אבחון וטיפול בכאב פנים מתמיד ממקור לא ידוע

1. (‫טיפוסי‬ ‫לא‬ ‫פנים‬ ‫בעבר:כאב‬ ‫)כונה‬ ‫ידוע‬ ‫בלתי‬ ‫ממקור‬ ‫מתמיד‬ ‫פנים‬ ‫כאב‬
‫הגדרה‬
‫טיפוסי‬ ‫לא‬ ‫פנים‬ ‫בעבר:כאב‬ ‫כונה‬ ‫ידוע‬ ‫בלתי‬ ‫ממקור‬ ‫מתמיד‬ ‫פנים‬ ‫כאב‬‫כרוני‬ ‫,כאב‬‫אלבאולרי‬‫מתמיד‬
.‫טיפוסית‬ ‫לא‬ ‫ואודונטלגיה‬‫ידוע‬ ‫בלתי‬ ‫ממקור‬ ‫מתמיד‬ ‫פנים‬ ‫כאב‬‫נוטה‬ ‫ולטיפול.הוא‬ ‫לאבחנה‬ ‫קשה‬
‫טיפולים‬ ‫מספר‬ ‫עברו‬ ‫אשר‬ ‫כואבות‬ ‫שיניים‬ ‫עקירת‬ ‫באתרי‬ ‫או‬ ‫בשיניים‬ ‫להופיע‬‫דנטליים.הכאב‬ ‫הליכים‬ ‫או‬
‫ולבלוק‬ ‫כאב‬ ‫משככות‬ ‫לתרופות‬ ‫עמיד‬ ‫הטיפוסי‬ ‫וחמור.הכאב‬ ‫מתמשך‬ ‫כאב‬ ‫עד‬ ‫וקל‬ ‫עמום‬ ‫מכאב‬ ‫נע‬
‫הרדמה.זהו‬‫כאב‬‫פנים‬‫מתמיד‬‫שאינו‬‫בעל‬‫התכונות‬‫של‬‫נוירלגיה‬‫גול‬‫גולתית‬‫ולא‬‫ניתן‬‫לייח‬‫סו‬‫להפרעה‬
‫שונה‬.
‫אפידמיולוגיה‬
‫פחות‬ ‫ידוע‬ ‫בלתי‬ ‫ממקור‬ ‫מתמיד‬ ‫פנים‬ ‫כאב‬ ‫של‬ ‫השכיחות‬‫ה‬‫של‬ ‫מזו‬‫העצב‬ ‫של‬ ‫נורלגיה‬) ‫המשולש‬TN
trigeminal neuralgia‫שכיחות‬ .(‫ה‬‫מוער‬ ‫הכללית‬ ‫האוכלוסייה‬ ‫קרב‬‫כת‬‫ב‬-0.03%‫הארעותה‬ ‫ואילו‬
‫ידועה‬ ‫אינה‬.
‫פתופיסיולוגיה‬
‫הספרות‬‫גורסת‬‫המשולש‬ ‫העצב‬ ‫של‬ ‫החישה‬ ‫מערכת‬ ‫של‬ ‫חריג‬ ‫שריגוש‬‫עשוי‬‫ה‬‫מכריע‬ ‫תפקיד‬ ‫לשחק‬
‫של‬ ‫בהתפתחות‬‫ידוע‬ ‫בלתי‬ ‫ממקור‬ ‫מתמיד‬ ‫פנים‬ ‫כאב‬.
‫קליניים‬ ‫מאפיינים‬
‫מיקום,הקרנה‬:‫אחד‬ ‫בצד‬ ‫אחד‬ ‫מסוים‬ ‫לאזור‬ ‫מוגבל‬ ‫ידוע‬ ‫בלתי‬ ‫ממקור‬ ‫מתמיד‬ ‫פנים‬ ‫כאב‬ ,‫כללי‬ ‫באופן‬
‫הפנים‬ ‫של‬‫המחלה‬ ‫פרוץ‬ ‫עם‬,‫הכאב‬‫עמוק‬.‫נוירולוגי‬ ‫פיזור‬ ‫בעל‬ ‫למקמו,ואינו‬ ‫וקשה‬
‫הכאב‬ ‫אופי‬:‫מנדנד‬‫כ‬ ,‫ו‬‫ו‬ ‫אב‬‫עמום‬,‫אך‬‫חד‬ ‫להיות‬ ‫יכול‬.‫לעיתים‬
‫הכאב‬ ‫עוצמת‬‫מע‬ ‫היום‬ ‫במהלך‬ ‫:משתנה‬‫ו‬.‫בינונית‬ ‫עד‬ ‫קלה‬ ‫צמה‬
‫משך‬‫ו‬‫מחזוריות‬‫הכאב‬:‫יומ‬ ‫הכאב‬‫על‬ ‫המשפיעים‬ ‫לסירוגין.גורמים‬ ‫או‬ ‫מתמשך‬ ‫להיות‬ ‫יכול‬ ‫והוא‬ ,‫יומי‬
‫הכאב‬.‫עייפות‬ ,‫מתח‬ :
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© Copyright 2016 International Association for the Study of Pain. All rights reserved.
IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the
study of pain and translate that knowledge into improved pain relief worldwide.

2. :‫מבדלת‬ ‫אבחנה‬) ‫הלעיסה‬ ‫במערכת‬ ‫תפקודיות‬ ‫הפרעות‬temporomandibular disorders‫וכאב‬ (
.‫שיניים‬
:‫קשורים‬ ‫גורמים‬‫עם‬ ‫קרובות‬ ‫לעתים‬ ‫קשור‬‫מצבי‬‫תסמונת‬ ‫כגון‬ ‫אחרים‬ ‫כרוניים‬ ‫כאב‬‫ה‬‫מעי‬‫הרגיז‬‫כאב‬ ,
‫כרוני‬‫מפושט‬.‫גב‬ ‫כאבי‬ ‫או‬ ,‫ראש‬ ‫כאבי‬ ,‫קיפוח‬ ‫או‬ ‫תחושתי‬ ‫בקיפוח‬ ‫מלווה‬ ‫אינו‬ ‫הכאב‬.‫אחר‬ ‫נוירולוגי‬
,‫ודיכאון‬ ‫חרדה‬‫ל‬ ‫נטייה‬‫קטסטרופיזציה‬‫הכאב‬ ‫של‬‫ואיכות‬‫ירודה‬ ‫חיים‬‫מצב‬ ‫עם‬ ‫קרובות‬ ‫לעתים‬ ‫קשורים‬
‫זה‬.
‫אבחנה‬ ‫אמצעי‬
) ‫ממוחשבת‬ ‫טומוגרפיה‬ ‫כגון‬ ‫דימות‬ ‫אמצעי‬computed tomography -CT(‫מגנטית‬ ‫תהודה‬ ‫דימות‬ ‫או‬
)magnetic resonance imaging -MRI(‫מדגימים‬ ‫אינם‬ ‫והלסתות‬ ‫הפנים‬ ‫של‬‫רלוונטי‬ ‫חריג‬ ‫מצב‬ ‫כל‬
‫בכך‬ ‫צורך‬ ‫על‬ ‫מצביעים‬ ‫הקלינית‬ ‫והבדיקה‬ ‫הרפואית‬ ‫ההיסטוריה‬ ‫כאשר‬ ‫רק‬ ‫לביצועם‬ ‫התוויייה‬ ‫וקיימת‬.
‫טיפול‬
‫מעטים‬ ‫מבוקרים‬ ‫אקראיים‬ ‫מחקרים‬ ‫קיימים‬‫,ומרבית‬‫אפשרויות‬‫ה‬‫מסוג‬ ‫מחקרים‬ ‫על‬ ‫מבוססות‬ ‫טיפול‬
‫פתוחה‬ ‫תווית‬ ‫ניסוי‬)open-label(‫כגון‬ ‫טריציקליות‬ ‫דיכאון‬ ‫נוגדות‬ ‫תרופות‬ .amitriptyline)50-100
‫או‬ (‫יום‬ / ‫מ"ג‬nortriptyline)20-50‫יעיל‬ (‫מ"ג‬‫ות‬‫ב‬ ‫משתמשים‬ ‫אם‬‫הן‬.‫חודשים‬ ‫כמה‬ ‫במשך‬‫מעכבים‬
‫סלקטיבים‬‫של‬ ‫מחודשת‬ ‫ספיגה‬ ‫של‬) ‫ונוראפינפרין‬ ‫סרוטונין‬duloxetine,venlafaxine,‫ו‬
mirtazapine‫משמש‬ (‫ים‬‫אף‬‫הם‬.‫רוב‬ ‫פי‬ ‫על‬ ‫יעילים‬ ‫אינם‬ ‫הם‬ ‫,אולם‬‫ה‬‫חול‬‫עשויים‬ ‫ים‬‫תועלת‬ ‫להפיק‬
‫קוגניטיבי‬ ‫מטיפול‬-‫התנהגותי‬‫מנת‬ ‫על‬ ‫במקביל‬‫חייהם‬ ‫איכות‬ ‫את‬ ‫לשפר‬.
‫אלמוזנינו‬ ‫גלית‬ ‫תרגום:ד"ר‬
Persistent Idiopathic Facial Pain (Previously “Atypical Facial Pain”)
Definition
Persistent idiopathic facial pain (PIFP), previously termed “atypical facial pain”,
“chronic persistent alveolar pain”i
, and “atypical odontalgia,” PIFP is difficult to diagnose
and treat. It arises in teeth or dental extraction sites of typically painful teeth that
have undergone several treatments or procedures. Pain may range from dull and
mild to continuous and severe. It is typically resistant to analgesic medications and
anesthetic blockade. It is a persistent facial pain that does not have the
characteristics of cranial neuralgias and cannot be better attributed to a different
disorder.
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© Copyright 2016 International Association for the Study of Pain. All rights reserved.
IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the
study of pain and translate that knowledge into improved pain relief worldwide.

3. Epidemiology
The prevalence of PIFP is far less frequent than that of trigeminal neuralgia (TN). Its
prevalence in the general population is estimated at 0.03%. Its incidence is unknown.
Pathophysiology
The literature suggests that abnormal sensitization of the trigeminal nociceptive
system may play a crucial role in the development of PIFP.
Clinical Features
Location, radiation: Generally, PIFP is limited to one particular area on one side of the
face at disease onset, is deep and poorly localized, and does not follow a neurological
distribution.
Character: Nagging, aching, and dull, but can be sharp at times.
Severity: Varying often throughout the day from mild to moderate.
Duration and periodicity: Daily, and can be continuous or intermittent.
Factors affecting it: Stress, fatigue.
Differential Diagnosis: Odontalgia and temporomandibular disordersii
Associated factors: Often associated with other chronic pain conditions such as irritable
bowel syndrome, chronic widespread pain, headache, or back pain. Not associated with
sensory loss or other neurological deficits. Anxiety and depression, high catastrophizing,
and impaired quality of life are often associated with this condition.
Investigations
Radiographic imaging, cranial computed tomography (CT), or magnetic resonance
imaging (MRI) of the face and jaws do not demonstrate any relevant abnormality and
are only indicated if the history and examination suggest a need.
Therapy
There are very few randomized controlled trials, and most treatment choices are
based on open-label studies. Tricyclic antidepressants such as amitriptyline (50–100
mg/day) or nortriptyline (20–50 mg) are effective if used for several months. Selective
serotonin and norepinephrine reuptake inhibitors (duloxetine, venlafaxine, and
mirtazapine) are used as well but are often ineffective. Patients benefit from
simultaneous cognitive-behavioral therapy to improve their quality of life.
__________________________________________________________________________________________
© Copyright 2016 International Association for the Study of Pain. All rights reserved.
IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the
study of pain and translate that knowledge into improved pain relief worldwide.

4. References
[1] Aggarwal VR, McBeth J, Zakrzewska JM, Lunt M, Macfarlane GJ. The
epidemiology of chronic syndromes that are frequently unexplained: do they have
common associated factors? Int J Epidemiol 2006;35:468–76.
[2] Forssell H, Tasmuth T, Tenovuo O, Hampf G, Kalso E. Venlafaxine in the
treatment of atypical facial pain: a randomized controlled trial. J Orofac Pain
2004;18:131–7.
[3] Harrison SD, Glover L, Feinmann C, Pearce SA, Harris M. A comparison of
antidepressant medication alone and in conjunction with cognitive behavioural therapy
for chronic idiopathic facial pain. Proceedings of the 8th World Congress on Pain.
Seattle: IASP Press; 1997. p. 663–723.
[4] Taiminen T, Kuusalo L, Lehtinen L, Forssell H, Hagelberg N, Tenovuo O, et al.
Psychiatric (axis 1) and personality (axis 11) disorders in patients with burning mouth
syndrome or atypical facial pain. Scand J Pain 2011;2:155–60.
i
Durham J, Exley C, John MT, Nixdorf DR. Persistent dentoalveolar pain: the patient's experience. J
Orofac Pain. 2013 Winter;27(1):6-13. doi: 10.11607/jop.1022.
ii
Drangsholt M, Truelove E. Trigeminal neuralgia mistaken as temporomandibular disorder. J Evid
Base Dent Pract 2001;1:41-50.
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__________________________________________________________________________________________
© Copyright 2016 International Association for the Study of Pain. All rights reserved.
IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the
study of pain and translate that knowledge into improved pain relief worldwide.