The Orofacial Pain is very complex.

Among the reasons that would explain this complexity they highlight: The complicated orofacial inervation, the wide sensitive cortical representation of the orofacial structures and the high prevalence of the oral pathology.

The nerves in charge of picking up the orofacial sensibility have an intricate organization, since in her they intervene: The cranial nerves Trigeminal, Facial, Glossophayingeal and Vagus and the first three Upper Cervical nerves.

As a consequence of the great inervation density for surface unit, the orofacial structures are broadly represented in the sensitive cortical area (sensorial homunculus of Wilder Penfield).

The high prevalence of dental and parodontal illnesses and the frequency with which they are carried out surgical treatments on the oral structures are factors that increase the incidence of the orofacial pain.

All the orofacial structures, somatic and neuropathic, they can cause pain.

The diagnosis and treatment of the orofacial pain is complicated by the density of the anatomical structures of the area and the mechanisms of referred pain.

It proves of this complexity it is the quantity of described syndromes with orofacial pain.

Here we present 23 of these syndromes that he will be necessary to keep them in mind in certain cases of differential diagnosis:

AURICULOTEMPORAL NERVE SYNDROME

Synonyms: Frey, Frey-Baillarger Syndrom, Dupuy Syndrom

This not very common syndrome was described from 1757.

The patient typically presents blush and perspiration in the affected side of the face, mainly in the temporary area, during the food.

The intensity of the perspiration frequently increases with the ingestion of spicy. In occasions, there are pain and sensorial alterations in the swig and in the jaw.

This syndrome is caused by the trauma to the auriculotemporal nerve, in form of parotiditis, hurt by firearm in the parotid area, septicemia, mandibular resection, or more commonly, conservative parotidectomy. He has been pointed out as complication in 80% of the cases post-parotidectomy.

After the traumatism of the auriculotemporal nerve, the sweat glands and the glasses of the skin on their distribution, they are denervated producing sensorial dysfunctions.

In the regeneration process, the parasympathetic nerves take mistaken roads and they grow together with the nice roads. Because the sympathetic terminations of the sweat glands are colinergic, the parasympathetic nerves activate the glands. This way, a gustatory stimulus produces perspiration and blush.

The syndrome appears totally developed of two months to two years after the trauma (on the average nine months) and it generally lasts a lifetime.

There are cases in that the surgical treatment of intracranial division of the auriculotemporal nerve has been effective.

CAROTODYNIA'S SYNDROME

The carotodynia refers to the pain that is born of an or both arteries external carotids and which you can irradiate toward the ipsilateral side of the face and the hearing.

In occasions, a nuisance in the head and the face can be the first manifestation of the carotodynia. Although the pharynx can exhibit a slight hiperemia, they are absent the exudatives changes of the bacterial infection. The regional lymphatic ganglion are not enlarged. Most of patient complains about irritated throat, which can be erroneously tried with antibiotics.

The dilation, distension or displacement of a segment of the artery stimulates the sensitive roads to the pain in the adventitious tunic. The head movement, the deglution, the mastication, the cough, the yawn or the sneeze, they can precipitate the pain.

The diagnosis settles down applying digital pressure on the carotideal segment affected with a slight later displacement. This pressure unchains the painful pattern of a spontaneous attack.

The specific etiology is still ignored, although it is supposed of viral origin.

The initial treatment is conservative and it consists on the support to the patient and the prescription of a diet with the help of moderate soft and analgesic foods. The unsociable cases have been managed surgically by means of the interruption of the cervical nice fibers and the division of the sheath carotideal.

CHARLIN'S

Synonyms: Ciliary neuralgia, Nasal Nerve Syndrome, Nasociliary Neuralgia, Supraorbital Neuralgia, Nasociliaris Nerve Syndrome

This syndrome is a migraine form caused by spasm vasomotor of the meningeus half artery that one manifests with violent pain that affects the orbit, the temple, front, nose and maxillary regions.

The attacks can last from 15 to 60 minutes, they spread to be disseminated toward the inferior half of the head and they can study with vomits. It has been informed cases of suicide due to the intensity of the pain.

The treatment for the relief of the symptoms is the application of cocaine in the anterior etmoidal nerve to the nostril on the affected side.

The essential characteristics of the Charlin's syndrome are:

COSTEN'S SYNDROME

James B. Costen, Belgian otorhinolaryngologyst, described its concept of this entity for the first time the year 1934 [Syndrome of the ear and sinus symptoms dependent upon disturbed function of the temporomandibular joint. Ann Otol Rhinol Laryngol 1934; 43: 1-15].

The investigator tried to relate the cases of auditory dysfunction, tinnitus, facial and temporary neuritis, otalgia and glossodynia with the TMJ disfunction caused by the excessive closing of the jaw.

The current consent is that he should give way the concept of Costen's syndrome.

CRANIOFACIAL PAIN SYNDROME

Synonym: Primary Atypical Facial Neuralgia

This syndrome is a frequent and controversial craniofacial pain .

It is a not well defined transition between the classic migraine and the Trigeminal neuralgia. Many authors consider it like a variant of the vascular migraine. Engle classifies it as a symptom of hysterical conversion.

The characteristics of the Craniofacial Pain Syndrome are:

A rational method for the treatment consists on a careful and detailed history of the nature of the pain and of the aggravating factors. .

Underlying local illnesses should be excluded (heard, nose, throat, dental and neurological). It is necessary to analyze the conditions of the patient's life.

It can be necessary the pharmacological treatment, as tranquilizers and analgesic.

EAGLE'S SYNDROME

The pain of the Eagle's syndrome characteristically is experienced in constant form during the whole convalescence after an amigdalectomy.

During the following years a throat irritation persists. The patient has the sensation of a strange body in the throat and dysphagia. The pain refers toward the hearing.

An Styloid Process very elongated is the cause of the pain in the Eagle's syndrome. These pharyngeal pains come from the shrink or the fibrosis that it happens during the scaring after the amigdalectomy in the nervous sensitive terminations of V, VII, IX and cranial even X whose branches inervation the affected area.

The diagnosis of an elongated styloid process made with the soft palpation of the tonsillar fossa with the index finger. Digital palpation of the styloid in the tonsillar fossa will exacerbate the dull pain. The X-rays will confirm this condition later on.

The treatment is the surgical division of the elongated styloid process.

STILOID PROCESS-CAROTID ARTERY SYNDROME

If the Eagle's syndrome is presented with migraine, then the stiloid process is pressing on the internal or external carotid artery.

This diminishes the caliber of these arteries and it irritates the sympathic fibers in the arterial wall.

The insuficience of the external carotid artery produces suborbital pain along the road irrigated by this artery.

FOIX'S SYNDROME

Synonym: Lateral Wall Cavernous Sinus Syndrome

There is paralysis of the III, cranial nerve IV and VI that he gives place to proptosis and edema of the lids and the conjunctive one. The dissemination to the cranial nerve V gives place to a trigeminal neuralgia.

The cause of this syndrome is a tumor that includes the lateral wall of the cavernous sinus or of the sphenoid bone, intracraneal aneurysms or thrombosis of the cavernous and lateral sinus.

The treatment, if it is possible, is the extirpation of the body producing of the pressure.

GLOSSOPFARYNGEAL NEURALGIA SYNDROME

This syndrome is characterized by a paroxysmal pain (that lasts 20 to 30 seconds), followed by a sensation of burning (that lasts from 2 to 5 minutes) in the later part of the tongue , pharynx and soft palate and that he extends toward the hearing.

A trigger area is generally located on the lateral wall of the pharynx, in the base of the tongue or in the area of the later external hearing to the mandibular branch. The movement of the tongue, the yawns or the cough, they can precipitate the attack.

The provoked pain is intense and several and in general it is continued for shed tears and homolateral salivation.

You proceeds to the cocaine application of the lateral pharyngeal wall to determine the presence of a true glosopharyngeal neuralgia syndrome.

A idiopathic type of this syndrome exists in which most of the symptoms give after the fifty years. In groups of younger ages, the organic causes can be anomalous arteries in the pont angle, arachnoiditis , perineural fibrosis, elongation of the stiloid process or a viral infection.

In persistent cases it is suitable the surgical correction of the diagnosed cause.

GOTDFREDSEN'S SYNDROME

Synonym: Cavernous Sinus Syndrome-Pharyngeal Tumor

This syndrome produces an ophthalmoplegia -for affectation of the VI cranial nerve-, it anesthetizes or neuralgia in the area of the V cranial nerve and paralysis of the tongue in the affected side.

It is consequence of the compression of the hypoglossal nerve for enlargement of retropharynx lymphatic ganglion affected .

The treatment is the elimination of the tumoral mass.

HORNER'S SYNDROME

This syndrome is characterized by miosis to paresis of the pupil's dilator, ptosis to paresia of the flat elevator superior lid muscle, anhidrosis and vasodilatation on the due face to the interruption of the sweat motor and vasomotor control, and facial pain.

The main importance of this syndrome is that it indicates the presence of a primary illness. Injure in the cerebral shaft, the marrow cervical or thoracic discharge can produce this syndrome.

The dissemination to the simpathic plexuses carotided of lesions of the Gasser ganglion, or aneurysms of the internal carotid artery, finally they can produce the facial sweat, facial pain and sensorial loss.

The treatment is the elimination of the tumor or the aneurysm.

HORTON'S SYNDROME

Synonyms: Ciliary Neuralgia, Cluster Headache, Histaminic Headache, Migraine Neuralgia, Petrous Neuralgia

The Horton's syndrome at the moment is known more commonly as Cluster Headache or Histaminic Headache.

The attack happens in series or in groups and the pain is unilateral, severe and lancinanting.

The pain is so intense that they are common the declarations like "almost I become crazy with the pain". The pain can last from 10 minutes to 10 hours.

The recurrent attacks of exruciating pain of lancinanting type affect the unilateral temporary area, from the external zone of the eye and the line of the hair, passing to the forehead, side of the head and shoulder. It can be irradiated toward the maxillary one and the jaw, although not toward the lips neither the tongue.

The level of the pain is intensified and during this, the patient cannot be put to bed and she prefers to sit down or to walk. Some patients can end up attempting the suicide.

This syndrome happens mainly in men bigger than 40 years of age, it is of night nature, it can repeat daily and to only disappear during months to repeat in a similar station of the following year.

The differential diagnosis should include the presence of migraine syndrome (in Horton's Syndrome it doesn't happen the pre-headache phenomena and the nausea and the vomits are not present) and the trigeminal neuralgia (a trigger area doesn't exist).

The attacks can throw for the ingestion of alcoholic drinks or the histamine injection. The symptoms coincide with those of autonomous hyperactivity and they are born of the main intracraneal branches of an or both internal carotids arteries.

The reflective variety of treatments the lack of permanent success. Drugs type ergotamine and methisergide are used.

HUNT'S SYNDROME

Synonyms: Geniculate Ganglion Syndrome, Otitic Herpes Zoster , Ramsey-Hunt's Syndrome

The Hunt's Syndrome is a special form of infection for herpes zoster of the geniculate ganglion. In this case they happen lesions for zoster in the external hearing and possibly in the mucous one oral.

There is a deep pain from behind in the fissure of the hearing between the pavilion and the mastoid process or in the hearing. Next, the pain can be irradiated and to embrace the face, heard, neck and occipital area.

The pain can be unilateral, paroxismal or constant and, in general, it precedes to the appearance of the zoster vesicles. Intraoral, the zoster vesicles can contaminate theperiamygdalin region, oropharynx and the later and lateral third of the tongue with associate pain.

The geniculate ganglion of the intermediate nerve innervated the cutaneous and mucous regions, as well as the ganglion of the cranial nerves IX and X. The outlying sensorial distribution of the intermediate nerve is also located in areas innervated by sensorial fibers of the cranial nerves V, IX and X.

JACOD'S SYNDROME

Synonyms: Jacod's Triad, Negri-Jacod's Syndrome, Retrosphenoidal Space Syndrome

This syndrome is characterized by an triad of ophthalmoplegia, a lesion of the optic sheaf with unilateral amaurosis and trigeminal neuralgia, combined with characteristic of the pterygopalatine fossa syndrome and Trotter's syndrome .

In opinion of Jacod, the tumor that causes this syndrome is intracraneal and he extends along the floor of the cranial medial fossa, to invade the nerves that pass through the oval foramen, bigger round foramen and the sphenoidal fissure.

The tumor can extend along these roads or intracraneal to produce ophthalmoplegia for invasion of the cranial nerves III, IV and VI, as well as blindness if the optic nerve is affected.

Others authors consider to this syndrome like pathognomonic of nasopharingeal malignant tumors that originate inside or near the latero-pharingeal area.

The treatment is the surgical extirpation of the tumor, whenever it is possible.

MIGRAINE SYNDROME

• A discharge of autonomous centers in the previous brain that causes cerebral arterial vasoconstrictions.
• Vasomotor Edema.
• Allergy.
• Related endocrine factors especially with the pituitary gland.
• Toxic absorption.
• Psychological Factors derived of a compulsive obsessive migraine personality.

PLUMMER-VINSON'S SYNDROME

Synonym: Anemia for iron deficit

This syndrome is a manifestation of the iron deficiency that happens mainly in 40-50 year-old women.

The symptoms include the flat and painful tongue, fissures in the corners of the mouth, due dysphagia to oesophagical hardship, paleness yellow-lemon of the skin, achlorhydria and atrophies of the mucous ones buccal, glossopharyngeal and oesophagical.

The cause is the achlorhydria in the stomach that gives place to inability to absorb iron.

The treatment of the anemia implies the iron administration and an abundant diet in proteins.

PTERYGOPALATINE FOSSA SYNDROME

This syndrome is seemed to the Trotter's syndrome.

However, the pain of the Pterygopalatine Fossa Syndrome is manifested in the maxillary one more than in the jaw, the anesthesia of the infraorbital areas happens and of the palate, to that which can follow blindness and nervous motorboat paralysis of the pterygoids muscles.

The cause is a metastasic tumor in the pterygopalatine fossa. In their expansion the tumor affects the maxillary division of the V cranial nerve and the adjacent structures.

The treatment is directed toward the tumor.

RAEDER'S SYNDROME

Synonyms: Paratrigeminal Neuralgia, Paratrigeminal Paralysis, Paratrigeminal Syndrome

The Raeder's Syndromer is strange and it is characterized by pain in or around the eye, it is presented with a Horner's incomplete syndrome (miosis and ptosis without enophthalmos and sweating in the face), as well as paralysis of the trigeminal nerve.

This syndrome also possesses a narrow relationship with the cluster headache except that, as Raeder settled down, all the cases are due to next lesions to the base of the medial cranial fossa, with damage to the V cranial nerve.

In this syndrome two symptoms types exist.

The patients with the migraine and reflection type have migraine antecedents with recurrence of the symptoms. The cause is the local irritation, generally due to infection (of the hole, abscess dental, otitis).

The second type is symptomatic without migraine history and with a sudden beginning of the symptoms. The cause is an aneurysm of the internal carotid, congenital abnormality of the carotideal siphon, traumatism to the base of the skull, metastasic tumors or primary tumors.

The treatment is directed to the cause.

SLUDER'S SYNDROME

Synonyms: Migraine of the inferior half, Inferior Facial Neuralgia Syndrome, Sluder Neuralgia, Sphenopalatine Ganglion Neuralgia, Sphenopalatine ganglion Syndrome

The Sluder's Syndrome is a not very common facial neuralgia characterized by sharp pain in the inferior half of the face below the brows.

The pain is unilateral, constant and burring; it can refer to the eye, nose, maxillary, heard teeth, zygoma, palate, pharynx and even until the shoulder and arm. Sialorrhea can be presented, tearing, sneezes, photophobia and salivation. A trigger area doesn't exist.

The distribution and the duration of the pain is variable and he can simulate the Horton's histaminic syndrome.

Many investigators have refused that the Sluder's syndrome exists like a different clinical entity.

The cause is affection of the sphenopalatine ganglion due to a common irritation as the sinusitis. It is thought that the resulting pain is of neurovascular distribution and therefore, of origin and visceral type.

The affected areas correspond those irrigated by the sanguine vessels that they receive visceral autonomous fibers and sensorial motorboats through the sphenopalatine ganglion.

The treatment consists on the application of cocaine, injection of alcohol or resection of the sphenopalatine ganglion.

SYNDROME OF PAIN AND BLUSH SUBMANDIBULAR, RECTAL AND OCULAR

This syndrome was described for the first time in 1959 by Hayden and Grossman.

It is characterized by a very brief exruciating pain in the submandibular, rectal and ocular areas, as well as for blush of the adjacent skin.

The submandibular and ocular pain happens with more frequency that the rectal pain. The submandibular pain is deaf, it is not irradiated and it is generally unilateral.

It seems that the pain happens for the observation of foods; hard around 30 seconds and it continues him a profuse salivation. The orbital pain is acute, it is not irradiated and it is of difficult localization, he associates with tearing abundant, strabismus and blurred vision that it lasts 90 seconds. The rectal pain can last from 10 to 60 seconds and it culminates with defecation.

With base in the study of a family, it is believed that this condition is a feature dominant autosomic, with variable penetrance of the components.

TEMPORAL ARTERITIS SYNDROME

Synonyms: Cranial Arteritis Syndrome, Temporal Arteritis

This syndrome consists of painful inflammation of an or more temporal arteries.

He is formed cellulitis on the inflamed artery and it is presented with photophobia, diplopia, transitory or permanent blindness, low-grade fever, chills, loss of weight, anorexy, profuse sweat, general uneasiness and it tires. There is a moderate leukocytosis. The erythrocyte sedimentation rate (ESR) is invariably increased.

The histological examination of an affected artery reveals arteritis characterized by hyperplasia of the intimate one and destruction and internal fragmentation of the elastic one. A reaction granulomatous affects all the layers of the artery.

The treatment is with the help of corticosteroids. The section and the surgical removal of the affected fabric is effective when interrupting the perivasculars sympathic fibers.

TROTTER'S SYNDROME

Synonyms: Sinus of Morgagni Syndrome, Peritubular Syndrome

In this syndrome pain is experienced in the jaw and in the tongue, with migraine of the affected side, unilateral deafness, deviation of the palate, faulty mobility of the palatine and internal pterygoid muscles, and cervical adenopathy.

The etiology of this syndrome is a neoplasia (in general malignant) that he originates deeply in the lateral wall of the pharynx and it invades the sinus of Morgagni.

It is more often observed in the males from thirty to forty years of age.

The treatment is directed toward the tumor and its symptoms.

VAIL'S SYNDROME

Synonyms: Vidian Neuralgia

The Vail's syndrome is characterized by attacks severe paroxysm of pain that embrace the nose, face, eye, heard, head, neck and shoulder.

The women are those most commonly affected ones and the pain in general is night.

Vail believed that the condition was derived of an infection of the breast sphenoidal, with inflammation of the vidian nerve, which is disseminated then to the spfenopalatine ganglion or geniculate.

Another theory proposes the vasodilatation of the internal maxillary artery. Some authors consider this syndrome like a variant of Charlin's and Sluder's syndrome.

Vail considered essential the drainage of the breast sphenoidal for the permanent relief.