[Neurologist, otolaryngologist...? Which specialist should treat facial pain?].

Pain is a major public health problem. The management of orofacial pain may be a difficult challenge to the medical and dental professions. Ideally, severe cases of this type of pain should be treated by a team drawn from several disciplines such as neurology, otolaryngology, dentistry and psychiatry. Trigeminal neuralgia patients develop brief, very severe unilateral pain, usually radiating from the upper or lower jaw toward the ear, and confined to the distribution of the trigeminal nerve. The pain may be triggered by chewing, shaving or exposure to cold wind. Most patients respond to carbamazepine, with phenytoin or baclofen as an alternative. Intractable pain may require surgical treatment. Horton's syndrome (cluster headache) is always unilateral and is often associated with unilateral lacrimation and rhinorrhoea. The pain is extreme, and its typical localisation the eye, forehead, temple, jaws, or teeth. Treatment with ergotamine and sumatriptan has been used with some success, calcium blockers (e.g., verapamil) being used as prophylaxis. Atypical facial pain is a continuous ache with intermittent episodes, localised to non-muscular, non-joint facial areas. The pain may be unilateral or bilateral, and may persist for many years. Typically, these patients consult a variety of specialists, such as dentists and otolaryngologists. Surgical procedures such as tooth extraction or sinus surgery, even if skillfully executed, exacerbate the condition, are are thus contraindicated. If the patient does not respond to reassurance, antidepressants may be tried. In sinusitis, the pain location is dependent upon which paranasal sinus is affected. Routine diagnostic nasal endoscopy and coronal plane computed tomography enable subtle pathological changes that are related to chronic pain to be identified. If medical treatment fails to afford relief, surgery should be considered. Pain, limited range of jaw motion, and joint noises are the common characteristics of temporomandibular disorders. Treatment usually consists of non-surgical means such as splints, occlusal equilibration, and non-steroidal anti-inflammatory drugs. Surgical treatment is indicated in a few carefully selected cases. Most dental pain is attributable to caries or periodontal disease. When pus is present, drainage affords excellent pain relief. Acute pericoronitis involving mandibular third molars responds to irrigation, removal of maxillary third molar trauma, and--in cases of serious infection--antimicrobial therapy. Early recognition of a case of chronic pain improves the chances of successful management, and avoids frustration and disillusion both to patient and doctor.