Atypical facial pain / Burning mouth syndrome / Psychogenic facial pain
These terms are used to describe oro-facial pain which cannot be explained by any organic or physical cause. It is a diagnosis arrived at by exclusion and patients will often have undergone extensive dental investigations or interventions which have provided no relief. The pain may be described in terms that do not fit the norm such as ‘drawing’, ‘itching’ or ‘burning’; is often poorly localised and may cross the midline; it may be persistent and described as being so severe as to be unbearable and yet the person’s daily life is not affected (compared to someone with acute irreversible pulpitis who can think of little else other than relief of the pain). This does not mean that the pain is not ‘real’, it is, but the cause is not physical.
The group of patients who most commonly present are middle-aged and older women and the key features are:
- Vague and anatomically anomalous distribution such as crossing the midline.
- Unusual descriptive terms.
- No triggers such as hot or cold food.
- Poor response to analgesia, although sometimes no analgesia has been tried despite the severity described.
- Worse in the morning.
- Sleeping and eating rarely disturbed.
- Maybe associated history of neck pain, back pain and abdominal disorders such as IBS.
- May have long history of ineffective dental interventions.
There may be a strong correlation with depressive illness and a useful first step is to ask the patient to complete a H.A.D. score or similar psychological questionnaire. Referral to an Oral Medicine specialist is usually indicated because the management of this group of patients can be lengthy and complex.