OralMedicine Anne M Hegarty Joanna M Zakrzewska Differential Diagnosis for Orofacial Pain, Including Sinusitis, TMD, Trigeminal Neuralgia 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 chronic pain 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 Oral Medicine, 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, pulpitis which may in turn influence the extent and Periodontal – periapical periodontitis, acute necrotizing nature of the pain. ulcerative gingivitis/periodontitis Chronic orofacial pain results in decreased quality of life and psychological Mucosal disease Ulcerative/erosive disorders including desquamative gingivitis effects rarely seen in dental pain. Bony pathology Alveolar osteitis (dry socket) Clinical examination Osteomyelitis 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, muscles of mastication and Salivary gland 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 Trigeminal neuralgia 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 Postherpetic neuralgia abnormalities. Sensation to light touch Burning mouth syndrome and pin prick can easily be elicited by the use of cottonwool and an appropriate Vascular Migraine sterile pin, respectively, and assessment of Tension type headache the facial nerve 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 mandible 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 = Cluster Headache 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 Attrition 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 erythema bone Boring Swelling Tooth mobility Acute Unerupted Ache Continuous Moderate Biting Ear Removal Fever pericoronitis or partially to severe Unilateral of trauma Malaise erupted Irrigation Regional third Antibiotics lymphadenopathy molar 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 Surgery salivary Sub- Aching severe taste of regional if of eating Erythema gland mandibular food/drink associated Removal of Possible infection 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 Palate Tingling +/- moderate Spicy, involved Abnormal Lips Tender paroxysms acidic saliva Pharynx Itching foods Sensory change Postherpetic Localized to Burning Continuous Mild to Touch Nil Medication Allodynia Oral Medicine neuralgia site of Tingling