Often dentists are confronted with patients who are suffering from head and facial pain. The pain is often not only dental but has a complex mix of causes.

Facial Pain Causes
Man with tooth pain

Let´s start with pain in the Jaw Joint. Jaw joint pain can be acute or chronic. The most common cause of acute jaw joint pain, which is limited in time of occurrence, is acute jaw joint inflammation, caused by leaving the mouth open for extended periods of time, such as during dental treatments. The consequence is jaw joint effusion, which refers to a collection of fluid and/or blood in the joint interior. It can occur because of various reasons, including rheumatic conditions, mechanical injuries, and bad posture. The most common cause, however, is over straining of the joint from activities like extended and intensive opening of the mouth during dental checkups, or excessive yawning. A day after visiting the dentist, a patient may feel that his/her teeth are not fitting together correctly. He/she may also experience pain while opening the mouth.
Jaw joint effusions also can occur in diseased, abnormal joints, such as those affected by arthrosis due to a lack of tooth support in the back regions of the jaw. If the back teeth are missing, chewing forces are not transmitted via the teeth to the jaw bone. Instead, chewing muscles press the joint head into the joint socket, which leads to a heavily stressed jaw joint. Every person reacts differently to overstressed joints. Over the years, many will experience joint deformation as well as joint degeneration – others not. X-rays will reveal shrinkage of the jaw joint gap, sanding facets in the joint area, and other modification phenomena. Initially, most patients feel very few effects of chronic joint arthrosis; symptoms are felt only from acute processes. For example, an acute effusion after a dentist’s appointment is perceived as a painful period, and the phenomenon is called activated arthrosis. To avoid pushing things this far, early treatment for missing and tilted teeth in the back regions of the jaw is very important because chewing forces can then be transmitted to the teeth rather than to the jaw joints.
However, middle ear diseases and certain bone diseases can also cause jaw joint pain. The most common misdiagnoses for jaw joint pain are atypical facial pain and trigeminal neuralgia. Through imaging, clinical diagnostics, and precise questioning about pain characteristics, it is possible to differentiate jaw joint pain from other causes of pain in the skull area.

Jaw Pain Treatment
According to the cause, treatments vary. In general, cooling ice wraps and resting the joint for a few days helps. This means no chewing gum or food requiring intensive chewing. In addition, gentle mouth opening exercises should be performed.
If the cause of Jaw Joint Pain is Jaw Joint arthrosis due to reduced bite in the back region of the jaw, the bite is first restored using an occlusal splint, which is eventually followed by well-fitting dentures. This leads to the desired transfer of chewing forces away from the jaw joint and towards the jaw bone via the teeth. In principle, only easily reversible methods should be used for the treatment of jaw joint pain because facial pain often has multiple causes. The patient usually wears the occlusal splint overnight. If pain reduces with this splint, a definitive bite reconstruction will be facilitated through new crowns and/or implants.

Jaw Joint Cracking
Jaw Joint Cracking normally do not cause pain. Jaw joint cracking is a common symptom in patients with forced mouth openings. The causes of joint cracking have not been fully identified. Air bubbles in the synovial fluid are identified as the most common explanation (cavitations). These cause a sound during pressure balancing because of bubble formation. Bumps in the articular surfaces are also considered to be a cause. The jaw joint was, and sometimes still is, treated as a special joint. Thus, jaw joint treatment is often carried out immediately, even for phenomena considered normal for other joints. However, this is a wrong practice. If certain changes occur slowly and/or if certain symptoms, such as reduced mouth opening, have existed for a lifetime, they simply represents a normal variation and do not have to be treated. If changes occur over a short period of time, a doctor’s opinion should be sought. This is a general rule in medicine, and is no different as far as the jaw joint is concerned. In this context, it should be mentioned that the absence of pain does not automatically mean that everything is in order. This is another general rule of medicine. Joint cracking is much less of a problem than generally assumed. The most common argument against finger cracking is that it causes arthritis, but this is not true. If a patient has experienced jaw joint cracking since childhood, it is simply a variation. For example, if one experiences a joint ache while chewing a lot or after leaving the mouth open for extended periods of time, it just means that the joint is more sensitive. The patient should adjust his/her lifestyle accordingly. Some people run a marathon and never experience knee issues, while others run around the block twice and experience swelling in the knees. This indicates that patients with hypersensitive joints need to adjust their lifestyle accordingly. This means no chewing gum or foods requiring intensive chewing, such as gummy bears. Furthermore, the dentist should be made aware of the fact that the patient will need more breaks during dental treatment. If jaw joint cracking appears suddenly with other problems, such as reduced mouth opening, pain, and/or a feeling that the teeth are not fitting together correctly, the patient should immediately consult a doctor. Possible causes may be disc displacement, jaw joint effusion, encroachment in the jaw joint, and middle ear or bone diseases.

Bruxism and Facial Pain
Another common cause of facial pain is muscular pain. Bruxism is derived from the latin term “Bruxismus,” which means unconscious grinding of the teeth against each other. Bruxism is usually observed while the patient is sleeping, but in severe cases, it can occur throughout the day. The patient himself/herself is unable to notice anything unless told, but it is annoying for anyone sleeping with the sufferer. Some patients also complain about muscle pains or cramps in the jaw region on awakening.
During bruxism, the teeth lock together and the periodontium (which attaches the tooth to the jaw) gets overloaded. In severe cases, the jaw joint can suffer damage, thus leading to severe facial pain and ringing in the ears (tinnitus). Dizziness, disturbance of vision, and nausea are also frequently experienced.
In case a patient knows that he/she grinds his/her teeth, either from the presence of muscle pain or flattened and chipped teeth or from a partner of friend, then he/she should see a dentist. The nightguard (or splint) is a separator that prevents the teeth from grinding against each other when worn, thus preventing damage to the teeth and chewing apparatus. It usually lasts for 2–5 years and can be easily replaced. Measures to deal with stress, usually psychotherapy, are also helpful. Even if bruxism cannot be curbed completely, most patients at least learn how to deal with it and will know when it is necessary to use the nightguard, for example, when they are overstressed at work or are facing personal problems.

Trigeminal Neuralgia
Another rare reason for facial Pain could be Trigeminal Neuralgia. Trigeminal neuralgia is distinguished by attacks of extremely strong, sharp, electrifying, and flashing pain in the regions supplied by the trigeminal nerve. These pain attacks are triggered off by chewing and speaking. Our body is equipped with numerous pain receptors, known as nociceptors. Nociceptive pain is caused when these receptors are irritated by environmental factors (cold, heat, pressure, etc.). A simple example would be hot soup. Sometimes, however, these special sensors do not give rise to pain signals; rather, a nerve starts to send false signals on its own, leading to what is called neuropathic pain. In trigeminal neuralgia, the functioning of the trigeminal nerve is affected, leading to attacks of strong, sharp, electrifying, and flashing pain. Multiple attacks may occur over weeks or months. Blunt, burning, or throbbing pain may occur, especially at the onset of an attack. The duration of the attack itself is usually seconds, but may occasionally extend up to 2 minutes. Pain attacks are usually set off by the slightest disturbances such as shaving in what are called the trigger zones. Other triggers are cold air, speaking, chewing, facial movements, tooth brushing, and emotional stress. The trigger zones may be very small, sometimes only one or two millimeters long. The V2 and V3 branches of the trigeminal nerve are the ones most usually affected, either alone or in combination. Very rarely, the V1, V2, and V3 branches are affected together. In 90% cases, the pain attacks start after the 40th year of life, with the tendency increasing with age. The course of the illness is progressive as a rule. In the early stages, there are pain-free intervals of several months or even years. Approximately 1/3 of patients experience barely one episode in their lives. Each nerve consists of many small nerve fibers, and normally, individual nerve fibers are separated from each other by an isolating sheath. In patients with trigeminal neuralgia, this sheath is damaged, which leads to short circuits in the nerve. There are various possible causes of damage to the isolating sheath. If the cause is known, we call this symptomatic trigeminal neuralgia. A brain tumor can press on the nerve, for example, thereby damaging the nerve sheath and causing a short circuit. Another cause of symptomatic trigeminal neuralgia would be illnesses causing degeneration of the isolating sheath. Often, immunodeficiency diseases such as multiple sclerosis play a big role in the pathogenesis.
If the doctor cannot find the cause, this condition is called idiopathic trigeminal neuralgia. In most cases of idiopathic trigeminal neuralgia, an anatomically abnormal blood vessel compresses the root of the trigeminal nerve as it leaves the spinal cord. The constant pulsations of the blood vessel cause damage to the corresponding nerve root and give rise to wrong connections in the nerve, which appear to be the cause of pain. Whether such cases should be diagnosed as idiopathic remains controversial. It is likely that the types classified as idiopathic equate to a form of compression caused by a blood vessel, which is not detectable on magnetic resonance imaging.
Apart from the causes described above, all other trigeminal nerve-related pains originate from injury to the trigeminal nerve (for example, because of interventions by dentists or ear–nose–throat practitioners). Clinically, there is often chronic pain in between attacks as well as disturbances to sensitivity in the region affected by the trigeminal nerve, e.g., numbness in the lip. Differentiation of these various forms is meaningful chiefly with regard to the choice of treatment options.
The treatment is designed according to the cause and is initially conservative in most cases. Surgical procedures are considered only if medications fail. Psychotherapy does not have any effect and is only indicated as an adjuntive treatment in cases exhibiting a high risk of suicide. Surgical measures in the facial area of the skull, such as tooth extractions or sinus surgeries, are naturally ineffective but often practiced. The main aim of treatment lies in the prevention of further attacks. Individual attacks themselves die down so quickly that no treatment can be delivered quickly enough. For the 30%–50% patients that do not respond to medication, surgical procedures may be considered.
Microvascular decompression is a prime form of treatment, although it carries a high risk of complications. This involves locating and removing the offending blood vessel. This surgery may not always be possible in patients with symptomatic trigeminal neuralgia or other trigeminal neuropathies.
Unfortunately, trigeminal neuralgia is frequently the most convenient diagnosis for unexplained pain in the facial area. If one does not have any trigger zones, and the characteristics of the pain are different from those described above, then it is not trigeminal neuralgia.

Why we should not use the term TMJ facial pain
Myoarthropathy is derived from the Greek words myo, which means muscle, arthro, which means joint, and pathos, which means suffering. Therefore, myoarthropathy of the chewing system refers to a condition in which individuals suffer from discomfort in the chewing muscles and/or the jaw joint. Unfortunately, the term craniomandibular dysfunction (CMD) or Temporomandibular Joint disorder (TMJ) is still frequently used for pain in the jaws, jaw joints, and facial area. This term is unclear because it is undefined. In the medical field, it is common for two diagnoses to coexist for the same disease. This mirrors medical developments, which have shifted from a purely subjective to evidence-based therapy. The term myoarthropathy (MAP) is clearly defined. The patient is treated for exactly what he is suffering from, whether it is pain and/or limited functionality such as reduced mouth opening. In other words, doctors who use the term MAP to describe pain in the jaws, jaw joints, and facial area support the opinion that many symptoms, such as jaw joint cracking, lifelong restriction of mouth opening, jaw deviation during mouth opening (deflexion), and many more, simply represent normal variations as long as the patient does not experience any discomfort or pain. In such cases, treatment is not necessary.
In contrast, doctors who use the term CMD or TMJ frequently treat symptoms but not the actual causes of these symptoms, and treatment often consists of inconsistent therapy concepts. Moreover, diagnostic and treatment indicators are first and foremost determined by the patient rather than the treating professional as far as MAP is concerned. MAP sums up muscle and jaw joint problems as well as combinations thereof. Therefore, the doctor has to differentiate between these three options and initiate the most appropriate treatment for patients suffering from pain and/or sudden restriction of mouth opening. Through a combination of special questionnaires and clinical examinations, the doctor can easily pinpoint the correct diagnosis. The questionnaires help the doctor to differentiate between depression, nonspecific physical symptoms, bite problems, and chewing muscle issues. Imaging techniques, such as magnetic resonance imaging, are seldom necessary. Unfortunately, these are often needlessly performed. Treatment depends on the respective diagnosis. However, one principle should always be considered. Because our jaw joint is very adaptable, any irreversible measures, such as the fitting of a new prosthesis, should be avoided in MAP therapy. For example, during the acute phase of jaw joint pain, a so-called Michigan splint is completely sufficient because the body is capable of regulating many changes in the chewing apparatus on its own. These restructuring processes only take a little bit of time, and a splint can help to bridge this time span.

Paranasal sinus infection
Latin: sinusitis - can also cause facial pain, they can be acute or chronic; the respective conditions are termed acute sinusitis and chronic sinusitis. The paranasal sinuses form a system of cavities around the nasal area within our skull. The nasal cavities are connected to the sinuses by small passages. There are four sinuses, each present bilaterally: the maxillary sinus, frontal sinus, sphenoidal sinus, and ethmoidal sinus.
A mucosal infection can have many different causes, which can be subdivided into three broad categories: rhinogenic, exogenic, and endogenic. The following examples explain these mechanisms.
Rhinogenic means that the cause lies in the nose itself. For example, birth defects and nasal fractures can cause air to swirl in the nose during breathing. Such swirling can be compared to the use of a drier. It can put increased strain on certain mucosal areas, which are then in danger of drying up and swelling. If these processes occur close to a connecting tunnel, the drainage of that paranasal sinus is disrupted, leading to secretion blockage and, ultimately, sinusitis.
Exogenic causes include all external factors. Inhalation of poisonous gases and pollen, as well as use of some medications, can damage the paranasal sinus mucosa, thus initiating sinusitis. Fairly abstract causes also exist. For example, a bacterial blood infection can cause bacterial distribution through the blood stream into the paranasal mucosa. This is also called hematogenic sinusitis. Sometimes, sinusitis is induced by root canal treatments. A poor root canal treatment in the upper back teeth can lead to maxillary sinusitis, also known as odontogenic sinusitis maxillaris. The roots of these teeth lie very close to the maxillary sinus, sometimes even extending into it. Therefore, a bad root canal treatment can lead to irritation of the sinus lining with subsequent inflammation.
Endogenic causes refer to all internal factors. An example would be certain autoimmune diseases, which can occur in conjunction with sinusitis. A combination of causes is also possible. For example, the upper back teeth may have undergone poor root canal treatment, thereby causing mucosal irritation. However, the body is able to contain the infection at this stage, so the patient barely notices anything. Then the springtime pollen season begins, and the patient suffers from allergies. This combination of causes results in an overstrained mucosa. Pollen and the consistent tooth irritation lead to an acute infection called acute sinusitis. After the acute phase, characterized by a running nose, facial pain, and general discomfort, the mucosa undergoes changes that lead to chronic sinusitis. Now the disease can develop its own momentum, even after the pollen season passes by.
This is just one of the numerous imaginable scenarios. However, when provided with an exact disease description, the doctor is usually able to determine the cause and initiate appropriate treatment. Obviously, the cause itself must be considered when choosing treatment. For example, if the cause is a poor root canal treatment, then that treatment needs to be repeated. Additional supportive measures can also be taken; these are mentioned below.
Drinking lots of water. When the skin sweats, so does the mucosa. This accelerates the self-cleansing mechanism.
Using decongestant nasal drops. These lead to better air circulation in the paranasal sinuses, thus allowing secretions to drain better.
Practicing deep inhalation, which also accelerates the self-cleansing mechanism.

Sometimes dental Materials can cause head and face pain
Composites are special plastics used in the field of dentistry as filling or restorative materials. They comprise three components: a composite matrix, a dispersive component, and a bonding component.
The composite matrix consists of monomers, co-monomers, initiators, stabilizers, and similar ingredients that give the composite its plasticity and make it shapeable. The monomers are tiny building blocks, like Lego bricks, and when the composite is exposed to halogen light, these monomers bind with the polymers to create bigger building blocks—a hardening process called polymerization.
During polymerization, unavoidable shrinkage of the material occurs. The amount of shrinkage is proportional to the volume of the filling. For this reason, large cavities should be filled and hardened in layers when composites are used in order to prevent the loss of a tight seal following polymerization shrinkage. In addition, because the polymerization process is very sensitive to humidity, composite fillings should be atempted only after isolating the tooth using a coffer dam.
Unfortunately, another disadvantage of the composite matrix is that it is not stable enough to withstand heavy occlusal forces, which break down the polymer and free the monomers. Monomers are poisonous and damage the tooth nerve, necessitating root canal treatment. They can also result in facial pain if the material is not used correctly.
To combat polymerization shrinkage and give the composite matrix better physical properties (stability against occlusal forces), fillers are added to the composite matrix. Fillers form the main part of the dispersal component and comprise tiny pieces of sand, glass, or quartz, and they are classified as macrofillers, microfillers, or complex microfillers according to particle size.
Macrofillers are created by a mechanical process. Glass, for example, is ground into dust that is added to the composite matrix. These composites are strong and can withstand excess load; however, they are not very polymerizable. Therefore, they may promote the development of plaque and increase the risk of caries.
Microfillers are produced chemically and added to the composite matrix. They are very polymerizable but not resistant to occusal forces.
Complex microfiller composites are prepared with both macro- and microfillers in an attempt to combine the positive features of both with varying degrees of success. Painstaking research is still being conducted to determine the ideal composition of composite restorative materials.
In order to combine inorganic fillers with organic composite matrices (monomers), we need a bonding component, which gives special features to the composite material.
Before we get into detailed chemistry, let’s sum up: composites should not be used for posterior teeth that are involved in mastication, and the use of a coffer dam and the insertion of a composite filling in increments decreases the risk of complications such as toothache and shrinkage. Many dentists specialize in composite fillings, and such work is very expensive.
Opting for a ceramic inlay needs to be decided on an individual basis. While it is true that ceramic inlays are glued to the tooth with plastic glues, ceramics are resistant to occusal forces. In addition, the interface between the tooth and the filling is extremely fine if done well, thus minimizing polymerization shrinkage and monomer release.
The complications that arise when composite fillings are used incorrectly or in contraindicated areas are very harmful to the tooth. The tooth becomes sensitive to cold and heat for some time after the filling is done. The patient often experiences a sharp, acute pain in that tooth on stimulation. We call this acute pulpitis, that is, acute inflammation of the dental nerve (or pulp). The cold test will demonstrate a lingering response at this stage.
Eventually, the pulp dies completely, a process called necrosis. The tooth is now painless, even on cold stimulation, because necrosed pulp simply does not function. By this stage, a root canal treatment should be performed at the earliest.
If the root is not treated, the dead pulp tissue will cause an inflammatory reaction days, months, or even years later, and the tooth will suddenly become painful again. This time, it will be a blunt pressure pain, especially while chewing. The cause is inflammation of the bone surrounding the tip of the root (periapical infection), which arises from the necrotic pulp.

You’re better off investing a bit more in gold, ceramic, or titanium inlays as these will spare you these complications!

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