Atypical Facial Pain Research Articles

Case studies illustrating the management of trigeminal neuropathic pain using topical 5% lidocaine plasters.

Chronic trigeminal pain, with its severe related functional problems, is difficult to treat. Treatment is often empirically based on medications used for other chronic pain conditions. Systemic sodium channel and calcium channel blocking agents may cause a multitude of complications that are often poorly tolerated by the patient. The aim of this case report was to assess the efficacy of topical 5% lidocaine plasters in reducing pain and reducing adjuvant medication in patients with orofacial neuropathic pain. Fourteen patients with chronic orofacial pain conditions referred to the oral surgery department were instructed to wear 5% lidocaine plasters for 12 hours each day over the painful area. The conditions included post-surgical neuropathy (n = 10), multiple sclerosis-related pain (n = 1), persistent idiopathic facial pain (n = 1), Ramsay Hunt syndrome (post-herpetic neuralgia, n = 1) and trigeminal neuralgia (n = 1). Data were collected on patient demographics, pain levels and medication. Pain levels improved in 12 out of 14 patients. Nine patients had a reduction in adjuvant medication, two of whom completely stopped adjuvant treatment. This case series demonstrates that of the use of 5% lidocaine plasters may play a useful role in the management of chronic trigeminal pain. A suggested novel approach for the management of orofacial pain, for clinicians, is presented. Management of chronic orofacial pain continues to be a major challenge to the clinician.Patients are often placed on a multitude of medications in an attempt to alleviate pain without success.Topical 5% lidocaine plasters, currently used for the management of post-herpetic neuralgia, offer the option of locally targeting trigeminal pain without the multiple side-effects of systemic medication.This case series demonstrates that lidocaine plasters decrease verbal pain scores in extraoral, trigeminal and neuropathic pain, and reduce the use of other neuromodulatory agents in some, but not all, patients.The plasters should be considered as a useful adjuvant in the management of pain in these patients.

Medically unexplained symptoms and somatisation in ENT

Somatisation has been described as the perception of a physiological event influenced by emotion. A review of the medical literature was carried out using the following Medical Subject Headings: somatisation (which identified 357 articles), medically unexplained symptoms (749 articles), unexplained or idiopathic dizziness (142 articles), tinnitus (360 articles), catarrh (1068 articles) and globus pharyngeus (3114 articles). Up to 40 per cent of out-patient attendances have medically unexplainable symptoms. In ENT clinics, this includes patients with dizziness, tinnitus, 'pseudo' eustachian tube dysfunction, being 'unable to hear', catarrh and postnasal drip, atypical facial pain, globus pharyngeus, and functional dysphonia. Medical explanations of these symptoms often differ from patients' perceptions. Demonstrating normal test results and providing reassurance have little effect on patients' doubts and anxieties. Consultations that recognise the symptoms and their impact, and offer a tangible and involving explanation are more likely to satisfy and empower patients. The treatment of medically unexplained symptoms has changed in recent years; there is now more emphasis on psychological factors due to an association with anxiety and depression.

Intraoral somatosensory abnormalities in patients with atypical odontalgia—a controlled multicenter quantitative sensory testing study

Intraoral somatosensory sensitivity in patients with atypical odontalgia (AO) has not been investigated systematically according to the most recent guidelines. The aims of this study were to examine intraoral somatosensory disturbances in AO patients using healthy subjects as reference, and to evaluate the percent agreement between intraoral quantitative sensory testing (QST) and qualitative sensory testing (QualST). Forty-seven AO patients and 69 healthy control subjects were included at Universities of Washington, Malmö, and Aarhus. In AO patients, intraoral somatosensory testing was performed on the painful site, the corresponding contralateral site, and at thenar. In healthy subjects, intraoral somatosensory testing was performed bilaterally on the upper premolar gingiva and at thenar. Thirteen QST and 3 QualST parameters were evaluated at each site, z-scores were computed for AO patients based on the healthy reference material, and LossGain scores were created. Compared with control subjects, 87.3% of AO patients had QST abnormalities. The most frequent somatosensory abnormalities in AO patients were somatosensory gain with regard to painful mechanical and cold stimuli and somatosensory loss with regard to cold detection and mechanical detection. The most frequent LossGain code was L0G2 (no somatosensory loss with gain of mechanical somatosensory function) (31.9% of AO patients). Percent agreement between corresponding QST and QualST measures of thermal and mechanical sensitivity ranged between 55.6% and 70.4% in AO patients and between 71.1% and 92.1% in control subjects. In conclusion, intraoral somatosensory abnormalities were commonly detected in AO patients, and agreement between quantitative and qualitative sensory testing was good to excellent.

Biopsychosocial Aspects of Atypical Odontalgia

Background. A few studies have found somatosensory abnormalities in atypical odontalgia (AO) patients. The aim of the study is to explore the presence of specific abnormalities in facial pain patients that can be considered as psychophysical factors predisposing to AO. Materials and Methods. The AO subjects (n = 18) have been compared to pain-free (n = 14), trigeminal neuralgia (n = 16), migraine (n = 17), and temporomandibular disorder (n = 14). The neurometer current perception threshold (CPT) was used to investigate somatosensory perception. Structured clinical interviews based on the DSM-IV axis I and DSM III-R axis II criteria for psychiatric disorders and self-assessment questionnaires were used to evaluate psychopathology and aggressive behavior among subjects. Results. Subjects with AO showed a lower Aβ, Aδ, and C trigeminal fiber pain perception threshold when compared to a pain-free control group. Resentment was determined to be inversely related to Aβ (rho: 0.62, P < 0.05), Aδ (rho: 0.53, P < 0.05) and C fibers (rho: 0.54, P < 0.05), and depression was inversely related with C fiber (rho: 0.52, P < 0.05) perception threshold only in AO subjects. Conclusion. High levels of depression and resentment can be considered predictive psychophysical factors for the development of AO after dental extraction.

Quantitative sensory testing in trigeminal traumatic neuropathic pain and persistent idiopathic facial pain

The objective of this article was to investigate, with a systematic protocol of quantitative sensory testing, patients with persistent idiopathic facial pain (PIFP) and others with trigeminal traumatic neuropathic pain (TTN) compared to controls. Thirty patients with PIFP, 19 with TTN, and 30 controls were evaluated on subjective numbness and dysesthesia and with a systematic protocol of quantitative sensory testing for thermal evaluation (cold and warm), mechanical detection (touch and pinpricks for mechanical pain), superficial pain thresholds, and corneal reflex. We found that PIFP and TTN had numbness and dysesthesia higher than controls (p<0.001 and p=0.003), and that in both of them mechanical pain by pinpricks detection was abnormal intra and extra orally at the mandibular branch (p<0.001). Cold, warm, and tactile detections and pain thresholds were similar among the groups. Corneal reflex was abnormal in TTN (p=0.005). This study supports neuropathic mechanisms involving pain processing in PIFP and that the criterion on absence of sensorial variations in PIFP should be revised.

Diagnostic Utility of 18 FDG-PET in Neurolymphomatosis Presenting as Atypical Facial Pain (P06.146)

Diagnostic Utility of ¹⁸ FDG-PET in Neurolymphomatosis Presenting as Atypical Facial Pain (P06.146)

Quantitative sensory testing in atypical odontalgia patients after local anesthesia

Atypical Odontalgia (AO) is a term applied to a continuous pain in the teeth or in the tooth socket after extraction in the absence of any identifiable dental cause, under the International Classification of Headache Disorders (ICHD) and somatosensory abnormalities are common features in these patients, where Quantitative Sensory Testing (QST) are helpful tools to evaluate these cases.

Anhaltender idiopathischer Gesichtsschmerz und atypische Odontalgie

The terms 'persistent idiopathic facial pain' (PIFP) and 'atypical odontalgia' (AO) are currently used as exclusion diagnoses for chronic toothache and chronic facial pain. Knowledge about these pain conditions in medical and dental practices is of crucial importance for the prevention of iatrogenic tissue damage by not-indicated invasive interventions, such as endodontic treatment and tooth extraction. In the present paper, etiology and pathogenesis, differential diagnostic criteria, and diagnostic approaches will be explained and relevant therapeutic principles will be outlined.

Chairside Intraoral Qualitative Somatosensory Testing: Reliability and Comparison Between Patients with Atypical Odontalgia and Healthy Controls

To assess intraoral inter- and intraexaminer reliability of three qualitative measures of intraoral somatosensory function and to compare these measures between patients with atypical odontalgia (AO) and healthy controls. Thirty-one AO patients and 47 healthy controls participated. Inter- and intraexaminer reliability was tested on a subgroup of 46 subjects (25 AO; 21 healthy). Sensitivity to touch, cold, and pinprick stimuli was evaluated on the painful gingival site and the corresponding contralateral site in AO patients, and bilaterally on the gingiva of the first maxillary premolars in controls. Patients were asked to report hypersensitivity, hyposensitivity, or normal sensitivity to stimuli on the painful site compared with the nonpainful site. Kappa values were calculated, and chi-square and Fisher's exact tests were used to compare frequencies between groups. Kappa values ranged between 0.63 and 0.75. The frequency of hypersensitivity to either modality was significantly higher in patients (29% to 61%) than in controls (9% to 17%) (P < .015), whereas reports of hyposensitivity were similar between groups (2% to 16%) (P > .057). Only 3.2% of the AO patients had no reports of abnormal sensitivity on any of the tests, compared with 59.6% of the healthy subjects (P < .001). Intraoral qualitative somatosensory testing can detect intraoral sensory disturbances in AO patients, and the reliability is sufficient for initial screening of orofacial somatosensory function.

Utility of Stellate Ganglion Block in Atypical Facial Pain: A Case Report and Consideration of Its Possible Mechanisms

We present this report of a young patient with chronic severe atypical facial pain who was successfully controlled with stellate ganglion block under ultrasound guidance. The patient had a history of severe disabling, unilateral, facial neuropathic pain with minimal response to analgesic medications. Upon assessment the patient had features suggestive of trigeminal neuralgia, although postherpetic neuralgia could not be ruled out. As a diagnostic test intervention, stellate ganglion block was tried under ultrasound guidance. The patient showed significant improvement in pain control and functional disability lasting beyond 10 weeks. Subsequent blocks reinforced the analgesia. Atypical facial pain has several differential diagnoses. The involvement of sympathetic system in its causation or sustenance is uncertain. Stellate ganglion block achieves sympathetic block of cervicofacial structures, and its blockade has been shown to affect chronic pain conditions. Although its mechanism is not clear, one has to consider its possible role in conditions of stress apart from directly controlling the sympathetic activity. There is certainly a role in exploring the potential benefits of stellate ganglion block in such clinical conditions. The technique of stellate block under ultrasound is also described, as it influences the safety and precision of the block.

Seven-Year Follow-up of Patients Diagnosed with Atypical Odontalgia: A Prospective Study

To examine the long-term prognosis of 46 previously examined atypical odontalgia (AO) patients. In 2002 and 2009, AO patients completed validated instruments measuring pain characteristics (pain frequency and intensity), physical functioning (Graded Chronic Pain Severity, GCPS) and emotional functioning (Symptoms Checklist, SCL-90R). The main outcome was global improvement. Baseline data on quantitative somatosensory testing and responsiveness to lidocaine injection were available for a subgroup of patients. Paired tests compared baseline and follow-up data, and logistic regression explored the possible prognostic value of baseline data. Data from 37 patients (80%) were obtained. Thirteen patients (35%; 95% confidence intervals [CI] 20.2%-52.5%) rated their overall pain status as significantly improved, 22 (60%; 95% CI 42.1%-75.3%) as a little improved or unchanged, and two patients (5%; 95% CI 0.7%-18.2%) as worse. Five patients (14%; 95% CI 4.5%-28.8%) were pain-free, indicated by a characteristic pain intensity score of 0. Average pain intensity decreased (from 5.7 ± 2.0 to 3.5 ± 2.4; P < .001). Pain frequency (P < .001) and GCPS (P < .001) also decreased, whereas SCL-90R scores remained unchanged and 26 of the 37 patients reported ongoing treatment. Low baseline pain intensity was the only factor predictive of favorable outcome. A third of the AO patients improved considerably over time, but for many of the patients, AO was a persistent and treatment-resistant condition.

Atypical Facial Pain Secondary to an Unusual Iatrogenic Endonasal “Contact Point”

Dear Editor, Headache and facial pain are common complaints in clinical setting. However, among different etiologies, clinicians must think also to a possible rhinologic source of pain ⇓. Rhinosinusitis ⇓ or nasal anatomical abnormalities (e.g., large turbinate, concha bullosa, or septal spurs) can cause craniofacial pain through a “contact pressure point” mechanism between opposite mucosal surfaces ⇓. At present, the diagnosis is made mainly by identifying rhinogenic causes, but its pathogenesis is still under debate as well as the therapeutic options. We report the case of a 55-year-old woman presenting an atypical facial pain started 3 weeks after dental implant positioning on right maxillary incisor region. Pain attacks were characterized by a right recurrent orbitozygomatic pounding hurt associated to ipsilateral dull “sense of pressure.” Patient's symptoms were reported as moderate to severe, lasting hours, exacerbated by nasal fossa engorgement (due to the physiological nasal cycle or postural changes), and scarcely responsive to common …

Neuropathic pain after dental treatment

The head and neck regions are the most common sites of the human body to be involved in chronic pain conditions. Neuropathic pain is a chronic pain condition, and refers to all pain initiated or caused by a primary lesion or dysfunction or transitory perturbation in the peripheral or central nervous system (CNS). Trigeminal neuralgia, atypical odontalgia (phantom tooth pain), burning mouth syndrome, traumatic neuropathies, postherpetic neuralgias and complex regional pain syndrome are neuropathic pain conditions in the orofacial region that can be encountered in pain and dental clinics. The majority of the time this problem is misdiagnosed by the dentist, which can lead to unnecessary treatments. These treatments may include endodontic treatment and extraction of the tooth or teeth in the region. In this review, only post-traumatic peripheral pain neuropathies seen after dental treatments will be discussed.

口腔顎顔面痛症例報告３ - Cracked tooth syndrome（CTS）と Atypical odontalgia（AO）

口腔顎顔面痛症例報告３ - Cracked tooth syndrome（CTS）と Atypical odontalgia（AO）

Neurophysiological features of atypical facial pain

Unlike clinical research, neurophysiological testing has higher accuracy and sensitivity in revealing neurogenic defects responsible for the orofacial pain and sensory disturbance. This reseach was aimed at studying neurophysiologicl aspects of the atypical facial pain. The disorder turns out to have such specific traits as brainstem structure disfunction which occurs as higher brainstem structure sensibility, with the trigeminal system being involved during autonomic disorders. The mutimodal evoked potential potentials (auditory evoked potentials, Sympathetic Skin Response and trigeminal evoked potentials) research is recommended for differencial diagnostics for different kinds of the facial pain, verifying predominate pathogenic mechanisms, defining treatment course and treatment efficiency estimation.

Interventional Procedures for Facial Pain

Interventional pain procedures are critical in the diagnosis and management of a variety of facial pain conditions. Trigeminal neuralgia (TN) is the most frequent diagnosis for facial pain, with a reported prevalence 10 times greater than persistent idiopathic facial pain (PIFP). Although pharmacological treatments and psychological interventions benefit many patients with these diagnoses, the pain remains disabling for a significant portion of others. Percutaneous interventions targeting the gasserian ganglion and its branches have proven effective in the management of TN, while there is also supportive evidence for treating the sphenopalatine ganglion in PIFP.

Effectiveness of Duloxetine for the Treatment of Chronic Nonorganic Orofacial Pain

We examined the pain-relieving effect of duloxetine on chronic nonorganic orofacial pain (burning mouth syndrome and atypical odontalgia), considering the influence of baseline depressive symptoms. In this study of 12 weeks, duloxetine was administered in a fixed-flexible dose of 20 to 40 mg/d to 41 patients with burning mouth syndrome and/or atypical odontalgia. Pain was evaluated using the visual analog scale (VAS) at baseline and at 2, 4, 6, 8, 10, and 12 weeks of treatment. Depressive symptoms were assessed using the Hamilton Depression Rating Scale at baseline and at 12 weeks of treatment. We analyzed the data from 29 patients who completed the study. The VAS score at 12 weeks of treatment was significantly lower than that at baseline. The time course of the VAS scores revealed its significant decrease from 2 weeks of treatment compared to the baseline score. To investigate the influence of baseline depressive symptoms on the pain-relieving effect of duloxetine, the subjects were divided into 2 groups based on the Hamilton Depression Rating Scale score on initial consultation: groups with (≥8) and without (≤7) depressive symptoms. Two-way repeated-measures analysis of variance revealed no significant interaction between time and initial presence or absence of depression. An additional intent-to-treat last-observation-carried-forward analysis including dropped-out patients revealed a similar result. Duloxetine significantly relieved chronic nonorganic orofacial pain. Its pain-relieving effect appeared from 2 weeks of treatment. Furthermore, the pain-relieving effects of duloxetine similarly appeared regardless of the presence or absence of baseline depressive symptoms.

Patients appearing to dental professionals with orofacial pain arising from intracranial tumors: a literature review

A small proportion of patients with orofacial pain appearing to dentists and dental specialists will have intracranial tumors as the underlying cause. These patients may undergo unnecessary dental interventions before the correct diagnosis is made. A search of the literature using the PubMed database was performed to identify case reports of this occurrence. Cases were analyzed for common characteristics or presenting features that may aid dentists in identifying patients with intracranial tumors. Twenty-eight cases were identified. Features consistent with the diagnoses of trigeminal neuralgia, persistent idiopathic facial pain, and temporomandibular disorders were the most common presentations. Fifty-nine percent of patients presented with sensory or motor function loss at their initial diagnosis. Patients who present with symptoms that extend beyond the typical presentation of these entities are at highest risk for intracranial tumors and should be further evaluated.

Atypical Odontalgia — An Update

Atypical odontalgia is a commonly misdiagnosed condition that frequently leads to unnecessary dental treatments such as extraction and endodontic therapy. These treatments often worsen the pain. Despite greater recognition and understanding of this condition, proper diagnosis and treatment remains a challenge. It is believed that atypical odontalgia is a neuropathic condition. This article updates the current understanding of the etiology and pathophysiology of atypical odontalgia, and provides appropriate diagnostic and management approaches for this condition.

Non-Immersive, Virtual Reality Mirror Visual Feedback for Treatment of Persistent Idiopathic Facial Pain

Dear Editor, This letter describes a preliminary proof-of-concept test of a novel, non-invasive, virtual reality mirror visual feedback (VRMVF) therapy for persistent idiopathic facial pain. Persistent idiopathic face pain (PIFP) shares some characteristics with complex regional pain syndrome (CRPS) type 1: The pain develops after a relatively minor noxious event; is not associated with a specific nerve injury; and results in constant, severe, and often disabling pain. Patients with both conditions may develop allodynia and/or thermal sensitivity, and may limit movement of the affected part to minimize pain. Mirror visualization feedback (MVF) is one approach used for CRPS that might also prove useful in treating PIFP. In 1996, Ramachandran discovered that MVF therapy might mitigate phantom limb pain in amputees [1]. Attempts to expand on this use of MVF have included efforts to treat phantom limb pain, fibromyalgia [2] CRPS [3] and facial pain [4] both in the original format and using virtual reality (VR) [5–7]. We theorized that the similarities between CRPS and PIFP might make a MVF therapy that relies on painless touch effective in treating PIFP as well. In our method, a digital model (or “avatar”) represents the patients head and neck, with the computer screen serving as the “mirror.” This method would allow the …