Characteristics and natural disease history of persistent idiopathic facial pain, trigeminal neuralgia, and neuropathic facial pain.

OBJECTIVE: This study aimed to characterize key features, and to assess the clinical development of common nondental facial pain syndromes such as persistent idiopathic facial pain (PIFP), trigeminal neuralgia (TN), and neuropathic facial pain (NEUROP). METHODS: This is a longitudinal study in which prospective questionnaire data of patients presenting to a specialized outpatient clinic were collected from 2009 to 2019. A telephone interview was conducted with the same patients in 2020 to assess the natural disease history. RESULTS: n = 411 data sets of patients with chronic facial pain were compiled. Among these were n = 150 patients with PIFP, n = 111 patients with TN, and n = 86 patients with NEUROP. Guideline therapy had not been initiated in 38.7% (58/150; PIFP), 19.8% (22/111; TN), and 33.7% (29/86; NEUROP) patients. Of the patients with PIFP, 99.3% (149/150) had primarily consulted a dentist due to their pain syndrome. The additional telephone interview was completed by 236 out of the 411 patients (57.4%). Dental interventions in healthy teeth had been performed with the intention to treat the pain in many patients (78/94 [83.0%] PIFP; 34/62 [54.8%] TN; 19/43 [44.2%] NEUROP), including dental extractions. 11.3% (7/43) of the patients with TN had never profited from any therapy. In contrast, 29.8% (28/94) of the patients with PIFP had never profited from any therapy. Furthermore, the primary pharmaceutical therapy options suggested by national guidelines were, depending on the substance class, only considered to be effective by 13.8% (13/94; antidepressants) and 14.9% (14/94; anticonvulsants) of the patients with PIFP. CONCLUSIONS: Facial pain syndromes pose a considerable disease burden. Although treatment of TN seems to be effective in most patients, patients with PIFP and NEUROP report poor effectiveness even when following guideline therapy suggestions. In addition, unwarranted dental interventions are common in facial pain syndromes.

[Botulinus toxin in complex treatment of myofacial pain syndrome]. / Botulotoksin v kompleksnom lechenii patsientov s miofastsial'nym bolevym sindromom disfunktsii visochno-nizhnecheliustnogo sustava.

The aim of the study was to assess the efficacy of type A Botulinus toxin (BTA) in pain release by TMJ functional pain disorders. The study included 211 patients with TMJ functional pain disorder (20.4% males and 79.6% females; mean age 45.3 years). The patients underwent clinical examination and bioelectric activity assessment of masticatory muscles by electromyography (EMG). EMG specters of 20 healthy volunteers with intact dental arches served as a control. After examination BTA was injected in muscular pain trigger points. All patients had muscular hypertonus, unilateral in 88.6% and bilateral in 11.4%. EMG showed the decrease of masticatory muscle activity on affected side to mean values of 165±20 mkV (30.0%, p<0.05) and on contralateral side to 460±31 mkV (89.6%, p>0.05). BTA injections in tensed muscles released significantly muscle-induced facial pain and improved quality of life. During 6 months follow up myofacial pain disorder relapse was seen in 3 patients. The results allow recommending BTA injection in muscular pain trigger points for treatment of myofacial pain syndrome and prolonged muscle relaxation.

The pterygopalatine ganglion and its role in various pain syndromes: from anatomy to clinical practice.

The postsynaptic fibers of the pterygopalatine or sphenopalatine ganglion (PPG or SPG) supply the lacrimal and nasal glands. The PPG appears to play an important role in various pain syndromes including headaches, trigeminal and sphenopalatine neuralgia, atypical facial pain, muscle pain, vasomotor rhinitis, eye disorders, and herpes infection. Clinical trials have shown that these pain disorders can be managed effectively with sphenopalatine ganglion blockade (SPGB). In addition, regional anesthesia of the distribution area of the SPG sensory fibers for nasal and dental surgery can be provided by SPGB via a transnasal, transoral, or lateral infratemporal approach. To arouse the interest of the modern-day clinicians in the use of the SPGB, the advantages, disadvantages, and modifications of the available methods for blockade are discussed.▪

[Experience in treatment of patients with neuropathic facial pain using ziconotide]. / Erfahrungen mit intrathekaler First-line-Therapie mit Ziconotide bei Patienten mit Neuropathischen Gesichtsschmerzen.

We report on the intrathecal use of ziconotide in three patients with idiopathic facial pain after surgery of the mouth, jaw or face and one patient with neuropathic pain after damage of the lingual nerve. The therapy was successful in three patients but one patient with idiopathic facial pain had pain relief only during the test phase of ziconotide with an external pump and not after implanting the Synchromed® pump. With intrathecal morphine therapy this patient achieved good pain relief. We recommend that patients with neuropathic facial pain should be treated with ziconotide after implementation of guideline-based therapy. In the test phase the ziconotide dose should be increased by 0.6 µg/day per week after an initial dose of 0.6-1.2 µg/day to avoid side-effects.

Decreased mandibular cortical bone quality after botulinum toxin injections in masticatory muscles in female adults.

This study aimed to clarify how masticatory muscle atrophy induced by botulinum toxin (BTX) injection affects cortical bone quality of the mandible using 3D modeling technology. A total of 39 young (26.9 ± 6.0 years) and 38 post-menopausal (55.3 ± 6.3 years) females were included. Computed tomography (CT) images were obtained before and after 12 months of treatment. Predictor variables were application of a stabilization splint, and/or two times of BTX injection in the bilateral temporalis and masseter muscles within a six-month interval. Outcome variables were changes in average Hounsfield units (HU) and cortical thickness of region of interest (ROI). 3D mandibular models were reconstructed using CT images, and models were used to calculate average HU and cortical thickness of ROIs, including inferior half of the lateral surface of ascending ramus, coronoid process, and temporomandibular joint condyle. Cortical bone quality at muscle insertion site was influenced by decreased muscle thickness but seemed not to be affected by decreased functional loading. Reduced functional loading seemed to influence cortical bone quality of the condyles. These effects were more remarkable in post-menopausal females. Hence, decreased masticatory muscle thickness may lead to alterations of the mandibular cortical structures, especially in post-menopausal females.

Atypical odontalgia--a form of neuropathic pain that emulates dental pain.

In order for the neuropathic pain associated with AO to occur in the oral or facial area, a deafferentation process must be initiated as previously explained. Deafferentation happens when there is a trauma to tissues including, but not limited to, endodontic therapy, a surgical extraction or even a simple one, a deep scaling, an injurious dental injection, and even the placement of a crown. Thankfully, most patients heal uneventfully. Apparently a small percentage of patients have a genetic predisposition to deafferentation pain. In reviewing articles on this subject, there is often material about the inadvertent dental treatment of patients with AO. Many patients often have undergone numerous invasive procedures in an effort to ameliorate pain. It is not possible to read a research paper about AO without reading about the recurrent theme of either overtreatment or unnecessary treatment. Caution should be exercised when performing endodontic therapy solely for the relief of pain without objective need for such therapy. It is common for the AO patient to undergo many other irreversible dental treatments with no resolution of pain symptoms. When the dentist encounters a patient in pain for which there is no dental connection, he or she should strongly consider referring the patient to a facility or practitioner who has expertise in dealing with the non-dental source of dental pain.

[Atypical facial pains--sluder's neuralgia--local treatment of the sphenopalatine ganglion with phenol--case report]. / Nietypowe bóle twarzy--neuralgia sludera-- leczenie miejscowe--przyieganie zwoju skrzydlowo-- podniebiennego fenolem--opis przypadków.

AIM: Chronic reccuring head and facial pain can be very difficult for successful treatment. Such a pain can be in some rare cases Sluder's sphenopalatine ganglion neuralgia. The aim of the study was to obtain the pain relief by local treatment in patients with Sluder's sphenopalatine ganglion neuralgia. METHODS: We described three cases of Sluder's neuralgia among all the seventeen patients with reccuring head and face pain that were seen in our department. In all these cases 4% Xylocaine was applied intranasally, into the region of shenopalatine ganglion, behind the posterior tip of the middle turbinate four times for ten minutes. According to Kern, the diagnosis of Sluder's neuralgia was confirmed only in cases where local anesthetic block of the sphenopaltine ganglion was successful. It means the patients were pain-free for at least an hour after application of Xylocaine, so they were qualified for phenolization and 88% phenol was applied on the cotton carriers (number of the applications depended on the patient). RESULTS: The total relief of pain of different duration was obtained in all the presented cases. CONCLUSION: The relief of pain obtained by intranasal phenolization of sphenopalatine ganglion in three patients shows it could be the effective treatment of Sluder's neuralgia. The patients were totally free from the pain and accompanying symptoms like nasal obstruction, rhinorrhea, epiphora or conjunctivitis. The relief period was different but the patients were satisfied with the effectiveness and simplicity of the treatment. They did not need to take the additional medications for months and were able to continue work.

Facial neuralgias: analysis of the different types seen at Lagos University Teaching Hospital, (Luth).

OBJECTIVE: To highlight the presentations, characteristics. the difficulties in diagnosis, treatment and response to treatment types of facial neuralgias seen at Lagos University Teaching Hospital. METHODS: Twelve patients with facial neuralgias diagnosed and treated in dental clinic of the Lagos University Teaching Hospital were studies. Using strict for diagnosis, patients were categorized into: trigeminal, glosspharyngeal and post herpetic neuralgias. RESULTS: Eight patients had trigeminal neuralgia; three patients had post -herpetic neuralgia and one patient had glossopharyeal neuralgia. In six patients with Trigeminal neuralgia. mandibular branch was affected, while in the two patients maxillary branch was affected. Six patients with Trigeminal neuralgia responded to carbamazepine alone and 2 had additional drugs. The only patients with glosspharyngeal neuralgia responded to carbamazepine. One patient with post herpetic neuralgia tested positive for HIV. All the post herpetic neuralgia responded poorly to carbamezepine. CONCLUSION: Facial neuralgias are uncommon and usually present in the dental clinic. They can easily be misdiagnosed with resulting inappropriate. Correct diagnosis and treatment with carbamezepine is beneficial in majority of patients.

Orofacial neuralgia. Diagnosis and treatment guidelines.

Patients with facial pain, without overt dental disease, are often seen in both medical and dental practice. The differential diagnosis includes (a) cluster headache, in which patients have severe unilateral pains lasting 30 to 120 minutes that respond to verapamil, corticosteroids or lithium; (b) migraine, in which attacks are longer and are often accompanied by nausea and visual disturbance, and can be managed using anti-inflammatory analgesics, with or without metoclopramide, or sumatriptan, although frequent attacks are best suppressed by continuous propranolol or pizotifen; (c) trigeminal neuralgia, knifelike unilateral pains usually responsive to carbamazepine; and (d) temporal arteritis, a steadier pain very responsive to corticosteroids. There is no evidence that continuous 'idiopathic facial pain' is a result of malocclusion (i.e. the way in which the teeth fit together), and its aetiology remains obscure, although there is some biochemical evidence linking it to depression. Many patients respond to simple analgesia and firm reassurance from the physician, although antidepressant therapy (e.g. nortriptyline or dothiepin) is often of great value.

A preliminary comparison of the efficacy and tolerability of botulinum toxin serotypes A and B in the treatment of myofascial pain syndrome: a retrospective, open-label chart review.

BACKGROUND: Myofascial pain syndrome (MPS) is characterized by acute or chronic regional muscle pain associated with single or multiple trigger points within taut bands of muscle. Botulinum toxins have clinical utility when sustained focal muscle relaxation is required and may be a useful addition to the treatment armamentarium for MPS. OBJECTIVE: The purpose of the present article was to compare the efficacy and tolerability of botulinum toxin serotypes A and B (BTX-A and BTX-B) in the treatment of MPS. METHODS: This was a retrospective, open-label, single-center chart review. Charts of all patients who received either BTX-A or BTX-B for MPS between January and November 2001 were included in the review. Patients rated the intensity of their pain on a visual analog scale (VAS) from 0 = no pain to 10 = worst pain imaginable before and after receiving BTX-A or BTX-B. RESULTS: The charts of 91 patients (74.7% female, 25.3% male; mean [SD] age, 47 [10.2] years) who received BTX-A (n = 56; mean dose, 256.9 U; range, 100-600 U) or BTX-B (n = 35; mean dose, 9000 U; range, 2500-20,000 U) were included in this retrospective review. Patients who received BTX-A had significantly greater mean reductions in VAS pain scores compared with those who received BTX-B (mean reduction, 2.7 vs 1.8, respectively; P < 0.001). Patients who received BTX-A also reported significantly longer durations of pain relief compared with those who received BTX-B (4.5 vs 2.7) months; P < 0.001). Eight of 56 patients (14.3%) in the group that received BTX-A reported mild adverse events that included flulike symptoms, injection-site pain, and weakness of the neck muscles. Seven of 35 patients (20.0%) in the group that received BTX-B reported adverse events that included mild flulike symptoms, dry eyes, severe visual disturbances, and severe dry mouth. CONCLUSION: Patients with MPS who received BTX-A reported significantly greater reductions in pain for longer durations compared with those who received BTX-B. No patients who received BTX-A experienced severe systemic adverse events, compared with 4 patients who received BTX-B. The results of this comparison are consistent with the US Food and Drug Administration-approved labeling indicating that BTX-A is not interchangeable with any other botulinum toxin in terms of biological activity.

Clinical experience with the use of peripheral vasodilator in oral disorders.

Conventional therapies practised in the treatment of asymptomatic neuralgia, oral submucous fibrosis and paraesthesic numbness, are empirical and symptomatic in nature. These are usually prolonged and may be inadequate, impractical with complete or incomplete remissions associated with or without relapses. High dosages of drugs administered for longer duration, are also not infrequently without side-effects. With these problems in view, the clinical use of nylidrin hydrochloride a peripheral vasodilator, was experienced for over 10 years. Irrespective of age, sex and status, 97 cases were randomly extracted from the hospital and oral surgery clinical records. The projected sample included 33 cases of asymptomatic neuralgia, 58 cases of oral submucous fibrosis and 6 cases of numbness. Neuralgia, where mean age was 50 years, was treated with nylidrin hydrochloride, vitamin B-complex and carbamazepine. Oral submucous fibrosis where mean age was 38 years, was treated with nylidrin hydrochloride, vitamins A,E,B-complex, iodine, placental extract, local and systemic corticosteroids and physiotherapy. Paraesthesic numbness, following iatrogenic or accidental trauma to the affected nerve, was treated with nylidrin hydrochloride and B-complex therapy. Peripheral vasodilator administered in all 97 cases, initially contained low divided doses, which steadily were increased or decreased as per individual response. There were reportedly no side-effects, except complaints of flushingly warm skin. Supportive therapy with antibacterials, tranquilizers and analgesics, along with minor dental surgery, were given as and when required. The success rate was 72.16% in total, while individually it varied from 84.85% in neuralgia, 62.07% in oral submucous fibrosis and 100% in numbness.(ABSTRACT TRUNCATED AT 250 WORDS)

Headache and facial pain in children and adolescents.

Headaches commonly affect children and adolescents. Proper diagnosis and management is dependent on thorough history taking and a comprehensive physical and neurological examination. Additional diagnostic testing is indicated in some cases. The second edition of the headache classification system by the International Headache Society has recently become available. The classification system is primarily based on adults, but we discussed the subtle distinctions made regarding children. In addition to the primary headache types of migraine, tension-type, and cluster headaches, we discussed selected symptomatic headaches. Emphasis was placed on migraine and tension-type headaches because these are the most common pediatric headache types. We briefly discussed genetic aspects of headaches. Genetic factors have been hypothesized for chronic tension headache and other forms of migraine, but genetic linkage has only been established for familial hemiplegic migraine. We reviewed the nonpharmacologic and pharmacologic therapies, including abortive and prophylactic medications for various age groups. Unlike headaches, facial neuralgias are rare in otherwise healthy children. Facial pain may be neurological, vascular, or dental in origin. We focused on trigeminal neuralgia, glossopharyngeal neuralgia, occipital neuralgia, and Bell's palsy as neurological causes of facial pain in children.

Understanding placebos in dentistry.

The placebo effect is capable of relieving pain and affective disorders. The mechanism of placebo action is pharmacologic and psychologic, being related to the patient-practitioner relationship and the clinical treatment setting. The placebo effect also occurs with all active or real treatments. The effects of placebos in management of orofacial pain and MPD syndrome have been demonstrated. Placebo effects may account for a third to two-thirds of responses in mandibular dysfunction. Many treatments suggested for management of pain may be acting solely as placebos. Health professionals active in management of pain should understand and use the placebo effect to improve patient care.

[Trigeminal neuralgia and other facial pain--diagnosis and therapy]. / Trigeminusneuralgie und andere Gesichtsschmerzen--Diagnostik und Therapie.

The hallmark of trigeminal neuralgia is the abrupt onset of short pains in the face or in a part of the face, described as stabbing, lightning or electric shocks. Attacks are often triggered by cutaneous stimuli to the face or the oral cavity, which may be such minor activities as talking, chewing, brushing the teeth, or even wind blowing on the face. As a result, facial hygiene as well as a good diet may be neglected. Although 1% of the patients may eventually develop the disorder bilaterally, pain does not cross the midline during any single episode. The clinical course is characterized by exacerbations and remissions, but as the disorder progresses, remissions become shorter and exacerbations more severe. Carbamazepine is the most powerful drug for this condition, but side effects may occur. Neurosurgical treatment may then be considered; the different techniques and approaches are mentioned. Other pain conditions in the face will be reviewed. If the trigeminal neuralgia may be considered as a nerve irritation, like the glossopharyngeal neuralgia and the nasociliary neuralgia, nerve lesion may elicit neurogenic or neuropathic pain, characterized by chronic burning pain; post-zoster pain, iatrogenic and posttraumatic pain illustrate this condition. Cluster headache (Horton neuralgia), Sluder's neuralgia and auriculotemporal neuralgia may be related to a dysfunction of the autonomous nervous system. Finally, lesion in the mandibular joint may cause unilateral facial pain.

[Essential facial neuralgia with bilateral involvement: apropos of a case seen at the Cité Verte Hospital in Yaoundé]. / Névralgie faciale essentielle à évolution bilatérale: à propos d'un cas observé à l'Hôpital de la Cité Verte à Yaoundé.

Despite the fact that essential facial neuralgia is a well known clinical entity as relates to its evolution and treatment, its physiopathology is still a controversial issue. The form with bilateral evolution that we observed and that we are reporting here is extremely rare and its physiopathology is even more controversial. The case of our patient is all the more complicated in that, the pain topography is limited to the right to a sensitive region of the trigeminal nerve (superior maxillary) and to the left to the region of the mandible (inferior maxillary) A similar disease evolution is not described so far in the present literature of the disease. We have therefore seized this opportunity to out line the possible causes of faulty diagnosis in order that essential facial neuralgia should not be labelled as facial pain of tumoral, vascular or other origin.

Toxina botulínica tipo A nas DTM musculares: há eficácia? / Botulinum toxin type A in muscle TMD: There's effectiveness?

Os objetivos dessa revisão da literatura foram verificar a eficácia da toxina botulínica tipo A (BTX-A) na diminuição da dor em indivíduos com DTM e identificar os parâmetros ideais para o local, número de aplicações, dosagens e tempo de duração. Foram selecionados 19 artigos das bases de dados do Google Acadêmico e PubMed, que incluíram 14 artigos de pesquisa clínica e 5 de revisão sistemática. Foi possível concluir a respeito da toxina botulínica que os músculos indicados para a aplicação são principalmente os masseteres e os temporais, podendo ser aplicado também nos músculos pterigoideos, lateral e medial, digástrico e platisma. Os locais de escolha são os que apresentam maior volume e sensibilidade à palpação (pontos-gatilho) ou maior atividade eletromiográfica em repouso. As dosagens variam de um total de 10U a 400U de BTX-A por indivíduo, sendo distribuídas pelos músculos indicados. A BTX-A, em geral, é aplicada em dose única, porem alguns autores preconizam uma segunda aplicação se a primeira não fez o efeito esperado. O efeito da toxina botulínica sobre os músculos e a dor, em geral, tem duração variada, sendo relatado desde 3 a 4 semanas até 3 a 5 meses. A maioria dos estudos observou à eficácia da BTX-A na diminuição da dor de indivíduos com DTM. Porém é necessário que mais estudos clínicos randomizados, duplo cegos, multicêntricos e controlados sejam realizados para que a eficácia da BTX-A seja comprovada e para que um protocolo de atendimento seja realizado.(AU)

The objectives of this literature review were to verify the efficacy of botulinum toxin type A (BTX-A) in reducing pain of TMD patients and to identify the optimal parameters for the location, number of applications, dosages and duration. We selected 19 articles from Google Scholar and PubMed databases that included 14 articles of clinical research and 5 systematic reviews. It was concluded about BTX-A that the muscles appropriate to the application are mostly masseter and temporal and can also be applied in the pterygoid muscle lateral and medial, digastric and platysma. The choices of locations are those who have higher volume and sensitivity to palpation (trigger points) or higher EMG activity at rest. Dosages vary from a total of 10U to 400U of BTX-A by individual, being distributed by the indicated muscles. BTX-A in general is applied in a single dose, but some authors recommend a second application if the first did not make the expected effect. The effect of BTX-A on muscle and pain in general has varying duration, being reported from 3 to 4 weeks for 3 to 5 months. Most studies have noted at the effectiveness of BTX-A in patient pain reduction DTM. However more randomized, double-blind, multicenter, controlled clinical trials needs to be carried out so that the effectiveness of BTX-A could be confirmed and a management protocol, stabilished.(AU)

[Managing patients with chronic orofacial pain in the outpatient departments of dental and maxillofacial surgeons. Results of a survey]. / Versorgung von Patienten mit chronischem orofazialem Schmerz. Ergebnisse einer Befragung in ambulanten zahnärztlichen und Mund-Kiefer-Gesichts-Chirurgie-Einrichtungen.

OBJECTIVE: The aim of this study was to evaluate the significance attributed by dental and maxillofacial surgeons to the ambulatory management of chronic orofacial pain syndromes. MATERIALS AND METHODS: All the dentists and oral and maxillofacial surgeons working in ambulatory capacities within a county of the German Rhine Area were asked to answer a questionnaire on demographic data, diagnostic and therapeutic principles, and the use of analogue scales, surgical, minimal-invasive or pharmacological procedures. RESULTS AND DISCUSSION: Seventy-two ambulatory institutions reported 985 patients suffering from temporomandibular disorders (40.2%), headache-syndromes associated with facial pain (18.2%), and atypical odontalgia respectively phantom tooth pain (17.0%). Patients were characterized by prior dental treatment or trauma (41.9%), female gender (66.8%), middle age (81.1%, 20-60 years), very frequent change of therapists (54.6%) and long-term perseverance of pain (61.1% >6 months). Only 7% of therapists used visual or numerical analogue scales to assess pain intensity. Therapeutic procedures consisted of analgesics (15.7%) and further surgical procedures (47.7%). Pain therapists were rarely involved (12.5%). CONCLUSION: Dental and maxillofacial surgeons should apply an interdisciplinary and multimodal approach to diagnostics and therapy at an earlier stage in order to optimize the pain management of patients with chronic orofacial pain.

Sluder's sphenopalatine ganglion neuralgia--treatment with 88% phenol.

Patients who experience chronic recurring head and face pain present a diagnostic and therapeutic challenge. Treatment options for Sluder's neuralgia, an uncommon cause for recurring head and face pain, are controversial. We reviewed the outcomes of patients who underwent intranasal phenolization of the sphenopalatine ganglion for the treatment of Sluder's neuralgia. Eight patients were treated with intranasal cauterization of the sphenopalatine ganglion between 1990 and 1995. Patients were treated an average of 13 times. Overall, patients experienced a 90% decrease in head and face pain for an average of 9.5 months duration. Interestingly, the patients described recurrent pain as less severe, less frequent, and of shorter duration. Intranasal phenolization of the sphenopalatine ganglion appears to be a safe and effective, although temporary, treatment for patients with Sluder's neuralgia. This article will review the symptomatology, differential diagnosis, and phenolization technique for treatment of Sluder's neuralgia.