OralMedicine

Anne M Hegarty

Joanna M Zakrzewska Differential Diagnosis for Orofacial , Including , TMD, Trigeminal

Abstract: Correct diagnosis is the key to managing facial pain of non-dental origin. Acute and chronic facial pain must be differentiated and it is widely accepted that refers to pain of 3 months or greater duration. Differentiating the many causes of facial pain can be difficult for busy practitioners, but a logical approach can be beneficial and lead to more rapid diagnoses with effective management. Confirming a diagnosis involves a process of history-taking, clinical examination, appropriate investigations and, at times, response to various therapies. Clinical Relevance: Although primary care clinicians would not be expected to diagnose rare pain conditions, such as trigeminal autonomic cephalalgias, they should be able to assess the presenting pain complaint to such an extent that, if required, an appropriate referral to secondary or tertiary care can be expedited. The underlying causes of pain of non-dental origin can be complex and management of pain often requires a multidisciplinary approach. Dent Update 2011; 38: 396–408

Management of orofacial pain can only be To establish a differential expanded and grouped in more recent effective if the correct diagnosis is reached diagnosis for orofacial pain we must first years.2 Questions include: and may involve referral to secondary consider the history, examination and Onset; or tertiary care. The focus of this article relevant investigations. Frequency; is differential diagnosis of orofacial pain Although both may co-exist, Duration; (Table 1) rather than available therapeutic the more rare non-dental pain must be Site; options. distinguished from dental pain to avoid Radiation, deep or superficial; The underlying cause of the unnecessary dental treatment and to Triggering; majority of facial pain presentations in organize appropriate referral for the Aggravating or relieving factors; primary care will be of a dento-alveolar patient. It is essential that patients are Quality; origin. These will not be discussed further referred to the correct departments within Severity; here but their differentiating features are secondary or tertiary care to ensure the Associated symptoms. summarized in Table 2. most efficient management for patients This format allows a logical and to maximize use of NHS resources. approach to history-taking, which is essential. Orofacial pain interferes with Anne M Hegarty, MSc(OM), MBBS, Pain history daily life activities, impacting negatively MFD RCSI, FDS RCS(OM), Consultant A thorough pain history is on quality of life and this impact should and Honorary Clinical Lecturer in crucial and time needs to be taken when therefore be established.3,4 , Charles Clifford Dental taking it as it should provide sufficient Other aspects of the history Hospital, Sheffield S10 2ZS and Joanna detail to guide clinicians to the most likely of particular relevance when considering M Zakrzewska, MD, FDS RCS, FFPMRCA, diagnosis. It is also important to institute chronic orofacial pain aetiologies and Professor and Consultant in Facial relevant investigations. determining best therapy include: Pain, University College Hospitals NHS In 1936, Ryle’s classic analysis of Previous management; Foundation Trust, Eastman Dental pain highlighted 11 essential questions to Past medical and dental history; Hospital, 256 Gray’s Inn Road, London be included in the pain history1 and these Medications and allergies; WC1X 8LD, UK. still apply today and have been further Social and family history, which may 396 DentalUpdate July/August 2011 OralMedicine

Aetiology Disorders disclose psychological factors and aspects of a patient’s beliefs of the cause of pain, Dento-alveolar Dental – dentine sensitivity, cracked tooth, which may in turn influence the extent and Periodontal – , acute necrotizing nature of the pain. ulcerative /periodontitis Chronic orofacial pain results in decreased quality of life and psychological Mucosal disease Ulcerative/erosive disorders including effects rarely seen in dental pain.

Bony pathology Alveolar (dry socket) Clinical examination Infected dental cyst Clinical examination should Osteonecrosis include a thorough extra-oral and intra- oral examination to corroborate history Sinusitis Maxillary, paranasal, ethmoidal and/or frontal findings and assist in reaching a diagnosis. Extra-oral examination should include Salivary glands Salivary duct calculi causing obstruction temporomandibular joints (TMJs), regional Infective sialadentitis lymph nodes, and tumour cervical muscles, salivary glands and face and eyes for any autonomic signs, such Musculoskeletal Temporomandibular disorder as flushing, tearing, ptosis or sweating. Cranial nerves examination may be Neuropathic required in some cases and, in primary Glossopharyngeal neuralgia care at least, a gross examination of the Trigeminal neuropathic pain and dysaesthesia in relation to facial and trigeminal nerves would be pathology/iatrogenic nerve damage expected to assess any motor or sensory abnormalities. Sensation to light touch Burning syndrome and pin prick can easily be elicited by the use of cottonwool and an appropriate Vascular sterile pin, respectively, and assessment of Tension type headache the should include a patient’s Temporal arteritis ability to raise the eyebrows, close the eyes TAC (SUNCT/SUNA, PH, CH) tightly shut and show his/her teeth whilst observing any facial asymmetry. Other Chronic idiopathic facial pain Limitation of mouth opening Atypical odontalgia and/or deviation of the on Central post stroke pain opening, TMJ tenderness, TMJ crepitus Cancer – secondaries and/or click and masticatory muscle pain or tenderness may indicate Referred from Eyes temporomandibular disorders (TMD) Ears and can be determined by palpation Intracranial over the TMJs and masticatory muscles. Heart Most patients can open comfortably to 35–45mm, equating to approximately three finger breadths, although some (This list is not exhaustive) may open to a greater distance. Crepitus and clicking can usually be elicited by TAC = Trigeminal autonomic cephalalgia palpation over the TMJs and loud clicking SUNCT = Short-lasting, Unilateral, Neuralgiform headache with Conjunctival injection will be audible. Facial swelling/asymmetry should be assessed. and Tearing The intra-oral examination SUNA = Short-lasting, Unilateral, Neuralgiform headache attacks with cranial Autonomic should include a comprehensive oral symptoms examination, including: PH = Paroxysmal Hemicrania Assessing the teeth;

CH = Occlusion; Salivary glands; Oral mucosae; and Table 1. Aetiology of orofacial pain. Oropharyngeal region. July/August 2011 DentalUpdate 397 OralMedicine

Diagnosis Site Character Duration Severity Triggers Radiation Relieving Associated Appropriate factors factors referral point

DENTOALVEOLAR Reversible Tooth Sharp Intermittent Mild to Thermal Adjacent Removal pulpitis Stimulation moderate Tactile teeth of stimulus Erosion evoked Chemical Upper/ Caries lower jaw Cracked tooth

Irreversible Tooth Sharp Intermittent Mild to Heat Regional Cold Deep caries pulpitis Throbbing Continuous severe Chewing Unilateral Lying Upper/ supine lower jaw

Periapical Tooth/ Deep Paroxysmal Moderate Biting Regional Removal of Periapical periodontitis gingival/ Continuous to severe Unilateral trauma Boring Swelling Tooth mobility

Acute Unerupted Ache Continuous Moderate Biting Ear Removal or partially to severe Unilateral of trauma Malaise erupted Irrigation Regional third lymphadenopathy mainly lower

BONY PATHOLOGY Alveolar Affected Sharp Continuous Moderate Nil Regional Irrigation Loss of clot osteitis bone Deep 4–5 days to severe Unilateral Antibiotics Exposed (Dry socket) seated post- bone Ache extraction Halitosis

MUCOSAL DISEASE Mucosal Affected Sharp Intermittent Mild to pathology mucosa Burning severe Tingling

SINUSITIS Maxillary Over Dull Continuous Mild to Touch Rare Drainage History of sinusitis affected Aching moderate Bending Medication URTI Purulent sinus Boring Biting nasal Unilateral upper discharge or bilateral teeth Fullness over cheek +/- erythema over cheek

SALIVARY GLANDS Blocked 80% Burning Paroxysmal Mild to Smell or Local or Cessation Swelling Oral salivary Sub- Aching severe taste of regional if of eating Erythema gland mandibular food/drink associated Removal of Possible cause infection with pus from salivary gland duct

MUSCULOSKELETAL TMD Masticatory Dull Continuous Mild to Prolonged Ears Medication Clicking Facial Pain Centre muscles Aching or moderate Chewing Head Warm Crepitus Oral Surgery TMJs Throbbing Intermittent Opening Neck compresses Limitation in Sharp wide such Avoidance mouth opening as yawning of triggering Deviation of Stress factors mandible on opening Ear pain, fullness Tinnitus Depression Anxiety

NEUROPATHIC

BMS Tongue Burning Continuous Mild to Stress To sites Eating Altered taste Oral Medicine Tingling +/- moderate Spicy, involved Abnormal Tender paroxysms acidic saliva Itching foods Sensory change

Postherpetic Localized to Burning Continuous Mild to Touch Nil Medication Allodynia Oral Medicine neuralgia site of Tingling moderate Local Hyperalgesia Facial Pain Centre herpes Shooting anaesthetic Altered zoster Tender sensation infection Itching Intra-oral but more often extra-oral

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Trigeminal Local to Burning, Continuous Mild to Light touch Regional Medication Allodynia Facial Pain Centre neuropathic widespread tingling severe Spontaneous Local Trauma pain Neuroana- Aching anaesthetic history tomical Throbbing Sensory change

TN Trigeminal Sharp Paroxysmal Moderate Light touch Unilateral Medication Trigger Facial Pain Centre nerve Shooting Seconds to severe Cold air Surgery points Stabbing Remits Washing Possible Electric- weeks/ face sensory shock like months Spontaneous change

Glosso- Ear Sharp Paroxysmal Moderate Swallowing Regional Medication Possible TN Facial Pain Centre pharyngeal Tonsils Shooting Seconds/ to severe Coughing Rarely neuralgia Neck Stabbing minutes Remits Touch bilateral for weeks/months

VASCULAR

Cluster Unilateral Boring Regular Moderate Smoking Periorbital Medication Autonomic Facial Pain Centre headaches Periorbital Throbbing Recurring to severe Alcohol Temple features Temple 1–8 attacks Altitude such as nasal per day, lasting seasonal congestion, 15–180 mins eye redness/ ‘Alarm clock’ injection wakening Complete remission for months to years Paroxysmal Unilateral Boring Paroxysmal Moderate Neck Periorbital Medication Autonomic Facial Pain Centre hemicrania Periorbital 1–40 attacks to severe movement Temple features Neurology Temple per day lasting 2–30 mins

SUNCT/ Unilateral Stabbing Recurring Moderate Cutaneous Orbital Medication Tearing Facial Pain Centre SUNA mainly first 1–200 to severe triggers Temporal Conjunctival Neurology & second attacks injection or division per day, other autonomic trigeminal 10–250 features for SUNA seconds each Tension type Bilateral Ache Recurring Mild to Stress Bilateral Medication None Facial Pain Centre headache Band around Pressure irregularly severe Body Exercise Neurology head postures Stretching

Temporal Unilateral Throbbing Continuous Moderate Pressure over Temporal Medication Jaw claudication Facial Pain Centre arteritis Temporal Dull to severe temporal artery Neurology Aching Tender Migraine Unilateral Throbbing Paroxysmal Moderate Stress Fronto- Medication Nausea General Medical Fronto- to severe Food temporal Sleep Vomiting Practitioner temporal Exercise Photophobia Neurology Alcohol Phonophobia (if complicated) Oestrogen Barometric pressure

OTHER Atypical Tooth Dull Continuous Mild to Touch Rare Nil Prior dental Facial Pain Centre odontalgia bearing Aching, moderate treatment area tingling Throbbing Sharp

CIFP Non Dull Continuous Mild to Stress Deep poorly Rest Multiple body Facial Pain Centre anatomical Aching Intermittent moderate Fatigue localized symptoms Intra-oral Nagging Paroxysmal Chewing No specific Life events Extra-oral Sharp radiation site Throbbing

URTI = upper respiratory tract infection TMD = temporomandibular disorder BMS = TN = trigeminal neuralgia CIFP = chronic idiopathic facial pain SUNCT = Short-lasting, Unilateral, Neuralgiform headache with Conjunctival injection and Tearing /SUNA Short-lasting, Unilateral, Neuralgiform headache with Autonomic features

Table 2. Differential diagnosis of orofacial pain based on history highlighting appropriate referral centre for non-dental causes.

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blood cells fall in a column of blood within an hour and is a non-specific measure of . In giant cell arteritis, the ESR usually exceeds 50 mm/hr and sometimes 100 mm/hr. GCA can cause a sudden loss of vision due to anterior ischaemic optic neuropathy, constituting a medical emergency, therefore ESR should be checked and treatment commenced as soon as possible if GCA is suspected to prevent possible sight loss. Baseline blood tests may be useful in eliminating any possible systemic disorders which may cause or exacerbate facial pain. A variety of conditions may lead to burning sensation of the oral mucosae, including vitamin and nutritional deficiencies and, therefore, to diagnose burning mouth syndrome (BMS) correctly, it is essential to check full blood count,

haematinics (iron, vitamin B12 and folate levels) and blood glucose before reaching a diagnosis of BMS. Immunological tests Figure 1. Bitewing radiograph showing root-filled upper molar. help to exclude connective tissue disorders which can cause trigeminal neuropathy. Intra-oral radiographs may involve periapical, bitewing and occlusal As most primary care Investigations views, while extra-oral radiographs include practitioners are familiar with dental panoramic tomography (DPT) and examining the oral cavities, these will The history and examination oblique laterals. Intra-oral radiographs are not be detailed here. alone may lead us to the correct diagnosis. the recommended first line investigation Oral malignancy, in Investigations help exclude or confirm a for diagnosing caries, periodontal and particular gingival or alveolar bone diagnosis, assist in treatment planning periapical pathology (Figure 1), with malignancy, may present with and monitor treatment effects, including DPT being reserved for bony and facial pain. Clinical features of oral adverse effects. Investigations can be when views of the condyles are required. malignancy may also include sensory broadly classified as haematological, Other forms of radiological studies, such changes or . Metastatic disease radiological, physiological and as CT, MRI, bone scintigraphy, ultrasound spreading to the jaws must also be psychological. Simple chairside tests to scan, sialography and arthrography, may considered. Evidence of oral candidosis confirm a dental source of pain include be useful in diagnosing salivary gland or may be relevant when vitality testing using heat, cold and electric disease, malignancies, bony pathology excluding a diagnosis of burning mouth stimuli, transillumination to highlight and disease, syndrome (BMS). proximal caries or a cracked tooth and but should only be carried out if there are Pain associated with the use of tooth ‘slooth’ to assist localization clinical indications. MRI will demonstrate salivary glands may occur as a result of of cracked cusps. With transillumination, secondary causes of trigeminal neuralgia. salivary stones blocking the ducts and a light beam is reflected where there More complex investigations, giving rise to intermittent pain typically is a change in the integrity of the such as quantitative sensory testing (QST) associated with eating. There may be tooth structure. The tooth ‘slooth’ is an which may be useful when investigating tenderness of the glands. Bimanual instrument incorporating an indentation trigeminal neuropathic pain, should palpation of the submandibular glands allowing pressure to be directed to a only be arranged by specialists who is essential. and tumours specific cusp to elicit pain suggestive of a can interpret the results. Quantitative of the salivary glands may also give cracked cusp. sensory testing is a psychophysical test rise to localized pain in the region of Measuring erythrocyte and is a reliable way of assessing large the glands and a purulent discharge sedimentation rate (ESR) in giant cell and small sensory nerve fibre function. may be seen from the openings of the arteritis (GCA) is important as a high Results should always be interpreted in ducts within the mouth, indicative ESR helps to reach the diagnosis. ESR is light of the patient’s clinical presentation. of infection. Pain may be relieved by a simple haematological investigation Psychological investigations are generally massaging the glands involved. which measures the rate at which red not arranged by the primary dental 400 DentalUpdate July/August 2011 OralMedicine

been bothered by ‘feeling down,’ depressed, or hopeless? 2. During the last month, have you often been bothered by having little interest or pleasure in doing things?9

Non-dental causes of facial pain

Maxillary sinusitis Maxillary sinusitis causes a constant boring pain with zygomatic and dental tenderness from the inflammation of the maxillary sinus.10 Acute maxillary sinusitis is defined by the International Association for the Study of Pain (IASP) as constant burning pain with zygomatic and dental tenderness from the inflammation of the maxillary sinus.10 In chronic cases Figure 2. Visual Analogue Scale (VAS). there may be no pain or just occasional mild diffuse discomfort. Diagnostic criteria for maxillary sinusitis include: Purulence in the nasal cavity; mark on this line the point which they Simultaneous onset of headache and feel best represents their perception of sinusitis; their facial pain. This can also be used as Pain over the antral area which may a verbal rating scale asking patients to radiate to the upper teeth or forehead; and express their pain as a range from 0 to 10. Headache disappearing after treatment Another commonly used pain assessment of acute sinusitis.10 tool is the McGill Pain Questionnaire The character of the pain of which allows the patient to indicate maxillary sinusitis is dull, aching, boring easily the quality of his/her pain using and tender, of mild to moderate severity, such descriptors as throbbing, shooting, is usually continuous and may be either 7 Table 3. Example of a statement from HADS. distressing, excruciating. unilateral or bilateral commencing after A number of psychological an upper respiratory tract infection. The tests are useful in patients with chronic pain is triggered by bending forward, practitioner but should be encouraged. facial pain as it has been reported that touching the area or biting on the upper There are a wide variety of validated depression may be co-existent in up to teeth. Headache is located over the antral 5 questionnaires available that assess all 50% of patients and anxiety in 15%. The area. In the presence of the key diagnostic aspects of pain experience including: Hospital Anxiety and Depression Scale symptoms, investigations are not required Pain intensity; (HADS) is a screening tool which involves but confirmation of the diagnosis can be Mood; and the patient completing a questionnaire confirmed by maxillary sinus radiographic Disability. composed of statements (Table 3), with examination (although this is not generally Their use should be mandatory a choice of answers relevant to either advised as, apart from showing possible in patients with chronic orofacial pain.5 generalized anxiety or depression. fluid levels in acute sinusitis, it is not of The Visual Analogue Scale, VAS (Figure 2), The answers are scored and, when great benefit), computerized tomography is useful for assessing pain intensity and the final score is compared to a set of (CT) or magnetic resonance imaging (MRI). the McGill Pain Questionnaire useful for normal values, anxiety or depression is assessing pain quality. suggested, triggering a referral to either a 8 The VAS is a simple, psychologist or psychiatrist. Temporomandibular disorders reproducible instrument that allows the Recent NICE guidelines on Temporomandibular disorders severity of pain to be expressed as a depression advocate the use of two encompass pain affecting the masticatory numerical value.6 The VAS is represented questions in primary care settings to muscles and/or temporomandibular joints as a plain horizontal 100 mm line (Figure determine patients at risk of being (TMJs). They consist of muscular pain 2) with 0 representing no pain and 100 depressed: MSK (referred to by some as myofascial representing worst possible pain. Patients 1. During the last month, have you often pain), TMJ disc interference disorders and 402 DentalUpdate July/August 2011 OralMedicine

TMJ degenerative joint disease; this Glossopharyngeal neuralgia (GPN) their pain. Many BMS patients score latter rarely causes pain but results in Defined by the IASP as sudden high in tests for depression or anxiety, limitation of opening.11 In the case of severe recurrent pain in the distribution possibly because the condition is not trauma, the pain is usually self-limiting of the glossopharyngeal nerve, GPN is recognized, patients are not believed but psychological aspects may contribute very rare, with an incidence of 0.7 per and they are not given an adequate to chronicity of the pain, therefore it 100,000, and is more common in females explanation. is important to manage it early. TMD and those aged over 50 years.19 Classic When excluding an organic (MSK) is more prevalent in females and and secondary forms are recognized. cause for BMS, a thorough, systematic the natural history is that of intermittent Classic GPN is severe recurrent stabbing soft tissue examination is important and pain with continuation for many years.12 pain in the ear, base of tongue, tonsillar recommended investigations include: Tension type headaches can be mistaken fossa or below the angle of the mandible. Haematological and biochemical for TMD. There is increasing evidence that It is precipitated by swallowing, talking or investigations to assess if anaemic, low in

TMD is linked to many other chronic pain coughing. iron, folate or vitamin B12, or if there is a conditions, such as headaches, migraine, Secondary GPN presents raised level of glucose; post-traumatic stress disorder and with an additional ache that may persist Microbiological tests for candidosis; fibromyalgia.13 The relationship between between attacks and is secondary Baseline saliva flow rate if there is any TMD pain and clenching habit or to a cranial demonstrable by question of hyposalivation; is far from simple5,13,14, and daily variations investigations or surgery. The pain is Sensory testing; in pain do not correlate with self-reports unilateral in location and there are no Allergy testing; and of clenching or grinding.15 obvious motor neurological defects. Immunological testing for conditions Episodes of pain may last from weeks to such as Sjögren’s syndrome or systemic months. . A detailed drug Trigeminal neuralgia Although also rare, a history will highlight any drugs that may Trigeminal neuralgia (TN) is syndrome known as Eagles syndrome be associated with burning oral pain. defined by the International Association should be considered in patients for the Study of Pain (ISAP) as a presenting with classical symptoms ‘sudden and usually unilateral severe of GPN. Eagles syndrome describes Trigeminal neuropathic pain brief stabbing recurrent pain in the symptoms related to an elongated Trigeminal neuropathic pain distribution of one or more branches of styloid process impinging on adjacent or traumatic induced neuralgia is a form the fifth cranial nerve’.16 Idiopathic and anatomical structures and is associated of chronic facial pain arising as secondary secondary forms are recognized and with pain and dysphagia on chewing and to to the trigeminal nerve, such as conditions such as multiple sclerosis, on turning the head to the affected side. facial trauma or a dental procedure. It is benign or malignant lesions being rare but increasingly recognized and the contributory factors. Categorization of pain is described as a continuous burning TN into classical and atypical forms is Burning mouth syndrome (BMS) sensation localized to the injured area, 17 based on symptoms and not aetiology. BMS is characterized but may be described as constant, dull, TN is being increasingly recognized by continuous burning pain of burning with or without intermittent with its annual incidence now being the in the absence of sharp stabbing pain. Numbness and estimated around 12.8 per 100,000, any contributing local or systemic tingling may also be present due to 20,21 with a peak incidence in 50–60-year- pathology. There is an increasing nerve dysfunction. The pain symptoms olds. TN symptoms arising in younger number of studies suggesting that this is may be classed under the following: patients should alert the clinician to the not just a psychological condition but is Dysaesthesia (abnormal perception of 13 possibility of an underlying cause, such probably neuropathic. pain); as multiple sclerosis. The symptoms of BMS include: Allodynia (due to a stimulus which Classical TN presents with Burning sensation affecting tongue, does not normally provoke pain); or shooting, sharp, unbearable pain in the palate, gingiva, lips and pharynx; Hyperalgesia (an increased sensitivity distribution of one or more branches Tingling sensation; to pain). of the trigeminal nerve, of moderate Altered taste; Proposed mechanisms for 17,18 to intense severity, lasting seconds. Perceived dry mouth; and trigeminal neuropathy include peripheral The right side of the face is affected in Altered tactile sensations. or central sensitization, beta fibre 60% of sufferers, it is unilateral in 97% Most patients have continuous reorganization and sympathetically of cases and rarely in first division only. pain but it can vary throughout the day. maintained pain due to alpha receptor It is precipitated by light touch, but may Most patients do not associate food or sprouting.19 be spontaneous, and there are often drink with the onset of pain but some will Trigeminal neuropathy, with associated trigger points. Patients may describe the pain as being exacerbated and without pain, is associated with a have periods of remission lasting days, by certain foods, such as spicy or acidic number of connective tissue disorders weeks or longer. food, whereas others find feeding relieves including:

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dull and diffuse in nature. Unlike PHN, the onset of pain usually precedes the rash by several hours or days and the disease is self-limiting. PHN is thought to affect 40% of patients and most patients are more than 70 years of age. Following initial exposure to the herpes zoster virus from chicken pox, the virus lies dormant in the trigeminal ganglion and, when activated, gives rise to the rash of . PHN is the result of damage to the nerve by the virus.

Chronic idiopathic facial pain Chronic (persistent) idiopathic facial pain (CIFP), previously , is persistent facial pain which is poorly understood, but its persistence is likely to result in psychological distress. The pain is described as aching, heavy, Figure 3. Temporal arteritis with swollen temporal artery highlighted. nagging, sometimes throbbing or stabbing.25 It does not follow anatomical pathways and can be local or very extensive, radiating into the head and Scleroderma; AO often results in repeated, neck. The pain is often constant but with Sjögren’s syndrome; and possibly unnecessary, dental varying intensity. Mixed connective tissue disease; treatment such as extractions, root canal Psychological stresses or Systemic lupus erythematosus; therapy and apicectomies in the pursuit fatigue may worsen the symptoms and it Rheumatoid arthritis; and of pain relief.21 A patient presenting with is therefore important to take a relevant Dermatomyositis. such pain and giving a history of multiple psychosocial history and record associated The underlying pathology for extractions possibly preceded by root stress-related factors. Information trigeminal nerve dysfunction in these canal therapies should raise suspicions of regarding marital status, family medical patients is unknown but could be related AO. Diagnosis and management as early history, employment status, history of to a form of vasculitis.22 as possible is vital24 to avoid unnecessary depression or anxiety and sleep problems invasive treatments. are all relevant. Exploring patients’ beliefs Atypical odontalgia (AO) about their pain can be particularly Considered by most as a Post-herpetic neuralgia (PHN) enlightening. There are no specific form of trigeminal neuropathic pain, PHN is persistent burning pain relieving factors and the patient may also atypical odontalgia may in fact have both but can be an excruciating/severe pain suffer irritable bowel syndrome, back and psychological and neuropathic origins. accompanied by intermittent shooting neck pain and poor sleep. There is limited evidence on the incidence sensation localized to the site of previous and prevalence of AO. Clinical features herpes zoster infection, occurring 3–6 Migraine include persistent pain, often commencing months after resolution of the infection.19 Migraine affects one in four in conjunction with some form of dental Allodynia, hyperalgesia and numbness women and one in 12 men in the UK.26 It treatment, particularly root canal therapy in the affected area have been reported. is a chronic headache disorder affecting or extraction. In fact, over 80% of patients The neuralgia is dermatomal in location. the frontotemporal region. It often relate the onset of their pain to dental Ramsay Hunt syndrome, also caused co-exists with TMD, which may exacerbate treatment, including local anaesthesia.13 by herpes zoster infection, specifically . The headache is typically The most common site of pain is the molar of the geniculate ganglion of the VIIth unilateral, severely disabling , usually and region. The pain is intra-oral, cranial nerve,22 presents with facial pain, lasting 4–72 hours and is associated with well localized and not associated with lower motor neuron palsy and ipsilateral photophobia, phonophobia, nausea and/ radiation to adjacent areas or extra-orally. vesicles, affecting the skin of the ear canal, or vomiting. It may be preceded by an aura Several studies have reported associated auricle and/or mucous membrane of the in 15% of cases, with visual disturbances features of hyperaesthesia and allodynia at oropharynx. The pain is usually localized, being most common.3 It will not be the pain site, with a prolonged response to paroxysmal, deep within the ear, but can discussed further here but the salient ethyl chloride.23 radiate externally and may become more features of the condition are highlighted July/August 2011 DentalUpdate 405 OralMedicine

in Table 2. Changes in frequency, intensity Trigeminal autonomic cephalalgias (TACs) Department of Health’s NIHR Biomedical and location are often found in women TACs are a group of headache Research Centre funding scheme. whose migraines are hormonally driven. syndromes incorporating short lasting severe unilateral headache attacks, accompanied by cranial autonomic References Tension type headache symptoms. TACs is included in the 1. Ryle JA. The Natural History of Disease. Episodic and chronic forms of International Headache Society London: Oxford University Press, 1936: tension-type headache are recognized. classification of headaches28 and includes p43. The episodic form lasts from 30 minutes cluster headache, paroxysmal hemicrania 2. Blau JN. How to take a history of head to days, with a pressing quality, of mild and short-lasting unilateral neuralgiform or facial pain. Br Med J 1982; 285: to moderate intensity, is bilateral, with headache attacks with conjunctival 1249–1251. less than 15 attacks per month and injection and tearing (SUNCT), all of 3. Murphy E. Managing Orofacial Pain in no aggravating factors or associated which display trigeminal distribution Practice. London: Quintessence, 2008. symptoms, unlike the chronic form which, pain and ipsilateral cranial autonomic 4. Murray H, Locker D, Mock D, although of similar character and location, features. The primary site of pain is in the Tenenbaum HC. Pain and the quality occurs more than 15 times per month for distribution of the first division of the of life in patients referred to a at least 6 months with associated nausea, trigeminal nerve and autonomic features craniofacial pain unit. J Orofac Pain photophobia or phonophobia. The present. They are rare, not expected to be 1996; 10: 316–323. pathophysiology of this form of headache diagnosed in primary care and the main 5. Svensson P, Baad-Hansen L, Newton- is not fully understood, its prevalence is features are highlighted in Table 2. John T, Ng S, Zakrzewska JM. quoted as 2.2% and is more common in Investigations. In: Orofacial Pain. females.27 It can mimic TMD MSK. Zakrzewska J, ed. Oxford: Oxford Conclusions University Press, 2009: pp25–42. Giant (temporal) cell arteritis (GCA) 6. Scott J, Huskinson EC. Graphic Differentiating the many GCA is a form of vasculitis representation of pain. Pain 1976; 2: causes of facial pain can be difficult for involving cell-mediated immune damage 175–184. busy practitioners, but a logical approach to walls and mainly affects 7. Melzack R, Katz J, Jeans ME. The role of to history-taking is important and will blood vessels in the head and neck compensation in chronic pain; analysis aid more rapid diagnoses with effective region. It is rare under the age of 50 using a new method of scoring The management. Although primary care years and females are about 3 times McGill Pain Questionnaire. Pain 1975; clinicians would not be expected to more likely than men to develop this 23: 101–112. diagnose rare pain conditions, they disease. The temporal artery is commonly 8. Zigmond AS, Snaith RP. The Hospital should be able to assess the presenting affected giving rise to temporal arteritis. Anxiety and Depression Scale. Acta pain complaint and refer to the Symptoms include unilateral or bilateral Psychiatr Scand 1983; 67: 361–370. appropriate secondary or tertiary care headache of aching or throbbing quality, 9. Pilling S, Anderson I, Goldberg D, centre. It is important that primary care often intense and continuous. Patients Meader N, Taylor C. Br Med J 2009; 339: practitioners provide sufficient detailed may have features of scalp tenderness, b4108. information of history, examination and visual changes and/or neurological 10. Vickers ER, Zakrzewska JM. Dental investigation findings in their referral changes. causes of orofacial pain. In: Orofacial letters to ensure appropriate direction of Criteria stipulated by the Pain. Zakrzewska JM, ed. Oxford: the referral within the secondary/tertiary International Headache Society (IHS) for Oxford University Press, 2009: pp69– care institution. a diagnosis of temporal arteritis is any 81. Underlying causes of orofacial new persistent headache in the temporal 11. Forssal H, Ohrbach R. pain are wide ranging and complex, but a region, with either swollen tender scalp Temporomandibular disorders (TMD). greater understanding of a patient’s facial artery (Figure 3) and raised ESR or CRP, In: Orofacial Pain. Zakrzewska J, ed. pain symptoms, towards establishing a or temporal artery biopsy demonstrating Oxford: Oxford University Press, 2009: diagnosis or differential diagnosis, can giant cell arteritis.19 Major improvement pp105–118. be achieved by obtaining a good pain or resolution of headache within 3 days 12. Bergstrom I, List T, Magnusson T. history, carrying out a good clinical of high dose steroid treatment also helps A follow-up study of subjective examination and instituting relevant confirm the diagnosis. symptoms of temporomandibular investigations or referring to secondary GCA may be associated with disorders in patients who received or tertiary care when appropriate. polymyalgia rheumatica, jaw claudication, acupuncture and/or interocclusal weight loss, altered sensation or loss of appliance therapy 18–20 years earlier. vision. Owing to the high risk of early Acknowledgement Acta Odontol Scand 2008; 66: 88–92. visual loss as a result of anterior ischaemic Joanna Zakrzewska undertook 13. Zakrzewska JM. Facial pain: an update. optic neuropathy, prompt diagnosis and this work at UCL/UCLHT who received Curr Opin Support Palliat Care 2009; 3: management is essential. a proportion of funding from the 125–130. 406 DentalUpdate July/August 2011 OralMedicine

14. De Boever JA, Nilner M, Orthlieb JD, report of the Quality Standards Oxford: Elsevier, 2002: pp209–245. Steenks MH. Recommendations by Subcommittee of the American 23. List A, Feinmann C. Persistent the EACD for examination, diagnosis, Academy of Neurology and the idiopathic facial pain (atypical facial and management of patients with European Federation of Neurological pain). In: Orofacial Pain. Zakrzewska temporomandibular disorders and Societies. Neurology 2008; 71: 1183– JM, ed. Oxford: Oxford University Press, orofacial pain by the general dental 1190. 2009: pp93–104. practitioner. J Orofac Pain 2008; 22: 19. Jitpimolmard S, Radford SG. 24. Baad-Hansen L. Atypical odontalgia 268–278. Neuropathic pain. In: Orofacial Pain. – pathophysiology and clinical 15. Glaros AG, Owais Z, Lausten L. Zakrzewska JM, ed. Oxford University management. J Oral Rehab 2008; 35: Diurnal variation in pain reports in Press, 2009: pp135–155. 1–11. temporomandibular disorder patients 20. Patton LL, Siegel MA, Benoliel R, De 25. Zakrzewska JM. Diagnosis and and control subjects. J Orofac Pain Laat A. Management of burning mouth management of non-dental pain. Dent 2008; 22; 115–121. syndrome: systematic review and Update 2007; 34: 134–136. 16. Zakrzewska JM. Assessment and management recommendations. Oral 26. Scully C. Medical Problems in treatment of trigeminal neuralgia. Br J Surg Oral Med Oral Pathol Oral Radiol 5th edn. Oxford: Churchill Livingstone, Hosp Med 2010; 71: 490–494. Endod 2007; 103 (Suppl): S13–S39. 2009. 17. Cruccu G, Gronseth G, Alksne J et al. 21. Zakrzewska JM, Forssell H, Glenny AM. 27. Loder E, Rizzoli P. Tension-type AAN-EFNS guidelines on trigeminal Interventions for the treatment of headache. Br Med J 2008; 336: 88–92. neuralgia management. Eur J Neurol burning mouth syndrome. Cochrane 28. Anonymous. Headache Classification 2008; 15: 1013–1028. Database Syst Rev 2005; CD002779. Subcommittee of the International 18. Gronseth G, Cruccu G, Alksne J et al. 22. Chong MS. Other neurological causes Headache Society. The International Practice parameter: the diagnostic of head and face pain. In: Assessment Classification of Headache Disorders evaluation and treatment of trigeminal and Management of Orofacial Pain. 2nd Edition. Cephalalgia 2004; neuralgia (an evidence-based review): Zakrzewska JM, Harrison SD, eds. 24(Suppl 1): 9–160.

BookReview McMinn’s Color Atlas of Head and Neck groups related anatomical information in and this may create difficulty in identifying Anatomy 4th edn. By BM Logan and PA useful ‘reference lists’ (for example, structures individual structures. All in all, however, Reynolds. Mosby Elsevier, 2009. ISBN passing through the foramina of the skull). the new material in McMinn’s Color Atlas of 9780323056144. New material is located Head and Neck Anatomy improves what was predominantly within chapter one. Here there already an excellent resource. This atlas will McMinn’s Color Atlas of Head and Neck Anatomy is a helpful two-page spread giving an ‘at a continue to prove an invaluable purchase is the foremost specialist atlas of the anatomy glance’ schematic representation of the stages for undergraduate and postgraduate dental of the head and neck. Since its first publication of tooth eruption from five months in utero to students, dental professionals, and for all in 1981, the thoroughness and detail with full adult dentition, a set of images produced those for whom a mastery of the complex which the anatomy of the head and neck using current methods of 3D reconstruction anatomy of the head and neck is a pre- region is covered in this high quality resource from CT scans to illuminate the anatomical requisite. have ensured that it is required reading for relativities of the tooth, space, bone Dr Ruth E Joplin and Dr Susan M Davis dental students in the UK and worldwide. This and nerve, and a remarkable exemplar of College of Medical and Dental Sciences new 4th edition retains the content and format an adult skull containing 13 sutural . Birmingham of the 3rd edition, supplemented by additional Clinical content has also been expanded. pages on developmental and clinical topics. The essentials of several developmental and The core of the atlas comprises genetic abnormalities are summarized in six chapters, of which the first five (‘Skull and illustrated text. A further informative section skull bone articulations’, ‘Cervical vertebrae and on craniosynostosis and its surgical solution neck’, Face, orbit and eye’, ‘Nose, oral region, ear could perhaps have been improved by a more and eye’ and ‘Cranial cavity and brain’) are built extensive description of the conditions and around images of superb dissections. These surgical procedures which are mentioned are extensively labelled and accompanied by here. There is also a new set of histological concise but informative text. The sixth chapter, images of dental tissue, which may require ‘Radiographs’, utilizes the same format to reference to a histological textbook to be fully illustrate the osseous and vascular anatomy understood by the beginner. of the region. There are additionally two Layout throughout this text, appendices: the first, which deals with dental whilst generally good, is sometimes a little anaesthesia, presents the anatomical rationale crowded, possibly leading to some confusion. underlying anaesthetic procedures; the second A few images are a little on the small side, 408 DentalUpdate July/August 2011