O.Surgery Lec.6 Diagnosis and Management of Orofacial Pain.pdf

# Classification and characteristics of orofacial pain Orofacial pain can be classified into typical somatic, psychogenic, vascular, and neuralgic types, each with distinct characteristics and subtypes. ## 1. Classification and characteristics of orofacial pain Orofacial pain encompasses a diverse range of conditions affecting the face, mouth, and surrounding structures, which can be broadly categorized based on their origin and underlying mechanisms [3](#page=3). ### 1.1 Typical orofacial pain Typical orofacial pain, also known as somatic pain, arises from musculoskeletal or visceral structures and is interpreted through an intact pain transmission and modulation system [12](#page=12). #### 1.1.1 Dental pain Dental pain originates from various structures within the oral cavity, including the teeth and surrounding tissues [4](#page=4). #### 1.1.2 Periodontal pain Periodontal pain is associated with inflammation and infection of the gums and supporting structures of the teeth [4](#page=4). #### 1.1.3 Mucosal pain Mucosal pain involves conditions affecting the oral lining, such as traumatic ulcerations, aphthous stomatitis, viral ulcerations, and erosive lichen planus. It often presents as a burning sensation, exacerbated by spicy or hot foods. Biopsy is recommended if an ulcer persists for over two weeks [16](#page=16). #### 1.1.4 Bone pain Bone pain in the orofacial region can stem from alveolar osteitis (dry socket), fractures, osteomyelitis, or tumors. The pain can range from a dull ache to severe throbbing. Investigations include X-rays and biopsy, with treatment involving analgesics, antibiotics, or surgery [17](#page=17). #### 1.1.5 Salivary gland pain Diseases affecting salivary glands, such as sialadenitis, duct obstruction, mumps, and tumors, can cause localized, intermittent dull pain accompanied by gland swelling and xerostomia. Investigations may involve plain radiography or sialography, with treatment tailored to the specific condition [18](#page=18). #### 1.1.6 Temporo-mandibular joint (TMJ) pain TMJ pain can arise from traumatic arthritis, where damage to the capsule and meniscus due to direct mandibular trauma leads to moderate to severe, well-localized pain aggravated by jaw movement. Osteoarthritis of the TMJ is a degenerative condition causing well-localized pain provoked by jaw movements, with audible crepitus and tenderness. Investigations for TMJ disorders include X-rays (TMJ, PA, OPG views, or MRI) and serum uric acid levels for osteoarthritis. Treatments range from conservative therapy and analgesics for traumatic arthritis to occlusion correction, medication, arthrocentesis, or surgery for osteoarthritis [19](#page=19) [20](#page=20). #### 1.1.7 Maxillary sinus pain Sinusitis commonly presents as dull or severe maxillary pain, which may be unilateral or bilateral and worsens when the head is bent forward. This pain can be mistaken for dental issues due to sensitivity in the upper premolar and molar teeth. Diagnosis involves X-rays, specifically the occipitomental view, to visualize a radio-opaque sinus. Treatment includes antibiotics, analgesics, nasal decongestants, or surgery [21](#page=21). ### 1.2 Psychogenic orofacial pain Psychogenic orofacial pain originates from psychological factors rather than direct physical damage to the tissues [22](#page=22). #### 1.2.1 Facial arthromyalgia (TMJ myofascial pain dysfunction syndrome) This condition can manifest as clicking in the joint during chewing or talking, or as a severe continuous ache in one or both joints. The pain may radiate to the temporal, occipital regions, or the angle of the mandible. Tenderness is present in the TMJ and associated muscles. Patients may also experience pain in other body areas, such as cervical pain or irritable bowel syndrome [23](#page=23). #### 1.2.2 Atypical facial pain Atypical facial pain is a diagnosis of exclusion for chronic facial pain that does not fit other specific categories [4](#page=4). #### 1.2.3 Atypical odontalgia Atypical odontalgia, also known as pain resulting from deafferentation, occurs when there is damage to the afferent pain transmission system, usually due to trauma or surgery like extractions or endodontic treatment. It is characterized by continuous or almost continuous burning or aching pain, which may include sharp paroxysms [55](#page=55). #### 1.2.4 Oral dysthesia Oral dysthesia involves abnormal sensations within the mouth, commonly affecting the elderly, particularly those experiencing menopause or loneliness. Symptoms include a burning tongue, dry mouth despite adequate saliva, a sandy sensation in saliva, denture intolerance, and taste abnormalities. Treatment may involve reassurance and Trifluoperazine [27](#page=27). #### 1.2.5 Factitious ulceration This is self-inflicted ulceration that can be difficult to identify, especially if it mimics aphthous ulcers. Lesions may be caused by fingernails or erosive substances like aspirin. Patients often deny self-infliction. Histopathological examination typically reveals no underlying pathology. Treatment may include Trifluoperazines [28](#page=28). ### 1.3 Vascular orofacial pain Vascular orofacial pain is associated with abnormalities in blood vessels and includes chronic headache types. #### 1.3.1 Migraine Migraine headaches are characterized by unilateral location, pulsating quality, and moderate to severe pain. Approximately 40% of patients experience an aura, a neurological disturbance such as flashing lights or visual disturbances, preceding the headache [30](#page=30). #### 1.3.2 Cluster headache Cluster headaches are intensely severe unilateral orbital, supraorbital, or temporal pains lasting 15 to 180 minutes. They are often described as a stabbing sensation and are typically centered around the eye and temporal regions. Accompanying symptoms include parasympathetic overactivity such as lacrimation, conjunctival injection, ptosis, or rhinorrhea. Cluster headaches are also known as "alarm clock headaches" [36](#page=36). #### 1.3.3 Giant cell arteritis Giant cell arteritis, also known as temporal arteritis, is an inflammation of the cranial arterial tree, most prevalent in individuals over 50 years of age. It involves a giant cell granulomatous reaction. A common complaint is dull aching or throbbing temporal or head pain, affecting about 70% of patients and serving as the presenting symptom in one-third [39](#page=39). #### 1.3.4 Tension-type headache Tension-type headaches are the most common type of headache reported by patients. They are more prevalent in women and typically present as bilateral pain, often in the bi-temporal or frontal-temporal areas. Patients describe the sensation as their head being "in a vice" or a "squeezing hatband" [33](#page=33). ### 1.4 Neuralgia Neuralgia refers to neuropathic pain arising from damage or alteration to the pain pathways, most commonly due to peripheral nerve injury from surgery or trauma [42](#page=42). #### 1.4.1 Primary neuralgia Primary neuralgias are idiopathic conditions affecting specific cranial nerves. * **Trigeminal neuralgia:** This refers to any neuropathic pain of trigeminal nerve origin. The etiology is often unclear and may be attributed to viral infections, demyelination due to vascular compression, or narrowing of nerve foramina [42](#page=42). * **Glossopharyngeal neuralgia:** The hallmark symptom is sharp, electric shock-like pain triggered by swallowing, with a trigger zone in the oropharynx or base of the tongue. The pain radiates to the throat or tongue and can be referred to the lower jaw. Treatment may involve Tegretol [49](#page=49). #### 1.4.2 Secondary neuralgia Secondary neuralgias result from lesions or conditions affecting the nerves. * **Extra cranial lesions:** * **Two mental nerves neuralgia:** Pain in the lower mental areas can occur due to pressure from a lower denture flange on the mental nerve, which becomes superficial due to alveolar bone resorption. Treatment involves relieving the inner surface of the denture or mental nerve transposition [50](#page=50). * **Causalgia:** This is a well-localized, persistent burning pain at the site of a peripheral nerve injury. Excision of scar tissue may provide temporary relief. Treatment options include antidepressants, cryotherapy, or peripheral nerve avulsion [52](#page=52). * **Frey's auriculotemporal syndrome:** This condition arises after parotid gland or TMJ surgery or trauma, causing a burning sensation in the temporal or facial region with flushing and sweating during eating. It is thought to be due to reinnervation of sympathetic fibers by parasympathetic secretomotor fibers of the auriculotemporal nerve [53](#page=53). * **Herpes zoster:** Pain and burning precede a vesicular eruption caused by the Varicella virus affecting peripheral nerves. If the geniculate ganglion is involved (Ramsay Hunt Syndrome), it can lead to ipsilateral facial palsy, otalgia, and vesicular rash. Treatment includes acyclovir, anticonvulsants, or tricyclic antidepressants [57](#page=57). * **Post herpetic neuralgia:** This persistent burning pain can occur after untreated herpes zoster reactivation, attributed to the destruction of large myelinated sensory fibers. Treatment may involve ibuprofen and tricyclic antidepressants [58](#page=58). * **Nasopharyngeal carcinoma:** This can cause neuralgic pain as a secondary symptom [5](#page=5). * **Cranial base lesions:** * **Petrous temporal osteitis:** Inflammation of the petrous temporal bone can lead to neuralgic pain [5](#page=5). * **Cholesteatoma:** The presence of cholesteatoma in the cranial base can cause secondary neuralgia [5](#page=5). * **Intracranial lesions:** * Lesions in the posterior or middle cranial fossae can cause neuralgic pain [5](#page=5). * **Multiple sclerosis:** This neurological condition can manifest with neuralgic pain in the orofacial region [5](#page=5). ### 1.5 Other orofacial pain (Referred pain) Referred pain originates from a different site but is perceived in the orofacial region. #### 1.5.1 Ocular pain Ophthalmic diseases, such as acute glaucoma, can present as ill-defined facial pain [61](#page=61). #### 1.5.2 Cardiac pain Severe pain from ischemic heart disease may be referred to the mandibular teeth due to shared autonomic sensory innervation [61](#page=61). #### 1.5.3 Ear, nose, and tonsil pain Pain from conditions like otitis externa, peritonsillar abscess (quinsy), or nasal infections can be referred to the orofacial region [62](#page=62). #### 1.5.4 Elongated styloid process (Eagle's Syndrome) An elongated styloid process can cause pain upon swallowing and palpation in the tonsillar fossa, which may be perceived in the orofacial area. Diagnosis is confirmed by X-ray [63](#page=63). --- # Diagnostic approaches to orofacial pain Diagnosing orofacial pain involves a systematic approach that prioritizes patient history, detailed pain characterization, and targeted investigations to differentiate between various etiologies [6](#page=6) [7](#page=7). ### 2.1 The importance of patient history A thorough patient history is fundamental for diagnosing orofacial pain, especially when physical signs are absent. This history should encompass detailed information about the pain and the patient's overall health [7](#page=7). #### 2.1.1 Key components of pain history When assessing pain, clinicians should gather specific information, including: * **Character of the pain:** Descriptors such as sharp, dull, throbbing, burning, or stabbing are crucial [8](#page=8). * **Severity of the pain:** Categorized as mild, moderate, or severe [8](#page=8). * **Site and radiation:** The exact location of the pain and if it radiates to other areas [8](#page=8). * **Timing:** The frequency and duration of pain episodes or attacks [8](#page=8). * **Provoking factors:** Stimuli that trigger or worsen the pain, such as hot or cold temperatures, sweet substances, or bruxism [8](#page=8). * **Relieving factors:** Factors that alleviate the pain, including analgesics (prescription or over-the-counter), narcotics, or the application of heat [9](#page=9). * **Associated clinical features:** Presence of swelling, ulcers, or trismus (difficulty opening the mouth) [9](#page=9). * **Pain elsewhere in the body:** Inquiring about pain in other locations, such as abdominal or cervical pain, can provide systemic clues [9](#page=9). #### 2.1.2 Broader patient history Beyond pain characteristics, a comprehensive history includes: * **General medical history:** Overall health status and any existing medical conditions [9](#page=9). * **Emotional history:** Assessment of anxiety, depression, or the use of antidepressant medication [9](#page=9). * **Family history:** Information about the health or cause of death of family members, which might suggest genetic predispositions [9](#page=9). > **Tip:** Pain is a subjective symptom, and tools like the Visual Analogue Scale (VAS) and Verbal Rating Scale (VRS) can be used to objectively document pain severity and monitor disease control [7](#page=7). ### 2.2 Laboratory investigations and diagnostic tests Depending on the suspected etiology, various laboratory investigations and specific diagnostic tests may be employed. #### 2.2.1 Investigations for specific conditions * **Temporo-Mandibular Joint (TMJ) Disorders:** * **Traumatic arthritis of TMJ:** X-rays (TMJ, PA, OPG views) or MRI can be used for diagnosis [19](#page=19). * **Osteoarthritis of the TMJ:** X-rays (TMJ, PA, or OPG views) and serum uric acid levels are helpful [20](#page=20). * **Maxillary Sinusitis:** * An occipitomental view X-ray can reveal a radioopaque sinus, indicating inflammation [21](#page=21). * **Arteritis (e.g., Temporal Arteritis):** * Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) testing is indicated. * A biopsy of the affected artery may be necessary for definitive diagnosis [41](#page=41). * **Neuropathic Pain (e.g., Trigeminal Neuralgia):** * While often diagnosed clinically, local anesthesia of trigger zones can temporarily arrest pain, aiding diagnosis [45](#page=45). * Diagnostic tests like ESR can help rule out systemic inflammatory conditions that might mimic or exacerbate neuropathic pain [64](#page=64). #### 2.2.2 Differentiating pain origins It is essential to differentiate between organic (physical) and psychogenic (psychological) origins of pain, with the patient's history serving as a primary tool for this distinction [8](#page=8). ### 2.3 Differential diagnostic considerations The complexity of the head and neck anatomy, involving various structures like eyes, ears, salivary glands, muscles, joints, and sinus membranes, can make accurate diagnosis challenging [6](#page=6). #### 2.3.1 Mimicking dental pain Conditions such as maxillary sinusitis can present with pain that mimics dental pulpitis, particularly in the upper premolar and molar teeth, which become tender to percussion [21](#page=21). #### 2.3.2 Characteristics of specific pain types * **Temporal Arteritis:** Characterized by localized, severe, throbbing pain, and may be associated with weight loss, polymyalgia rheumatica, fever, decreased vision, and jaw claudication. ESR is often elevated [64](#page=64). * **Migraine:** Presents as acute, unilateral, throbbing pain often accompanied by nausea, vomiting, photophobia, and phonophobia [64](#page=64). * **Cluster Headaches:** Acute, severe, sharp stabbing pain, typically unilateral, and associated with rhinorrhea and lacrimation on the affected side [64](#page=64). * **Tension Headaches:** Chronic, global or unilateral aching pain, often associated with multisomatic complaints [64](#page=64). * **Trigeminal Neuralgia:** Characterized by severe paroxysmal pain, often triggered by mild superficial stimulation, affecting V2 and V3 branches. The pain is usually unilateral and patients are frequently pain-free between attacks, with no neurological deficits or dentoalveolar cause found [45](#page=45). > **Tip:** When no detectable disease signs are present, the patient's history becomes the sole evidence for diagnosis, emphasizing the need for meticulous history-taking [7](#page=7). > **Example:** A patient presents with severe facial pain. A detailed history reveals the pain is sharp, stabbing, and triggered by light touch on the cheek. The pain is unilateral, affecting the right V2 distribution, and the patient is completely pain-free between episodes. Examination reveals no visible lesions, and dental investigations are negative. Local anesthetic block of the infraorbital nerve provides complete temporary pain relief. These findings strongly suggest trigeminal neuralgia [45](#page=45). --- # Specific neuralgias and their management This topic explores various neuralgias, focusing on their etiologies, clinical presentations, and management strategies [4](#page=4) [5](#page=5). ### 4.1 Understanding Neuralgia Neuralgia is a neuropathic pain arising from damage or alteration to the pain pathways, most commonly due to a peripheral nerve injury from surgery or trauma. It can be classified as primary, where the cause is unclear, or secondary, resulting from identifiable lesions. The etiology of neuralgia is often attributed to viral infection of the nerve ganglion, demyelination of intracranial nerve roots due to nerve compression by vascular loops, or narrowing of nerve foramina [42](#page=42) [5](#page=5). ### 4.2 Primary Neuralgias #### 4.2.1 Trigeminal neuralgia Trigeminal neuralgia (TN), also known as tic douloureux, is a type of neuropathic pain originating from the trigeminal nerve [42](#page=42). **Clinical Presentation:** * Characterized by severe, paroxysmal pain described as sharp, electric shock-like, or stabbing, typically lasting from seconds to one minute [43](#page=43). * A refractory period follows each attack, during which the pain cannot be re-elicited [43](#page=43). * Pain is often provoked by specific activities or touching "trigger zones". Common trigger zones include the corner of the lips, cheek, ala of the nose, lateral brow, teeth, gingiva, or tongue [43](#page=43) [45](#page=45). * Most commonly affects the mandibular (V3) and maxillary (V2) branches of the trigeminal nerve. The ophthalmic distribution (V1) is rarely involved [44](#page=44) [45](#page=45). * Typically unilateral (96% of cases), with the right side more commonly affected than the left [45](#page=45). * Patients are often pain-free between attacks [45](#page=45). * No neurological deficits are usually present [45](#page=45). * Can be an early manifestation of multiple sclerosis [44](#page=44). * Patients are typically middle-aged or elderly, most frequently over 50 years, with women being more affected than men [43](#page=43). **Management:** * **Medical:** * Anticonvulsants are the first-line treatment: * Carbamazepine (Tegretol): 100-400 mg every 6 hours [46](#page=46). * Phenytoin: 200-400 mg twice daily [46](#page=46). * Newer anticonvulsants like gabapentin and oxcarbazepine are also used [46](#page=46). * Baclofen, an antispastic agent, can also be employed [46](#page=46). * **Surgical/Interventional:** * Injection of 60% or 90% alcohol into the mental or infraorbital foramina, preceded by 2% lignocaine to reduce pain. Aspiration is crucial before injection to avoid entering a blood vessel [47](#page=47). * Peripheral neurectomy [47](#page=47). * Cryotherapy [47](#page=47). * Microvascular decompression (Janetta procedure) to relieve compression of the trigeminal nerve by a vascular loop [47](#page=47). * Gamma Knife radiosurgery [47](#page=47). * Percutaneous needle thermal rhizotomy [47](#page=47). > **Tip:** Dentists must be aware of TN to avoid unnecessary dental treatments or extractions, as a local anesthetic block of a trigger zone can temporarily relieve pain, leading to a misdiagnosis of a dental cause [48](#page=48). #### 4.2.2 Glossopharyngeal neuralgia **Clinical Presentation:** * Characterized by sharp, electric shock-like pain, typically triggered by swallowing [49](#page=49). * The trigger zone is usually in the oropharynx or at the base of the tongue [49](#page=49). * Pain may radiate to the throat or tongue and can be referred to the lower jaw [49](#page=49). **Management:** * Carbamazepine (Tegretol): 100-400 mg every 6 hours [49](#page=49). ### 4.3 Secondary Neuralgias Secondary neuralgias result from identifiable lesions, which can be extra-cranial, cranial base, or intracranial [5](#page=5). #### 4.3.1 Two mental nerves neuralgia **Clinical Presentation:** * Pain occurs in the lower mental areas, often exacerbated by pressure from the lower denture flange [50](#page=50). * This can be due to the mental nerve becoming superficial as a result of alveolar bone resorption [50](#page=50). * Another cause is entrapment of the mental nerve due to narrowing of the mental foramen [51](#page=51). **Management:** * Relieving the inner surface of the denture over the affected mental area [50](#page=50). * Mental nerve transposition [50](#page=50). * Decompression of the mental nerve by removing a ring of bone around the margin of the foramen in cases of entrapment [51](#page=51). #### 4.3.2 Causalgia **Clinical Presentation:** * A well-localized, persistent burning pain at the site of a peripheral nerve injury [52](#page=52). * Exploration and excision of scar tissue may provide temporary relief, but pain returns as new scar tissue forms during healing [52](#page=52). **Management:** * Antidepressants [52](#page=52). * Cryotherapy [52](#page=52). * Avulsion of the peripheral nerve [52](#page=52). #### 4.3.3 Frey's auriculotemporal syndrome This syndrome is characterized by gustatory sweating and flushing of the preauricular and temporal area, often associated with pain [5](#page=5). #### 4.3.4 Herpes zoster **Clinical Presentation:** * Preceded by unilateral pain and burning sensation, followed by a vesicular eruption [57](#page=57). * Can affect any peripheral nerve, caused by the Varicella virus [57](#page=57). * If the geniculate ganglion and nervous intermedius of the facial nerve are involved (Ramsay Hunt Syndrome), it can lead to ipsilateral facial palsy, otalgia, and an erythematous vesicular rash of the auricle and oropharynx [57](#page=57). **Management:** * Acyclovir (systemic or topical) [57](#page=57). * Anticonvulsants or tricyclic antidepressants may also be used [57](#page=57). #### 4.3.5 Post herpetic neuralgia **Clinical Presentation:** * Occurs after reactivation of the Varicella virus, which can remain dormant in peripheral nerve ganglia [58](#page=58). * Presents as persistent burning pain in an area of diminished sensation [58](#page=58). * Attributed to destruction of large myelinated sensory fibers by the Varicella virus [58](#page=58). **Management:** * Ibuprofen 400 mg every 4-6 hours [58](#page=58). * Supplemented with Tricyclic antidepressants [58](#page=58). #### 4.3.6 Odontalgia resulting from deafferentation (Atypical odontalgia) **Clinical Presentation:** * Pain occurs due to damage to the afferent pain transmission system, often caused by trauma or surgery (e.g., extraction, endodontic treatment) [55](#page=55). * Pain is typically burning or aching, continuous or almost continuous, with occasional sharp paroxysms [55](#page=55). * May present with allodynia, hyperesthesia, or hypoesthesia [56](#page=56). * No dentoalveolar cause is found [56](#page=56). * History of surgical or other trauma and symptoms lasting over 4-6 months are common [56](#page=56). * Local anesthetic blocks are equivocal [56](#page=56). * Further peripheral surgical procedures can worsen symptoms and expand the perceived pain area [56](#page=56). #### 4.3.7 Neuroma **Clinical Presentation:** * Forms after peripheral nerve transection when sprouting of the proximal nerve segment occurs without distal connection [59](#page=59). * Neuromas become sensitive to mechanical and chemical stimuli, causing pain that is commonly burning or shock-like [59](#page=59). * Damage to the mandibular or lingual nerve after third molar surgery is a potential cause a dentist might encounter [59](#page=59). #### 4.3.8 Nasopharyngeal carcinoma **Clinical Presentation:** * Involvement of the mandibular and maxillary nerves can lead to a combination of facial pain, hypoesthesia, and wasting of the masseter muscle [60](#page=60). **Management:** * Radiotherapy [60](#page=60). * Cytotoxic drugs [60](#page=60). #### 4.3.9 Multiple sclerosis **Clinical Presentation:** * Can present as trigeminal neuralgia [60](#page=60). * In most cases, it is accompanied by other neurological disturbances, such as loss of taste, facial sensation disturbances, and sensory, reflex, or motor neurological deficits [60](#page=60). ### 4.4 Other Neuralgia Categories * **Extra cranial lesions:** Include two mental nerves neuralgia, causalgia, Frey's auriculotemporal syndrome, herpes zoster, post-herpetic neuralgia, and nasopharyngeal carcinoma [5](#page=5). * **Cranial base lesions:** Such as petrous temporal osteitis and cholesteatoma [5](#page=5). * **Intracranial lesions:** Affecting the posterior or middle cranial fossae, or associated with multiple sclerosis [5](#page=5). --- # Vascular and other orofacial pain conditions This section details orofacial pain stemming from vascular issues, such as migraines and cluster headaches, and pain referred from ocular, cardiac, or ear, nose, and tonsil sources. ### 4.1 Vascular orofacial pain Vascular orofacial pain conditions primarily include chronic headaches, with migraine, tension-type headache, cluster headache, and giant cell arteritis being the most prominent. #### 4.1.1 Migraine Migraine headaches are characterized by unilateral, pulsating pain of moderate to severe intensity. Approximately 40% of patients experience an aura, a neurological disturbance that can manifest as flashing lights or partial vision loss, typically preceding the headache by several minutes to an hour. Complicated auras may involve transient hemiparesis, aphasia, or blindness. Nausea and photophobia (light intolerance) are common during attacks in about 80% of individuals. Migraines can last from 4 to 72 hours if untreated and are often exacerbated by sneezing, light, smell, noise, or certain vasoactive foods or drugs. Migraines are at least twice as prevalent in women compared to men [30](#page=30) [31](#page=31). The underlying mechanism is not fully understood but is believed to involve neurogenic inflammation of intracranial blood vessels, stemming from neurotransmitter imbalances in specific brainstem centers [32](#page=32). Treatment options include nonsteroidal anti-inflammatory drugs, opioid analgesics, antiemetics, vasoactive ergotamine tartrate, antidepressants, anticonvulsants, and botulinum toxin [32](#page=32). #### 4.1.2 Tension-type headache Tension-type headaches are the most frequently diagnosed headaches by physicians. They are more common in women than men and are generally bilateral, often presenting as bi-temporal or frontal-temporal pain. Patients commonly describe the sensation as their head being in a "vice" or encircled by a "squeezing hatband". These headaches can occur with or without pericranial muscle tenderness. For a diagnosis of chronic tension-type headache, symptoms must be present for more than 15 days per month [33](#page=33) [34](#page=34). Treatment typically involves tricyclic or other antidepressants. When tension-type headaches coexist with migraines, migraine treatments are usually effective [34](#page=34). > **Tip:** Dentists must differentiate tension-type headaches from masticatory myofascial pain, as symptoms can overlap. In tension-type headaches, pain does not proportionally increase with applied pressure or refer to other areas [35](#page=35). #### 4.1.3 Cluster headache (Alarm Clock Headache) Cluster headaches are characterized by intensely severe, unilateral head pain, typically centered around the eye and temporal regions. The pain, described as a stabbing sensation, lasts 15–180 minutes if untreated. Associated symptoms include parasympathetic overactivity, such as lacrimation, conjunctival injection, ptosis, or rhinorrhea on the affected side [36](#page=36). Attacks occur with a frequency ranging from one every other day to eight per day, often with precise regularity, such as waking the patient at the same time nightly. Headaches can appear in clusters, lasting for months before remitting for similar periods. Alcohol ingestion and tobacco smoking are consistent triggers. Men are significantly more likely than women to experience cluster headaches [37](#page=37). Treatment involves preventive measures with verapamil, lithium salts, anticonvulsants, corticosteroids, and certain ergot compounds. Symptomatic treatment includes triptans, ergots, and analgesics. Oxygen inhalation (7 to 10 L/min) can also be an effective abortive treatment [38](#page=38). > **Tip:** The regularity of cluster headaches, even waking patients at night, is a key distinguishing feature [37](#page=37). #### 4.1.4 Giant cell arteritis Giant cell arteritis, also known as temporal arteritis, is an inflammation of the cranial arterial tree (vasculitis) that can affect any or all branches of the aortic arch. It is most common in individuals over 50 years of age and results from a giant cell granulomatous reaction. A common complaint, affecting 70% of patients, is a dull aching or throbbing temporal or head pain, which is the presenting symptom in one-third of cases [39](#page=39). Other symptoms include jaw claudication (weakness and pain in the jaw or tongue during mastication). Arteritis of the superficial temporal artery may present as headache or local pain. Maxillary artery involvement can cause pain in the masticatory muscles, while lingual artery arteritis can lead to ulceration and necrosis of the tongue [40](#page=40). Diagnostic investigations include erythrocyte sedimentation rate or C-reactive protein testing, and a biopsy of the affected artery. Treatment involves high-dose corticosteroids, often for extended periods, and prompt intervention is crucial to prevent blindness from disease extension to the ophthalmic artery [41](#page=41). > **Example:** A patient over 50 presenting with new-onset unilateral temporal throbbing pain, jaw claudication, and systemic symptoms like weight loss and fever should be evaluated for giant cell arteritis [39](#page=39) [40](#page=40) [41](#page=41). ### 4.2 Other orofacial pain (referred pain) Orofacial pain can also arise from sources outside the orofacial region, a phenomenon known as referred pain. These include pain originating from ocular, cardiac, and ear, nose, and tonsil (ENT) structures. #### 4.2.1 Ocular pain Ophthalmic diseases, such as acute glaucoma, can present as poorly defined facial pain and require management by an ophthalmologist [61](#page=61). #### 4.2.2 Cardiac pain Severe pain from ischemic heart disease may refer to the teeth of the left mandible due to shared autonomic sensory innervation. This pain is typically provoked by exertion and is diagnosed via ECG, with treatment managed by a cardiologist [61](#page=61). #### 4.2.3 Ear, nose, and tonsil pain Pain from an infected external ear canal, such as a furuncle, impacted wax, or fungal infection, can be elicited by moving the pinna and may refer to the mandible. Peritonsillar abscess (quinsy) can occasionally manifest as pain in the maxilla, which a patient might misinterpret as a toothache. These conditions are treated by an ENT specialist [62](#page=62). #### 4.2.4 Elongated styloid process (Eagle's Syndrome) An elongated styloid process, diagnosed by X-ray, can cause pain originating from this anatomical abnormality. Tenderness on swallowing and palpation in the tonsillar fossa are characteristic findings [63](#page=63). ### 4.3 Comparison of Headache Types | Feature | Temporal Arteritis | Migraine | Cluster | Tension-type | |------------------|-----------------------------|-----------------------------------------|---------------------------------------------------|---------------------------------------| | Onset | Acute or chronic | Acute | Acute | Chronic | | Location | Localized | Unilateral (approx. 40%) | Unilateral (orbital, supraorbital, temporal) | Global, often bilateral (frontal, temporal) | | Associated symptoms | Weight loss, polymyalgia rheumatica, fever, decreased vision, jaw claudication | Nausea, vomiting, photophobia, phonophobia | Rhinorrhea, lacrimation of ipsilateral side | Multisomatic complaints | | Pain character | Severe throbbing over affected area | Throbbing | Sharp stabbing | Aching | | Prior history | Generally absent | Present | Present | Present | | Diagnostic test | Erythrocyte sedimentation rate (+), artery biopsy | None specific—history | None specific—history | None specific—history | | Pages | | | | | [30](#page=30) [31](#page=31) [32](#page=32) [33](#page=33) [34](#page=34) [35](#page=35) [36](#page=36) [37](#page=37) [38](#page=38) [64](#page=64). --- ## Common mistakes to avoid - Review all topics thoroughly before exams - Pay attention to formulas and key definitions - Practice with examples provided in each section - Don't memorize without understanding the underlying concepts

| Term | Definition | |------|------------| | Orofacial Pain | Pain experienced in the face and oral cavity, encompassing a wide range of conditions affecting the structures of the head and neck. | | Acute Pain | Pain that is of short duration, typically moderate to severe in intensity, and may not be adequately relieved by mild analgesics. | | Chronic Pain | Pain that persists for a long duration, generally considered to be 4 to 6 months or longer, often mild to moderate in severity and frequently associated with psychological influences like depression. | | Somatic Pain | Pain that originates from musculoskeletal or visceral structures and is transmitted through an intact pain pathway, with common orofacial examples including temporomandibular joint disorders and periodontal pain. | | Neuropathic Pain | Pain that arises from damage to or alteration in the pain pathways, most often resulting from peripheral nerve injury due to surgery or trauma, affecting how pain signals are transmitted. | | Psychogenic Pain | Pain that is influenced or caused by psychological factors such as stress, anxiety, neurosis, or depression, rather than a direct physical pathology. | | Dental Pain (Odontalgia) | Pain originating from the dental structures, such as the pulp or periapical tissues, often provoked by thermal changes or percussion, and associated with conditions like pulpitis or periapical abscesses. | | Periodontal Pain | Pain associated with the structures supporting the teeth, including the gums and alveolar bone, often presenting as a dull ache and linked to conditions like periodontitis or acute periodontal abscesses. | | Mucosal Pain | Pain affecting the lining of the mouth, such as from traumatic ulcers, aphthous stomatitis, or viral infections, often characterized by a burning sensation provoked by irritants like spicy food. | | Bone Pain | Pain arising from the bones of the maxillofacial region, which can be caused by conditions such as alveolar osteitis, fractures, osteomyelitis, or tumors, and may present as a dull ache or severe throbbing. | | Salivary Gland Pain | Pain associated with diseases of the salivary glands, including sialadenitis, duct obstruction, or tumors, typically presenting as localized, intermittent dull pain accompanied by gland swelling. | | Temporo-Mandibular Joint (TMJ) Pain | Pain originating from the TMJ, which can be caused by traumatic arthritis or osteoarthritis, characterized by localized pain aggravated by mandibular movements, and may include clicking or crepitus. | | Maxillary Sinus Pain | Pain originating from the maxillary sinus, commonly due to sinusitis, presenting as dull or severe pain that worsens with head bending, and can be mistaken for dental pain due to referred tenderness. | | Migraine | A type of vascular headache characterized by unilateral, pulsating pain, often severe, with associated symptoms such as nausea and photophobia, and may be preceded by an aura. | | Cluster Headache | A severe, unilateral headache typically centered around the eye and temporal regions, characterized by intense, stabbing pain and associated autonomic symptoms like lacrimation and rhinorrhea, occurring in clusters. | | Tension-type Headache | A common type of headache, often bilateral and described as a squeezing sensation, frequently associated with pericranial muscle tenderness, and can be chronic if present for more than 15 days per month. | | Neuralgia | Pain that occurs in the distribution of a nerve or nerves, often described as sharp, electric shock-like, or stabbing. | | Trigeminal Neuralgia (TN) | A severe neuropathic pain condition affecting the trigeminal nerve, characterized by sudden, sharp, electric shock-like or stabbing pain in the face or mouth, often provoked by specific trigger zones. | | Glossopharyngeal Neuralgia | A neuropathic pain condition affecting the glossopharyngeal nerve, typically presenting as sharp, electric shock-like pain triggered by swallowing, with a trigger zone in the oropharynx or base of the tongue. | | Allodynia | Pain that is caused by a stimulus that does not normally provoke pain, such as light touch. | | Hyperalgesia | An increased sensitivity to noxious stimulation, meaning that stimuli that are normally painful are perceived as more intense. | | Dysesthesia | An unpleasant abnormal sensation, which can be spontaneous or evoked, and includes a range of abnormal feelings. | | Paresthesia | An abnormal sensation, such as tingling, prickling, or numbness, which can occur spontaneously or be evoked by stimulation. |