J Clin Exp Dent. 2017;9(1):e91-5.Journal section: Oral Medicine and PathologyPublication Types: ResearchCraniofacial pain in ischemic heart 4317/jced.53078Frequency of craniofacial pain in patients with ischemic heart diseaseMahin Bakhshi 1, Rezvan Rezaei 2, Maryam Baharvand 3, Sedigheh Bakhtiari 1Associate Professor, Dept. of Oral Medicine, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, IranResident of Pediatric Dentistry, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran3Professor, Dept. of Oral Medicine, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran12Correspondence:Oral Medicine Department-Dental Faculty-Shahid BeheshtiUniversity of Medical Science-Velenjak [email protected]: 01/03/2016Accepted: 26/05/2016Bakhshi M, Rezaei R, Baharvand M, Bakhtiari S. Frequency of craniofacial pain in patients with ischemic heart disease. J Clin Exp do/volumenes/v9i1/jcedv9i1p91.pdfArticle Number: 53078 Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488eMail: [email protected] in:PubmedPubmed Central (PMC)ScopusDOI SystemAbstractBackground: Referred craniofacial pain of cardiac origin might be the only symptom of ischemic heart accidents.This study aimed to determine the frequency of craniofacial pain in patients with ischemic heart disease.Material and Methods: This cross-sectional study was accomplished on 296 patients who met the criteria of havingischemic heart disease. Data regarding demographics, medical history and referred craniofacial pain were recordedin data forms. In addition, patients underwent oral examination to preclude any source of dental origin. Chi-squaretest, Student’s t-test and backward regression model were used to analyze the data by means of SPSS softwareversion 21. P 0.05 was considered significant.Results: A Total of 296 patients were studied comprising of 211 men (71%) and 85 women (29%) with the mean ageof 55.8. Craniofacial pain was experienced by 53 patients out of 296, 35 (66%) of whom were male and 18 (34%)were female. None of the patients experienced craniofacial pain solely. The most common sites of craniofacial painwere occipital and posterior neck (52.8%), head (43.3%), throat and anterior neck (41.5%) respectively. We foundno relationship between craniofacial pain of cardiac origin with age, diabetes, hypertension, and family history. Onthe other hand, there was a significant relationship between hyperlipidemia and smoking with craniofacial pain ofcardiac origin.Conclusions: Radiating pain to face and head can be expected quite commonly during a cardiac ischemic event.Dental practitioners should be thoroughly aware of this symptomatology to prevent misdirected dental treatmentand delay of medical care.Key words: Craniofacial pain, ischemic heart disease, myocardial infarction, angina pectoris, referred pain.Introductionstress. Convergence of vagus, trigeminal, and cervical(C2, C3) nerves, may cause the pain radiate to otherareas like right or left shoulder, scapular region, neck andlower jaw (2-6). In rare occasions, pain is solely perceived in the aforementioned areas instead of the chest,Ischemic heart disease is considered as a major causeof death in adults (1). The cardinal symptom of ischemic heart disease is chest pain characteristically inducedby activities such as walking, climbing stairs, eating, ore91

J Clin Exp Dent. 2017;9(1):e91-5.Craniofacial pain in ischemic heart diseasewhich leads to increased mortality due to misdiagnosis.Kreiner et al. (6) reported the occurrence of craniofacialpain during ischemic heart accidents to be nearly 40%,which was the sole symptom of ischemic heart disease in6% of cases. Ischemic heart disease can be manifested asangina pectoris and myocardial infarction (MI), with theformer having two clinical types of stable and unstableangina. Patients with stable angina has a good prognosis,whereas those with unstable angina experience episodesof chest pain even in the rest position and are likely toprogress to MI soon (7).Pain of dental, periodontal, sinus and musculoskeletalorigins are amongst the most common types of orofacialpain. However, pain in these areas might be originatedfrom other regions, which are referred to as heterotopicpain (5). Cardiac pain can be presented as heterotopicpain, where in the orofacial region leads to unnecessarydental procedures and delay in diagnosis and treatmentof cardiac disease. There are several reports regardinginappropriate dental treatment due to misdiagnosis ofpain source (8). On the other hand, in developed countries missed diagnosis of MI has been described in 2-27%of cases (9,10). As demonstrated in a study, one fourthof misdiagnosis of MI resulted in lethal or potentiallylethal complications (8) lack of chest pain and slowtwitch (ST) elevation being the most important causes(10). Patients suspected of acute myocardial infarction(AMI) with no chest pain have a three times higher riskof death compared with those having chest pain (11).Another study revealed that in the absence of chest pain,one-year mortality rate of cardiac patients was twice ashigh as those experiencing chest pains. Orofacial painwas recorded as the sole symptom of ischemic heart disease in 6% of patients, while 32% had orofacial painaccompanied with pain in other regions. The frequencyof craniofacial pain of cardiac origin is higher in womenthan in men as shown in two studies (12,7).Many studies have been conducted about frequency ofcardiac pain in different parts of body (13-18), howeverfew studies addressed referral of cardiac pain to headand neck areas with most of them being case reports(19-27). Therefore, this study aimed to determine thefrequency of craniofacial pain in patients with ischemicheart disease.betes mellitus, hypertension, smoking, hyperlipidemia,and family history of heart disease were all recorded indata forms. Patients with history of chronic headache,earache, severe psychiatric disorders, pain in the tempororomandibular joint (TMJ) region, surgery or presenceof a diagnosed mass in the jaws, and recent odontogenicpain were excluded from the study. Meanwhile, all eligible patients underwent oral examination by means ofdental mirror and flashlight while lying on their beds,and those who found to have dental problems (severe orcomplex dental caries and any suspected tooth with pulpexposure) were banned from entering the study.On the day after angiography, patients were fully informed about details of the study, and then requested to fillout the data forms, which was sub divided into two part,providing demographics and pain characteristics (headand neck pain before or during heart attack, pain in otherparts of body, seeking or receiving dental care due tocraniofacial pain). Thereafter patients were shown anatomic illustrations representing chest, abdomen, back,shoulders, arms, face, neck, and mouth, and asked tomark site of their pain on the picture (6) (Fig. 1). To ensure the acuity of data, all questionnaires were reviewedby the researcher, and patients were asked once moreregarding having pain and pointing to site of pain.Fig. 1. Figure of the body and the craniofacial structures subdividedinto different areas.The study protocol was approved by oral medicine department of Shahid Beheshti University of MedicalSciences and Shahid Rajaie Cardiovascular, Medical &Research Center. All patients were obtained informedconsent to participate in the study.-Data analysis:To analyze the data, SPSS software version 21 was used.Descriptive statistics was used to report the results.Moreover, Chi-square test was used to examine differences between two genders in terms of symptoms, andStudent’s t-test to assess the distribution of age betweentwo groups (with pain and without pain). In order toMaterial and MethodsThis cross-sectional study was accomplished on 296 hospitalized patients who met the criteria of having ischemicheart disease (angina pectoris or myocardial infarction)verified by means of angiography in Shahid Rajaie Cardiovascular, Medical & Research Center, Tehran, Iran.History of previous cardiovascular disease such as hospitalization in coronary care unit (CCU), consumption ofcardiovascular medications, history of severe chest painas well as risk factors of coronary heart disease like diae92

J Clin Exp Dent. 2017;9(1):e91-5.Craniofacial pain in ischemic heart diseaseanalyze the effect of gender, age, type of cardiac disease, and coronary risk factors on chance of having craniofacial pain, backward regression model was utilized.P 0.05 was considered significant.back, and left shoulder. On the other hand, those withcraniofacial pain had cardiac pain most commonly in leftside of the chest, mid-chest, and back respectively.We found no relationship between age and craniofacialpain of cardiac origin. However, there was a statisticallysignificant difference between men and women with craniofacial pain in terms of sex (p 0.02).Meanwhile, no association was detected between craniofacial pain of cardiac origin with diabetes, hypertension,and family history. There was a significant relationshipbetween hyperlipidemia (p .001) and smoking (p .003)with craniofacial pain of cardiac origin (Fig 3).ResultsThe present study was aimed to determine the frequency of craniofacial pain of cardiac origin in patients withischemic heart disease hospitalized in Shahid RajaieCardiovascular, Medical & Research Center in the year2014-2015. A Total of 296 patients entered the studycomprising of 211 men (71%) and 85 women (29%)age ranging 29 to 85 years with the mean age of 55.8.Of the total sample, 133 patients were hospitalized forMI, 71 for unstable angina, and 92 for stable angina. Inregard to medical records, 166 patients had history ofhospitalization in CCU, 209 were taking cardiovascular medications, and 150 experienced severe chest pain.Meanwhile, medical history taking revealed diabetes in95 patients, hypertension in 134, smoking in 106, andhyperlipidemia in 148 and presence of ischemic heartdisease in first-degree relatives in 149.Craniofacial pain was experienced by 53 patients out of296, 35 (66%) of whom were male and 18 (34%) werefemale. The age range of men was 57.9 and that of women was 62.8. Thirty six patients (66%) were hospitalized because of MI, and 17(34%) for unstable angina.None of the patients experienced craniofacial pain solely, but all had concomitant pain in mid-chest or leftchest. In case of craniofacial pain, the most common sites of pain were occipital and posterior neck (52.8%),head (43.3%), throat and anterior neck (41.5%) respectively. Pain in the left mandible was recorded in 28.3% ofpatients. The right neck was the least frequently site ofreferred craniofacial pain (3. 7%) (Fig. 2).There was no report of referral pain in the maxilla orteeth among our patients.The most prevalent site of pain in patients without historyof craniofacial pain were mid-chest, left side of the chest,Fig. 3. Coronary risk factors in patients with and without craniofacial pain.DiscussionIschemic heart disease is considered one of the majorfatal events among adults (1). Patients with ischemicheart disease may experience referred pain in the headand neck areas. Induction of pain radiation after physicalactivity and relief following rest is indicative of cardiacorigin (7). There are a few studies regarding frequencyof cardiac pain referred to head and neck in patients withischemic heart disease. The objective of the present study was to determine the frequency of craniofacial painof cardiac origin in patients hospitalized at Shahid Rajaie Cardiovascular, Medical & Research Center.In this study patients were selected after confirmation ofhaving severe coronary stenosis based on angiographicinterpretation by an experienced cardiologist. In othersimilar studies the method of patient selection was notmentioned (27,28).Danesh-Sani et al. (28) found 34% of patients havingcraniofacial pain of cardiac origin, which was the onlypresentation of ischemic heart disease in 13.3% of them.In Kreiner et al. (27) study, these values were 38% and15% respectively. In the present study, 17.9% of patientsreported to have referred craniofacial pain accompaniedby pain in other parts of the body, and none of them pre-Fig. 2. Distribution of pain location.e93

J Clin Exp Dent. 2017;9(1):e91-5.Craniofacial pain in ischemic heart diseasesented with craniofacial pain as the sole symptom duringheart attack. Due to low public awareness of craniofacialpain as a symptom of cardiac ischemia, the frequencyfound in our study regarding craniofacial pain of cardiacorigin is likely to constitute an underestimation.In accordance to our results, there was no associationbetween age and craniofacial pain in similar studies(p 0.2). We found a significant difference between menand women with craniofacial pain with respect to age ina way that mean age of women was significantly morethan of men (p 0.025).Previous studies have demonstrated significant differences between men and women in terms of referred pain tocraniofacial region. Kreiner et al. (27) and Danesh-Saniet al. (28) showed that women experienced craniofacialpain more frequently than did men. Danesh-Sani et al.(28) reported significantly higher frequency of craniofacial pain among men compared to women. In the presentstudy, there was no significant difference between menand women in regard to craniofacial pain (p 0.352).Kreiner et al. (27) noticed that the most common sites of craniofacial pain were upper throat and anteriorneck (81.7%), left mandible (45.1%), and right mandible (40%). However, Danesh-Sani et al. (28) found leftmandible as the most common site of involvement withreferred craniofacial pain . In this study, regions of occipital and back neck (52.8%), head (43.3%), and anteriorneck and throat (41.5%) were found to be the most prevalent sites of craniofacial pain. Pain in the left mandiblewas perceived by 28.3% of our patients, and there was asignificant difference between left and right mandible inthis regard in a way that left mandible was significantlyaffected higher than right mandible (p 0.02).Contrary to our results, Danesh-Sani et al. (28) andKreiner et al. (29) reported that the most common siteof pain in the absence of chest pain was maxillofacialregion. In this study, patients without chest pain reportedregions of back and low back as the most prevalent sitesof pain.We were not able to take panoramic views of hospitalized patients. In addition, patients examined by meansof observation with dental mirror in supine position.Danesh-Sani et al. (28) ordered panoramic views for allpatients, which might have excluded more patients dueto having non-cardiac pain.It is noteworthy that the previous studies neither addressed craniofacial pain after angiography, nor consideredcoronary risk factors such as diabetes, hypertension,hyperlipidemia, smoking, and family history. Our study found no relationships between craniofacial pain ofcardiac origin with diabetes, hypertension, and familyhistory. However, there was a significant relationshipbetween craniofacial pain with hyperlipidemia (p 0.01)and smoking (p 0.03).In Kreiner et al. (6) study, three cardiac patients expe-rienced bilateral toothache in the mandible, and one hadleft maxillary odontogenic pain. In addition, the ratioof bilateral craniofacial pain to unilateral pain was 6:1,whereas this ratio was 1:1 in the arms. However there was no report of referral pain in the maxilla or teethamong in present study.Regarding the crucial risk of ischemic heart disease andpossibility of pain referral solely to the craniofacial area,it is recommended that further studies be conductedwith larger sample size, more elaborate oral examination including radiographic imaging as well as detailedinspection of facial, muscular, and temporomandibularstructures, and recording pattern of pain.Radiating pain to face and head areas can be expectedquite commonly during a cardiac ischemic event. Sincedental practitioners may play an important role to detectsuch atypical symptoms of cardiac origin; they shouldbe thoroughly aware of this symptomatology in order toprevent misdirected dental treatment and delay of medical care.References1. Hui G Koch B, Calara F, Wong ND. Angina in Coronary Artery Disease Patients With and Without Diabetes: US National Health and Nutrition Examination Survey 2001-2010. Clin Cardiol. 2016;39:30-6.2. Korenevsky M, Jalali N, Vilke GM, Wilson MP. The tooth, the whole tooth, and nothing but the tooth: can dental pain ever be the solepresenting symptom of a myocardial infarction? A systematic review.J Emerg Med. 2014;46:865-72.3. Kreiner M, Falace D, Michelis V, Okeson JP, Isberg A. Quality difference in craniofacial pain of cardiac vs. dental origin. J Dent Res.2010;89:965-9.4. Niwa H, Sato Y, Matsuura H. Safety of dental treatment in patientswith previously diagnosed acute myocardial infarction or unstable angina pectoris. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2000;89:35-41.5. López-López J, Garcia-Vicente L, Jané-Salas E. Orofacial pain ofcardiac origin: Review literature and clinical cases. Med Oral PatolOral Cir Bucal. 2012;17:538-44.6. Kreiner M, Okeson JP, Michelis V, Lujambio M, Isberg A. Craniofacial pain as the sole symptom of cardiac ischemia: a prospective multicenter study. J Am Dent Assoc. 2007;138:74-9.7. Fazlyab M, Esnaashari E, Saleh M, Shakerian F, Akhlagh MoayedD, Asgary S. Craniofacial Pain as the Sole Sign of Prodromal Anginaand Acute Coronary Syndrome: A Review and Report of a Rare Case.Iran Endod J. 2015;10:274-80.8. McCarthy BD, Beshansky JR, D’Agostino RB, Selker HP. Misseddiagnoses of acute myocardial infarction in the emergency department:result from a multicenter study. Ann Emerg Med. 1993;22:582-97.9. Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA,Beshansky JR, et al. Missed diagnoses of acute cardiac ischemia in theemergency department.N Engl J Med. 2000;342:1163-70.10. Chan WK, leung KF, lee YF, Hung CF, Kung NS, Lau FL .Undiagnosed acute myocardial infarction in the emergency departments:reasons and implications. Eur J Emerg Med. 1998;5:219-24.11. Fesmire FM, Wears RL. The utility of the presence or absence ofchest pain in patient with suspected acute myocardial infarction. Am JEmerg Med. 1989;7:373-7.12. Peñarrocha Diago M, Silvestre Donat FJ, Rodriguez Gil R. Facialpain of cardiac origin. Rev Stomatol Chir Maxillofac. 1990;9:477-9.13. Everts B, Karlson BW, Währborg P, Hedner T, Herlitz J. Localization of pain in suspected acute myocardial infarction in relationto final diagnosis, age and sex, and site and type of infarction. HeartLung. 1996;25:430-7.e94

J Clin Exp Dent. 2017;9(1):e91-5.Craniofacial pain in ischemic heart disease14. Goldberg RJ, O’Donnell C, Yarzebski J, Bigelow C, Savageau J,Gore JM. Sex differences in symptom presentation associated withacute myocardial infarction: a population-based perspective. Am HeartJ. 1998;136:189-95.15. Herlitz J, Karlsson T, Dellborg M, Karlson B, Engdahl J, SandénW. Occurrence, characteristics, and outcome of patients hospitalizedwith a diagnosis of acute myocardial infarction who do not fulfill traditional criteria. Clin Cardiol .1998;21:405-9.16. Goldberg R, Goff D, Cooper L, Luepker R, Zapka J, Bittner V, et al.Age and sex differences in presentation of symptoms among patientswith acute coronary disease: the REACT Trial-Rapid Early Action forCoronary Treatment. Coron Artery Dis. 2000;11:399-407.17. Philpott S, Boynton PM, Feder G, Hemingway H. Gender differences in descriptions of angina symptoms and health problems immediately prior to angiography: the ACRE study-Appropriateness ofCoronary Revascularisation study. Soc Sci Med. 2001;52:1565-75.18. Culic V, Miric D, Eterovic D. Correlation between symptomatologyand site of acute myocardial infarction. Int J Cardiol. 2001;77:163-8.19. López-López J, Adserias-Garriga MJ, Garcia-Vicente L, JanéSalas E, Chimenos-Küstner E, Pereferrer-Kleiner D. Orofacial pain ofcardiac origin, serial of clinical cases. Med Oral Patol Oral Cir Bucal.2012;17:633-7.20. de Oliveira Franco AC, de Siqueira JT, Mansur AJ. Bilateral facialpain from cardiac origin. A case report.Br Dent J. 2005;198:679-80.21. Okajima Y, Hiari A, Higashi M, Harigaya K. Vasospastic An ginain a 13-Year-Old Female Patient Whose Only Symptom Was Toothach. Pediatr Cardiol. 2007;28:68-71.22. Batchelder BJ, Krutchoff DJ, Amara J. Mandibular pain as the initial and sole clinical manifestation of coronary insufficiency: report ofcase. J Am Dent Assoc. 1987;115:710-2.23. Christoforidou A, Bridger MW. Angina masquerading as sinusitis.J Laryngol Otol. 2006;120:961-2.24. Rothwell PM. Angina and myocardial infarction presenting withpain confined to the ear. Postgrad Med J. 1993;69: 300-1.25. Mortazavi H, Dalband M. Bilateral temporomandibular joint painas the first and only symptom of ischemic cardiac disease: a case report. Chang Gung Med J. 2011;34:1-3.26. Dundar R, Kulduk E, Kemal Soy F, Sengul E, Ertas F. Myocardial infarction as a rare cause of otalgia. Case Rep Otolaryngol.2014;2014:106938.27. Kreiner M, Alvarez R, Waldenström A, Michelis V, Muñiz R, Isberg A. Craniofacial pain of cardiac origin is associated with inferiorwall ischemia. J Oral Facial Pain Headache. 2014;28:317-21.28. Danesh-Sani SH, Danesh-Sani SA, Zia R, Faghihi S. Incidence ofcraniofacial pain of cardiac origin: results from a prospective multicentre study. Aust Dent J. 2012;57:355-8.29. Kreiner M, Okessn J. Toothache of cardiac origin. J Orofac Pain.1999;13:201-7.AcknowledgementsThe authors are greatly thankful to Dr. Reza Kiani, cardiologist, fellowship of cardio intervention, and Ms. Elaheh Ardestani, nursingstaff of angiography ward at Shahid Rajaie Cardiovascular, Medical &Research Center, for their utmost cooperation.Conflict of InterestThe authors have no funding, financial relationships, or conflicts ofinterest to disclose.e95

of craniofacial pain were mid-chest, left side of the chest, Fig. 2. Distribution of pain location. back, and left shoulder. On the other hand, those with craniofacial pain had cardiac pain most commonly in left side of the chest, mid-chest, and back respectively. We found no relationship between age