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Forum Category: General Dentistry

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Lyn Wilson

Orofacial Pain

I'm interested in hearing your experiences with treating patients in pain and how you feel your school does in teaching you diagnosis and pain management. Now, I'm not talking typical odontogenic pain, but the crazy stuff-non odontogenic pain, like TMD, trigeminal neuralgia, burning mouth, etc. At AU-DCG we have a course which discusses TMD and other common presentations of non-odontogenic orofacial pain, which I thought was really helpful and complemented our instruction in endodontics well. Do you have classes on atypical facial pain diagnosis and treatment at your school, or have you had any unique patient experiences with orofacial pain that might help others learn?
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Orofacial Pain

10:59 AM | Oct 21,2017
This is an interesting topic. I had my first experience with neuralgia when I was in my emergency rotation and the patient came in begging us to pull a tooth, but when we took a look, the pain could not be localized. Recently, we had a lecture on TMD and minimally invasive surgeries, where these pain disorders were classified into Nonarticular Temporomandibular Disorders (muscle spasms, myofacial pain and dysfunction, fibromyalgia, myotonic dystrophies, myositis ossificans progressiva) and Temporomandibular Joint Disorders (disk derangement, ostoarthritis, systemic inflammatory disorders, traumatic injuries, hypermobility, and neoplasms). There are different models explaining how these disorders become painful, including the following three: 1. direct trauma model, in which trauma causes inflammation and cell breakdown in the joint, followed by an increase in blood supply and neurovascular activity, as well as physical disruption of cells, leading to free radical formation. 2. Hypoxia Reperfusion Model, where a hypoxic trauma event occurs, resulting in inflammation and increased pressure, limiting the outflow of degraded end products within the joint space. This increased pressure results in a deoxygenated situation, causing reperfusion, which leads to free radical formation within the joint space. 3. Neurogenic inflammation model occurs with neuropeptide (substance p and calcitonin) release after a nerve has undergone a traumatic experience in the retrodiscal tissue or anterior joint space. The release of these neuropeptides can trigger other chemicals to degrade elements within the joint space, resulting in the production of free radicals. There are countless ways to assess patients in order to diagnose the disorder as appropriately as possible. Some of these ways include checking if the pain is bilateral or unilateral, or if the pain is continuous or increases with function in an area generally localized to the joint, if the pain occurs only at a certain time of day, or if mandibular hypermobility is present. Imaging and lab testing can be implemented to assess the maxilla, mandible, and both joint spaces. Depending on the diagnosis, different treatment modalities may be implemented to quell the patient's pain, including nonsurgical treatment, athrocentesis, athroscopic surgery, open joint surgery, or total joint replacement. Generally, surgical treatment of TMD is only part of the overall management and should not be considered as a first line of treatment. More localized pain tends to respond better to surgical treatment, and failure to manage associated pain and dysfunction decreases the likelihood of success after surgical treatment. Initially, it is best to start with bite appliance therapy, such as a night guard. Other options include diet modification (such as no gum chewing), or nonsteroidal anti-inflammatory medications, or muscle relaxants tend to also help, in conjunction with moist heat/ice and physical therapy. Dentists should recommend for patients to attempt these treatment modalities for at least 1-2 months prior to considering surgical treatment. Often times, patients may have underlying psychological issues or may be undergoing stressful life events that may be contributing to the etiology of their pain, as many of these issues manifest in conjunction with clenching, bruxing, or other oral habits that put additional stress on orofacial muscles, and ultimately cause myofacial pain, so be on the lookout for those too.