Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2012; 57: 355358

SCIENTIFIC ARTICLE

doi: 10.1111/j.1834-7819.2012.01698.x

Incidence of craniofacial pain of cardiac origin: results from

a 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, Iran
Dentist, Private Practice, Mashhad, Iran.

ABSTRACT
Background: The aim of this study was to reveal the incidence and distribution pattern of craniofacial pain of cardiac
origin.
Methods: We undertook a prospective study of 248 consecutive patients (aged 26 to 88 years) hospitalized with confirmed
cardiac ischaemic periods. Digital OPG radiographs were obtained from all patients for radiographic examination of the
jaws and dentition. Patients underwent clinical and radiographic examinations, and symptoms were evaluated in detail to
determine 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 acute
myocardial 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 frequently
experienced 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 as
pressure and or a burning sensation that is provoked by physical activity and relieved by rest. Craniofacial pain of cardiac
origin usually occurs bilaterally. Dental practitioners can play a crucial role in the diagnosis of craniofacial pain of cardiac
origin.
Keywords: Craniofacial pain, ischaemic heart disease, myocardial infarction.
Abbreviations and acronyms: ACC = American College of Cardiology; AMI = acute myocardial infarction; TMJ = temporomandibular
joint.
(Accepted for publication 23 November 2011.)

INTRODUCTION
Patients presenting with craniofacial pain for treatment
is a routine occurrence in dental practice.1 Pain in the
orofacial region may originate from sources other than
teeth. Non-odontogenic craniofacial pain, also called
heterotopic pain, is the greatest diagnostic challenge for
clinicians.2 The characteristic symptom of ischaemic
heart disease is chest pain, which may radiate to the
shoulders, arms and neck.3,4 However, cardiac pain may
extend to the jaws and cause toothache.57 It has been
stated that craniofacial pain was the sole symptom of
cardiac ischaemia in 6% of patients.7 According to the
literature, a significant number of patients face lethal or
potentially lethal complications due to the misdiagnosis
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of referred cardiac pain to the craniofacial region.79

Different studies of emergency department patients
revealed that the mortality rate increases significantly
in patients who have never developed chest pain
compared with patients who had chest pain as their
chief complaint.7,1013 It is crucial to recognize the actual
source of the pain promptly, not the region of the pain, to
refer the patient for appropriate therapy and avoid
unnecessary dental treatments.2,7 Until now, pain referral to the craniofacial region has mainly been documented through case reports.2,8,9,1416 To the best of our
knowledge, this is the first study where digital OPG was
used to investigate the origin of craniofacial pain in
the orofacial region in patients with cardiac ischaemia.
The aim of this prospective study was to determine the
355

SH Danesh-Sani et al.
incidence and distribution of craniofacial pain of cardiac
origin, and to analyse differences in males and females.
SUBJECTS AND METHODS
We prospectively studied 350 consecutive patients
admitted to three cardiology departments with signs
and or symptoms suggesting ischaemic heart disease
between May and September 2011. The study protocol
was approved by the Medical School Ethics Committee.
Informed consent was obtained from each patient.
Patients were selected for the study according to the
American College of Cardiologys (ACC) diagnostic
criteria for ischaemic heart disease.17 Cardiologists
diagnosed AMI for a patient according to ACC
diagnostic criteria.17 Digital OPG radiographs were
obtained from all patients for radiographic examination of the jaws and dentition. Radiographs were
evaluated for presence of dental decay, impacted teeth
and neoplasm of the jaws. By using digital OPG, we
excluded 48 patients who had chronic craniofacial pain
due to the presence of impacted teeth (n = 8), toothache
of adontogenic origin (n = 39) and neoplasm (n = 1).
On the basis of clinical examinations, 54 patients were
excluded from the study due to craniofacial pain caused
by temporomandibular joint (TMJ) disorder, chronic
headache and asymptomatic ischaemia. There were 156
males and 92 females (total 248), aged between 26
and 88 years (mean: 60.3 years) who met the inclusion
criteria. All patients were requested to answer a
questionnaire prepared by the investigators. Each
questionnaire was subdivided into two parts, providing
demographic information and detailed symptoms of
patients. All questionnaires were reviewed and interpreted by investigators to provide a complete picture of
atypical symptoms and to determine the accuracy of the
data. Patients were asked to describe their symptoms by
pointing to the affected areas. In relation to the
distribution of symptoms between males and females,
data were statistically analysed by v2 test. Statistical
analysis was performed by SPSS software (SPSS,
Version 15, Chicago, USA).
RESULTS
Eighty-five patients (34.2%) reported craniofacial pain
during a period of ischaemia. Incidence of craniofacial
pain was significantly higher in females than males
(p = 0.024). Seventy-two patients (84.7%) experienced
pain in the craniofacial region, chest, shoulders and
arms. Thirteen patients (15.3%) reported pain in the
craniofacial area with no other concomitant symptoms.
The distribution of pain in different craniofacial regions
as described by 85 patients during a period of cardiac
ischaemia is shown in Fig. 1. In different sites affected
by the referred craniofacial pain, the left mandible
356

Le TMJ/Ear
region
13.1%

Right TMJ/Ear
region
11.9%

Right Maxilla
0%

Le Maxilla
0%

Right Mandible Le Mandible

34.5%
42.4%

Fig. 1 Distribution of craniofacial structures affected by pain induced

by cardiac ischaemia.

Le TMJ/Ear
region
9%

Right TMJ/Ear
region
7.8%

Right Maxilla
0%

Right Mandible
15.5%

Le Maxilla
0%

Le Mandible
14.6%

Fig. 2 Distribution of craniofacial structures affected by pain induced

by myocardial infarction.

(42.4%) was the most frequently affected site. Two

patients (2.3%) reported toothache in the mandibular
teeth on both sides. A total of 129 patients (52%)
experienced AMI, 62 of whom reported craniofacial
pain. Two male patients (1.5%) experienced craniofacial pain as the only symptom. The distribution of
pain in different craniofacial regions in 62 patients who
experienced AMI is shown in Fig. 2. The region most
frequently affected was the right mandible. Twenty-two
patients (9%) experienced no chest pain. The differences between males and females were not statistically
significant. Table 1 shows different locations affected
by pain during a period of cardiac ischaemia in the
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Incidence of craniofacial pain of cardiac origin

Table 1. Distribution of pain during cardiac ischaemia
in patients without chest pain
Region of pain
Craniofacial region
Left arm
Left shoulder
Right shoulder
Right arm

Number of patients
affected by pain
12
5
4
2
1

(54.5%)
(22.7%)
(18.1%)
(9%)
(4.5%)

absence of chest pain. Patients without chest pain most

frequently experienced pain in craniofacial structures.
DISCUSSION
Stimulation of nervous system neurons by cardiac
nociceptive input can lead to pain referral to the
craniofacial area.2,18 The distribution pattern of cardiac
pain referral to different craniofacial structures may be
explained by this complex convergence of inputs.2,18
According to the literature, the prevalence of pain
referral to the craniofacial region needs to be further
investigated.1924 To the best of our knowledge, this
series of 248 cases investigated for incidence of
craniofacial pain of cardiac origin is the largest reported
in the literature. When comparing our findings with a
previous study,7 we found differences in the prevalence
of craniofacial pain of cardiac origin. This may be
attributed to the radiographic examination of patients
by OPG. Digital OPGs exhibit a perfect general outlook
of the jaws and teeth. In the current study, eight
patients were excluded during radiographic examination due to referred orofacial pain of impacted teeth.
Thirty-nine patients were excluded due to toothache
diagnosed as being of pulpal origin. The findings of this
multicentre 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 was
described as the only symptom in 5.2% of patients
with cardiac ischaemia. Craniofacial pain can be
expected in 1.5% of patients as the sole symptom of
AMI. Therefore, pain referral to the craniofacial region,
along with typical sites of cardiac pain, should be
considered by practitioners to avoid misdiagnosis. A
study conducted by Kreiner et al. reported craniofacial
pain as the sole symptom in 6% of individuals
experiencing cardiac ischaemia.7 In their study, 4% of
patients who experienced AMI reported craniofacial
pain as the sole symptom. In the current study, a high
level of pain occurrence in different craniofacial
structures was observed in the mandible, TMJs and
ears (in descending order). Odontogenic pains may also
radiate to these regions.25 Therefore, pain of cardiac
origin should be included in the differential diagnosis of
referred craniofacial pain when a lack of local sources
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becomes evident. Dental practitioners may help diagnose ischaemic heart disease by knowing which characteristics indicate cardiac pain. Pain of cardiac origin
is usually described as pressure and or a burning
sensation provoked by physical activity and relieved
by rest.26 Pain of cardiac origin usually occurs bilaterally in craniofacial structures.26 Dental craniofacial
pain appears unilaterally and is described as aching and
throbbing.26 Cardiac pain radiated to the mandible was
reported in different studies.5,14,27 In the present study,
the left mandible (42.4%) was the most frequently
affected site by pain induced by cardiac ischaemia.
Although some studies have reported the occurrence of
pain in the maxillary region,5,14,27 pain referral to the
maxillary area was not reported by our patients. Pain in
the ear and periauricular region has been documented
in previous reports.9,15,23,27 Our findings revealed that
pain referral to the ear and TMJ region was experienced by 25% of patients. Toothache of cardiac origin
was reported by Kreiner et al.2 Pain of cardiac origin
may 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 mandibular teeth on both sides. Most patients in previous
reports experienced craniofacial pain concomitant
with pain in other areas typical of anginal pain,
which facilitated diagnosis of pain with cardiac origin.2,3,5,14,27 Different studies found that a lack of chest
pain in patients with ischaemic heart disease exposed
them to a significantly higher risk of life-threatening
complications.12,13,28 These findings highlight the clinical importance of knowing about incidences of pain
distribution in patients without chest pain during an
ischaemic period. In the present study, 22 patients (9%)
experienced an ischaemic event without chest pain; five
were ischaemic episodes associated with AMI. It is
interesting to note that referred craniofacial pain was
reported by 54.5% of patients without chest pain
during an ischaemic period. According to the literature,
most misdiagnoses of AMI patients from emergency
departments were related to atypical symptom presentation.10,11,29,30 The present study found considerable
incidence of referred craniofacial pain in patients
during ischaemic episodes. Therefore, to reduce the
misdiagnosis rate of ischaemic heart disease, practitioners should not underestimate referred craniofacial
pain during history taking. However, our results
indicated that in 5.2% of all cases, cardiac pain is
localized solely to the craniofacial structures. As found
in previous investigations, our study found a small but
important incidence of pain referral to the craniofacial
structures as the sole symptom during ischaemic
episodes.7,20 In the current study, the incidence of
craniofacial pain induced by cardiac ischaemia was
significantly higher in females than males which
supports previous works.20,21,23
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SH Danesh-Sani et al.
CONCLUSIONS

16. Durso BC, Israel MS, Janini ME, Cardoso AS. Orofacial pain of
cardiac origin: a case report. Cranio 2003;21:152153.

Craniofacial pain of cardiac origin was the sole

symptom in 5.2% of patients. However, in the absence
of chest pain, craniofacial structures were more affected
than other areas. Dental practitioners can play a crucial
role in the diagnosis of craniofacial pain of cardiac
origin. The association of pain with exertion and pain
relief at rest could be helpful to suspect craniofacial
pain of cardiac origin during history taking. Dentists
should be aware of the characteristics of craniofacial
pain of cardiac origin for early differential diagnosis.

17. Cannon CP, Battler A, Brindis RG, et al. American College of

Cardiology key data elements and definitions for measuring the
clinical management and outcomes of patients with acute coronary syndromes: a report of the American College of Cardiology
Task Force on Clinical Data standards (Acute Coronary Syndromes Writing Committee). J Am Coll Cardiol 2001;38:2114
2130.

ACKNOWLEDGEMENTS
This study was supported by grants from the Mashhad
University of Medical Sciences.
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Address for correspondence:

Dr Seyed Amir Danesh-Sani
Department of Dental Research
Mashhad Dental Faculty
Vakilabad Boulevarde
Mashhad 6517659114
Iran
Email: amirds_dds@yahoo.com
2012 Australian Dental Association