Differential diagnosis of facial pain and guidelines for management

Abstract

The diagnosis and management of facial pain below the eye can be very different dependant on whether the patient visits a dentist or medical practitioner. A structure for accurate diagnosis is proposed beginning with a very careful history. The commonest acute causes of pain are dental and these are well managed by dentists. Chronic facial pain can be unilateral or bilateral and continuous or episodic. The commonest non-dental pains are temporomandibular disorders (TMDs), especially musculoskeletal involving the muscles of mastication either unilaterally or bilaterally; they may be associated with other chronic pains. A very wide range of treatments are used but early diagnosis, reassurance and some simple physiotherapy is often effective in those with good coping strategies. Dentists will often make splints to wear at night. Neuropathic pain is usually unilateral and of the episodic type; the most easily recognized is trigeminal neuralgia. This severe electric shock like pain, provoked by light touch, responds best to carbamazepine, and neurosurgery in poorly controlled patients. Trauma, either major or because of dental procedures, results in neuropathic pain and these are then managed as for any other neuropathic pain. Red flags include giant cell arteritis which much be distinguished from temporomandibular disorders (TMD), especially in >50 yr olds, and cancer which can present as a progressive neuropathic pain. Burning mouth syndrome is rarely recognized as a neuropathic pain as it occurs principally in peri-menopausal women and is thought to be psychological. Chronic facial pain patients are best managed by a multidisciplinary team.

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis

“…170 Orofacial pain syndromes including temporomandibular disorders have been extensively reviewed in recent years. 171,172 In summary, the differential diagnosis of ARS includes AR, headache or facial pain syndrome, and dental conditions. Although diagnosis is most often possible solely on clinical grounds, additional testing may be helpful to differentiate ARS from other entities with overlapping symptoms.…”

Applications of sensory and physiological measurement in oral‐facial dental pain

“…There are at least three potential etiologies for TMD pain including degradation of TMJ structures, inflammation in the joint (i.e., degenerative joint disease‐arthritis) and myofascial pain. There is limited evidence that peripheral inflammation in local musculature (e.g., temporalis, medial pterygoid, and masseter) contributes to myalgic pain in TMD,16 and instead this type of TMD pain is thought to occur mainly via the central nervous system (CNS) mechanisms 17, 18, 19…”

“…TN has typical clinical features but is frequently of unknown etiology. TN is classified into Classical and Symptomatic subtypes 19, 26. Classical TN typically manifests as sudden, sharp, shooting, shock‐like pain, elicited by slight touching of “trigger points,” that can radiate.…”

Management of Temporomandibular Joint Dysfunction Syndrome: An Overview

“…(48,49) The differential diagno-sis and associated clinical findings are presented in Table-1 50 In differential diagnosis of TMJ disorders and pains, problems such as neoplasms, migraine,neuralgia and mental disorders should be considered. Practitioners must be alert for unusual pain locations, pain qualities, pain-aggravating and pain-relieving events, and other factors (e.g., unexplained fever) suggestive of disorders that may mimic TMD symptoms (e.g., infection, giant cell arteritis, meningitis, etc.).…”