Applied Evidence

Zeroing in on the cause of your patient's facial pain

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The overlapping characteristics of facial pain can make it difficult to pinpoint the cause. This article, with a handy at-a-glance table, can help.


 

References

PRACTICE RECOMMENDATIONS

› Advise patients who have a temporomandibular disorder that in addition to taking their medication as prescribed, they should limit activities that require moving their jaw, modify their diet, and minimize stress; they may require physical therapy and therapeutic exercises. C
› Consider prescribing a tricyclic antidepressant for patients with persistent idiopathic facial pain. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Facial pain is a common complaint: Up to 22% of adults in the United States experience orofacial pain during any 6-month period.1 Yet this type of pain can be difficult to diagnose due to the many structures of the face and mouth, pain referral patterns, and insufficient diagnostic tools.

Specifically, extraoral facial pain can be the result of temporomandibular disorders, neuropathic disorders, vascular disorders, or atypical causes, whereas facial pain stemming from inside the mouth can have a dental or nondental cause (FIGURE). Overlapping characteristics can make it difficult to distinguish these disorders. To help you to better diagnose and manage facial pain, we describe the most common causes and underlying pathological processes.

Extraoral facial pain

Extraoral pain refers to the pain that occurs on the face outside of the oral cavity. The TABLE2-15 summarizes the site, timing and severity, aggravating factors, history and exam findings, and management of several common causes of extraoral facial pain.

Musculoskeletal pain

Temporomandibular disorders (TMD) are a broad group of problems that affect the temporomandibular joint (TMJ), muscles of mastication, and/or associated bony and soft tissue structures.6 They may occur secondary to malocclusion, traumatic injuries, oral parafunctional habits (eg, bruxism), hormonal influences, or psychogenic factors.6 TMD is more prevalent in women, with a peak occurrence between ages 20 and 40 years.6,8

TMD can be articular (intracapsular) or nonarticular (extracapsular). Nonarticular disorders (>50% of TMD) usually affect the muscles of mastication and include chronic conditions such as fibromyalgia, muscle strain, and myopathies.8 Muscle-related pain and dysfunction are believed to arise from parafunctional habits such as bruxism or clenching. Articular disorders include synovitis/capsulitis, joint effusion, trauma/fracture, internal derangement (disturbance in the normal anatomic relationship between the disc and condyle), arthritis, and neoplasm.16

What you’ll see. Orofacial pain (usually dull and located in the preauricular region), joint noise, and restricted jaw function are key signs and symptoms of TMD. Exacerbation of pain with mandibular functions (eg, chewing, yawning, or swallowing) is a pathognomonic sign. Joint sounds such as clicking or crepitus are common. In most cases, crepitus correlates with osteoarthritis.6 Nonspecific TMD symptoms include headache, earache, insomnia, tinnitus, and neck and shoulder pain.6

The gold standard of diagnosis of TMD consists of taking a detailed history, evaluating the patient’s head and neck, and conducting a general physical examination and behavioral/psychological assessment.17 Imaging of the TMJ and associated structures is essential.17

Treatment. Nonsteroidal anti-inflammatory drugs, opioids, muscle relaxants, antidepressants, anticonvulsants, anxiolytics, and corticosteroids are options for treating TMD.6,8 Isometric jaw exercises, maxillomandibular appliances, and physical therapy are valuable adjuncts for pain relief. Advise patients to establish a self-care routine to reduce TMJ pain that might include changing their head posture or sleeping position, and limiting activities that require using their jaw, such as clenching, bruxism, and excessive gum chewing. Some patients may need to adopt a non-chewing diet that consists of liquid or pureed food. Massage and moist heat can help relax muscles of mastication and improve range of motion.

Exacerbation of orofacial pain with mandibular functions such as chewing, yawning, or swallowing is a pathognomonic sign of temporomandibular disorder.

Approximately 5% of patients with TMD undergo surgery, typically simple arthrocentesis, arthroscopy, arthrotomy, or modified condylotomy.6 Total joint replacement is indicated only for patients with severely damaged joints with end-stage disease when all other conservative treatments have failed. Joint replacement primarily restores form and function; pain relief is a secondary benefit.8

Neuropathic pain

Trigeminal neuralgia (TN) is sudden, usually unilateral, severe, brief, stabbing, recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve.9 It most commonly presents in the lower 2 branches of the trigeminal nerve and usually is caused by compression of the trigeminal nerve root by vascular or nonvascular causes.4 The pain is severe and can profoundly impact a patient’s quality of life.

TN attacks typically last from a few seconds to up to 2 minutes. As many as 30 attacks can occur daily, with refractory periods between attacks. After the initial attack, individuals are left with a residual dull or burning pain. TN can be triggered by face washing, teeth brushing, speaking, eating, shaving, or cold wind.4

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