Facial pain of cardiac origin: a case report
Dor facial de origem card?ca: um relato de caso
Ana Carolina de Oliveira Franco; Jos? Tadeu Tesseroli de Siqueira; Alfredo Jos?Mansur
Hospital das Cl?icas and Instituto do Cora?o (InCor), Faculdade de Medicina da Universidade de S? Paulo, S? Paulo, Brazil
Address for correspondence
CONTEXT: Cardiac pain may radiate to the face and
lead patients to seek dental care. Dentists may contribute towards the
diagnosing of ischemic heart disease and thus refer patients for
Key words: Facial pain. Temporomandibular joint disorders. Angina pectoris. Myocardial infarction.
CONTEXTO: A dor de origem card?ca pode apresentar
irradia?o para a face e motivar pacientes a procurarem atendimento
odontol?ico. Nestas situa?es, cirurgi?s-dentistas podem contribuir para
o diagn?tico da cardiopatia isqu?ica e serem encaminhadores de pacientes
para avalia?o cardiol?ica.
Palavras-chave: Dor orofacial. Transtornos da articula?o temporomandibular. Angina pectoris. Infarto do mioc?dio. Cardiopatia isqu?ica.
Complaints of pain in the face or teeth have been recognized as a symptom of angina pectoris or myocardial infarction.1 There are reports of facial pain caused by ischemic heart disease. Cases of misdiagnosis that led to unnecessary dental treatment such as endodontic procedures have been reported.2 We report the case of a patient whose chief complaint was excruciating facial pain that, after deeper investigation, was attributed to angina pectoris due to ischemic heart disease.
A 50-year-old diabetic woman with the chief complaint of excruciating pain in the upper and lower jaw and left temporal area that had lasted for six months was referred to a dentist for evaluation of a suspected temporomandibular disorder. The pain was severe to the point of repeated visits to medical emergency departments.
On evaluation, she said that the pain would start in the chest and radiate to the neck, face and left temporal region. These five-minute bouts of pain would occur every day, triggered by exertion and emotions, and they were alleviated by resting. She also complained of pain in masticatory muscles during mastication; nonsteroidal anti-inflammatory drugs alleviated this pain.
The dental examination revealed an edentulous upper jaw with a full prosthetic set of teeth and partially edentulous lower jaw and decreased vertical dimension. Physical examination revealed pain not only in masseter but also in pterygoid muscles. X-ray of facial bones did not reveal any bone abnormalities. A diagnosis of temporomandibular disorder was made. Upper and lower appliances were installed for vertical dimension repositioning, and the patient was freed from 50% of her facial pain.
She was eventually referred for cardiological evaluation, since her pain was starting in the chest and because she had a past medical history of coronary artery bypass grafting surgery, some years previously. A diagnosis of angina pectoris was made and proper treatment was introduced. The therapy was successful and the patient became free of angina after nine months.
The chief complaint of this patient was facial pain. This was the reason why she was first referred to a dentist for evaluation of a suspected temporomandibular disorder, in spite of her past medical history of coronary artery bypass graft surgery. Moreover, this first diagnosis was supported by the fact that the patient also complained of pain in masticatory muscles during mastication. Physical examination revealed pain in the masticatory system that led to the diagnosing of a temporomandibular disorder, and the correct treatment was instituted. However, the pain was associated with exertion and she was eventually referred for cardiological evaluation. The patient?s dental condition was also poor, with lost teeth, which suggested a possible source of the facial pain. It cannot be overemphasized how important it is to have an accurate evaluation of the quality of the pain.
Several reports have demonstrated that improper diagnosis leads to unnecessary dental treatment.1-3 Indeed, there are reports of patients who underwent dental extractions for the treatment of facial pain that was eventually diagnosed as angina due to ischemic heart disease.2
Myofascial pain from masticatory muscles may be acute and regional, or chronic associated with widespread pain, and may have atypical presentation, such as angina. The masticatory system contributes towards a variety of clinical presentations and may further complicate diagnosis. There may be complaints of pain in the preauricular, face, jaw, temporal and occipital areas, and palpation of the masticatory muscles (masseter, pterygoid and temporal) on physical examination may increase the pain in these muscles.4 Loss of posterior occlusal support, due to missing teeth associated with loss of vertical dimension, may contribute towards musculoskeletal pain. These conditions may increase the risk of pain and dysfunction in susceptible individuals. Thus, elimination of the causal factors and the use of rehabilitative procedures are useful for eliminating pain.4
When facial pain is recognized as a possible sign of heart disease, the dentist may have an important role as a diagnostician. Careful history-taking regarding the pain is of paramount importance.1-3 In these settings, dentists may contribute towards the diagnosing of ischemic heart disease and thus refer patients for cardiological evaluation.
1. Tzukert A, Hasin Y, Sharav Y. Orofacial pain of cardiac origin. Oral Surg Oral Med Oral Pathol. 1981;51(5):484-6.
2. Kreiner M, Okeson JP. Toothache of cardiac origin. J
Orofac Pain. 1999;13(3):201-7.
3. Biagini A, Emdin M, Mazzei MG, et al. Clinical
characteristics of anginal pain in man. Funct Neurol. 1989;4(1):43-5.
4. Fricton JR, Kroening R, Haley D, Siegert R.
Myofascial pain syndrome of the head and neck: a review of clinical
characteristics of 164 patients. Oral Surg Oral Med Oral Pathol.
Address for correspondence:
Sources of funding: None
Ana Carolina de Oliveira Franco, DDS.
Doctor of Dental Surgery, Hospital das Cl?icas and Instituto do Cora?o
(InCor), Faculdade de Medicina da Universidade de S? Paulo S? Paulo,