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ePaper created 2015-04-13, 15:09:21 | version 1.33.01
Dental Tribune United Kingdom Edition | 1/201528 Pain is one of the most complex health conditions encountered, as it affects not only the sufferers, but also the community in which they live. It is often associated with other co-morbidities, especially anxi- ety,depressionandchronicpainelsewhere. Intheorofacialregion,themostcommonly reported pain is dental, and this inevitably requires a visit to a dentist, who in most in- stances can provide a cure. However, there are other pains encountered in the orofa- cial region that can become chronic, de- fined as pain that has been present for over three months. These pains need to be diag- nosed correctly, as their management is different. At present, we have no biomarkers for chronicpain,andtheonlywaywecanmake a diagnosis is to listen carefully to the his- tory the patient gives. We need to elicit the key features of pain, for example onset, du- ration, location, severity, character, pro- voking and relieving factors, as well as the impact on quality of life and activities of daily living. It is essential to determine the presenceofotherillnesses,especiallyother chronic pain. Chronic orofacial pain has a significant psychological impact, as the face used to express pain from other parts of the body is now in pain itself. Patients with chronic orofacial pain are also con- fused as to whom they should consult, a dentist or a doctor. Their choice of health care provider will significantly affect both first-line treatment and subsequent refer- ral. Painisnotoriouslydifficulttocommuni- cate and poor communication of pain is cited as the main barrier to treatment and management. This “unsharability” of pain can be correlated with its resistance to lan- guage. This results in an intense burden of sufferingandisolationfortheindividual.It is further compounded when patients do not have the requisite language skills. Yet we know that words may help a clinician in the differential diagnosis; for example, pa- tients with musculoskeletal pain will use words such as “heavy”, “aching” and “nag- ging”, whereas those with neurological causes will describe their pain as“burning”, “pins and needles”, “shooting” and “stab- bing”. We also try to measure pain using a scale of 1 to 10, but do these verbal measures re- ally capture the experiences of those with facial pain? This question recently led to a project with a visual artist to create photo- graphic images of pain. Thus images were co-created by the artist Deborah Padfield and facial pain sufferers, aiming to reflect the individual experience of pain. A selec- tion of these images were then made into pain cards, which are now being used with other pain patients to help improve mu- tual understanding and communication between doctors and patients. They appear to be helpful in describing the characteris- tics of the pain, as well as initiating discus- sions about its impact. Once a dental or oral mucosal cause of pain has been excluded, the commonest cause of pain in the lower part of the face is temporomandibular disorders (TMD). TMD can present as clicking or locking of the jaw and can come on suddenly. It can presentononlyonesideorboth.Paininthe muscles of mastication with or without pain in the joint itself is the commonest form of this group of disorders. It is very common and up to 20 per cent of cases can become chronic. The pain is centred in the pre-auricular area and can spread down the mandible and neck, as well as up to the forehead. It can be associated with clicks on opening or closing and rarely with reduced opening. The pain is described as dull, aching, sore and occasionally sharp. When the main muscles are palpated, the same character pain is elicited. A careful history is essential in order to identify any potential red flags. It is impor- tanttocheckforpossibletemporalarteritis in anyone over the age of 50 having his or herfirstepisode,as prompttreatmentwith steroids is required to prevent blindness. Any history of malignancy, neurological deficits, weight loss or severe trismus will require prompt investigation. Traditional TMD has been managed by dentists with the provision of a variety of intra-oral appliances. They do provide pain relief, but this may be due to the natural history of the condition. Current data from the world’s largest study on TMD in the US has highlighted that the most common provoking factors are psychosocial. There is increasing evidence that patients with TMD also experience pain in other parts of thebodyandaremorelikelytobeheadache and migraine sufferers. This data therefore suggests that our approach to manage- ment of these conditions needs to be radi- cally changed to include a more holistic ap- proach as described below. A condition with increasing incidence is persistent dentoalveolar pain, also known Avoiding irreversible dental treatment Types of orofacial pain and understanding them correctly By Prof.Joanna Zakrzewska,London © Halfpoint / shutterstock.com TRENDS & APPLICATIONS AD DTUK0115_28-29_Orofacial 09.04.15 16:42 Seite 28 DTUK0115_28-29_Orofacial 09.04.1516:42 Seite 28