Zeroing in on the cause of your patient&#039;s facial pain

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Applied Evidence

Zeroing in on the cause of your patient's facial pain

J Fam Pract. 2015 September;64(9):524-526,528-531B

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References

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Diagnosis can be tricky because more than half of patients with TN experience less severe pain after the main sharp attack; this presentation is called TN type II.⁷ A detailed patient history and careful evaluation can help identify patients with TN type II. TN can be misdiagnosed as TMD, especially if it presents unilaterally.¹⁵

Treatment. Anticonvulsants are the primary medications used to treat TN.

Post-traumatic trigeminal pain is usually the result of an injury or dental procedure, such as facial trauma, tooth extraction, root canal, or dental implants.^12,18,19 Nerve injury is assumed to be the cause. This type of pain can start within 3 to 6 months of a trauma. It is located in the trigeminal area and patients describe it as burning, tingling and, at times, sharp.¹⁵ Patients who have sustained injury to the lingual or inferior alveolar nerves have reported feeling “pins and needles.”¹²

Common triggers include temperature changes or simple touch. Not all injuries result in pain; some patients may have only sensory impairment¹⁵ or sensory deficits such as allodynia or hypoesthesia.

Treatment. The first line of treatment for post-traumatic trigeminal pain is tricyclic antidepressants (TCAs) followed by pregabalin or gabapentin.¹⁴

Glossopharyngeal neuralgia (GN) is similar in presentation to TN but is much rarer.¹⁵ GN pain occurs deep in the throat, ear, or posterior tongue.¹⁵ When the pain occurs in the inner ear, GN can be misdiagnosed as TMD. In most cases, no cause of GN can be determined.

Patients describe GN pain as shooting, sharp, and electrical shock-like, lasting from seconds to minutes, with recurrent attacks throughout the day. Like TN, GN can present as episodes of attacks that last weeks to months. Triggers include chewing, drinking, swallowing, and talking, as well as light touch.^13,15 Some patients with GN experience syncope due to the anatomical proximity of the vagus nerve.¹⁴

Treatment. Anticonvulsants are the first-line treatment for GN. Local anesthetics or surgery can be considered for patients who don’t improve after medical therapy.¹⁵

Postherpetic neuralgia (PHN) can cause facial pain when the characteristic vesicular rash of the varicella zoster virus (shingles) occurs on the face. PHN usually affects the first division of trigeminal nerve, but the second and third divisions can be affected as well.¹³

What you’ll see. The acute phase of PHN begins a few days before the initial rash has resolved and can last up to a month after. A new pain may begin one to 6 months after the initial rash has healed.²⁰ This pain, which patients often describe as sharp, stabbing, or burning, can be constant or intermittent. Dysesthesia, hypoesthesia, and allodynia may also occur within the affected dermatome.

PHN is usually diagnosed based on the patient’s history and clinical presentation. However, direct fluorescent antibody stain, viral culture, or polymerase chain reaction performed on vesicular fluid from a herpetic lesion during the initial rash are the laboratory tests of choice if confirmation is needed.

Treatment. PHN is managed with anticonvulsants and TCAs.

Numb chin syndrome (NCS) is characterized by hypoesthesia, paresthesia, thermalgesic anesthesia, or pain over the chin in the region supplied by the mental nerve, a terminal branch of the mandibular division of the trigeminal nerve.^5,21,22

NCS can be caused by odontogenic conditions, such as dental abscess, dental anesthesia, dental trauma, or osteomyelitis; systemic conditions such as amyloidosis, sickle cell disease, sarcoidosis, multiple sclerosis, human immunodeficiency virus, or diabetes; or malignancies such as lymphoma, leukemia, breast cancer, lung cancer, prostate cancer, or head and neck cancers.²¹ In one study of patients with NCS, cancer was the cause of the condition in 89% of patients.²²

What you’ll see. NCS is characterized by numbness of the skin in the lower lip, chin and mucous membrane inside the lip that extends to the midline.⁵ Depending upon the etiology, patients may present with percussion-induced pain, loosening of teeth, sequestra, and mobility of fractured segments. Patients with metastatic malignancy may develop constitutional symptoms.

Making the diagnosis. Panoramic radiography is a useful starting point. If possible, a computerized tomography scan of the head and neck should also be done. Nuclear bone scintigraphy (bone scanning) may help identify bone disease such as osteomyelitis. A biopsy may be needed if a mass lesion is present.

Treatment. In NCS that is the result of a dental etiology, the prognosis usually is good. For example, NCS that is the result of an abscess usually resolves after the abscess is drained. However, if NCS is caused by metastasis, the prognosis is grim; the average length of survival after diagnosis is approximately 5 months if NCS is caused by mandibular metastasis and 12 months if leptomeningeal metastasis is present. Treatment does little to affect the outcome in these cases.^21,22