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Chronic Idiopathic Orofacial Pain

: Is it in your mind?

Associate Professor Mookhda Siritapetawee

(DDS. MSc.)

Faculty of Dentistry, Khon Kaen University

Injury without pain --------� congenital analgesia

Pain without injury ----------� idiopathic pain

How to measure -------�Hx. Taking 80%

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Pain Models

•Biomedical Models

•Psychiatric Models

•Biopsychosocial Models

Biomedical Models

•Pain is always a sign of tissue damage or

compromise

•Greater tissue damage : greater levels of pain

Psychiatric Models

•Pain in the absence of observable pathology

is “Psychogenic” i.e. the somatic expression

of unresolved emotional conflicts

•Certain personality types are more prone to

developing pain than others

Biopsychosocial Model

•Pain is a multifactorial phenomenon: interaction

of biological, psychological and social factors

•Physical and psychological operate at all levels

of the pain experience

Affective dimension of pain:

2 stages mechanism:

1. Primary : immediate experience akin to

hypervigilance or fear

2. Secondary : body state awareness of strong

negative subjective experience

Multiple dimensions of pain experience

Physiological dimension : location

onset

duration

cause

syndrome

Sensory dimension : intensity

quality

pattern

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Cognitive dimension : meaning of pain

view of pain

coping skill and strategies

previous treatment

attitudes and beliefs

factors influencing pain

Behavioural dimension : communications

interpersonal interaction

physical activity

pain behaviours

medications

Behavioural dimension : interventions

sleep

Sociocultural dimension : ethnocultural background

family and social life

work and home responsibility

recreation and liesure

environmental factors

attitude and beliefs

social influences

Chronic idiopathic orofacial pain

Definition : a condition of facial pain without known

origin or abnormality

Eg.

• Atypical facial pain

• atypical odontalgia

• glossopyrosis (burning tounge)

• facial arthromyalgia

Clinical features of atypical facial pain

•Duration 2-21 years

•Periodicity varies from constant daily pain to

months that are pain free

•Character deep poorly localized pain burning,

viscious, throbbing,stabbing, nagging

•Site usually unilateral, 14% bilateral

•Radiation in 83% of cases

Severity : mild to severe, VAS~ 6.7

Provoking factors : stress, cold weather, chewing

head movement, life events

Relieving factors : local warmth and pressure,

medication

Associated factors : may follow trauma, psychiatric

condition, altered sensations,

lacrimation, facial swelling &

flushing

Psychological associations : depressions,

psychiatric diagnosis,

psychosis, hysteria

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Management :

1. Establish and advice patients of diagnosis2. Reassure and explain possible aetiology or

exacerbating factors3. Empathise with patient4. Discuss with patient for :

(i). Antidepressant : if pain is a major problem(ii). Cognitive behavioral therapy (CBT)

: if life is affected by pain5. Review patient regularly with regard to symptoms

psychological status and ability to cope with thecondition

Atypical odontalgia :

Duration : 2 months to 20 years

Periodicity : continuous or last from a few minutesto hours

Character : severe throbbing , aching

Site : teeth and gingivae

Radiation : to other teeth

Severity : varies from mild to severe

Provoking factors : hot and cold, pressure on tooth

Relieving factors : antidepressant, counselling,avoidance of unnecessary pulp

extirpation or extraction

Associated factors : bruxism, hypersensitivity to heator cold, emotional problemsanxiety or depression

Management :

1. Establish and advice patients of diagnosis2. Reassure and explain possible aetiology or

exacerbating factors3. Empathise with patient4. Discuss with patient for :

(i). Antidepressant : if pain is a major problem(ii). Cognitive behavioral therapy (CBT)

: if life is affected by pain5. Review patient regularly with regard to symptoms

psychological status and ability to cope with thecondition

GlossodyniaGlossodynia and Sore Mouthand Sore Mouth((also known as Burning Tongue or Oral also known as Burning Tongue or Oral

DysaesthesiaDysaesthesia)) ((IVIV--6)6)

DefinitionDefinition

BurBurnninging pain in the tongue from any causepain in the tongue from any cause..

Site Site

Most often tip and lateral borders of Most often tip and lateral borders of glossalglossal mucosamucosa .. Palate and lips are often Palate and lips are often involved and sometimes other involved and sometimes other buccalbuccalmucosamucosa;; sometimes even the latter alonesometimes even the latter alone..

SystemSystem

CutaneousCutaneous

Main FeaturesMain Features

PrevalencePrevalence---- common; common; Age of onsetAge of onset----mainly mainly over 50 years of a ge ; over 50 years of a ge ; SexSex - -- - women women predominate; predominate; QualityQuality----burning, superficial burning, superficial pain; may be throbbing; pain; may be throbbing; Time PatternTime Patternrecurrent and variable, persisting for 5recurrent and variable, persisting for 5--10 10 days at a time or continuously; days at a time or continuously; IntensityIntensity----usual ly mi ld, sometimes very severe.usual ly mi ld, sometimes very severe.

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Associated SymptomsAssociated Symptoms

Taste is often subjectively alteredTaste is often subjectively altered,, some some patients are uncomfortable with their bitepatients are uncomfortable with their bite..Aggravated by local surface irritants oAggravated by local surface irritants orrsometimes hot foodssometimes hot foods .. Some patients are Some patients are overtly depressedovertly depressed .. Topical anaesthetic Topical anaesthetic applied to the site of pain arrests itapplied to the site of pain arrests it ..Temporary relief by food and drink is Temporary relief by food and drink is almost almost pathognomonicpathognomonic.. Denture intolerance Denture intolerance and cancer phobia are common featuresand cancer phobia are common features ..

Signs and Laboratory FindingsSigns and Laboratory Findings

Some patients are Some patients are anaemicanaemic or have low or have low serum ironserum iron,, or Bor B1212 or or folatefolate deficiencydeficiency..Some have Some have impaimpaiirmentsrments of taste on of taste on threshold testingthreshold testing..

Usual CourseUsual Course

Months or yearsMonths or years,, and may be intractableand may be intractable..May respond to antidepressant drugs or May respond to antidepressant drugs or calcium antagonistscalcium antagonists..

ComplicationsComplications

Secondary emotional changesSecondary emotional changes ..

PathologyPathology

UnknownUnknown,, but clinical presentation bears a but clinical presentation bears a strong relationship to adverse life eventsstrong relationship to adverse life events..

Summary of Essential Features and Summary of Essential Features and Diagnostic CriteriaDiagnostic Criteria

Burning tongueBurning tongue,, odd tasteodd taste,, dry mouthdry mouth ,,uncomfortable biteuncomfortable bite,, denture intolerancedenture intolerance..

Diagnostic CriteriaDiagnostic Criteria

Pain referred to the tonguePain referred to the tongue.. NeuriticNeuritic pains pains in the tonguein the tongue.. Phantom bitePhantom bite.. Erosive lichen Erosive lichen planusplanus.. Undiagnosed malignancyUndiagnosed malignancy..

PathologyPathology

ReferencesReferences

FeinmannFeinmann,, CC.,., HarrisHarris,, MM.. PsychogenicPsychogenic facial painfacial pain::The clinical The clinical presentationpresentation..BritBrit.. DentDent.. JJ.,., 156156 (1984)(1984) 165165--

185.185.

MarvachMarvach,, JJ..JJ.. ““Phantom BitePhantom Bite”” classification and classification and treatmenttreatment.. JJ..ProsthetProsthet.. DentDent.,., 4949 (1984)(1984) 556556--559.559.

Temporomandibular Pain and Dysfunction Syndrome (III-3)

DefinitionDefinition

Aching in the muscles of mastication plus, in some cases, and occasional brief severe pain on chewing, possibly leading to restricted jaw movement.

((also called also called MyofascialMyofascial Pain Dysfunction SyndromePain Dysfunction Syndrome))

SiteSite

Preauricular, temporal, zygomatic, occipital,temporomandibular.

SystemSystem

Musculoskeletal

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Main FeaturesMain Features

Prevalence-- young adult , middle-upper class;there may be a history of mild trauma to face or jaws; history of recent psychosocial stress common. Age of Onset-- most often 15-35 years;range 5-55 years . Sex Ratio-- strong female predilection . Start -- evoked by mandibular o p e n i n g . Te e t h c l e n c h i n g o r o c c u r s spontaneously during sleep or with stress .Quality-- cramping, locking, penetration, aching.Occurrence-- episodic, with mandibular function,neck flexion and spontaneously . Intensity--variable from dull ache to severe distress .Duration - - minutes to hours , sometimes p e r s i s t i n g f o r y e a r s .

Associated SymptomsAssociated Symptoms

Clicking or popping of temporomandibularjoint, tinnitus, rarely facial auricular paraesthesias, occasional depression or anxiety; relief by local anaesthetic injection of trigger zones. May also be associated with other facial pains, e.g. atypical odontalgia,pain of psychological origin.

SignsSigns

Varying malocclusion, restricted mandibular opening, temporomandibular joint crepitus,subluxation, tenderness on palpation of muscles of mastication.

Laboratory FindingsLaboratory Findings

Elevated electromyograph voltage in masticatory muscles with trigger zones,increased “silent period” of the massetericchin tap reflex.

Radiographic Findings Radiographic Findings

Normal temporomandibular joint radiographic structure, variable meniscus displacement with arthrography. Occasional pre-senile osteo-arthrosis.

Usual CourseUsual Course

Variable, dependent on resolution of complex multiple factors of trauma, myofascial trigger points, and psychosocial stress response. Often responds to benign physical measures including bite guards and reassurance, and to counselling.

ComplicationsComplications

Possible degenerative joint disease with long duration of trauma; secondary iatrogenic medical-surgical disease.

Social and Physical DisabilitySocial and Physical Disability

Interference with mastication, social, vocational and sexual activity, development of secondary psychological changes.

PathologyPathology

Unknown.

Summary of Essential Summary of Essential FeatursFeatursand Diagnostic Criteriaand Diagnostic Criteria

Muscle tenderness; temporomandibular joint clicking; mandibular dysfunction; high psychophysiologic stress response. Dull ache with severe exacerbations. Frequently long standing. Associated with trismus, clicking,locking of the joint and bruxism. Related to adverse life events. Association with malocclusion unproven.

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Differential DiagnosisDifferential Diagnosis

Degenerative joint disease, rheumatoid arthritis, traumatic arthralgia, temporal arteritis, otitis media, parotitis, mandibular osteomyelitis, stylohyoid process syndrome,deafferentation pains, pain of psychological origin.

Cognitive Behavioural treatment

Aims : Teach the patient to monitor and evaluatenegative thoughts and to generate more accurateand adpative thoughts

Technique : 1. explain the gate control theory of pain2. Help them to recognize their negative thought

and give them alternative positive thoughts

Open gates

•Overexertion•Muscle tension•Anxiety•Depression•Anger•Worry•Increase attention to pain

Close gate

•Muscle relaxation•Heat or ice•Happiness•Mental relaxation•Attention focus on something•Coping self statement

Coping skills treatments : relaxation and distraction

positive coping self statement

Summary Summary

management of non dental pain facial painmanagement of non dental pain facial pain

• Careful diagnosis – history, exam,

investigations

• Medical – analgesics, anticonvulsants, antidepressants

• Surgical – mainly trigeminal neuralgia

• Psychosocial – cognitive behaviour

therapy, relaxation, biofeedback

• Patient information – in control, makes

decisions , takes responsibility

Summary Summary

Achieved by the use of :

• evidence based methodology

• effective narrative

• patient centred approach

• Biosychosocial approach

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Case study Mrs CB Case study Mrs CB 48 year old presented with sore tongue December 2005

HPC: first began 2 years ago and is gradually getting worse

Constant burning , affects tongue, lips palate intensity VAS 6/10

No provoking or relieving factors

Mouth feels dry at times with bad taste

o/e nil, partially dentate

Was referred to oral surgeon who found she was anaemic , now her iron status is normal but no difference to pain. Has used difflam oral rinse and dosulepin with no help.

Mrs CB ProblemsMrs CB Problems

• Lack of diagnosis

• Lack of reassurance not

cancer

• Multiple treatments

• Has few leisure activities

Prepare a PICO for Mrs CB

patient intervention comparison outcome

Mrs CB ProblemsMrs CB Problems

• Lack of diagnosis

• Lack of reassurance not

cancer

• Multiple treatments

• Has few leisure activities

Mrs CBMrs CBIn a patient with burning mouth syndrome who

has tried multiple treatments

and is depressed

would treatment with tricyclic depressants

provide the best pain relief and improve quality of

life?

Zakrzewska JM., Glenny AM, and Forssell H.Interventions for the treatment of burning mouth syndrome. The Cochrane Library

http://www.update-software.com/cochrane/Zakrzewska JM, Glenny AM, Forssell H.Interventions for the treatment of burning mouth syndrome J. Orofacial Pain: 2003: 17; 293-300

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Burning mouth syndrome.

Buchanan J, Zakrzewska J.

Clinical Evidence

Updates:

www.clinicalevidence.com

Overall summary of Overall summary of RCTsRCTsMay be beneficialMay be beneficial

• Cognitive behaviour therapy (CBT)

• Topical clonazepam

• Gabapentin

Unknown efficacyUnknown efficacy

• HRT

• Dietary supplements

• Benzydamine hydrochloride

• Antidepressants

Not effectiveNot effective

• Topical analgesia

What treatment for Mrs CB? What treatment for Mrs CB?

• CBT

• Gabapentin

Diagnosis, reassurance,

education

altered taste dry mouth

tongue thrusting

Case Study Mr AKCase Study Mr AK

56 year old Kenyan man presented with facial pain

in March 2004

HPC : three years ago developed pain intra-orally

after having two dental extractions in the lower

quadrants.

Went back to his dentist who root filled another

molar and as this gave no relief extracted the

tooth but this gave no relief .

Referred by dentist for a diagnosis

Mr Mr AKAK’’ss problem list problem list

• Unexplained pain not just oral but widespread

• PMH – NIDDM, cardiac problems

• SH lonely, no leisure activities

• ? Illness beliefs

Prepare a PICO for Mr AK

patient intervention comparison outcome

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PICO Mr AKPICO Mr AK

In a middle aged man with chronic idiopathic

facial pain

would treatment with tricyclic antidepressants be

as effective

as a course of cognitive behaviour therapy

in order to reduce pain and improve quality of

life?

Systematic reviews Systematic reviews

• Antidepressants for neuropathic pain Saarto

T Wiffen PJ Cochrane Database of

systematic reviews 2005

• Pharmacologic interventions in the treatment

of temporomandibular disorders, atypical

facial pain, and burning mouth syndrome. A

qualitative systematic review. List T et al

J.Orofac Pain. 2003;17:301-10

• A systematic review of antidepressants in

neuropathic pain. McQuay et al Pain 1996:

217-227

CBT and PainCBT and Pain

Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Morley et al Pain 1999; 80: 1-13

Comparison of antidepressant medication alone and in conjunction with cognitive behaviouraltherapy for chronic idiopathic facial pain. Harrison et al Proceedings of 8th World Congress on Pain IASP Press.1997 :8, 663-672

Aims of cognitive change Aims of cognitive change

• Reduce distress caused by pain –

acceptance

• Reduce depression

• Lessen fear

• Reduce frustration

• Increase control

• Decrease healthcare

FluoxetineFluoxetine 20mg and CBT20mg and CBT

Double blind randomised controlled trial 178 for

three months

Groups with and without CBT, active, placebo

• Multidimensional pain inventory MPI

• MPQ

• Beck Depression

• Spielberger state trait anxiety

– Harrison et al 1997

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CBT handbooksCBT handbooks

How would you manage Mr AK? How would you manage Mr AK?

• Tricyclic antidepressant

• CBT

• Ensure treatment goals

addressed

ReferencesReferences

Feinmann, C., Harris, M., Cawley, R.M. Psychogenicfacial pain. Presentation and treatment. Brit.M e d . J . , 2 8 8 ( 1 9 8 4 ) 4 3 6 - 4 3 8 .

Griffiths, R.H. Report of the president’s conference on the examination diagnosis and management of temporomandibular disorders.J. Am. Dent. Assoc. 166(1983) 75-77.

Greene, C.S., Lasking, D.M. Splint therapy for the myofascia l pain -dysfunct ion (MPD )s y n d r o m e : a c o m p a r a t i v e s t u d y .J . A m . D e n t . A s s o c . , 8 4 ( 1 9 7 2 ) 6 2 4 - 6 2 8 .