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News Bulletin : ADA News Bulletin October 2011
37 OCTOBER 2011 opinion page It should be mentioned here, that it may be the observant dental practitioner whom is the first health professional that is able to put ‘two and two together’ and realise there is much more to the story than that is being told, and he/she is then able to point the patient in the right direction for appropriate treatment and refer accordingly. Becoming part of the overall patient management team remains vital however, and may include anything from routine dental care, treatment under sedation, resolution of any dental pathologies/contributors to the orofacial pain complaint, occlusal and periodontal stability and rehabilitation if indicated, and so forth. Table 1 is adapted from Sarlani et al.5 and has been presented in a previously published ADA TAS article on orofacial pain. It highlights the differential diagnoses that must be included when assessing a patient that presents with any orofacial pain complaint. By far the most common pain complaint a dental practitioner will encounter that typically does not arise directly from a dental cause, is pain of the masticatory muscles, impaired function around or in the TM joints. In a timely release, the Australian and New Zealand Academy of Orofacial Pain (ANZAOP) printed its position statement on the assessment and management of temporomandibular disorders and best practice in orofacial pain management in the ADA News Bulletin July 2011. To recap in summary, the American Association of Dental Research (AADR) and the ANZAOP recommend that the differential diagnoses and treatment of TMDs and related orofacial pain conditions be based primarily on a thorough history, clinical and radiological examination. The use of currently available technological devices does not have the specificity or sensitivity to differentiate between subgroups of TMD and orofacial pain conditions. Additionally, any irreversible treatment such as occlusal adjustment, fixed prostheses, and other modalities are not indicated in the treatment of TMDs. Over the past eight years, it has been the author’s experience that the use of occlusal splints in the initial treatment and management of TMDs is largely less effective than conservative measures alone when the splint is used without the intervening psychosocial support and lifestyle changes that may have contributed to the TMD in the first place. Only following the intense use of conservative measures, the resolution of all dental and non- dental contributing factors, alteration of psychosocial influences, adjunctive use of prescription and non-prescription medications, and moderation or management of co-morbidities, is an occlusal splint warranted. This may take many weeks, if not several months of careful and progressive intervention on the patients’ behalf before a splint may be useful or beneficial, and this includes articular disc derangements. However, there will always be the handful of cases where an occlusal or bruxism splint may be a useful initial adjunct, but only when all of the aforementioned approaches are utilised simultaneously and with vigor. Unfortunately, in many cases it has been seen that the construction and issuing of a bruxism or TMJ splint without any or little preceding treatment or advice as described previously, can render the patient’s orofacial pain complaint and resultant psychological stress much worse when it fails to provide the ‘perceived benefits’ the patient was hoping for, both physically and financially. This can lead to a sense of failure and frustration for both the patient and dental practitioner, loss of patient rapport and confidence in the practitioner (and indeed the whole of the dental practice), and a deviation away from a proper diagnosis should the patient fail to follow up any further care or investigations into their pain complaint. In SUMMARY Chronic orofacial pain is a complex complaint that often presents to the dental office and includes dental and non dental causes, musculoskeletal and ligamentous conditions such as TMJ disorders and bruxism, and neuropathic and neurovascular disorders. In a mix of symptom presentation, these pain complaints can often occur simultaneously. When an orofacial pain complaint does arise, patients are often faced with not knowing whether they should see a general medical practitioner or a dentist, and there is good evidence to show that many patients with non-dental causes of pain nevertheless are given dental treatments including occlusal splints.6 It is crucial to understand that patients suffering orofacial pain complaints are often extensively investigated and frequently off- loaded by healthcare professionals including GP to dentist, dentist to GP, specialist to specialist, dentist to specialist and back again in a continuing evolving circle in search for a diagnosis. The dental practitioner may see the patient at any point in this cycle and often multiple times. The patient is thus typically over investigated and over treated by the time they eventually arrive at an orofacial pain practice. It is important therefore that general and specialist medical practitioners be aware that orofacial pain does not always contain a dental origin and therefore, they may be best placed to treat these patients more appropriately. On the other hand, there is an increasing understanding that chronic orofacial pain including TMDs share similar pain mechanisms and pathogenesis as other general chronic pain conditions. Therefore, the dental practitioner who chooses to treat these cases should be encouraged at all times to take a more biopsychosocial approach to diagnosis and treatment, rather than a purely mechanistic driven one. Tony Eldridge Hobart 7000 REfEREnCES References are available on request from email@example.com dISCLAIMER The statements made in the above article are published on the authority of the author and have not been peer-reviewed. They do not necessarily reflect the views of the ADA and publishing them is not to be regarded as an endorsement of them by the ADA. Table 1: Differential diagnosis of chronic orofacial pain. 1. Temporomandibular disorders a. Masticatory muscle disorders • Myofascial pain syndrome • Myositis • Myospasm • Local myalgia b. Articular disc derangements • Disc displacement with reduction • Disc displacement without reduction c. Temporomandibular joint disorders • Synovitis/capsulitis • Osteoarthritis 2. Tension-type headache 3. Neurovascular headache • Migraine • Cluster headache • Chronic paroxysmal hemicrania 4. Neuropathic a. Episodic • Trigeminal neuralgia • Glossopharyngeal neuralgia b. Continuous • Herpetic neuralgia • Postherpetic neuralgia • Traumatic neuralgia • Eagle’s syndrome c. Vascular • Giant cell arteritis • Carotid artery dissection d. Idiopathic • Atypical odontalgia • Burning mouth syndrome 5. Other causes of orofacial pain a. Local pathology • Dental • Sinus • Nasal • Salivary b. Distant pathology (referred pain) c. Systemic diseases d. Psychogenic • Somatoform disorders • Factitious disorders • Malingering
ADA News Bulletin September 2011
ADA News Bulletin November 2011