Differential diagnosis of facial pain

1. SUBMITTED BY
ANN MARY
PART A

2. • INTRODUCTION
• PAIN
 DEFINITION
 DIAGNOSIS
 TYPES AND NATURE
 CLASSIFCATION
• DD OF CHRONIC UNILATERAL FACIAL PAIN
 ODONTOGENIC PAIN
 TRIGEMINAL NEURALGIA
 POST HERPETIC NEURALGIA
 GLOSSOPHARYNGEAL NEURALGIA

3.  NERVOUS INTERMEDIUS
 SUNCT
 SUNA
 MIGRAINE
 CLIUSTER HEADACHE
 ATYPICAL FACIAL PAIN
 ATYPICAL ODONTALGIA
 TEMPEROMANDIBULAR DISORDERS
• CONCLUSION
• REFERENCE

4. • Pain is a multifaceted experience involving physical,cognitive, and
emotional aspects.
• Pain and fear of pain continue to be the strongest motivation for
people to seek dental care.
• Pain is a personal experience of the sufferer that cannot be
shared and it wholly belongs to the sufferer.
• The head and face are subjected to chronic persistent or recurring
pains more often than any other portion of the body.
• Orofacial pain is prevalent in general population ;around 23% ,of
which 7-11% of which is chronic.

5. • Acute orofacial pain is primarily associated with the teeth and
their supporting structures . Most frequently dental pain is due to
dental caries , although a broken filling or tooth abrasion may also
cause dental sensitivity.
• Other oral pains are usually periodontal or gingival in origin.

6. DEFINITION
• An unpleasant emotional experience associated with actual or
potential tissue damage or described in terms of such damage.
- International Association for the Study of Pain (IASP)
• An unpleasant sensation associated with actual or potential tissue
damage and mediated by specific nerve fibers to the brain, where
its conscious appreciation may be modified by various factors.
- Bell’s Orofacial pain ,6th edition

7. • Pain is derived from
Greek word “ Poin ” meaning penalty
Latin word “ Poena ” meaning suffering,punishment

8. • The most frequent source of orofacial pain is dental disease and
it has been estimated that toothache is a major health problem.
• Many conditions manifest as only orofacial pain with no other
associated signs or symptoms . It has been clear that successful
diagnosis of pain depends on:
* History -An accurate and detailed history of pain
* Clinical examination-A detailed clinical examination of the
face and the associated organs.
* Knowledge-Thorough knowledge of the conditions that
may produce orofacial pain.

9. DIAGNOSIS OF PAIN
HISTORY KNOWLEDEG
DIAGNOSIS OF PAIN
HISTORY KNOWLEDGE
CLINICAL
EXAMINATION

10. • Pain may be judged subjectively or objectively. Subjective
evaluation depends on the patient’s description of the complaint.
Objective evaluation relates to what the pain does to the patient
physically as seen by change in the vital signs , skin , pupil size
and muscle effects.
• There is definite relationship between intensity and duration of
pain.The higher the intensity of pain, the shorter the period of
time that can be tolerated by the sufferer.

11. • Accordingly low intensity pain can be sustained for up to several
hours , whereas maximum intensity pain can be tolerated for a
few days.The higher the intensity of pain ,more likely it is to be
intermittent.

12. •According to pain intensity
* Mild
* Moderate
* Severe
•According to onset
* Spontaneous
* Induced
*Triggered

13. • According to temporal relationship and duration
* Intermittent
* Continuous
* Protracted
* Intractable
* Recurrent
* Remission
* Periodic

14. •According to Qualities of pain
* Steady pain
* Paroxysmal pain
* Dull pain
* Itching
* Pricking
* Stinging
* Burning
*Throbbing
* Aching

15. •According to pain localization
* Localized
* Diffuse
* Radiating
* Lancinating
* Spreading
* Enlarging
* Migrating

16. • The American Academy of Orofacial pain has classified orofacial
pain as follows
I INTRACRANIAL STRUCTURES
• Neoplasm
• Aneurysm
• Hematoma
• Hemorrhage
• Abscess
• Edema

17. II EXTRACRANIAL STRUCTURES
• Teeth
• Ears
• Eyes
• Nose
• Throat
• Sinuses
• Tongue
• Glands

18. III MUSCULOSKELETAL DISORDERS
• TMJ disorders
• Masticatory muscle disorders
• Fibromyalgia
• Cervical disorders
• Generalized polyarthritis

19. IV NEUROVASCULAR DISORDERS
• Migraine headaches
• Cluster headaches
• Tension type headache
• Cranial arteritis

20. V NEUROLOGIC DISORDERS
• Paroxysmal neuralgias
* Trigeminal neuralgia
* Glossopharyngeal neuralgia
• Continuous neuralgias
* Atypical odontalgia
* Traumatic neuroma
* Neuritis
* Postherpetic neuralgia

21. • Bell has classified orofacial pain as follows:
A AXIS I
• Odontogenic pain
* Pulpal pain
* Periodontal pain
* Pain due to odontogenic cyst , tumour etc
• Oral soft connective tissue pain
* Vesiculobullous lesions
* Ulcerative lesions
* Cancers

22. • Temperomandibular joint pain
* Ligamentous pain
* Retrodiscal pain
* Capsular pain
* Arthritic pain
* Internal disc derangement
• Muscle pain
* Myofacial pain
* Myospasm
* Myositis

23. • Neuropathic pain
* Trigeminal neuralgia
* Glossopharyngeal neuralgia
* Geniculate neuralgia
* Superior laryngeal neuralgia
* Nervous intermedius
* Peripheral neuritis
* Herpes zoster
* Postherpetic neuralgia
* Atypical odontalgia

24. • Osseous and periosteal pain
* Osteomyelitis
* Osteodystrophies
* Fracture
* Bone tumours
* Other bone lesions
• Maxillary sinus associated pain
* Sinusitis
* Fracture
* Cyst and tumours

25. • Salivary gland associated pain
* Sialadenitis
* Sialolithiasis
• Ear pain
* Otitis media
• Neurovascular pain/headache
* Migraine with aura
* Migraine without aura
* Cluster headache
* Paroxysmal hemicrania

26. B. AXIS II (due to psychological conditions)
* Generalized anxiety disorders
* Posttraumatic neuralgia
* Myofascial pain dysfunction syndrome
* Burning mouth syndrome

27. ACUTE PAIN
• Acute pain may be considered to be a protective mechanism for
the body ,by stimulating the sympathetic nervous system and is
often accompanied by the automatic signs of stress and anxiety.
• It serves as a diagnostic value to the clinician in determining the
nature and site of the disturbance.

28. CHRONIC PAIN
• Pain of more than 6 months duration may be considered as
chronic pain.
• It is not self limiting and appears to be permanent.
• Merskey et.al described chronic pain as persistent pain that is not
amenable ,as a rule to treatment based on specific remedies or to
the routine methods of pain control such as non narcotic
analgesics.

29. • ODONTOGENIC PAIN
* PULPAL PAIN
* PERIODONTAL PAIN
• NON ODONTOGENIC PAIN
* CHRONIC SIALADENITIS
* TEMPEROMANDIBULAR DISORDERS
• NEURALGIAS
* TRIGEMINAL NEURALGIA
* POST HERPETIC NEURALGIA

30. * GLOSSSOPHARYNGEAL NEURALGIA
* NERVOUS INTERMEDIUS
* SUNCT
* SUNA
• NEUROVASCULAR
* MIGRAINE
* CLUSTER HEADACHE
• ATYPICAL FACIAL PAIN
• ATYPICAL ODONTALGIA
• TEMPEROMANDIBULAR DISORDERS

31. PULPAL PAIN
• Pulpal pain forms a major component of the dental pain.
• Pulpal pain is classified as visceral type of pain and manifests
features characteristics to such a type of pain.
• Pulpal pain can be brought about by a variety of causes ,the most
common being dental caries,trauma,chemical irritants and rarely
anachoresis.

32. PERIODONTAL PAIN
• Pulpal pathology leading to necrosis of the pulp after a while
spills into periodontium via the apical foramen and/or the
accessory foramina.
• The periodontal ligament pain is described by the patient as
sharp jerks or pricking type of pain.
• Pain is usually intermittent in nature and occurs whenever there
is loading of the ligament such as during chewing

34. • It is also called as
• Tic Douloureux
• Trifacial neuralgia
• Fothergill disease
DEFINITION
• Defined as sudden usually
unilateral,severe,brief,stabbing,lancinating,recurring pain in the
distribution of one or more branches of fifth cranial nerve.

35. CLINICAL FEATURES:
• AGE AND SEX: fourth and fifth decade,more common in females
• DIVISION OF INVOLVEMENT:
• Maxillary-66%
• Mandibular-49%
• Opthalmic-16%
• Right side> left side
• Pain manifests as sudden unilateral intermittent,paroxysmal and
of short duration.Elicited by slight touching superficial trigger
zones during shaving,brushing,washing face,cold wind
• Pain is usually confined to one part of one division of nerve,very
rarely crosses midline

36. • Two pain related phenomenon occur particular to TN
• Latency-It refers to the short period of time between stimulation
of trigger area and pain onset.
• Refractory period-This is a period of no pain,which occurs after
the attack.
• Other features:The patient grimaces with pain ,clutches his hands
over the affected side of face stopping all the activities and holds
or rub his face which may redden or water the eyes until attack
subsides
• In extreme cases the patient will have a motionlessface- The
frozen or mask like face.

37. DIAGNOSIS:
• Clinical diagnosis-Abrupt onset of pain with trigger points ,pain is
extreme in nature with less time duration.Pain is localized to
known distribution of trigeminal nerve.Spontaneous remission
can occur.
• Advanced investigations
* Brain MRI with contrast
* Functional MRI
* PET(Positron Emission Tomography)

38. MANAGEMENT
MEDICAL MANAGEMENT
• Carmazepine 100-200mg bid or tid
• Other medications like
Oxcarbazepine,Gabapentin,Phenytoin,Baclofen,Topiramate
SURGICAL MANAGEMENT
• Radiofrequency Rhizotomies
• Gamma knife radiosurgery
• Balloon Gangliolysis

39. POST HERPETIC NEURALGIA
• It is a dermatomal disease persisting or recurring more than or equal to 3
months after the acute HZ stage.

40. CLINICAL FEATURES
• Usually affects the elderly group of patients over 6O years
• No specific gender predilection.
• PHN is characterized by excruciating,superimposed,lancinating
pain.Pain quality is burning,throbbing,stabbing,shootingor
sharp.
• Burning pain is significantly higher in patients not treated with
antivirals for acute HZ.
• Itching is very common and prominent in trigemial dermatomes.
• Paresthesia ,hyperesthesia and allodynia

41. MANAGEMENT
• Though the condition is not fatal,patient mat experience significant
pain for a prolonged period of time thereby decreasing the quality of
life.The main goal of therapy is to achieve relief from the constant
gnawing pain.
• Drugs employed are
 Tricyclic antidepressants-Amitriptyline 10mg/day up to 50 mg/day
Nortriptyline 10-25 mg /day
Corticosteroids –Dexamethasone
Prednisolone
Methyl prednisolone
Anticonvulsants –Gabapentin
Antiviral drugs-famciclovir

42. • Topical therapy with capsaicin and lignocaine
* 0.025-0.075% Capsaicin cream apply for3-5 times a day
* 5% lidocaine patch can be applied
• Invasive therapies include epidural and intrathecal steroids and a
variety of neurosurgical techniques.
• The most promising surgical intervention seems to be dorsal root
entry zone lesion that provide relief in 59% of treated cases
• Prevention with a vaccine has been advocated for the older
population those at risk.

44. • Harris (1926) coined the term
• It is a neuropathy similar to TN but occurs due to affliction in the distribution
of the ninth cranial nerve.
CLINICAL FEATURES
• Manifest in older age group usually beyond 60 years of age.
• Characteristics of pain in GN
* Unilateral
* Intermittent,last for a few second
* Severe sharp stabbing and shooting pain.
* Localized in the throat ,radiating to the ear.
* The pain radiate from the pharynx ,tonsil,and posterior tongue base
upward to the eustachian tube and inner ear or to the mandibular angle.

45. TRIGGERING FACTORS:
Swallowing,chewing,talking,sneezing,cleaning the throat and
touching the gums or oral mucosa ,sudden movements of the
head,raising the arm on the side of the pain and lateral movement
of the jaw.
TRIGGER ZONES:Pharynx,posterior tongue,ear,and infra auricular
retromandibular area.

46. DIAGNOSIS:
•Clinical examination usually yields no specific
information but careful probing reveals certain
sensitive areas or trigger points that are usually
located in the oropharyngeal walls or pre tonsillar
area.Thus palpation of the lateral aspect of the throat
can easily provoke an attack confirming the diagnosis.
• An elective MRI scan of the brain may be performed
to detect any intracranial or extracranial tumours or
any vascular abnormalities.

47. MANAGEMENT
• Medical management of GPN is similar to TN.
• The anticonvulsant,carbamazepine is the drug of choice.Baclofen
also helps in management by providing a synergistic action with
carbamazepine.
• Failure of medical therapy necessitates the need for considering
surgical options.Surgical procedures include
* Direct surgical neurotomies
* Percutaneous radiofrequency
* Thermal rhizotomy

48. • Also called as geniculate neuralgia
• It is the neuralgia of 7th cranial nerve characterized by
pain in the ear and less frequently in the anterior tongue
or soft palate.
• The pain is not as sharp asTN.
TRIGGER ZONES:
• External auditory canal and a small area on the
soft palate and the posterior auricular region.

49. MANAGEMENT
• Medications are similar to TN –
Carbamazepine,Oxcarbazepine,Gabapentin,Baclofen,Phenytoin
etc
• Surgery includes
Excision of the nervous intermedius and geniculate ganglion.
Microvascular decompression

51. • Also called as migraine syndrome or migraine headache.
DEFINITION
• Recurrent headache combined with autonomic
disturbances(aura)
ETIOLOGY
• Trigeminovascular neuron activation :Activation of
trigeminovascular neurons surrounding a cephalic blood vessel
due to vasoconstriction cerebral ischemia
compensatory vasodialatation with subsequent pain and
cerebral edema.
• Hereditary : It has got autosomal dominant inheritance pattern.

52. TRIGGERING FACTORS: Includes
* Dietary factor(chocolate,missing meal , aged cheese)
* Psychogenic(stress,anxiety,depression)
* Hormonal(menstruation,ovulation,oral contraceptives)
* Sleep disturbances
* Physical (glare,flashing light,fluorescent light,odors,high
attitude)
* Drugs (nitroglycerine,histamine,ranitidine,estrogen)
* Miscellaneous (head,trauma,fatigue,physical exertion)

53. CLINICAL FEATURES:
• AGE-Young age
• SEX- Female predilection with a ratio of four to one.
• LOCATION-Unilateral and felt in temporal ,frontal and orbital
regions.Rarely it can be felt in parietal,post auricular and occipital areas.
• ONSET- Begin immediately or soon after awakening.Attack may be
recurrent or episodic with variable frequencyusually 1 to 4 in a month.
• NATURE OF PAIN- Starts with mild headache,which later increases in
severity.Throbbing in nature at the peak.
• ASSOCIATED SYMPTOMS-Nausea,vomiting,anorexia,sensitivity to light
and sound,mood changes.

54. TYPES
MIGRAINE WITH AURA(CLASSIC MIGRAINE):
• Headache is preceded by an aura of symptoms.It includes a
reversible sensory,motor,visual and speech disturbances.
Visual -Zigzag flickering light and blurred vision.
Sensory- numbness,paresthesia and anesthesia of the face.
Motor- unilateral muscle weakness in the face
• .The classic visual aura symptom is called the fortification
scotoma.
• Usually develops in 5-20 min and last less than I hour.

55. • Head ache is followed by a resolution phase in which patient feels
tired and irritable
MIGRAINE WITHOUT AURA(COMMON MIGRAINE):
• No preheadache period occurs.
• Clinically patients have moderate to severe pulsating unilateral
head pain aggravated by walking stairs or similar routine activity.
• There will be associated symptoms with these multiple attacks
each lasting for 4-72 hrs.

56. DIAGNOSIS
• Clinical diagnosis-Pre headache symptoms with presence of trigger
zone with throbbing type of pain.
MANAGEMENT:
• Prophylaxis-This is mainly given to patients who are experiencing 4 to
6 episodes of migraine in a month.Beta blockers are used,propanol is
the most commonly used prophylactic drug.
• Severe attacks-Controlled by ergotamine tartarate combined with
caffeine,aspirin,acetaminophen,belladona and phenobarbital.

57. • Mild cases- Treated by methergine,beta adrenergic agents and
calcium channel blockers.
• Drug therapy-Drugs like
* Ergotamine 2 mgsublingual tablet
* Sumatriptan 50-100mg tablet
will provide relief from symptoms.If required,it can be repeated
after 2 hrs
• Non pharmacological management-Includes diet control,stress
management,sleep regulation and pressure on ipsilateral carotid
artery.

59. Also called as
• Migranious neuralgia
• Sphenopalatine neuralgia
• Histaminic cephalgia
• Periodic migraine
• Horton syndrome
• Histamine headache
• Ciliary neuralgia
• Sluder’s head ache
• Raeder’s syndrome

60. • It is the most painful and severe of all headache disorders and has
been referred to as suicide headache.
• Characterised by unilateral periorbital pain and cranial autonomic
features like lacrimation,rhinorrhoea,ptosis etc
• It is called as cluster as attacks occur in groups or cycles.Within a
cycle,the individual cluster attacks can show a pattern,recurring
everyday at about the same time.Thus it is also known as ‘Alarm
Clock Headache’

61. ETIOLOGY
• Vascular causes:abnormal hypothalamic function,head trauma
and abnormal release of mast cells.
• Triggering factors:headache can be initiated by alcohol,cocaine
and nitroglycerine.
CLINICAL FEATURES
• AGE AND SEX-common in third to fourth decade of life with
male predilection.
• LOCATION-Deep intense pain last for 15 minutes to 3
hours,which is unilateral and involves the periorbital area,often
radiating to the ipsilateral temple and maxilla including the
teth.Pain is present in the distribution of opthalmic nerve.

62. • NATURE OF PAIN-Pain is paroxysmal,burning and lancinating
without trigger zones.
• ASSOCIATED FEATURES-Lacrimation from the eye,nasal
congestion,rhinorrhea,forehead and facial sweating,miosis and
eyelid edema etc
DIAGNOSIS: Clinical diagnosis-Alarm clock headache without
trigger zone will diagnose this condition.

63. MANAGEMENT
• Drug therapy-Drugs include
Ergotamine 2 mg sublingual tablet
Prednisolone
Lithium carbonate
Sumatriptan 50- 100 mg tablet
• Oxygen inhalation-inhaling oxygen at the rate of 9L/min may
shorten attacks of symptoms.
• Intranasal spray-intranasal spray of lidocaine 4% is also effective.

64. • Prophylactic medications like lithium,sodium
valproate,methysergide etc are also used.
• Surgical-includes
* Trigeminal sensory rhizotomy
* Superficial petrosal neurectomy
* Gamma knife radiosurgery

65. • AFP was an umbrella term used to categorize all facial pains that didn’t
mimic the classic symptoms of trigeminal neuralgia.
CLINICAL FEATURES
This entity is very similar to TN but following feature differentiate it with
TN:
• The pain is continuous
• Pain persist even on night time
• Moderate,dull,burning pain
• May be present bilateral
• Mostly associated with stress
• May be associated with autonomic sign like rhinorrhoea,lacrimation etc

66. • Facial pain ,typically manifests in middle aged women who often
describe some kind of a vague,intractable burning,aching or
cramping ,on one side of the face,often in the region of trigeminal
nerve that may extend into the upper neck or back of the scalp.
• Mostly associated with stress and psychological problem.

67. DIAGNOSIS
• Diagnosing AFP is a challenging task.The diagnostic path for
AFP is based on a process of elimination.
• When a patient complaints of the above mentioned
symptoms,we must first rule out any other conditions.The
conditions needing careful considerations are
oral,paranasal sinus related,myofacial and neurologic
causes.
• Tests to be performed include radiographs of the
skull,advanced imaging modalities especially including the
brain and the skull base

68. MANAGEMENT
• Antidepressants /antianxiety drugs:
* Amitriptyline 10 mg/day up to 50 mg/day at bed
* Nortriptyline 10-25 mg/day at bed
* Alprazolam 0.5 mg /day at bed
* Gabapentin initially 300 mg/day for 3 days then
300mgtid/day, can increase up to 1800-2700 mg/day.
• Other alternative modalities include hot and cold compresses and
acupressure and/acupuncture.

69. •Also called as Idiopathic,Phantom tooth pain.
•The etiology and symptoms are same as that of atypical
facial pain but the patient attributes the pain with the
teeth.
•Many dental treatments may have been attempted
including serial extraction,with no improvement in the
pain.
•There is no specific signs,diagnosis is by exclusion

70. It includes
• Temperomandibular joint myofascial pain dysfunction syndrome
• Osteoarthritis
• Rheumatoid arthritis
• Trauma
• Developmental defects
• Ankylosis
• Infection
• Neoplasia

71. • It is a myogenic pain condition characterized by
local areas of firm,hypersensitibe bands of muscle
tissue known as trigger points.
The characteristic feature of pain are
• Pain is usually continuos ,diffuse,dull and deep quality.
• Pain is increased during muscle activity,chewing etc
• Pain persist even on night time.
• The pain radiates to the surrounding area i.e, head and
neck,ear,TMJ,tooth,sinus etc

72. • Orofacial pain conditions occur due to complex pathophysiology
often associated with psychological co-morbidities.
• Chronic orofacial pain may have a significant impact upon quality
of life and daily functioning.
• Early diagnosis and referral to secondary care is of paramount
importance.
• A biopsychosocial approach to pain management may address
the multifactorial etiology of orofacial pain,whilst limiting the
economic and health related burden associated with these
conditions.

73. • Burket’s Oral Medicine,Twelfth edition
• Textbook of Oral Medicine and Oral Radiology,PEEYUSH SHIVARE
• Textbook of Oral Medicine,Oral Diagnosis and Oral Radiology-Ravikiran
Ongole,Praveen B N,Second edition
• Textbook of Oral Medicine-Anil Govindrao Ghom,Savita Anil Ghom
Third edition

74. THANK YOU