Orofacial pain is pain or discomfort in the mouth or face, which includes the eyes, nose, forehead, cheeks and chin.

Conditions affecting teeth, mucous membranes, bones, joints, muscles or nerves, ranging from migraines to TMJ disorder, can cause orofacial pain. Psychological conditions associated with orofacial pain are also numerous and include anxiety and mood disorders. Occasionally a cause of orofacial pain cannot be determined.

To diagnose the cause of orofacial pain, a physician will obtain a medical history and conduct a physical examination. Patients may be asked to complete a pain assessment form. Other tests may be performed including x-rays, CAT scans and an MRI.

The type of treatment a patient may receive will depend upon the cause of the pain. Common treatment options include dentistry, medications, electrical therapy, thermotherapy and acupuncture.

Orofacial pain refers to pain or discomfort that is experienced in the mouth or face. Areas of the face include the eyes, nose, forehead, cheeks and chin. Some pain in these areas, however, could also be caused by dental pain, which originates in the teeth or jaws.

Orofacial pain may be acute (short–term) or chronic (lasting longer than three months). It may occur in different parts of the face such as teeth, periodontal tissues, salivary glands, paranasal sinuses, eyes, nose, ears, temporomandibular joints of the jaw (TMJ disorder), bones, muscles, nerves or blood vessels.

Orofacial pain may become particularly problematic for individuals because it affects a person’s ability to meet basic human needs such as eating and drinking, swallowing, smiling and communicating.

Not only can orofacial pain be a symptom of certain disorders, but it can also be an indication of an underlying disease elsewhere in the body.

Some types of orofacial pain are related to problems with nerves.  Cranial nerves are 12 pairs of nerves that emerge from the brainstem instead of the spinal cord that, among other roles, provide sensation to the mouth and face, and the cervical plexus nerves are nerves that supply sensation to the back of the head and some neck muscles.

The cranial nerves are known by name and Roman numeral. The following is a list of these nerves, along with their primary functions:

• I. Olfactory - smell
  
  
• II. Optic - vision
  
  
• III. Oculomotor – most eye movements
  
  
• IV. Trochlear – some eye movement
  
  
• V. Trigeminal – facial sensation
  
  
• VI. Abducens – some eye movement
  
  
• VII. Facial – facial expression and some sense of taste
  
  
• VIII. Acoustic (also known as the auditory or vestibulocochlear nerve) – hearing and balance
  
  
• IX. Glossopharyngeal – pharyngeal muscles and some sense of taste
  
  
• X. Vagus – parasympathetic sensation to internal organs
  
  
• XI. Spinal accessory – neck muscles
  
  
• XII. Hypoglossal – most movements of the tongue

The facial nerve is a major motor nerve that controls muscles of facial expression and supplies sensation to the scalp.  Some taste sensations and secretions of the mouth are also controlled by it.  Another major cranial nerve is the trigeminal nerve, which provides sensation to most of the face and head via three main branches. Because there is some interface between these nerves, certain types of dental pain can result in referred pain throughout the face and side of the head.  If these nerves are irritated or there is a loss of blood supply to any of the nerves, orofacial pain may result.

Many conditions may cause orofacial pain. Orofacial pain may be the result of problems in the:

• Mouth or teeth (odontogenic pain)
  
  
• • Dental disease. Dental diseases are one of the most common causes of orofacial and dental pain. Among common types of dental disease are tooth decay, gingivitis (inflammation of the gums, the early form of periodontal disease), pulpitis (inflammation of the dental pulp), chipped teeth and pericoronitis (a soft tissue infection around the crown of an erupting tooth).
    
    
  • Facial trauma. The orofacial area, especially the mouth and teeth, is susceptible to injuries from automobile, motorcycle and bicycle accidents; sports injuries; and other types of blunt trauma.
    
    
  • Mouth sores. Infections such as thrush and injuries such as biting the inner cheek are frequent causes of oral sores. Common types of mouth sores include cold sores and canker sores.  Infections from HIV or fungal diseases may also lead to oral sores.
    
    
  • Burning mouth syndrome. Condition characterized by a burning sensation of the tongue or lips. It can be caused by chronic infections, reflux of stomach acid, blood diseases or hormone imbalances.
    
    
  • Bruxism. Medical term for grinding, gnashing or clenching the teeth. In most cases, it is mild but it can be frequent and lead to jaw disorders, headaches and damaged teeth.
    
    
  • Oral cancer. Cancer of the mouth can cause orofacial pain. Treatments for oral cancers such as radiation therapy can also result in orofacial pain by causing mucositis (mouth inflammation and sores).
    
    
• Blood vessels (vascular pain)
  
  
• • Facial headaches. Migraines, cluster headaches, tension headaches and other types of headaches can lead to pain in the face as well as the head.

• • Carotodynia. Characterized by pain caused by pressure on the carotid arteries, which supply blood to the head and neck. The carotid arteries can also be tender during a migraine.
    
    
  • Temporal arteritis. Inflammation of the temporal arteries, which are located along the side of the head. This can lead to headaches, difficulty chewing and may lead to visual impairment if left untreated.
    
    
• Muscles, joints or bones (musculoskeletal pain)
  
  
• • TMJ disorder. Acute or chronic inflammation of one or both of the temporomandibular joints connecting the jaw to the skull. The potential causes include wear and tear, arthritic inflammation, injury, stress, some dental appliances or grinding of the teeth.
    
    
  • Sinusitis. Inflammation of the air–filled cavities (sinuses) in the dense portions of the bones of the skull.
    
    
  • Injuries to the cervical spine or other parts of the neck or skull, such as whiplash or fractures. These can cause referred pain to the orofacial region if the cervical nerves are damaged.
    
    
  • Osteomyelitis. Acute or chronic bone infection. Risk factors for osteomyelitis include diabetes and intravenous (I.V.) drug abuse.
    
    
  • Osteonecrosis. Death of bone tissue. Deterioration of the jawbone has in rare cases resulted from use of bisphosphonates, medications commonly used to treat osteoporosis.

• Nerves (neurogenic pain)
  
  
• • Postherpetic neuralgia. Painful condition affecting the nerve fibers and skin. It is caused by herpes zoster (shingles). The pain is often described as burning or a sharp shooting sensation, and can be associated with severe itching due to a rash.
    
    
  • Trigeminal neuralgia (also known as tic douloureux). A disorder of the fifth cranial nerve (trigeminal) that causes episodes of intense, stabbing, electric-shock–like pain in the lips, eyes, nose, scalp, forehead, and upper and lower jaw. This is the most common type of cranial neuralgia.
    
    
  • Glossopharyngeal neuralgia. A cranial neuralgia marked by repeated episodes of severe pain in the tongue, throat, ear and tonsils. The pain can last from a few seconds to a few minutes.
    
    
  • Superior laryngeal neuralgia. A cranial neuralgia marked by pain radiating from the throat to the ear or eye. Episodes last seconds or minutes and may occur spontaneously or as the result of coughing, swallowing or speaking.
    
    
  • Cluster–tic syndrome. A combination of trigeminal neuralgia and cluster headache.
    
    
  • Bell’s palsy. A temporary paralysis of one side of the face, caused by injury to either of the facial nerves. Pain near the ear or neck sometimes precedes Bell’s palsy.
    
    
  • Jabs and jolts syndrome. There are several names for this condition, including idiopathic stabbing headache. It results in pain that can last up to 10 seconds but usually lasts less than two seconds. It can occur on its own or in combination with other types of headaches, such as migraines and cluster headaches.
    
    
  • Short–lasting neuralgiform headache with conjunctival injection and tearing (SUNCT) syndrome. Condition characterized by brief pain, typically near the eye, but can occur in the temple or face. It is a rare syndrome that predominantly affects men.
    
    
  • Ramsay Hunt syndrome. Infection of a portion of the facial nerve with the herpes zoster virus, which causes shingles. It causes paralysis of the facial muscles on the same side of the face as the infection.
    
    
• Emotions (psychogenic pain). Sometimes psychological factors or emotional disorders, such as depression or anxiety, result in orofacial pain.
  

In some cases the source of orofacial pain remains unknown (idiopathic).

To diagnose the cause of orofacial pain, a physician will review the patient’s medical history and conduct a physical examination.

A patient may be asked to complete a pain assessment form or otherwise fully describe the pain, including the nature of the pain, site where it occurs, time of day it occurs, conditions that cause it and conditions that alleviate or worsen the pain, and previous treatment attempted to relieve the orofacial pain.

Patients may be referred to other specialists who treat different kinds of orofacial pain, such as dentists, neurologists (physicians who specialize in the nervous system), otolaryngologists (physicians who specialize in treating disorders of the ears, nose and throat), oral and maxillofacial surgeons, psychologists or psychiatrists (professionals who specialize in treating emotional disorders), or specialist in pain management.

Patients may undergo special types of examinations, such as a neurological examination or a psychological examination.

A blood test may be ordered to detect infection or other possible causes of pain. Sometimes physicians will perform imaging tests to further determine the cause. Some common imaging tests that may be performed include:

• X-ray. An image of an organ, bone structure or other body part on film or fluorescent screen. It is produced by a low dose of radiation.
  
  
• CAT scan (computed axial tomography). A test that allows for multiple x–rays to be taken from different angles around the patient. It creates images of organs and bones within the body. It may be performed alone or with the use of an injected special dye (contrast medium).
  
  
• MRI (magnetic resonance imaging). A noninvasive or minimally invasive imaging test that can help physicians diagnose diseases of numerous organs and vessels. MRI uses powerful magnets rather than radiation to produce images on a computer screen and film.
  
  
• Radionuclide imaging. Use of tiny amounts of radioactive substances to detect internal pathologies. A bone scan, PET scan or other nuclear medicine test may be ordered if the physician suspects disorders such as osteomyelitis (bone infection), hidden fractures or a tumor.

Orofacial pain is a complex problem that can stem from many disorders.  To effectively manage a patient’s specific orofacial pain problem, a clinician must be able to diagnose the condition. Methods for treating orofacial pain vary according to the cause of the pain. Some types of orofacial pain may be treated with a combination of therapies.

Common treatment methods include:

• Dentistry. A variety of dental procedures are used to treat dental pain, including filling cavities and placing crowns over broken or decayed teeth.
  
  
• Medication. A variety of over–the–counter analgesics, anti-inflammatories, oral anesthetic gels and sprays, and other types of medications may be used to treat orofacial pain. Drugs available by prescription such as anticonvulsants (drugs that prevent or relieve convulsions) and antidepressants (drugs used to treat certain kinds of pain and depression) and triptans (drugs used to treat migraines) are also used. Some studies have found that injections of the anti-wrinkle treatment botulinum toxin A (Botox) can help relieve trigeminal neuralgia, migraines and other conditions.
  
  
• Injections.  Certain type of nerve blocks may provide relief of certain types of pain.  These are performed by specialist in pain management.
  
  
• Heat therapy and cold therapy. Applying cold with ice or other methods may reduce inflammation. Heat therapy relaxes muscles and reduces pain. These methods are frequently used to treat acute orofacial pain due to injuries.
  
  
• Electrical therapy. A common type of electrical therapy called transcutaneous electrical nerve stimulation (TENS) is sometimes used to treat orofacial pain caused by nerve conditions. Patients can be trained in physical therapy or occupational therapy to use TENS at home. Iontophoresis (use of electrical current to deliver medication through the skin to underlying tissues) targets a high concentration of a drug to a specific area and avoids toxic effects elsewhere in the body.
  
  
• Phonophoresis. Form of ultrasound therapy used to deliver medications such as analgesics and anti-inflammatories through the skin.
  
  
• Complementary and alternative medicines (CAM). Some type of CAM treatments, such as acupuncture, acupressure or biofeedback, may be used to treat orofacial pain.
  
  
• Cognitive behavioral therapy. Treatment in which patients learn to replace negative though patterns with positive ones. This therapy may be useful in cases of chronic orofacial pain.
  
  
• Surgery. In rare cases, surgery may be needed to correct some types of nerve conditions, musculoskeletal problems and other disorders that cause orofacial pain.

Many types of orofacial pain cannot be prevented. Some types of orofacial pain caused by dental diseases can be avoided by practicing good dental hygiene such as regular tooth brushing and flossing. People can reduce their risk of orofacial trauma pain by practicing commonsense safety precautions, such as using seatbelts in cars and using appropriate headgear and mouth guards for contact sports.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about orofacial pain:

1. What could be causing my orofacial pain?
   
   
2. Is it likely due to a problem in my mouth, teeth, jaw, skull, cranial nerves, cranial blood vessels, ears, eyes, nose or elsewhere in my head?
   
   
3. Can orofacial pain indicate that there is a problem elsewhere in my body?
   
   
4. How will my orofacial pain be diagnosed?
   
   
5. What do my test results show? What is the source of my pain?
   
   
6. Can I control my orofacial pain at home with cold or heat treatments?
   
   
7. Which over-the-counter medicines can help me? Are there any I should avoid?
   
   
8. What are my other treatment options for orofacial pain?
   
   
9. If noninvasive treatments fail, could I need surgery?
   
   
10. What can I do to reduce my risk of orofacial pain?