Facial pain - Newcastle Hospitals NHS Foundation Trust

Everyone is aware of toothache, but not everyone is aware of facial pain. Facial pain conditions can be broadly categorised into three main types:

Temporomandibular disorder (TMD).
Pain coming from conditions affecting the sensory nerves (E.g., Burning mouth syndrome, “phantom” tooth pain and trigeminal neuralgia).
Nerve injury after surgery.

Meet the team

The facial pain team is a specialist service. During your appointment, students, specialist trainees or visiting UK and international clinicians from the UK may be present.

The facial pain team includes:

Professor Justin Durham, Lead and honorary consultant oral surgeon
Mrs Emma Beecroft, academic oral surgery specialty registrar
Mrs Emily Carter, specialist oral surgeon
Dr Jamie Coulthard, clinical psychologist
Mrs Margaret Corson, consultant in restorative dentistry
Mrs Hannah Desai, senior lecturer and honorary consultant oral surgeon
Dr Rachel Green, senior lecturer and honorary consultant oral surgeon
Dr Chris Penlington, clinical psychologist and lecturer

We work closely with the specialist headache teams. This includes a monthly joint headache and facial pain clinic with Dr Paul Dorman, consultant neurologist and honorary senior lecturer or Dr Will Sedley, senior lecturer and honorary consultant neurologist.

The facial pain team is part of the wider chronic pain service based in the RVI.

Temporomandibular disorder (TMD)

After toothache, the most common facial pain are temporomandibular disorders (TMD).

TMD are a group of conditions that commonly present as an aching discomfort around the jaw joint often worsened by activities such as biting or talking.

Noises such as popping or clicking within the joint may be heard, locking or difficulty opening the jaw and headaches may also be associated.

TMD can affect the jaw joint itself, the muscles which control jaw movement, or both.

TMD management

As TMD is a very common condition, and easily manageable in its early stages. The booklets and video links below explain in more detail what causes TMD and how it is best managed.

Temporomandibular Disorders (TMD) – Information for patients

What to do about jaw pain

Self management for temporomandibular disorders

Self-management for TMD

The vast majority of TMD (>75%) do not worsen with time. It is important to understanding that pain does not equal damage, continuing to use your jaw normally is important and will not cause harm.

TMD tends to present cyclically with periods where pain feels worse and periods where it feels better. Supported self-management strategies we advise that all individuals with TMD symptoms build into their daily self-care routine are outlined below.

Their use will be particularly beneficial at times where your pain worsens to help manage symptoms as they have been shown to support TMD recovery and pain management, resulting in improvement in most cases.

Self-management strategies expected to be beneficial for all TMDs

Caffeine avoidance

Caffeine is a stimulant that can worsen pain, increase stress and cause muscle tension. Decreasing caffeine intake is beneficial for anyone suffering with pain.

Short-term soft diet

Eating foods with a softer consistency such as omelettes, pasta, well-cooked potatoes or stews will reduce the work your jaw has to do in times of pain.

This short term rest (5-10days) can help recovery. Returning to a normal diet should happen as soon as possible.

TMD nutrition guide

Parafunctional and postural habits

Habits that stress the jaw joint and facial musculature should be avoided. Chewing gum, pencil tops and nail-biting are common behaviours likely to worsen TMD.

Examine your posture and try and maintain your head up and shoulders back. Examine your usual positions during the day, for instance working at a desk and ensure that they are ergonomic.

Jaw tension

Apart from when you are eating your teeth should be apart. If you are aware, you hold tension in your face or jaw, placing stickers or marks on items you look at regularly throughout the day (watch, phone, computer screen) can act as a reminder to reduce jaw tension and ensure teeth are not clenched.

Diaphragmatic breathing to aid relaxation

5-breathing-techniques blog

Concentrate on taking deep slow breaths in through your nose and feeling your chest expand with your hands on your stomach. Your hands will move inwards and slightly upwards if you are doing it correctly. You can just use the technique for five minutes every two hours to aid relaxation and whenever you start to feel tension or stress develop through the working day.

Gentle exercise

Completing regular gentle exercise has been shown to provide benefit for individuals with any condition which causes pain. Exercise does not have to be organised, a simple activity such as a daily walk or completing a gentle full body stretching routine has been shown to support pain management.

Maintaining social contacts and completing activities which provide joy

Limiting activities, such as eating or talking, in a bid to reduce TMD pain can in fact worsen the situation. Maintaining social relationships for example, continuing to see friends socially or talking on the telephone to family members, limits isolation and ensures continued support which is important for any individual living with pain.

In addition, pain can lead to people feeling like they have “lost” who they were. Taking time every day to complete an activity or hobby which brings the individual joy (e.g., knitting, quiz nights, reading), provides relaxation, and can support the release of chemicals in the brain associated with pain reduction.

Thermal modalities

Apply moist heat or ice to affected muscles and any area on your head, face, and neck where you feel pain.
A warm moist flannel wrapped around a heat pack or warm hot water bottle will provide moist heat.
Apply for 15-20 minutes twice daily to the affected areas.
Ice can be applied to affected areas using an ice pack wrapped in a tea towel placed onto the skin overlying the affected muscle until the muscle feels frozen and numb (usually within 5 -10 minutes of application of the covered ice pack).
For some people, heat feels most beneficial, for others cold.
Trying heat for 3 days and then cold for 3 days may help provide information as to which works for you.

Facial massage

Massaging painful areas improves blood supply, relieves tension, and reduces pain. The two most affected muscles in TMD are the temporalis and masseter.

Massage techniques for these muscles are demonstrated in the video and also explained below.

Temporalis

Using index and middle fingers apply gentle pressure to temporal region either side of the head. Make small circular motions applying pressure to any tender regions.

Masseter

Place left thumb inside the right cheek, the left index finger outside the right cheek. Between the thumb and index finger is the masseter muscle. Gentle squeeze thumb and finger together to apply pressure to the muscle. The muscle should be stretched from top to bottom and back to front.

Massages should be completed for one minute per muscle three times a day.

Coordination training

Coordination training exercises help with jaw alignment, exercise 1 (N-stretch) will provide benefit for anyone with TMD pain of any type.

Exercise 2 (N-stretch combined) will benefit anyone whose jaw does not open straight when looking in a mirror. Coordination training exercises are demonstrated in the video and are explained below.

Coordination training exercise 1

N-Stretch Open your jaw normally and then curl your tongue to the top and back of your mouth. You should feel your jaw move backwards slightly.
Keeping your tongue in this position close in a slow controlled manner over five-six seconds (one set).
Complete 20 repetitions up to four times a day.

Coordination training exercise 2

Practice opening straight in the mirror, gently place a hand lightly on either side of your face to guide your jaw to open in the straight manner.
Do this in a slow, controlled manner over five-six seconds (one set).
Complete five-six sets up to four times a day.

Only complete this exercise if your jaw deviates to one side when opening.

Further self-management strategies expected to be beneficial for some specific TMD.

In addition to all of the above management strategies likely to be beneficial for any type of TMDs, the below additional exercises are likely to be beneficial in certain specific instances.

Static stretching

Safe and beneficial for any TMD presenting with reduced mouth opening.

Please do not use this exercise if you are able to open your mouth normally.

Apply thermal modality (as above) to jaw joint at both sides for 5 minutes prior to static stretch exercises.
Gently open to point of maximum opening.
Place your index fingers on the lower canine teeth and your thumbs on your upper canine teeth (fingers and thumbs will be crossed).
Stretch gently for 30 seconds to the point of discomfort and a small amount further and hold for 30 seconds.
Complete 5-6 repetitions up to 3 times per day.

Mobilisation

This exercise must only be used if you have been formally diagnosed with disc displacement with reduction and limited opening.

Please do not use this exercise if you have not been told you have this diagnosis.

Lightly hold a small cotton wool roll between your upper and lower front incisor teeth.
While gently holding the cotton wool roll move the lower jaw to one side then back to the centre over 5-6 seconds.
Continue to gently hold the cotton wool roll and move to the lower jaw to the opposite side over 5-6 seconds.
5-6 repetitions should be completed 3-4 times daily with each movement made over 5-6 seconds in a slow controlled manner.

Isometric tension exercise

Isometric tension exercises work to strengthen the main muscles which move the jaw.

This video demonstrates 2 exercises, exercise 1 is suitable for anyone told they have a muscular TMD.

Isometric tension exercise 1

(Suitable for musculature TMD)

Place the back of your hand under your lower jaw and provide gentle resistance upwards as you try to open.
Try and open against this resistance and hold your opening against this resistance for five-six seconds (one set).
Complete five-six sets up to four times a day.
The same exercise is completed with gentle pressure placed to the side of your lower jaw while you open and move your jaw to one side.
Again, opening with lateral movement should be against gentle resistance and at maximum opening laterally opening should be help against the resistance for five to six seconds.
Complete five-six sets up to four times a day.

Isometric tension exercise 2

This video demonstrates 2 exercises, the second of which should only be used and is likely to support recovery for individuals who have had a TMD diagnosis of disc displacement with reduction.

Only complete this exercise if you have been given a diagnosis of disc displacement with reduction.

Place the back of your hand under your lower jaw and provide gentle resistance upwards as you try to open and push lower jaw forwards (protrude jaw) whilst opening.
Complete 10 repetitions each held for 5-6 seconds 2-3 times a day.

Nerve based pain

Phantom tooth pain

Phantom tooth pain is pain that persists for a long time after a problematic tooth has been extracted or root canal treated.

Burning mouth syndrome

Burning mouth syndrome is a painful, burning sensation that can affect the mouth which otherwise looks physically normal.

Trigeminal neuralgia

Trigeminal neuralgia is a sudden, severe, sharp, stabbing facial pain often described like “electric shocks” in the face which lasts seconds to minutes. Between painful shocks often no pain is felt, but in rare cases there may be some lower intensity pain felt between shocks.