Dent ist ry Division of t he Cent ral Inst it ut e and Experiment al Neurosurgery Division of t he Psychiat ric Inst it ut e, Hospit al das Clínicas, School of M edicine, Universit y of São Paulo, São Paulo SP, Brazil (HC/FM USP): 1DDS, PhD, Head, Orof acial Pain Team, Dent ist ry Division,
HC- FM USP; 2DDS, M sC, Orof acial Pain Team, Dent ist ry Division, HC/FM USP; 3DDS, Orof acial Pain Team, Dent ist ry Division, HC/FM USP; 4DDS, Post -graduat ion St udent , Orof acial Pain Team, Dent ist ry Division ,HC/FM USP; 5M D, PhD, Head, Pain M ult idisciplinary Cent er,
Neurology Division, and Experimental Neurosurgery Division, Psychiatric Institute, HC/FMUSP; 6DM D, Prof essor of Universit y of Dentistry
and M edicine of New Jersey/USA; 7DDS, M D, PhD, Pharmacology Prof essor, Universit y of Sant o Amaro (UNISA), São Paulo SP, Brazil. *The preliminary result s of t his st udy w ere present ed at 8t h World Congress on Pain, in Vancouver/Canada, August 1996.
Received 15 January 2004, received in f inal f orm 23 June 2004, Accept ed 9 August 2004.
Dr. José Tadeu Tesseroli de Siqueira - Rua M aria Cândida 135 - 02071010 São Paulo SP - Brasil. E-mail: jt t [email protected]
CLINICAL STUDY OF PATIENTS WITH
PERSISTENT OROFACIAL PAIN
José Tadeu Tesseroli de Siqueira
1, Lin Hui Ching
2,
Cibele Nasri
3, Silvia Regina Dow gan Tesseroli de Siqueira
4,
M anoel JacobsenTeixeira
5, Gary Heir
6, Luís Biela S. Valle
7ABSTRACT - Objetive: To evaluate a sample of patients with persistent facial pain unresponsive to prior treat-ment s. M et hods: Hospit al records of 26 pat ient s w it h persist ent f acial pain w ere review ed (20 f emale and
6 male). Result s: Pat ient s w ere classif ied int o t hree groups according t o t heir present ing sympt oms:
a)Group I, eight patients (30.7%) with severe, diffuse pain at the face, teeth or head; b)Group II, eight patients (30.7%) with chronic non-myofascial pain and; c)Group III, ten patients with chronic myofascial pain (38.4%). We f ind 11 diff erent diagnoses among t he 26 pat ient s: pulpit is(7), leukemia(1), oropharyngeal t umor(1), at ypical odont algia(1), Eagle’s syndrome(1), t rigeminal neuralgia(4), cont inuous neuralgia(1), t emporomandibular disorders (9), f ibromyalgia (2), t ensiont ype headache(1), conversion hyst eria(2). Af t er t he t reat -ment program all pat ient s had a six-mont h f ollow -up period w it h pain relief , except t he pat ient w it h t umor.
Conclusion: The w ide variabilit y of orof acial pain diagnosis (benign t o lif e-t hreat ening diseases) indicat es
t he necessit y t o reevaluat e pat ient s present ing recurrent pain t hat is ref ract ory t o t he usual t reat ment s.
KEY WORDS: orof acial pain, t rigeminal neuralgia, t umor, t emporomandibular disorders, at ypical f acial pain
Est udo clínico de pacient es com dor orof acial persist ent e
RESUM O - Objet ivo: Avaliar uma amost ra de doent es com dor f acial persist ent e. M ét odo: Foram
revisa-dos 26 prontuários de doentes com dor facial persistente (20 mulheres e 6 homens). Resultados: Classificação
dos doent es, após o diagnóst ico: a)Grupo I, oit o pacient es (30,7% ) com dor f acial dif usa de f ort íssima int en-sidade; b)Grupo II, oit o pacient es (30,7% ) com dor crônica de nat ureza não-miof ascial e; c)Grupo III, dez pacient es com dor crônica miof ascial (38,4% ). Foram encont rados 11 diagnóst icos dif erent es ent re os 26 pacient es: pulpit es(7), leucemia(1), t umor de orof aringe(1), odont algia at ípica(1), síndrome de Eagle(1), neuralgia idiopát ica do t rigêmeo(4), neuralgia at ípica(1), disordens t emporomandibular (9), f ibromialgia(2) cef aléia t ipo-t ensão(1), hist eria de conversão(2). O acompanhament o dos doent es, após receberem a respect iva t erapia, f oi de seis meses, com alívio da dor, excet o para o doent e com t umor de orof aringe.
Conclusão: A variabilidade das f ont es da dor f acial inclui doenças benignas e doenças graves, sendo
indis-pensável a reavaliaçâo de doent es que não respondem aos t rat ament os convencionais para a dor.
PALAVRAS-CHAVE: dor orof acial, neuralgia t rigeminal, t umor, art iculação t emporomandibular, dor f acial at ípica.
The complex innervat ion and f unct ion of f acial st ruct ures makes t he diagnosis of f acial pain and it s t reat ment very dif f icult and f rust rat ing1,2.
Pa-t ienPa-t s w iPa-t h chronic f acial pain, even af Pa-t er receiv-ing mult iple t reat ment s, should be caref ully reas-sessed and clinically re-examined. M yof ascial pain syndromes, t emporo mandibular disorders (TM D), neuralgias, ENT diseases, dent al pain, t umors,
neu-rovascular pain or psychiat ric diseases f requent ly present w it h overlapping signs and sympt oms3,4.
Ref erred, severe, acut e pain f requent ly makes t he diagnosis dif f icult .
secondary adjacent muscle hyperact ivit y. Pat ient s can present w it h muscular hyperact ivit y result ing f rom persist ent acut e or chronic pain, and elicit sec-ondary muscle pain7-9. Theref ore, t he eliminat ion
of t he primary source of pain is essent ial but , in chronic pain, is not alw ays enough f or cont rol of pain. An incorrect and inef f ect ive t reat ment may perpet uat e or generat e chronic pain. The under-st anding of secondary pain mechanisms of cran-iof acial pain is necessary f or t he f ormulat ion of an accurat e diagnosis10.
The goal of t his st udy is t o demonst rat e t he vari-abilit y of possible diagnoses in a sample of pat ient s w it h persist ent f acial pain and how t he orof acial pain specialt y t eam w as able t o assist in t heir diag-nosis and management .
M ETHOD
This is a ret rospect ive st udy of a sample of pat ient s w it h persist ent f acial pain unresponsive t o previous t reat ment s w ho w ere ref erred t o an orof acial pain t eam
of a large t eaching hospit al. The st udy w as approved by t he Et hics Commission of t he hospit al.
The records of 26 consecut ive pat ient s, 20 f emale and 6 male, w ere analyzed. Pat ient s w ere select ed accord-ing t o t he descript ion of t heir chronic pain sympt oms and classif ied in accordance w it h t he crit eria of t he In-t ernaIn-t ional AssociaIn-t ion f or In-t he SIn-t udy of Pain11and ref
-erences of t he American Academy of Orof acial Pain12.
This sample represent s 4% of all new pat ient s w it h oro-f acial pain complaint s admit t ed t o t he Orooro-f acial Pain Clinic during t he period of t his st udy (August 1992 -December 1996). In order t o ensure consist ency in int er-view met hods, t he diagnoses w ere conf irmed by clini-cal examinat ion perf ormed by members of a t rained and calibrat ed int erdisciplinary pain t eam.
The st andardized diagnost ic prot ocol w as applied t o all pat ient s equally. It consist s of a st andardized int er-view and syst emat ic evaluat ion of cervical, cranial, f acial, oral and dent al st ruct ures. The general charact erist ics f or dif f erent ial diagnosis of t he diseases are present ed in Table 1. Diagnoses w ere:
Pulpitis – History of daily, throbbing, diffuse pain,
trig-ger by hot or cold and w aking t he pat ient during t he
Table 1. Dif f erent ial diagnosis in pain f requent ly observed in t he orof acial region1,2,7,12,14.
Idiopat hic Pulpit is Orof acial Temporo Fibromyalgia Eagle’s
t rigeminal (ref erred neoplasia mandibular syndrome
neuralgia dent al pain) disorders
Pain Elet ric Trobbing Variable Dull, st abbing Dull Dull
shock-like (at ypical)
Pain durat ion Seconds M inut es Variable M inut e t o hours Const ant Short
-t o hours durat ion
Int ensit y Severe Slight t o severe Severe M oderat e M oderat e M iddle Localizat ion Good Dif f use Dif f use Good, Dif f use Dif f use Dif f use Charact erist ics Trigger zone, Diurnal or Ref erred pain TM J or muscle, Generalized Usually pain
diurnal noct urnal f requent ly pain t o body pain, is in t he
dent al neurological movement , spont aneous t hroat / sensit ivit y, look signs, WBC limit ed open mout h f loor f or dent al abnormalit ies mout h
problem
Local t reat ment No Dent al Surgical Physical therapy, Physical Cort icoid
t reat ment s, splint s, t herapy inject ion,
local anesthesia anest het ic surgery
blocks t he pain inject ion,
General Ant i- NSAIDs, Chemot herapy, NSAIDs TAD, NSAIDs
t reat ment convulsivant s analgesics radiot herapy myorelaxant s HSCT
Trigger Non-noxious M echanical, Jaw movement Palpat ion, jaw Palpat ion, Sw alling
st imulus f oods, cold, f unct ion f unct ion
heat , suit
Table 2.General charact erist ics of t he sample (n = 26).
P A G N Pain Pain Pain Descript ive t erms (bef ore t he f inal diagnosis) side int ensit y durat ion
(mont hs)
1 13 M 4 L M /S 3 Dent al and TM J const ant pain, generalized dent al mobilit y, parest hesia of t he lef t low er lip.
2 35 F 3 R S 30 Jaw and f acial t hrobbing pain; diurnal/noct urnal; dent al generalized sensit ivit y t o percussion.
3 41 F 4 R S 10 Dent al and f acial pulsat ing pain; headache; diurnal/noct urnal; dent al sensit ivit y t o percussion of #47; cold w at er
provoked t he severe at t ack.
4 39 F 5 L S 60 Dent al and f acial const ant pain; diurnal/noct urnal; NSAIDs, TAD, splint , ant ibiot ics, root t herapy (t eet h: 33,34,35), t oot h ext ract ion (#35) w it hout relief of t he pain; she had been a 3 years hist ory of TM D t hat w as cont rolled t ot ally; t enderness of t he mast icat ory muscles.
5 60 M 2 R S 10 Headache and dent al const ant pain; diurnal/noct urnal; pain beginning during f lying; presence of subgingival decay at dist al f ace of t oot h #43. The pain w as ref erred t o superior t eet h and t emporal region. An at t ack was caused by air flow of the dental equipment into the dental cavity (#43).
6 50 F 2 L S 20 Facial and dent al pulsat ing pain; parest hesia of t he lef t low er lips; hist ory of t he jaw f ract ure 1 year bef ore t his complaint .
7 40 F 3 R S 30 Facial jabbing pain; diurnal/noct urnal; subgingival decay at t he t oot h #18.
8 31 M 5 R S 7 Cervical and f acial jabbing pain; diurnal/noct urnal; NSAIDs, TAD, benzodiazepines, codeine and physical cervical t herapy w it hout relief of t he pain; he had been one day hospit alizat ion due t he int ensit y of t he pain.
9 22 M 15 L S 12 Lef t TM J pulsat ing pain, diurnal/noct urnal, complet e dent it ion, dislocat ion of t he lef t TM J disc, painf ul jaw movement .
10 18 F 3 R M 24 Const ant dent al and f acial pain, t oot h ext ract ion of #18 w it hout relief of t he pain, hist ory of chronic t hroat pain.
11 55 F 3 L M 24 Jaw episodic pain, cancerophoby
12 35 F 7 B M 72 TM J const ant pain; had been carried out 4 TM J surgery, mult iple t oot h ext ract ion, complet e dent ure, physical, and pharmacological
t reat ment s w it hout any relief of t he pain. Epilepsy.
13 38 F 3 L S 6 Facial elect ric shock-like episodic pain and dull pain; during t he f irst appoint ment she had 15 at t acks last ing f rom 15 t o 40 seconds each one. M asset er muscle t enderness.
14 40 F 1 B M 60 TM J const ant pain; oral rehabilit at ion procedures, dent al splint s and physical t herapy w it h improvement of jaw movement , w it hout relief of t he pain. Pain st art ed af t er a spinal anest hesia.
night . The dent al source of pain w as ident if ied by a clini-cal evaluat ion and diagnost ic anest het ic block12.
Acut e leukemia – Diagnosis is made w it h laborat
o-ry examinat ion of t he peripheral blood (WBC) and bone marrow. WBC is usually elevat ed, but some case pres-ent w it h normal or decreased count s. Anemia (pallor, short ness of breat h and f at igue) and t hrombocyt
ope-nia are ot her f requent clinical f indings13. Oral signs and
symptoms frequently lead to a diagnosis of the leukemia; i.e., looseness and mobilit y of t he t eet h and parest he-sia of t he lips is report ed during t he leukemic cellular inf ilt rat ion in t he periodont al membrane and periph-eral t rigeminal nerve, respect ively13.
Trigeminal neuralgia – Hist ory and clinical evaluat ion
Cont inuat ion
15 57 M 3 R S 48 TM J and f acial elect ric shock-like pain during jaw movement s and t oot h brushing; t enderness of masset er muscle; 2 periapical surgery of t he t oot h #14, w it h part ial and t emporary relief of t he pain.
16 54 M 11 R M 24 Dent al pain (#14); const ant ; root t herapy of f our t eet h t w ice; periapical surgery of 2 t eet h t w ice (#a4,15), oral rehabilit at ion, sonot herapy; w it hout relief of t he pain.
17 64 F 3 L M 120 TM J pain during jaw movement ; edent ulous; inadequat e complet e dent ures.
18 43 F 5 B M 48 TM J const ant pain; headache; jaw locking during eat ing; sleep bruxism, oral breat h, severe periodont al disease, t enderness of t he mast icat ory muscles.
19 62 F 5 R M 300 Cervical and f acial const ant /dull pain; dent al sensit ivit y of mult iple t eet h; t enderness of t he mast icat ory muscles; generalized body pain under cont rol (Fibromyalgia).
20 49 F 5 R M /S 60 Dent al, f acial and cervical const ant /dull pain; generalized gingivit is; t enderness of t he mast icat ory muscles; generalized body pain (Fibromyalgia).
21 42 F 3 B M 120 Const ant headache; upper inadequat e dent ure; reduced dimension of t he f ace.
22 62 F 3 L M 24 Const ant f acial pain; episodic f acial elect ric shock-like pain; t enderness of t he mast icat ory muscles.
23 70 F 6 R M 36 Gingival and f acial const ant /burning pain; 3 oral bone surgeries; 10 complet e dent ures w it hout relief of t he pain; t he pain began f t er t he f irst dent al surgery.
24 56 F 4 B M 48 Facial episodic/jabbing pain beginning 3 mont hs af t er a maxillary sinus surgery; pain w as w orse w hen she eat s bread; mult iple t oot h ext ract ion (9 t eet h) w it hout pain relief .
25 51 F 4 B M 36 Facial const ant /jabbing/burning pain; t he pain began af t er an oral surgery; inadequat e complet e dent ures, t enderness of t he mast icat ory muscles.
26 47 F 7 B M 24 Facial const ant /dull pain; headache, hist ory of idiopat hic t rigeminal neuralgia, migraine and TM D; inadequat e upper complet e dent ure; depressed; mot her of t w o neural disabilit ies children. Lives in anot her cit y; seeking f or several healt h prof essionals.
and t he presence of paroxysmal and elect ric shock-like pain w it h a t rigger zone11.
Tumor (Oropharyngeal) – Based on computed
tomog-raphy (CT) and magnet ic resonance image (M RI) of t he cranial and f acial region. The clinical charact erist ics of t he pain are variable and at ypical14.
Temporomandibular disorders – The diagnosis is by
hist ory and clinical exam. Inclusionary crit eria include t he presence of limit ed opening, t enderness of t he mast i-cat ory muscles and joint sounds during mandibular f unc-t ion. CT is used in degeneraunc-t ive process of unc-t he unc-t emporo-mandibular joint (TM J)12,14.
Eagle’ syndrome – Charact erized by pain in t he
oro-pharyngeal region during mandibular act ivit ies, mean-ly sw allow ing. Image exams usualmean-ly show a st yloid pro-cess elongat ed and t he inf lammat ion is t he cause of t he pain. Palpat ion of t he post erior and medial region of t he mandible angle is painf ul. The precise diagnosis is made w it h clinical examinat ion14.
Fibromyalgia – Characterized by widespread pain,
de-creased pain t hreshold, sleep dist urbance, f at igue, psy-chological distress and chronic headache. Patients thought t o have f ibromyalgia w ere diagnosed based on t he demonst rat ion of mult iple t ender point s. These t ender points were bilaterally, symmetrical but did not refer pain w hen provoked. Diagnosis in t his condit ion is clinical15.
Diagnosis of ment al healt h disorders w as made by
a psychiat ric examinat ion according t o t he diagnost ic cri-t eria f or hyscri-t erical conversion, or pain associacri-t ed w icri-t h depression11,16.
Radiographic and laborat ory evaluat ion - Panoramic radiography of t he jaw w as perf ormed f or all pat ient s. CT scan of t he craniof acial region w it h cont rast , M RI and hemat ological examinat ion (complet e blood count ) w as perf ormed in t hose cases w it h recurrent pain w it hout clinical evidences of benign pain if a st ruct ural lesion w as suspect ed. CT, M RI and hemat ological t est s w ere made f or pat ient s w it h clinical diagnost ic of t rigeminal neural-gia f or dif f erent ial diagnost ic bet w een idiopat hic and sympt omat ic t rigeminal neuralgia.
Treat ment – Pat ient s received appropriat e t reat ment
af t er achieving an accurat e diagnosis. Pulpit is w as t reat -ed w it h convent ional dent al management . Trigeminal neuralgia w as t reat ed w it h carbamazepine. Pat ient s w it h syst emic disorders, oropharyngeal t umor and leu-kemia, w ere ref erred f or specif ic t reat ment , according t o t he diagnosis. No f urt her comment ary regarding t re-at ment of syst emic diseases is included in t his st udy as t hese pat ient s w ere ref erred out of t he st udy. A pain as-sessment was performed immediately after the treatment program and af t er a six-mont h f ollow -up period. A sub-ject ive scale w as used f or t his evaluat ion included f ive it ems: SD (Pain f ree), O (Opt imum), S (Sat isf act ory), PM (Poor improvement ) and SM (Wit hout improvement ).
St at ist ical analysis – Pat ient s w ere separat ed int o
groups and comparisons were conducted for general cha-ract erist ics of t he sample. The dat a w as analyzed in t he SPSS 10 f or Window s program.
RESULTS
In 80.7% of t he pat ient s t he previous diagno-sis w as incorrect and t he average number of healt h prof essionals consult ed w as 4.7.
Patients were classified into three groups accord-ing t heir f inal diagnoses: Group I - Acut e pain: Eight pat ient s (30.7% ) w it h severe, diff use pain ref erred t o t he ipsilat eral f ace, t eet h or t emporal region; Group II - Chronic non-myofascial pain: Eight patients (30.7% ) w it h chronic non-myof ascial pain and; Group III - Chronic myof ascial pain: Ten pat ient s w it h chronic myof ascial pain (38.4% ) associat ed w it h ot her painf ul comorbidit ies such as f ibromyal-gia, t rigeminal neuralgia and cont inuous neuralgia Acut e and chronic pain condit ions w ere classi-f ied according t o t he IASP11classif icat ion of
chron-ic pain. Throbbing pain during t he day or t he night w as more common in dent al lesions; paroxysmal pain w as t he most common expression of t rigemi-nal neuralgias; and const ant , pressure and burn-ing pain w ere t he most common complaint s in chronic musculoskelet al pain.
referred to a hematologist and received chemother-apy and a bone marrow t ransplant .
In summary, in t he Group I, seven pat ient s pre-sent ed w it h dif f use unilat eral craniof acial pain f rom dent al causes (pulpit is), and one pat ient had dent al pain and general dent al mobilit y because of a syst emic disorder. Tw o pat ient s in t his group received eit her dent al ext ract ions or oral surgery f or t he t reat ment w it hout any improvement pri-or t o receiving a f inal diagnosis.
All t he pat ient s of t his group w ere pain f ree af -ter an accurate diagnosis and correct treatment and remained so at six mont hs of f ollow -up evaluat ion.
Group II - Chronic non-myof ascial pain – Eight patients (3 men and 5 women), ranging in age from 18 t o 57 years old (median 36.50±13.59) report ed unilat eral (6) and bilat eral (2) localized pain w hich w as diurnal and moderat e t o severe in t he f acial or cranial region. The durat ion of pain w as on
average 31.2 mont hs. The previous diagnosis w as TM D f or all pat ient s. A f inal diagnosis and respec-t ive respec-t rearespec-t menrespec-t s w ere provided. For Eagle’s syndro-me (1) t he pat ient received a st yloidect omy. Oro-pharyngeal t umor (1) w as t reat ed w it h chemot her-apy. The pat ient w it h t ension-t ype headache (TTH) (1) was treated with tricyclic antidepressants (TCAs). Trigeminal neuralgia (2) w as t reat ed w it h carbama-zepine (1) and t rigeminal percut aneous radiof quency rhizot omy (1). Psychiat ric disorders (2) re-ceived psychot herapy. At ypical odont algia (1) w as t reat ed w it h TCAs. All, except f or t he pat ient w it h t umor, report ed relief .
In summary, this group presented with different diagnosis for their chronic pain. Six patients previous-ly received some form of oral surgery (dental extrac-tions or periapical surgery), without improvement.
The f inal evaluat ion of t his group w as: pain f ree in six, sat isf act ory improvement in one (TTH) and without improvement in one (oropharyngeal tumor).
Table 3. Previous and f inal diagnosis of t he t hree groups (n=26).
Case Group I (n = 8) Group II (n = 8) Group III (n = 10)
PD FD PD FD PD FD
1 TM J; Leukemia TM D; AFP Neoplasm TM J TM J
Periodont it is
2 TN; Pulpit is TM D Conversion TM D TM D;
M yof ascial pain hyst eria Bruxism
3 TN; Pulpit is TM D Eagle’s Fibromyalgia TM D;
M yof ascial pain syndrome Fibromyalgia
4 TN, M yof ascial Pulpit is TM D Conversion Fibromyalgia TM D;
pain; AFP hyst eria Fibromyalgia
5 TN Pulpit is TM D TN TM D TM D
6 TN; TM D Pulpit is TM D TTH TM D TM D
7 TN; CH Pulpit is TM J TN TM D TM D
8 TM D AO TM D TM D; TN
9 TM D TM D; CTN
10 TM D TM D; CTN
Group III - Chronic myofascial pain – Ten patients (w omen) aging 42 t o 70 years old (median 59±9) received a prior diagnosis of TM D. The average du-rat ion of pain w as 6.8 years. Despit e t he diagno-sis of TM D, pain cont rol w as unsat isf act ory due t o inadequat e t reat ment and t he presence of ot her causes. The f inal diagnoses w ere, respect ively, TM D (5), TM D associat ed w it h f ibromyalgia (2); TM D as-sociat ed w it h t raumat ic t rigeminal neuralgia (2); or TM D associat e w it h t rigeminal neuralgia (t ic doulourex) (1). Treat ment w as perf ormed accord-ingly: a) neuropat hic pain7; b) f ibromyalgia15or c)
chronic myof ascial pain17.
Summarizing, in t his group, t he musculoskele-t al f acial pain w as associamusculoskele-t ed w imusculoskele-t h musculoskele-t rigeminal neu-ralgia, f ibromyalgia or non-paroxysmal pain of t he oral cavit y. Four pat ient s report ed t he beginning of t he pain af t er f acial surgery. Three pat ient s re-port ed oral surgery and one pat ient changed t he dent al prost hesis previously as t he t reat ment of pain, w it hout any improvement . The f inal evalu-ation of this group was: pain free in six and satisfac-t ory improvemensatisfac-t in f our.
The Table 2 show s t he general charact erist ics of t he sample. The diagnosis of pat ient s w it h organ-ic pat hology w as achieved in accordance w it h t he Int ernat ional Associat ion f or t he St udy of Pain11
(Table 3).
DISCUSSION
The original diagnosis w as incorrect or incom-plet e in 80.7% of t he cases. We f ind 11 dif f erent diagnoses among t he 26 pat ient s of t his sample: pulpit is (7), leukemia (1), oropharyngeal t umor (1), at ypical odont algia (1), Eagle’s syndrome (1), t ri-geminal neuralgia (4), cont inuous neuralgia (1), TM D (9), f ibromyalgia (2), conversion hyst eria (2) and t ension-t ype headache (1). All of t he 26 pa-t ienpa-t s w ere ref erred pa-t o our service w ipa-t h a prior sus-pect diagnosis of TM D. These pat ient s f ailed t o im-prove due t o misdiagnosis.
The pat ient s in t his st udy w ere seen by an aver-age of 4.6 dent ist s or physicians bef ore t o arriving at our clinic. Only af t er appropriat e t reat ment , adequat e pain cont rol w as achieved in t he major-it y of t he pat ient s remained pain f ree six-mont h f ollow up evaluat ion. The average of 4.88 healt h care, 70% of t he pat ient s saw a general dent ist and 30% saw a physician, w as f ound in anot her st udy about referral patterns for all types for facial pain18.
Dent al pain, t rigeminal neuralgia and
oncolo-gic condit ions may present w it h similar clinical sympt oms7,13,19. Tumors can provoke t hrobbing
pain w hen compressing t issues, such as t he pat ient w it h an oropharyngeal t umor w ho report ed pain during t he mout h opening movement . They cause neurological abnormalit ies t oo, as t he lef t lips pa-rest hesia in t he pat ient w it h leukemia. Trigeminal neuralgia is a sudden, usually unilat eral, severe, brief , st abbing and recurrent pain in t he dist ribu-t ion of one or more branches of ribu-t he V cranial ner-ve11; and seldom aw akens t he pat ient f rom sleep20.
On t he ot her hand, pulpalgias can be t riggered by cold or hot liquids, and can aw aken t he pat ient from sleep causing dental tenderness6,20. Therefore,
t he use of specif ic diagnost ic crit eria is import ant t o help in t he diff erent ial diagnost ic process. A sim-ple examsim-ple is seen in six of t he seven pat ient s t hat present ed w it h pulpit is w ho described noct urnal episodes of pain. Three of t hese pat ient s realized an increase in pain w it h an applicat ion of a ext er-nal st imulus in t heir t eet h (cold air). These pains w ere int errupt ed by t he local anest hesia block.
This sample included t w o int erest ing cases of dent al pain of nonodont ogenic origin (acut e leu-kemia and at ypical odont algia), and seven pat ient s w it h craniof acial pain f rom odont ogenic origin. This demonst rat ed t hat t he locat ion of pain is not alw ays t he same as it s source10. The at ypical
odon-t algia, odon-t haodon-t is a neuropaodon-t hic pain, is localized in odon-t he t oot h or gingival, but t he pain of pulpit is can vary great ly in it s clinical present at ion and int ensit y6,20,21.
Although trigeminal neuralgia (TN) has a well de-f ined diagnosis, it is ode-f t en conde-f used w it h ot her so-urces of f acial pain w it h similar sympt oms22. This is
due t o t he great variet y of f acial pain sources, t he relat ive rarit y of TN and t he absence of t he specif -ic t est s f or it s diagnosis23. In t his sample, w e
exami-ned 5 pat ient s w it h a diagnosis of TN and t hree of t hem w ere associat ed w it h TM D. Tw o pat ient s pre-sent ed w it h neoplasias (leukemia and nasopharyn-geal t umor). This show s a necessit y and import ance of a diff erent ial diagnosis in orof acial pain10, and
demonst rat ed t hat pain may be an init ial manif es-t aes-t ion of a es-t umor14,19. These cases also demonst rat e
sclero-sis)7. In this study idiopathic trigeminal neuralgia was
t he prevalent diagnosis.
This sample includes a pat ient w it h Eagle’s syn-drome and anot her w it h t ension-t ype headache. These pat ient s also present w it h sympt oms simi-lar t o TM D and w e need know t he diagnost ic crit e-ria f or t hese disorders14,23,24. Anot her diff icult y is in
t he dif f erent ial diagnosis of orof acial pain t hat involves psychiat ric disorders and simulat es organ-ic f acial pain. This w as t he case of t w o pat ient s w it h psychiat ric dist urbances w ho w ere event ually diag-nosed with hysterical conversion disorder. Diagnosis of ment al healt h disorders is a challenge t hat de-mands caref ul examinat ion by specialist s16. The
diagnosis of t hese cases w as possible due t he f act of t hey w ere seen in a large t eaching hospit al w it h great experience in chronic pain.
In Group III, chronic muscle pain w as associat -ed w it h neuropat hic pain or f ibromyalgia. This just if ies t he need f or mult iple t herapies in some cases, and t he t reat ment should be adjust ed t o t he etiology. Five patients from Group III presented with musculoskelet al pain associat e w it h ot her sources of pain (TN, f ibromyalgia) and due t o t his f act or, they did not improve with prior treatment. Another import ant point is t he hist ory of t he pat ient ’s pain. In t his sample, t w o pat ient s w it h TM D also present -ed f ibromyalgia, a condit ion f requent ly f ound in patients with TMD25,26, which requires specific
treat-ment . How ever, t he pat ient s present ing w it h mus-cle pain in Group III received therapeutic procedures direct ed at t he removal of cont ribut ing f act ors t hat act ed direct ly or indirect ly t o perpet uat e t he complaint . This included t he correct ion of inade-quat e dent ures, excessive loss of t eet h w it hout reposit ioning and paraf unct ional habit s. The origi-nal complaint s may w orsen in pat ient s w it h neuro-pat hic pain due t o accompanying myogenic dist ur-bances27. Invasive procedures should not be repeat
-ed w hen a relief of pain is not achiev-ed (f our pa-t ienpa-t s in Group III had oral surgeries). The re-eval-uat ion of t he signs and sympt oms is an essent ial st ep in t hese cases. Theref ore, it is very import ant t o have t he abilit y t o ident if y t he various aspect s of pain complaint s and ident if y t heir primary caus-es w hen more t han one t ype of pain is prcaus-esent as in t he cases present ed here.
The know ledge of t he diagnost ic crit eria f or f a-cial pain is ext remely import ant in t he process of diff erent ial diagnosis. An accurat e diagnosis leads t o an eff ect ive t herapeut ic t reat ment st rat egy.
Se-vere and diff use pain, such as ref erred dent al pain, can conf use t he pat ient and t he clinician and make t he diagnost ic process diff icult . This of t en leads an incorrect diagnosis and t reat ment . The clinician must be prepared, and not allow t he pat ient t o in-f luence t he diagnosis, (t he pat ient ’s report oin-f t he intensity of the complaint can confuse the clinician). In t his w ay w e can decrease t he incidence of iat ro-genic disorders and realize a more correct diagno-sis, more ef f ect ive t reat ment , and decrease t he risk f or chronic pain28.
In conclusion, this study demonstrates a wide va-riability of different diagnosis for facial pain, includ-ing ref erred dent al pain. It is import ant t o remem-ber t hat some pain condit ions are uncommon (f or example, t umor) and can be conf used w it h ot her, more common pain conditions that are present with a t ypical signs and sympt oms (f or example, pulpi-t is), leading pulpi-t o a misdiagnosis, iapulpi-t rogenesis and ch-ronicit y of t he pain. In t his ent ire sample, t he cause f or persist ent pain w as perpet uat ed by an incor-rect diagnosis and misdiincor-rect ed t reat ment . This de-monst rat es t hat a syst emat ic evaluat ion, based on specif ic diagnost ic crit eria can help t o clarif y t he diagnoses and f ormulat e t he t reat ment st rat egies f or an appropriat e t herapeut ic regimen. Finally, an int erdisciplinary t eam is of t en necessary f or t he diagnosis and treatment of many facial painful con-dit ions29. The dat a present ed in t his st udy are
con-sist ent w it h dat a report ed in ot her st udies, indi-cat ing t hat w hile most orof acial pain is benign, t here are cases w here it may represent serious and even lif e t hreat ening disease. This st udy also high-light s t he responsibilit y of t he general pract it ion-er, dent ist or physician, t o ref er dif f icult pat ient s f or a more det ailed and specialized evaluat ion.
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