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Practice Practice Pointer

Orofacial pain

BMJ 2018; 361 doi: (Published 16 May 2018) Cite this as: BMJ 2018;361:k1517
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Visual summary available

A strategy for identification and initial management of orofacial pain

Rapid Response:

Re: Orofacial pain

It is very useful for the ENT surgeons to remind us of the features of rhinosinusitis and to attempt to put this into the context of other diagnosis that need to be considered. The visual summary is very useful but unfortunately not entirely accurate 1.

Certainly the recent publication based on the Biobank data of 500,000 people shows that the overall prevalence of facial pain is 1.9% of which 48% is chronic and highlights the significant association with psychological distress and with other chronic pain 2. Migraines and tension type headaches are certainly very common and most should be managed in primary care.

As previous head of the largest UK multidisciplinary facial pain service seeing over 700 new chronic facial pain patients a year we have a very different experience. Temporomandibular disorders are certainly the largest component of our work but these patients do not have the features described in the article. The reference quoted is from 2000 whereas we published a review in the BMJ recently which highlights that the most common pain is musculoskeletal and is not caused by bruxism or associated with locking and jaw laxity 3.

Trigeminal neuropathic pain is not mentioned and yet is due to a large extent to dental work and trauma to the face 4 .

Although cluster headache is highlighted as a severe pain there is no mention of trigeminal neuralgia, an excruciating, unilateral episodic facial pain often located in the maxillary and mandibular areas. These patients also need urgent referral for both medical (anticonvulsant drugs) and surgical management as reported in our BMJ article and podcast . 5


1. Zakrzewska JM. Differential diagnosis of facial pain and guidelines for management. Br J Anaesth 2013;111(1):95-104. doi: aet125 [pii];10.1093/bja/aet125 [doi]
2. Macfarlane TV, Beasley M, Macfarlane GJ. Self-Reported Facial Pain in UK Biobank Study: Prevalence and Associated Factors. J Oral Maxillofac Res 2014;5(3):e2. doi: 10.5037/jomr.2014.5302 [doi];v5n3e2ht [pii]
3. Durham J, Newton-John TR, Zakrzewska JM. Temporomandibular disorders. BMJ 2015;350:h1154.
4. Renton T, Yilmaz Z. Profiling of patients presenting with posttraumatic neuropathy of the trigeminal nerve. J Orofac Pain 2011;25(4):333-44.
5. Zakrzewska JM, Linskey ME. Trigeminal neuralgia. BMJ 2014;348:g474.

Competing interests: No competing interests

21 May 2018
Joanna Zakrzewska
UCLH NHS Foundation Trust
Eastman Dental Hospital, Pain Management Centre UCLH NHS Foundation Trust