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When a patient complains of pain in the face rather than the head the physician has to consider foremost the possibilities of dental disorders (which accounts for up to 90% of pain in and about the face), sinus disease, esp. of the maxillary sinuses, temporomandibular joint (TMJ) dysfunction, eye disorders, lesions of the oropharynx or posterior third of the tongue, trigeminal neuralgia and chronic paroxysmal hemicrania.
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The key to the diagnosis is the clinical examination because even the most sophisticated investigation may provide no additional information.
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Red flag pointers for facial pain
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persistent pain: no obvious cause
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unexplained weight loss
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trigeminal neuralgia: possible serious causes
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herpes zoster involving nose
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person >60 years: consider temporal arteritis, malignancy
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Cervical spinal dysfunction
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The upper cervical spine can cause facial pain from lesions of C2 or C3 via the lesser occipital or greater auricular nerves which may give pain around the ear. It is important to remember that C2 and C3 share a common pathway with the trigeminal nerve.
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Dental caries, impacted teeth, infected tooth sockets and dental roots can cause pain in the maxillary and mandibular regions. Impacted third molars (wisdom teeth) may be associated with surrounding soft tissue inflammation, causing pain which may be localised to the mandible or radiate via the auriculotemporal nerve to the ear.
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Features of dental caries
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Pain is usually confined to the affected tooth but may be diffuse.
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Pain is almost always aggravated by thermal changes in the mouth:
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Pain may be felt in more than one tooth.
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Dental pain will not cross the midline.
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Treatment of dental pain
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Arrange urgent dental consultation.
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Pain relief aspirin 600 mg (o) 4–6 hrly or paracetamol 0.5–1 g (o) 4–6 hrly.
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If pain severe add codeine 30 mg (o) 4–6 hrly.
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Dental infection (e.g. tooth abscess)
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Dental treatment may relieve but if moderate to severe:
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If unresponsive: amoxycillin/clavulanate 875/125 mg (o) bd
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If widespread (e.g. adjacent fascial infection) use parenteral antibiotics (e.g. procaine penicillin 1 g (IM) daily for 5 d).
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Alveolar osteitis (dry tooth socket)
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Refer for localised toileting. Usually heals naturally in 14 days. Antibiotics of no proven use.
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Pain from paranasal sinuses
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Infection of the paranasal sinuses may cause localised pain. Localised tenderness and pain may be apparent with frontal or maxillary sinusitis. Sphenoidal or ethmoidal sinusitis causes a constant pain behind the eye or behind the nose, often accompanied by nasal blockage.
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The maxillary sinus is the one most commonly infected. It is important to determine whether the sinusitis is caused by stasis following an URTI or acute rhinitis or due to dental root infection.
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Clinical features of acute sinusitis
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Clinical features of chronic sinusitis
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Vague facial pain
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Offensive postnasal drip
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Nasal obstruction
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Toothache
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Malaise
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Halitosis
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Management of maxillary sinusitis
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Analgesics
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Antibiotics (first choice) (Sinusitis):
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Nasal decongestants (oxymetazoline—containing nasal drops or sprays) only if congestion
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Inhalations (a very important adjunct)
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Surgical drainage may be necessary by atrial lavage or frontal sinus trephine.
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Temporomandibular joint (TMJ) dysfunction
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This condition is due to abnormal movement of the mandible, esp. during chewing. The basic cause is dental malocclusion.
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Treatment of TMJ dysfunction
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If organic disease, such as rheumatoid arthritis and obvious dental malocclusion is excluded, a special set of instructions or exercises can alleviate the annoying problem of TMJ arthralgia in about 3 wks.
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Method 1: ‘Chewing’ a piece of soft wood
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Obtain a rod of soft wood ∼5 cm long × 1.5 cm wide. An ideal object is a large carpenter's pencil.
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Instruct the patient to position this at the back of the mouth so that the molars grasp the object with the mandible thrust forward.
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The patient then rhythmically bites on the object with a grinding movement for 2–3 mins at least 3 times/d.
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Method 2: The ‘six by six’ program
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This is a specific program recommended by some dental surgeons. The 6 exercises should be carried out 6 times on each occasion, 6 times a day, taking about 1–2 mins.
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Injection into the TMJ
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Indications: painful rheumatoid arthritis, osteoarthritis or TMJ dysfunction not responding to conservative measures.
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Trigeminal neuralgia (‘tic douloureux’) is a condition of often unknown cause which typically occurs in patients >50 yrs, affecting the 2nd and 3rd divisions of the trigeminal nerve and on the same side of the face. Brief paroxysms of pain, lasting on average 1–2 mins often with associated trigger points, are a feature.
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Note: Precise diagnosis is essential.
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Patient education, reassurance and empathic support is very important in these patients.
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Medical therapy:
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carbamazepine (from onset of attack to resolution) 50 mg (elderly patients) or 100 mg (o) bd initially, gradually ↑ dose to avoid drowsiness every 7 d to 200 mg bd (maintenance); or to a maximum of 600 mg bd
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alternative drugs if carbamazepine not tolerated or ineffective (but question the diagnosis if lack of response):
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Surgery: refer to a neurosurgeon if medication ineffective.
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Glossopharyngeal neuralgia
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This is a rare condition with similar clinical features of severe laminating pains.
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Sites: Back of throat around tonsillar fossa and adjacent fauces deep in ear. May extend to external ear and neck.
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Triggers: swallowing, coughing, talking
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Treatment: as for trigeminal neuralgia
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Facial migraine (lower half headache)
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Migraine may rarely affect the face below the level of the eyes, causing pain in the area of the cheek and upper jaw. It may spread over the nostril and lower jaw. Pain is dull and throbbing and nausea and vomiting are commonly present. Treatment is as for other varieties of migraine.
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Chronic paroxysmal hemicrania
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In the rare condition of chronic or episodic paroxysmal hemicrania there is a unilateral facial pain that can resemble chronic cluster headache but the duration is briefer, about 15 mins, and it may recur many times a day even for years. It responds specifically, sometimes dramatically, to indomethacin.
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Herpes zoster and postherpetic neuralgia
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Herpes zoster may present as hyperaesthesia or a burning sensation in any division of the 5th nerve, esp. the ophthalmic division.
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This is mainly a diagnosis of exclusion whereby patients, usually middle-aged women, complain of diffuse pain in the cheek (unilateral or bilateral) without demonstrable organic disease or which does not conform to a specific nerve distribution. It is usually described as deep-seated, severe, continuous and ‘boring’.
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