Teeth and supporting tissues, e.g. dental. Maxillary sinus, salivary gland

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1 MJDF Facial Pain. Patricia Thomson Always start with SOCRATES S site O onset C character R radiation A associated features T timing E exacerbating/relieving factors S severity Examine the cranial nerves to establish if neurological lesion, and carry out a routine examination to determine if dental disease. Although rare, consider neoplasia. Causes of facial pain may be categorized as: Teeth and supporting tissues, e.g. dental. Maxillary sinus, salivary gland Psychogenic : atypical facial pain, BMS, TMJ Neurological: Idiopathic trigeminal neuralgia, malignant neoplasm involving Trigeminal nerve, Glossopharyngeal neuralgia, herpes zoster, MS Vascular: migraine, periodic migrainous neuralgia, Giant cell arteritis. Referred pain: nasopharyngeal, ocular, aural, cardiorespiratory (angina, lesions in the neck or chest). Always look for a dental cause first. Differential diagnosis: TMD Trigeminal neuralgia Oral dysaesthesia/ BMS (burning mouth) Maxillary Sinusitis Periodic migrainous neuralgia -Cluster Headache Giant cell arteritis- temporal arteritis Atypical facial pain Glossopharyngeal neuralgia Shingles Neoplasia MS Cerebrovascular disease

2 Burning mouth syndrome (Glossodynia, oral dysaesthesia) Includes a number of disorders which include burning/pain, in absence of soft tissue abnormalities, as well as bad taste and perceived dry mouth Diagnosis of exclusion. Neuropathic pain with either a disturbance of the way in which information is passed from the oropharynx to the brain, or the understanding of the information by the brain. Unknown aetiology. Test for B12, folate and Iron deficiencies. Test for diabetes. Most common finding is anxiety. 1-15% of population affected. Mainly females, and especially of peri-menopausal age. Rare in women below 30 and men below 40. F:M 7:1 May be relieved by eating and alcohol. Usually bilateral symptoms. There may be changes to sleep patterns and there may be mood changes. They are supertasters. There are no organic signs of disease and there are no neurological signs. Do cranial nerve examination to exclude serious disease. Type 1 asymptomatic on waking; symptoms increase in severity as day goes on. Good prognosis. Type 2 symptoms present on waking and continue throughout day. Associated with significant anxiety and depressive element. Poorer prognosis than type 1. Type 3 intermittent symptoms and often unusual sites e.g. floor of mouth. May have association with aetiological factors such as allergy. Aetiological factors: Nutritional deficiencies such as iron, folate, vit B12, B1 and B6. Undiagnosed or poorly controlled diabetes mellitus Denture problems Mucosal infections such as candida Lichen planus Erythema migrans- geographic tongue Tongue thrusting, clenching Xerostomia Parafunctional activity Psychological factors- psychogenic- cancerophobia, depression, anxiety Drugs Captopril, ACE inhibitors, cytotoxic drugs Allergy- denture base materials, food additives Investigations: Haematological, blood glucose, microbiology, prosthetic evaluation, psychology evaluation, patch testing.

3 Treatment: reassurrance, correct underlying organic problems, possible tricyclic antidepressants- Nortriptyline- and neuropathic drugs such as gabapentin. Can also make soft splint if occlusal trauma in parafunctional habit. Can chew gum. Also suggested are Yoga and relaxation exercises. Maxillary sinusitis Unilateral midface pain similar to pulpal or periapical pain in upper molar teeth. Suspect if no dental pathology, and no TMD. Rarely affects kids below age 9 as sinus not developed. Most caused by viral infection, so no antibiotics. Constant throb which varies in intensity. May be history of sinusitis and bad taste and halitosis. Worse in morning, and may have tenderness over cheek. May be more painful bending forward or lying down. Refer to GP for appropriate treatment, but can prescribe spray or drop nasal decongestant. If accompanied by obstruction to breathing, cheek swelling or numbness of upper lip, take this seriously, as may be antral carcinoma. Trigeminal neuralgia. Pain of sudden, intense, and short duration -seconds. May be due to demyelination of the nerve or pressure from an adjacent blood vessel. May also be more sinister; may be due to pressure from a tumour, or multiple sclerosis. It is a rare condition usually affecting the over 50s. More women affected than men and prevalence 0.16%- 0.3%. Usually short intense pain affecting one branch of the trigeminal nerve, usually mandibular or maxillary. Like an electric shock that stops patient in their tracks. Trigger areas on touching,, shaving, washing etc. Usually in morning, and does not disturb sleep. Usually unilateral. Aetiology may be that a cerebral blood vessel becomes artherosclerotic and less flexible with age, then presses on the roots of the trigeminal nerve in the posterior cranial fossa. Needs specialist referral and management at beginning. When stabilised can be managed in 1y care. Carbamazepine (anticonvulsant) prescribed by specialist. LA can be given as an emergency for acute situation. Gabapentin and phenytoin can also be given. Must determine if CNS lesion such as MS or tumour so must examine cranial nerves to exclude serious cause. Xrays, scans and blood tests are often required. Rx options: Drugs- Carbamazepine, phenytoin, gabapentin, baclofen. Problems with Carbamazepine: Balance disturbed Blood pressure may increase Liver function may become impaired

4 Surgical- Bupivacaine injections, cryosurgery, neurectomy, balloon compression of ganglion, Gamma knife radiosurgery. Glossopharyngeal neuralgia Uncommon. Severe lancinating pain in distribution of glossopharyngeal nervebase of tongue, pillars of fauces. Can be triggered by swallowing, coughing, chewing. Treatment principles similar to trigeminal neuralgia, but carbamazepine is less effective. Occasionally it is secondary to tumours. Specialist opinion necessary. Atypical Facial Pain Sometimes termed medically unexplained symptoms(mus). Has a psychogenic component. Common features: constant chronic discomfort, pain of a boring or burning nature, poorly localized and may cross midline. Rarely wakens patient from sleep, and lack of objective signs of organic disease. Recent adverse life events, and usually multiple other MUS such as headache, neck pain, itching, IBS, insomnia etc. Cure is uncommon and few persist in use of analgesics. V important to examine cranial nerves to exclude serious disease, as many similar symptoms may occur in those cases. Treatment involves reassurance, NSAIs, check bloods for deficiencies, and check dentures. May need to use antidepressants- Amitryptiline. CBT (cognative behavioural therapy) can be useful. Avoid operative intervention. Salivary Gland Salivary duct disorder may cause blockage. Pain usually localized and severe, and intensified by increased saliva production at meal times. May see swelling and tenderness with some trismus. Neurological (neuropathic) causes of facial pain Any lesion affecting the trigeminal nerve can cause pain often with physical signs such as facial sensory or motor impairment. Such as:

5 Trauma Cerebrovascular disease Demyelinating disease Neoplasia Infections such as herpes zoster and HIV/AIDS Herpetic and post herpetic neuralgia Shingles. Often preceded by neuralgia, but unilateral rash and ulceration is common. Continuous burning pain. Vascular causes The pain is usually obviously in the head rather than the mouth, but sometimes involves both. These disorders include migraine, migrainous neuralgia and giant cell arteritis. Giant Cell Arteritis- temporal arteritis Vascular pain syndrome of predominately older people. Unilateral temporal and/or jaw pain, often reported as burning sensation. May affect artery in head and neck. Involvement of retinal or ciliary vessels may cause blindness. Affected arteries may be thickened or tender. May also have claudication of muscles of mastication. May have fever, malaise, anorexia. Elevated ESR and C-reactive protein. Infiltration of arterial wall by giant cells. Early diagnosis essential to prevent ophthalmic complications. Steroids administered immediately. Periodic Migrainous Neuralgia Cluster Headache (Alarm Clock headache) Severe unilateral pain of orbital, supraorbital or temporal regions. Men most common M:F 4:1. Pain lasts mins, and will usually waken patient. Often also have running nose, lacrimation, facial sweating nasal congestion. Agitated or restless during attack. May be precipitated by alcohol. Can last for days or weeks. Rx Acute- Sumatriptan (Imagrin- reduces vascular inflammation), oxygen. Prophylaxis- Indometacin, beta blockers, calcium channel blockers, lithium. Specialist treatment.