面部疼痛的鉴别诊断和治疗指南（一）
山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。
本次文献选自Zakrzewska JM. Differential diagnosis of facial pain and guidelines for management. Br J Anaesth. 2013;111(1):95-104.本次学习由杨聪娴副主任医师主讲。
Editor’s key points：Accurate diagnosis offacial pain is the fifirst stepin successfulmanagement.Dental and non-dentalcauses are both common,with consequentdiffificulties in appropriatereferral.The evidence formanagement is oftenextrapolated from otherchronic pain conditions.Well-designed clinicaltrials of facial pain areneeded, with clinicallyrelevant outcomemeasures.
Summary： The diagnosis and management of facial pain below the eye can be verydifferent dependant on whether the patient visits a dentist or medical practitioner. Astructure for accurate diagnosis is proposed beginning with a very careful history. Thecommonest acute causes of pain are dental and these are well managed by dentists.Chronic facial pain can be unilateral or bilateral and continuous or episodic. Thecommonest non-dental pains are temporomandibular disorders (TMDs), especiallymusculoskeletal involving the muscles of mastication either unilaterally or bilaterally;they may be associated with other chronic pains. A very wide range of treatments areused but early diagnosis, reassurance and some simple physiotherapy is often effectivein those with good coping strategies. Dentists will often make splints to wear at night.Neuropathic pain is usually unilateral and of the episodic type; the most easilyrecognized is trigeminal neuralgia. This severe electric shock like pain, provoked by lighttouch, responds best to carbamazepine, and neurosurgery in poorly controlled patients.Trauma, either major or because of dental procedures, results in neuropathic pain andthese are then managed as for any other neuropathic pain. Red flflags include giantcell arteritis which much be distinguished from temporomandibular disorders (TMD),especially in .50 yr olds, and cancer which can present as a progressive neuropathicpain. Burning mouth syndrome is rarely recognized as a neuropathic pain as it occursprincipally in peri-menopausal women and is thought to be psychological. Chronic facialpain patients are best managed by a multidisciplinary team.
Keywords: diagnosis; facial pain; guidelines
编者观点：
准确的诊断是正确治疗的第一步；
口腔科疾病和非口腔科疾病都非常常见，诊断和治疗存在一定困难；
治疗方法通常由其他慢性疼痛推断而来；
需要设计良好的临床试验，试验中需要包含临床结果测量。
摘要：眶下部面部疼痛的诊断和治疗经常因患者就诊于口腔科还是其他科室而出现不同的方案。首先需要仔细问询病史。急性疼痛的常见病因一般是口腔科疾病，在口腔科会得到较好的处理。慢性面部疼痛可以是单侧或双侧，持续性或发作性。非口腔科疾病中最常见的是颞下颌关节功能紊乱（TMD），可以是单侧或双侧，包含各咀嚼肌的骨骼肌源性疼痛，可以与其他慢性疼痛相关。虽然治疗方案多样，但是如果能正确诊断，早期诊断、确诊和简单理疗对很多患者有效。口腔科医生通常建议夜间带牙套。神经病理性疼痛通常是单侧发作性的，最常见的是三叉神经痛。这种由轻触引发的严重电击样疼痛，通常对卡马西平敏感，控制不好的患者通常进行神经外科手术。大的创伤或者口腔科操作带来的创伤，导致神经病理性疼痛。需要与TMD鉴别的疾病是巨细胞动脉炎，通常发生于50岁以上患者；肿瘤患者通常表现为进行性加重的神经病理性疼痛。灼口综合征通常发生于围绝经期妇女，并且认为是心理因素相关的，很少诊断为神经病理性疼痛。慢性面部疼痛最好由一个交叉学科的团队治疗。
关键词：诊断；面部疼痛；指南
INTRODUCTION
The area from the eyes down to the lower mandible of theface is a territory shared between the medical and dental professions. The public remain confused as to who they shouldconsult when they develop chronic pain in this area. Thecare pathway may be very different depending on who theyconsult. Dentists will refer their patients to dental schoolsand oral and maxillofacial surgeons, whereas general practitioners will refer to ear, nose and throat (ENT) neurology, orpain medicine. Dental pain is extremely common and it canalso co-exist with other conditions. Patients with facial painwill often have other co-morbidities, including depressionand chronic pain elsewhere: a biopyschosocial approach isneeded for successful management.
概述
眼眶下方到下颌下部的区域由口腔科医生和内科医生共同管理。该区域疼痛的患者通常在选择就诊科室时会感到迷惑。就诊的科室不同，治疗方案可能会不同。口腔科医生会把他们的病人转给口腔科教育机构和口腔颌面外科医生，而全科医生会把病人转给耳鼻喉科(ENT)神经学或疼痛科。牙痛是非常常见的，它也可以与其他疾病共存。面部疼痛的患者通常会有其他合并症，包括抑郁症和其他部位的慢性疼痛:成功的治疗需要生物心理社会方法。
The diagnostic criteria for orofacial pains can be found bothin the International Association for the Study of Pain (IASP)classifification1 and in the International Headache Classifification2 (to be re-published in 2013); there are some variationsbetween the two classififications. Very few of the criteria forfacial pain have been validated by case control studies. Froma clinical perspective, it may be most useful to divide chronicpain into those with continuous or episodic pain and then unilateral or bilateral, rather than using the more conventional classififications (e.g. neuropathic and vascular) which arehelpful in management (Fig. 1). It must always be remembered that facial pain can be secondary to primary cancer ora metastasis from elsewhere. It is important to attempt a diagnosis as Durham and colleagues3 have shown that lack ofa diagnosis in patients with temporomandibular disorders(TMDs) impacted on sufferers’ daily lives.
口面部疼痛的诊断标准可以在国际疼痛研究协会(IASP)分类和国际头痛分类中找到(在2013年重新发布);这两种分类之间有一些差异。面部疼痛的标准很少被病例对照研究证实。从临床角度来看，可以将慢性疼痛划分为持续性或发作性疼痛，或是单侧或双侧疼痛，而不是使用更传统的分类(如神经性和血管性)，对治疗很有帮助(图1)。一定要记住，面部疼痛可能是继发于肿瘤或转移瘤。此外，Durham和他的团队已经表明，颞下颌关节紊乱(TMD)患者不能及时诊断将会影响患者的日常生活。