CRANIO® The Journal of Craniomandibular & Sleep Practice

ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20

Pharmacological Treatment of Facial Pain Peter F. Chase, Rosalind N. Donoghue & Dennis M. Harness To cite this article: Peter F. Chase, Rosalind N. Donoghue & Dennis M. Harness (1992) Pharmacological Treatment of Facial Pain, CRANIO®, 10:3, 262-264, DOI: 10.1080/08869634.1992.11677920 To link to this article: http://dx.doi.org/10.1080/08869634.1992.11677920

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Date: 23 August 2017, At: 00:02

Pharmacological Treatment of Facial Pain

Peter F. Chase, D.D.S. Rosalind N. Donoghue, D.D.S. Dennis M. Harness, Ph.D.

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Univen;ity of the Pacific School of Dentistry Facial Pain Research Center 2155 Webster Street San Francisco, California 94115

''Prescribing a single drug and evaluating its specific effects provide valuable diagnostic information that can lead to, or help clarify, a final diagnosis."

262 JNL CRANIOMANDIBULAR PRAC JULY 1992 VOL 10, NO.3

Pharmaceuticals are often necessary in the diagnosis and treatment of facial pain disorders. Prescribing a single drug and evaluating its specific effects provide valuable diagnostic information that can lead to, or help clarify, a final diagnosis. This information explores relevant drug classes and provides specific examples of pharmaceuticals used for facial pain diagnoses and treatment. Those drug classes discussed were chosen in regard to efficacy and simplicity of use, and with minimal iatrogenic problems. Before prescribing any medication, a review of the current Physician's Desk Reference (PDR) 1 and the American Medical Associations Drug Evaluations is warranted. The patient's physician should also be contacted in regard to possible therapeutic contraindications. The diagnosis and treatment of orofacial pain can be a complex and often frustrating endeavor. A working diagnosis is developed through a thorough history and clinical examination evaluating the origin, dynamics, and pathway of the pain. A systematic approach to administration and subsequent evaluation of the effect of a medication contributes to clarifying the diagnosis, directing the treatment for an individual's facial pain problem, and directing necessary referrals. Multiple authors have addressed drug therapy for the treatment of facial pain. However, new drugs and information provide an opportunity for clarification and alternative treatment approaches.2.3 For example, primary muscle and joint disorders can be differentiated from other facial pain complaints. The pharmacological management of craniomandibular

disorders (CMD) has been previously described by Gangarosa. 4 The craniomandibular mechanism has multiple components: the maxillary, mandibular and temporal bones, masticatory muscles, articular disks and ligaments, teeth, periodontium, and neurovascular system. For optimal function, these components must work together in harmony, be of durable genetic quality and operate within a healthy psychological and physiological environment. Craniomandibular disorders result from mechanism imbalances, a lack of tissue durability, or an unhealthy physiological or psychological environment.5 Patients presenting with facial pain often complain of jaw joint pain (arthralgia) and/or muscle pain (myalgia). Pathology may be limited to the muscle, the joint, or be interrelated. Muscle problems may cause secondary joint dysfunction or joint problems may cause secondary muscle dysfunction. 6 The role of dentists in the treatment of craniomandibular disorders is to reduce patients' symptoms by relieving abnormal structural stress and managing psychological and physiological factors that may contribute to the condition. Appropriate therapy may include physical, psychological, behavioral, pharmacological, dental, and surgical approaches. This information presents the pharmacological approach to the diagnosis and treatment of facial pain disorders with special emphasis on craniomandibular, musculoskeletal problems, and related pathology.

Classes of Drugs Drugs currently used for diagnosis and treatment of facial pain can be summarized in the following classes.

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Systemic Medication 1. Analgesic 2. Anti-inflammatory A. Non-steroid B. Steroid 3. Muscle relaxant 4. Anti-anxiety 5. Anti-depressant 6. Decongestant/antihistamine 7. Antibiotic 8. Hypnotics 9. Dietary supplement I0. Miscellaneous A. Anti-migraine agents B. Anti-trigeminal neuralgia agents

Local and Topical Medication l. Otic (ear) drop preparation

2. Anesthetic 3. Steroid Table 1 summarizes these drug classifications and lists examples and adult dosages of medications. The medications selected were chosen for maximum efficiency, ease of dosage, minimal side effects, and specificity of action. Multiple drugs were selected for most categories to provide a difference in chemical structure and mechanism of action. Individual responses to specific medications vary and where one medication may not relieve a patient's signs and symptoms, another drug of different chemical formula or mechanism of action may be effective.

Table 1 Systemic Medication I. Analgesic A. Tylenol with 30 mg codeine (acetaminophen, codeine, McNeil, Fort Washington, PA): one tablet every four hours B. Vicodin (hydrocodone, Knoll, Whippany. NJ): one to two tablets every four to six hours (maximum eight tablets/day) II. Anti-inflammatory A. Motrin (ibuprofen, Upjohn, Kalamazoo, Ml): 800 mg three times a day B. Ansaid (flurbiprofen, Upjohn, Kalamazoo, Ml): 100 mg three times a day C. Feldene (piroxicam, Pfizer, New York, NY): 20 mg every day D. Voltaren (diclofenac sodium, Geigy, Ardsley. NY): 50 mg three times a day Ill. Muscle relaxant A. Flexeril (cyclobenzaprine, Merck, Sharp & Dohme, West Point, PA): 10 mg three times a day B. Paraflex (chlorzoxazone, McNeil, Fort Washington, PA): 250 mg two tablets four times a day C. Norflex (orphenadrine, 3M, St. Paul, MN): one tablet twice a day IV. Anti-anxiety A. Xanax (alprazolam, Upjohn, Kalamazoo, Ml): 0.25 to 0.5 mg three times a day B. Ativan (lorazepam, Wyeth, Philadelphia, PA): I mg three times a day C. Vistaril (hydroxyzine, Pfizer, New York, NY): 50 mg four times a day V. Anti-depressant A. Prozac (fluoxetine, Lily, Indianapolis, IN): 20 mg four times a day B. Desyrel (trazodone HCI, Meade Johnson, Evansville, IN): 150 to 400 mg/day (50-, 100-, 150-mg tablets) three times a day, doses increase by 50 mglg every four days C. Elavil (amitriptyline HCI, Merck, Sharp/Dohme, West Point, IN): 75 mglday in divided doses increased to a maximum of 150 days as necessary VI. Decongestant/antihistamine A. Trinalin (azatadine maleate/pseudonephedrine sulfate, Schering. Kenilworth, NJ): one tablet twice a day B. Extendryl SR (phenylephrine, chlorpheniramine methoscopalamine, Fleming, Fenton, MO): one tablet twice a day C. Seldane (terfenadine, Merrell Dow, Cincinnati, OH): 60 mg one tablet twice a day VII. Antibiotic A. Penicillin VI 500 mg four times a day B. Amoxicillin 250 to 500 mg four times a day C. Erythromycin 500 mg four times a day D. Kaflex (cephalexin, Dista, Indianapolis. IN): 250 mg four times a day VIII. Hypnotics A. Dalmane (Fiurazopan Roche, Manati, Puerto Rico): 30 mg before retiring B. Chloral Hydrate (Roxane, Columbus, OH): 500 mg 15 to 30 minutes before bedtime IX. Dietary supplement A. Ensure (Ross, Columbus, OH): (Complete balance liquid nutrition): One-8-oz can/day chocolate or vanilla; 24 cans/case

263 JNL CRANIOMANDIBULAR PRAC JULY 1992 VOL. 10, NO.3

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Table 1 cont.

''Researchers have found that patients suffering from facial pain respond to placebos to a greater extent than the general population.''

X. Miscellaneous A. Anti-migraine agents I. Cafergot (ergotamine and caffeine, Sandoz, East Hanover, NJ): one tablet at attack; onset one tablet every 1/2 hr as needed (maximum six tablets/attack, 10/week) 2. lnderal (propranolol, Wyeth-Ayerst, Philadelphia, PA): initial dose 40 mg twice a day progress to effective range 160 to 240 mg B. Anti-trigeminal neuralgia agents I. Tegretol (carbamazepine, Geigy, Ardsley, NY): 100 mg chewable, 200-mg tablet 100 mg twice a day increase by 200 mglday (maximum 1200 mglday) Local Medication I. Otic drop preparations A. Cerumenolytic I. Murine (ear wax removal system, Ross, Columbus, OH): place five to 10 drops then warm water, rinse (maximum four days) 2. Debrox (carbamide peroxide, Marion, Kansas City, MO): one treatment/day of five to 10 drops for three to five minutes, then warm water rinse (maximum four days) 3. Cerumenex (triethanolamine polypeptide/chlorbutanol, Purdue Federick, Norwalk, CT): one treatment/day of five to 10 drops for 15 to 30 minutes, then warm water rinse (maximum four days) B. Anti-inflammatory/anti-microbial I. Otic Domeboro Solution (aluminum acetate, Miles, West Haven, CT): four to six drops every two to three hours 2. Cortisporin Otic Solution (polymyxin B/neomycin sulfate/hydrocortisone, Burroughs Wellcome, Research Triangle Park, NC): four drops four times a day (maximum 10 days) I 0-ml bottle II. Anesthetic A. Injection I. 2% Xylocaine (lidocaine, Astra, Westboro, MA) 2. 1.5% Duranest (etidocaine, Astra, Westboro, MA) B. Vapocoolant I. Fluori-methane (Gebaeur, Cleveland, OH) C. Iontophoresis I. 2% Xylocaine (lidocaine, Astra, Westboro, MA): with I :50,000 epinephrine Ill. Steroid A. Celestone (betamethasone, Schering, Kenilworth, NJ): I cc/side (6 mglcc) B. Methylprednisolone sodium succinate

Researchers have found that patients suffering from facial pain respond to placebos to a greater extent than the general population. 6 · 7 Although the placebo effect is not fully understood, its occurrence is well documented and its effects should be considered. Selected drugs are often necessary in the diagnosis and treatment of facial pain disorders. Prescribing a single drug and evaluating its specific effects provides valuable diagnostic information, leading to or clarifying a final diagnosis. Before prescribing these or any medications, a review of the current Physician's Desk Reference (PDR) 1 and the American Medical Associations Drug Evaluations should be

264 JNL CRANIOMANDIBULAR PRAC JULY 1992 VOL. 10, NO. 3

made and the patient's physician contacted regarding any therapeutic contraindications.

References I. 2.

3.

4.

5.

6.

7.

Physician ·s Desk Reference, 44th Ed. New Jersey, Medical Economics Co, 1990 The President's Conference on the Examination, Diagnosis and Management of Temporomandibular Disorders, Chicago, American Dental Association, 1982 Morgan D: Diseases of the Temporomandibular Apparatus, 2nd ed. St. Louis, The CV Mosby Co, 1982 Gangarosa L, Mahan P: Pharmacologic Management ofTMJ/MPDs. ENT 1 1981;61: 30-41 Gelb H: Clinical Management of Head, Neck and TMJ Pain and Dysfunction, 2nd ed. Philadelphia: WB Saunders Co, 1985 Sarna! B, Laskin 0: The Temporomandibular Joint, 3rd ed. Springfield: Charles C Thomas Publisher. 1979 Bell W: Temporomandibular Disorder, 3rd ed. Chicago: Year Book Medical Publishers, 1990

Pharmacological treatment of facial pain.

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