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Pain syndromes of the face
RX intelligent management of the patient with face pain will frequently depend on the asMe diagnostic ability of the dental surgeon and his reaiization that not, all face pain is related to pathologic processes in t,he teeth or surrounding struc.tures. The responsibility of collaborated therapy for patients who present themselves to him with “toothache” is a serious one and should bc eagerly accepted by the alert dentist,. It is entirely probable t,hat most patients with face pain will consult their dent,ists for the first professional help or will he referred for dental survey by general practitioners of medicine. This situaCon emphasizes the important role that dentistry must exercise in the therapy of face pain. It is entirely t,rue, of course, that, in the majority of instances the presenting symptoms ma.y be resol.ved efficiently and adequately by appropriate therapy directed a,t an offending tooth or its supporting tissue. This discussion is directed toward syndromes which are not the result of specific dental tissue injury or infection together with diagnostic aids for their reeognition and methods of therapy. It is strongly urged that unnecessary extractions or other dental manipulations which are performed in the futile hope that face pain reflects dental disease be abandoned for a more careful history into -the nature of the patients’ complaints. If dent,al surgery is confined to the therapy of proved disease,much of the chronicity of face pain may be prerentable. Although the dental surgeon is usually interested in pain conducted by the dental branches of the mandibular and maxillary nerves, it is necessary to outline brie@ the sensory innervation of the face since other nerves may be t,he locus of disability. The trigeminal nerve is the most important sensory nerve of the face. It is distributed through its three main branches and numerous peripheral offshoot,s to the anterior portion of the scalp, the forehead, and a,11 structures below to the chin. It extends laterally to the chin-ear line. Its innervation also includes the conjunctivae, the mucosae of the nose and mouth, the anterior two-thirds of the tongue, the teeth, and the bone structure of the face. The facial nerve, which is largely motor, does subserve sensation from the skin of the coneha, the posterior portion of the external auditory canal, a,nd the posterior aspect of the tympanic membrane. The vagus nerve furnishes sensation to the skin overlying the mastoid process and participates in the supply to the external auditory meatus and the tympanum. Sensation from the upper and posterior parts of the auricle is mediated by branches from t,he second and occasionally t,he third cervical nerves. Finally, the glossopharyngeal Anesthesia
?3?.xn
t%e Department Service, Bellevue
#of Anesthesia, Hospital.
New 542
York
University
College
of
Medicine
and
the
nerve is sensory to the pharynx, tonsils, and posterior third of the tongue. It is readily apparent that on anatomical grounds alone the evaluation of face pain offers considerable complexity even if one does not include autonomic disturbances which are implicit in the sympathetic supply to the vasomotor and secretory facial structures from the upper three thoracic segments of the spinal cord. Accurate diagnosis of the nature of face pain is often complex and difficult, but is of urgent importance if successful therapy is to be expected. A meticulous history is a necessity, but may be difficult to secure from patients whose persistent pain pleads for immediate positive measures designed to arrest the acute sufferings. The dentist must beware of the temptation to extract a tooth which is the site of symptoms until he is satisfied that it is really diseased and not merely a reference point of pain. The type of pain, its character, duration, and distribution are important information. These details are often not. elicited from patients since accuracy in the description of pain is frequently subordinated to the most pressing aspect of the suffering. It is, therefore, the obligation of those responsible for professional care to obtain the necessary data and to analyze accurately the information obtained. A thorough local examination is essential to discover pathologic lesions in the mouth and other facial structures. Neuralgia, either idiopathic or referred, is the most frequent cause of face pain. No structural pathology of nerve can be demonstrated. It is characterized by pain alone. True idiopathic neuralgia in the face is most commonly seen in the branches of the trigeminal nerve, although the glossopharyngeal is occasionally involved. Pain is continuous and is confined to a specific nerve distribution. Although the patient experiences pain continuously, characteristically its intensity varies. Its character is one of aching or a boring sensation which becomes intense and subsides at recurrent intervals. It always involves a nerve or its main branches and never a small or secondary branch. There are no “trigger” areas which are capable of precipitating or increasing the intensity of the pain on stimulation. Muscle spasm or contraction does not occur as part of the syndrome. Tic douloureux, a type of idiopathic neuralgia, is universally known and classical among painful states. It is not synonymous with trigeminal neuralgia and is not confined to the trigeminal nerve. The pain is characteristically paroxysmal and excruciating and is associated with tonic muscular spasm in the affected zone. The pain begins suddenly and ends as it begins, instantaneously. The duration of painful episodes, although variable, tends to increase as the disease progresses, and the interval between attacks may vary enormously even in the same patient. In the pain-free intervals, other than characteristic trigger points, there is no subjective or objective evidence of pathology of the involved nerve. The trigger points are small, well-delineated areas on the mucosa or the skin which will fire the pain pattern upon even light stimulat,ion. ‘Tic douloureux may involve the entire nerve, a primary branch, or a secondary branch. It most commonly affects the trigeminal nerve or its branches, but tic of th.e glossopharyngeal nerve is by no means rare in a large practice. Referred neuralgia represents a syndrome characterized by pain projected to a, peripheral part by a disease process in a deep homologous embryological
segment and, therefore, always keynotes a definite pathologic icsion which is After transmission, t,he pain is usually referret the site of the painful stimulus. to a superficial branch of the homologous nerve. The pain is usually lancinating, Tenderness along the peripheral tearing, or may be describccl as throbbing. nerve and hyperesthesia in the appropriate skin section aid in localization and diagnosis. The locus of reference is variable. The origin may be any of a multiplicity The variety of possibilities of the of lesions of the skin or mucous membranes. origin of referred pain makes mandatory a careful search in a.11the structnrc~s of the face for a local lesion which may be responsible for the disability. The findings of neoplastie or infectious disease are a secure guide to therapy. In office or hospital pract,ice, most inst,ances of referred face pain are associated with a pathologic tooth. Odontalgia is usually recognized’ easily, but caution is required in that pain from a diseased tooth may be referred to almost, any nerve of the ipsila.teral side of the face. Meticulous study will usually expose an offending tooth as the site of maximum pain, but corroboration of pathologic act.ivit,y is necessary to establish the diagnosis. Confirmation with specific nerve block ma.y be helpful. Pain may be referred to parts of the face from the ocular orbit, the maxillary sinus, the ear, and the cervical segment of the cord. These conditions meril; consideration by the dental surgeon, when he is unable to recognize specific local lesions or the idiopathic neuralgias which may account for the presenting symptoms. Advice from the a.ppropriate medical specialist is indicated under these circumstances. Psychogenic facial neuralgia must be considered and presents many diffculties in diagnosis especially in differentiation from true or referred neuralgias. Characteristic signs of psychogenic face pa.in have been suggested, but it is wiser to realize that any pain may be simulated if driven by psychic forces. Some help in diagnosis may be obtained by the disregard of anatomical pathways in the syndrome, the association of pain with the emotional stresses of anxiety, fear, fatigue, or depression, and the presence of other neurotic manifestations. The temptation to la,bel diagnostic problems psychogenic must be avoided. Psychogenic neuralgia should be a positive diagnosis, rat,her than one by exclusion. It is essential. to realize that psychic overtories and preoccupation are not rarely superimposed on recognizable causes of face pain. Insight into the nature of psychogenic pain, and adequate assist.snee to the pat.ient will improve the therapeutic index of the dentist or physician whose interest includes the problems of face pain. Neuritis, due to intlammation of the peripheral sensory nerves or their ganglia, may be responsible for face pain, Irritation, followed by destruction of nerve, is associated with demonstrable tissue changes in the nerves themselves and the structures they supply. Rtiological factors are mu1tipl.e a.nd are usually systemic conditions, e.g., trauma? chemical and bacterial intoxication, avitaminoses, parasitic disease, metabolic and circulatory disorders. The symptoms are gradual in onset with progressive increase in pain a,ccompunied by deep and superficial tenderness. Involvement is frequently bilateral. As the disease
PAIN
SYNDRONES
OF
FACE
545
progresses1 trophic and vasomotor changes may
become evident, and spotty areas of analgesia appear within the hyperesthetic zonle. It is important to dlifferentiate the neurit,ides from the neuralgias because of the difference in prognosis and therapy. Alterations in activity of the autonomic nervous system have been described in t,he production of face pain. Sympathalgia of the face is unilateral and nonsegmental in distribution. The pain is burning in quality and continuous, but not necessarily severe. The diagnosis is suggested by simultaneous signs of hyperactive sympathetic activity in the form of excessive sweating and rapid and easy alterations in the cutaneous blood supply. Nerve block of the sympathetic ganglia is aonfirmat,ory evidence. Treatment The therapy of true trigeminal neuralgia consists of -therapeutic nerve block of the affected peripheral branches with procaine solution. Block may be 1:epeatedif necessary, but the prognosis for relief is poor if the initial procedure is ineffective in securinp a satisfactory issue. As a rule, temporary and often permanent relief will follow single procaine block. In aged or debilitated patients, alcoholization of the involved nerve is useful. Emphasis is again placed upon the fact that this chronic pain of la,tc adult life may resemble referred dental neuralgia at the onset. True glossopharyngeal izcuralgia is qualitatively similar to true trigeminal neuralgia except, t,ha.t in the former pain is distributed in the throat or back of the tongue and never radiat.es to the gums or teeth. It also dif?ers in being a disease of younger people. Glossopharyngeal nerve block1 at the styloid process is completed with procaine for diagnostic and therapeutic purposes. Unfortunately, alcohol cannot be utilized effciently or safely in this block. The recurrence and per&ence of inea.pacitating pain after successful nerve block are indications for intracranial section of the ninth nerve. Trigeminal tic douloureux which differs from true trigeminal neuralgia by intervals of complete freedom from pain is a chronic disease characterized by severe pain and muscle spasm. Trigger points are always present. The disease is progressive and is usually seen in elderly patients. Medical therapy has accounted for relatively little success. Huge dosesof vitamin B complex, ferrous sulfate, and a course of cobra venom will rarely produce a successful issue. Usually, chemical or surgical interrupt.ion of nerve is indicated. Most satisfactory resu1t.sare oht.ained by effecting nerve block with procaine and alcohol of the involved secondary branches. If a main branch is the site of the disorder, it must be blocked. The principle of nerve block is attack on the most peripheral port,ions of the trigeminal nerve possible. Alcohol block will afford relief of pain from months to years in most instances. Those patients whose relief is transient merit surgical section of the sensory root of the trigeminal nerve. When successive alcohol blocks are required, their efficacy diminishes and surgical t,herapy is necessary. Therapy in Iall the referred neuralgias consists of the removal of the underlying disease. Accurate diagnosis is of paramount importance in the trea.tment of all the referred neuralgias because cure is impossible without eradication of
Kerve block is of diagnostic value and in some the basic pathologic process. circumstances may be therapeutic as in sphenopalatine neuralgia. Slcoholieation of nerves is uniformly unsatisfactory and frequently technically dangerous. If the source of pain is malignant disease, radical excision or irradiation will not guarantee pain relief. In these cases,persistence of pain is not unusual and In these patients, nerve block is is often refractory to nerve block therapy. indicated both for the assistance it affords in suggesting symptomatic surgical section or for the occasional instanee of therapeutic value it provides. The outlook for pain relief is not a brilliant one in malignancy at the present, time. The treatment of neuritis is systemic. Efforts are directed toward determining the causative factors and instituting measures for their arrest or elimination. Nerve block has been insufficiently utilized in these conditions for adequate evaluation. Experience is not extensive enough in the therapy of facial sympathalgia for definitive remarks. The few cases treated have responded well to nerve block of the stellate ganglion or the upper thoracic sympathetic ganglia. Alcohol has not been found necessary. Surgical interruption is indicated in recurrence which becomesrefractory to nerve block. SUmmary 1. The dentist’s responsibility in problems of face pain has been considered. 2. A brief account of the various types of face pain is presented together with valuable diagnost,ic hints. 3. Nerve blocking is frequently useful diagnostically and therapeutically in the mana.gementof patients with pain in the faee and its contents. 4. %mphasis is placed on the difficulties o-f diagnosis and treatment which can be ameliorated only by meticulous care in the study of each problem. Reference 1. Hovenstine, Burg.
FL $.,
auil
Papper,
FL MI.:
Glossopharyngeal
Nerve
Block.
111 press,
Am.
J.
?3?.xn
t%e Department Service, Bellevue
#of Anesthesia, Hospital.
New 542
York
University
College
of
Medicine
and
the
nerve is sensory to the pharynx, tonsils, and posterior third of the tongue. It is readily apparent that on anatomical grounds alone the evaluation of face pain offers considerable complexity even if one does not include autonomic disturbances which are implicit in the sympathetic supply to the vasomotor and secretory facial structures from the upper three thoracic segments of the spinal cord. Accurate diagnosis of the nature of face pain is often complex and difficult, but is of urgent importance if successful therapy is to be expected. A meticulous history is a necessity, but may be difficult to secure from patients whose persistent pain pleads for immediate positive measures designed to arrest the acute sufferings. The dentist must beware of the temptation to extract a tooth which is the site of symptoms until he is satisfied that it is really diseased and not merely a reference point of pain. The type of pain, its character, duration, and distribution are important information. These details are often not. elicited from patients since accuracy in the description of pain is frequently subordinated to the most pressing aspect of the suffering. It is, therefore, the obligation of those responsible for professional care to obtain the necessary data and to analyze accurately the information obtained. A thorough local examination is essential to discover pathologic lesions in the mouth and other facial structures. Neuralgia, either idiopathic or referred, is the most frequent cause of face pain. No structural pathology of nerve can be demonstrated. It is characterized by pain alone. True idiopathic neuralgia in the face is most commonly seen in the branches of the trigeminal nerve, although the glossopharyngeal is occasionally involved. Pain is continuous and is confined to a specific nerve distribution. Although the patient experiences pain continuously, characteristically its intensity varies. Its character is one of aching or a boring sensation which becomes intense and subsides at recurrent intervals. It always involves a nerve or its main branches and never a small or secondary branch. There are no “trigger” areas which are capable of precipitating or increasing the intensity of the pain on stimulation. Muscle spasm or contraction does not occur as part of the syndrome. Tic douloureux, a type of idiopathic neuralgia, is universally known and classical among painful states. It is not synonymous with trigeminal neuralgia and is not confined to the trigeminal nerve. The pain is characteristically paroxysmal and excruciating and is associated with tonic muscular spasm in the affected zone. The pain begins suddenly and ends as it begins, instantaneously. The duration of painful episodes, although variable, tends to increase as the disease progresses, and the interval between attacks may vary enormously even in the same patient. In the pain-free intervals, other than characteristic trigger points, there is no subjective or objective evidence of pathology of the involved nerve. The trigger points are small, well-delineated areas on the mucosa or the skin which will fire the pain pattern upon even light stimulat,ion. ‘Tic douloureux may involve the entire nerve, a primary branch, or a secondary branch. It most commonly affects the trigeminal nerve or its branches, but tic of th.e glossopharyngeal nerve is by no means rare in a large practice. Referred neuralgia represents a syndrome characterized by pain projected to a, peripheral part by a disease process in a deep homologous embryological
segment and, therefore, always keynotes a definite pathologic icsion which is After transmission, t,he pain is usually referret the site of the painful stimulus. to a superficial branch of the homologous nerve. The pain is usually lancinating, Tenderness along the peripheral tearing, or may be describccl as throbbing. nerve and hyperesthesia in the appropriate skin section aid in localization and diagnosis. The locus of reference is variable. The origin may be any of a multiplicity The variety of possibilities of the of lesions of the skin or mucous membranes. origin of referred pain makes mandatory a careful search in a.11the structnrc~s of the face for a local lesion which may be responsible for the disability. The findings of neoplastie or infectious disease are a secure guide to therapy. In office or hospital pract,ice, most inst,ances of referred face pain are associated with a pathologic tooth. Odontalgia is usually recognized’ easily, but caution is required in that pain from a diseased tooth may be referred to almost, any nerve of the ipsila.teral side of the face. Meticulous study will usually expose an offending tooth as the site of maximum pain, but corroboration of pathologic act.ivit,y is necessary to establish the diagnosis. Confirmation with specific nerve block ma.y be helpful. Pain may be referred to parts of the face from the ocular orbit, the maxillary sinus, the ear, and the cervical segment of the cord. These conditions meril; consideration by the dental surgeon, when he is unable to recognize specific local lesions or the idiopathic neuralgias which may account for the presenting symptoms. Advice from the a.ppropriate medical specialist is indicated under these circumstances. Psychogenic facial neuralgia must be considered and presents many diffculties in diagnosis especially in differentiation from true or referred neuralgias. Characteristic signs of psychogenic face pa.in have been suggested, but it is wiser to realize that any pain may be simulated if driven by psychic forces. Some help in diagnosis may be obtained by the disregard of anatomical pathways in the syndrome, the association of pain with the emotional stresses of anxiety, fear, fatigue, or depression, and the presence of other neurotic manifestations. The temptation to la,bel diagnostic problems psychogenic must be avoided. Psychogenic neuralgia should be a positive diagnosis, rat,her than one by exclusion. It is essential. to realize that psychic overtories and preoccupation are not rarely superimposed on recognizable causes of face pain. Insight into the nature of psychogenic pain, and adequate assist.snee to the pat.ient will improve the therapeutic index of the dentist or physician whose interest includes the problems of face pain. Neuritis, due to intlammation of the peripheral sensory nerves or their ganglia, may be responsible for face pain, Irritation, followed by destruction of nerve, is associated with demonstrable tissue changes in the nerves themselves and the structures they supply. Rtiological factors are mu1tipl.e a.nd are usually systemic conditions, e.g., trauma? chemical and bacterial intoxication, avitaminoses, parasitic disease, metabolic and circulatory disorders. The symptoms are gradual in onset with progressive increase in pain a,ccompunied by deep and superficial tenderness. Involvement is frequently bilateral. As the disease
PAIN
SYNDRONES
OF
FACE
545
progresses1 trophic and vasomotor changes may
become evident, and spotty areas of analgesia appear within the hyperesthetic zonle. It is important to dlifferentiate the neurit,ides from the neuralgias because of the difference in prognosis and therapy. Alterations in activity of the autonomic nervous system have been described in t,he production of face pain. Sympathalgia of the face is unilateral and nonsegmental in distribution. The pain is burning in quality and continuous, but not necessarily severe. The diagnosis is suggested by simultaneous signs of hyperactive sympathetic activity in the form of excessive sweating and rapid and easy alterations in the cutaneous blood supply. Nerve block of the sympathetic ganglia is aonfirmat,ory evidence. Treatment The therapy of true trigeminal neuralgia consists of -therapeutic nerve block of the affected peripheral branches with procaine solution. Block may be 1:epeatedif necessary, but the prognosis for relief is poor if the initial procedure is ineffective in securinp a satisfactory issue. As a rule, temporary and often permanent relief will follow single procaine block. In aged or debilitated patients, alcoholization of the involved nerve is useful. Emphasis is again placed upon the fact that this chronic pain of la,tc adult life may resemble referred dental neuralgia at the onset. True glossopharyngeal izcuralgia is qualitatively similar to true trigeminal neuralgia except, t,ha.t in the former pain is distributed in the throat or back of the tongue and never radiat.es to the gums or teeth. It also dif?ers in being a disease of younger people. Glossopharyngeal nerve block1 at the styloid process is completed with procaine for diagnostic and therapeutic purposes. Unfortunately, alcohol cannot be utilized effciently or safely in this block. The recurrence and per&ence of inea.pacitating pain after successful nerve block are indications for intracranial section of the ninth nerve. Trigeminal tic douloureux which differs from true trigeminal neuralgia by intervals of complete freedom from pain is a chronic disease characterized by severe pain and muscle spasm. Trigger points are always present. The disease is progressive and is usually seen in elderly patients. Medical therapy has accounted for relatively little success. Huge dosesof vitamin B complex, ferrous sulfate, and a course of cobra venom will rarely produce a successful issue. Usually, chemical or surgical interrupt.ion of nerve is indicated. Most satisfactory resu1t.sare oht.ained by effecting nerve block with procaine and alcohol of the involved secondary branches. If a main branch is the site of the disorder, it must be blocked. The principle of nerve block is attack on the most peripheral port,ions of the trigeminal nerve possible. Alcohol block will afford relief of pain from months to years in most instances. Those patients whose relief is transient merit surgical section of the sensory root of the trigeminal nerve. When successive alcohol blocks are required, their efficacy diminishes and surgical t,herapy is necessary. Therapy in Iall the referred neuralgias consists of the removal of the underlying disease. Accurate diagnosis is of paramount importance in the trea.tment of all the referred neuralgias because cure is impossible without eradication of
Kerve block is of diagnostic value and in some the basic pathologic process. circumstances may be therapeutic as in sphenopalatine neuralgia. Slcoholieation of nerves is uniformly unsatisfactory and frequently technically dangerous. If the source of pain is malignant disease, radical excision or irradiation will not guarantee pain relief. In these cases,persistence of pain is not unusual and In these patients, nerve block is is often refractory to nerve block therapy. indicated both for the assistance it affords in suggesting symptomatic surgical section or for the occasional instanee of therapeutic value it provides. The outlook for pain relief is not a brilliant one in malignancy at the present, time. The treatment of neuritis is systemic. Efforts are directed toward determining the causative factors and instituting measures for their arrest or elimination. Nerve block has been insufficiently utilized in these conditions for adequate evaluation. Experience is not extensive enough in the therapy of facial sympathalgia for definitive remarks. The few cases treated have responded well to nerve block of the stellate ganglion or the upper thoracic sympathetic ganglia. Alcohol has not been found necessary. Surgical interruption is indicated in recurrence which becomesrefractory to nerve block. SUmmary 1. The dentist’s responsibility in problems of face pain has been considered. 2. A brief account of the various types of face pain is presented together with valuable diagnost,ic hints. 3. Nerve blocking is frequently useful diagnostically and therapeutically in the mana.gementof patients with pain in the faee and its contents. 4. %mphasis is placed on the difficulties o-f diagnosis and treatment which can be ameliorated only by meticulous care in the study of each problem. Reference 1. Hovenstine, Burg.
FL $.,
auil
Papper,
FL MI.:
Glossopharyngeal
Nerve
Block.
111 press,
Am.
J.