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Heterotopic Pain & Its Role In Facial Pain

Author: Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain

Date: March 18, 2024


As Orofacial Pain specialists, we have learned that pain in the face, jaw, and teeth does not always originate from these structures. Rather, it can originate from another source in the neck or shoulder regions and/or from local or distant organ and tissue pathology.

This is called heterotopic pain and can be classified in three ways:

  • Spreading heterotopic pain: Pain felt within the same anatomic or nerve boundary of the source.
  • Referred heterotopic pain: Pain felt outside the anatomic boundary of the source and often from a different nerve entity
  • Central heterotopic pain: Pain felt in the oral and facial region, with an origin within the cranium and often involving brain structures.

Common Presentations

Building on research from the 1960s, we now acknowledge that facial pain complaints focused in the teeth, lips, ears, eyes, forehead, nose, and sinuses can, at times, be the result of overworked,and sensitized muscles in the jaw/neck. In these muscles there are often knot-like, hyperirritable  and palpable nodules called trigger points. These trigger points when active have the ability to give rise to both spreading and referred pain.

Research has also revealed a close interplay between nerve pathways in the jaw, face, and teeth and those in the cervical spine, pharyngeal region, parotid gland, sinus cavities, and even intracranial tissues. Consequently, it is not uncommon for the origins of orofacial pain to be found elsewhere.

Referred Pain

Most commonly, as seen in the diagrams below, muscles in the jaw and neck can lead to heterotopic pain.. For instance, the masseter and temporalis (jaw) muscles can be responsible for symptoms in and beyond their borders and have been linked to the experience of pain in the ears, teeth, sinuses, and behind the eyes.

When overworked by daytime jaw overuse behaviors and sleep bruxism, the masseters and temporalis muscles can become sensitized leading to spreading and/or referred pain. In a similar fashion fatigued neck muscles can also be responsible for pain symptoms beyond their borders, with pain being commonly experienced in the face, jaw, and teeth.

Since these pain scenarios are commonly seen in our office, recognition leads to effective treatment, even though symptoms may have persisted for weeks or months.

There are times however when things are not what they appear to be ..

Case Study: Mark

Beyond these common and familiar situations, we encounter multiple cases during the year when heterotopic pain has a more worrisome origin.

Consider the story of Mark, a 16-year-old male who presented with his mother in the recent past after 6 months of facial and jaw pain on the right side often radiating to the teeth. Dull, achy pain prompted  dental evaluations and ultimately the removal of his lower right wisdom tooth and two rounds of antibiotics without success. He was thereafter told that he needed to see a specialist to get his TMJ problem under control.

At our consultation visit, Mark related that about one week prior to our appointment, he began to experience  increased periods of limited jaw motion and a sense of spontaneous twitching of his jaw muscles. In addition and most importantly, he related that speaking had begun to bring on his pain often at an acute level. These newer symptoms would not persist, but rather come and go throughout the day.

An examination did not reveal limited jaw motion, or any other mechanical problems associated with the jaw. In addition though there was some palpation pain in the jaw/neck muscles, it was not at a high level. In addition there was no indication of jaw clenching or grinding activity as his jaw muscles were not overbuilt and there was no evident wear on his teeth. At first glance there was insufficient evidence to diagnose a TMJ problem.

What was of most concern, however, were his symptoms. They did not match the physical findings on examination. And, with the knowledge that  facial and jaw pain that emerged with speaking commonly had a nerve origin, additional evaluation was in order. Based on past experiences a decision was made to obtain a brain MRI to determine whether Mark’s pain had a central origin.

A few days later, the MRI report indicated the presence of an intracranial cyst-like mass pressing on the trigeminal nerve, the nerve responsible for sensations in the orofacial area, inclusive of the teeth.

A neurosurgery referral led to surgery and the successful removal of a benign and slow growing brain tumor. A central heterotopic pain problem had been identified and managed.

In Conclusion

Heterotopic pain problems are common in the orofacial region. Although most are readily identified and managed in our office, there are times when careful listening is the key to recognizing that something is not quite right and additional assessments are necessary.

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