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News Bulletin : ADA News Bulletin October 2011
36 OCTOBER 2011 InTROdUCTIOn Orofacial pain is a complaint that presents to each and every dental practitioner on any given working day. Most complaints arise due to acute odontological causes such as tooth abscess, dental decay, a fractured tooth or restoration, and periodontal disease. Our profession becomes so versed in diagnosing and treating these conditions it becomes almost intuitive and second nature and thereby takes very little chair-side time. When the pain complaint has no obvious dental cause, is more chronic in nature or the description of pain is somewhat vague or ‘outside the square’, the diagnosis and cause of the pain can become somewhat more elusive and challenging. In this two part series we will review chronic orofacial pain complaints (in particular temporomandibular disorders (TMD) and the role of our dental profession in the overall management of these conditions, and consider oromandibular dystonia’s and the increasing use of Botox as a treatment modality. OROfACIAL PAIn The diagnosis and management of chronic orofacial pain can be difficult for the dental practitioner due to the multi-factorial nature of the problem involving organic, psychological, social and cultural variables.1 Diagnosis and management therefore often requires a multidisciplinary approach to reach successful treatment outcomes that is supported in a review by Madland and Feinmann whom have suggested a need for a diagnostic category of ‘chronic facial pain’. 2 The diagnosis of a particular chronic orofacial pain complaint and the efficacy of any treatment modality relies on the appropriate recording of the patient’s pain experience at various time intervals and is usually based on the patient’s history, verbal descriptors, and physical evaluation. However, therein lies the dilemma. Attempting to incorporate into a busy general dental practice the time required to take an adequate orofacial pain assessment is often quite a juggling act when faced with a pain complaint that has no obvious dental cause. Many patients that have had ongoing pain for sometime may also wish to portray their entire pain history in a very disjointed and ‘rapid-fire’ manner. This can lead to a host of multiple symptoms being portrayed in a confusing array that appear to have no correlation or relationship to the presenting complaint. Symptoms such as irritable bowel syndrome (IBS), headache, neckache, lower back pain, dysmenorrhea, pruritis, cold intolerance (cold hands and feet), and cognitive dysfunction,3 whilst multiple sensitivities to various foods, substances, and chemicals are often reported by those with chronic orofacial pain, as is dizziness, chronic fatigue, and sleep disturbances.4 Wading through this seeming cacophony of symptoms to determine what is relevant and what is not is often a difficult and daunting task. Additionally, thorough investigation of a pain history requires an understanding and respect of the patient’s trust and confidentiality requirements. Having a patient seated in a dental chair with safety glasses on, bib chain around the neck and an ever-present caring nurse in the same room, will often form an invisible but formidable barrier between truth and that which we are told. In this situation, an accurate diagnosis of orofacial pain with significant psychosocial influences will most likely elude the best of the best. A question therefore that should be considered is: “Are modern dental surgeries the most appropriate locations to diagnose and treat non-odontological orofacial pain complaints?” This question poses to invoke a myriad of reactions from the profession that may include both emotional and clinical reasoning. If we look at excerpts from a variety of case examples: Case A: A 22-year-old male referred by a psychiatrist for ‘headaches, TMD pain, and extreme tiredness’. The existing bruxism splint was not providing relief of symptoms including waking tiredness and constant tension type headaches. A thorough medical and social history revealed a caffeine intake of 20 cups of brewed coffee and 6 red bulls per day, and a sleep disordered breathing habit. An ambulatory sleep study confirmed moderate obstructive sleep apnoea due, primarily by bronchoscopic evaluation, to a severe anatomical narrowing of the laryngopharynx. Case B: A 69-year-old female referred by medical GP for ‘unilateral facial numbness, daily migrainous headaches, TMJ pain, and tinnitus’. Patient presented with a 4 litre ice-cream container containing 16 different splints totaling some $15,000 worth of previous treatment that also included multiple extractions and root canals over a 12 year period. The patient eventually elucidated a history of severe unreported depression stemming from the sudden death of her 33-year-old son from suicide in 1996, death of her husband from cancer in 2000, loss of her home from a gambling addiction in 2003, and a diagnosis of breast cancer in 2005. Her reason for not admitting this to any GP or dentist she had seen over the previous years was ‘embarrassment’. Case C: A 16-year-old female referred by medical GP for ‘TMD pain despite the use of an existing bruxism splint’. With guided questioning, the girl revealed a history of drug experimentation, self-harm, and constant suicidal ideation. Case D: A 37-year-old female referred by osteopath for ‘ongoing neck pain and headaches possibly due to bruxism’. Patient revealed distress due to an unexpected pregnancy as the result of an extra- marital liaison. We quickly see that in all of these cases, the roll of a dentist whilst crucial to exclude odontological causes of orofacial pain remains limited in the overall care of the patient. A carefully constructed piece of maxillary or mandibular acrylic worn during sleep is even more limited in the initial phase of diagnosis and treatment. Whilst these patients may remain on the outside realm of ‘typical’ they are certainly not rare, and highlight how a seemingly innocent report or finding of orofacial pain such as pain within the TMJ or a TMD, dental sensitivity, headaches, vague tooth ache, tooth wear, and other bruxism related findings can be and often are in actual fact, superficial symptoms that are likely related to a much deeper running psychosocial problem or behaviour. The major contributing factor to the orofacial pain complaint therefore is often easily missed or overlooked by both medical and dental professionals when a ‘tooth and splint’ orientated approach is taken. OROFACIAL PAIN AND THE dental practitioner – Part 1 opinion page
ADA News Bulletin September 2011
ADA News Bulletin November 2011