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A. Causes of Chronic Facial Painnavigator

  1. Broad Categories
    1. Inflammation
    2. Infection
    3. Neoplasm
    4. Vascular Etiology
  2. Common Causes
    1. Broken teeth
    2. Dental caries (cavities)
    3. Root abscesses
    4. Other abnormalities of teeth, gingiva, maxilla, mandible
  3. Eye Pain
    1. Glaucoma
    2. Orbital cellulitis
    3. Tumors of facial bones
  4. Inflammatory
    1. Postherpetic facial pain (neuralgia)
    2. Trigeminal neuralgia (see below)
    3. Systemic Lupus Erythematosus - pain in middle of face, steady and aching
  5. Local Injury to Trigeminal Nerve
    1. Tumor
    2. Aneurysm
    3. Trauma (including fractures of facial bone)
    4. Sinus surgery
  6. Vascular Causes of Facial Pain
    1. Temporal (Giant Cell) Arteritis
    2. Migraine
    3. Raeder's Paratrigeminal Neuralgia (Tolosa-Hunt Syndrome)
  7. Glossopharyngeal Neuralgia
    1. About 16% as common as trigeminal neuralgia
    2. Paroxysms of pain often lasting longer than 2 minutes
    3. Triggered by yawning or swallowing food
    4. Onset of pain often preceded by sensation of something stuck in the throat
    5. Pain lacks lancinating electrical quality found in trigeminal neuralgia
  8. Geniculate Neuralgia (Nervus Intermediate Neuralgia) - pain deep in ear or pinna

B. Trigeminal Neuralgia navigator

  1. Neuropathic pain syndrome
  2. Compression of trigeminal nerve by impinging blood vessel may be most common cause
  3. Clinical Criteria (Table 1, Ref [1])
    1. Paroxysmal attacks of pain that last <2 minutes
    2. Pain with at least 4 of the following characteristics:
    3. Distribution along at least one division of trigeminal nerve
      1. Sudden, intense, sharp (lancinating), superficial, stabbing, or burning in quality
      2. Severe intensity
      3. Precipitation from trigger zones (face, mouth) or by certain daily activities
    4. Absence of symptoms between paroxysms
    5. Absence of neurologic deficit
    6. Characteristic pattern of attacks in individual patients
    7. Pain that extends down the throat may be combination of trigeminal and glossopharyneal neuralgias
    8. Other causes of pain ruled out (see above)
  4. Typically occurs in patients in age late 50s
  5. Increased risk in patients with contralateral trigeminal neuralgia or hypertension
  6. Secondary causes include multiple sclerosis and acoustic neuroma
  7. Treatment
    1. Medicines: Carbamazepine (Tegretol®), Gabapentin (Neurontin®), Pregabelin (Lyrica®)
    2. Percutaneous rhizotomy
    3. Microvascular decompression
  8. Percutaneous Rhizotomy
    1. Ablation of trigeminal nerve
    2. Radiofrequency, chemical (ethanol, glycerol), or balloon compression ablation
    3. Radiofrequency thermal lesion with fluoroscopic guidance as outpatient most common
    4. Generally preferred in older persons who do not respond to medicines adequately
  9. Microvascular Decompression
    1. Performed with patient under general anesthesia
    2. Suboccipital craniotomy is required (3-4 hour surgery, 2-3 day hospital stay)
    3. Generally preferred for younger patients for more definitive correction
    4. At 10 years, 70% of patients are free of pain

C. Atypical Facial Painnavigator

  1. Steady, aching or throbbin pain
  2. Pressure and sensation of swelling in the face
  3. May have paroxysmal component
  4. Strong female predominance, most common in women <45 years old
  5. Frequent extension beyond trigeminal distribution, often bilateral
  6. Absence of true trigger zones on face
  7. Associated Conditions
    1. Clinical depression
    2. Disruption of social relationships
    3. Fibromyalgia

D. Aphthous Ulcers [2]navigator

  1. Main Causes
    1. Idiopathic (usually since childhood): aphthae or aphthae with fever, pharyngitis, adenitis
    2. Infections: herpesvirus, HIV; cytomegalovirus in immunocompromised persons
    3. Rheumatic Diseases: Behcet's Syndrome, Reactive Arthritis (Reiter's Syndrome)
    4. Sweet's Syndrome: red plaques on skin, fever, aphthous ulcers on genital or other mucosae
    5. Gluten-sensitive enteropathy (Celiac Disease)
    6. Inflammatory Bowel Disease (IBD): ulcerative colitis, Crohn's Disease
    7. Drugs, NSAIDs, ß-adrenergic blockers, nicorandil (Ikorel®), alendronate (Fosamax®)
    8. Erythema Multiforme
    9. Cyclic Neutropenia
    10. Stomatitis/Mucositis - usually associated with radiation, chemotherapy
  2. Painful ulcers in oral cavity
  3. Important to rule out serious causes of ulcers as above
  4. Treatment of Mild Disease
    1. Topical Anesthetics
    2. Protective Bioadhesives: carmellose (pectin+gelatin, Orabase®), qid until ulcers heal
    3. Topical Glucocorticoids
    4. Antimicrobial Mouth Rinses
    5. Amlexanox (Aphthasol®) Topical
  5. Topical Anesthetics (all apply qid for 2 weeks or until ulcers heal)
    1. Benzydamine oral rinse 0.15% (Difflam®, Tantum®)
    2. Lidocaine gel 5%
    3. Viscous Xylocaine
  6. Topical Glucocorticoids (all apply qid for 2 weeks or until ulcers heal)
    1. Triamcinolone Dental paste 1% (Adcortyl® or Kenalog® in Orabase)
    2. Hydrocortisone 2.5mg pellets (Corlan®)
    3. Fluocinonide Cream 0.05% (Metosyn®)
  7. Antimicrobial Mouth Rinses
    1. Chlorhexidine gluconate 0.12% or 0.2% aqueous mouthwash (Peridex®) - weeks to months
    2. Chlorhexidine gluconate gel - weeks to months
    3. Tetracycline (250mg) or doxycycline (100mg) in 10mL water mouthwash qid x 3 days
  8. Treatment of Severe Disease
    1. Systemic Glucocorticoids: prednisone po 10-60mg qd x 1 week with 1 week taper
    2. Thalidomide (Thalomid®): 50-200mg daily for 4-8 weeks

References navigator

  1. Eskandar E, Barker FG II, Rabinov JD. 2006. NEJM. 355(2):183 (Case Record) abstract
  2. Scully C. 2006. NEJM. 355(2):165 abstract