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  • Updated 05.23.2024
  • Released 04.11.1994
  • Expires For CME 05.23.2027

Pain, headache, and oromandibular structures

Introduction

Overview

The treatment of orofacial pain can be a diagnostic challenge. Misdiagnosis can result in delays in care or mistreatment.

This article explores this complex relationship between headache and oromandibular disorders and specifically describes overlapping disorders, such as atypical odontalgia, chronic orofacial pain, contact point headache, and “lower-half migraine.” This article also includes guidance for diagnosis and management, including updated treatment options such as onabotulinumtoxinA and pulsed sphenopalatine (pterygopalatine) ganglion treatment for oromandibular disorders and referred facial pain.

This article reviews the relationship between head pain and oromandibular structures and the importance of considering both cranial and oromandibular pathologies in the differential diagnosis of oromandibular, face, and head pain.

Key points

• The International Classification of Orofacial Pain, published in 2020, removed anatomical boundaries and applied the fundamental principle that head and face disorders should be guided by clinical characteristics, rather than location.

• The International Classification of Orofacial Pain describes purely orofacial (without headache) counterparts to primary headache disorders.

• Temporomandibular joint disorders are common and are comorbid with headache disorders such as migraine.

• Evidence suggests central sensitization is a very common problem in temporomandibular joint disorders, idiopathic orofacial pain, and primary headache disorder.

• In many common primary headache disorders, such as migraine, cluster headache, and trigeminal neuralgia, pain is referred to dental structures.

• An understanding of primary orofacial disorders and referred that dental pain from primary headache disorders will help clinicians avoid unnecessary antibiotics and surgical interventions.

Historical note and terminology

Head pain and pain in the oromandibular structures (eg, teeth, gums, jaw, tongue) may be related in two ways: (1) headache arising in the oromandibular structures and referred to the head and (2) head pain perceived in the oromandibular structures. Historically, disorders treated by neurologists and dentists have been divided by the ala-tragus line, an artificial line running from the lateral surface of the external nose to the inferior boarder of the tragus (85). Neurologists have traditionally treated problems that arise from structures above the line and dentists have treated problems that arise from structures below the line. Unfortunately, this artificial division, stunted the exploration of the relationship between oromandibular structures and head pain (63). In 2020, the International Classification of Orofacial Pain removed anatomical boundaries and applied the fundamental principle that head and face disorders should be guided by clinical characteristics, rather than location (84).

Oromandibular, face, and head pain can originate from dentialveolar structures, myofascial structures, the temporomandibular joint, cranial nerves, and primary trigeminovascular activation. Some types of orofacial pain are idiopathic, in which the condition arises spontaneously. There may also be a psychosocial aspect to orofacial pain. A framework of these pain etiologies is summarized below (84).

Table 1. Summary of the International Classification of Orofacial Pain Classification System

(1) Orofacial pain attributed to disorders of dentoalveolar and anatomically related structures

(a) Dental pain

(i) Pulpal pain and its subtypes
(ii) Periodontal pain and its subtypes
(iii) Gingival pain

(b) Oral mucosal, salivary gland, and jawbone pains

(i) Oral mucosal pain and its subtypes
(ii) Salivary gland pain and its subtypes
(iii) Jaw bone pain and its subtypes

(2) Myofascial orofacial pain

(a) Primary myofascial orofacial pain

(i) Acute primary myofascial orofacial pain
(ii) Chronic primary temporomandibular joint pain and its subtypes

(b) Secondary myofascial orofacial pain and its subtypes

(3) Temporomandibular joint pain

(a) Primary temporomandibular joint pain

(i) Acute primary temporomandibular joint pain
(ii) Chronic primary temporomandibular joint pain and its subtypes

(b) Secondary temporomandibular joint pain

(i) Temporomandibular joint pain attributed to arthritis and its subtypes
(ii) Temporomandibular joint pain attributed to disc displacement and its subtypes
(iii) Temporomandibular joint pain attributed to degenerative joint disease
(iv) Temporomandibular joint pain attributed to subluxation

(4) Orofacial pain attributed to lesion or disease of the cranial nerves

(a) Pain attributed to lesion or disease of the trigeminal nerve

(i) Trigeminal neuralgia and its subtypes
(ii) Other trigeminal neuropathic pain and its subtypes

(b) Pain attributed to a lesion or disease of the glossopharyngeal nerve

(i) Glossopharyngeal neuralgia and its subtypes
(ii) Glossopharyngeal neuropathic pain and its subtypes

(5) Orofacial pains resembling presentations of primary headaches

(a) Orofacial migraine

(i) Episodic orofacial migraine
(ii) Chronic orofacial migraine

(b) Tension-type orofacial pain

(c) Trigeminal autonomic orofacial pain

(i) Orofacial cluster attacks, episodic and chronic subtypes
(ii) Paroxysmal hemifacial pain, episodic and chronic subtypes
(iii) Short-lasting unilateral neuralgiform facial pain attacks with cranial autonomic symptoms (SUNFA), episodic and chronic subtypes
(iv) Hemifacial continuous pain with autonomic symptoms

(d) Neurovascular orofacial pain

(i) Short-lasting neurovascular orofacial pain
(ii) Long-lasting neurovascular orofacial pain

(6) Idiopathic orofacial pain

(a) Burning mouth syndrome (BMS) and it subtypes
(b) Persistent idiopathic facial pain and its subtypes
(c) Persistent idiopathic dentoalveolar pain and its subtypes
(d) Constant unilateral facial pain with additional attacks

(7) Psychosocial assessment of patients with orofacial pain

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