Galore International Journal of Health Sciences and Research Vol.2; Issue: 2; April-June 2017 Website: www.gijhsr.com Review Article P-ISSN: 2456-9321

Atypical Facial : A Mini-Review

Lydia Nabil Fouad Melek

BDS, MSc, PhD, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Champolion Street, Azarita, Alexandria University, Egypt. ______

ABSTRACT day over more than 3 months, in the absence of clinical neurological deficit’. PIFP is the Persistent idiopathic facial pain (PIFP), current diagnostic terminology that previously called “”, is a historically was considered under the name diagnostic entity that describes chronic facial of atypical facial pain (AFP). [2] pain without evidence of structural or other specific causes of pain. Most of the data clearly [2] indicate that PIFP is a rare disorder. It is more Diagnostic criteria for PIFP common in women, and the mean age of onset Diagnostic criteria is in the mid forties. Careful interdisciplinary A. Facial and/or oral pain fulfilling collaboration is needed to establish the criteria B and C diagnosis and management of persistent B. Recurring daily for >2 hours per day idiopathic facial pain (PIFP). The diagnostic for >3 months criteria for PIFP include the presence of daily or C. Pain has both of the following near daily pain that is initially confined but may characteristics: subsequently spread, which cannot be attributed 1 Poorly localized, and not to any pathological process. So, the diagnosis of PIFP is mainly done by exclusion of other following the distribution of a disorders. peripheral nerve 2 Dull, aching or nagging quality Key words: persistent idiopathic facial pain; D. Clinical neurological examination is atypical facial pain; atypical odontalgia; normal trigeminal neuropathy E. A dental cause has been excluded by appropriate investigations INTRODUCTION F. Not better accounted for by another Persistent idiopathic facial pain ICHD-3 diagnosis (PIFP), previously called “atypical facial pain”, is a diagnostic entity that describes Comments from ICHD [2]: chronic facial pain without evidence of A wide variety of words are used to structural or other specific causes of pain. describe the character of Persistent [1,2] The etiology of PIFP is unknown but idiopathic facial pain (PIFP) but it is most surgery or injury in the often depicted as dull, nagging or aching. It distribution could be reported as a past can have sharp exacerbations, and is precipitating event. aggravated by stress. Pain may be described as either deep or superficial. With time, it DEFINITION may spread to a wider area of the The International Classification of craniocervical region. Disorders (ICHD, version 3) Persistent idiopathic facial pain published by the International Headache (PIFP) may be comorbid with other pain Society (IHS) describes persistent idiopathic conditions such as chronic widespread pain facial pain (PIFP) as ‘persistent facial and/or and . In addition, it oral pain, with varying presentations but presents with high levels of psychiatric recurring daily for more than 2 hours per comorbidity and psychosocial disability.

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A continuum seems to exist from the pain. However, many patients cannot Persistent idiopathic facial pain (PIFP) reliably recall the sequence of events. induced by insignificant trauma to Painful There are no clinically evident neurosensory post-traumatic trigeminal neuropathy caused deficits in PIFP. [2] Clinical and imaging obviously by significant insult to the investigations do not reveal any relevant peripheral nerves. Persistent idiopathic abnormalities of the face. facial pain (PIFP) may originate from a Pain in PIFP is usually deep but can minor operation or injury to the face, be superficial as well. It is poorly localized, maxillae, teeth or gums but persist after radiating and mostly unilateral, although up healing of the initial noxious event and to 40% of cases may have bilateral pain. without any demonstrable local cause. Pain is most often localized to the upper However, psychophysical or jaw, and may extend to the eyes, nose, neurophysiological tests may demonstrate cheek and temple. Severity of the pain may sensory abnormalities. be aggravated by emotional stress. Most The term atypical odontalgia has PIFP patients report persistent, long lasting been applied to a continuous pain in one or (years) daily pain that tends to spread, in a more teeth or in a tooth socket after non-dermatomal pattern, with time. Often extraction, in the absence of any usual PIFP may coexist with other chronic dental cause. This is thought to be a sub or headache syndromes. form of Persistent idiopathic facial pain Psychiatric and psychosocial disorders have (PIFP) although it is more localized, the often been associated with PIFP. [2,6] mean age at onset is younger and genders Differential diagnosis are more balanced. Based on the history of It is important for clinicians to trauma, atypical odontalgia may also be a clearly distinguish PIFP from other sub form of Painful post-traumatic persistent orofacial pain disorders that may trigeminal neuropathy. be confused with it, such as trigeminal Etiology with persistent background pain, Some risk factors have been painful traumatic trigeminal neuropathies suggested as etiologic factors but have not (PTTN), myofascial pain and others. The been proven. A role of female hormones has clinician must exclude other likely disorders also been suggested as PIFP is more by thorough clinical examination, follow up common in females. Interestingly, for many and imaging if there are indications. years, a psychogenic origin has been In PTTN, pain is unilateral and may postulated for this condition, [3] however it’s be precisely located to the distribution of the not clear if psychological distress is the affected nerve with evident sensory cause or the consequence of PIFP. dysfunction, particularly if a major nerve Prevalence branch has been injured. In PTTN, pain Most of the data clearly indicate that intensity is moderate to severe and the pain that PIFP is a rare disorder. The population character is usually burning or shooting, prevalence of PIFP is estimated to be 0.03% which is typical of a and some studies have shown that it is more syndrome. More often there is clinically common in women. [4,5] The mean age of severe , hyperalgesia or negative onset is in the mid 40’s. [6] neurosensory signs, which should be absent Clinical features in PIFP. [7,8] Pain onset in PIFP is often Contrary to , in associated with minor surgical or other PIFP there is a high prevalence of bilateral invasive dental or otolaryngologic pain, and other chronic pain, and procedures; these may be reported as the a low prevalence of stabbing pain, touch- initiating event or as an attempt to manage evoked pain and remission periods. As opposed to trigeminal neuralgia, in PIFP

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 21 Vol.2; Issue: 2; April-June 2017 Lydia Nabil Fouad Melek. Atypical Facial Pain: A Mini-Review there is no association between the painful The use of medications, known to side and the presence of or degree of have an effect in painful neuropathies, i.e. compression from a neurovascular contact and antiepileptic drugs, in the root entry zone of the ipsilateral could be of benefit in PIFP. is trigeminal nerve. In addition, TN is usually often the first drug of choice in PIFP [15] as responsive to therapy. [6] it reduces the nociceptive charges In myofascial pain, patients will originating from the myofascial tissues and often describe dysfunction associated with so helps in controlling the pain. Different chewing foods and a limited range of medications have also been tried in clinical mandibular movements. Characteristically trials for management of PIFP as Selective the pericranial, masticatory and cervical serotonin reuptake inhibitors (SSRIs), muscles are painful to moderate manual Calcitonin, Sumatriptan, Topiramate and pressure and some may display the classical others. [16-18] ‘‘trigger point’’phenomenon in response to Other recent techniques used for muscle manipulation. These findings should relief of neuropathic pain as using high- be absent in PIFP patients. [9-11] frequency repetitive transcranial magnetic Pathophysiology stimulation (rTMS) may be also promising Currently, the prevalent belief is that for management of PIFP. [12] PIFP is a disproportionate reaction to a mild Complementary and alternative injury, but the exact pathophysiology is still medicine approaches as acupuncture, unclear. [12] The large number of PIFP hypnosis, simple relaxation etc. [19,20] have patients presenting with a history of mild also been suggested. trauma and subclinical sensory changes has When to refer led to the suggestion that PIFP and PTTN Diagnosis of PIFP is difficult may represent extremes of a spectrum of especially when the clinician cannot find an clinical presentations. As such, PIFP would objective explanation to the patient’s therefore be considered a neuropathic pain subjective pain experience. So, there is a syndrome. [13] need for a multidisciplinary diagnostic How can GPs diagnose it with certainty? approach for exclusion of relevant The diagnostic criteria for PIFP differential diagnoses. include the presence of daily or near daily pain that is initially confined but may REFERENCES subsequently spread, [2] which cannot be 1. A. Woda, P. Pionchon, A unified concept of attributed to any pathological process. So, idiopathic orofacial pain: clinical features, J the diagnosis of PIFP is mainly done by Orofac Pain 13(3) (1999) 172-84; exclusion of other disorders. discussion 185-95. 2. S. Headache Classification Committee of Treatment the International Headache, The Careful interdisciplinary International Classification of Headache collaboration is needed to establish the Disorders, 3rd edition (beta version), diagnosis and management of persistent Cephalalgia 33(9) (2013) 629-808. idiopathic facial pain (PIFP). Clinicians 3. C. Feinmann, M. Harris, R. Cawley, should be aware of the importance of Psychogenic facial pain: presentation and listening to the patients and acknowledging treatment, Br Med J (Clin Res Ed) the symptoms that patients are describing as 288(6415) (1984) 436-8. a real condition. [14] Patient education is 4. D. Mueller, M. Obermann, M.S. Yoon, F. important to clarify the diagnosis, and Poitz, N. Hansen, M.A. Slomke, P. certainly the patient should be discouraged Dommes, E. Gizewski, H.C. Diener, Z. Katsarava, Prevalence of trigeminal from any further invasive interventions neuralgia and persistent idiopathic facial aimed at pain relief in the absence of clear pain: a population-based study, Cephalalgia associated pathology. 31(15) (2011) 1542-8.

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