Patient Presentation
A 3-year-old male came to clinic complaining of right sided facial pain. His mother said that for the past few days he had been touching his right cheek and saying it hurt. He was eating less but was drinking and didn’t have any fever. She had looked in his mouth and said it wasn’t red and didn’t see any problems. She denied any trauma to his head or neck, pulling at his ears, or any rashes. The night before he had woken her up complaining of the pain. She had given him ibuprofen with relief. He pointed to his right cheek and also his mouth when asked where the pain was. The past medical history was non-contributory.

The pertinent physical exam showed a well appearing male with normal growth parameters. He had no obvious swelling of the face and neck and could move his neck in all directions when asked. Externally he seemed to have some pain with palpation of the right mandible. Inspection of the mouth found several large cavities especially in the molars. On the right mandible there was redness and swelling around the gum of the first molar. This tooth also had a large cavity and the patient cried when the tooth was touched with a tongue blade. No other intraoral lesions were noted. His eyes, ears and nose were normal. He had a few shotty cervical nodes and one that was 0.5 cm on the right side.

The diagnosis of dental caries and dental abscess were made. The mother said that he didn’t like his teeth to be brushed so she did it infrequently. He had not had care with a dentist because of cost. The patient was started on oral antibiotics and a dental visit was arranged for the following day. Dental care for the patient and siblings was arranged through the clinic social worker.

Discussion
Dental caries are one of the most common infections. It is usually caused by Streptococcus viridans. Dental caries are also quite preventable with brushing the teeth at least twice a day with a fluoridated dentifrice, use of dental floss, and preventative dental appointments with application of fluoride varnish and sealants as appropriate. Fluoridated water supplies also help. A review can be found here.

Facial pain is often acute, self-limited and etiologies that may be obvious such as trauma or infection. Facial pain can also overlap with cranial pain (mainly headache), neck pain (often lymphadenopathy or muscle strain), or deeper pain (e.g. dental, pharyngeal or otalgia). Children (and adults too) may have problems distinguishing the location of their pain and may have many different words or behaviors which may indicate pain or discomfort. Psychological problems such as post-traumatic stress disorder may also potentially manifest as facial pain. Also as the nerve fibers for pain and pruritis travel together, these different sensations can occur together or be confused with each other.

In a 2009 Dutch study, the incidence overall of facial pain was 38.7/100,000 people years looking mainly at an adult population. In their under 18 year population, cluster headache and atypical facial pain were the most common diagnoses. Atypical facial pain is defined as pain that does not fulfill other diagnostic criteria (such as those below) or has a functional definition of daily pain for more than 2 hours in the absence of clinical neurological deficits. In adults it occurs in about 2% of the population and is less likely in children. Treatment depends on the probable cause. Chronic pain may need special care with ongoing education and support, lifestyle interventions (e.g. food, sleep, exercise), psychological therapy such as biofeedback, relaxation and cognitive behavior therapy. Pharmacological, mechanical and surgical treatments are generally reserved for severe, chronic pain.

Learning Point
The differential diagnosis of facial pain is large. It is important to consider adjacent structures and their differential diagnoses also.
The differential diagnosis of facial pain includes:

• Trauma
  • Contusions
  • Lacerations
• Dermatologic
  • Sunburn
  • Contact dermatitis
  • Herpes labialis
  • Varicella neuralgia
• Adjacent structures
  • Oropharyngeal
    • Dental caries and abscesses
    • Oral ulcers
    • Temporomandibular joint disorders including bruxism
    • Infections – Streptococcal pharyngitis, adenovirus
  • Ear
    • Otitis media or external
    • Eustacian tube dysfunction
    • Red ear syndrome – has burning sensation
  • Headache
    • Cluster
    • Migraine
    • Tension
  • Neck
    • Muscle strain
    • Lymphadenopathy
  • Eye
    • Irritation
    • Foreign body
• Atypical facial pain
• Infection of facial, head, neck structures
• Central and peripheral nervous system
  • Brain tumor or structural abnormality
  • Bell’s palsy
  • Trigeminal neuralgia – causes are brain tumor, Chiari malformation and multiple sclerosis
  • Glossopharyngeal neuralgia – due to arterial compression of the nerve or tumor
  • Occipital nerve neuralgia – causes are irritation of the nerve or stenosis of the formen magnum
  • Paroxsysmal hemicrania
• Pain syndromes or systemic disease
• Psychogenic
  • Post-traumatic stress disorder
• Tumor of head, neck and face
• Vasospasm

Questions for Further Discussion
1. How are common headaches treated? A review can be found here
2. What causes temporomandibular joint pain? A review can be found here
3. Who do you refer to for local dental care?
4. What causes facial nerve palsy? A review can be found here

Related Cases

Disease: Facial Injuries and Disorders | Tooth Disorders

Symptom/Presentation: Pain

Specialty: Dentistry / Orthodontia | Social Services

Age: Preschooler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Facial Injuries and Disorders and Tooth Decay.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Grazzi L, Usai S, Rigamonti A. Facial pain in children and adolescents. Neurol Sci. 2005;26 Suppl 2:s101-103. doi:10.1007/s10072-005-0419-4

Koopman JSHA, Dieleman JP, Huygen FJ, de Mos M, Martin CGM, Sturkenboom MCJM. Incidence of facial pain in the general population. Pain. 2009;147(1):122-127. doi:10.1016/j.pain.2009.08.023

Grazzi L, Sansone E, Rizzoli P. Atypical Facial and Head Pain in Childhood and Adolescence. Curr Pain Headache Rep. 2018;22(6):43. doi:10.1007/s11916-018-0698-0

Horswell BB, Sheikh J. Evaluation of Pain Syndromes, Headache, and Temporomandibular Joint Disorders in Children. Oral and Maxillofacial Surgery Clinics of North America. 2018;30(1):11-24. doi:10.1016/j.coms.2017.08.007

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa