Specialist Pain Therapy

Letters to the editor Idiopathic Facial Pain Syndromes—an Overview and Clinical Implications by Dr. med. Christian Ziegeler, Prof. Dr. med. Dr. med. dent. Thomas Beikler, Prof. Dr. med. Dr. med. dent. Martin Gosau, Prof. Dr. med. Arne May in issue 6/2021

The authors deserve praise and recognition for their review article (1). The often fruitless consultations with doctors of the diverse medical specialties, including oromaxillofacial surgery, confirm an urgent need for facial pain specialists.

Two examples may illustrate this: if the pain region is within the region that is innervated by the second or third trigeminal branch, the cause may be an area on the gingival margin—mostly in the premolar area—that measures but a few millimeters and is clinically mostly normal. Changes in symptoms immediately or some time after a test treatment can be considered confirmation of an initial suspected diagnosis. Referral—in such cases to a neurologist—is no substitute for the required causal therapy.

If sensitivity is impaired in any way, up to the already mentioned sensation of infraorbital swelling in the upper jaw or even the entire side of the face, ipsilateral occipital highly pressure sensitive swellings along the superior nuchal line can be found. A hundred years ago, Max and Felix Lange described these changes and named them “nodule related headaches.” Resolving such tendinous nodules/indurations by applying digital gelotripsy results in immediate change and even alleviation of symptoms. In my experience, physiotherapeutic measures have not been helpful. Physiotherapy as prophylaxis, however, is urgently advised after successful treatment. Tendon indurations irritate the innervation of the face and are responsible for the most diverse facial paresthesias and transferred pain—even cases of visual impairment have been observed.

These examples are intended to emphasize the necessity to classify maxillofacial pain after an extremely careful medical history and diagnostic evaluation on the one hand. On the other hand they should underline the urgent need for intensified training regarding special pain therapy in the maxillofacial region. Increased referrals to the neighboring specialists can theoretically alleviate this lack of specialist expertise but not really make up for it.

DOI: 10.3238/arztebl.m2021.0207

Dr. med. Dr. med. dent. Jan Jürgens

Facharzt für Mund-, Kiefer-, Gesichtschirurgie

Würzburg

References

1. Ziegeler C, Beikler T, Gosau M, May A: Idiopathic facial pain syndromes—an overview and clinical implications. Dtsch Arztebl Int 2021; 118: 81–7.