Maxfacts

Given that many facial pain conditions belong to the category of idiopathic (unknown cause) pain, it will not come as a surprise that various attempts to treat some of these chronic pain conditions may include an element of trial and error. Fortunately, even if highly unpleasant and immensely irritating, most of these conditions do not represent life-threatening circumstances and thus there is room to try different options – and hope for the best along the way.

Idiopathic / atypical facial pain

Often the ill-defined nature of idiopathic / atypical facial pain will have resulted in unnecessary dental work. The treatment / management of the condition is aiming to control the pain, usually by use of medication.

In light of the association of atypical facial pain with neuroses, particularly depression, and the possibility of a psychogenic basis, emphasis has been placed on the use of antidepressant therapeutic agents as the main analgesic medication option. Some tricyclic antidepressants have been shown to be effective in reducing painful symptoms in doses far below those used in depression. Another option can be the analgesic agent pregabalin, which is used to treat neuropathic pain and convulsions (seizures) and has a secondary effect in reducing anxiety.

Trigeminal neuralgia

Usually, trigeminal neuralgia responds well to the drug carbamazepine (used to treat epilepsy, diabetic neuropathy and neuropathic pain). Other drugs known to have an effect include the analgesics gabapentin or pregabalin, the antidepressant amitriptyline and a muscle relaxant such as baclofen.

Carbamazepine is usually the drug of choice with approximately 70 % of patients reporting significant relief. Side effects include drowsiness, confusion, vertigo, nausea, vomiting, aplastic anaemia, and liver failure. The lowest dose required to control the pain, and regular monitoring of liver function and blood plasma are in order. It is also advisable to withdraw this kind of medication slowly to prevent acute psychosis associated with abrupt withdrawal. Despite this apparent array of unwanted effects for most patients with trigeminal neuralgia this drug is a godsend.

If medical therapy fails to bring about relief of pain, invasive techniques such as cryotherapy, peripheral nerve blocks, percutaneous destruction of the trigeminal ganglion may be indicated.

Open neurosurgical procedures such as microvascular decompression of the root of the trigeminal nerve are an excellent option where it has been demonstrated that a microvascular loop compresses the trigeminal nerve root; these cases are comparatively rare.

Other facial pain syndromes

Odontalgia

• Protecting the area from pain-triggering local stimuli
• Simple analgesics

Pulpitis

• Extirpation (removal) of the pulp, root canal treatment, or tooth extraction
• Combination of analgesics such as non-steroidal anti-inflammatory drugs (NSAIDS) , paracetamol and codeine

Periapical periodontitis and abscess

1. Extirpation or tooth extraction
2. Antibiotics
3. Combination of analgesics such as non-steroidal anti-inflammatory drugs (NSAIDS) , paracetamol and codeine

Atypical odontalgia

• Avoidance of unnecessary dental treatments, such as pulp extirpations or tooth extraction
• Counselling and cognitive behavioural therapy
• Antidepressants and /or phenothiazines (antipsychotic drugs)

Glossodynia and sore mouth (also known as ‘burning mouth syndrome’ or ‘oral dysaesthesia’)

• Vitamin B, iron and / or folic acid supplements to eliminate any deficiencies
• If nothing else helps, alpha-lipoic acid (a vitamin-like antioxidant that is found in many vegetables) as a supplement may be worth a try
• Antidepressants

Cracked tooth syndrome

• Dental work to repair cracked portion of tooth
• Simple analgesics

Trigeminal herpes zoster

• Acute phase: stellate ganglion (nerve) blocks using local anaesthetic such as bupivacaine for severe pain
• Pregabalin and / or tricyclic antidepressants for systemic pain control
• Capsaicin cream applied locally
• Transcutaneous electrical nerve stimulation

Postherpetic neuralgia

• Treatment options as for trigeminal herpes zoster (see above), may include cognitive behavioural therapy

Secondary neuralgia from central nervous system lesions

• Treatment involves treatment of the underlying cause(s)

Glossopharyngeal (affecting tongue and throat (pharynx)) neuralgia

• Application of local anaesthetic to trigger point relieves the pain
• Some symptom relief from carbamazepine and other drugs used for the treatment of trigeminal neuralgia (see above) but not as effective