One of the most recognizable paintings in the Western world is Edvard Munch’s The Scream. The subject of the piece, the screaming man, is pictured with his mouth wide open and his hands clasped against the sides of his face. For anyone who’s ever experienced chronic orofacial pain (pain in the mouth, jaws or face), this painting may seem eerily illustrative of their suffering. But those with orofacial pain don’t have to live in agony. Most common facial pain syndromes are short-lived and treatable. There are more severe types of orofacial pain, but research into those disorders is promising.

Causes of OROFACIAL PAIN

The No. 1 cause of facial pain is a toothache. Injuries to the face are also common sources of pain. Most cases of dental- and injury-related orofacial pain are acute and respond well to treatment, says John K. Neubert, DDS, PhD, associate professor in the departments of orthodontics and neuroscience at the University of Florida. For example, when it comes to tooth decay, common dental procedures fillings or root canals—sometimes followed by a short course of pain medication—are usually enough to address the issue and resolve the pain.

Other types of orofacial pain are more complex and diffcult to treat. One of the most notable examples is trigeminal neuralgia. Sometimes referred to as “the suicide disease,” trigeminal neuralgia can cause severe jolts of excruciating pain. “It’s a horrible disease,” says Dr. Neubert. “It’s not something you’d wish on your worst enemy.”

Because of the severity of trigeminal neuralgia, re-searchers like Dr. Neubert are interested in learning more about it—with the ultimate goal finding effective treatments and pain management therapies. Dr. Neubert is leading a team of researchers at the University of Florida in the study of trigeminal neuralgia. “It’s an exciting project that uses brain imaging to study patients with trigeminal neuralgia,” he says. “Because pain in the face and in the body have a lot of similar mechanisms, we’re hopeful that this research will not only help us in treating trigeminal neuralgia, but that it can also be applied to other areas of pain research.”

On the spectrum of orofacial pain—ranging from toothaches and injuries at the acute, treatable end and trigeminal neuralgia at the chronic, severe end—there are a variety of other pain syndromes that fall in between. They include:

TMJ

A common type of facial pain is TMJ [temporomandibular joint disorder]. It’s a complex disease, affecting both muscles and joints in the face. The exact causes of TMJ are varied, but the pain associated with the disorder can often be remedied with nonpharmaceutical self-care treatments, pain medication or, sometimes, surgery.

HEADACHES

Tension headaches and certain types of migraine headaches can cause pain in the face. Dr. Neubert says that when he did his residency in facial pain management, many of the cases he saw were related to headache pain.

REFERRED PAIN

Referred pain is a sensation in which pain is felt at a different site than where it originates. It’s common for referred pain from the neck and shoulder regions to be felt in the face—or for pain in one region of the face to be felt elsewhere in the face. For example, pain around the sinuses or chewing muscle can be felt in the teeth. A serious source of referred pain is a heart attack, warns Dr. Neubert. “It’s not uncommon for someone having a heart attack to complain of pain in the lower jaw,” he says. “If someone is having both chest pain and orofacial pain, they should see a doctor immediately.”

RARE DISORDERS

A couple of rare causes of orofacial pain are Sluder syndrome and Eagle syndrome. Sluder syndrome is a type of neuralgia that causes pain around the nose. It’s so rare that Dr. Neubert says he’s never seen a case of it. Eagle syndrome occurs when the stylohyoid ligament becomes calcified. While uncommon, it’s not a severe pain disorder. Dr. Neubert says that it’s easily treated with a straightforward surgical technique.

Orofacial pain disorders can usually be into one or more types of pain: nerve pain, joint pain and muscle pain, explains Dr. Neubert.

Trigeminal neuralgia is a nerve disorder. Sufferers of the condition often describe the pain as similar to an electrical shock. “It can feel like a lighting bolt going off in the face,” says Dr. Neubert.

TMJ, on the other hand, can lead to both muscle and joint pain. “The muscle problems tend to lead to an aching sensation,” says Dr. Neubert. “It’s kind of like when your leg muscles get sore after a long run—it’s that kind of sensation.“

The joint pain can have both achy and sharp components,” he continues. “The clicking and pop-ping that TMJ patients tend to experience are often associated with a very quick, sharp pain.”

face2Managing OROFACIAL PAIN

When the cause of orofacial pain is obvious, the treatment is typically straightforward. But, unfortunately, many causes of pain in the face are unknown. “We don’t know what causes most of these things,” says Dr. Neubert. “There can be a lot of different mechanisms for a lot of different people. There are certainly factors that can be involved, such as genetic factors or a history of trauma. There are just a lot of things that make this kind of pain very individualized.”

Often, people with orofacial pain present first to a dentist. Either they seek out the advice of their dentist when pain in the mouth or face arises, or they wait to bring up their symptoms during a routine dental exam. Most dentists are trained to examine patients for facial diseases, and if there is an obvious pathology associated with facial pain, it will very likely show up on an X-ray. Dr. Neubert says that the panoramic X-rays conducted at dentist offices are often a good first-step screening measure for determining the cause of orofacial pain. If the X-ray doesn’t show an obvious cause for orofacial pain—or if the symptoms described don’t indicate a common facial pain disorder (such as TMJ)—the dentist may then refer the patient to a pain management specialist for further investigation.

“Dentists are very good at identifying sources of dental pain,” says Dr. Neubert.“ And dental treatments are very good at addressing those things. But sometimes the pain is complex and the source isn’t obvious. For example, trigeminal neuralgia is not something that’s going to show up on an X-ray, and it will cause severe pain and require complex pain management.”

Integrative Therapies & REVERSIBLE, CONSERVATIVE CARE

When it comes to pain therapies prescribed by dentists, Dr. Neubert says reversible conservative care is usually what’s most utilized. “Particularly if it’s a pain disorder that we can’t find the cause of, we want to make sure that we aren’t exacerbating the situation,” he says. “That’s why we want any pain treatment to be easily reversible.”

These treatments typically involve a combination of physical therapy and pharmaceutical treatments, which can include anti-inflammatories and pain medications.

Psychological support is also essential, especially when it comes to the more debilitating disorders, like trigeminal neuralgia. “A lot of people in pain suffer from anxiety, depression and other psychological disorders, so we like to address those things with practices like biofeedback and relaxation techniques,” says Dr. Neubert. “Otherwise, a vicious cycle starts to occur. The person in pain becomes depressed. The depression can then increase chronic pain. As a result, the person then experiences more depression. It just goes around and around, so it’s important to address that.”

Mouth Guards, STRATEGIC CHEWING & PREVENTION

As for pain treatments specific to orofacial pain, one component that’s often incorporated is the use of a mouth guard. If the person is experiencing joint pain in the jaw, a soft diet may also be recommended. Unlike other joints in the body, the TM joint is impossible to rest completely because it’s connected by the lower jaw, explains Dr. Neubert. You can’t stop eating or talking, so it’s important to go easy with these activities, particularly by avoiding foods that require a lot of chewing.

One seemingly common-sense approach that often backfires on patients is strategic chewing. “If your right jaw hurts, you may start chewing on your left side, but that may actually cause more pain,” says Dr. Neubert. “By chewing on the left side, it actually crams the right jaw up against the bone even harder. So you’re actually loading the side that’s bothering you. For this reason, I always recommend that TMJ patients try to chew evenly and consistently, even if the pain on one side is pretty acute.”

Preventive dental care is also extremely important when it comes to orofacial pain. Regular brushing, flossing and dental cleanings can help reduce cavities and, therefore, also reduce the likelihood of painful complications. “Left untreated, cavities can quickly escalate to some pretty severe problems, including tooth loss, infection of the jaw and other issues,” says Dr. Neubert. “Proper dental care isn’t just good hygiene, it can help you avoid some painful situations down the road.” {PP}