Psychiatric comorbidity is found commonly in chronic pain conditions. Depression and anxiety disorders in relation to chronic pain conditions have been studied extensively, and theories on pathophysiology, diagnosis and treatment have been proposed.^7–10 Specifically with regard to facial pain, comorbidity with depression, anxiety and a history of physical or sexual abuse has been documented clearly in several case series.^9,11–13 Additional psychiatric disorders that are frequently associated with pain conditions are the somatoform disorders and personality disorders.¹⁴

In light of the complexity of the biopsychosocial model of pain, it is important that clinicians recognize and identify all of the concomitant conditions that influence chronic pain disorders, so that a correct diagnosis can be made and optimum treatment provided. Given the complexity of the condition of chronic pain, care must be taken that the pain control methods chosen—whether pharmacological, behavioral, physical, psychological or surgical—either eliminate or modify the pain experience and the pain behavior, without altering other aspects of normal human behavior and the human condition.

	Chronic orofacial pain.

TOP ABSTRACT Chronic orofacial pain. CASE REPORTS APPLYING THE INTERDISCIPLINARY... SUMMARY REFERENCES

 
Orofacial pain is an extremely common, multifactorial pain disorder. According to a 1989 survey, an estimated 39 million adults in the U.S. civilian population (approximately 22 percent of the population) had experienced orofacial pain more than once during the preceding six months.¹⁵ Although the most common type of orofacial pain is related to dental pathology (12.2 percent of the U.S. population), pain involving other regions of the head and neck—including the temporomandibular joint, or TMJ (5.3 percent of the U.S. population), and the face and cheek (1.4 percent)—also have a high prevalence. A recent study that involved random sampling of 5,860 households of older adults (aged 65 years and older) revealed that 17.4 percent had had orofacial pain symptoms within the past year.¹⁶ Another recent study demonstrated the most common facial pain conditions to include temporomandibular joint disorders, or TMD; phantom tooth pain; and burning mouth.¹⁷ These disorders provide challenging diagnostic dilemmas for dentists; however, epidemiologic data in the literature have been useful in providing the diagnostic criteria for these conditions.¹⁷

The annual cost to society related to chronic pain is extremely high, involving health care services, loss of work, decreased productivity and disability compensation. In the United States, this cost of chronic pain is estimated to be approximately $80 billion per year, with as much as 40 percent being linked to orofacial pain disorders.^18,19

The diagnosis and management of orofacial pain disorders are extremely complex and have been fraught with much controversy. This may be caused in part by the extremely complex anatomy involved with the facial region, the numerous disciplines that may be involved with the diagnosis and management of orofacial pain conditions and the complexity involved in the science of pain disorders in general. A 1996 National Institutes of Health Technology Assessment Conference on the management of orofacial pain and TMD concluded that the diagnostic classification for orofacial pain and TMD was inadequate, and that long-term, randomized controlled trials concerning the efficacy of a variety of treatment approaches have been inadequate.²⁰ Another conclusion by the panel at this conference was that multidisciplinary collaborations among a number of disciplines in the basic and applied sciences will be necessary to further advance our knowledge of the proper diagnosis and treatment of these conditions.

On a more practical level, there are a great number of people who are suffering from acute and chronic orofacial pain who first visit their dentists in need of diagnosis and management. If the pain is due to dental pathology, interventions by the dental team most commonly will result in resolution of symptoms. However, if the pain persists or reoccurs, the diagnosis of dental pathology becomes questionable. These patients typically will see numerous health care providers from a variety of disciplines in an attempt to obtain appropriate diagnosis and treatment and, thereby, relieve symptoms.

Chronic oral, facial and head pain may be due to any of a variety of conditions:

– neurogenic pain disorders (such as trigeminal neuralgia or postherpetic neuralgia);

– primary headache disorders (such as migraine or cluster headaches or cranial arteritis);

– intracranial pain disorders (such as neoplasm or aneurysm);

– intraoral pain disorders (such as odontogenic or mucosal disorders);

– pain disorders involving associated structures (such as otologic disease or disorders of the paranasal sinuses or salivary glands);

– musculoskeletal disorders (such as TMJ pathology—osteoarthritis, synovitis or neoplasia—or myofascial pain or dysfunction);

– psychological disorders (such as anxiety, depression or post-traumatic stress disorder).

Pain management is extremely difficult and must be based on well-founded diagnoses. All too frequently, there is misdiagnosis or, worse, no diagnosis, often leading to multiple treatments that are ineffective or potentially harmful.

	CASE REPORTS

TOP ABSTRACT Chronic orofacial pain. CASE REPORTS APPLYING THE INTERDISCIPLINARY... SUMMARY REFERENCES

 
The following case reports demonstrate the extreme complexity of oral, facial and head pain. These reports show how the treating clinicians encountered potential and actual pitfalls in the management of such pain. They also demonstrate how patients with orofacial pain can have a variety of diagnoses that cross multiple disciplines, requiring the expertise of an interdisciplinary team of specialists to establish accurate diagnoses and proper management. Finally, these case reports also illustrate how earlier collaboration with practitioners in a number of specialties can greatly improve our ability to diagnose and treat these conditions. Case 1 is an example of how earlier referral to an interdisciplinary team of specialists would have greatly enhanced a patient’s course of treatment.

Case 1. A 30-year-old woman visited an oral and maxillofacial surgeon at Columbia University, New York, in 1994, complaining of bilateral jaw joint pain, headaches and jaw locking. She reported that she had been in a motor vehicle accident in 1987, in which she had suffered multiple injuries, including a complex fracture of the clavicle. The patient reported that this required several operations by orthopedic and plastic and reconstructive surgeons, and she had healed poorly.

In February 1994, she had developed increasing jaw pain and locking and was seen by a dentist with expertise in TMD. He prescribed a full course of conservative treatment, including an oral appliance, muscle relaxants, anti-inflammatory drugs, moist heat and a soft diet. Conservative management was continued over the course of nine months; however, the symptoms continued at a high level. The clinical examination revealed limitation of mandibular movement with an interincisal opening distance of 29 millimeters, a right lateral excursion of 10 mm and a left lateral excursion of 5 mm. All movements were associated with significant right and left TMJ pain. Magnetic resonance imaging, or MRI, revealed bilateral anterior disk displacements.

The diagnosis of internal derangement of the TMJs with bilateral synovitis was established clinically. As the patient continued to have severe symptoms with conservative management, an oral and maxillofacial surgeon performed bilateral surgical arthroscopies in November 1994. This revealed bilateral synovitis and adhesions and osteoarthritis of the right TMJ (Figure 1). The surgeon lysed the adhesions and injected betamethasone under direct vision into the inflamed synovial membranes.

View larger version (112K): [in this window] [in a new window]   Figure 1. Arthroscopic view of the right temporomandibular joint, demonstrating significant osteoarthritis of the articular eminence (black arrow) and disk (outlined arrow).

For a short time, the symptoms diminished. However, after a miscarriage in March 1995, her symptoms increased significantly. In May 1995, because of severe pain, the patient was admitted to Columbia Presbyterian Medical Center, New York, for pain management and further diagnostic work-up. She was placed on patient-controlled analgesic therapy for pain management. MRI scans revealed that in the right TMJ, the disk was displaced anteriorly without reduction, and the posterior band was enlarged (Figure 2). Because of the severe pain and limitation of motion, and the failure of conservative measures to improve the patient’s condition, the dentist and the oral and maxillofacial surgeon thought that perhaps there was a mechanical obstruction in the right TMJ due to fibrosis and disk displacement. The patient underwent right TMJ arthroplasty with diskoplasty and diskal repositioning. The preoperative interincisal opening distance under general anesthesia was 33 mm with deviation to the right, and the postoperative interincisal opening distance was 44 mm. The patient’s immediate postoperative course was unremarkable.

View larger version (118K): [in this window] [in a new window]   Figure 2. Magnetic resonance image of the right temporomandibular joint with anterior disk displacement and bulging of the disk’s posterior band.

View larger version (82K): [in this window] [in a new window]   Figure 3. Postoperative wound dehiscence that could not be attributed to infection or systemic disease. Psychiatric evaluation revealed factitious illness with self-manipulation of the wound.

Comment. This case clearly illustrates how psychiatric disease can affect chronic facial pain. This patient had a combination of significant TMJ pathology and major psychiatric pathology, which made diagnosis and treatment very difficult. During the earlier stages of treatment, the treating clinicians saw no apparent evidence of any psychiatric illness, anxiety or depression. However, the patient did have significant psychiatric pathology, and an earlier evaluation of her psychological and social profile by specialists would have been appropriate. Had an interdisciplinary team been involved in the evaluation of this patient from the beginning, some of the extensive treatment likely could have been avoided.

Case 2. A 48-year-old woman visited an oral and maxillofacial surgeon at Columbia University in 1998, complaining of severe left-sided facial pain. She indicated that the pain had begun 12 days earlier and felt like a severe shock in her upper left molars. She reported that these episodes of sharp pain lasted several seconds and occurred approximately 10 to 20 times throughout the day. The painful episodes were not triggered by light touch or wind, nor were they associated with any tearing or nasal discharge. Certain movements of her jaw and chewing would sometimes trigger these painful episodes. Her medical history was unremarkable, and she denied taking any medications or having any allergies.

Clinical examination revealed the neck and oral soft tissues to be within normal limits. The TMJs were not tender and had a normal range of motion. Cranial nerve examination revealed an area of paresthesia following the distribution of the left infraorbital branch of the trigeminal nerve. The remainder of the examination yielded nothing remarkable, and no dental pathology was clinically evident. A panoramic radiograph, too, appeared unremarkable.

Based on the history and clinical examination, the surgeon made a tentative diagnosis of trigeminal neuralgia. The patient was placed on a regimen of 300 mg of gabapentin three times a day and given a follow-up appointment for one week later. By that time, her facial pain symptoms had subsided significantly, and she was tolerating the gabapentin well. However, because an intracranial lesion sometimes can cause trigeminal neuralgia with compression on the trigeminal nerve, the surgeon decided to obtain an MRI scan of the brain. The results of the scan revealed a large acoustic neuroma of the left brainstem (Figure 4). The patient was referred to a neurological surgeon, who subsequently performed a craniotomy and surgically removed the acoustic neuroma. After removal of this tumor, the patient’s pain symptoms resolved, and she is currently free of disease.

View larger version (117K): [in this window] [in a new window]   Figure 4. Magnetic resonance imaging, or MRI, of the brain of a 48-year-old woman with severe, shocklike, left-sided facial pain. Clinical examination revealed paresthesia involving the distribution of the left infraorbital nerve. An MRI scan (shown here) revealed an acoustic neuroma.

	APPLYING THE INTERDISCIPLINARY APPROACH

TOP ABSTRACT Chronic orofacial pain. CASE REPORTS APPLYING THE INTERDISCIPLINARY... SUMMARY REFERENCES

 
Chronic nonmalignant pain disorders often have a cause that is unknown or poorly understood and can lead to profound changes in psychological state, level of functioning and interpersonal relationships. Treatments that are aimed solely at the proposed pathophysiological mechanism of pain production often are inadequate; thus, pain management must be guided toward the psychological and social consequences that the pain syndrome produces as well.²¹ Functional restoration of the whole person should be the aim of treatment for chronic pain disorders.

The appropriate treatment regimen may vary greatly from patient to patient, depending on not only the pain but also on numerous associated factors. Treatments based on preconceived notions that are not evidence-based can become a moral dilemma for many clinicians. Overtreatment with certain medical and surgical interventions can become problematic when the doctor and patient are both searching for a "cure." In many chronic pain problems, a cure can have many meanings, and deciding what is best for a patient may not involve merely eliminating pain, but also providing a framework within which each patient has his or her own rehabilitation goals. In certain chronic pain disorders, the pain may not be entirely eliminated; however, this should not prevent the clinician from providing adequate care for the consequences of the pain and the accompanying suffering.

It is our opinion that regardless of the level of expertise an individual clinician has obtained, no single specialist is fully equipped to diagnose and manage patients with complex oral, facial and head pain. The case reports here clearly demonstrate the importance of obtaining the expertise of a team of specialists in the early diagnosis and treatment of complex orofacial pain conditions. Dentists are superb at diagnosing and managing orofacial pain and often are the first health care providers from whom patients seek help. However, dentists and patients easily can be fooled into thinking that orofacial pain is odontogenic in nature when, in fact, the origin of the pain is another source. This is owed to a number of factors, including the complex regional anatomy of the head and neck, referred pain patterns, centrally mediated pain and psychiatric comorbidity associated with chronic pain conditions. As a result of the complex nature of orofacial pain and the difficulty in diagnosing it, as well as of the pain’s often being localized in the dental structures, it is common for a patient with this condition to undergo multiple dental evaluations and interventions (such as extractions, endodontic care and apicoectomy).

Some patients who have chronic facial pain have a specific and clear diagnosis, and they are treated within the discipline best equipped to deal with the condition. An example of this is the patient with facial pain stemming from sinusitis who is referred to an otolaryngologist, or the patient with trigeminal neuralgia resistant to medication therapy who then is treated by a neurological surgeon. However, in many patients with complex facial pain, the diagnosis is elusive, and often a number of diagnoses are involved. An example of this is a patient with atypical odontalgia, depression, complex migraine headache, tension-type headache and myofascial disorders who has been treated with multiple interventions. When a patient gives a history of multiple dental procedures, oral appliances, drug treatments and invasive procedures, none of which eliminated the pain, the dentist must search for another source of the pain and make appropriate referrals to specialists with expertise in the interdisciplinary diagnosis and management of oral, facial and head pain. Dentists who evaluate and treat patients with complex, chronic orofacial pain frequently will need to draw on the expertise of specialists in anesthesiology, complementary medicine, general dentistry, endodontics, neurology, neurological surgery, oral and maxillofacial surgery, otolaryngology, physical therapy, psychiatry, psychology and radiology. Figure 5 shows an algorithm for the appropriate triage and management of the patient with chronic orofacial pain.

View larger version (37K): [in this window] [in a new window]   Figure 5. Triage of the patient with complex, chronic orofacial pain.

View larger version (38K): [in this window] [in a new window]   Figure 6. Example of clinical coordination of a case at a multidisciplinary center for treatment of oral, facial and head pain.

	SUMMARY

TOP ABSTRACT Chronic orofacial pain. CASE REPORTS APPLYING THE INTERDISCIPLINARY... SUMMARY REFERENCES

 
Chronic oral, facial and head pain is common, and appropriate diagnosis and management is a challenging problem for health care professionals. Most patients will first seek the care of dentists because of the pain’s localization in the oral cavity, jaw and surrounding structures. If the symptoms and clinical findings do not appear to be consistent with typical oral disease, or if standard treatments do not alleviate the pain, the dental clinician must consider other, more complex orofacial pain diagnoses. The dental professional should not hesitate to make referrals to key specialists, or a center with an interdisciplinary team, with the expertise to appropriately diagnose and manage chronic oral, facial and head pain.