Oro-Facial Pain
(dental perspective)
12 May 2014
Dr. Fung Siu Chung
Dept of Dentistry & Maxillofacial Surgery, UCH
Pain
‘unpleasant sensory and emotional experience associated with actual or potential
tissue damage, or described in terms of such damage’
International Association for the Study of Pain. Subcommittee on taxonomy of pain teams: a list with
definitions and notes on usage. Pain 1979;6:249–52
pain is the number one reason people seeking health care
is deemed the ‘ 5th vital sign ’, to mark its importance as health status indicator
Lanser P, Gesell S. Pain management: the fifth vital sign. Health & Benchmarks 2001;8(6): 68–70.
Pain
head and neck region is the most common site of the human body to be involved in
a chronic pain condition
Donaldson D, Kroening R. Recognition and treatment of patients with chronic orofacial pain. J Am
Dent Assoc 1979;99:961–6.
Orofacial Pain
orofacial region is plagued by a number of acute, chronic, and recurrent
painful maladies
Characteristics of Orofacial Pain
(1) High Degree of Prevalence
a population-based survey of 45,711 households revealed that 22% of the United
States population experienced orofacial pain on more than one occasion in a
6-month period
Lipton JA et al. Estimated prevalence and distribution of orofacial pain in the United States. J Am
Dent Assoc 1994; 124:115-21
other population-based surveys conducted in the United Kingdom, Germany, or
regional pain care centers in the United States report similar occurrence
rates
Characteristics of Orofacial Pain
(1) High Degree of Prevalence
affected by age & gender
~ 10% of adults and up to 50% of the elderly
Madland G, Newton-John T, Feinmann C. Chronic idiopathic orofacial pain: I: What is the evidence
base? Br Dent J 2001;191(1):22–4.
female of reproductive age & concentration of women in their 40s, seek treatment for
orofacial pain more frequently compared to men by a 2:1 ratio
Dao TT, LeResche L. Gender differences in pain. J Orofac Pain 2000;14(3):169–84.
Fillingim RB. Sex, gender and pain: women and men really are different. Curr Rev Pain 2000;4:24–30.
Characteristics of Orofacial Pain
(2) High Intensities
various orofacial pain conditions intensities are similar to that observed with those
of spinal pain disorders
McGill Total Pain Rank Index ( PRI(T)) 0-78
Characteristics of Orofacial Pain
(3) Diagnosis is sometimes challenging
orofacial pain is derived from many unique target tissues, such as the meninges,
cornea, tooth pulp, oral/nasal mucosa, and TMJ ----hence accurate Dx & Tx represents a significant health care problem
Dental ( Odontogenic ) Pain
most (>95%) orofacial pain are of local cause; arises from diseases of the teeth &
associated structures ( disease / defects ---)
Tooth and Gum
(diseases: mainly but not exclusively odontogenic infection)
( defects: neuralgic type of pain)
Dental ( Tooth + Gum) Structure
Dental ( Tooth + Gum) Structure
dental pulp as a model system to illustrate peripheral pain mechanisms associated
with the trigeminal system
Dental ( Odontogenic ) Pain
Originate from Tooth ( pulpal pain)
Dentinal Pain: tooth hypersensitivity ( defect of tooth --- neuralgic pain DDx )
( cervical hypersensitivity / non-carious tooth loss: abrasion/ attrition / erosion)
Dental ( Odontogenic ) Pain
Originate from Tooth ( pulpal pain)
Dental caries
Dental ( Odontogenic ) Pain
Originate from Tooth ( pulpal pain)
Dental caries
Pulpitis: reversible / irreversible
Dental ( Odontogenic ) Pain
Originate from Tooth ( pulpal pain)
Dental caries
Pulpitis: reversible / irreversible
Dental ( Odontogenic ) Pain
Originate from Tooth ( pulpal pain)
Dental caries
Pulpitis: reversible / irreversible
Apical peridontitis ( dental abscess of pulpal origin --- draining sinus)
Dental ( Odontogenic ) Pain
Root canal Therapy ( RCT)
Irreversible Pulpitis:
Apical peridontitis ( dental abscess of pulpal origin )
Dental ( Odontogenic ) Pain
Originate from Gum ( periodontal disease)
Gingivitis / Peridontitis (dental abscess , no draining sinus)
Dental ( Odontogenic ) Pain
Originate from Gum ( periodontal disease)
Gingivitis / Peridontitis (dental abscess , no draining sinus)
Dental ( Odontogenic ) Pain
Originate from both Pulp & Gum ( Prio-Endo Lesion)
Dental ( Odontogenic ) Pain
Originate from both Pulp & Gum
( Cracked Tooth Syndrome)
Dental ( Odontogenic ) Pain
Originate from Gum & Mucosa
Pericoronitis ( acute/ sub-acute /chronic)
cf gingivitis
Oral Pain ( Mucosal Pain)
Tongue, Cheek, others (Oral Mucosal Diseases)
Pathology ( autoimmune etiology)
Cheek ( bilateral): atrophic / erosive oral lichen plaus
Non-keratinzed epithelium: recurrent aphthous stomatitis
( minor / major / herptiform)
Oral Pain ( Mucosal Pain)
Tongue, Cheek, others (Oral Mucosal Diseases)
Infectious
Candidosis: C. albicans strictly opportunistic pathogenes
( disease of the diseased)
Tongue: median rhomboid glossitis, geographic tongue ( migratory glossitis) ----
Oral Pain ( Mucosal Pain)
Tongue, Cheek, others (Oral Mucosal Diseases)
Oral Dysaesthesia
Burning Mouth Syndrome (glossodynia, glossopyrosis)
cf . atypical ( idiopathic) facial pain / atypical odontalgia
International Association for the Study of Pain
as burning pain in the tongue or other oral mucous membrane associated
with normal signs and laboratory findings lasting at least 4 to 6 months
Facial Pain ( TMJ associated)
TMDs ( temporo-mandibular disorders)
Pain + Dysfunction of the TMJ & associated structures
refer to a large group of musculoskeletal disorders that originate from the
masticatory structures
Okeson J. Orofacial pain: guidelines for classification, assessment, and management. 3rd edition.
Chicago: Quintessence; 1996.
TMDs ( temporo-mandibular disorders)
Very Common !!
TMDs may occur in 10% of the population
Glass EG, McGlynn FD, Glaros AG, et al. Prevalence of temporomandibular disorder symptoms in a
major metropolitan area. Cranio 1993;11:217–20.
TMDs have been reported in 46.1% of the United States population
Le Resche L. Epidemiology of temporomandibular disorders: implications for the investigation of
etiologic factors. Crit Rev Oral Biol Med 1997;8:291–305.
TMDs ( temporo-mandibular disorders)
two broad types of TMDs:
(A) those primarily involving the masticatory muscles
myogenous TMDs (masticatory myalgia)
(B) those primarily involving the TMJ complex
arthrogenous TMDs
myogenous TMDs (masticatory myalgia)
myofascial pain / myositis / muscle spasm/ muscle contracture
arthrogenous TMDs
Disc derangement (DD) --- DDwR DDwoR ( ADP)
/ structural incompatibility of the articular surfaces / degenerative change
Myogenous TMDs
Subtypes: myofascial pain / myositis / muscle spasm/ muscle contracture
more common: > 90% in our practice, associated with stress, shopping around
cf neck / back pain
trigger sites --- tenderness on palpation (eg temporalis insertion on the
coronoid process): reproducible
diffuse pain
management: non-surgical approach
Arthrogenous TMDs
change in the structure of the condyle–disc complex
altering the normal biomechanics
Sub- types:
disc derangement (DD) --- DDwR DDwoR ( ADP)
/ structural incompatibility of the articular surfaces / degenerative change
DDwR vs DDWoR ( cf ADP)
Arthrogenous TMDs
clinical signs & symptoms vs biomechanical change ? association
DDx:
localized pain vs diffuse pain ( LA)
joint sound
+/- imaging of MRI
Tx:
Non-surgical
Minimal invasive surgical ( arthrocentesis)
remove the pain mediator of substance P, serotonin, prostaglandins,
leucotrienes, bradykinins ----
Neuropathic Pain
Neuralgic pain
Idiopathic trigeminal neuralgia
DDx: dentinal hypersensitivity
Tx: peripheral management of LA injection / neurolysis / cryotherapy
Idiopathic Chronic Orofacial Pain
(Malcolm Harris)

other terms--TMJ dysfunction syndrome
myofascial pain dysfunction syndrome
craniomandibular dysfunction syndrome
temporomandibular disorder (TMD)
facial arthromyalgia(consistent w/ fibromyalgia)

umbrella term for
atypical facial pain ( persistent idiopathic facial pain PIFP)
atypical odontalgia
facial arthromyalgia
oral dysaesthesia (mainly tongue burning mouth syndrome)
Idiopathic Chronic Orofacial Pain
(Malcolm Harris)

Definition
1.
duration > 3 Ms / recurrent
2.
continuous during the day
3.
not paroxysmal
4.
rarely disturbs sleep
5.
no neuroanatomical pattern
6.
standard clinical, radio & lab exam --- -ve
Idiopathic pain of other parts of the body
tension headache / neck pain / back pain / pelvic pain / irritable bowel etc
Idiopathic Chronic Orofacial Pain
(Malcolm Harris)

Management
medical management
NSAID --- no value systemically, some support for topical gel
Opioids --- for severe pain, intra-articular opioids has no value
eg dothiepin 75-225mg nocte---60% pain free, but also 40%
pain free for placebo!
Antidepressants --- tricyclics---RCT support
Idiopathic Chronic Orofacial Pain
(Malcolm Harris)
atypical facial pain ( PIFP) / headache ( migraine , tension-type) /NPC --- TMDs
atypical odontalgia --- crack tooth syndrome
facial arthromyalgia --- joint complex vs masticatory muscle
oral dysaesthesia(mainly tongue burning mouth syndrome --- Candidosis
Team Management
Thank You!
Comment & Questions