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Craniofacial pain of cardiac origin: an interdisciplinary study
Umeå University, Faculty of Medicine, Department of Odontology, Oral and Maxillofacial Radiology.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Referred pain is frequently associated with misdiagnosis and unnecessary therapy directed to the pain location instead of its origin. When craniofacial pain is the sole symptom of myocardial ischemia, failure to recognize its cardiac source can endanger the patient. In particular, patients with acute myocardial infarction (AMI) who do not experience chest pain run a very high risk of misdiagnosis and death. Pain that is limited to the craniofacial region during myocardial ischemia has so far been described only in case reports and its overall prevalence is unknown. Experimental research in animals suggests a vagal involvement in the pathological mechanisms of cardiac pain referred to the face.

The aim of this study was to gain knowledge about the prevalence, clinical characteristics and possible mechanisms of craniofacial pain of cardiac origin, in order to improve the clinician’s ability to make a correct diagnosis. It was hypothesized that the quality of craniofacial pain from cardiac versus dental origin would differ, implying a high diagnostic validity. It was also hypothesized that craniofacial pain can be the sole symptom of a prodromal (pre-infarction) angina episode and that this pain location would be especially associated with cardiac ischemia in the areas more densely innervated by vagal afferent fibres.

The study group was comprised of consecutive patients who experienced craniofacial pain of a verified cardiac (n=326) or dental (n=359) origin. Demographic details on age, gender and pain characteristics (location, quality and intensity) were assessed in both groups. Cardiovascular risk factors, cardiac diagnosis and ECG signs of ischemia were also assessed in the cardiac pain group. Ethics approval and informed consent for each patient was obtained.

Craniofacial pain was found to be the sole symptom of myocardial ischemia in 6% of patients and was the sole symptom of an AMI in 4% of patients; this craniofacial pain was more prevalent in women (p=0.031). In those patients without chest pain, it was the most frequent pain location and was the only symptom of prodromal angina in 5% of AMI patients. The craniofacial pain included the throat, the jaws, the temporomandibular joints/ears and the teeth, mainly bilaterally. The pain quality descriptors “pressure” and “burning” were statistically associated with pain of cardiac origin, while “throbbing” and “aching” were associated with an odontogenic cause (p<0.001). In myocardial ischemia patients, the occurrence of craniofacial pain was associated with an inferior localization of ischemia in the heart (p<0.001).

In conclusion, this study showed that pain in the craniofacial region could be the sole symptom of cardiac ischemia and AMI, particularly in women. Craniofacial pain of cardiac origin was commonly bilateral, with the quality pain descriptors “pressure” and “burning”, and pain provocation with physical activity and pain relief at rest. The association between the presence of craniofacial pain and inferior wall ischemia suggests a vagal involvement in the mechanisms of cardiac pain referred to the craniofacial region. Since the possibility of misdiagnosis and death in this group of patients is high, awareness of this clinical presentation needs to be brought to the attention of researchers, clinicians and the general public.

Place, publisher, year, edition, pages
Umeå: Umeå university , 2011. , 70 p.
Series
Umeå University odontological dissertations, ISSN 0345-7532 ; 117
Keyword [en]
Acute myocardial infarction, myocardial ischemia, craniofacial pain, referred pain
National Category
Dentistry
Identifiers
URN: urn:nbn:se:umu:diva-43148ISBN: 978-91-7459-160-6OAI: oai:DiVA.org:umu-43148DiVA: diva2:411910
Public defence
2011-05-20, 933, byggnad 3A 9tr, Norrlands Universitetssjukhus, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2011-04-29 Created: 2011-04-20 Last updated: 2011-05-27Bibliographically approved
List of papers
1. Craniofacial pain as the sole symptom of cardiac ischemia: a prospective multicenter study
Open this publication in new window or tab >>Craniofacial pain as the sole symptom of cardiac ischemia: a prospective multicenter study
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2007 (English)In: The Journal of the American Dental Association (1939), ISSN 0002-8177, Vol. 138, no 1, 74-79 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Craniofacial pain can be the only symptom of cardiac ischemia. Failure to recognize its cardiac source can put the patient's life at risk. The authors conducted a study to reveal the prevalence of, the distribution of and sex differences regarding craniofacial pain of cardiac origin.

METHODS: The authors prospectively selected consecutive patients (N = 186) who had had a verified cardiac ischemic episode. They studied the location and distribution of craniofacial and intraoral pain in detail.

RESULTS: Craniofacial pain was the only complaint during the ischemic episode in 11 patients (6 percent), three of them who had acute myocardial infarction (AMI). Another 60 patients (32 percent) reported craniofacial pain concomitant with pain in other regions. The most common craniofacial pain locations were the throat, left mandible, right mandible, left temporomandibular joint/ear region and teeth. Craniofacial pain was pre-ponderantly manifested in female subjects (P = .031) and was the dominating symptom in both sexes in the absence of chest pain.

CONCLUSIONS: Craniofacial pain commonly is induced by cardiac ischemia. This must be considered in differential diagnosis of toothache and orofacial pain.

CLINICAL IMPLICATIONS: Because patients who have AMI without chest pain run a higher risk of experiencing a missed diagnosis and death, the dentist's awareness of this symptomatology can be crucial for early diagnosis and timely treatment.

Keyword
Angina pectoris; cardiac ischemia; myocardial infarction; orofacial pain; toothache
Identifiers
urn:nbn:se:umu:diva-22652 (URN)17197405 (PubMedID)
Available from: 2009-05-14 Created: 2009-05-14 Last updated: 2011-04-29Bibliographically approved
2. Quality difference in craniofacial pain of cardiac vs. dental origin
Open this publication in new window or tab >>Quality difference in craniofacial pain of cardiac vs. dental origin
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2010 (English)In: Journal of Dental Research, ISSN 0022-0345, E-ISSN 1544-0591, Vol. 89, no 9, 965-969 p.Article in journal (Refereed) Published
Abstract [en]

Craniofacial pain, whether odontogenic or caused by cardiac ischemia, is commonly referred to the same locations, posing a diagnostic challenge. We hypothesized that the validity of pain characteristics would be high in assessment of differential diagnosis. Pain quality, intensity, and gender characteristics were assessed for referred craniofacial pain from dental (n = 359) vs. cardiac (n = 115) origin. The pain descriptors "pressure" and "burning" were statistically associated with pain from cardiac origin, while "throbbing" and "aching" indicated an odontogenic cause. No gender differences were found. These data should now be added to those craniofacial pain characteristics already known to point to acute cardiac disease rather than dental pathology, i.e., pain provocation/aggravation by physical activity, pain relief at rest, and bilateralism. To initiate prompt and appropriate treatment, dental and medical clinicians as well as the public should be alert to those clinical characteristics of craniofacial pain of cardiac origin.

Place, publisher, year, edition, pages
Sage, 2010
Keyword
acute myocardial infarction, cardiac ischemia, craniofacial pain, dental pain and referred pain
National Category
Dentistry
Identifiers
urn:nbn:se:umu:diva-35486 (URN)10.1177/0022034510370820 (DOI)000281081500014 ()20448243 (PubMedID)
Available from: 2010-08-20 Created: 2010-08-20 Last updated: 2011-04-29Bibliographically approved
3. Craniofacial pain can be the sole prodromal symptom of an acute myocardial infarction: an interdisciplinary study
Open this publication in new window or tab >>Craniofacial pain can be the sole prodromal symptom of an acute myocardial infarction: an interdisciplinary study
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(English)Manuscript (preprint) (Other academic)
Identifiers
urn:nbn:se:umu:diva-43288 (URN)
Available from: 2011-04-26 Created: 2011-04-26 Last updated: 2011-04-29Bibliographically approved
4. Craniofacial pain of cardiac origin is associated with inferior wall ischemia
Open this publication in new window or tab >>Craniofacial pain of cardiac origin is associated with inferior wall ischemia
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(English)Manuscript (preprint) (Other academic)
Identifiers
urn:nbn:se:umu:diva-43289 (URN)
Available from: 2011-04-26 Created: 2011-04-26 Last updated: 2015-04-15Bibliographically approved

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