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Anne M Hegarty
Joanna M Zakrzewska
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
Diagnosis Site Character Duration Severity Triggers Radiation Relieving Associated Appropriate
factors factors referral point
DENTOALVEOLAR
Irreversible Tooth Sharp Intermittent Mild to Heat Regional Cold Deep caries
pulpitis Throbbing Continuous severe Chewing Unilateral
Lying Upper/
supine lower jaw
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 moderate Local Hyperalgesia Facial Pain Centre
herpes Shooting anaesthetic Altered
zoster Tender sensation
infection Itching
Intra-oral
but more
often
extra-oral
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 Neurology
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
Table 2. Differential diagnosis of orofacial pain based on history highlighting appropriate referral centre for non-dental causes.
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 bruxism to a cranial lesion 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. lupus erythematosus. 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 Trigeminal neuropathic pain
of GPN. Eagles syndrome describes
brief stabbing recurrent pain in the Trigeminal neuropathic pain
symptoms related to an elongated
distribution of one or more branches of or traumatic induced neuralgia is a form
styloid process impinging on adjacent
the fifth cranial nerve’.16 Idiopathic and of chronic facial pain arising as secondary
anatomical structures and is associated
secondary forms are recognized and to injury to the trigeminal nerve, such as
with pain and dysphagia on chewing and
conditions such as multiple sclerosis, facial trauma or a dental procedure. It is
on turning the head to the affected side.
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,
based on symptoms and not aetiology.17 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 oral mucosa 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
with a peak incidence in 50–60-year- pathology.20,21 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
possibility of an underlying cause, such probably neuropathic.13 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
to intense severity, lasting seconds.17,18 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:
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 blood vessel 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
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 Dentistry
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, pulp 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 bones. 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