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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.
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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
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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.
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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.
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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.
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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 ...