Oro-facial pain

Red flags

  • Weight loss
  • History or suspicion of malignancy
  • Neurological changes

The following may lead to more urgent PPMS categorisation

  • Severe symptoms despite optimum management
  • Escalating opioid dependency

These conditions should be initially assessed by Neurologist, dentist or other to exclude important underlying conditions before referral to PPMS.

Oro-facial pain coniditions include:

  • Trigeminal neuralgia
    • Chronic pain affecting the distribution of the 5th cranial nerve
    • Pain can be intermittent (TN1) or continuous (TN2)
    • May be caused by pressure on the nerve of a blood vessel or rarely tumour or previous trauma
  • Post herpetic neuralgia
    • Persistent pain after herpes zoster infection
    • More common in elderly and affecting the face
  • Atypical facial pain
    • A pain disorder of the face, is often compared to trigeminal neuralgia but is a different entity. Symptoms are more persistent, with few, if any, periods of remission. Pain is usually localized to one side of the face and can be described as sharp, dull, crushing, aching, burning, pulling or squeezing. There are many possible causes of ATFP, and diagnosis is usually reached through a process of elimination
  • Chronic temporomandibular pain
    • More common in chronic widespread pain syndrome and chronic fatigue syndromes
  • Glossopharyngeal neuralgia
    • Repeated severe episodes of pain involving the tongue, throat, ear and tonsils
    • May be caused by pressure from blood vessels, tumour, infections but often no cause is found

Other important information for referring practitioners

Lifestyle changes

  • Encourage healthy activity within pain limits
    • Consider physio referral
    • Desensitisation massage
    • Hydrotherapy
  • Ensure adequate sleep
  • Check for mood disturbances and relationship difficulties
    • Consider psychology referral for any mood disturbances and to assist with pain control

Medical management

  • Optimise medical management of predisposing secondary condition (if present)
  • Set realistic goals
  • Treat associated mood disorders
  • Avoid over-reliance of medication, encourage self-management and set realistic goals for treatment
    • Consider nerve blocking procedure if single nerve involvement
    • Transcutaneous electrical nerve stimulation (TENS)
    • If trialling medication, start at low dose and titrate upwards
    • Agree on trial period for medication

Current medications used in chronic oro-facial pain are:

  • Amitriptyline:
    • start at 10mg and slowly escalate dose (this may take weeks)
    • max dose 75-100mg
    • consider nortriptyline in older patients
    • anti-cholinergic effects on bladder can be troublesome in elderly males
  • Pregabalin:
    • PBS restricted for neuropathic pain refractory to treatment with other drugs
  • Carbamazepine (used primarily for trigeminal neuralgia and post herpetic neuralgia)
  • Duloxetine:
    • PBS approved for neuropathic pain and major depressive disorder
  • Consider topical 5% lignocaine patch for post herpetic neuralgia

Try to avoid opioid medications. Only use an opioid for exacerbations and set time limits on prescribing.

Referral requirements

A referral may be rejected without the following information.

  • Persistent Pain Management Service eReferral form
  • Reason for referral
    • Comprehensive multidisciplinary management plan
    • Specific concerns re medication overuse/dependence
    • Need for focussed multidisciplinary approach
  • History of condition
    • Date of onset and timeline
    • Any cause identified for pain
    • Management of condition.
    • Treatments trialled and reasons for failure
    • Include relevant specialist letters (pain medicine specialists)
    • List red flags
  • Current and previous relevant medical conditions
  • Current medications and past medications trialled for pain
  • List drug dependencies e.g. alcohol, cannabis, opioids and forensic issues
  • Allergies
  • Relevant examination findings
    • Plot sensory symptom distribution
    • Look for patterns of involvement (single nerve (entrapment), glove/stocking etc)
  • Investigations
    • FBC, E/LFT, BS, CRP
    • B12, folate, TSH
    • ANA, anti DNA Abs
    • CT/MRI head (must indicate suspected diagnoses)

Additional referral information (useful for processing the referral)

  • Patient to complete entry patient questionnaire prior to first consultation
  • Investigations related to co-morbidities e.g. diabetic control
  • Other relevant imaging
  • Nerve conduction studies

Out of catchment

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander
  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can’t order, or the patient can’t afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary
  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use
  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander
  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature
  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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