ORAL MEDICINEORAL MEDICINE Orofacial Disease: Update for the Clinical Team: 9. Orofacial Pain CRISPIAN SCULLY AND STEPHEN PORTER acute sinusitis a cold is often followed by Abstract: Orofacial pain, the main reason why many patients seek dental advice, usually has local pain and tenderness (but not a local cause—primarily the sequelae of dental caries—but a wide range of diseases, particularly neurological, psychogenic and vascular disorders, can cause orofacial pain. This swelling) and radio-opacity of the article will discuss disorders that can present with pain and the neurological, psychogenic and affected sinuses, sometimes with an vascular causes of orofacial pain. obvious fluid level. Pain may be The first article in this series made several general observations on diagnosis and treatment aggravated by change of position of the which should be borne in mind in relation to the material presented here. head. With maxillary sinusitis, pain may be felt in related upper molars, which Dent Update 1999; 26: 410-417 may be tender to percussion. The pain of Clinical relevance: Orofacial pain is the main presenting complaint of many patients. ethmoidal or sphenoidal sinusitis is deep in the root of the nose. Tumours can also cause orofacial pain by infiltrating branches of the trigeminal nerve. rofacial pain is the main reason palpation via the external auditory O why many patients seek dental meatus. When acutely inflamed, the Eyes advice. This usually has a local cause, joint may appear swollen and warm to Disorders of refraction, retrobulbar neuritis mainly the sequelae of dental caries. touch. A splinting protective mechanism or glaucoma can cause pain, which may However, a wide range of diseases, by the masticatory muscles may result in radiate to the orbit or frontal region. particularly neurological, psychogenic and muscle spasm, producing secondary vascular disorders, can cause orofacial pain and trismus. pain (these are summarized in Table 1). Ears Middle-ear disease may cause Salivary Glands headaches. LOCAL CAUSES Pain from the salivary glands is localized, may be quite severe and may be intensified by increased saliva production Local causes: Temporomandibular Joint such as occurs before and with meals. The Various orofacial lesions Pain from the temporomandibular joint affected gland may be swollen and tender Neurological disorders: Trigeminal neuralgia may result from dysfunction, acute to palpation. In acute parotitis, mouth Malignant neoplasms involving the inflammation, trauma, and, rarely, opening causes severe pain and thus some trigeminal nerve primary or secondary malignant tumours trismus, and there may be fever and Glossopharyngeal neuralgia Herpes zoster (including post-herpetic or can be referred. It is usually malaise. Salivary flow from the affected neuralgia) intensified by movement of the gland is usually reduced. In children, the Psychogenic causes: mandible; the joint may be tender to most common cause of salivary pain is Atypical facial pain and other oral symptoms mumps. In adults, pain from salivary Vascular disorders: glands results usually from blockage of a Migraine Crispian Scully, PhD, MD, MDS, FDS RCPS, salivary duct by calculus or a mucus plug. Migrainous neuralgia FFD RCSI, FDS RCS, FDS RCSE, FRCPath, Giant cell arteritis FMedSci, Professor, and Stephen Porter, PhD, Referred pain: MD, FDS RCSE, FDS RCS, Professor, Eastman Angina, nasopharyngeal, ocular and aural Dental Institute for Oral Health Care Sciences Sinuses and Pharynx disease and International Centre for Excellence in Disease of the paranasal sinuses and Chest disease (rare) Dentistry, University of London. nasopharynx can cause orofacial pain. In Table 1. Causes of orofacial pain. 410 Dental Update – November 99 ORAL MEDICINE trigeminal region; nor are other Dental surgeon Ancillary, Hygienist, Nurse neurological abnormalities present. Refer to specialist. Understand disease and Understand disease and management in or der to Neurological assessment is needed management in order to extend education extend education of, and reassure, patient because similar pain is secondary to of, and reassure, patient multiple sclerosis, tumours, Alert specialist to any possible adverse Oral health education of patient neurosyphilis, HIV infection and other effects of treatment lesions. Oral healthcare; in particular to avoid Avoid any trigger zones causes of pain Diagnosis and Management Patients with trigeminal neuralgia are Oral health education of patient Alert dental surgeon to any changes, or possible adverse effects of treatment ideally seen at an early stage by a specialist in order to confirm the Avoid any trigger zones diagnosis and initiate treatment (Tables Avoid drug interactions with carbamazepine 2 and 3). or other agents Medical treatment, typically using anticonvulsants, is successful for most Table 2. Roles of the dental clinical team in the management of a patient with trigeminal neuralgia. patients. Carbamazepine (Tegretol) is still the main agent used. It must be given continuously prophylactically for Neck atherosclerotic blood vessel pressing on long periods. However, it is not an Neck pain, usually from cervical the roots of the trigeminal nerve. analgesic and, if given when an attack spondylosis, occasionally causes pain to starts, will not relieve the pain. be referred to the face. Clinical Features Carbamazepine must be used carefully Trigeminal neuralgia has the following and under strict medical surveillance main characteristics. because it can have a range of adverse NEUROLOGICAL CAUSES Pain which is: effects, particularly affecting balance, Sensory innervation of the mouth, face blood cells, blood pressure and liver and scalp depends on the trigeminal ● severe; function. Typically, the dose is increased nerve, and disease affecting this nerve ● of abrupt onset and termination; to try to control the pain while at the can cause orofacial pain or sensory ● electric shock-like, brief, stabbing same time trying to avoid ataxia and loss—or, indeed, both. (lancinating); other adverse effects. If carbamazepine Severe orofacial pain suggestive of ● unilateral; fails, phenytoin or baclofen or other trigeminal neuralgia but with physical ● restricted to the trigeminal nerve drugs are occasionally useful. signs such as facial sensory or motor distribution. If medical treatment fails or the impairment can result from: adverse drug effects are too pronounced, The pain usually involves the surgery may be required. Injections of ● cerebrovascular disease; mandibular and, rarely, the other local analgesic will temporarily block ● multiple sclerosis; divisions of the trigeminal nerve. the pain. Local cryosurgery to the ● infections such as HIV; or In some patients the pain is triggered. ● neoplasms. The trigger site may bear no relation to the painful area, but is always ipsilateral to the pain. Patients do not necessarily Neuralgia with no ● This is an uncommon disorder recognize the trigger for what it is, and ● The cause is unknown but involves Apparent Organic Cause may find that pain is brought on by spontaneous activity of pain ner ves Such conditions have many names: chewing, talking, swallowing, smiling or ● It is not inherited ● It is not known to be infectious idiopathic trigeminal neuralgia, temperature change—usually exposure ● Similar symptoms may be seen in some trigeminal neuralgia, benign paroxysmal to cold air. neurological conditions (which we will trigeminal neuralgia, tic doloureux. Pain-free Intervals Between Attacks exclude) ● There are usually no long-term Trigeminal neuralgia is the most This is often an intermittent disease, consequences common neurological cause of orofacial with apparent remissions for months or ● X-rays and blood tests may be required pain. It is, however, rare and seen years. However, recurrence is common. ● Symptoms may be controlled but not cured by drugs with an anticonvulsant mainly in middle-aged or older patients. Very often the pain spreads to involve a action wider area over time and the intervals ● Uncontrolled pain may be treated by Aetiology between episodes tend to shorten. freezing the nerve, or by surgery The cause is unclear, but trigeminal Lack of Neurological Abnormality Table 3. Patient information sheet: trigeminal neuralgia may be due to an There is no sensory loss in the neuralgia. Dental Update – November 99 411 ORAL MEDICINE trigeminal nerve branches involved PSYCHOGENIC CAUSES OF OROFACIAL PAIN ● This is fairly common (cryoanalgesia) can produce analgesia ● The cause is not completely known without permanent anaesthesia, but the ● It is not inherited ● benefit can usually be measured only in It may be caused by increased nerve Tension Headaches sensitivity months rather than years. ● There may be a background of stress For intractable cases neurosurgery, Tension headaches are not uncommon ● There are usually no serious long-term such as destruction of the trigeminal stress-related pains in the forehead, temple consequences ● X-rays and blood tests may be required ganglion (radiofrequency ganglionolysis) and/or neck, seen mainly in young adults. ● Treatment takes time and patience; some or decompression of the trigeminal nerve, nerve-calming drugs can help Aetiology may be required. Unfortunately, pain is Table 5. Patient information sheet: atypical exchanged for anaesthesia and risk of Tension headaches are caused by anxiety or facial pain. damage to the cornea and, occasionally, stress-induced muscle tension, presumably continuous anaesthesia but with