Diagnosis and Treatment of Non-dental Facial Pain

Session Introduction

Diagnosis and Treatment of Non-Dental Facial Pain

Logo.jpg

Overview

Orofacial pain is defined as pain lasting over three months in the mouth or face - is increasing in prevalence, with approximately 7% of the UK population having experienced it. The current management is by either dentists or general medical practitioners, both of whom have radically different approaches to treatment. While management of orofacial pain has improved quite dramatically over recent years, it is essential that dentists and general practitioners are aware of these advances and of the differences in their approaches. This e-learning package demonstrates the alerting features, pathways for referral, common treatments and post treatment and referral Issues surrounding the diagnosis and treatment of facial pain.

Author Joanna Zakrzewska

 

 

Introduction

ebr_fp_36.jpg

There exists a considerable body of evidence to show that chronic facial pain is widespread in the UK (19%); of these cases, 67% have a non-dental cause for their pain [1].

Professional care is then sought by half of this population.17% take time off work or are unable to carry on normal activities because of the pain and up to 70% of these pain patients report a psychological impact [2].

History and examination can often diagnose dental and oral causes of pain, whereas other causes rely heavily on an accurate history.

Common categories of non-dental facial pain include the following:

 

Patient Descriptions

Mouse over the link to watch the video.

video.jpg

The accurate diagnosis of facial pain relies heavily on the patient's descriptions of pain and his or her history.

 

 

 

 

 

 

 

 

 

 

Knowledge Check

  

  

Diagnosis of Non-Dental Facial Pain

ebr_fp_37.jpg

The clinician will need to acquire information from the following sources in order to establish an accurate diagnosis:

The diagnosis should be reconsidered if:

Learning Bite: Oral cancer presents in a multitude of forms and always needs to be carefully considered.

 

 

Dental and Oral Mucosal Pain Disorders

P6.jpg

Dental and oral mucosal pain disorders have their sources in the dental structures and/or the mucosal tissues of the oral cavity.

Dental pain disorders include:

Mouse over the links below.

Oral mucosal pain disorders include:

Mouse over the image for futher information.

Dental and Oral Mucosal Pain Disorders

Diagnostic Considerations

P7.gif

The diagnostic key begins with listening carefully to the patient in order to identify the pain disorder. An oral examination will often reveal the offending tooth or oral lesion.

Mouse over the links below.

Dental radiographs can be helpful in reaching a diagnosis in cases when dental pain is suspected but not obvious on the examination.

Mouse over the image for further information.

Note: In all dental examinations, cancer needs to specifically looked for and eliminated.

Dental and Oral Mucosal Pain Disorders

Knowledge Check

Dental and oral mucosal pain disorders arise from sources in the dental structures and/or the mucosal tissues of the oral cavity.

 Question

Musculoskeletal Pain Disorders

ebr_fp_12.jpg

The musculoskeletal structures provide a very common source of orofacial pains.

The important structures to be considered are:

Pains that arise from these structures have been collectively called temporomandibular disorders (TMD).

Many practitioners refer to these problems as temporomandibular joint (TMJ) disorders. However, muscle pain is the most common type of TMD rather than the joints.

Mouse over the image for further information.

 

Musculoskeletal Pain Disorders

Clinical Features

ebr_fp_13.jpg

Mouse over the links below.

The various clinical features of musculoskeletal pain disorders include clenching habits (shown opposite) or worn teeth due to grinding (bruxism).

 

 

 

 

 

Musculoskeletal Pain Disorders

Diagnostic Considerations

An important task for the clinician is to differentiate these conditions, as the management of muscle pain is different than the management of joint pain.

Mouse over to watch the video.

  

Musculoskeletal Pain Disorders

Further Diagnostic Considerations

Image5.gif Further diagnostic considerations include:

Musculoskeletal Pain Disorders

Treatment

ebr_fp_17.jpg

After identifying the possible diagnoses, treatment and onwards referral of patients should follow the stages shown opposite.

Mouse over the image for further information.

 

 

 

 

 

 

 

 

Musculoskeletal Pain Disorders

Knowledge Check

Select all correct answers from the list below.

Question

Mouse over for feedback.

Neurovascular Orofacial Pain Disorders

P15.gif

Most neurovascular orofacial pain conditions are not greatly influenced by provocation of the dental or masticatory structures. If pain is not affected greatly by jaw function, then it is unlikely to be dental, mucosal or musculoskeletal. Instead it is more likely a pain disorder that fits into this category.

Pain from these conditions may present in a variety of ways from constant to episodic, from mild to severe. Two of the most significant subcategories in this group are:

Atypical facial pain is the term used for patients whose symptoms do not indicate either category. More frequently the term chronic or persistent idiopathic facial pain or atypical odontalgia is used if the pain presents in a very localised area. Some of these patients may be misdiagnosed and may have some form of neuropathic trigeminal pain (shown opposite).

Neurovascular Orofacial Pain Disorders

Neuropathic Pain Disorders

ebr_fp_19.jpg

Neuropathic pain is characterised by pain felt in structures that have no clinical evidence of any pathology and which follows a nerve distribution.

The diagrams opposite illustrate common patterns of neuropathic pain which may also share one or more features below:

Mouse over the image for further information.

Neurovascular Orofacial Pain Disorders

Episodic Neuropathic Pain Disorders

ebr_fp_20.jpg

Trigeminal or glossopharyngeal neuralgia are episodic neuropathic pain disorders characterised by quick, intense, sharp, light touch-provoked pains (shown opposite) in the peripheral distribution of the affected nerve. It is usually momentary with complete remission of pain between episodes.

The trigeminal autonomic cephalgias which occur in the trigeminal region are often episodic but of longer duration than trigeminal neuralgia but most frequently in the first division.

They are characterised by episodic pain with autonomic symptoms which can include tearing, eyelid oedema, nasal congestion, sweating and restlessness.

 

 

 

Neurovascular Orofacial Pain Disorders

Continuous Neuropathic Pain

ebr_fp_21.jpg

Mouse over the links below.

Continuous neuropathic pain disorders are characterised by fluctuations of pain intensity from high to low but they never completely resolve. Conditions that present with this pain include:

Symptoms include tingling and burning pain in the distribution of a nerve branch or branches. The patient may also describe numbness or sensations of dysesthesia (crawling or itching) in the painful area. A sensory loss may also be detected with careful testing.

Mouse over the image for further information.

Neurovascular Orofacial Pain Disorders

Burning Mouth Syndrome

ebr_fp_25.jpg

Burning mouth syndrome (BMS) is a condition which occurs principally in peri-menopausal women and its prevalence is estimated at 1% of the population. Patients complain of burning, itching, abnormal sensations of the tongue and other areas of the oral mucosa often associated with altered taste and dryness.

Patients' complaints are often ignored and they are told that this is psychological and this can then lead to depression. Many also worry that they have oral cancer. The symptoms (shown opposite) are not progressive and up to 30% may get resolution over the years.

A variety of conditions can cause BMS and these need to be excluded as many are treatable.

 

Neurovascular Orofacial Pain Disorders

Neurovascular Orofacial Pain Disorders

painUntitled-2.gif

When considering a diagnosis of neuropathic pain, it is important to illicit from the patient any history of nerve damage. This can result from direct trauma including dental work such as extractions, root canal fillings or infection such as HSV.

Patients report their pain in the form of tingling and burning sensations – pins and needles, numbness, increasing pain due to touch.

Features of neuropathic disorders:

Mouse over the image for further information.

 

Psychological and Other Co-Morbidities

ebr_fp_26.jpg

When a pain condition becomes more chronic, other influencing factors can further complicate and perpetuate the condition. There are further resources on the site regarding psychosocial issues which can complement your study.

Some of these influencing factors may be psychological and include:

Learning Bite: Depression may be the result of the experience of chronic pain and on occasion may have resulted in the pain itself.

Mouse over the image for further information.

Psychological and Other Co-Morbidities

Multiaxial Approach

consult.jpg

It has been proposed that a multiaxial approach should be taken to all pain patients. Several parameters of illness are thus considered simultaneously and an appropriate scale for each parameter or axis is established.

Patients may have both a physiological diagnosis and a psychological one some cases the latter may be more important to management than the physiological one.

The psychological factors can change the whole approach to management and may be the reason why patients fail to respond to treatment.

 

 

 

Psychological and Other Co-Morbidities

ebr_fp_28_med.jpg

Facial pain can be caused by other closely related conditions such as:

 Or other complaints that may also be elicited include:

To be confident of an accurate diagnosis, clinicians must ask about other associated pains (shown opposite) and investigate these appropriately.

The image shown opposite shows a patient's own illustration of the nature and location of associated pain.

Mouse over image to zoom.

Psychological and Other Co-Morbidities

Other Co-Morbidities Case Study

ebr_vvs_02.jpg

A patient (Ms X) presented with typical features of temporomandibular disorder (TMD). Further questioning revealed that she had more frequent migraines that were not well controlled.

The patient had recently divorced and had a very erratic life style. She felt a lack of pleasure in life and felt her mood was low which made her reluctant to go out.

Question: What is the possible mechanism?

Mouse over for the answer.

 

 

 

 

Psychological and Other Co-Morbidities

Knowledge Check

  

 

Pathways for Referral

Untitled4A.gif

If dental pain is severe patients should see their dentists or go to an emergency dental clinic within 24 hours. Patients with suspected cancer need to be seen urgently by specialists.

Musculoskeletal pain disorders can be acute if associated with jaw locking but the majority once reassured can be dealt with as routine.

Some of the neuralgias can result in acute severe pain and may need emergency treatment with anticonvulsants and then onward referral. The majority are long standing and can be referred as routine.

Learning Bite: If patients show acute symptoms and psychosis, an urgent referral to mental health services is required as detection of suicidal risk and patient self harm is crucial.

Effective management of the pain problem will result in resolution of many of the issues.

Mouse over the links below.

Management of Patients

Drug Management

P27.gif

The most commonly used drugs are the tricyclic antidepressant, e.g. nortriptyline. If there is significant depression then escitalopram may be useful. In neuropathic type pain, drugs such as gabapentin and pregabalin are useful. These drugs need to be used for at least eight weeks and patients need to be told that they will not have an instant effect. Adequate doses need to be used and these need to be raised slowly.

Specialist centres will often prescribe these but then ask GPs to continue the prescriptions. Some patients need these drugs for a year or so but up to 40% will require long term maintenance.

GPs need to be aware that patients may not present to them initially but see a dentist and then be referred to a specialist dental unit, e.g. oral medicine who will then recommend these drugs. Dentists cannot prescribe these drugs so patients will be asked to go to their GP for repeat prescriptions and shared care.

In chronic facial pain there is no evidence that the use of opioids has an impact.

Management of Patients

Management of non-dental facial pain is long-term and it is essential to ensure that patients accept they have a pain that's cause is not always known and for which there is no magic cure.

In general, the pain should not get worse with time unless co-morbidities come into play, e.g. depression, other medical problems, significant life events.

Flow.gif

Reassurance, Patient Control and Self Care

ebr_fp_31.jpg

It is important to reassure patients that they do not have cancer. If this is one of their concerns, a thorough oral examination may be required.

When the pain is mainly intra-oral they may become convinced that there is a dental cause. In some patients this may be the case and so patients may sometimes require an opinion from a consultant in restorative dentistry to clarify this issue.

Patients need to take control and not allow the pain to dominate them. It is important to supply patients with information, e.g verbal, leaflets, books and web links.

Counselling should be provided if there are significant psychosocial events that impact on the pain.

If these simple measures do not provide significant relief then drug management becomes necessary.

Mouse over the image for further information.

Management of Patients

Drug Management

ebr_fp_32.jpg

Management of patients may include:

 

 

 

 

 

 

Self Assessment

Question 1

Select all correct answers from the list below.

 Question

Mouse over for feedback.

Self Assessment 

Question 2 

Select all correct answers from the list below.

 Question

Mouse over for feedback.

Self Assessment

Question 3

Select all correct answers from the list below.

 Question

Mouse over for feedback.

Self Assessment

Question 4

Select all correct answers from the list below.

 Question

Mouse over for feedback.

Key Points

Logo.jpg

Session Key Points

  • Patients with pain need to have their history taken with care – time must be taken over this
  • Co-morbidities need to be elicited e.g. depression, anxiety, other pain, poor sleep
  • Patients need to be reassured that they do not have a serious cause for their pain
  • An explanation for the pain is essential
  • Patients may need referral to specialist centres if they do not respond to first line treatments
  • A biopsychosocial approach to management is essential
  • Patients need to accept they have chronic pain and self manage

 

 

 

Session Summary

Logo.jpg

Further Reading and Activities

Refer to the following text for additional information:

  • Macfarlane, T. V., Blinkhorn, A. S. et-al 2004 Can one predict the likely specific orofacial pain syndrome from a self-completed questionnaire? Pain:111:270-277
  • Locker, D. & Grushka, M. 1987 The impact of dental and facial pain J. Dent. Res. 66: 1414-1417National Institute for Clinical Excellence Clinical Guideline 60, Depression in adults View
  • British Society for Oral Medicine. View
  • Eds Zakrzewska JM & Harrison SD Assessment and management of orofacial pain Elsevier Vol 14 in Series on Pain research and clinical management 2002, pp 244 View
  • Orofacial Pain Editor Zakrzewska J M Oxford University Press 2009 View
  • British Pain Society [Internet]. London View
  • Brain and Spine Foundation, London View
  • Refer to NICE guidelines 96 Neuropathic Pain 2010 View

Acknowledgements

  • The Wellcome Trust. Images supplied by The Wellcome Trust. Not for reproduction without express permission of the copyright owner. View
  • UCL/UCLHT - This work was undertaken by Prof. Joanna Zakrzewska of UCL/UCLHT who received a proportion of funding from the Department of Health's NIHR Biomedical Research Centre funding scheme. View