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FACIAL PAIN

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.

The key to the diagnosis is the clinical examination because even the most sophisticated investigation may provide no additional information.

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Table F1 Pa in in the face: diagnostic strategy model

Probability diagnosis

Dental pain

  • caries

  • fractured tooth

  • periapical abscess

Maxillary sinusitis

TMJ dysfunction

Serious disorders not to be missed

Cardiovascular

  • aneurysm of cavernous sinus

  • internal carotid aneurysm

  • ischaemia of posterior inferior cerebellar artery

  • myocardial ischaemia

Neoplasia

  • carcinoma (e.g. mouth, sinuses, nasopharynx)

  • metastases (e.g. orbital, base of brain)

Severe infections

  • periapical abscess → osteomyelitis

  • acute sinusitis → spreading infection

  • erysipelas

  • herpes zoster

Pitfalls (often missed)

TMJ dysfunction

Migraine variants (continues)

  • cluster headache

  • facial migraine

  • chronic paroxysmal hemicrania

Eye disorders: glaucoma, iritis, optic neuritis

Chronic dental neuralgia

Parotid gland: mumps, other infection, carcinoma, sialectasis

Glossopharyngeal neuralgia

Trigeminal neuralgia

Atypical facial pain

Masquerades

Depression

Spinal dysfunction

Red flag pointers for facial pain

  • Persistent pain: no obvious cause

  • Unexplained weight loss

  • Trigeminal neuralgia: possible serious causes

  • Herpes zoster involving nose

  • Person >60 years: consider temporal arteritis, malignancy

Cervical spinal dysfunction

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.

Dental disorders

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.

Features of dental caries

  • Pain is usually confined to the affected tooth but may be diffuse.

  • Pain is almost always aggravated by thermal changes in the mouth:

    • – cold—if dental pulp vital

    • – hot—if dental pulp is necrotic

  • Pain may be felt in more than one tooth.

  • Dental pain will not cross the midline.

Treatment of dental pain

  • Arrange urgent dental consultation.

  • Pain relief aspirin 600 mg (o) 4–6 hrly or paracetamol 0.5–1 g (o) 4–6 hrly.

  • If pain severe, add ibuprofen 400 mg (o) 4–6 hrly to paracetamol.

Dental infection (e.g. tooth abscess) Dental treatment may relieve but if moderate to severe:

  • amoxicillin 500 mg (o) tds ...

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