SC I ENT I F I C ART I C L EAustralian Dental Journal 2012; 57: 355358

doi: 10.1111/j.1834-7819.2012.01698.x

Incidence of craniofacial pain of cardiac origin: results froma prospective multicentre study

SH Danesh-Sani,* SA Danesh-Sani, R Zia,* S Faghihi

*Department of Cardiology, Mashhad University of Medical Sciences, Mashhad, Iran.Dental Research Center, Mashhad Dental School, Mashhad, IranDentist, Private Practice, Mashhad, Iran.

ABSTRACT

Background: The aim of this study was to reveal the incidence and distribution pattern of craniofacial pain of cardiacorigin.Methods: We undertook a prospective study of 248 consecutive patients (aged 26 to 88 years) hospitalized with confirmedcardiac ischaemic periods. Digital OPG radiographs were obtained from all patients for radiographic examination of thejaws and dentition. Patients underwent clinical and radiographic examinations, and symptoms were evaluated in detail todetermine the prevalence and distribution pattern of craniofacial pain of cardiac origin.Results: Craniofacial pain was the sole symptom of cardiac ischaemia in 13 patients (5.2%); two developed acutemyocardial infarction (AMI). Pain in the craniofacial region, chest, shoulders and arms was experienced by 72 patients.The most frequently affected region was the left mandible. In the absence of chest pain, patients most frequentlyexperienced pain in craniofacial structures. Incidence of craniofacial pain was significantly higher in females than males(p = 0.024).Conclusions: Cardiac pain commonly radiates to the craniofacial structures. Pain of cardiac origin is usually described aspressure and or a burning sensation that is provoked by physical activity and relieved by rest. Craniofacial pain of cardiacorigin usually occurs bilaterally. Dental practitioners can play a crucial role in the diagnosis of craniofacial pain of cardiacorigin.

Keywords: Craniofacial pain, ischaemic heart disease, myocardial infarction.

Abbreviations and acronyms: ACC = American College of Cardiology; AMI = acute myocardial infarction; TMJ = temporomandibularjoint.

(Accepted for publication 23 November 2011.)

INTRODUCTION

Patients presenting with craniofacial pain for treatmentis a routine occurrence in dental practice.1 Pain in theorofacial region may originate from sources other thanteeth. Non-odontogenic craniofacial pain, also calledheterotopic pain, is the greatest diagnostic challenge forclinicians.2 The characteristic symptom of ischaemicheart disease is chest pain, which may radiate to theshoulders, arms and neck.3,4 However, cardiac pain mayextend to the jaws and cause toothache.57 It has beenstated that craniofacial pain was the sole symptom ofcardiac ischaemia in 6% of patients.7 According to theliterature, a significant number of patients face lethal orpotentially lethal complications due to the misdiagnosis

of referred cardiac pain to the craniofacial region.79

Different studies of emergency department patientsrevealed that the mortality rate increases significantlyin patients who have never developed chest paincompared with patients who had chest pain as theirchief complaint.7,1013 It is crucial to recognize the actualsource of the pain promptly, not the region of the pain, torefer the patient for appropriate therapy and avoidunnecessary dental treatments.2,7 Until now, pain refer-ral to the craniofacial region has mainly been docu-mented through case reports.2,8,9,1416 To the best of ourknowledge, this is the first study where digital OPG wasused to investigate the origin of craniofacial pain inthe orofacial region in patients with cardiac ischaemia.The aim of this prospective study was to determine the

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Australian Dental JournalThe official journal of the Australian Dental Association

incidence and distribution of craniofacial pain of cardiacorigin, and to analyse differences in males and females.

SUBJECTS AND METHODS

We prospectively studied 350 consecutive patientsadmitted to three cardiology departments with signsand or symptoms suggesting ischaemic heart diseasebetween May and September 2011. The study protocolwas approved by the Medical School Ethics Committee.Informed consent was obtained from each patient.Patients were selected for the study according to theAmerican College of Cardiologys (ACC) diagnosticcriteria for ischaemic heart disease.17 Cardiologistsdiagnosed AMI for a patient according to ACCdiagnostic criteria.17 Digital OPG radiographs wereobtained from all patients for radiographic examina-tion of the jaws and dentition. Radiographs wereevaluated for presence of dental decay, impacted teethand neoplasm of the jaws. By using digital OPG, weexcluded 48 patients who had chronic craniofacial paindue to the presence of impacted teeth (n = 8), toothacheof adontogenic origin (n = 39) and neoplasm (n = 1).On the basis of clinical examinations, 54 patients wereexcluded from the study due to craniofacial pain causedby temporomandibular joint (TMJ) disorder, chronicheadache and asymptomatic ischaemia. There were 156males and 92 females (total 248), aged between 26and 88 years (mean: 60.3 years) who met the inclusioncriteria. All patients were requested to answer aquestionnaire prepared by the investigators. Eachquestionnaire was subdivided into two parts, providingdemographic information and detailed symptoms ofpatients. All questionnaires were reviewed and inter-preted by investigators to provide a complete picture ofatypical symptoms and to determine the accuracy of thedata. Patients were asked to describe their symptoms bypointing to the affected areas. In relation to thedistribution of symptoms between males and females,data were statistically analysed by v2 test. Statisticalanalysis was performed by SPSS software (SPSS,Version 15, Chicago, USA).

RESULTS

Eighty-five patients (34.2%) reported craniofacial painduring a period of ischaemia. Incidence of craniofacialpain was significantly higher in females than males(p = 0.024). Seventy-two patients (84.7%) experiencedpain in the craniofacial region, chest, shoulders andarms. Thirteen patients (15.3%) reported pain in thecraniofacial area with no other concomitant symptoms.The distribution of pain in different craniofacial regionsas described by 85 patients during a period of cardiacischaemia is shown in Fig. 1. In different sites affectedby the referred craniofacial pain, the left mandible

(42.4%) was the most frequently affected site. Twopatients (2.3%) reported toothache in the mandibularteeth on both sides. A total of 129 patients (52%)experienced AMI, 62 of whom reported craniofacialpain. Two male patients (1.5%) experienced cranio-facial pain as the only symptom. The distribution ofpain in different craniofacial regions in 62 patients whoexperienced AMI is shown in Fig. 2. The region mostfrequently affected was the right mandible. Twenty-twopatients (9%) experienced no chest pain. The differ-ences between males and females were not statisticallysignificant. Table 1 shows different locations affectedby pain during a period of cardiac ischaemia in the

Right TMJ/Earregion11.9%

Le TMJ/Earregion13.1%

Le Maxilla0%

Right Maxilla0%

Right Mandible34.5%

Le Mandible42.4%

Fig. 1 Distribution of craniofacial structures affected by pain inducedby cardiac ischaemia.

Right TMJ/Earregion7.8%

Le TMJ/Earregion

9%

Le Maxilla0%

Right Maxilla0%

Right Mandible15.5%

Le Mandible14.6%

Fig. 2 Distribution of craniofacial structures affected by pain inducedby myocardial infarction.

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absence of chest pain. Patients without chest pain mostfrequently experienced pain in craniofacial structures.

DISCUSSION

Stimulation of nervous system neurons by cardiacnociceptive input can lead to pain referral to thecraniofacial area.2,18 The distribution pattern of cardiacpain referral to different craniofacial structures may beexplained by this complex convergence of inputs.2,18

According to the literature, the prevalence of painreferral to the craniofacial region needs to be furtherinvestigated.1924 To the best of our knowledge, thisseries of 248 cases investigated for incidence ofcraniofacial pain of cardiac origin is the largest reportedin the literature. When comparing our findings with aprevious study,7 we found differences in the prevalenceof craniofacial pain of cardiac origin. This may beattributed to the radiographic examination of patientsby OPG. Digital OPGs exhibit a perfect general outlookof the jaws and teeth. In the current study, eightpatients were excluded during radiographic examina-tion due to referred orofacial pain of impacted teeth.Thirty-nine patients were excluded due to toothachediagnosed as being of pulpal origin. The findings of thismulticentre population based study suggest that 34.2%of patients during a cardiac ischaemic episode and 48%of patients during AMI experienced craniofacial pain.Pain referral to the craniofacial structures wasdescribed as the only symptom in 5.2% of patientswith cardiac ischaemia. Craniofacial pain can beexpected in 1.5% of patients as the sole symptom ofAMI. Therefore, pain referral to the craniofacial region,along with typical sites of cardiac pain, should beconsidered by practitioners to avoid misdiagnosis. Astudy conducted by Kreiner et al. reported craniofacialpain as the sole symptom in 6% of individualsexperiencing cardiac ischaemia.7 In their study, 4% ofpatients who experienced AMI reported craniofacialpain as the sole symptom. In the current study, a highlevel of pain occurrence in different craniofacialstructures was observed in the mandible, TMJs andears (in descending order). Odontogenic pains may alsoradiate to these regions.25 Therefore, pain of cardiacorigin should be included in the differential diagnosis ofreferred craniofacial pain when a lack of local sources

becomes evident. Dental practitioners may help diag-nose ischaemic heart disease by knowing which char-acteristics indicate cardiac pain. Pain of cardiac originis usually described as pressure and or a burningsensation provoked by physical activity and relievedby rest.26 Pain of cardiac origin usually occurs bilater-ally in craniofacial structures.26 Dental craniofacialpain appears unilaterally and is described as aching andthrobbing.26 Cardiac pain radiated to the mandible wasreported in different studies.5,14,27 In the present study,the left mandible (42.4%) was the most frequentlyaffected site by pain induced by cardiac ischaemia.Although some studies have reported the occurrence ofpain in the maxillary region,5,14,27 pain referral to themaxillary area was not reported by our patients. Pain inthe ear and periauricular region has been documentedin previous reports.9,15,23,27 Our findings revealed thatpain referral to the ear and TMJ region was experi-enced by 25% of patients. Toothache of cardiac originwas reported by Kreiner et al.2 Pain of cardiac originmay be referred to the maxillary left posterior region.3

In the present study, there were only two patients(2.3%) who suffered from toothache affecting mandib-ular teeth on both sides. Most patients in previousreports experienced craniofacial pain concomitantwith pain in other areas typical of anginal pain,which facilitated diagnosis of pain with cardiac ori-gin.2,3,5,14,27 Different studies found that a lack of chestpain in patients with ischaemic heart disease exposedthem to a significantly higher risk of life-threateningcomplications.12,13,28 These findings highlight the clin-ical importance of knowing about incidences of paindistribution in patients without chest pain during anischaemic period. In the present study, 22 patients (9%)experienced an ischaemic event without chest pain; fivewere ischaemic episodes associated with AMI. It isinteresting to note that referred craniofacial pain wasreported by 54.5% of patients without chest painduring an ischaemic period. According to the literature,most misdiagnoses of AMI patients from emergencydepartments were related to atypical symptom presen-tation.10,11,29,30 The present study found considerableincidence of referred craniofacial pain in patientsduring ischaemic episodes. Therefore, to reduce themisdiagnosis rate of ischaemic heart disease, practitio-ners should not underestimate referred craniofacialpain during history taking. However, our resultsindicated that in 5.2% of all cases, cardiac pain islocalized solely to the craniofacial structures. As foundin previous investigations, our study found a small butimportant incidence of pain referral to the craniofacialstructures as the sole symptom during ischaemicepisodes.7,20 In the current study, the incidence ofcraniofacial pain induced by cardiac ischaemia wassignificantly higher in females than males whichsupports previous works.20,21,23

Table 1. Distribution of pain during cardiac ischaemiain patients without chest pain

Region of pain Number of patientsaffected by pain

Craniofacial region 12 (54.5%)Left arm 5 (22.7%)Left shoulder 4 (18.1%)Right shoulder 2 (9%)Right arm 1 (4.5%)

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Incidence of craniofacial pain of cardiac origin

CONCLUSIONS

Craniofacial pain of cardiac origin was the solesymptom in 5.2% of patients. However, in the absenceof chest pain, craniofacial structures were more affectedthan other areas. Dental practitioners can play a crucialrole in the diagnosis of craniofacial pain of cardiacorigin. The association of pain with exertion and painrelief at rest could be helpful to suspect craniofacialpain of cardiac origin during history taking. Dentistsshould be aware of the characteristics of craniofacialpain of cardiac origin for early differential diagnosis.

ACKNOWLEDGEMENTS

This study was supported by grants from the MashhadUniversity of Medical Sciences.

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Address for correspondence:Dr Seyed Amir Danesh-Sani

Department of Dental ResearchMashhad Dental Faculty

Vakilabad BoulevardeMashhad 6517659114

IranEmail: amirds_dds@yahoo.com

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