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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 3  |  Issue : 1  |  Page : 1-5

Pain in the face: An overview of pain of nonodontogenic origin


1 International Medical Center, Jeddah, Saudi Arabia; Department of Oral and Maxillofacial Surgery, SRM Kattankulathur Dental College and Hospital, Kanchipuram, Tamil Nadu, India
2 Department of Oral and Maxillofacial Surgery, SRM Kattankulathur Dental College and Hospital, Kanchipuram, Tamil Nadu, India

Date of Web Publication2-Nov-2018

Correspondence Address:
Dr. Kamal Kanthan Ravikumar
International Medical Center, Jeddah

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijosr.ijosr_1_17

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  Abstract 


It is common for pain in the orofacial region to be mistaken for a toothache, and similarly, other pains of the head and neck to mimic odontogenic pain orofacial pain may pose a diagnostic dilemma for the dental practitioner. The purpose of this article is to: (a) provide the dental practitioner with an understanding of pain etiology to consider when developing differential diagnoses for orofacial pains and (b) review various types of nonodontogenic pains which may be mistaken for a toothache. Ultimately, this article will aid the dental practitioner with preventing misdiagnosis and delivery of incorrect and sometimes irreversible procedures for nonodontogenic pain.

Keywords: Facial pain, headaches, myofascial, nonodontogenic


How to cite this article:
Ravikumar KK, Ramakrishnan K. Pain in the face: An overview of pain of nonodontogenic origin. Int J Soc Rehabil 2018;3:1-5

How to cite this URL:
Ravikumar KK, Ramakrishnan K. Pain in the face: An overview of pain of nonodontogenic origin. Int J Soc Rehabil [serial online] 2018 [cited 2018 Nov 19];3:1-5. Available from: http://www.ijsocialrehab.com/text.asp?2018/3/1/1/244541




  Introduction Top


The orofacial pain is the most frequent site for a patient seeking medical consult for pain with 12.2% of the population reporting dental pain as the most common orofacial pain.[1] Consequently, it is common for pain in the orofacial region to be mistaken for a toothache, and similarly, other pains of the head and neck to mimic odontogenic pain. Therefore, orofacial pain may pose a diagnostic dilemma for the dental practitioner. The purpose of this article is to: (a) provide the dental practitioner with an understanding of pain etiology to consider when developing differential diagnoses for orofacial pains and (b) review various types of nonodontogenic pains which may be mistaken for a toothache. Ultimately, this article will aid the dental practitioner with preventing misdiagnosis and delivery of incorrect and sometimes irreversible procedures for nonodontogenic pain.

Pain in the facial region may be broadly classified based on their origin as local cause, neurologic, vascular, and psychogenic. As mentioned in [Table 1], a classification system is useful when attempting to make a diagnosis to facilitate treatment decisions and to predict future outcomes. As illustrated in [Table 1], facial pain due to local causes that are from dental origin includes pulpitis, dentinal hypersensitivity, and periapical periodontitis. Those arising from gingival include primary herpetic gingivostomatitis, acute necrotizing ulcerative gingivitis, and desquamative gingivitis. The management of such conditions lies within the scope of the general dental practitioner.
Table 1: Classification of orofacial pain

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Pain with musculoskeletal-mucosal and soft-tissue origin includes internal derangement of temporomandibular joint (TMJ), myofascial pain dysfunction syndrome, maxillary sinusitis, and salivary gland diseases.

The pain of neurologic and vascular origin includes trigeminal neuralgia (TN), glossopharyngeal neuralgia (GN), postherpetic neuralgia (PHN), Ramsay-Hunt syndrome, Tolosa–Hunt syndrome, optic neuritis, cluster headaches, and cranial arteritis. Facial pain due to musculoskeletal and neurologic-vascular causes requires appropriate specialist referrals to oral and maxillofacial surgeons and neurologists, respectively. The presence of psychosocial disability will also affect referrals as those with higher levels would require referrals to psychiatrist. Idiopathic facial pain/atypical facial pain, burning mouth syndrome (BMS) are certain conditions with psychological background.

The diagnosis of the majority of facial pain is based on careful history and examination. The patient must be given time to “tell their story” to determine both the pain disease and the pain illness/suffering. We ask patients to complete a questionnaire or question directly about their treatment goals as it gives us an indication of which issues are important to the patient, for example, reassurance that their pain is not caused by a serious underlying disease, taking less medication, having a diagnosis, or being able to communicate about their pain.


  The Individual Conditions and Their Management are Discussed Below Top


Trigeminal neuralgia

TN typically manifests as unilateral sharp lancinating pain, elicited by touching a superficial trigger point and radiating from that point across the distribution of a branch of trigeminal nerve. Pain lasts for few seconds but might recur with variable frequency. TN occurs with average frequency of about 4 in 100,000 persons in the middle to late life with a slight female predisposition. TN can, however, be a feature of early multiple sclerosis in young adults, HIV disease, Lyme disease, neoplasia or vascular malformations in central and peripheral distribution of trigeminal nerve. The current evidence is that TN is as a result of microcompression, due to impingement of aberrant vessels on trigeminal nerve as it leaves the brain stem.

Medical management includes carbamazepine typically start −100 mg tds and increased to max of 1600 mg/day until pain relief is achieved about 20% of patients develop side effects that limit therapy such as tremors, ataxia, others include hepatic enzyme induction, hyponatremia, bone marrow suppression, and folate depletion. Skin rashes develop 3 months after therapy accompanied by pyrexia and lymphadenopathy-increased risk of lymphoma. Hence, monitoring of clinical and hematological parameters is required. Phenytoin is alternative to carbamazepine and can also be used in combination with it. Typically, 100 mg tds to a maximum of 600 mg/day.

Antispasmodic baclofen-L-baclofen can be used as an adjunct to carbamazepine therapy.

[Table 2] lists the drugs used in the medical management of TN.
Table 2: Drugs used Neuralgia

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Other interventional treatment modalities include permanent anesthesia following alcohol and glycerol injection which include the risk of local tissue damage. Patients with intractable pain affecting life, either percutaneous thermocoagulation of trigeminal ganglion or direct exploration of trigeminal root after craniotomy and insertion of sponge between nerve and aberrant artery is carried out as neurosurgical procedure with high morbidity rate.

Glossopharyngeal neuralgia

GN is characterized by lancinating pain of oropharynx or the neck triggered by swallowing, coughing, or talking. The presence of unilateral pain radiating to ear and mouth. Syncope may be a feature. Rarely cardiac arrhythmias due to vagal stimulation, xerostomia, or excessive salivation may be present. Can be associated with multiple sclerosis and benign and malignant CNS tumors. There is usually a clustering of pain attacks lasting week to months.

Management includes carbamazepine which is the mainstay of therapy. Baclofen may be of benefit as well. Local surgical measures such as peripheral neurectomies or cryosurgery – rarely possible. Surgical section of glossopharyngeal nerve and upper roots of vagus can be of benefit. Central surgical methods such as microvascular decompression may cause complete resolution in 75% of patients.

Postherpetic neuralgia

It typically affects the ophthalmic division of trigeminal nerve. PHN represents pain in the area of a previous episode of infection by varicella-zoster virus that persists for >1 month after cessation of accompanying vesicular rash.

Pain is deep-seated burning or throbbing sensation sometimes lancinating nature mimicking TN. Patients have herpetic scarring in the area of orofacial pain, and there can be hypoesthesia, hyperesthesia, and hypoalgesia. Pain persists for months to years, no remission periods. The severity of pain has been found to correlate with preservation and not loss of thermal sensory function which suggests that rather than being due to deafferentation and central reorganization, a significant component of pain in allodynic PNH is generated by activity in primary afferent nociceptor.

Management includes Oral acyclovir 800 mg five times daily given not >72 h after onset of herpetic rash hastened healing and reduced acute pain and likelihood of PHN developing. The efficacy of newer drugs includes valaciclovir, famciclovir, and sorivudine under evaluation.

High-dose systemic steroids at the time of the attack of shingles can be given but beware of disseminated herpes which could be fatal.

Antidepressant drugs-amitriptyline, nortriptyline-slow upward titration beginning nightly dose of 25 mg and rising in similar increments weekly. Side effect includes sedation, anticholinergic effects, and postural hypotension. Maximum dose 150 mg/day. Intravenous (IV) morphine and IV ketamine can be used in severe cases for pain relief. Topical applications-aspirin/diethyl ether mixture, lignocaine/capsaicin. LA blockage with bupivacaine of stellate ganglion through anterior paratracheal approach gives short-term pain relief of PHN.

Temporomandibular joint dysfunction

Temporomandibular joint dysfunction is themost common noninfective pain disorder of orofacial region. Clinical features are pain within and around the TMJ and associated muscles of mastication, clicking, limitation of mouth opening, locking of joint in opening or closing and slight female predisposition.

It is essential to establish whether the condition is due to extra-articular condition or intraarticular pathology. The differential diagnosis of intraarticular versus extra-articular conditions is given in [Table 3].
Table 3: Temperomandibular Joint disorder symptoms and signs

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Masticatory muscle pain and dysfunction (MPD) describes the painful and debilitating extra-articular pains of the jaws, head, and neck. These problems generally result from abuse of masticatory musculature secondary to abnormal parafunctional habits such as bruxism and clenching of teeth in response to stress and or myofascial pain. However, if not controlled or eliminated, these habits can cause intraarticular pathology by creating TMJ overload.

Intraarticular pathology includes the pathologic entities that occur to intraarticular structures of TMJ, namely the articular disc. The important distinction is that masticatory and cervical MPD are not primarily centered in the joint, whereas these conditions are directly related to the TMJ. Radiographs are taken to exclude primary joint disease. Oblique lateral transcranial projection, orthopantomogram, superior mesenteric vein, computed tomography (CT) scans, and magnetic resonance imaging are principal radiologic methods for eliciting boney and soft-tissue pathologies of TMJ, respectively.

Management includes soft diet, limited talking, avoid excessive yawning, local application of ice for acute pain, heat fomentation and massage of muscles of mastication for chronic pain. Passive and active jaw exercises recommended for joint clicking, restricted opening mouth opening, and irregular mandibular movements. Patients with asymptomatic clicking of TMJ may benefit from replacement of any lost posterior teeth and occlusal splint therapy. Hard acrylic plane splint reduces muscle and joint pain but unlikely to reduce joint clicking and limited opening. Myogenous pain improves with nocturnal splint therapy. Arthrogenous pain requires continuous wear of splint for at least a short term. Anterior repositioning device eliminates reciprocal clicking and tenderness of TMJ by reduction of pain due to forward positioning of the device allowing retrodiscal tissue time to repair. However, the disadvantage is the development of posterior open bite. Soft splint-lessen TMJ dysfunction-related headache and clicking. Psychotropic agents include dothiepin hydrochloride in daily doses of between 25 and 225 mg amitriptyline, nortriptyline, diazepam, and alprazolam. Complementary therapies include acupuncture therapy-benefit lasts <6 months, ultrasound therapy, transcutaneous electrical nerve stimulation (TENS). Electromyography-provide some benefit against nocturnal bruxism intra-articular corticosteroid has little benefit long term. Intra-articular injection of sclerosant is useful in patients with TMJ dysfunction secondary to joint hypermobility.

Referral to maxillofacial surgeon is appropriate for the patients who suffer from internal derangement of TMJ particularly those with nonreducing disc-closed lock who would benefit from arthrocentesis and lavage of TMJ.

Atypical facial pain

It is essentially a diagnosis by exclusion. Pain is usually a continuous dull ache with intermittent severe episodes primarily affecting areas of face other than joint and muscles of mastication, zygoma, and maxilla. Pain may be bilateral not responsive to many years to analgesics. Atypical odontalgia has similar character but localized to one or more premolar or molar teeth, simulating pulpitis. Other symptoms include headache, neck and back pain, dermatitis or pruritis, IBS, dysfunctional uterine bleeding. There is probable association with neuroses particularly depression. It is biochemically vulnerable and can be identified by a reduced urinary excretion of conjugated tyramine sulfate which is also found in patients with endogenous depression. Reassurance by the clinician and antidepressant therapy is the main mode of treatment and would warrant psychiatrist referral at some point. TENS and sphenopalatine ganglion blocks have some benefit.

Maxillary sinusitis

Since the roots of the maxillary dentition are in intimate contact with, and often protruding into, the sinus cavity, it is comprehensible that the dentition could be a potential source of sinus inflammation and infection. Due to the close proximity between maxillary posterior roots and the maxillary sinus, an infectious process in the dentition or surrounding periodontal tissue may present as an acute or chronic sinusitis; conversely, inflammation and infection originating in the maxillary sinus may be perceived as odontogenic pain. Patients may present with facial pain and pressure in the maxillary posterior region. Other symptoms such as headache, halitosis, fatigue, cough, nasal discharge/drainage or congestion and ear pain may be more identifiable as being associated with sinus disease.[2] Sinus pain can also present as a continuous dull ache or diffuse lingering pain in the maxillary teeth with sensitivity to percussion, mastication, and/or temperature.[3],[4] This hypersensitivity is often felt in multiple teeth, making it more indicative of a pain of sinus origin rather than odontogenic pain.[4]

Often a history of respiratory infection, nasal congestion, and sinus disease may precede the onset of the toothache.[2] Pain may be elicited by palpation of the infraorbital regions or manoeuvring the head to below the levels of the knees, initiating gravitational shifting of fluid in the sinus.[2],[5] The absence of an offending tooth or gingival inflammation on intraoral examination may further lead to the conclusion that there is sinus inflammation or infection. Although chronic sinusitis may erode the wall of the sinus, it is rarely associated with intraoral soft-tissue swelling or pain.[6] Intraoral or panoramic radiographs may be useful to exclude the dentition as being the source of the problem. The sinuses may appear cloudy, opacified, and congested on the panoramic radiograph. Increased fluid levels and thickening of the sinus mucosal membrane may be apparent on CT scan. Once identified, treatment should be directed toward the maxillary sinus infection. Most cases of acute sinusitis are of viral origin and require nasal decongestants, a therapy targeted at reducing the soft tissue edema to allow drainage of the sinus through the ostium into the middle meatus of the nasal cavity.[7] In the cases of bacteria-induced sinusitis, a regimen of antibiotics is additionally prescribed. Management is beyond the scope of a dental professional and appropriate referral to an otorhinolaryngologist or the general medical practitioner is appropriate once there is a clear understanding that the source of the odontogenic pain is of sinus origin.

Burning mouth syndrome

It presents as a variety of symptoms including pain, burning or itching in the tongue, lips or elsewhere in oral mucosa, usually bilateral. Alteration in taste and dryness of mouth symptoms relieved or exacerbated with eating or drinking.

  • BMS Type-1: Burning is absent on waking but increases as days go on
  • BMS Type-2: Burning present on waking and persists throughout the day
  • BMS Type-3: Symptoms are intermittent.


Suspected local factors for BMS are ill-fitting dentures, candidal infection, fusospirochetal infection. The systemic factors include Iron, folic acid, Vit B12 deficiency, underlying undiagnosed DM. There is a strong Psychological association and 44%–92% of patients have anxiety or depression.

Management is by chlordiazepoxide and dothiepin. Local application of agents such as lidocaine in carboxymethylcellulose or benzydamine hydrochloride spray.

Cluster headaches

Usually male predilection. Unilateral headache around eye, zygoma, or upper teeth in episodes lasting 30 min−2 h. Pain associated with lacrimation, nasal congestion, and ptosis. Occurs 1–3 times daily often fixed hours very commonly wakes patients from sleep. Pain occur in bouts lasting 4–12 weeks at intervals of 6 mt–5 years. Management is by verapamil 120 mg tds, prednisolone 40 mg/day.

Migraine

Typical attacks occupy hemicranium, accompanied by nausea and vomiting and are preceded by cortical disturbances that may produce visual, motor, or sensory symptoms that may last for 20–30 min. Occasional-patients are confused and might have syncopal attacks. Management includes high-dose corticosteroid-like prednisolone 80 mg daily. Risk of irreversible blindness if left untreated.

Cardiac pain referred to the jaw

Ischemic cardiac pain can present as referred pain to the jaws and teeth. When cardiac pain presents in the orofacial region commonly affected areas include pain(s) in the neck, throat, ear, teeth, mandible, and headache. Alternate sources of pain should be considered when local anesthetic and analgesics fail to alleviate dental symptoms. Appropriate questioning and thorough medical history are essential in identifying the true source of pain, especially when a cardiac toothache is suspected. Clinical characteristics of pain may vary between patients. Pain may be episodic, lasting from minutes to hours, and varies in intensity, although almost invariably is precipitated by exertional activities and alleviated with rest. Intriguingly, patients experiencing cardiac pain reported the descriptor of “pressure” more often when compared to any other disorder. If the pain is associated with cardiac or chest pain, it is most often relieved by sublingual nitroglycerin, and immediate referral to a medical practitioner is imperative.


  Discussion Top


The clinical presentation of nonodontogenic pain is varied and may mimic other pain disorders which may not originate in the orofacial region. The extent of pain may vary from very mild and intermittent pain to severe, sharp, and continuous. Furthermore, pains that are felt in the tooth do not always originate from dental structures, so it is important to distinguish between site and source of pain to provide correct diagnosis and appropriate treatments. The site of pain is where the pain is felt by the patient, whereas the source of pain is the structure from which the pain actually originates. In “primary” pain, the site and source of pain are coincidental and in the same location.[8] That is, pain occurs where damage to the structure has occurred. Therapy for primary pain is obvious and does not pose a diagnostic dilemma for the clinician.

Pain with different sites and sources of pain, known as heterotopic pains, can be diagnostically challenging. Once diagnosed, treatment should be posed at the source of pain, rather than the site. Neurologic mechanisms of heterotopic pain are not well understood, but it is thought to be related to central effects of constant nociceptive input from deep structures such as muscles, joints, and ligament. In patients who present with toothache pain, dental practitioners should consider alternate etiologies of the pain when appropriate diagnostic tests do not lead to odontogenic etiology.[9] Failure to establish the etiology of the pain will result in incorrect diagnosis and inappropriate treatment.


  Conclusion Top


There are a multitude of nonodontogenic pains that can present at the site of a tooth and can mimic a toothache. Dental practitioners should also have an understanding of the complex mechanism of odontogenic pain and the manner in which other orofacial structures may simulate dental pain.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lipton JA, Ship JA, Larach-Robinson D. Estimated prevalence and distribution of reported orofacial pain in the United States. J Am Dent Assoc 1993;124:115-21.  Back to cited text no. 1
    
2.
Okeson JP. Non-odontogenic toothache. Northwest Dent 2000;79:37-44.  Back to cited text no. 2
    
3.
Osguthorpe JD, Hadley JA. Rhinosinusitis. Current concepts in evaluation and management. Med Clin North Am 1999;83:27-41, vii-viii.  Back to cited text no. 3
    
4.
Falk H, Ericson S, Hugoson A. The effects of periodontal treatment on mucous membrane thickening in the maxillary sinus. J Clin Periodontol 1986;13:217-22.  Back to cited text no. 4
    
5.
Murphy E, Merrill RL. Non-odontogenic toothache. J Ir Dent Assoc 2001;47:46-58.  Back to cited text no. 5
    
6.
Rafetto L. Clinical examination of the maxillary sinus. Oral Maxillofac Surg Clin North Am 1999;11:35-44.  Back to cited text no. 6
    
7.
Kretzschmar DP, Kretzschmar JL. Rhinosinusitis: Review from a dental perspective. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:128-35.  Back to cited text no. 7
    
8.
Balasubramanium R, Turner L, Fischer D, Klasser G, Okeson J. Non-odontogenic toothache revisited. Open J Stomatol 2011;1:92-102.  Back to cited text no. 8
    
9.
Kwon PH, Laskin DM. Clinician's Manual of Oral and Maxillofacial Surgery. 3rd ed. London: Quintessence Books; 2001. p. 432.  Back to cited text no. 9
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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