What Is Atypical Facial Pain?
Atypical Facial Pain ‘Atypical’ pain is a diagnosis of exclusion after other similar conditions have been investigated and eliminated, hence the reason why it is diagnosed late in the day at frustration for many patients. But it is idiopathic and is characterized by chronic, constant pain without any apparent cause in the face or brain.
Cause Atypical odontalgia or phantom tooth pain is a variation of atypical facial pain where intense discomfort is associated with a particular tooth or group of teeth with no obvious dental cause on examination, special tests or on a radiograph.
Atypical facial pain syndrome is more common in women than in men with most patients aged between 30 and 50 years. The most commonly affected area is the maxillary region although any area of the face can be involved. Clinical presentation of Atypical Facial Pain is very variable in its presentation but mostly described by a continuous, daily pain of variable intensity with no cause. Typically, the pain is deep ( unlike trigeminal neuralgia) and poorly localized and is described as dull and aching. It does not awaken the patient from sleep.
Characteristics At initial onset the pain may be confined to a limited area on one side of the face, while later in the day, it may spread to involve a larger area. Atypical odontalgia is characterized also by a continuous, dull, aching pain of moderate intensity in apparently normal teeth or endodontically treated teeth and occasionally after an extraction or post-extraction sites. Atypical odontalgia is a variation localised to a tooth. It is not usually affected by testing the tooth with cold, heat or electric stimuli. Moreover, the toothache frequently remains unchanged for months or years hence the differentiation of atypical odontalgia from pulpal/periodontal origin dental pain.
Treatment Many a dentist will end up extracting the tooth but the pain remains in the underlying alveolar ridge. Occasionally, the pain may spread to adjacent teeth, especially after extraction of the painful tooth or after an unnecessary extraction. The lack of a demonstrable organic/physical cause will cause a high level of anxiety and depression among these patients. Often, they will see multiple dentists and become increasingly disillusioned by the advice received. Genetic factors could be important in some patients with chronic facial pain as their nerves are susceptible to damage from minor insults that would not normally produce chronic pain and this can be seen in patients where this type of pain follows a successful minor/easy procedure such as a tooth extraction. There are no specific tests that can confirm the diagnosis of idiopathic/atypical facial pain and is based on not finding any other cause.
Treatment of Atypical or Idiopathic facial pain is managed by a variety of ways including medication, psychological treatments and physical treatments such as acupuncture or TENS nerve stimulation. But many of these patients have a poor response to all treatment options and will do the rounds having had consultations with a lot of specialists, multiple ineffective alternative therapy treatments, and even surgical explorations at considerable costs and considerable stress to their partners/family. As mainstream treatments can be ineffective a different approach is to accept the pain but try to improve patients quality of life as well as trying to ease some of the pain often with an increase in mood, activity and social contact. Analgesics will not work for atypical facial pain. Pain relief is mainly through the use of tricyclic antidepressant and anti-epileptic drugs intended normally for use in the treatment of depression or epilepsy but have proved very helpful in these patients. The tricyclic antidepressants such as amitriptyline and nortriptyline are often generally helpful in both reducing pain experience and improving mood and coping with the associated depression including some placebo effect that something is being done. Interestingly, newer antidepressant drugs such as fluoxetine and paroxetine seem less effective. However, the newer antiepileptic medications such as gabapentin and valproate are very successful also in treating neuropathic pain. Education, physical therapy, psychological/CBT/NLP counselling, and alternative pain management strategies, such as acupuncture and TENS/biofeedback, may also be useful in holistic patient care. Surgical procedures are rarely effective and can aggravate the condition and may lead to a painful permanent disabling facial numbness. Atypical odontalgia patients may undergo many unsuccessful unnecessary dental procedures before the correct diagnosis is made. Once the diagnosis is made, dental treatment aimed to relieve the pain is not advised since it can result in further deterioration of the patient's dentition without any beneficial effect on the pain.
Gabapentin combined with tricyclic antidepressants can make the extremes of the pain less severe but must be used continuously and not only during an acutely painful episode.