This document discusses orofacial pain and its diagnosis. It describes how pain is transmitted through pathways in the body and classified the main types of orofacial pain as being of dental origin, non-dental origin, or psychogenic origin. It provides details on diagnosing pain based on factors like site, onset, character, radiation, exacerbating factors and severity. Common causes of dental pain include pulpal pain, periodontal pain and bone pain, while non-dental sources include neurological issues, vascular problems and disorders of the sinuses, salivary glands and more. Diagnosis relies heavily on understanding these diagnostic factors from the patient's history and description of their pain.

1. Orofacial Pain and Altered
Sensation
Dr. Ishfaq Ahmad

2.  Pain in the head, face, mouth, or teeth is the main reason why many patients
consult their dental professional.
 Pain is an unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage. Pain relation with
tissue damage may not be constant and it is often associated with affective and
cognitive responses.

3. Pain pathway
 The pain pathway starts at nociceptors and is transmitted via sensory nerves, the
spinal cord dorsal horn, midbrain, thalamus and hypothalamus eventually to be
perceived in the brain in the cerebral cortex (somatosensory and limbic)

5. OROFACIAL PAIN
 Most orofacial pain (probably over 95%) arises from diseases of the teeth and is
thus termed ‘odontogenic’.
 There are also non-odontogenic causes that can be of organic origin
(neurological, vascular or referred) or non-organic (psychogenic or ‘functional’).
 Most orofacial pain and most recurrent headaches (tension-type, migraine and
cluster headaches) are not life threatening, but these conditions can interfere with
the quality of life.
 The causes of orofacial pain can be remembered from the mnemonic; ‘let
veterans read news papers’ (local, vascular, referred, neurological, psychogenic).

7. Pain of dental origin
 Pulpal pain
 Periodontal pain
 Bone pain
 Pain associated with denture bases

8. Pulpal pain
 Exposure of dentine, such as:
 Root dentine hypersensitivity
 Caries
 Defective restoration Fractured or cracked tooth
 Pulpitis
 Initial pulpitis (hyperaemia)
 Acute pulpitis
 Suppurative pulpitis (pulpal abscess)
 Chronic pulpitis
 Chronic hyperplastic pulpitis (pulp polyp)
 Galvanism
 Aerodontalgia

9. Periodontal pain
 Acute apical periodontitis of pulpal origin Traumatic periodontitis
 Chronic apical periodontitis of pulpal origin
 Acute periodontitis of gingival origin (periodontal/ parodontal abscess)
 Periodontal-endodontic lesion

10. Gingival pain
 Traumatic gingivitis
 Acute necrotising ulcerative gingivitis (ANUG)
 Herpetic gingivostomatitis
 Pericoronitis (including 'teething')
 'Desquamative' gingivitis:
 Lichen planus
 Mucous membrane pemphigoid

11. Bone pain
 Dry socket (osteitis)
 Osteomyelitis)
 Infected dental cyst
 Trauma, fracture

12. Pain of non-dental origin
 Neurologic
 Vascular origin
 Maxillary antrum/nasopharynx
 Salivary glands
 Oral mucosa
 Jaws/masticatory muscles
 Ears
 Eyes
 Psychogenic

13. Neurologic
 Trigeminal neuralgia
 Glossopharyngeal neuralgia
 Herpes zoster
 Post-herpetic neuralgia
 Geniculate herpes (Ramsay-Hunt syndrome)
 Bell's palsy
 Multiple sclerosis
 HIV disease
 lntracranial tumours
 Causalgia

14. Vascular origin
 Migraine
 Periodic migrainous neuralgia
 Paroxysmal facial hemicrania
 Giant cell arteritis
 Referred pain, e.g. cardiac ischaemia

15. Maxillary antrum/nasopharynx
 Sinusitis
 Malignancy

16. Salivary glands
 Acute bacterial sialadentitis
 Chronic bacterial sialadentitis
 Sjogren's syndrome
 Malignancy
 Calculi, stenosis of duct, obstruction of duct orifice
 HIV disease
 Mumps

17. Oral mucosa
 Herpes zoster
 Geniculate herpes (Ramsay-Hunt syndrome)
 Herpetic gingivostomatitis
 Late stage carcinoma
 Mucosal ulceration

18. Jaws/masticatory muscles
 Temporomandibular joint disorders
 Fractures
 Osteomyelitis
 Infected cysts
 Malignancy

19. Others
 Ears
 Otitis media
 Eyes
 Glaucoma
 Psychogenic
 Atypical facial pain Atypical odontalgia
 Burning mouth syndrome

20. DIAGNOSIS OF PAIN
 The most important means of diagnosis of orofacial pain is the history. Indeed, there
are no investigations available to prove that the patient is suffering pain, or the
severity of it. In order to differentiate the widely disparate causes, it is essential to
determine key points about the pain which can be remembered by the acronym
‘SOCRATES’.
 Site: valuable information can be obtained by watching the patient when asked if the
pain is localized or diffuse. For example, patients frequently point with one finger
when describing trigeminal neuralgia, but atypical ( idiopathic) facial pain is much
more diffuse and may radiate.
 Onset: the average duration of each episode may help diagnosis. For example, pain
from exposed dentine is fairly transient, lasting only for seconds, while the pain from
pulpitis lasts for a longer period. Trigeminal neuralgia is a brief lancinating pain lasting
up to about 5 s, migrainous neuralgia lasts 30–45 min, migraine lasts hours or days,
while atypical (idiopathic) facial pain is persistent.

21. DIAGNOSIS OF PAIN
 Character: patients should be asked about the severity and whether the pain is
‘sharp’, ‘dull’, ‘aching’, ‘throbbing’ or ‘shooting’. Trigeminal neuralgia is sharp and
shooting (lancinating); odontogenic pain often throbbing; giant cell arteritis is
‘burning’ while atypical (idiopathic) facial pain is typically dull.
 Radiation: is the pain referred elsewhere?
 Associated features: some types of pain may be associated with other features
that are helpful diagnostically. These include a swollen face in dental abscess,
nausea and vomiting in migraine, a history of nasal stuffiness or lacrimation in
migrainous neuralgia, or a number of other complaints such as dry mouth, bad
taste, irritable bowel syndrome, back pain, etc., in some patients with atypical
(idiopathic) facial pain.

22.  Time course: determine whether the pain occurs at specific times. A pain diary
can help. For example, the pain of sinusitis is often aggravated by lying down,
periodic migrainous neuralgia frequently disturbs the patient's sleep at a specific
time each night, around 2.00 a.m. The pain of temporomandibular joint pain–
dysfunction syndrome may be more severe on waking whereas atypical
facila pain tends to worsen through the day.
 Exacerbating and relieving factors: ask if any factors influence the pain. For
example, temperature often aggravates dental pain, touching a trigger zone may
precipitate trigeminal neuralgia attacks, stress may worsen atypical (idiopathic)
facial pain, and alcohol may induce migrainous neuralgia episodes. Exercise may
induce cardiac angina pain referred to the mouth. It may be necessary to resort
leading questions, asking about the effects of temperature, biting, posture,
analgesics, alcohol, etc.

23.  Severity: Ask the patient to rate the pain severity on a scale of zero (no pain) to
10 (most severe pain that the patient has experienced), or ask them to mark this
a line divided into 10 equal sections (visual analogue scale) or use an assessment
instrument such as the McGill pain questionnaire. These help assess the severity,
accepting always that it is subjective, and may also be useful in monitoring the
response to treatment. Disturbance of the normal sleep pattern by pain is also
useful in assessing the severity.

24. Character of the pain
 Three characters of pain are commonly described:
 Sharp/stabbing
 Dull/throbbing/boring
 Burning

25.  Sharp/stabbing pain is often associated with:
 Exposed dentine (sensitive root dentine, fractured restoration, fractured tooth,
caries, cracked tooth)
 Early pulpitis
 Trigeminal neuralgia
 Glossopharyngeal neuralgia

26.  Dull/throbbing/boring pain is often associated with:
 Late pulpitis
 Apical and lateral periodontitis Periodontal-endodontic lesion Pericoronitis
 Acute necrotizing ulcerative gingivitis (ANUG) Dry socket
 Periodic migrainous neuralgia Herpes zoster
 Giant cell arteritis Tumours
 Sinusitis
 Temporomandibular joint disorders Atypical odontalgia
 Atypical facial pain

27.  Burning pain is often associated with:
 Burning mouth syndrome
 Post-herpetic neuralgia
 Ramsay Hunt syndrome

28. Severity of pain
 Severity of pain may be assessed by the patient scoring the pain on a scale of O to 10. Zero representing no
pain and 10 repre senting the worst imaginable pain.
 If the patient has not resorted to analgesics, the pain may often not be severe. Pain controlled by mild
analgesics such as aspirin is not severe.
 Pain preventing sleep or waking the sufferer up at night is often severe. Interestingly, atypical facial pain and
trigeminal neuralgia, despite being unbearable during the day. do not affect sleep.
 Periodic migrainous neuralgia characteristically disturbs sleep often at similar times of the night ('alarm clock
awakening').
 Acute pulpitis and acute periodontitis may prevent sleep and awaken a patient at night.
 Extreme (unbearable) pain. that may even lead to suicidal depression, may be associated with neuralgias such
as:
 Trigeminal neuralgia
 Glossopharyngeal neuralgia
 Periodic migrainous neuralgia
 Post-herpetic neuralgia

29. Site of pain
 Pain arising from pathology is usually unilateral.
 Bilateral pain or pain crossing the midline may suggest:
 Sinusitis (if maxillary)
 Central nervous system disease
 Psychosomatic pain, e.g. atypical facial pain, atypical odontalgia, burning mouth
syndrome.

30. Duration of pain
 Sharp stabbing pain usually lasts for a few seconds or minutes.
 Dull throbbing pain may last for hours. days or weeks.
 Pain is not usually continuous over very long periods of time. Continuous pain for
years may suggest a psychosomatic origin.

31. Timing/exacerbating factors
 Excruciating pain on the merest contact with a trigger zone on the face suggests
trigeminal neuralgia. Similar pain on swallowing suggests glossopharyngeal neuralgia.
 Pain on biting or touching a tooth may indicate acute periodontitis, or pericoronitis.
 Pain on hot or cold stimulation of a tooth suggests:
 Exposure of root or coronal dentine
 Caries
 Defective restoration
 Unlined recent restoration
 Cracked/fractured tooth
 Pulpitis

32. Timing/exacerbating factors
 Pain with sweet foods suggests
 Exposure of root or coronal dentine (i.e. dentinal hypersensitivity)
 Caries
 Intermittent pain on biting, particularly on release of pressure, suggests a cracked tooth.
 Alcohol may precipitate periodic migrainous neuralgia.
 Pain related to meals may indicate:
 Salivary gland obstruction (salivary stimulation)
 Temporomandibular joint disorder (pain with jaw movement)
 Glossopharyngeal neuralgia (trigger zone in throat)
 Trigeminal neuralgia (trigger zone on face)
 Giant cell arteritis
 Dental or oral mucosa! disease

33. Relieving factors
 Sharp/stabbing pains respond poorly to analgesics.
 Dull/throbbing pains usually respond to analgesics.
 Constant dull/throbbing pains of very long duration (years),
 completely unaffected by analgesics, may suggest atypical facial pain, atypical
odontalgia or burning mouth syndrome.
 Other symptoms
 Swelling, discharge, bad taste, bad breath, raised temperature, malaise or
cervical lymphadenopathy may indicate an infective origin.