of the jaw and upper part of the neck for C3. Pressure over the mid-superior nuchal line directly affects the greater occipital nerve and may reproduce the headache in patients with occipital neuralgia.

Because of the overlap of cranial nerves V, VII, IX, and X and their convergence on the spinal trigeminal nucleus, a more detailed examination of these nerves may be necessary. Cranial nerve IV and VI palsies may indicate increased intracranial pressure.

Muscle Function

Pain in the masticatory muscles, face, posterior cervical spine, and upper part of the back (the suprascapular and pectoral girdle) is a common cause of head, face, and neck pain, so the neck, shoulder, and masticatory muscles should be assessed thoroughly. The size of the muscles can be assessed visually (e.g., temporal hollowing, masseteric hypertrophy). The muscles should be palpated, trigger points noted, and head and neck posture assessed. A more thorough evaluation of the masticatory muscles includes measuring the maximum interincisal opening and lateral and protrusive excursions. Tremors, deviations, and fasciculations should also be noted.

Temporomandibular Joint

The lateral pole of the mandibular condyle should be palpated for tenderness with the mouth open and closed. Coarse and fine crepitation should be noted and joint noises auscultated. Clicks and pops and their position in the opening or closing cycle should be observed. Determining whether they are eliminated by separating the teeth with a tongue blade or by posturing the jaw forward will help focus on the functional importance of these joint noises.

Intraoral Examination

Interdigitation of the maxillary and mandibular teeth should be evaluated when the mouth is closed (dental occlusion), as well as the state of the dentition and oral hygiene. Evidence of wear on the teeth, excessive toothbrush abrasion, or erosion of the palatal surfaces of the teeth from repetitive vomiting should be assessed. The health of the oropharyngeal mucosa should be recorded, as well as the moistness of the mucosa and pooling of saliva. The parotid and submandibular glands can be milked to evaluate the quality and quantity of saliva expressed. The tongue and soft palate should be centered midline and move freely and symmetrically. Excessive draping of the soft palate, as seen in sleep apnea, should be noted.

Diagnostic Imaging

Periapical dental films and panoramic radiographs are inexpensive, are readily available, do not expose patients to excessive radiation, and offer detailed information about the teeth and jaws. Computed tomography (CT) can provide more detailed images of the bony structures of the jaws, TMJs, and base of the skull. Three-dimensional imaging can be helpful in some instances. Magnetic resonance imaging (MRI) is best for evaluating the soft tissues and can be used for assessing the deep oropharyngeal and nasopharyngeal anatomy and the internal anatomy of the TMJs. In addition, the brain can be evaluated with MRI, with and without gadolinium enhancement. MRI can also help determine whether the vasculature is impinging on the trigeminal ganglion, which can cause trigeminal neuralgia (TN).

A bone scan with technetium 99m will highlight areas of metabolic activity within the bone and can help identify areas of infection, tumor extension and continued growth, or degenerative change in the TMJ.

Laboratory Studies

Routine blood tests include a complete blood count and differential to exclude anemia and blood dyscrasias. The erythrocyte sedimentation rate may be elevated in patients with temporal arteritis. Rheumatoid factor and Lyme titer may be helpful in evaluating TMJ disease.

Common Facial Pain Disorders

As described earlier, the specialized structures of the head and face have a rich sensory innervation supplied by the trigeminal system, other cranial nerves, and the upper cervical roots. Consequently, pain is one of the most prominent symptoms of disease in this area. In most cases, the acute pain symptoms correlate closely with other signs and symptoms of disease. However, correlation between pain and symptoms may not be evident in a number of more complex, chronic pain problems, particularly those involving the craniofacial complex ( Box 31-4 ).

BOX 31-4
Common Craniofacial Pain Conditions

  • Dentoalveolar pathology

    • Pulpal

    • Periodontal

  • Odontogenic and non-odontogenic pathology

  • Trigeminal neuralgia and “equivalents”

  • Headache and neck pain

  • Temporomandibular disorders

  • Oral mucous membrane disease

  • Oral manifestations of systemic disease

  • Neuropathic pain (persistent idiopathic facial pain)

  • Burning mouth/tongue syndrome

Tooth-Related Disorders ( Table 31-1 )

Tooth pulp has a specialized and possibly exclusively nociceptive innervation. In contrast, periodontal tissues are innervated by a wide variety of sensory afferents. Dental pain is usually well localized, and the quality of the pain can range from a dull ache to severe electric shocks, depending on the specific cause and extent of disease. Dental pain is typically provoked by thermal or mechanical stimulation of the damaged tooth. Clinical and radiographic findings of dental decay, tooth fracture, or abscess drainage may confirm the source of dental pain.

TABLE 31-1
Odontogenic Pain
DIAGNOSIS PULPITIS PERIODONTAL CRACKED TOOTH DENTINAL
Diagnostic features Spontaneous and/or evoked deep/diffuse pain in compromised dental pulp. Pain may be sharp, throbbing, or dull Localized deep continuous pain in compromised periodontium (e.g., gingiva, periodontal ligament) exacerbated by biting or chewing Spontaneous or brief sharp pain in a tooth with a history of trauma or restorative work (e.g., crown, root canal) Brief, sharp pain evoked by different kinds of stimuli to the dentin (e.g., hot or cold drinks)
Diagnostic evaluation Look for deep caries and recent or extensive dental work. Pain provoked or exacerbated by percussion or thermal or electrical stimulation of affected tooth. Dental x-rays helpful (periapical) Tooth percussion over compromised periodontium provokes pain. Look for inflammation or abscess (e.g., periodontitis). Apical dental x-rays helpful (bitewings, periapical) Presence of tooth fracture may be detectable by x-ray. Percussion should elicit pain. Dental x-rays are helpful (periapical taken from different angles) Exposed dentin or cementum caused by recession of periodontium. Possible erosion of dentinal structure. Cold stimulation reproduces pain
Treatment Medication: NSAIDs, non-opiate analgesics
Dentistry: remove carious lesion, tooth restoration, endodontic treatment, or tooth extraction
Medication: NSAIDs, non-opiate analgesics, antibiotics, mouthwashes
Dentistry: drainage and débridement of periodontal pocket, scaling and root planing, periodontal surgery, endodontic treatment, or tooth extraction
Medication: NSAIDs, non-opiate analgesics
Dentistry: depends on level of the tooth fracture-restoration; treatment, or extraction of the tooth
Medication: mouthwash (fluoride), desensitizing toothpaste
Dentistry: fluoride or potassium salts, tooth restoration, endodontic treatment
Patient education: diet, tooth-brushing force and frequency, proper toothpaste
NSAIDs , non-steroidal anti-inflammatory drugs.

Dentinal pain is often evoked by stimuli and not well localized. It may result from areas of exposed dentin or defective restorations. Successful treatment involves the removal of any carious lesions and restoration of the tooth. In cases of exposed dentin sensitivity, treatment involves the use of desensitizing physical and chemical agents to decrease dentinal tubule permeability or decrease the sensitivity of dentinal neurons. Cervical hypersensitivity has also been managed successfully with the use of CO 2 and neodymium : yttrium-aluminum-garnet (Nd : YAG) lasers (see Table 31-1 ).

Pulpal pain, by contrast, is not stimulus-dependent, although it may be exacerbated by various stimuli (thermal, chemical, mechanical). When the patient describes the pain as mild to moderate and does not have a history of pain or pain on percussion, it is likely to be due to reversible pulpitis. Treatment is based on removal of the causative factor (e.g., caries), indirect pulp capping as necessary, and restoration of the tooth. When the described pain is moderate to severe or associated with a previous history of pain or with pain referral, it is most likely due to partial pulpal necrosis and irreversible pulpitis. Successful treatment consists of endodontic therapy or extraction (see Table 31-1 ).

Poorly localized pain in the orofacial region may also result from an incompletely fractured tooth. The typical pain of a cracked tooth is a sharp pain on biting and cold or hot hypersensitivity. However, patients may also complain of a more diffuse pain throughout the ipsilateral jaw, neck, ear, masticatory muscles, or TMJ. The diagnosis is based on the history and percussion or palpation of the individual cusps, transillumination of nonrestored or minimally restored teeth with fiberoptics, and probing of suspicious fissures, and it is confirmed by removal of restorations and direct inspection with or without staining. Treatment is dependent on the extent of the fracture (see Table 31-1 ).

Acute dental pain typically responds to local treatments (e.g., ice packs and reduced mechanical stimulation) or to systemic, non-steroidal anti-inflammatory drugs (NSAIDs). Opioid analgesics are also occasionally indicated, depending on the extent of objective pathology. Opioids should be used only short-term and in combination with NSAIDs. In many cases, treatment with antibiotic agents is appropriate and palliative until a definitive dental intervention is performed, as described earlier.

Disorders of the Periodontium (Periodontal Disease)

Chronic periodontal disease is an immune-mediated inflammatory process initiated by pathogenic oral microorganisms and resulting in either focal or generalized areas of destruction of the tooth-supporting structures and surrounding bone. Chronic periodontitis is not generally a chronically painful disorder. Typically, patients may notice gingival sensitivity and tenderness or gingival enlargement because of inflammation and bleeding with brushing or probing examination. There is loss of gingival attachment around the necks of teeth and soft tissue pocketing around the roots of teeth with loss of bone support, which may result in tooth sensitivity, tenderness, and mobility.

In patients with an acute infection in the periodontal tissues, tenderness to touch, erythema, and bleeding may be evident. An acute periodontal abscess may cause swelling and purulence (see Table 31-1 ). When inflammation or infection (i.e., acute pericoronitis) occurs in the soft tissue or bone around an erupting or partially erupted tooth (particularly third molars), similar signs and symptoms may be seen, with pain being a primary complaint.

The pain associated with periodontal disorders is likewise generally responsive to NSAIDs, opioid analgesic agents, or combination analgesic agents. An acute abscess may also have to be incised and drained. Areas of generalized periodontitis may be treated by tooth scaling and curettage of the gingival pocketing and, possibly, local or systemic antibiotic therapy.

Oral Mucous Membrane Disorders

Diseases of the oral mucosa are numerous and have a variety of local and systemic causes. Typically, these diseases are associated with pain and oral mucosal lesions, including vesicles, bullae, erosions, erythema, or red and white patches. Pain may be a symptom of the primary disease process, be secondary to an associated process (i.e., infection), or be related to damaged oral mucosa (i.e., mouth movements, chewing food, thermal, chemical) and is often treated with both systemic and local analgesic agents. Ulcerations of autoimmune etiology or unknown cause, such as aphthous ulcers, can be managed symptomatically with topical corticosteroids in an adherent vehicle for individual lesions. When multiple lesions are present, patients should use a solution containing corticosteroid with or without 2% viscous lidocaine.

Disorders of the Maxilla and Mandible

Numerous disorders of the bony structure of the jaws may be associated with pain. These disorders are generally classified as being of odontogenic or non-odontogenic origin. Tumors may be benign or malignant (either primary or metastatic disease). Frequently, additional historical or examination findings warrant further evaluation (e.g., swelling, mass, discoloration, numbness, weakness, bleeding, drainage, tooth loss or mobility). Pain can be treated symptomatically until a definitive diagnosis is established and definitive therapy is initiated.

Salivary Gland Disorders

Disorders of the three major pairs of salivary glands (parotid, submandibular, and sublingual) and the many hundreds of minor salivary glands in the mouth may also produce pain as a primary or associated symptom. These disorders are often accompanied by other signs and symptoms (including swelling, drainage, cervical adenopathy, or generalized signs of systemic infection), depending on the cause of the disorder. Disorders of the parotid gland can extend locally to produce otologic symptoms or cranial nerve (V, VII, or IX) involvement. Disorders of the submandibular gland may result in symptoms of impaired swallowing or impairment of cranial nerves V, IX, and XII.

Burning Mouth/Tongue Syndrome (Oral Burning)

See the section on neuropathic pain and Table 31-2 .

TABLE 31-2
Trigeminal Neuropathic Pain Disorders
DIAGNOSIS TRIGEMINAL NEURALGIA DEAFFERENTATION PAIN ACUTE AND POST-HERPETIC NEURALGIA BURNING MOUTH SYNDROME
Diagnostic features Brief severe lancinating pain evoked by mechanical stimulation of trigger zone (pain free between attacks). Usually unilateral, affects V2/V3 areas (rarely V1). Possible pain remission periods (for months/years) Spontaneous or evoked pain with prolonged after-sensation following tactile stimulation. Trigger zone caused by surgery (tooth extraction) or trauma. Positive and negative descriptors (e.g., burning, nagging, boring) Pain associated with herpetic lesions, usually in the V1 dermatome. Spontaneous pain (burning and tingling), but may be manifested as dull and aching. Occasional lancinating evoked pain Constant burning pain of the mucous membranes, tongue, mouth, hard or soft palate, or lips. Usually affects women >50 years
Diagnostic evaluation MRI for evidence of tumor or vasocompression of the trigeminal tract or root (cerebropontine angle). Rule out MS, especially in young adults Etiologic factors such as trauma or surgery in the painful area. Order MRI if the area is intact to rule out peripheral or central lesions Small cutaneous vesicles (AHN) or scarring (PHN), usually affecting V1. Loss of normal skin color. Corneal ulceration can occur. Sensory changes in affected area (e.g., hyperesthesia, dysesthesia) Rule out salivary gland dysfunction (xerostomia) or tumor, Sjögren’s syndrome, candidiasis, geographic or fissured tongue, chemical or mechanical irritation, nutrition, and menopause
Treatment Medication: anticonvulsants (e.g., carbamazepine, gabapentin), antidepressants (e.g., amitriptyline, nortriptyline, desipramine), non-opiate analgesics, BTX. Combination of baclofen and anticonvulsants can produce good results
Surgery: microvascular decompression of trigeminal root, ablative surgeries (e.g., rhizotomy, Gamma Knife)
Medication: anticonvulsants (e.g., carbamazepine, gabapentin), antidepressants, non-opiate analgesics, topical agents (e.g., 5% lidocaine patches)
Surgery: ablative surgeries (e.g., rhizotomy, Gamma Knife)
Medication: acyclovir (acute phase), anticonvulsants, antidepressants, non-opiate analgesics, topical agents (e.g., 5% lidocaine patches)
Surgery: ablative surgeries (e.g., rhizotomy, Gamma Knife)
Medication: anticonvulsants, benzodiazepines, antidepressants, non-opiate analgesics, topical agents (e.g., lidocaine, mouthwashes)
Cognitive-behavioral: biofeedback, relaxation, coping skills
AHN, acute herpetic neuralgia; BTX, botulinum toxin; MS, multiple sclerosis; PHN, post-herpetic neuralgia.

Ophthalmologic Disorders

Pain in and around the eye is a common problem. Most ophthalmologic conditions producing eye pain are associated with obvious ocular symptoms, signs, or histories that implicate the eye as the origin of pain. Several facial pain and headache syndromes have “eye pain” as the chief symptom. In addition, during the history and physical examination, several signs and symptoms warn of more serious eye disease and even potentially life-threatening problems.

A complete ocular history should include any previous visual loss, ophthalmic diseases (e.g., corneal infections, uveitis, glaucoma), use of contact lenses, recent or remote ocular surgery, and ocular trauma. In addition to noting the specific features of the pain when taking the history for eye pain, such as the time of onset, severity, exacerbating and palliating factors, radiation, quality, duration, and frequency, the specific location of the pain should be ascertained (e.g., intraocular, retrobulbar, periocular, or frontal), as well as associated symptoms such as tearing, loss of vision, double vision, photophobia, and discharge.

Simple instruments are required to perform the basic eye examination, and a pain specialist can triage patients with eye pain and identify those who require formal ophthalmologic consultation. Such equipment includes a near vision card (Snellen card), a hand light, and a direct ophthalmoscope. The Snellen card is used to check visual acuity, which should be tested by using the patient’s spectacle correction, and each eye should be tested individually. The pupil’s response to light, the regularity of the pupil, and relative afferent papillary defects should be evaluated with a hand light. In addition, extraocular motility and the eyelids should be examined. A hand light should be used to assess the conjunctiva for chemosis, injections, and foreign bodies and the cornea for keratitis, foreign bodies, and lacerations. Evaluation of the optic nerve with a direct ophthalmoscope should be sufficient to exclude gross optic atrophy, funduscopic abnormalities, and papilledema.

Ocular and Orbital Causes of Eye Pain

The eye is rarely the source of head and facial pain localized to the periorbital structures without clinical signs such as red eye or symptoms such as decreased vision or a history of eye trauma. If findings on the basic eye history and examination are normal, an intraocular cause of the pain is less likely. However, in some ocular causes of eye pain, the eye is superficially normal. The clinician should be able to recognize the features of these uncommon causes of eye pain and make the necessary urgent or semi-urgent referral to an ophthalmologist.

In addition, a number of facial pain syndromes accompanied by prominent ophthalmologic signs and symptoms may be encountered by the oral and maxillofacial surgeon. The history and physical examination will define the differential diagnosis of these syndromes. Treatment of these disorders is specific to the disorder and may be part of the therapeutic spectrum of the oral and maxillofacial surgeon.

Otologic Disorders ( Table 31-3 )

Ear pain is a common complaint that may be due to otologic or non-otologic causes. The pain, often described as dull and aching with a stopped-up sensation, may be localized to the area around the ear or may spread to involve half or all of the head. It may also be referred to the vertex. Pain in the ear is as likely to be referred from other structures as it is to be stemming from the ear itself. If ear pain is not part of the orofacial pain complaint, it is highly unlikely that the ear is the pain source.

TABLE 31-3
Paranasal, Periocular, Periauricular, and Head and Neck Cancer Pain
DIAGNOSIS PARANASAL SINUS PAIN PERIOCULAR PAIN PERIAURICULAR PAIN HEAD AND NECK CANCER
Diagnostic features Bilateral or unilateral throbbing or pressure in the frontal area, pain exacerbated by leaning forward or palpation over the sinus Pain or tenderness with or without eye movements, deep orbital pain, referred pain Diffuse aching or sudden pain with or without aural discharge (e.g., otitis media) Variety of symptoms. Pain may be due to tumor, nerve compression, secondary infection, secondary myofascial pain, deafferentation, radiotherapy, chemotherapy
Diagnostic evaluation History of chronic allergies, frequent URIs, sinusitis, headaches of various types, sinus surgery
Refer to ENT for endoscopic and/or CT study (e.g., sinus opacification)
Examine the eyelids, lacrimal function, conjunctiva, sclera. Ophthalmoscopy and ophthalmology referral. Rule out primary headache, temporal arteritis, orbital pseudotumor The area is innervated by multiple cranial and cervical nerves, so complete functional and structural examination necessary (e.g., inspect tympanic membrane, TMJ, and myofascia). CT and MRI invaluable for mastoiditis and cholesteatoma Complete evaluation by multidisciplinary team, CT, MRI, endoscopy, biopsy, and surveillance. Treatment coordination by oncologist
Treatment ENT evaluation/treatment
Medication: sinusitis—topical decongestants, systemic antibiotics; chronic sinus pain—NSAIDs, non-opiate analgesics, topical agents (lidocaine spray), anticonvulsants, antidepressants, BTX
Surgery
Proper ophthalmologic evaluation and treatment
Medication: NSAIDs, non-opiate analgesics, systemic antibiotics, topical corticosteroids, BTX across the forehead and glabellar areas in selected cases
Surgery
Proper ENT evaluation and treatment
Medication: NSAIDs, non-opiate analgesics, systemic antibiotics, topical corticosteroids, BTX in selected cases
Surgery
Oncologic evaluation and treatment
Medication: anticonvulsants, antidepressants, opiate or non-opiate analgesics, topical agents, muscle relaxants
Surgery: ablative surgeries
BTX , botulinum toxin; CT , computed tomography; ENT , ear, nose, and throat; MRI , magnetic resonance imaging; NSAIDs, non-steroidal anti-inflammatory drugs; TMJ, temporomandibular joint; URI, upper respiratory infection.

Primary otalgia arises from disease of the external or middle ear and is identified by inspection of the external ear and tympanic membrane. If the inspection reveals abnormal findings, otologic referral for comprehensive diagnosis and treatment would be appropriate. In the absence of local pathology, the pain is probably referred to the ear from another structure.

Sensory innervation of the ear involves cranial nerves V, VII, IX, and X, as well as C2 and C3. Pain referred to the ears (secondary otalgia) may originate in any structure with common innervations. Treatment of referred ear pain requires proper identification of the pain source.

Disorders of the Paranasal Sinuses (see Table 31-3 )

Sinus pain or “sinus headache” is another common complaint. Rhinosinusitis is inflammation of the nose or paranasal sinuses (or both) and is characterized by blockage or congestion, discharge, facial pain or pressure, loss of smell, or any combination of these symptoms. The inflammation is often due to allergy, infection, drugs, or hormones. Patients may also complain of sore throat, dysphonia, or coughing. The symptoms are frequently bilateral. Unilateral symptoms or associated bloody discharge may result from neoplasm and necessitates further evaluation and identification of the source of the pain. Immediate referral is necessary when any of the following symptoms are present: periorbital edema, a displaced globe, double vision, reduced visual acuity, or frontal swelling.

The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) recommends nasal endoscopy and CT of the paranasal sinuses for definitive diagnosis of rhinosinusitis, although most cases can be diagnosed clinically. The clinical findings must include two or more major factors or one major factor and two minor factors. These include chronic facial pressure of the maxillary region, headache, rhinorrhea, postnasal drip, decreased sense of smell, and dental pain. Classification of adult rhinosinusitis (acute, subacute, chronic, and acute exacerbations of chronic rhinitis) is important in providing appropriate treatment.

Acute sinusitis is assumed to be viral. Analgesics for pain relief, intranasal decongestants, and nasal irrigation with hypertonic saline can improve the symptoms but will not shorten their duration. If the symptoms worsen or do not improve within 7 days, the AAO-HNS guidelines suggest the addition of antibiotics and topical steroids. When the symptoms are severe or do not respond to treatment, appropriate referral must be considered.

Management of chronic rhinosinusitis is dependent on the underlying cause. The goal of treatment is elimination of infection and inflammation, removal of occlusion, and improvement of symptoms. Proper referral for evaluation and management is necessary. Patients who are refractory to conservative therapies may require surgery.

Chronic facial pain and headache are not generally thought to be due to chronic/recurrent sinus pathology and are probably another headache or facial pain syndrome. Recent consensus guidelines offer data to support this along with diagnostic and therapeutic recommendations for facial pain and headaches.

Temporal Arteritis

Orofacial pain may be vascular in origin. In giant cell arteritis (GCA), giant cells infiltrate the walls of the cranial arteries. In temporal arteritis, the superficial temporal artery is affected. Other arteries commonly affected by GCA include the maxillary, ophthalmic, and posterior ciliary arteries. It most commonly affects the elderly. The involved artery may be enlarged and tender to palpation. Patients often complain of intense or deep headache that worsens on lying flat, malaise, weakness, and weight loss. Jaw claudication is a common finding that can mimic the much more common temporomandibular disorders. Occlusion of the optic artery may result in visual disturbances, including blindness. Laboratory studies reveal elevated erythrocyte sedimentation rates and C-reactive protein. Arterial biopsy is required for definitive diagnosis. Treatment with high-dose corticosteroid (40 to 60 mg/day) therapy should begin immediately, followed by referral for biopsy and long-term management. A delay in treatment may result in irreversible blindness. GCA is usually self-limited, but relapse does occur.

Other Disorders

Another vascular source of orofacial pain is carotid artery dissection. The pain is generally unilateral, and damage to the sympathetic plexus often results in unilateral Horner syndrome. Suspicion of carotid artery dissection necessitates immediate referral. Treatment includes the administration of anticoagulant or antiplatelet therapy or stent placement.

Orofacial pain may result from systemic disease, including connective tissue diseases, the diagnosis and treatment of which are beyond the scope of this text. However, it should be noted that appropriate diagnosis of underlying systemic disease, should it exist, is paramount in managing the associated symptoms.

Tumors

Numerous intracranial and extracranial tumors can cause oral cavity, oropharyngeal, facial, and head pain as a primary initial symptom (see Table 31-3 ). Cancers of the upper aerodigestive tract, jaws, base of the skull, and neck may all be manifested as pain along with other associated signs and symptoms. In addition, numerous intracranial tumors and lesions (e.g., vascular malformations) can be accompanied by facial pain and headache. These are primarily tumors of the cerebellopontine angle; however, various primary brain neoplasms and metastatic disease have been associated with facial pain and headache. Headache and facial pain of unknown origin should warrant careful evaluation for an underlying occult tumor.

Patients with facial pain or headache should undergo a comprehensive medical history and careful physical examination with particular attention directed to the cranial neurologic examination. Consideration should be given to obtaining appropriate imaging studies, including CT, MRI, and magnetic resonance angiography.

Temporomandibular Disorders

Temporomandibular disorders are defined as a subgroup of craniofacial pain problems that involve the TMJ, masticatory muscles, and associated head and neck musculoskeletal structures. Patients with temporomandibular disorders most frequently have complaints of pain, limited or asymmetric mandibular motion, and TMJ sounds. The pain or discomfort is often localized to the jaw, TMJ, and muscles of mastication. Common associated symptoms include ear pain and stuffiness, tinnitus, dizziness, neck pain, and headache. In some cases the onset is acute and the symptoms are mild and self-limited. In other patients, a chronic temporomandibular disorder with persistent pain in association with physical, behavioral, psychological, and psychosocial symptoms develops, similar to the findings in patients with chronic pain syndromes in other areas of the body (e.g., arthritis, low back pain, chronic headache, fibromyalgia, and chronic regional pain syndrome [CRPS]), all requiring a coordinated interdisciplinary diagnostic and treatment approach.

Temporomandibular disorders are classified as one subtype of secondary headache disorder in the Classification of Headache Disorders II by the IHS (see Box 31-2 ). The American Academy of Orofacial Pain has expanded on this IHS classification, as shown in Boxes 31-5 and 31-6 .

BOX 31-5
Temporomandibular Joint Articular Disorders

  • Congenital or developmental

    • Aplasia

    • Hypoplasia

    • Hyperplasia

    • Neoplasia

  • Disc derangement disorders

    • Disc displacement with reduction

    • Disc displacement without reduction

  • Temporomandibular joint dislocation

  • Inflammatory disorders

    • Capsulitis/synovitis

    • Polyarthritides

  • Osteoarthritis (non-inflammatory)

    • Primary osteoarthritis

    • Secondary osteoarthritis

  • Ankylosis

  • Fracture

BOX 31-6
Masticatory Muscle Disorders

  • 11.7.2.1—Local myalgia

  • 11.7.2.2—Myofascial pain

  • 11.7.2.3—Centrally mediated myalgia

  • 11.7.2.4—Myospasm

  • 11.7.2.5—Myositis

  • 11.7.2.6—Myofibrotic contracture

  • 11.7.2.7—Neoplasia

From Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders: 2nd edition, Cephalalgia 24(Suppl 1):9-160, 2004.

The prevalence among adults in the United States of at least one sign of temporomandibular disorders is reported to be 40% to 75%, and in those with at least one symptom, the prevalence is 33%. TMJ sounds and deviation on opening the jaw occur in approximately 50% of otherwise asymptomatic persons and are considered within the range of normal and do not require treatment. Other signs such as decreased mouth opening and occlusal changes occur in less than 5% of the general population. Temporomandibular disorders are most commonly reported in young to middle-aged adults (20 to 50 years). The female-to-male ratio of patients seeking care has been reported to be 3 : 1 to as high as 9 : 1. Despite the high prevalence of temporomandibular disorders, signs, and symptoms, only 5% to 10% of symptomatic people require treatment, given the wide spectrum of symptoms and the fact that the natural history of this disorder suggests that many patients (up to 40%) undergo spontaneous resolution of their symptoms.

Common Facial Pain Disorders

As described earlier, the specialized structures of the head and face have a rich sensory innervation supplied by the trigeminal system, other cranial nerves, and the upper cervical roots. Consequently, pain is one of the most prominent symptoms of disease in this area. In most cases, the acute pain symptoms correlate closely with other signs and symptoms of disease. However, correlation between pain and symptoms may not be evident in a number of more complex, chronic pain problems, particularly those involving the craniofacial complex ( Box 31-4 ).

BOX 31-4
Common Craniofacial Pain Conditions

  • Dentoalveolar pathology

    • Pulpal

    • Periodontal

  • Odontogenic and non-odontogenic pathology

  • Trigeminal neuralgia and “equivalents”

  • Headache and neck pain

  • Temporomandibular disorders

  • Oral mucous membrane disease

  • Oral manifestations of systemic disease

  • Neuropathic pain (persistent idiopathic facial pain)

  • Burning mouth/tongue syndrome

Tooth-Related Disorders ( Table 31-1 )

Tooth pulp has a specialized and possibly exclusively nociceptive innervation. In contrast, periodontal tissues are innervated by a wide variety of sensory afferents. Dental pain is usually well localized, and the quality of the pain can range from a dull ache to severe electric shocks, depending on the specific cause and extent of disease. Dental pain is typically provoked by thermal or mechanical stimulation of the damaged tooth. Clinical and radiographic findings of dental decay, tooth fracture, or abscess drainage may confirm the source of dental pain.

TABLE 31-1
Odontogenic Pain
DIAGNOSIS PULPITIS PERIODONTAL CRACKED TOOTH DENTINAL
Diagnostic features Spontaneous and/or evoked deep/diffuse pain in compromised dental pulp. Pain may be sharp, throbbing, or dull Localized deep continuous pain in compromised periodontium (e.g., gingiva, periodontal ligament) exacerbated by biting or chewing Spontaneous or brief sharp pain in a tooth with a history of trauma or restorative work (e.g., crown, root canal) Brief, sharp pain evoked by different kinds of stimuli to the dentin (e.g., hot or cold drinks)
Diagnostic evaluation Look for deep caries and recent or extensive dental work. Pain provoked or exacerbated by percussion or thermal or electrical stimulation of affected tooth. Dental x-rays helpful (periapical) Tooth percussion over compromised periodontium provokes pain. Look for inflammation or abscess (e.g., periodontitis). Apical dental x-rays helpful (bitewings, periapical) Presence of tooth fracture may be detectable by x-ray. Percussion should elicit pain. Dental x-rays are helpful (periapical taken from different angles) Exposed dentin or cementum caused by recession of periodontium. Possible erosion of dentinal structure. Cold stimulation reproduces pain
Treatment Medication: NSAIDs, non-opiate analgesics
Dentistry: remove carious lesion, tooth restoration, endodontic treatment, or tooth extraction
Medication: NSAIDs, non-opiate analgesics, antibiotics, mouthwashes
Dentistry: drainage and débridement of periodontal pocket, scaling and root planing, periodontal surgery, endodontic treatment, or tooth extraction
Medication: NSAIDs, non-opiate analgesics
Dentistry: depends on level of the tooth fracture-restoration; treatment, or extraction of the tooth
Medication: mouthwash (fluoride), desensitizing toothpaste
Dentistry: fluoride or potassium salts, tooth restoration, endodontic treatment
Patient education: diet, tooth-brushing force and frequency, proper toothpaste
NSAIDs , non-steroidal anti-inflammatory drugs.

Dentinal pain is often evoked by stimuli and not well localized. It may result from areas of exposed dentin or defective restorations. Successful treatment involves the removal of any carious lesions and restoration of the tooth. In cases of exposed dentin sensitivity, treatment involves the use of desensitizing physical and chemical agents to decrease dentinal tubule permeability or decrease the sensitivity of dentinal neurons. Cervical hypersensitivity has also been managed successfully with the use of CO 2 and neodymium : yttrium-aluminum-garnet (Nd : YAG) lasers (see Table 31-1 ).

Pulpal pain, by contrast, is not stimulus-dependent, although it may be exacerbated by various stimuli (thermal, chemical, mechanical). When the patient describes the pain as mild to moderate and does not have a history of pain or pain on percussion, it is likely to be due to reversible pulpitis. Treatment is based on removal of the causative factor (e.g., caries), indirect pulp capping as necessary, and restoration of the tooth. When the described pain is moderate to severe or associated with a previous history of pain or with pain referral, it is most likely due to partial pulpal necrosis and irreversible pulpitis. Successful treatment consists of endodontic therapy or extraction (see Table 31-1 ).

Poorly localized pain in the orofacial region may also result from an incompletely fractured tooth. The typical pain of a cracked tooth is a sharp pain on biting and cold or hot hypersensitivity. However, patients may also complain of a more diffuse pain throughout the ipsilateral jaw, neck, ear, masticatory muscles, or TMJ. The diagnosis is based on the history and percussion or palpation of the individual cusps, transillumination of nonrestored or minimally restored teeth with fiberoptics, and probing of suspicious fissures, and it is confirmed by removal of restorations and direct inspection with or without staining. Treatment is dependent on the extent of the fracture (see Table 31-1 ).

Acute dental pain typically responds to local treatments (e.g., ice packs and reduced mechanical stimulation) or to systemic, non-steroidal anti-inflammatory drugs (NSAIDs). Opioid analgesics are also occasionally indicated, depending on the extent of objective pathology. Opioids should be used only short-term and in combination with NSAIDs. In many cases, treatment with antibiotic agents is appropriate and palliative until a definitive dental intervention is performed, as described earlier.

Disorders of the Periodontium (Periodontal Disease)

Chronic periodontal disease is an immune-mediated inflammatory process initiated by pathogenic oral microorganisms and resulting in either focal or generalized areas of destruction of the tooth-supporting structures and surrounding bone. Chronic periodontitis is not generally a chronically painful disorder. Typically, patients may notice gingival sensitivity and tenderness or gingival enlargement because of inflammation and bleeding with brushing or probing examination. There is loss of gingival attachment around the necks of teeth and soft tissue pocketing around the roots of teeth with loss of bone support, which may result in tooth sensitivity, tenderness, and mobility.

In patients with an acute infection in the periodontal tissues, tenderness to touch, erythema, and bleeding may be evident. An acute periodontal abscess may cause swelling and purulence (see Table 31-1 ). When inflammation or infection (i.e., acute pericoronitis) occurs in the soft tissue or bone around an erupting or partially erupted tooth (particularly third molars), similar signs and symptoms may be seen, with pain being a primary complaint.

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Jun 4, 2016 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Nonsurgical Management of Facial Pain
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