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Pain in the oral and facial structures is a common symptom. Although in most cases, the cause can be determined readily, the anatomy of the area is so complex that the diagnosis may be difficult.

Pain originating in the mouth and face is mediated mainly by the fifth (trigeminal) cranial nerve. This nerve has three branches: ophthalmic, maxillary, and mandibular. In addition, the facial (nervus intermedius root), glossopharyngeal, vagus, and cervical nerves also innervate parts of this region. These nerves have a tortuous anatomic course and distribution and do not follow an orderly pattern. All pain fibers from this region (with the exception of those from the cervical nerves) travel to the spinal nucleus of cranial nerve V. From there, they are connected to higher centers.1–4

The emotional significance of pain in this region may be heightened for several reasons. The mouth and face are highly innervated by sensory fibers. This area is represented on the sensory homunculus as much larger than its actual size. The trigeminal nervous system develops early, and reflex suckling activity has been observed in utero. Furthermore, in most western civilizations, the face is one of the few parts of the body exposed to view. It is through the face that humans communicate and express their feelings toward fellow human beings.

It is imperative that a thorough history be obtained before the patient is examined or special tests are ordered. In most cases, the diagnosis may be made with this information alone.

It also is important to obtain the patient’s description of the pain. Primary neuralgias frequently are described as sharp and lancinating, vascular headaches as throbbing, and muscle pain as a continuous, dull ache. The intensity of the pain should be measured against the patient’s own experience of pain, need for medication, and effect on lifestyle, for example, sleep, work, and social activities. The origin of the pain should be ascertained by asking the patient to indicate this with one finger. Its distribution pattern should be traced accurately in terms of the local anatomy. The patient should be urged to remember the events surrounding the original onset of the pain, even though this may have occurred several years previously.

Any other instances of similar pain should be determined, although the patient may not associate these with the current problem. The time relationship of the pain should be clarified in terms of duration, frequency of attacks, and possible remissions. In many instances, aggravating factors (e.g., lying down, chewing, the sight or smell of food, alcohol, or stress) and relieving factors (e.g., heat and cold) are important clues. The effect of past treatment should be elucidated carefully (which medications helped, whether surgery altered the nature of the pain, whether endodontic treatment or extractions affected the pain). Finally, the presence or absence of associated factors, such as swelling, flushing, tearing, and nasal congestion, must be ascertained. The patient may ...

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