Orofacial Pain Management
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Direct answer
Before reaching for analgesics or a diagnosis of neuralgia, exclude the tooth: dental pain remains the commonest orofacial pain, and most "atypical" facial pain histories conceal an untreated pulp or cracked cusp. Beyond the dental sieve, management sorts pain by mechanism — musculoskeletal (temporomandibular disorders, treated reversibly), neuropathic (trigeminal neuralgia's electric seconds, first-line carbamazepine), neurovascular (cluster headache with autonomic features; paroxysmal hemicrania, abolished by indomethacin) and the persistent idiopathic and burning mouth syndromes managed with adjuvants and reassurance. Two emergencies anchor the topic: giant cell arteritis threatening sight in everyone over fifty with jaw claudication, and any pain carrying neurological red flags demanding imaging.
What you must remember
- The dental sieve first: pulpal and periapical pain is stimulus-provoked and localised, periodontal pain is chewing-provoked — clear these before any exotic diagnosis, or healthy teeth will be sacrificed to a nerve pain.
- Trigeminal neuralgia: paroxysmal electric shocks of seconds, unilateral, in the mandibular and maxillary divisions more than the ophthalmic; cutaneous or intraoral trigger zones, a refractory period, no sensory deficit between attacks; first-line carbamazepine (begun about 100 mg twice daily, titrated), with MRI to exclude demyelination or tumour in atypical presentations.
- Cluster headache: strictly unilateral orbital or temporal pain of 15-180 minutes with lacrimation, rhinorrhoea, ptosis; acute relief by 100 per cent oxygen at high flow and subcutaneous sumatriptan, verapamil for prophylaxis.
- Paroxysmal hemicrania answers absolutely to indomethacin — the drug response is itself diagnostic, a favourite single-best-answer fact.
- Giant cell arteritis: new headache in a patient over fifty, scalp tenderness, jaw claudication on chewing, visual threat; raised ESR and CRP; high-dose corticosteroids started immediately, temporal artery biopsy within about two weeks — steroids never wait for the biopsy.
- Burning mouth syndrome: bilateral burning of the tongue and mucosa with normal appearing tissue, typically postmenopausal; screen deficiencies (iron, folate, B12, glucose, thyroid) and dryness before accepting the diagnosis; management ranges from reassurance and cognitive behavioural therapy to clonazepam or alpha-lipoic acid trials.
- Red flags demanding imaging: neurological deficit, numbness, fever, weight loss, night pain, new headache over fifty, papilloedema, immunosuppression.
- Treatment ladder principle: reversible before irreversible — splints, physiotherapy and medication precede occlusal reconstruction, and no tooth is extracted for a pain that has not been proven dental.
Excluding the tooth before blaming the nerve
A 48-year-old woman reports six months of right-sided facial electric shocks, triggered by washing her face and by brushing, each lasting seconds, dozens of times a day; between attacks she is normal. The dental history and examination — periapical views, bite test, cold testing — find no culprit tooth, which matters because trigeminal neuralgia is diagnosed after dental exclusion, not before it. Neurological examination shows no sensory deficit. The diagnosis is classical trigeminal neuralgia, and management begins with carbamazepine at about 100 mg twice daily, titrated to effect with monitoring for drowsiness, hyponatraemia and rash, most patients responding within days. Neuroimaging is arranged to exclude a structural cause — mandatory in younger patients, bilateral disease or any deficit, where multiple sclerosis and tumours rise in probability. She is counselled on trigger avoidance and reviewed; if medication fails or is intolerated, the referral conversation covers microvascular decompression and stereotactic radiosurgery. Had the story instead been a 55-year-old with jaw ache on chewing, temple headache and blurred vision, the same clinic would have ordered ESR urgently and started high-dose steroids the same hour — the branch point that separates chronic disease management from sight-saving emergency.
Where students slip
The trap with teeth is literal: candidates who recommend extraction or root canal treatment for trigeminal neuralgia have failed the sieve — the pain's seconds-long electric character and trigger zones are neural, and dental treatment brings relief only by placebo and time. The second slip is arteritis sequencing: waiting for temporal artery biopsy before steroids risks blindness; the biopsy remains useful for up to about two weeks on steroid therapy, so treatment leads investigation. The third is reflexive therapy: labelling every chronic facial pain trigeminal neuralgia and prescribing carbamazepine for what is actually persistent idiopathic pain, temporomandibular disorder or burning mouth — mechanisms with different treatments entirely.
Frequently asked questions
What are the clinical features of trigeminal neuralgia?
Second-long paroxysmal electric shocks, strictly unilateral, in the second and third divisions, with trigger zones and a refractory period but no sensory loss.
Which drug is first-line and how is it started?
Carbamazepine, at about 100 mg twice daily titrated to response with toxicity monitoring; most classical cases respond.
How is cluster headache treated acutely?
100 per cent oxygen at high flow or subcutaneous sumatriptan; verapamil prophylaxis.
Why is giant cell arteritis an emergency?
Untreated it causes irreversible visual loss; steroids start immediately, with temporal artery biopsy within about two weeks.
What is paroxysmal hemicrania's diagnostic response?
Absolute abolition by indomethacin — a diagnostic criterion distinguishing it from cluster headache.
How is burning mouth syndrome assessed?
Bilateral burning with normal-looking mucosa after excluding deficiency, diabetes, hypothyroidism, xerostomia and candidosis.