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Updates in Orofacial Pain

Olga Korczeniewska, PhDInstructor, Department of Diagnostic Sciences

Rutgers School of Dental Medicine, Newark, NJ

Photo Source: The Recover Clinic

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Facial Pain

• Other definitions include the forehead

Pinna• International Headache Society• Pain below the orbitomeatal line,

anterior to the pinnae and above the neck

(ICHD-3 2018; ICOP 2020)

Orofacial Pain

• Pain perceived in the face and/or oral cavity

• Caused by• Diseases or disorders of orofacial structures• Dysfunction of the nervous system• Referral from distant sources

Photo Source: The Recover Clinic

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A Fundamental Principle of ICOP

“the characteristics of the disorder, not their location (head versus face), should guide the new conceptualization and diagnostic criteria”

ICOP 2020

Chronicity

In General• Pain lasting for more than 3 months

In orofacial pain (OFP) and headache (HA)• Pain occurring on > 15 days / month and

lasting for > 2 h / day for at least the last 3 months

ICD-11; ICHD-3 2018; Benoliel R. et al. Pain, 2019

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1. Orofacial pain attributed to disorders of dentoalveolar and anatomically related structures

2. Myofascial orofacial pain

3. Temporomandibular joint (TMJ) pain

4. Orofacial pain attributed to lesion or disease of the cranial nerves

5. Orofacial pains resembling presentations of primary headaches

6. Idiopathic orofacial pain

ICOP 2020

ICOP 2020

• Gender

Can we Identify Patients at Risk for OFP?Factors Influencing Pain

Women: Temporal Summation of Pain & Conditioned Pain Modulation

Age -> Temporal Summation of pain

Age -> Conditioned pain modulation

Filingim RB. Pain; 2017

• Age

Fillingim RB, et al. JPain. 2009; Mogil JS. NatREvNeurosci. 2012

Popescu A. et al. Pain. 2010

Fillingim, RBY., Turk, RP. D.C. Springer; NY: 2016

Edwards RR., Fillingim RB., J Pain, 2001; Lautenbacher S. et al., Pain, 2005; Naugle, KM, J Pain Res 2016

Edwards RR., et al., Pain 2003; Riley 3rd JL., et al., Pain 2010

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• Genetics• Reported heritability of chronic pain: 16-50%

Zorina-Lichtenwalter K. et al. Neuroscience, 2016

Can we Identify Patients at Risk for OFP?Factors Influencing Pain

“Of the genes relevant to pain, which ones when inherited in different forms are responsible for inherited variability in pain?”

Mogil JS., Pain 2005

Roger B. Fillingim; Pain. 2017 April ; 158(Suppl 1): S11–S18.

Pain ratings in response to a heat stimulus (48 deg C) by 321 healthy young adults.

Range: 4 to 100

Pain Experience - Highly Variable Among Individuals

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Genetics & Treatment Response

• Clinically actionable polymorphisms in CYP2D6 & OPRM1Risk categories for opioid effects and dependence• High-risk

• Dysfunctional CYP2D6 or OPRM1 (14% of the population)• Best managed with non-opioids

• Medium risk• Subnormal CYP2D6 or OPRM1 (~48% of the population)• Can be managed with opioids with dose monitoring

• Low-risk• Functional CYP2D6 and OPRM1 (~38% of the population)• can be managed with opioids

Psychosocial assessment of patients with orofacial pain

BIOLOGICAL FACTORS:Disease severity,

NociceptionInflammationBrain function

PSYCHOLOGICAL FACTORS:Anxiety,

Catastrophizing,Depression,

Physical symptom reporting,Fear-avoidance

SOCIAL FACTORS:Access to medical care,

Stigma,Support from family & friends

PAIN

These different sets of factors INTERACT to create the experience of painBased on ICOP 2020

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• All participants provided positive feedback post intervention• Majority described positive changes in either their subjective

level of pain or pain management post-intervention• Some attributed the positive change directly to the

intervention as a result of empowerment, increased self-management and cognitive restructuring

• Pre-emptive analgesia effective in controlling post –operative pain in iatrogenic injuries

• Preoperative sublingual piroxicam more effective for controlling postoperative pain and swelling after surgical implant placement than only postoperative administration (Bhutani N. et al. J Contemp Dent Pract. 2019)

• Preoperative ropivacaine provided immediate efficient pain relief after third molar extraction without benefits after discharge (Ghezal H. et al. J Stomatol Oral Maxillofac Surg. 2020)

• Pre-emptive analgesia with IV ibuprofen is more effective than IV acetaminophen in reducing postoperative pain and opioid use for third molar surgery (Viswanath A. J Oral Maxillofac Surg 2019)

Prevention of Post-Surgical Pain

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Can we prevent muscle and TMJ Pain?• Possibly in the future…

Unpublished data

Thank you for you attention