Idiopathic Facial Pain Syndromes–An Overview and Clinical Implications

Abstract

Background: Idiopathic facial pain syndromes are relatively rare. A uniform classification system for facial pain became available only recently, and many physicians and dentists are still unfamiliar with these conditions. As a result, patients frequently do not receive appropriate treatment.

Methods: This article is based on pertinent publications retrieved by a selective search in PubMed, focusing on current international guidelines and the International Classification of Orofacial Pain (ICOP).

Results: The ICOP subdivides orofacial pain syndromes into six major groups, the first three of which consist of diseases of the teeth, the periodontium, and the temporomandibular joint. The remaining three groups (non-dental facial pain) are discussed in the present review. Attack-like facial pain syndromes most closely resemble the well-known primary headache syndromes, such as migraine, but with pain located below the orbitomeatal line. These syndromes are treated in accordance with the guidelines for the corresponding types of headache. Persistent idiopathic facial pain (PIFP) is a chronic pain disorder with persistent, undulating pain in the face and/or teeth, without any structural correlate. Since this type of pain tends to become chronified after invasive procedures, no dental procedures should be performed to treat it if the teeth are healthy; rather, the treatmentis similar to that of neuropathic pain, e.g., with antidepressant and anticonvulsive drugs. Neuropathic facial pain is also undulating and persistent. It is often described as a burning sensation, and neuralgiform attacks may additionally be present. Trigeminal neuralgia is a distinct condition involving short-lasting, lancinating pain of high intensity with a maximum duration of two minutes. The first line of treatment is with medications; invasive treatment options should be considered only if pharmacotherapy is ineffective or poorly tolerated.

Conclusion: With the aid of this pragmatic classification system, the clinician can distinguish persistent and attack-like primary facial pain syndromes rather easily and treat each syndrome appropriately.

Figure

Flowchart for diagnostic history in patients with primary/idiopathic facial pain CMD, craniomandibular dysfunction; CGRP, calcitonin gene-related peptide; ENT specialist: ear, nose and throat specialist; PIFP: persistent idiopathic facial pain; PIDAP: persistent idiopathic dentoalveolar pain; SUNCT: short-lasting unilateral pain attacks with conjunctival injection and tearing; SUNFA: short-lasting unilateral pain attacks with autonomic symptoms

Figure:

48-year-old patient who had teeth extracted because of left facial pain. The pain started on the upper left side of the face (in the territory of second branch of CN-V) and spread after root canal treatment, root removal and finally tooth extraction initially to the adjacent tooth and later to the ipsilateral lower jaw (III branch of CN-V). Non-surgical pain management has now been started.