Diagnosing and treating persistent orofacial pain

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orofacial pain
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Persistent orofacial pain can be a cause of great irritation for dental patients, but growing understanding of the condition offers the prospect of better diagnoses and treatments. By Cameron Cooper

Complications with diagnosing and managing persistent tooth, mouth and facial pain have long been a frustration for some patients—and their dentists.

However, efforts to standardise the classification of orofacial pain could go a long way towards improving the response to such ailments. Under the International Classification of Orofacial Pain (ICOP), such types of pain now fit into an anatomically based classification scheme comprising six categories, with the latter category covering idiopathic orofacial pain such as burning mouth syndrome, persistent idiopathic facial pain and dentoalveolar pain, and constant unilateral facial pain with additional attacks. 

This category includes conditions previously known as atypical odontalgia and phantom tooth pain.

Professor Emeritus Chris Peck, from the MJ Cousins Pain Management and Research Centre at Royal North Shore Hospital Sydney, where he manages and undertakes research and teaching of orofacial pain, was on the taskforce that developed the new classifications. He is confident they will help dentists better identify and treat patients suffering from persistent, unknown pain.

“It’s incredibly important to have clarity around these classifications and definitions of pain because if you can’t make the diagnosis, how are you going to treat patients appropriately?” he asks. “That’s been a problem in the past.”

The condition

While the vast majority of orofacial pain is attributable to factors such as cavities or periodontal disease that dentists are familiar with treating, some cases can be harder to diagnose and manage.

Idiopathic orofacial pain, which often has no identifiable cause, has the hallmarks of chronic pain in that it is an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage and has persisted for at least three months on a daily basis for at least two hours a day. 

Factors such as nervous system sensitisation and anxiety and depression are typically associated with this type of pain. Dr Peck says acknowledgement of patients’ emotional response to pain is crucial because idiopathic orofacial pain can have a dramatic impact on patients psychologically and socially. “This link to emotional distress is important because the pain can interfere with people’s lives and social engagement,” he says.

It’s incredibly important to have clarity around these classifications and definitions of pain because if you can’t make the diagnosis, how are you going to treat patients appropriately? That’s been a problem in the past.

Dr Chris Peck, MJ Cousins Pain Management and Research Centre

Curiously, some idiopathic orofacial pains are more common in women aged over 60. While the reasons are unclear, it has been speculated that hormonal changes could be an influencing factor.

Dr Lalima Tiwari is an oral medicine specialist at the Perth Oral Medicine & Dental Sleep Centre. She concedes that there is no clear evidence as to why older women may over-present with such idiopathic orofacial pains, but she notes that it has been associated with sex-linked genetic differences and external stressors such as anxiety and depression. 

“And it’s known that women tend to suffer from those conditions a lot more,” Dr Tiwari says.

The treatment

For dentists contemplating how to assist patients complaining of persistent tooth or orofacial pain which does not have an apparent cause, Dr Peck offers a series of actions:

  • Use the ICOP classifications and biopsychosocial models to assign a physical and psychological diagnosis
  • Provide dental support to ensure no irreversible dental procedures are undertaken
  • Prescribe medication to better manage nervous system changes and significant psychological distress
  • Embrace psychology to reduce psychological distress, improve sleep and reduce activity limitation
  • Use physiotherapy to improve physical function and resiliency.

Most importantly, according to Dr Peck, it is advisable to work with other health practitioners and enlist the support of a general medical practitioner to help organise Medicare-funded psychology and physiotherapy services. In addition, he recommends reaching out to pain clinics or orofacial pain experts for support and advice and, where necessary, referral.

“So, it’s really a team-based approach,” Dr Peck says.

Dr Tiwari says any treatments that are administered will depend on a range of factors. 

However, if pain persists beyond three months and is considered to be chronic, specialists may advise using medications that fall into two classes. First, anti-epileptic drugs such as Lyrica and Gabapentin could be used if symptoms are constant during the day. Second, antidepressant drugs such as Nortriptyline and Endep may be appropriate for use in the evenings and at night to target pain and assist with sedation. “Patients can also get a better night’s sleep using these drugs,” Dr Tiwari says.

Just telling patients, ‘You’ll be fine’ and not following up with them is one of the things that can result in further frustration for the patient.

Dr Lalima Tiwari, oral medicine specialist, Perth Oral Medicine & Dental Sleep Centre

She agrees that consideration of a patient’s psychosocial history is crucial as part of a “multifactorial” approach to treatment. This can include asking in-depth questions about a patient’s life and any history of anxiety or depression.

“If the patient hasn’t addressed those factors, then we may consider a referral to a psychologist who has expertise in pain management as well.”

More than anything, Dr Tiwari urges dentists to be empathetic and listen if a patient returns to their practice complaining of pain and discomfort after a dental procedure. “Just telling patients, ‘You’ll be fine’ and not following up with them is one of the things that can result in further frustration for the patient.”

While certain medications can help treat neuropathic pain, Dr Peck says in instances of idiopathic orofacial pain where patients often do not respond to drug treatments, it is important to pursue alternative strategies that can address issues such as stress.

Transparency for all

Although it is clear that more research is required on diagnoses and treatments in relation to orofacial pain, Dr Tiwari says it is encouraging that dentists and other specialists now have access to clearer classifications of such conditions.

“Previously, patients would too often be dismissed and that would perpetuate the condition because it would take longer to get pain management,” she says.

She notes that, for dentists, these clearer classifications can also protect them from disgruntled patients who may be seeking to apportion blame for their pain. “Sometimes patients feel that their dentists have done something wrong, when they haven’t at all,” Dr Tiwari says.

For dentists whose training is often built around method-based treatments and biological, medical and technical knowledge, Dr Peck urges them to factor in psychological and social factors when treating patients with persistent pain.

“That’s something that we don’t always tend to do as dental practitioners.” 

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