NHS Direct report that facial pain including toothache is one of the commonest subjects that the public seek advice on and these reviews should help you to navigate your way from common toothache to the rare trigeminal neuropathic pains.
The first dilemma of facial pain patients is “who to consult”? Is this a dental problem or a medical one and who will be able to treat it most appropriately? There is no doubt that the dental conditions described by Renton in her first article are best managed by dentists. However, when patients present with persistent pain after dental surgery or due to other causes the boundaries become less distinct. As Renton points out these patients will now have psychosocial problems and possibly associated co-morbidities and by and large need to be managed by medical practitioners who can prescribe the recommended drugs and have access to multidisciplinary teams. Temporomandibular disorders, TMDs, (the back pains of the face) are by far the commonest non dental causes of facial pain. Durham and Wassell's review illustrate the wide range of guises under which they present and provide insight on the complexity of their aetiology. As to be expected dentist's training will lead to mechanical solutions for TMDs and hence the use of splints whereas like all chronic pain patients a biopsychosocial approach is essential if long term prognosis is to be improved. Many of these pains are continuous in nature but the one pain that stands out as an episodic, unilateral pain is trigeminal neuralgia. McMillan points out that diagnosis is crucial as only patients with classical trigeminal neuralgia and MRI evidence of neurovascular compression should be subjected to major neurosurgical procedure.
Management, therefore, must begin with a diagnosis through history taking — total absorption in patients' stories is crucial. Patients need to be given not just a diagnosis but be provided with an effective explanation that is action driven, be offered emotional support and in some cases relinquish pain relief as a primary goal.