口面部疼痛障碍还是三叉自主神经性头痛？对病理生理学的见解及其在医学和牙科中的意义。

文献信息

中文摘要

目的： 本叙述性综述强调了口面部疼痛考量在三叉自主神经性头痛（TACs）/三叉自主神经性口面部疼痛（TAOPs）鉴别诊断中的重要性。此外，我们提供了关于TACs在上颌（V2）和下颌（V3）三叉神经分布区（TAOPs）表现的病理生理学的新见解。
背景： TACs是终身性疾病，特征为严重的单侧头部疼痛，伴有颅自主神经现象。然而，所经历的头部疼痛可能牵涉到面部，仅存在于口面部区域作为TAOPs，甚至表现为牙痛。这些涉及V2/V3的表现可能类似于病因和病理生理学多样的疾病，这些疾病可能与TACs有一些相似之处，使患者在叙述症状时感到困惑，并给临床医生造成诊断困境，可能导致误诊。此外，TACs的病理生理学尚未与V2/V3表现（TAOPs）相关联进行讨论。
方法： 在PubMed/Scopus上进行了文献检索，以查找关于TACs和TAOPs的相关文献，以及口面部表现的病例报告。对我们已发表的几篇关于TACs临床前模型的文章进行了深入再分析，以评估V2-V3成分的潜力。
结果： TACs的口面部表现并不常见，但如果出现，可能导致误诊并带来重大后果。表现为涉及中面部的TACs作为TAOPs的患者，在获得正确诊断方面经历重要延迟，包括多次和多样的医疗提供者就诊，并有接受善意但误导性程序的风险。鉴别诊断考虑需要包括牙科/牙源性原因、鼻窦炎、颞下颌关节紊乱、Eagle综合征、三叉神经痛和偏头痛（口面部偏头痛、神经血管性口面部疼痛）。对临床前数据的再分析提供了关于这种口面部参与的新见解。在两个TAC特异性临床前神经元群体中，记录三叉神经或上唾液核神经元，观察到分别约20%和37.5%的神经元具有皮肤感受野，包括或完全位于V2-V3三叉神经分布区内。虽然数量不大，但这些表明，即使在可被视为TAC样的大鼠模型神经元群体中，它们也可以延伸到或完全涉及面部区域，类似于TAOPs。
结论： TACs在口面部区域潜在存在的现象可以从临床前模型到临床环境中观察到。国际头痛疾病分类（ICHD）需要认识到这种额外的定位，以及口内定位，包括牙齿结构。在医学和牙科环境中关于TACs/TAOPs的教育至关重要。证据表明，牙医是该患者群体首先就诊的提供者之一，因为与牙痛相似。专门从事口面部疼痛的牙医是识别TACs/TAOPs的关键盟友。医学/神经病学和牙科/口面部疼痛环境有巨大的机会和责任共同努力，以阻止该患者群体多年的疼痛。

英文摘要

OBJECTIVE: This narrative review highlights the importance of orofacial pain considerations in the differential diagnosis of trigeminal autonomic cephalalgias (TACs)/trigeminal autonomic orofacial pains (TAOPs). In addition, we provide novel insights into the pathophysiology of the presentation of TACs in the maxillary (V2) and mandibular (V3) trigeminal distributions (TAOPs).
BACKGROUND: TACs are lifelong disorders characterized by severe unilateral head pain accompanied by cranial autonomic phenomena. However, the head pain experienced may refer to the face, be present solely in the orofacial region as TAOPs, or even be experienced as a toothache. These presentations, involving V2/V3, may resemble disorders of diverse etiology and pathophysiology that may share some similarities with TACs, confusing the patient while relating symptoms, and creating a diagnostic dilemma for the clinician potentially leading to misdiagnosis. Moreover, TACs pathophysiology has not been discussed in relation to V2/V3 presentations (TAOPs).
METHODS: A literature search was performed on PubMed/Scopus to find relevant literature about TACs and TAOPs, and case reports of orofacial presentations. Deep reanalysis of several of our published articles on preclinical models of TACs was conducted to assess potential of V2-V3 components.
RESULTS: TACs orofacial presentations are not as common but if present can lead to misdiagnosis with significant consequences. Patients presenting TACs involving the midface as TAOPs experience an important delay for a correct diagnosis including multiple and diverse health provider visits, with a risk of having well-intended but misguided procedures. Differential diagnosis considerations need to include dental/odontogenic causes, sinusitis, temporomandibular disorders, Eagle syndrome, trigeminal neuralgia, and migraine (orofacial migraine, neurovascular orofacial pain). A reanalysis of preclinical data provides novel insights into this orofacial involvement. In two TAC-specific preclinical neuronal populations, recording either trigeminal or superior salivatory nucleus neurons, it was observed that ~20% and 37.5% of neurons, respectively, had cutaneous receptive fields that included or were exclusively within the V2-V3 trigeminal division. Whereas the numbers are not large, these demonstrate that even in rodent models in neuronal populations that could be considered TAC-like, they can extend to, or exclusively involve, the facial region, similar to TAOPs.
CONCLUSION: The potential presence of TACs in the orofacial region can be observed from preclinical models to the clinical setting. The International Classification of Headache Disorders (ICHD) needs to recognize this additional localization, as well as the intraoral one, including dental structures. Education about TACs/TAOPs in the medical and dental setting is vital. Evidence has shown that dentists are one of the first providers that are seen by this patient population due to similarities with dental pain. The dentist specialized in orofacial pain is a key ally in the identification of TACs/TAOPs. The medical/neurology and dental/orofacial pain settings have a great opportunity and responsibility to work together to stop years of pain in this patient population.