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Ensuring accurate diagnosis of orofacial pain disorders James R Fricton†: Dr Fricton received his BS and DDS

degree from the University of Iowa (IA, USA), and then undertook his postgraduate studies, completing an MS in Oral Biology at UCLA School of Dentistry (University of California, CA, USA) and an Anesthesiology and Pain Management Residency at UCLA Medical Center. After research and clinical training at UCLA, he joined the faculty at the University of Minnesota (MN, USA), where he is currently a Professor in the Department of Diagnostic and Surgical Sciences and Physical Medicine and Rehabilitation. He is also a Senior Research Investigator at HealthPartners Research Foundation (MN, USA). He has over 30 years experience in clinical care, research and teaching in the field of chronic pain, orofacial pain, temporomandibular muscle and joint disorders, muscle pain, and, more recently, health informatics. His sponsored research has focused on epidemiological studies and clinical trials of therapeutic strategies for chronic pain conditions. He has developed a biobehavioral framework for personalized care for chronic pain conditions and has integrated this pain research with studies of health information technology, focusing on the use of electronic health records, personal health records and clinical decision support to improve the outcomes and quality of healthcare. He is Principal Investigator for the NIH NIDCR’s temporomandibular joint (TMJ) Implant Registry and Repository, which includes research into the genetic, biomechanical and biobehavioral factors involved in the success or failure of TMJ implants. In addition, he has served on the governing board of the American Pain Society, and was president of both the American Board of Orofacial Pain and the American Academy of Orofacial Pain. He maintains an active private practice for patients with TMJ, orofacial, head and neck pain in Plymouth (MN, USA) and St Paul (MN, USA). Persistent orofacial pain often does not fit into the traditional diagnostic classifica� tion associated with conditions of the den� tal and other orofacial structures owing to the confusing presentation, the frequent overlying multiple comorbid conditions, and the behavioral and psychosocial fac� tors that complicate it. Patients ������������������ with oro� facial pain can be victims of this confusion and left without a diagnosis or treatment. If recognition and treatment is neglected or inadequate, the costs can be great and the personal impact tragic [1–11] . The pain becomes entrenched in the patient’s life

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with the development of dependent rela� tionships, emotional disturbances, impair� ments, disability, and many behavioral and psychosocial problems. They present a frustrating medical and dental picture undergoing costly dental or sinus surgeries, endodontic procedures, long-term medica� tions, and an ongoing dependency on the healthcare system. These patients also have a pattern of high healthcare utilization and miss work more frequently than those with other conditions [8,12] . In one study, orofacial pain patients had consulted an average of 7.5 professionals, in descending

University of Minnesota, School of Dentistry, Minneapolis, MN 55455, USA; Tel.: +1 612 624 2411; Fax: +1 612 626 0138; [email protected]

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Pain Manage. (2011) 1(2), 115–121

ISSN 1758-1869

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NEWS & VIEWS  ASK THE EXPERTS order: dentist, GP, neurologist, ear, nose and throat surgeon, oral and maxillo­facial surgeon, psychiatrist, ophthalmologist and dermatologist [13] . Therefore, the pur� pose of this article is to discuss accurate diagnosis of orofacial pain disorders. What are the first steps that should be taken when a patient presents with orofacial pain? QQ

“Patients with orofacial pain can be victims of this confusion and left without a diagnosis or treatment.”

The first steps in diagnosis of orofacial pain is to conduct a thorough history and orofacial examination. Ask the patient to carefully describe the location and clini� cal characteristics of the pain and associ� ated symptoms. Frequently, the source of the pain can be determined. For example, patients may localize the pain to one or more teeth, suggesting periodontal ligament sensitivity, while pain overlying the maxilla may be caused by sinusitus. However, oro� facial pain descriptions can also vary with the condition and frequently present with patterns of referred pain, confusing the diagnosis [10–14] . For example, myofascial pain of the tem� poralis muscle can present with pain referral patterns to the maxillary teeth. Trigeminal neuralgia may have a true trigger zone, with light touch in a tooth triggering lancinat� ing pain through the jaw. Tempomanibular joint pain may be intensified by movement of the jaw during mastication or speech, and radiate pain into the ear. The circumstances of the onset of pain may also reveal a diag� nosis. When trauma initiates the pain, this may be accidental or iatrogenic, such as with endodontic treatment, dental extraction or sinus surgery. The pain is either aggra� vated by the injury or initiated by it. If the pain spreads to a larger region of the face and does not follow any particular neural pathway, it is often myofascial in origin.

In one study of orofacial pain condi� tions, the distribution of diagnoses using the AAOP diagnostic categories were deter� mined for 35 patients who presented with a chief complaint of persistent, undiagnosed orofacial pain [14] . In all but one of these cases (97%) there was a specific physical diagnosis or multiple diagnoses for the cause of the persistent pain. The distribu� tion of these disorders included myofascial referred pain (54%), periodontal ligament sensitivity pain (31%), referred pain from tooth pathology (20%), neuropathic pain (9%), burning tongue/mouth (6%), tooth fracture (3%), occlusal awareness dysfunc� tion (3%), candidiasis (3%), sinus patho­ logy (3%) and pericoronitis (3%). These are the most difficult of the disorders to diagnose and, thus, are often overlooked in the clinical diagnostic process, and they are described here. „„ Myofascial referred pain

Myofascial pain is characterized by a regional, dull, aching muscle pain and the presence of localized tender sites (trig� ger points) in muscle, tendons or fascia (Figure 1) [15–17] . When palpated, these trig� ger points may produce a characteristic pattern of regional referred pain and/or autonomic symptoms on provocation. They often refer pain to areas of the face and teeth distant from the muscles that are generating the pain and can be confusing to clinicians. In these cases, the most common muscles referring pain to the face and teeth were masseter, temporalis and medial pterygoid. Treatment consists of a splint, exercises to stretch and relax the muscles, use of muscle relaxant medications, and cognitive behav� ioral training to reduce oral habits and other factors that place strain on the muscles [18] . „„ Neuropathic orofacial pain

What are the various conditions that can cause orofacial pain & are part of a differential diagnosis? QQ

Currently, the International Association for the Study of Pain [4] , the International Headache Society [5] and the American Academy of Orofacial Pain (AAOP) [6] each have well-defined classifications of orofacial pain that can be used as a guide to establish a diagnosis.

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Neuropathic pain disorders include neu� ralgias, neuropathies and other afflictions of the nervous system [6–8,19,20] . Neuralgias involve a paresthesia-like pain along a dis� tinct nerve distribution, and may be parox� ysmal or continuous. Paroxysmal orofacial neuralgias include trigeminal neuralgia (tic douloureux), glossopharyngeal neuralgia, facial neuralgia, nervus intermedius neu� ralgia and superior laryngeal neuralgia. The

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ASK THE EXPERTS  paroxysmal pain attack that is common to all of these follows a distinct unilateral course and is often described as having an electric quality such as shooting, cut� ting or stabbing. The pain generally fol� lows the specific distribution of the nerve involved. The attacks may last from only a few seconds to minutes, with no discomfort between the attacks. They may occur inter� mittently, with days to months between a series of attacks. Continuous neuralgias include posttherpetic neuralgias, post-traumatic or post­ surgical neuralgias, and burning tongue syn� drome. As with paroxysmal neuralgias, the pain follows the distribution of the cranial nerve involved. Some fluctuations in inten� sity occur over time. Patients frequently report uncomfortable abnormal sensations (dysesthesias) or pain in the distribution of the nerve, which varies from tingling, numbness and twitching to a prickling or burning pain. The dysesthesias are annoy� ing to the patient, since they are continuous and exacerbated by movement or touching the area. Anesthetic nerve blocks can be used diagnostically to decrease the pain for the duration of the anesthetic. „„ Sympathetically maintained pain

Sympathetically maintained pain is often characterized by a constant burning sensa� tion that is frequently associated with a prior history of tissue damage [21,22] . The main clinical features include pain described as burning and continuous, which is exacer� bated by movement, cutaneous stimulation or stress, with onset usually weeks after injury. Confirmation and treatment of early cases of sympathetically maintained pain of the tooth or facial area is achieved by a stel� late ganglion blockade of the sympathetic nerve input to the painful region. „„ Sinus/nasal orofacial pain

Problems in the maxillary sinuses and/or paranasal mucosa can refer pain to the upper teeth. The pain is usually felt in several teeth as dull, aching or throbbing. Sometimes it is associated with pressure below the eyes, and it can increase with lowering the head, putting pressure over the sinuses, coughing or sneezing. Tests performed on the teeth, such as a cold

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stimulus, chewing and percussion, can increase pain from a sinus origin. A his� tory of an upper respiratory infection, nasal congestion or sinus problem should lead to suspicion of a ‘sinus toothache’. Diagnostic tests such as a visual nasal exam, sinus x‑rays or MRI will reveal this condition. Treatment with antihistamines, decongestants and antibiotics will help. „„ Temporomandibular joint disorders

Temporomandibular joint (TMJ) disorders cause pain in front of or in the ear, which can radiate into the temples. The most common pain conditions include internal derangements, subluxation, arthralgia and osteoarthritis. The difficulty in diagnosing joint problems lies in determining if pain in the area of the joint is caused by muscle dysfunction, joint dysfunction or a systemic disease. The TMJ internal derangement or disk displacement is characterized by five progressive stages of clinical dysfunction involving disk displacement relative to the condyle. It is often associated with TMJ capsulitis and its attendant pain, tenderness and joint swelling. Stage  I is characterized by reciprocal clicking of the TMJ on opening and clos� ing. The opening click reflects the condyle moving beneath the posterior band of the disk until it snaps into its normal relation� ship on the concave surface of the disk. As the disk continues to be displaced, stage II causes periodic locking and limitation of opening. Stage III is characterized by an acute, sustained closed lock, while stage IV entails soft tissue remodeling of the disk and ligaments. Routine daily jaw function remodels the soft tissue disk until the jaw opens to nearly normal. In stage  V, soft tissue remodeling often progresses to the hard tissue remodeling and radiographic changes on the condylar head, and occa� sionally on the articular eminences. Disk perforation and bone-to-bone contact may cause degenerative changes and coarse crepitus upon opening and closing.

Figure 1. Temporalis and masseter myofascial trigger points (arrows) can refer pain to the teeth and orofacial structures.

„„ Migraine, cluster & neurovascular

disorders

Neurovascular pain disorders include migraine headaches and migraine vari� ants, cluster headaches, temporal arteritis,

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“Behavioral and psychosocial

contributing factors may be initiating and lead to the onset of symptoms, may be perpetuating and lead to continuation of the symptoms, or may be resultant as a product of having the illness.”

Figure 2. A 35-year-old female presented with chief complaints of pain in the maxillary region. The only positive examination finding was a decrease in sensation in the trigeminal 2nd division. The diagnosis was an adenocystic carcinoma in the cerebellar region (arrow).

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and angina pain. The usual description of vascular pain is a throbbing, pulsating or beating pain, which varies according to the specific diagnosis. Classic migraine head� aches begin abruptly with a visual aura and rapidly progress into throbbing or pulsat� ing pain. Common migraine headaches are similar to classic migraine but proceed into headaches without prodromata. Both clas� sic and common migraines tend to occur unilaterally over the entire head with a pre� dominance of pain in the frontal, temporal and retro-orbital areas. Other symptoms include nausea, vomiting, diarrhea, hyper� sensitivity to stimuli, cold extremities, water retention and sweating. As the name implies, cluster headaches occur in ‘clusters’ of days to weeks with remission periods of months to years. The pain is a continuous severe pain with throb� bing occurring unilaterally around and behind the eye and in the maxilla. During a cluster period, headaches can occur at an average of six attacks a day and last from 5 to 10 min with no pain in between. Giant cell arteritis can affect the tem� poral artery (temporal arteritis) and should always be considered in the elderly who present with a new-onset headache. Polymyalgia rheumatica often accompa� nies the disorder. Temporal arteritis most frequently occurs in the temporal region on one side (but can occur bilaterally) with moderate-to-severe intensity. The pain may have a sudden onset and be reported as a unilateral headache. Typical findings on examination include tender, swollen branches of the external carotid artery (usually the superficial temporal artery), and most individuals have an elevated sedi� mentation rate. The diagnosis is confirmed with a temporal artery biopsy, which shows the characteristic pathologic changes of giant cell arteritis. What are the most common conditions that pose a challenge to diagnosis? „„ Neoplasias & their lesions in the head QQ

Some tumors, aneurisms (abnormality of a blood vessel) and other intracranial disor� ders can cause pain in the orofacial region. Tooth symptoms are generally accompa� nied by other nerve malfunctioning or

Pain Manage. (2011) 1(2)

systemic symptoms, such as weight loss and fatigue. These accompanying symp� toms suggest more than a localized tooth problem is occurring. Tumors can also appear in the areas near the nerves of the teeth, which may cause the teeth to be loose or displaced. Proper imaging of the face, jaw and head is important to evalu� ate for these problems (Figure 2) . Although possible, these problems are very rare, and treatment needs to be directed to the ­specific problem. „„ Pain from dental structures

Orofacial pain from dental structures, such as pulpitis, periodontal ligament sensitivity and fractured teeth, can pres� ent a diagnostic dilemma particularly if it refers pain to areas that are distant from the involved tooth [23,24,25] . Although not common, patients may present with an ache in a tooth that responds normally to all available tests. Further pulp testing or radiographs reveal that an adjacent tooth, other distant tooth or periodontal structure is inflamed. Subsequent treatment of the inflamed tooth resolves the referred pain. Periodontal ligament pain is character� istic of deep somatic pain of the musculo­ skeletal type, and is caused by repetitive strain to the dental periodontal ligaments through clenching, gross occlusal prema� turities or trauma to the teeth [23,26,27,28] . Periodontal ligament pain is generally a dull aching pain in and around the teeth and can affect multiple teeth. Inflammatory fluid accumulation may cause displacement of the tooth in its socket with a resulting acute malocclusion and pain. The most common sign is tenderness of the teeth to percus� sion in the absence of pulpitis, periapical or periodontal abscess. Treatment consists of using a splint to protect the teeth, reducing oral habits and avoid chewing. Complete or incomplete tooth fractures can cause persistent tooth pain that is dif� ficult to diagnose (Figure 3) [29–31] . Pain can result when the pulp is exposed by frac� tures to the enamel and dentin, which become displaced when mechanical strain is placed on the tooth. Diagnosis is dif� ficult, particularly if an incomplete frac� ture is present, but can be made, by visual inspection, exploration of the tooth for

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ASK THE EXPERTS  loose fragments, tooth mobility tests, tooth discoloration and tooth provocation tests that cause pain when the fractured segment is moved. The pulps of these teeth may or may not respond to an electric pulp test or to thermal testing. Fractures need to be treated with temporary banding, crowns or endodontic treatment. „„ Burning mouth syndrome

Patients with idiopathic burning mouth syndrome typically characterize their symptoms as a burning sensation as if the mouth or tongue were scalded or on fire. Burning mouth syndrome accompanies other oral complaints, including xero­ stomia and dysgeusia [32–35] . The oral tis� sue often appears normal. There are many factors that can cause burning mouth, including candidiasis, painful geographic and/or fissured tongue, as well parafunc� tional habits, dysfunctional disorders of the musculo­skeletal system, allergies, xero­ stomia and injury following dental treat� ment. Systemic diseases and medications have also been demonstrated to directly or indirectly cause burning mouth from the resultant xero­stomia that may be pres� ent. Therefore, while it is not difficult to diagnose a condition as burning mouth, it is difficult to determine the underlying etiology that will suggest a treatment. „„ Salivary gland dysfunction

Patients with salivary gland dysfunction can experience orofacial pain through dif� ferent mechanisms (Figure 4) . It may occur through a blocked duct or construction causing referred pain from the glands to the face or teeth. It may also compromise the health of the teeth and supporting struc� tures by the absence of protective saliva. In such cases, a sialogram and imaging of the salivary glands is needed. What are the components to an orofacial pain diagnostic evaluation? QQ

An orofacial examination and the need for imaging studies, including CT and MRI scans and dental radiographs, varies depend� ing on the location of pain and the apparent diagnosis. The examination should include inspection and palpation of the head, neck and face, cranial nerve evaluation, and a

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dental examination. Inspection for rigid� ity in posture or clenching can show excess muscle tension in the neck, shoulders or jaws, and may be associated with myo­fascial pain. Asymmetry, swelling, weakness, loss of function, dysfunction, skin changes and other signs may lead to finding a neoplas� tic or infectious process. Inspection of the skin may reveal scars of past surgeries, skin trophic changes of causalgia, and color changes in local infection or systemic ane� mia. Palpation includes identifying tight muscle bands or myofascial trigger points, the skin for hyper­e sthesia in causalgia, lymph nodes for lymphadenopathy, joints for swelling and tenderness of arthritis, maxillary and frontal sinus tenderness, and the rest of the head and face for size or consistency changes. �������������������� Cranial nerve exami� nation should determine the presence of dysesthesia, allodynia and/or paresthesia, which may suggest neuropathic pain [36] . A dental examination includes identification of dental caries, periodontal infections, and pulp testing and percussion of teeth with the blunt end of a dental mirror. This can elicit pain from pulpal or periodontal infec� tion, or pain from periodontal ligament sensitivity or a cracked tooth.

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Figure 3. Common causes of persistant pain. Incomplete tooth fracture (A), referred pulpitis (B) and periodontal ligament pain (C) are common causes of persistent pain.

What are behavioral & psychosocial factors that may contribute to orofacial pain? QQ

Behavioral and psychosocial contributing factors may be initiating and lead to the onset of symptoms, may be perpetuating and lead to continuation of the symptoms, or may be resultant as a product of hav� ing the illness. As these factors are part of the problem and may complicate successful management, each needs to be evaluated. Once these factors are identified as part of the problem, long‑term successful manage� ment is dependent upon addressing them on a basis equal to and integrated with the physical diagnosis. Treating one without the other may prevent symptom reduction or maintenance of relief. Psychosocial contributing factors includ� ing prolonged emotional difficulty, such as anger, anxiety or depression, and social situ� ations, such as high levels of stress and being the victim of abuse, may complicate pain management by causing increased muscle

“Although each clinician may

have limited success in managing the ‘whole’ patient alone, the assumption behind a team approach is that it is vital to address different aspects of the problem with different specialists in order to enhance the overall potential for success.”

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NEWS & VIEWS  ASK THE EXPERTS How can a multidisciplinary team be utilized in the diagnosis & treatment of orofacial pain? QQ

Parotid duct

Parotid gland

Submandibular gland Sublingual gland

Figure 4. Salivary glands can cause orofacial pain from blockages, spasms, infections and tumors.

tension, central sensitization, poor relation� ships, and/or affect compliance and motiva� tion, or energy to change. These factors are common among chronic pain patients, and may result from having persistent pain, may make pain more difficult to tolerate and/or prevent successful management. The most common and traumatic behav� ioral contributing factors are oral parafunc� tional habits. These pernicious oral habits include bruxism, clenching, fingernail biting, lip and oral mucosal biting, object biting, gum chewing, protrusive and retru� sive habits, tongue thrust habits, and mal­ adaptive mandibular opening habits. They create excessive muscle strain and the resul� tant muscle fatigue or trauma may lead to musculoskeletal pain. Other behavioral fac� tors that may strain or weaken muscles and joints include sleep disturbances and dietary factors, such as nutrient-deficient diets.

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A patient with orofacial disorders may present a frustrating medical situation, which may include persistent aggravation of pain, a long history of treatments, long-term medications, repeated healthcare visits and ongoing dependency on the healthcare sys� tem [37–43] . Success of treatment is frequently compromised by the chronic nature of the disease and by long-standing maladaptive behaviors, attitudes and lifestyles that may actually perpetuate or result from the illness. Factors such as disability, chemical depend� ency, inadequate nutrition, sleep distur� bances and countless others are beginning to be studied and understood. Failure to help the patient change these factors often plays a major role in the failure to obtain successful long-term management of these disorders. To improve this situation, evaluation and management systems using an inter� disciplinary team of clinicians have been developed. Although each clinician may have limited success in managing the ‘whole’ patient alone, the assumption behind a team approach is that it is vital to address different aspects of the problem with different special� ists in order to enhance the overall potential for success. Although these programs pro� vide a broader framework for treating the whole complex patient, they have added another dimension to the skills needed by the clinician: those of working as part of a coordinated team. Failure to adequately integrate care may result in poor communi� cation, fragmented care, distrustful relation� ships, and eventually confusion and failure in management. Team coordination can be facilitated by a well-defined evaluation and management plan that clearly integrates team members. Financial & competing interests disclosure JR Fricton has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert t­estimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.

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Ask the Experts: Ensuring accurate diagnosis of orofacial pain disorders.

Dr Fricton received his BS and DDS degree from the University of Iowa (IA, USA), and then undertook his postgraduate studies, completing an MS in Oral...
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