To whom should a patient with a sour taste and facial pain be referred for evaluation and diagnosis?

Referral Pathway for Patients with Sour Taste and Facial Pain

A patient with sour taste and facial pain should be initially referred to a dentist for evaluation, followed by referral to oral/maxillofacial surgeons if salivary gland disorders are suspected or to ENT specialists if sinusitis is identified. 1

Initial Diagnostic Considerations

Step 1: Determine Likely Etiology

The combination of sour taste and facial pain suggests several possible conditions:

• Salivary gland disorders - Most likely cause when sour taste is present

  • Salivary stones (sialolithiasis) - Particularly in submandibular gland
  • Salivary gland infection or blockage
  • Tumors of salivary glands 1

• Sinusitis - Especially maxillary sinusitis

  • May occur after dental infection or treatment to upper premolars/molars
  • Can present with facial pain and altered taste 1

• Temporomandibular disorders (TMD)

  • Most common non-dental cause of facial pain
  • Affects 5-12% of population, peak age 20-40 years 1

• Burning mouth syndrome

  • Often accompanied by taste complaints
  • Suggests interaction between nociception and gustation 2

Step 2: Identify Red Flags Requiring Urgent Referral

• Progressive, unremitting pain
• Sensory changes or neurological deficits
• Unexplained weight loss
• History of cancer 3

Referral Algorithm

Primary Referral:

1. Dentist - First-line referral for comprehensive oral examination
   • Can evaluate dental causes, salivary flow, and oral mucosa
   • Can perform initial imaging (panoramic tomographs) 1

Secondary Referrals (based on initial findings):

1. Oral/Maxillofacial Surgeon - If salivary gland disorder is suspected

   • For management of salivary stones
   • For closure of oral antral fistula if present
   • For biopsy if tumor is suspected 1

2. ENT Specialist - If sinusitis is identified

   • Especially for maxillary sinusitis
   • For evaluation of nasal discharge 1

3. Neurologist - For suspected neuropathic facial pain

   • For trigeminal neuralgia-like symptoms
   • For atypical facial pain 3

4. Pain Specialist - For complex or refractory pain

   • Particularly if pain persists despite treatment of underlying cause
   • For multidisciplinary approach to pain management 3

Key Diagnostic Tests to Request Before Referral

• Imaging:

  • Dental X-rays for dental causes
  • Ultrasound for salivary gland diseases
  • CT or MRI for suspected tumors or complex cases 1

• Laboratory tests:

  • ESR and CRP if giant cell arteritis is suspected (patients >50 years with temporal headache)
  • Tests for autoimmune disorders like Sjögren's syndrome if dry mouth accompanies sour taste 1

Common Pitfalls to Avoid

1. Delayed diagnosis - Sour taste can be an early indicator of salivary gland dysfunction and should not be dismissed 4

2. Missing serious underlying conditions - Taste disturbances and facial pain can be manifestations of systemic diseases or malignancy 3

3. Inadequate follow-up - Salivary gland disorders may require long-term monitoring and management 5

4. Overlooking psychological factors - Depression and psychological factors can increase risk of chronicity in facial pain conditions 1

5. Treating symptoms without identifying cause - The sour taste may be due to altered salivary composition or flow, which requires specific treatment 4

By following this referral pathway, patients with sour taste and facial pain can receive appropriate evaluation and treatment to improve their quality of life and prevent complications from underlying conditions.