Connections: Facial pain - serious and chronic, but highly treatable | Winter 2018

Connections is a quarterly newsletter for primary care providers covering the latest developments and advances in medicine at OHSU. Learn about the many clinical, education and outreach resources available to you and your patients.

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From the OHSU Brain Institute

OHSU neurosurgeon Kim Burchiel, M.D., FACS

Kim J. Burchiel, M.D., F.A.C.S.

Dr. Burchiel directs the Facial Pain Program at OHSU, where he is head of functional neurosurgery and John Raaf Professor and chairman emeritus of neurological surgery. His clinical interests are surgical treatment of pain, particularly trigeminal neuralgia, and deep brain stimulation for movement disorders and other conditions.

A serious — even fatal — condition

A relatively common cause of facial pain, trigeminal neuralgia, is nicknamed "the suicide disease" because the intense pain it causes leads some patients to take their own lives.

Some pain can be managed chronically, but the pain of TN is simply too severe to endure long term. Older patients may stop eating and drinking because of pain from trigeminal neuralgia or another facial pain condition. Facial pain can be a sign of multiple sclerosis, or patients who have had shingles may have postherpetic neuralgia.

Right diagnosis = right treatment

In the OHSU Facial Pain Program, we see six to 10 patients weekly with new diagnoses of facial pain. Our task is to pinpoint the cause, whether trigeminal neuralgia, postherpetic neuralgia (shingles pain), multiple sclerosis, temporomandibular joint disorder or another cause.

Facial pain types

Orofacial pain

Dentists are usually the first practitioners to see patients with mouth and dental problems. You may see patients whose pain was not resolved with dental treatment.

Temporomandibular joint disorders

Some of these patients may have been told they have a temporomandibular disorder, or TMD. However, temporomandibular joint problems are still imperfectly understood. Varying clinical perspectives, including from TMJ specialists and otolaryngologists, make precise diagnosis and treatment difficult.

Is facial pain psychogenic?

Trigeminal neuralgia, shingles and MS are not psychogenic conditions. However, having TN or facial pain from another cause can powerfully affect a patient's sense of health and well-being. By the time they reach your practice, patients may display signs of trauma from severe, persistent pain. However, very few cases of facial pain are psychosomatic. In our practice, we estimate one or two cases a year — out of several hundred patients with facial pain — are classifiable as "atypical facial pain" of psychogenic origin.

Cost and time savings: avoid MRI

Magnetic resonance imaging before careful clinical diagnosis is not generally helpful.

Traditional MRI is expensive, time consuming and yields nothing of value for facial pain conditions. The OHSU Facial Pain Program is one of the few centers worldwide offering three-dimensional, high-resolution MRI that can help reveal the source of facial pain.

A diagnostic tool for you and your patients

The OHSU Facial Pain Program frequently receives referrals of patients with suspected trigeminal neuralgia or TMJ disorders. Frequently, these patients have a different disorder.

We developed a facial pain questionnaire to help patients and clinicians determine the nature of facial pain. It can also help patients avoid unnecessary dental procedures.

Take the facial pain questionnaire

Steps to helping patients with facial pain

Approximately half the facial pain we see in our practice is caused by trigeminal neuralgia. We suggest the following sequence for patients with facial pain concerns.

  1. Listen closely to the patient's history and description of facial pain.
  2. Use the OHSU Facial Pain Program questionnaire with the patient. The questions, based on 20 years' worth of data from our clinic, are designed to elicit helpful answers.
  3. If the questionnaire suggests a TMJ issue, refer for dental consultation.
  4. If the questionnaire suggests a specific facial condition, such as trigeminal neuralgia, dental referral is not appropriate. Instead, refer the patient to a specialist in facial pain.
    A caveat: General neurologists are seldom trained specifically in diagnosing facial pain. A facial pain specialist is preferable and cost saving.

Rapid diagnosis and treatment

The intensity of facial pain necessitates rapid diagnosis and immediate initiation of therapy as often as possible, and particularly when patients rate their pain on the high end of the scale. Initial treatment for orofacial pain is almost always medical.

Opioid medications are ineffective for orofacial pain, and the potential for addiction is enormous. Consult with a facial pain specialist immediately for patients in severe pain, and do not prescribe opioids.

Your facial pain resource at OHSU

The OHSU Facial Pain Program is a comprehensive resource for diagnosis and treatment. We offer internationally recognized expertise in surgery for trigeminal neuralgia, and our online artificial neural network to help diagnose facial pain conditions has been available for more than 15 years.

Contact us

The OHSU Facial Pain Program includes experienced specialists who are always available to consult with you.

If you have questions or would like to refer a patient for evaluation, please call the OHSU Physician Advice and Referral Service at 503-494-4567.