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Zeroing in on the Cause of Your Patient's Facial Pain

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Zeroing in on the Cause of Your Patient's Facial Pain Feras Ghazal, DDS; Mohammed Ahmad, Zeroing in on the cause MD; Hussein Elrawy, DDS; Tamer Said, MD Department of Oral Health of your patient's facial pain (Drs. Ghazal and Elrawy) and Department of Family Medicine/Geriatrics (Drs. Ahmad and Said), The overlapping characteristics of facial pain can make it MetroHealth Medical Center, Cleveland, Ohio difficult to pinpoint the cause. This article, with a handy at-a-glance table, can help. [email protected] The authors reported no potential conflict of interest relevant to this article. acial pain is a common complaint: Up to 22% of adults PracticE in the United States experience orofacial pain during recommendationS F any 6-month period.1 Yet this type of pain can be dif- › Advise patients who have a ficult to diagnose due to the many structures of the face and temporomandibular mouth, pain referral patterns, and insufficient diagnostic tools. disorder that in addition to Specifically, extraoral facial pain can be the result of tem- taking their medication as poromandibular disorders, neuropathic disorders, vascular prescribed, they should limit disorders, or atypical causes, whereas facial pain stemming activities that require moving their jaw, modify their diet, from inside the mouth can have a dental or nondental cause and minimize stress; they (FIGURE). Overlapping characteristics can make it difficult to may require physical therapy distinguish these disorders. To help you to better diagnose and and therapeutic exercises. C manage facial pain, we describe the most common causes and underlying pathological processes. › Consider prescribing a tricyclic antidepressant for patients with persistent idiopathic facial pain. C Extraoral facial pain Extraoral pain refers to the pain that occurs on the face out- 2-15 Strength of recommendation (SoR) side of the oral cavity. TheTABLE summarizes the site, timing A Good-quality patient-oriented evidence and severity, aggravating factors, history and exam findings, B Inconsistent or limited-quality and management of several common causes of extraoral facial patient-oriented evidence pain. C Consensus, usual practice, opinion, disease-oriented evidence, case series Musculoskeletal pain Temporomandibular disorders (TMD) are a broad group of problems that affect the temporomandibular joint (TMJ), muscles of mastication, and/or associated bony and soft tis- sue structures.6 They may occur secondary to malocclusion, traumatic injuries, oral parafunctional habits (eg, bruxism), hormonal influences, or psychogenic factors.6 TMD is more prevalent in women, with a peak occurrence between ages 20 and 40 years.6,8 TMD can be articular (intracapsular) or nonarticular (extracapsular). Nonarticular disorders (>50% of TMD) usually affect the muscles of mastication and include chronic condi- tions such as fibromyalgia, muscle strain, and myopathies.8 524 The Journal of family PracTice | SePTEMBER 2015 | Vol 64, no 9 figure Causes of facial pain Facial pain Extraoral oral Musculoskeletal neuropathic Vascular Atypical Dental nondental Temporo- Trigeminal Giant cell Persistent caries Salivary gland mandibular neuralgia arteritis idiopathic disorders Pulpitis disorders facial pain Post-traumatic malignancy Sinusitis Periapical disease trigeminal pain cancer cracked tooth Glossopharyngeal mucosal disorders neuralgia Sensitivity Burning mouth Postherpetic alveolar osteitis syndrome neuralgia Periodontal disease atypical numb chin Pericoronitis odontalgia syndrome Muscle-related pain and dysfunction are z Treatment. Nonsteroidal anti-inflam- believed to arise from parafunctional hab- matory drugs, opioids, muscle relaxants, its such as bruxism or clenching. Articular antidepressants, anticonvulsants, anxiolytics, disorders include synovitis/capsulitis, joint and corticosteroids are options for treating effusion, trauma/fracture, internal derange- TMD.6,8 Isometric jaw exercises, maxilloman- ment (disturbance in the normal anatomic dibular appliances, and physical therapy are relationship between the disc and condyle), valuable adjuncts for pain relief. Advise pa- arthritis, and neoplasm.16 tients to establish a self-care routine to reduce z What you’ll see. Orofacial pain (usu- TMJ pain that might include changing their ally dull and located in the preauricular head posture or sleeping position, and limit- region), joint noise, and restricted jaw func- ing activities that require using their jaw, such tion are key signs and symptoms of TMD. as clenching, bruxism, and excessive gum Exacerbation of pain with mandibular func- chewing. Some patients may need to adopt a tions (eg, chewing, yawning, or swallowing) non-chewing diet that consists of liquid or pu- is a pathognomonic sign. Joint sounds such reed food. Massage and moist heat can help as clicking or crepitus are common. In most relax muscles of mastication and improve cases, crepitus correlates with osteoarthritis.6 range of motion. Nonspecific TMD symptoms include head- Approximately 5% of patients with TMD ache, earache, insomnia, tinnitus, and neck undergo surgery, typically simple arthrocen- and shoulder pain.6 tesis, arthroscopy, arthrotomy, or modified The gold standard of diagnosis of TMD condylotomy.6 Total joint replacement is indi- consists of taking a detailed history, evaluating cated only for patients with severely damaged the patient’s head and neck, and conducting a joints with end-stage disease when all other general physical examination and behavioral/ conservative treatments have failed. Joint re- psychological assessment.17 Imaging of the placement primarily restores form and func- TMJ and associated structures is essential.17 tion; pain relief is a secondary benefit.8 conTinued JfPonline.com Vol 64, no 9 | SePTEMBER 2015 | The Journal of family PracTice 525 TABLE Extraoral facial pain: Differential diagnosis2-15 Site Timing; severity aggravating factors history and physical exam management Temporomandibular disorders TmJ, muscles of abrupt but often chewing that is clicking or locking of TmJ, nSaids, muscle mastication, ear. may constant; moderate to prolonged, headaches, bruxism. attrition relaxants, radiate to the neck severe opening mouth of teeth, tenderness along the surgery TmJ, clicking, reduced opening of mouth Trigeminal neuralgia along the distribution Sudden onset, lasts eating, light depression, fear of pain anticonvulsants of the second and third seconds to minutes, up touch, cold, some returning. attack can be division of the to 30 attacks daily; attacks could be triggered with light touch; trigeminal nerve moderate to severe spontaneous sensory changes very rare Post-traumatic trigeminal pain Trigeminal area 3-6 months after Touch, cold or heat history of trauma or dental TCAs, traumatic event; procedure. Sensory changes, pregabalin, moderate to severe including allodynia gabapentin Glossopharyngeal neuralgia deep in the ear, throat, Sudden attacks, lasts chewing, talking, Syncope (rare). Provoked by anticonvulsants, and posterior tongue seconds to minutes, drinking, light touch TCAs, neuropath- often multiple attacks swallowing ic medications, daily; moderate to local anesthetics, severe surgery Postherpetic neuralgia Site of zoster rash constant or intermittent; light touch history of zoster. Skin changes. anticonvulsants, moderate to severe hyperesthesia, hypoesthesia, Tcas allodynia numb chin syndrome over the chin in the abrupt or gradual odontogenic hypoesthesia, paresthesia, Varies based on region supplied by the causes (eg, thermalgesic anesthesia or pain etiology mental nerve dental abscess, over the chin. if related to dental trauma, dental causes: percussion- osteomyelitis) induced pain, loosening of teeth. if malignancy is present, Systemic causes constitutional symptoms may (sarcoidosis, hiV, be seen malignancy) Persistent idiopathic facial pain not well localized constant; moderate to Stress, fatigue other chronic pain, significant Tcas, cBT severe life events. exam is usually normal Giant cell arteritis Temporal region Sudden onset, mastication Vision changes, often associated Prednisone continuous; moderate to with polymyalgia rheumatica. severe Temporal area tenderness cBT, cognitive behavioral therapy; hiV, human immunodeficiency virus; nSaids, nonsteroidal anti-inflammatory drugs; Tcas, tricyclic antidepressants; TmJ, temporomandibular joint. neuropathic pain episodes of pain in the distribution of one Trigeminal neuralgia (Tn) is sudden, usually or more branches of the trigeminal nerve.9 unilateral, severe, brief, stabbing, recurrent It most commonly presents in the lower 526 The Journal of family PracTice | SePTEMBER 2015 | Vol 64, no 9 2 branches of the trigeminal nerve and usu- seconds to minutes, with recurrent attacks ally is caused by compression of the trigemi- throughout the day. Like TN, GN can pres- nal nerve root by vascular or nonvascular ent as episodes of attacks that last weeks to causes.4 The pain is severe and can profound- months. Triggers include chewing, drink- ly impact a patient’s quality of life. ing, swallowing, and talking, as well as light TN attacks typically last from a few sec- touch.13,15 Some patients with GN experience onds to up to 2 minutes. As many as 30 at- syncope due to the anatomical proximity of tacks can occur daily, with refractory periods the vagus nerve.14 between attacks. After the initial attack, indi- z Treatment. Anticonvulsants are the viduals are left with a residual dull or burning first-line treatment for GN. Local anesthetics pain. TN can be triggered by face washing, or surgery can be considered
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