Chronic orofacial pain; atypical facial pain?

Difficult to diagnose pain in the orofacial area may be a challenge to the dental practitioner. There still is uncertainty about the taxonomy of chronic orofacial pain, and even more so about its etiology. Treatment of chronic orofacial pain may aim at goals which are set in advance, but also at the underlying pain mechanisms. The disentanglement of pain into different pain mechanisms may be facilitated by applying a pharmacodiagnostic test. This test consists of intravenously administering several medications in low doses in orofacial pain patients. The response to the administration of these pharmaca is reported by means of a visual analogue scale (VAS) for pain. The profile, resulting from the consecutive VAS-scores, may be used as a guide for further treatment. Before the start of any treatment, the dentist should judge whether he himself is able to treat the patient or referral to a specialist is required.     

Are antibiotics effective for endodontic pain?

Although antibiotics are frequently prescribed to treat endodontic pain patients, there is little evidence from the clinical literature to support this indication. This review focuses on the clinical evidence regarding the efficacy of antibiotics for treating postendodontic pain.     

Persistent orodental pain, atypical odontalgia, and phantom tooth pain: when are they neuropathic disorders?

Patients with unrelenting pain in the teeth, gingival, palatal or alveolar tissues often see multiple dentists and have multiple irreversible procedures performed and still have their pain. Up to one-third of patients attending a chronic facial pain clinic have undergone prior irreversible dental procedures for their pain without success. In these cases, if no local source of infectious, inflammatory, or other pathology can be found, then the differential diagnosis must include a focal neuropathic pain disorder. The common diagnoses given include the terms atypical odontalgia, persistent orodental pain, or if teeth have been extracted, phantom tooth pain. One possibility is that these pain complaints are due to a neuropathic alteration of the trigeminal nerve. There are several diagnostic procedures that need to be performed in any patient suspected of having a trigeminal neuropathic disorder including (1) cold testing of involved teeth for pulpal nonvitality; (2) a periapical radiograph examining the teeth for apical change; (3) a panoramic radiograph examining for other maxillofacial disease; (4) a thorough head and neck examination also looking for abnormality; (5) a cranial nerve examination including anesthetic testing which documents any increased or decreased nerve trigeminal nerve sensitivity and rules out other neurologic changes outside the trigeminal nerve; and (6) MRI imaging in some cases. Finally, when a nonobvious atypical toothache first presents, direct microscopic examination of the tooth for incomplete tooth fracture is also suggested. The majority of these patients are women over the age 30 with pain in the posterior teeth/alveolar arch. Multiple causes exist for sustained neuropathic pain including direct nerve injury (e.g., associated with fracture or surgical treatment), nerve injection injury, nerve compression injury (e.g., implant, osseous growth, neoplastic invasion) and infection-inflammation damage to the nerve itself. Sustained nerve pain is commonly seen in patients with psychiatric impairment. It may be that the unrelenting nature of the pain itself alters the patient's personality. Treatment includes pharmacologic medications which suppress nerve activity. The common medications used for atypical odontalgia and phantom tooth pain include gabapentin, tricyclics, topical anesthetics, and opioids. A list of these medications is provided in table form. Data suggest that once the patient has failed dental treatment and pain persists, the long-term outcome is less than 25 percent will have complete pain relief with treatment. With earlier treatment, better pain control, and improved nerve activity suppression medications, this should also prevent secondary psychiatric disease from developing and lower the number of inappropriate treatments.     

Orofacial pain is prevalent—a systematic review

J Evid Base Dent Pract 2002;2:252-3     

Can a single pain rating replace a multiple pain rating in third molar surgery studies? Analysis of 220 patients

This study describes the comparison of multiple and single pain ratings in patients after surgical removal of the third molar. Correlation and agreement analysis were performed between the average pain intensity measured three times a day over a period of 7 days and one single pain rating (designated the 'recalled average' pain, as assessed by the patient) after surgical removal of the lower third molar. The study population consisted of patients participating in three randomized trials. The results show that both measurement correlated good to excellent, but there was a large variation in agreement between the ratings. In conclusion, in patients with surgical third molar removal a single pain rating is not an accurate predictor of the average pain measured by a multiple pain-rating test. A single pain rating cannot replace a multiple pain assessment.     

Are female patients with orofacial pain medically compromised?

BACKGROUND: Chronic pain has been linked to various medical conditions. The authors assessed whether certain medical conditions are more prevalent in female patients with orofacial pain than in age-matched controls. METHODS: The study sample consisted of 87 female adult subjects from a university-based orofacial pain center (OPC) and 87 age-matched female subjects from a university-based undergraduate dental clinic (UDC). Subjects were evaluated between February 2003 and July 2003, and they completed a standardized, 78-question medical history questionnaire as part of routine clinical protocol. Using the subjects' medical histories, the authors compared 11 major medical categories and 77 individual conditions for both groups. For statistical analyses, the authors used nonparametric Kolmogorov-Smirnov Z tests and chi2 tests and calculated odds ratios (ORs). RESULTS: The medical histories of subjects in the OPC group indicated a significantly greater number of medical conditions than did those of the subjects in the UDC group (Z = -4.411, P < .0001). Specifically, subjects in the OPC group reported having significantly more neurological (Z = -5.304, P < .0001), gastrointestinal (Z = -2.897, P = .004), pulmonary (Z = -2.298, P = .022), dermatologic (Z = -2.984, P = .003) and other conditions (Z = -2.885, P = .004) than did subjects in the UDC group. Subjects in the OPC group reported having 12 individual medical conditions significantly more often (P < .05, ORs ranged from 2.5 to 9.7) than did subjects in the UDC group. CONCLUSIONS: Female patients with orofacial pain complaints appear to have more systemic problems than do female patients seeking routine dental care. CLINICAL IMPLICATIONS: The presence of multiple medical conditions can influence orofacial pain management options and treatment outcomes. Patients with more medically complicated orofacial pain may require treatment on a multidisciplinary basis.     

Treating chronic pain how do we measure success?

In this article, the practitioner is provided with information on common techniques to determine whether a particular treatment for a chronic temporomandibular disorder (TMD) is successful. Although most clinicians rely on patient reports of relief as the primary evidence for success, we have found that these reports are poorly correlated with changes in pain. Reports of relief may reflect other aspects of therapy, such as the patient's relationship with the health care provider or improved ability to cope. Therefore, in order to know if a treatment is truly efficacious, we suggest that the clinician measure the patient's pain before, during and after treatment. Questionnaires designed to measure pain and relief in the clinic, as well as instructions for their use, are included. These can be used to document progress and for medico-legal purposes.     

Does temporomandibular disorder pain dysfunction syndrome affect dietary intake?

Temporomandibular disorder pain dysfunction syndrome (TDPDS) is the most common cause of facial pain after toothache. The symptoms are varied but are likely to affect the choice, intake and enjoyment of food. This has not been previously investigated. In this paper a preliminary study of 35 patients attending a department of oral and maxillofacial surgery at a general hospital is presented. Thirty-one subjects reported that eating was a problem; 15 prepared food differently and 24 considered that their choice of food was limited. Four of the five foods most often reported to be difficult to eat are valuable in the diet: meat (22), apples (20), bread (13), toast (7) and toffees (6). Twenty-three subjects reported eating a softer diet. Most (25) reported pain when eating. Such circumstances make it harder for TDPDS sufferers to meet current nutritional guidelines, especially, perhaps, for some to achieve an adequate intake of iron.     

Is there a relationship between head posture and craniomandibular pain?

An often-suggested factor in the aetiology of craniomandibular disorders (CMD) is an anteroposition of the head. However, the results of clinical studies to the relationship between CMD and head posture are contradictory. Therefore, the first aim of this study was to determine differences in head posture between well-defined CMD pain patients with or without a painful cervical spine disorder and healthy controls. The second aim was to determine differences in head posture between myogenous and arthrogenous CMD pain patients and controls. Two hundred and fifty persons entered the study. From each person, a standardized oral history was taken and blind physical examinations of the masticatory system and of the neck were performed. The participants were only included into one of the subgroups when the presence or absence of their symptoms was confirmed by the results of the physical examination. Head posture was quantified using lateral photographs and a lateral radiograph of the head and the cervical spine. After correction for age and gender effects, no difference in head posture was found between any of the patient and non-patient groups (P > 0.27). Therefore, this study does not support the suggestion that painful craniomandibular disorders, with or without a painful cervical spine disorder, are related to head posture.