An 80-year-old woman who moved into residential care 3 months ago is brought to your surgery. The elderly lady is complaining of an intense burning sensation affecting the right-hand side of her face which has been present for at least the past 3 months. The lower part of her face is spared. Nothing seems to make it better or worse. The patient is a poor historian and the carer knows little of her history before she came to live at the care home. On examination, you notice some scarring on the skin of her right cheek and forehead but nil else of note. The patient was recently prescribed a low dose of amitriptyline for anxiety by her GP and this seems to have helped a little with the pain.

Hey, fam! 🌟 Let’s break down this medical mystery in a way we can all understand! 🤓 So, we’ve got this sweet 80-year-old lady in a care home dealing with intense face pain on the right side! 😫 It’s been going on for 3 months, and nothing seems to make it better or worse. 😕 She’s a bit forgetful, but her carer noticed some scars on her right cheek and forehead. 🧐 Plus, she’s taking amitriptyline for anxiety, which kinda helps with the pain! 🙌 So what’s going on?

Some clues point to atypical facial pain – constant pain, no triggers, and a little help from amitriptyline! 🤔 But wait, there’s more – the pain’s got a specific spot, not touching the area of the trigeminal nerve! 🙅‍♀️ And that intense burning sensation? It screams postherpetic neuralgia! 🔥 The scarring on her face hints at previous herpes zoster – that’s a big clue! 📝 So, what’s the final verdict? 🤷‍♀️ Let’s put all the pieces together – atypical facial pain with a sprinkle of postherpetic neuralgia! 💥💔 We’ve cracked the case, fam! But stay tuned for more medical adventures! 🚀💙

RESEARCH

Atypical facial pain (AFP) is a type of facial pain that is characterized by persistent or recurrent pain in the face that does not fit the typical patterns of other facial pain syndromes such as trigeminal neuralgia (Koopman et al., 2009). It is considered a rare condition, but its exact incidence in the general population is not well established (Koopman et al., 2009). However, studies have shown that AFP is more common in women than men (Koopman et al., 2009).

Postherpetic neuralgia (PHN) is another type of facial pain that can occur after an episode of herpes zoster (shingles) (Koopman et al., 2009; Tolba et al., 2019). It is characterized by persistent pain in the area where the shingles rash occurred, even after the rash has healed (Tolba et al., 2019). The incidence of PHN has been studied in the general population, and it has been found to be relatively rare (Koopman et al., 2009). However, it is important to note that PHN can cause significant distress and compromise the quality of life for those affected (Jeon, 2016).

The diagnosis of AFP and PHN can be challenging, as there are no specific tests or imaging studies that can definitively confirm these conditions (Koopman et al., 2009). Diagnosis is typically based on clinical evaluation, medical history, and exclusion of other possible causes of facial pain (Koopman et al., 2009). In some cases, additional diagnostic procedures such as quantitative sensory testing or nerve blocks may be performed to aid in the diagnosis (Okayasu et al., 2014).

Treatment options for AFP and PHN vary depending on the severity and individual patient characteristics. Conservative management approaches may include medications such as anticonvulsants, antidepressants, and analgesics to help manage pain (Tolba et al., 2019; Akbaş et al., 2016). In some cases, interventional procedures such as sphenopalatine ganglion block, radiofrequency ablation, or neurostimulation may be considered (Ho et al., 2017; Tolba et al., 2019; Jeon, 2016). Surgical interventions, such as trigeminal tractotomy-nucleotomy or dorsal root entry zone operations, may be reserved for refractory cases (Bekar et al., 2020; Kanpolat et al., 2008).

Overall, AFP and PHN are distinct facial pain conditions that can significantly impact the quality of life of affected individuals. Accurate diagnosis and appropriate management are essential for providing relief and improving the well-being of patients experiencing these conditions. Further research is needed to better understand the incidence, etiology, and optimal treatment strategies for AFP and PHN.

A 65-year-old woman presents with a throbbing pain affecting her left temple. The headache began about a week ago and is accompanied by pain in the muscles around her jaw joint on eating. She has no previous history of facial pain or headache. Intraoral examination is unremarkable. There is no evidence of dental pathology or parafunctional habits.

The recent onset of unilateral pain of this nature in this site without any previous history should immediately raise the possibility of giant-cell arteritis. The patient is in the right age group (usually = 50 years). The accompanying pain in the muscles of mastication on chewing could represent temporomandibular joint dysfunction but is entirely consistent with giant-cell arteritis.

RESEARCH

Giant-cell arteritis (GCA), also known as temporal arteritis or Horton’s arteritis, is a systemic vasculitis that primarily affects large and medium-sized vessels, particularly the extracranial branches of the carotid arteries (Calvo-Romero, 2003). It is most commonly observed in individuals over the age of 50 (Joseph et al., 2019). GCA is characterized by inflammation of the blood vessels, which can lead to various symptoms and complications (Shenoy et al., 2023).

The diagnosis of GCA can be challenging, and early recognition is crucial to prevent serious complications such as blindness, stroke, and necrosis of the lips and tongue (Gualtierotti et al., 2018). The diagnosis of GCA is typically based on a combination of clinical features, laboratory tests, and imaging studies (Liedtke et al., 2023). The gold standard for diagnosis is a temporal artery biopsy, which reveals histologic evidence of arteritis (Bengtsson & Malmvall, 1981). However, it is important to note that giant cells are not required in the histopathological diagnostic criteria for GCA (Armstrong et al., 2008).

The symptoms of GCA can vary but commonly include severe temporal headaches, low-grade fever, malaise, depression, weight loss, and visual changes (Gualtierotti et al., 2018). Patients may also experience dental pain, dysphagia, dysarthria, chronic cough, and, rarely, necrosis of the lips and tongue (Gualtierotti et al., 2018). In some cases, GCA can present with orofacial symptoms such as toothache and pain/difficulty in chewing, which may lead patients to seek dental care initially (Shenoy et al., 2023).

Dentists play a crucial role in the early recognition and referral of patients with suspected GCA. Increased awareness of GCA among dental practitioners can minimize the risk of serious complications such as blindness and stroke (Shenoy et al., 2023). Dental practitioners should be alert to the possibility of GCA and should direct suspected cases to their general medical practitioner or a hospital specialist (Shenoy et al., 2023).

The management of GCA typically involves high-dose steroid treatment (Calvo-Romero, 2003). Early initiation of treatment is essential to prevent complications and improve outcomes (Lee et al., 2011). However, many questions about the diagnosis, treatment, and optimal patient follow-up of GCA remain unanswered (Iudici et al., 2023). International guidelines exist, but some aspects are based mainly on low-quality data or expert opinion (Iudici et al., 2023). The management of GCA patients can also be influenced by factors such as the care setting, physician’s experience, or resource availability (Iudici et al., 2023).

In conclusion, GCA is a systemic vasculitis that primarily affects large and medium-sized vessels. It can present with a wide range of symptoms, including orofacial symptoms such as dental pain and difficulty in chewing. Early recognition and referral of suspected cases are crucial to prevent serious complications. Dentists play an important role in the early detection of GCA and should be aware of the signs and symptoms associated with the condition. Further research is needed to improve the diagnosis, treatment, and management of GCA patients.

REFERENCES

Alimohammadi, M., Knight, A. (2013). Scalp Necrosis As a Late Sign Of Giant-cell Arteritis. Case Reports in Immunology, (2013), 1-2. https://doi.org/10.1155/2013/231565 Antonelli, J., Hottel, T. (2003). Oral Manifestations Of Renal Osteodystrophy: Case Report and Review Of The Literature. Special Care in Dentistry, 1(23), 28-34. https://doi.org/10.1111/j.1754-4505.2003.tb00286.x Armstrong, A., Tyler, W., Wood, G., Harrington, T. (2008). Clinical Importance Of the Presence Of Giant Cells In Temporal Arteritis. Journal of Clinical Pathology, 5(61), 669-671. https://doi.org/10.1136/jcp.2007.049049 Bajko, Z., Balasa, R., Maier, S., Motataianu, A., Barcutean, L., Andone, S., … & Filep, R. (2021). Stroke Secondary To Giant‑cell Arteritis: a Literature Review. Exp Ther Med, 2(22). https://doi.org/10.3892/etm.2021.10308 Bengtsson, B., Malmvall, B. (1981). The Epidemiology Of Giant Cell Arteritis Including Temporal Arteritis and Polymyalgia Rheumatica. Arthritis & Rheumatism, 7(24), 899-904. https://doi.org/10.1002/art.1780240706 Calvo-Romero, J. (2003). Giant Cell Arteritis. Postgraduate Medical Journal, 935(79), 511-515. https://doi.org/10.1136/pmj.79.935.511 Elad, S., Zadik, Y., Caton, J., Epstein, J. (2019). Oral Mucosal Changes Associated With Primary Diseases In Other Body Systems. Periodontol 2000, 1(80), 28-48. https://doi.org/10.1111/prd.12265 Gualtierotti, R., Marzano, A., Spadari, F., Cugno, M. (2018). Main Oral Manifestations In Immune-mediated and Inflammatory Rheumatic Diseases. JCM, 1(8), 21. https://doi.org/10.3390/jcm8010021 Iudici, M., Hemmig, A., Stegert, M., Courvoisier, C., Adler, S., Becker, M., … & Group, N. (2023). Management Of Giant-cell Arteritis In Switzerland: An Online National Survey. Swiss Med Wkly, 4(153), 40051. https://doi.org/10.57187/smw.2023.40051 Joseph, A., Pradeepan, J., Kumanan, T., Malaravan, M. (2019). Combined Left Central Retinal Artery Occlusion and Bilateral Anterior Ischemic Optic Neuritis: A Rare Presentation Of Giant Cell Arteritis. Case Reports in Rheumatology, (2019), 1-3. https://doi.org/10.1155/2019/3236821 Kawamoto, T., Ogasawara, M., Nakano, S., Matsuki−Muramoto, Y., Matsushita, M., Yamanaka, K., … & Tamura, N. (2019). Diagnosis Of Giant Cell Arteritis By Head-contrast Three-dimensional Computed Tomography Angiography: Two Case Reports. J Med Case Reports, 1(13). https://doi.org/10.1186/s13256-019-2199-0 Lee, Y., Padera, R., Noss, E., Fossel, A., Bienfang, D., Liang, M., … & Docken, W. (2011). Clinical Course and Management Of A Consecutive Series Of Patients With “Healed Temporal Arteritis”. J Rheumatol, 2(39), 295-302. https://doi.org/10.3899/jrheum.110317 Liedtke, F., Daher, I., Moura, M., Murad, A., Ferrari, R., Neiva, E., … & Souza, P. (2023). Clinical Evidence and Diagnosis Of Temporal Arteritis: A Concise Systematic Review. MedNEXT, 2(4). https://doi.org/10.54448/mdnt23203 Lim, Z., Sharp, C. (2021). Neck Swelling and Airway Narrowing As An Initial Manifestation Of Giant Cell Arteritis. BMJ Case Rep, 3(14), e237743. https://doi.org/10.1136/bcr-2020-237743 Mahe, E., Demellawy, D., Bane, A., Alowami, S. (2012). Giant Cell Temporal Arteritis Associated With Overlying Basal Cell Carcinoma: Co-incidence or Connection?. Rare Tumors, 3(4), 148-149. https://doi.org/10.4081/rt.2012.e46 McDonald, L., Baker, G., Kerr, O. (2019). Scalp Ulceration: a Rare Manifestation Of Giant Cell Arteritis. BMJ Case Rep, 11(12), e230795. https://doi.org/10.1136/bcr-2019-230795 Nayar, A., Casciello, M., Slim, J., Slim, A. (2013). Fatal Aortic Dissection In a Patient With Giant Cell Arteritis: A Case Report And Review Of The Literature. Case Reports in Vascular Medicine, (2013), 1-4. https://doi.org/10.1155/2013/590721 Nitta, S., Tanaka, T., Yanagihashi, R., Nonaka, H., Suzuki, S., Kimura, T., … & Nishiyama, H. (2021). Granulocyte Colony‐stimulating Factor Associated Arteritis In a Patient With Castration‐resistant Prostate Cancer. IJU Case Reports, 1(5), 29-31. https://doi.org/10.1002/iju5.12376 Regezi, J. (2002). Odontogenic Cysts, Odontogenic Tumors, Fibroosseous, and Giant Cell Lesions Of The Jaws. Modern Pathology, 3(15), 331-341. https://doi.org/10.1038/modpathol.3880527 Schmidt, W. (2006). Takayasu and Temporal Arteritis., 96-104. https://doi.org/10.1159/000092388 Seko, Y., Minota, S., Kawasaki, A., Shinkai, Y., Maeda, K., Yagita, H., … & Tada, Y. (1994). Perforin-secreting Killer Cell Infiltration and Expression Of A 65-kd Heat-shock Protein In Aortic Tissue Of Patients With Takayasu’s Arteritis.. J. Clin. Invest., 2(93), 750-758. https://doi.org/10.1172/jci117029 Shenoy, R., French, K., Eke, T., Mukhtyar, C. (2023). Recognizing Giant Cell Arteritis In Dental Practice. Dent Update, 3(50), 204-208. https://doi.org/10.12968/denu.2023.50.3.204 Sørensen, P., Lorenzen, I. (2009). Giant-cell Arteritis, Temporal Arteritis and Polymyalgia Rheumatica. Acta Medica Scandinavica, 1-6(201), 207-213. https://doi.org/10.1111/j.0954-6820.1977.tb15683.x Vrînceanu, D., Dumitru, M., Bănică, B., Eftime, I., Patrascu, O., Costache, A., … & Georgescu, M. (2021). Role Of Temporal Artery Resection In Horton’s Arteritis (Review). Exp Ther Med, 4(22). https://doi.org/10.3892/etm.2021.10533 Zakrzewska, J. (2013). Differential Diagnosis Of Facial Pain and Guidelines For Management. British Journal of Anaesthesia, 1(111), 95-104. https://doi.org/10.1093/bja/aet125

A 71-year-old woman attends your surgery complaining of a sharp pain which affects the back of her tongue and the area just beneath the angle of her jaw, always on the left-hand side alone. The pain lasts for about a minute and comes on when she swallows or chews. Her lower left first and second molar teeth are present and restored but they appear sound, are vital and are not tender to percussion.

While the tongue is commonly affected in burning mouth syndrome, the pain is of too short a duration and is described as sharp. The involvement of the area just below the angle of the jaw and pain on chewing might suggest dental pathology but the teeth are sound and not TTP. Similarly, were it not for the involvement of the tongue, a diagnosis of TN might be considered. However, taking into account the sites affected, the nature of the pain and when it is experienced, the diagnosis is glossopharyngeal neuralgia.

RESEARCH

Glossopharyngeal neuralgia is a rare condition that causes severe, stabbing pain in the throat, tongue, and ear. It happens because of a problem with a nerve called the glossopharyngeal nerve. This nerve is responsible for sending messages about feeling and pain from the throat and tongue to the brain. The exact cause of glossopharyngeal neuralgia is not fully understood, but it may be due to pressure on the nerve from blood vessels.

When someone has glossopharyngeal neuralgia, they experience sudden and intense pain attacks that can last for a short time. The pain can be triggered by things like swallowing, talking, or even just touching the affected area. It usually affects only one side of the face and can be very uncomfortable.

To diagnose glossopharyngeal neuralgia, doctors will ask about the person’s symptoms and do some tests. These tests may include imaging scans like an MRI to look for any problems with the nerve.

Treatment for glossopharyngeal neuralgia can involve medications to help manage the pain. Common medications include carbamazepine, oxcarbazepine, or gabapentin. In some cases, surgery may be necessary to relieve the pressure on the nerve. This can involve a procedure called microvascular decompression, where the blood vessels causing the compression are moved away from the nerve.

It’s important for dentists to be aware of glossopharyngeal neuralgia because it can cause neck pain that may be mistaken for dental problems. If a dentist suspects glossopharyngeal neuralgia, they will refer the patient to a specialist for further evaluation and treatment.

Overall, glossopharyngeal neuralgia is a rare condition that causes severe throat and ear pain. It can be diagnosed through medical tests and treated with medications or surgery. Dentists should be aware of this condition to provide appropriate referrals for their patients.

References:

Edvinsson, J., Viganò, A., Alekseeva, A., Alieva, E., Arruda, R., Luca, C., … & Haanes, K. (2020). The Fifth Cranial Nerve In Headaches. J Headache Pain, 1(21). https://doi.org/10.1186/s10194-020-01134-1 Fusco, D., Asteraki, S., Spetzler, R. (2012). Eagle’s Syndrome: Embryology, Anatomy, and Clinical Management. Acta Neurochir, 7(154), 1119-1126. https://doi.org/10.1007/s00701-012-1385-2 Gaul, C., Hastreiter, P., Duncker, A., Naraghi, R. (2011). Diagnosis and Neurosurgical Treatment Of Glossopharyngeal Neuralgia: Clinical Findings And 3-d Visualization Of Neurovascular Compression In 19 Consecutive Patients. J Headache Pain, 5(12), 527-534. https://doi.org/10.1007/s10194-011-0349-x Goel, V. (2020). Glossopharyngeal Neuralgia: An Approach To Diagnosis and Management. AHM Journal. https://doi.org/10.30756/ahmj.2020.02.07 Hamilton, K., Seligman, R., Blue, R., Lee, J. (2022). Refractory Glossopharyngeal Neuralgia Successfully Treated With Onabotulinumtoxina: a Case Report. Headache, 10(62), 1424-1428. https://doi.org/10.1111/head.14421 Han, A., Montgomery, C., Zamora, A., Winder, E., Carroll, C., Aquino, A., … & Kaye, A. (2022). Glossopharyngeal Neuralgia: Epidemiology, Risk Factors, Pathophysiology, Differential Diagnosis, and Treatment Options. Health Psychology Research, 5(10). https://doi.org/10.52965/001c.36042 Ishibashi, K., Yamanaka, K., Yamanaka, K. (2021). Gamma Knife Radiosurgery For Concurrent Trigeminal Neuralgia and Glossopharyngeal Neuralgia. Cureus. https://doi.org/10.7759/cureus.20717 Jiang, H., Zhou, D., Wang, P., Zeng, L., Liu, J., Tang, C., … & Wu, N. (2023). Case Report: Fully Endoscopic Microvascular Decompression For Glossopharyngeal Neuralgia. Front. Surg., (9). https://doi.org/10.3389/fsurg.2022.1089632 Khan, M., Nishi, S., Hassan, S., Islam, M., Gan, S. (2017). Trigeminal Neuralgia, Glossopharyngeal Neuralgia, and Myofascial Pain Dysfunction Syndrome: An Update. Pain Research and Management, (2017), 1-18. https://doi.org/10.1155/2017/7438326 Kim, J., Lee, C. (2021). Posterior Condylar Canal Dural Arteriovenous Fistula As a Rare Cause Of Glossopharyngeal Neuralgia: A Case Report. Headache, 8(61), 1281-1285. https://doi.org/10.1111/head.14190 Laha, R., Jannetta, P. (1977). Glossopharyngeal Neuralgia. Journal of Neurosurgery, 3(47), 316-320. https://doi.org/10.3171/jns.1977.47.3.0316 Liu, Q., Zhong, Q., Hong, Y., He, G. (2019). ≪p>ultrasound-guided Glossopharyngeal Nerve Block Via the Styloid Process For Glossopharyngeal Neuralgia: A Retrospective Study</p>. JPR, (Volume 12), 2503-2510. https://doi.org/10.2147/jpr.s214596 Mahalingappa, A., Gupta, R., Ramakrishnan, S. (2020). Glossopharyngeal Neuralgia Due To Exposed Glossopharyngeal Nerve Post Tonsillectomy and Transoral Styloidectomy. Int J Otorhinolaryngol Head Neck Surg, 9(6), 1725. https://doi.org/10.18203/issn.2454-5929.ijohns20203582 Martinez-Alvarez, R., Martinez-Moreno, N., Kusak, M., Rey-Portolés, G. (2014). Glossopharyngeal Neuralgia and Radiosurgery. JNS, Suppl_2(121), 222-225. https://doi.org/10.3171/2014.8.gks141273 Matak, I., Lacković, Z. (2014). Botulinum Toxin A, Brain and Pain. Progress in Neurobiology, (119-120), 39-59. https://doi.org/10.1016/j.pneurobio.2014.06.001 Memon, A., Samad, A., Finan, K. (2018). A Middle Age Woman With the Episodes Of Excruciating Pain In The Neck And Ear. Arch Clin Med Case Rep, 03(02), 65-67. https://doi.org/10.26502/acmcr.96550026 Nagata, K., Tajiri, K., Ueda, A., Okuda, Y., Tokimitsu, Y., Shinagawa, K., … & Yasuda, I. (2019). Glossopharyngeal Neuralgia With Syncope Caused By Recurrence Of Esophageal Squamous Cell Carcinoma. Intern. Med., 7(58), 933-936. https://doi.org/10.2169/internalmedicine.1838-18 Nishimura, S., Kubota, K., Okuyama, S., Matsuyama, J., Kazama, K., Tomii, M., … & Watanabe, K. (2021). Microvascular Decompression For Glossopharyngeal Neuralgia In the Semi-sitting Position: A Report Of Two Cases. Tohoku J. Exp. Med., 3(254), 183-188. https://doi.org/10.1620/tjem.254.183 O’Neill, F., Nurmikko, T., Sommer, C. (2017). Other Facial Neuralgias. Cephalalgia, 7(37), 658-669. https://doi.org/10.1177/0333102417689995 Pommier, B., Touzet, G., Lucas, C., Vermandel, M., Blond, S., Reyns, N. (2018). Glossopharyngeal Neuralgia Treated By Gamma Knife Radiosurgery: Safety and Efficacy Through Long-term Follow-up. Journal of Neurosurgery, 5(128), 1372-1379. https://doi.org/10.3171/2017.3.jns162542 Rahman, S., Singh, J., Muthusamy, R., Alam, M. (2018). The Development Of Eagle’s Syndrome After Neck Trauma. Contemp Clin Dent, 2(9), 319. https://doi.org/10.4103/ccd.ccd_870_17 Romero-Reyes, M., Salvemini, D. (2016). Cancer and Orofacial Pain. Med Oral, 0-0. https://doi.org/10.4317/medoral.21515 Souza, V., Passerini, M., Sobral, B., Baiardi, V. (2021). Clinical and Physiopathological Aspects Of The Glossopharyngeal Neuralgia. HM, 1(12), 5-11. https://doi.org/10.48208/headachemed.2021.2 Swain, B., Vidhya, S., Kumar, S. (2020). Eagle’s Syndrome Managed Successfully By Pulsed Radiofrequency Treatment. Cureus. https://doi.org/10.7759/cureus.10574 İlgüy, M., İlgüy, D., Güler, N., Bayirli, G. (2005). Incidence Of the Type And Calcification Patterns In Patients With Elongated Styloid Process. J Int Med Res, 1(33), 96-102. https://doi.org/10.1177/147323000503300110

A 65-year-old woman complained of a deep-seated aching sensation affecting the right-hand side of her face from her top jaw up to her forehead. She has suffered from the pain more or less continuously for about 4 years. There are no exacerbating or ameliorating factors. Analgesics have proved ineffective. Her GP referred her to an ENT consultant who carried out an MRI to check for sinus problems. She has also been seen by two other dentists and had root canal treatment on several teeth, two of which have subsequently been extracted. On examination, you detect no abnormalities.

So, what’s the dealio? Drumroll, please… It’s atypical facial pain! 💥🎉 The pain is constant, doesn’t get worse or better, and there are no triggers. Classic atypical vibes! 💯 We throw in an MRI just to make sure, but honestly, it’s mostly for reassurance. 🙌

Basically, it’s chronic face pain without any obvious causes. 🙅‍♀️ The diagnosis is like playing detective – ruling out other possible causes first! 🔍 This condition can be tricky since exams and tests often come back normal. 🤔 So, what’s the deal with treatment? It’s not a walk in the park! 😬 Docs try different approaches like meds, nerve blocks, physical therapy, even alternative therapies! 🌿💊 But here’s the kicker – evidence for their effectiveness is limited, and more research is needed!

RESEARCH

Atypical facial pain is a condition characterized by chronic facial pain without any identifiable structural or specific causes (Maarbjerg et al., 2016). It is often diagnosed based on the patient’s history, absence of neurological and radiological signs, and negative imaging results (Derbyshire et al., 1994). The pain is typically described as dull, aching, or nagging, and it may be continuous or intermittent (Deun et al., 2020). Atypical facial pain is considered a diagnosis of exclusion, meaning that other potential causes of facial pain must be ruled out before making this diagnosis (Deun et al., 2020).

Patients with atypical facial pain often present with normal neurological, radiological, and dental examination findings (Derbyshire et al., 1994). This can make the diagnosis challenging, as there are no specific tests or imaging studies that can definitively confirm the presence of atypical facial pain (Benoliel & Gaul, 2017). However, it is important to conduct a thorough evaluation to rule out other possible causes of facial pain, such as dental issues, temporomandibular disorders, sinusitis, and neuropathic conditions (Goel et al., 2015).

The exact etiology of atypical facial pain is not well understood. Traumatic neuropathic mechanisms are suspected to play a role in the development of the condition (Benoliel & Gaul, 2017). It has been suggested that the pain may be related to dysfunctional pain processing in the central nervous system (Weiss et al., 2017). Psychological factors, such as stress and anxiety, may also contribute to the development and maintenance of atypical facial pain (Mykletun et al., 2006).

Treatment for atypical facial pain is often challenging and may require a multidisciplinary approach. The goal of treatment is to alleviate pain and improve the patient’s quality of life. Various treatment modalities have been used, including medications, nerve blocks, physical therapy, cognitive-behavioral therapy, and alternative therapies such as acupuncture (Weiss et al., 2017; Naik et al., 2014). However, the evidence for the effectiveness of these treatments is limited, and more research is needed to determine the optimal approach for managing atypical facial pain (Weiss et al., 2017).

In conclusion, atypical facial pain is a chronic condition characterized by facial pain without any identifiable structural or specific causes. It is diagnosed based on the patient’s history, absence of neurological and radiological signs, and negative imaging results. The exact etiology of atypical facial pain is not well understood, but traumatic neuropathic mechanisms and dysfunctional pain processing in the central nervous system are suspected to play a role. Treatment for atypical facial pain is challenging and often requires a multidisciplinary approach. Further research is needed to improve our understanding of the condition and develop more effective treatment strategies.

References:

Akbaş, M., Salem, H., Emara, T., Dinc, B., Karsli, B. (2019). Radiofrequency Thermocoagulation In Cases Of Atypical Trigeminal Neuralgia: a Retrospective Study. Egypt J Neurol Psychiatry Neurosurg, 1(55). https://doi.org/10.1186/s41983-019-0092-9 Benoliel, R., Gaul, C. (2017). Persistent Idiopathic Facial Pain. Cephalalgia, 7(37), 680-691. https://doi.org/10.1177/0333102417706349 Delcanho, R., Peck, C. (2018). Neuropathic Pain: Diagnosis and Treatment From The Dental Clinic To The Multidisciplinary Pain Clinic. Aust Endod J, 2(44), 114-124. https://doi.org/10.1111/aej.12276 Derbyshire, S., Jones, A., Devani, P., Friston, K., Feinmann, C., Harris, M., … & Frackowiak, R. (1994). Cerebral Responses To Pain In Patients With Atypical Facial Pain Measured By Positron Emission Tomography.. Journal of Neurology, Neurosurgery & Psychiatry, 10(57), 1166-1172. https://doi.org/10.1136/jnnp.57.10.1166 Deun, L., Witte, M., Goessens, T., Halewyck, S., Ketelaer, M., Matic, M., … & Versijpt, J. (2020). Facial Pain: a Comprehensive Review And Proposal For A Pragmatic Diagnostic Approach. Eur Neurol, 1(83), 5-16. https://doi.org/10.1159/000505727 Foerster, Z., Kleinmann, B., Schlueter, N., Vach, K., Wolter, T. (2022). Multimodal Pain Therapy For Persistent Idiopathic Facial Pain – a Pilot Study. BioPsychoSocial Med, 1(16). https://doi.org/10.1186/s13030-022-00254-1 Forssell, H., Alstergren, P., Bakke, M., Bjørnland, T., Jääskeläinen, S. (2016). Persistent Facial Pain Conditions. Tidende, 1(126). https://doi.org/10.56373/2016-1-7 Garcia, R., Chen, Q., Posadas, E., Tran, J., Kwon, A., Qian, X. (2023). Continuous Ketamine Infusion As a Treatment For Refractory Facial Pain. Cureus. https://doi.org/10.7759/cureus.35638 Goel, R., Kumar, S., Panwar, A., Singh, A. (2015). Pontine Infarct Presenting With Atypical Dental Pain: a Case Report. TODENTJ, 1(9), 337-339. https://doi.org/10.2174/1874210601509010337 Kalyani, P., Chaudhary, M., Kumar, M. (2020). Prevalence Of Orofacial Pain Among Working Adults – a Retrospective Study. ijrps, SPL4(11), 496-502. https://doi.org/10.26452/ijrps.v11ispl4.3889 Lucas, J., Nida, A., Isom, S., Marshall, K., Bourland, J., Laxton, A., … & Chan, M. (2014). Predictive Nomogram For the Durability Of Pain Relief From Gamma Knife Radiation Surgery In The Treatment Of Trigeminal Neuralgia. International Journal of Radiation Oncology*Biology*Physics, 1(89), 120-126. https://doi.org/10.1016/j.ijrobp.2014.01.023 Maarbjerg, S., Wolfram, F., Heinskou, T., Rochat, P., Gozalov, A., Brennum, J., … & Bendtsen, L. (2016). Persistent Idiopathic Facial Pain – a Prospective Systematic Study Of Clinical Characteristics And Neuroanatomical Findings At 3.0 Tesla Mri. Cephalalgia, 13(37), 1231-1240. https://doi.org/10.1177/0333102416675618 McCartney, S., Weltin, M., Burchiel, K. (2013). Use Of An Artificial Neural Network For Diagnosis Of Facial Pain Syndromes: An Update. Stereotact Funct Neurosurg, 1(92), 44-52. https://doi.org/10.1159/000353188 Mykletun, A., Øverland, S., Krokstad, S., Bjerkeset, O., Hickie, I., Aarø, L., … & Prince, M. (2006). A Population-based Cohort Study Of the Effect Of Common Mental Disorders On Disability Pension Awards. Am J Psychiatry, 8(163), 1412. https://doi.org/10.1176/appi.ajp.163.8.1412 Naidu, J., Bhattacharya, P., Mendonsa, J., M, M., Satish, K. (2020). Multidisciplinary Management Of Chronic Atypical Facial Pain Of Psychogenic Origin: a Unique Case Report. International Journal of Clinical Pediatric Dentistry, 2(13), 196-198. https://doi.org/10.5005/jp-journals-10005-1729 Naik, P., Kiran, R., Yalamanchal, S., Kumar, V., Goli, S., Vashist, N. (2014). Acupuncture: An Alternative Therapy In Dentistry and Its Possible Applications. Medical Acupuncture, 6(26), 308-314. https://doi.org/10.1089/acu.2014.1028 Petra, N., Šarac, Z., Zovko, R., Ćurlin, M., Filaković, P. (2020). Dental Medicine and Psychiatry: The Need For Collaboration And Bridging The Professional Gap.. https://doi.org/10.31219/osf.io/a6cyg Potru, S., Singh, V. (2022). Treatment Of Persistent Idiopathic Facial Pain With High Cervical Spinal Cord Stimulation: Case Report.. https://doi.org/10.21203/rs.3.rs-2268308/v1 Rath, M., Pöllmann, W., W, K. (1993). Atypical Facial Pain–application Of the Ihs Criteria In A Clinical Sample. Cephalalgia, 12_suppl(13), 84-88. https://doi.org/10.1177/0333102493013s1218 Sanker, V., Devaragudi, S., Shariff, S., Deva, S., Mathew, R., Gupta, U. (2023). A Case Of Vagal Cephalgia As a Manifestation Of A Lung Neoplasm—a Case Report And Review Of Literature. Clinical Case Reports, 6(11). https://doi.org/10.1002/ccr3.7373 Shephard, M., MacGregor, E., Zakrzewska, J. (2013). Orofacial Pain: a Guide For The Headache Physician. Headache: The Journal of Head and Face Pain, 1(54), 22-39. https://doi.org/10.1111/head.12272 Tinastepe, N., Oral, K. (2013). Neuropathic Pain After Dental Treatment. Agri, 1(25), 1-6. https://doi.org/10.5505/agri.2013.55477 Vadhanan, P. (2022). Persistent Idiopathic Facial Pain Treated With Botulinum Toxin and Pulsed Radiofrequency Of Infraorbital Nerve: A Case Report. J Dent Anesth Pain Med, 1(22), 67. https://doi.org/10.17245/jdapm.2022.22.1.67 Weiss, A., Ehrhardt, K., Tolba, R. (2017). Atypical Facial Pain: a Comprehensive, Evidence-based Review. Curr Pain Headache Rep, 2(21). https://doi.org/10.1007/s11916-017-0609-9 Zakrzewska, J. (2016). Chronic/persistent Idiopathic Facial Pain. Neurosurgery Clinics of North America, 3(27), 345-351. https://doi.org/10.1016/j.nec.2016.02.012

A 62-year-old woman gives a history of a sharp pain lasting for a few seconds whenever she touches the skin over her lower jaw. It is making it difficult for her to carry out daily activities like washing her face or eating. The pain is confined to the left-hand side. Once an episode of pain is complete she can be pain free for about an hour, even if she touches her face in the area affected by the pain. She has been taking paracetamol at regular intervals but this has made no difference to the pain.

The patient gives a classic description including the distribution of pain, trigger zone and a refractory period after stimulation. While Trigeminal neuralgia (classical trigeminal neuralgia; CTN) is highly likely, MRI is obligatory to exclude STN and assess the possibility of DREZ compression.

Trigeminal neuralgia is a disorder characterized by paroxysms of high-intensity facial pain in the distribution of the fifth cranial nerve (Katusic et al., 1990). The treatment options for trigeminal neuralgia include both medical and surgical approaches. Carbamazepine and oxcarbazepine are the first-line pharmacological treatments for trigeminal neuralgia (Szok et al., 2019; Stefano et al., 2021). However, if these drugs fail to provide sufficient pain relief or are poorly tolerated, other medications such as lamotrigine, baclofen, gabapentin, pregabalin, and botulinum toxin type A may be considered (Stefano et al., 2021). Surgical options include microvascular decompression (MVD), which involves relieving vascular compression of the trigeminal nerve (Broggi et al., 2000). Stereotactic radiosurgery (SRS) can also be used for tumor-related trigeminal neuralgia (Kano et al., 2010). In cases where medical therapies and surgical procedures are ineffective, neuromodulation techniques may be considered (Chung & Huh, 2022). It is important to note that the choice of treatment depends on the individual patient’s condition and response to previous treatments (Perszke et al., 2022).

References:

Broggi, G., Ferroli, P., Franzini, A., Servello, D., Dones, I. (2000). Microvascular Decompression For Trigeminal Neuralgia: Comments On a Series Of 250 Cases, Including 10 Patients With Multiple Sclerosis. Journal of Neurology Neurosurgery & Psychiatry, 1(68), 59-64. https://doi.org/10.1136/jnnp.68.1.59 Chung, M., Huh, R. (2022). Neuromodulation For Trigeminal Neuralgia. J Korean Neurosurg Soc, 5(65), 640-651. https://doi.org/10.3340/jkns.2022.0004 Kano, H., Awan, N., Flannery, T., Iyer, A., Flickinger, J., Lunsford, L., … & Kondziolka, D. (2010). Stereotactic Radiosurgery For Patients With Trigeminal Neuralgia Associated With Petroclival Meningiomas. Stereotact Funct Neurosurg, 1(89), 17-24. https://doi.org/10.1159/000321187 Katusic, S., Beard, C., Bergstralh, E., Kurland, L. (1990). Incidence and Clinical Features Of Trigeminal Neuralgia, Rochester, Minnesota, 1945-1984. Ann Neurol., 1(27), 89-95. https://doi.org/10.1002/ana.410270114 Perszke, M., Egierska, D., Martynowicz, P. (2022). Trigeminal Neuralgia – Where Are We Today?. J Educ Health Sport, 9(12), 113-127. https://doi.org/10.12775/jehs.2022.12.09.015 Stefano, G., Nurmikko, T., Zakrzewska, J. (2021). Treatment Of Trigeminal Neuralgia: Pharmacological., 89-104. https://doi.org/10.1093/med/9780198871606.003.0009 Szok, D., Tajti, J., Nyári, A., Vécsei, L. (2019). Therapeutic Approaches For Peripheral and Central Neuropathic Pain. BN, (2019), 1-13. https://doi.org/10.1155/2019/8685954

A 36-year-old woman gives a 2-week history of a sharp pain lasting for a few seconds which comes on when she touches the left-hand side of her upper lip. One burst of pain can follow immediately after the preceding one. When you are taking her history, she mentions that about a month ago she consulted her GMP about a deterioration in hearing affecting her left ear.

The clinical features are strongly suggestive of Trigeminal Neuralgia. The patient’s age is a cause for concern as CTN would be extremely unusual for someone of her age. The absence of a refractory period after triggering the pain is also somewhat atypical. Therefore STN should be seriously considered. The presence of ipsilateral hearing loss raises further concerns about the possibility of a central lesion. Even if the patient were in the usual age group for CTN, this would raise the possibility of STN.

Research papers on – Latest treatment options in trigeminal neuralgia

Trigeminal neuralgia is a debilitating condition characterized by severe facial pain. The first-line treatment options for trigeminal neuralgia are pharmacological (Stefano et al., 2021). Carbamazepine and oxcarbazepine are the drugs of choice for managing trigeminal neuralgia (Szok et al., 2019; Stefano et al., 2021). These drugs are voltage-gated sodium channel blockers that stabilize hyperexcited neural membranes and inhibit repetitive firing (Stefano et al., 2021). However, they may cause sedative and cognitive side effects (Stefano et al., 2021). If the first-line drugs are ineffective or poorly tolerated, other medications such as lamotrigine, baclofen, gabapentin, pregabalin, and botulinum toxin type A can be considered (Stefano et al., 2021). Surgical interventions, such as microvascular decompression, gamma knife radiosurgery, and percutaneous rhizotomies, are available for patients who do not respond to medications or cannot tolerate them (Al-Quliti, 2015). Radiofrequency ablation is a minimally invasive procedure that has shown promising results in managing trigeminal neuralgia pain (Usman & Herbiyanto, 2022). It is important to note that treatment decisions should be based on individual patient characteristics and preferences (Stefano et al., 2021).

References:

Al-Quliti, K. (2015). Update On Neuropathic Pain Treatment For Trigeminal Neuralgia. NSJ, 2(20), 107-114. https://doi.org/10.17712/nsj.2015.2.20140501 Stefano, G., Nurmikko, T., Zakrzewska, J. (2021). Treatment Of Trigeminal Neuralgia: Pharmacological., 89-104. https://doi.org/10.1093/med/9780198871606.003.0009 Szok, D., Tajti, J., Nyári, A., Vécsei, L. (2019). Therapeutic Approaches For Peripheral and Central Neuropathic Pain. BN, (2019), 1-13. https://doi.org/10.1155/2019/8685954 Usman, N., Herbiyanto, J. (2022). Radiofrequency Ablation For Trigeminal Neuralgia Patient: a Case Report. JACR, 2(3), 342-348. https://doi.org/10.37275/jacr.v3i2.256

A 33-year-old man complains of an intense aching pain that occurs daily and lasts for about an hour. He outlines the affected area which extends upwards from his right cheek to his forehead. The episodes of intense pain have been going on for about a week. His nose feels blocked and runs when the pain is present. He experienced similar symptoms about 3 months ago which lasted for a couple of weeks and resolved spontaneously.

Pain is unilateral, severe and has occurred previously but age and duration of pain make CTN unlikely, however could be an atypical variant or STN. Associated nasal congestion and rhinorrhea is significant and not usually associated with TN. Therefore, the answer is Cluster headache, but MRI scan indicated in view of suspicion atypical or STN.

RESEARCH

There is evidence to suggest an association between cluster headache and dental problems. Patients with cluster headache often report dental or midfacial pain as a primary presentation, leading to misdiagnosis and unnecessary dental treatments (Egloff et al., 2016). In fact, a study found that many patients with cluster headache were initially examined by a dentist before being diagnosed (Peñarrocha-Diago et al., 2012). Additionally, it is not uncommon for patients with cluster headache to consult a dentist and be misdiagnosed (Byun et al., 2014). Furthermore, some individuals with cluster headache may experience cluster headache-like facial pain following dental extraction (Byun et al., 2014). However, it is important to note that the exact mechanism underlying the association between cluster headache and dental problems is still undetermined (Byun et al., 2014). Further research is needed to better understand this relationship.

REFERENCES

Byun, J., Jung, J., Choi, J. (2014). Cluster Headache-like Facial Pain Following Dental Extraction: a Case Report. Journal of Oral Medicine and Pain, 3(39), 115-118. https://doi.org/10.14476/jomp.2014.39.3.115 Egloff, C., Camelot, F., Pape, E., Scala-Bertola, J., Yasukawa, K., Clement, C. (2016). Diagnostics: Cluster Headache and Misuse Of Paracetamol. Br Dent J, 8(220), 377-377. https://doi.org/10.1038/sj.bdj.2016.279 Peñarrocha-Diago, M., Boronat, A., Peñarrocha-Oltra, D., Ata-Ali, J., Bagan, J. (2012). Clinical Course Of Patients With Episodic Cluster Headache Treated With Corticosteroids Inproximity To the Sphenopalatine Ganglion: A Preliminary Study Of 23 Patients. Med Oral, e477-e482. https://doi.org/10.4317/medoral.17578

1. 1. Slow growing = identified late 
   2. Initially, pt has asymptomatic symptoms
   3. Later develops swelling due to buccolingual expansion and come to dentist 
   4. Unilateral
   5. Mandible = posterior = Ramus/body = mc 
   6. If it occurs in anterior region = desmoplastic type = aggressive and resembles fibro osseous lesion
   7. 20% of cases seen in maxilla = can involve sinus 
   8. Epicenter = odontogenic in origin = above IAC
   9. Size = large, diffuse
   10. Borders = well defined 
   11. Internal structure =
       1. Multilocular
       2. septa are small and round = honeycomb appearance 
       3. Septa are large and round = soap bubble appearance
       4. Septa are curved and round
   12. Displace IAC inferiorly 
   13. Root resorption = Knife edge resorption
   14. Lower border of mandible = thin egg shell appearance due to aggressive expansion

1. Acute periapical abscess
   1. Swelling
   2. Vertical pain = tenderness on percussion
   3. Vestibular tenderness and obliteration = pathognomonic sign
   4. Widening of PDL = Only feature. It takes time for r/g features to develop, by that time acute has been converted into chronic
2. Chronic Periapical abscess
   1. Carious tooth 
   2. Sinus tract = pus will come out
   3. Hence, there will be a breach in the continuity of lamina dura
   4. Diffuse, ill-defined radiolucency surrounding root apex
   5. 
3. Periapical Granuloma
   1. Granuloma is made up of granulation tissue. It is formed due to new vascularizations.
   2. May or maynot be corticated
   3. Size is less than 1.5 cm in diameter
   4. Well defined
4. Periapical cyst
   1. Well defined 
   2. Surrounding corticated or sclerotic border
   3. Size is more than 1.5 cm 
5. Infected Cyst
   1. Partially well defined 
   2. Corticated border = evident only in few areas
6. PERIAPICAL CEMENTAL DYSPLASIA 2M*
   1. 
   2. Site = mandibular anteriors
   3. Teeth = vital
   4. Multifocal 
   5. Appearing as periapical radiolucency
   6. RL = initial stage
   7. Mixed = intermediate stage
   8. RO = mature stage
7. Phoenix abscess
   1. Acute exacerbated phases of chronic periapical abscess
   2. Pt complains that Every 6 months, swelling and pain
   3. Pulp is non vital
8. Lateral periodontal Cyst
   1. 
9. 
10.