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Dugoni School of Faculty Articles Arthur A. Dugoni School of Dentistry

12-2016 Orofacial Overview: Getting Rid of the Riddles Andrew L. Young University of the Pacific, [email protected]

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Recommended Citation Young, A. L. (2016). Orofacial Pain Overview: Getting Rid of the Riddles. California Dental Association Journal, 44(12), 729–735. https://scholarlycommons.pacific.edu/dugoni-facarticles/7

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CDA JOURNAL, VOL 44, Nº12

Orofacial Pain Overview: Getting Rid of the Riddles

Andrew Young, DDS, MSD

ABSTRACT While most that fi nd their way to the dental offi ce are dental in origin, some have less familiar roots: muscular, joint, neurological, headache, sinus or psychological. All of these roots can at times masquerade as a . The purpose of this article is to alert the dentist to the select features of each root that distinguish it from the rest, resulting in effi cient and appropriate treatment.

AUTHOR

Andrew Young, DDS, ain in the face and mouth is health care as a whole, temporomandibular MSD, is the director of the a frequent problem. A survey disorders (TMD) are primarily the orofacial pain curriculum of 45,711 households in the responsibility of the dentist.2 A smaller and treatment at the United States found that nearly proportion of dentists can recognize University of the Pacifi c, 22 percent of the population neuropathic pain and headaches, yet Arthur A. Dugoni School of Dentistry, where he is in Pexperienced pain in the orofacial region both conditions can masquerade as dental the departments of dental more than once in six months. This pain pain or TMD and, therefore, frequently practice and orthodontics. is particularly pertinent to the dentist. fi nd their way into the dental offi ce.3 He received a master Approximately 55 percent of those pains The aim of this article is to help of science in dentistry in were dental in origin and 24 percent were dentists who are presented with pain to orofacial pain from the University of Medicine and in the TMJ region. The remainders were recognize which of the seven categories Dentistry of New Jersey. facial pain, burning mouth or oral sores.1 it falls into. Included in this article is a Dr. Young is a diplomate Most orofacial pains originate from one table that summarizes the points, and of the American Board of of the seven following general categories: may also be used as a quick reference in Orofacial Pain and a fellow dental (including conditions managed by the offi ce (TABLE). The results of accurate of the American Academy of Orofacial Pain. periodontics and oral medicine), muscular, recognition are obvious: appropriate Confl ict of interest joint, neurological, headache, sinus and management, as quickly and completely disclosure: None reported. psychological. Dentists are comfortable as possible, and an impressed patient. and skillful in treating dental pain, but vary Conversely, the results of inaccurate in their abilities to recognize and manage recognition are regrettable: prolonged the other causes of orofacial pain. A pain at the least, but sometimes sizeable proportion of dentists can diagnose (particularly when the pain is intraoral) and treat temporomandibular disorders unnecessary, inappropriate and irreversible (i.e., muscular and joint pain) of mild to treatment, worsening prognosis and moderate complexity. And in American sometimes prompting litigation.

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TABLE Select, Distinctive Features in Orofacial Pain Differential Diagnosis

Dental Muscular Joint Neuropathic Headache Sinus Psychogenic Lesion Usually present None Sometimes fl attening None None Thickening of None Usually large of TMJ condyle sinus lining Location Specifi c to a tooth Region of a muscle Directly over TMJ May be a tooth Involves upper Multiple maxillary Any location or several muscles or tooth site half of head teeth possible May refer to teeth May be the May also May not distribution of a involve jaw correspond to nerve branch any anatomical structure(s) Quality Dull, sharp or Usually dull Usually sharp Electric, burning, Dull, sharp or Ache, pressure, Any quality throbbing tingling, numb, throbbing tender possible Sometimes sharp Sometimes dull dull, sharp or throbbing Intensity Mild to severe Mild to moderate Mild to moderate Mild to severe Mild to severe Mild to moderate Mild to severe Aggravators Hot, cold, air, Prolonged Any jaw movement May be May be Bending forward Often follows pressure to the opening, chewing (even small opening, spontaneous spontaneous no established tooth laterotrusion) trigger pattern Opening widely Pressing joint May be May be Percussion, cold continuous continuous and intraoral palpation may worsen Pressing muscle May have May have no triggers no triggers Light touch to skin Light or sound may trigger may trigger Alleviators Dental procedure Rest Rest Relief from dental Analgesics may Decongestants Often follows procedure lasts provide minimal to no established Antibiotics Massage and heat Analgesics Corticosteroids months at most full relief treatment Analgesics Muscle relaxants Night guard (if Antihistamines regimen Analgesics, bruxing at night) Analgesics antibiotics Antibiotics ineff ective Night guard (if Recovery from bruxing at night) illness Removal of allergens History Fully resolved with Usually resolves Usually resolves Often has history May come and go Pain matches Often follows dental procedure by 12-18 months by 12-18 months if of multiple failed onset and no established if untreated untreated dental procedures fl uctuations of pattern If untreated, lesion May come and go May persist stably sinus symptoms and pain will grow for lifetime May persist stably May worsen or for lifetime improve over lifetime May worsen over lifetime Prevalence Very common Common Common Rare Common Common Very rare

The characteristics of each pain category vary greatly beyond what are listed in this table. The few features selected for this table are those that are more distinctive for their pain category. They are listed here to alert the dentist to look deeper into the possibility of that type of pain when present.

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Masticatory Muscle Disorders may misinterpret this as TMJ pain. Yet Patients generally can localize joint The category called temporomandibular palpation of the TMJ will not reproduce pain well10 and will take one fi nger to point disorders encompasses pain and/or the pain (unless the TMJ is also infl amed). precisely to the TMJ. Yet as mentioned dysfunction of the TMJ and supporting Intensity — While muscle pain, earlier, several muscles lie close to that structures. It can thus be divided particularly when chronic and constant, area, so range of motion testing should be into joint pain and muscular pain. can signifi cantly degrade quality of done to differentiate between muscle and When a patient points to a region life, it very rarely is severe in intensity joint pain. While a 7 mm laterotrusion above his or her ear as the location of the (i.e., 9-10 on the visual analog scale).7 is a relatively insignifi cant movement pain, the diagnosis is relatively simple. A report of such an intensity warrants for the masseter muscle, for the TMJ Diagnosis becomes more challenging when investigating for possible headache, it requires translation to its maximum the patient points to the preauricular dental infection or neuropathic pain. distance. For this reason, pain or blockage region, which is common. There, the Medication — Muscle pain in the TMJ will reduce the jaw’s excursive TMJ and several muscles are in close responds well to muscle relaxants. movements and muscle pain will not. proximity. Muscles, the joint or both It also responds to NSAIDs, but not TMD pain is usually worsened with may be the cause. To further complicate jaw movement.10 When the doctor is the diagnostics, both muscle and joint contemplating a primary headache versus a conditions have sharp and/or dull qualities, TMD, this characteristic is helpful. It is also can limit maximum opening, hurt with jaw Although the TMJ can be helpful when contemplating the cause of a movement4 and frequently occur together.5 diagnostically challenging painful tooth site. Range of Motion — A helpful difference visualized by radiographs, between muscle and joint pains is their MRI and ultrasound, painful Neuropathic Pain effects on excursive jaw movements. joints do not always present Dental, muscular and joint pain Muscle pain generally does not limit are all somatic or “normal” pain. small movements, such as laterotrusion with visual fi ndings. They hurt because of the presence of and protrusion. When a muscle such excess infl ammatory and/or analgesic as the masseter is capable of stretching agents. Therefore, they usually respond 40 mm to 55 mm (when healthy) to predictably to NSAIDs, at least for the open,6 stretching 7 mm for a lateral as well as joint pain does and not as short term. Somatic pain is the type of movement is relatively insignifi cant. well as it does to muscle relaxants.7 pain that dentists encounter, diagnose Disorders of the TMJ, by contrast, do Referral — Painful muscles may also and treat the vast majority of the time. often limit these excursive movements.4 refer pain to remote sites.8 For example, Neuropathic pain is pain that is Palpation — If the pain is muscular pain in the anterior temporalis is known initiated by a lesion or dysfunction in origin, palpation should aggravate to cause pain in the maxillary incisors. of the nervous system itself, whether the pain. Palpating for muscle or joint The masseters can refer pain to the peripheral, central or both.11 It can pain requires more force than that used posterior teeth.9 When the source of a follow a traumatic event, such as a dental for head and neck cancer screenings. patient’s dental pain is unclear, muscular procedure, or develop spontaneously.11 When palpating for pain, roughly one origin should, therefore, be considered. Neuropathic pain differs from somatic to two pounds of pressure should be It can be ruled out simply by palpating pain in its presentation, its response to applied with two fi ngers for two seconds the painful masticatory muscles and treatment and its chronicity. A variety per site.4 If this does not reproduce the asking the patient to indicate if any of neuropathic conditions exist, and chief complaint, headaches should also site worsened the dental pain.9 the possible characteristics range from be considered as a possible explanation. seconds to constant in duration, rare However, the lateral pterygoid is diffi cult TMJ Disorders to constant in frequency and minimal to palpate, and its involvement in TMDs Although the TMJ can be to excruciating in intensity.12 But some is not infrequent. When this muscle is visualized by radiographs, MRI and other characteristics are more unique to painful, and the patient points to it as ultrasound, painful joints do not neuropathic pain, which when present can the location of the pain, the clinician always present with visual fi ndings. greatly help the clinician in diagnosing.

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Location — The location of pain for sometimes mistake this response for the increases the risk for misdiagnosis. trigeminal follows the nerve cold sensitivity in . A patient Anesthetic — The pain of some distribution of the trigeminal nerve report of cold drinks triggering pain may neuropathic conditions, such as trigeminal divisions. It may involve a single division, seem to reinforce the diagnosis of pulpitis, neuralgia, can be eliminated for the or two or three, but is unilateral the vast but more precise questioning would reveal duration of topical and/or injected local majority of the time.13-16 Yet while such a that the cold drink triggers the attack at anesthetic or longer.28 However, others, description would make a correct diagnosis the point of contact on the lip, before such as atypical odontalgia, may be easy, clinicians do not often become aware the cold ever reaches the tooth.13,20 reduced, but not eliminated, for the of the full and exact extent of the patient’s Quality — Like dental and TMD pain, duration of the anesthetic agent.29 Such pain location. Patients may just mention neuropathic pain can be dull, aching,21 responses should raise suspicion for the tooth, or the intraoral portion, but throbbing or sharp12 in quality. However, possible neuropathic pain, as well as not mention the extraoral portions. The it can also have the more uncommon referred pain and primary headaches. reasons for this incomplete description qualities of burning22 or electric.23 Misdiagnosis — Despite the above vary by patient. For some, the pain is more Natural History — Each neuropathic distinguishing features, neuropathic pain intense at the tooth or dental quadrant. pain condition has its own typical natural involving the mouth is still frequently For others, they assume their dentist misdiagnosed as odontogenic. It may would not have reason to be interested then mistakenly be treated by endodontic in areas beyond the mouth. Allowing therapy, crowns or extractions, even enough time in the dental appointment Although not appropriate, multiple times in multiple teeth, before 29,30 for thorough discussion can allow for the dental treatment for a arriving at the proper diagnosis. Several discovery of such critical information. factors contribute to this misfortune: Many neuropathic pain conditions, neuropathic pain condition ■ The location of the pain however, do involve only a single tooth or will initially provide relief, at a tooth site. tooth site, leading to many misdiagnoses typically for weeks to months. ■ Imprecise or inaccurate history from and improper dental treatments.17 the patient (e.g., the patient reports Duration and Frequency — The constant pain, when in reality the intermittent sharp and intense pain of attacks last 10 seconds but occur often comes to mind at repeatedly throughout the day). the mention of neuropathic pain, but many history. Trigeminal neuralgia worsens over ■ Inadequate familiarity with neuropathic conditions actually range the course of weeks to years.24 However, neuropathic pain.7,30 from many hours per attack to constant.7 it often occurs in clusters, during which ■ Initial favorable response Aggravators — Neuropathic pain pain attacks occur multiple times per to dental treatment. conditions also respond to stimuli in day. Clusters are separated by remission Response to Dental Treatment — atypical fashions. Atypical odontalgia, periods of days to years, during which Although not appropriate, dental formerly known as phantom tooth no attacks occur.14 In contrast, atypical treatment for a neuropathic pain pain, and with a suggested renaming to odontalgia fl uctuates, but often overall condition will initially provide persistent dentoalveolar pain,18 generally does not change in a lifetime.25 Burning relief, typically for weeks to months. is not worsened with pulp vitality testing mouth disorder has a slight chance of Subsequently, the pain returns with (cold, heat, percussion, apical palpation improving after several years.26,27 But equal or greater severity. But the initial and bite) and should raise suspicion that most patients who are diagnosed with response is misinterpreted as proof that the the pain is not odontogenic.19 Trigeminal neuropathic pain will have it for a problem is dental, and further treatment neuralgia, by contrast, responds in an lifetime. A dentist who is presented with is then done to the same tooth (e.g., exaggerated manner to stimuli for some such a history should know that a dental endodontic therapy is followed by an patients. For example, a cold draft of diagnosis would not be appropriate for extraction) or to adjacent teeth under air on the skin may trigger severe pain. such pain. But the dentists who see the the assumption that those teeth are also While dental conditions obviously do patient shortly after the pain onset would problematic when the pain returns. After not behave in this manner, dentists not have such a history to analyze, which one or more unsuccessful attempts to

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resolve the pain with dental treatment, ■ Unilateral autonomic features underlying sinus space.42 And while the dentist typically refuses to perform (nasal congestion, nasal discharge, pain increases when bending further dental treatment and refers to reddening of the eye, tearing of forward so that the head is below the a specialist. However, when faced with the eye, fl ushing of the face) only heart, a will also become such a refusal, the patient often changes on the same side as the headache, more painful with the same maneuver. dental providers until one is found who occurring only during the headache True odontogenic pain, however, will will perform more dental procedures. The or during an exacerbation of be relieved by intraoral local anesthetic persistent pain, resistant to analgesics a continuous headache. injections, while sinus pain will not.41 and antibiotics, creates the desperation ■ Phonophobia. And pain will generally be focused on a that drives repeated dental interventions. ■ Photophobia. single tooth, but sinusitis will aggravate This pattern continues, often until several ■ Nausea. several teeth. Sinusitis may also show teeth have been treated/extracted, either ■ Vomiting. thickening of the fl oor of the sinus on within the spread of the neuropathic ■ Aura (visual shapes or voids, a panoramic radiograph due to fl uid pain location or as the location of the tingling, numbness, speech accumulation and mucosal thickening.43 pain migrates.11 Unnecessary dental or motor disturbances). And sinusitis-related dental pain will treatment should be avoided,7 as it resolve with the sinusitis, whether worsens the condition and its prognosis.31 by decongestants, antihistamines, antibiotics, recovery from the causative Headache True odontogenic illness or the removal of allergens. Headaches can be roughly grouped as pain, however, will be primary or secondary. When the headache Psychogenic Pain is a symptom of another condition, such relieved by intraoral local True psychogenic pain (originating as TMD, this is classifi ed as a secondary anesthetic, while sinus in the mind, with no physiological headache. Examples of primary headaches pain will not. explanation) is extremely rare.44 It is include and cluster headaches.32 being described here to help the dentist Primary headaches are contemplated who is contemplating this as a possibility mostly on the differential for TMDs but and will then most often rule it out. should also be considered on the dental Psychogenic pain has no lesion, differential. While headaches are contemplated whether in the mouth or the nervous Primary headaches and TMDs are mostly on the differential for TMDs, some system. If there is a lesion, no matter often confused for a number of reasons. headaches do involve the lower half of how small, the pain response may be First, they overlap in locations. Many of the head, which includes the mouth. The exaggerated, but it is not psychogenic. the headache regions are masticatory or likelihood increases if the patient’s dental The anatomical spread of the pain cervical muscles.7 Secondly, they often pain worsens when the rest of the head may not follow any muscle, joint or nerve occur together,33-35 with 80 percent of hurts more or in conjunction with the distribution. The triggers may not follow TMD patients also reporting recurrent above associated signs and symptoms.7 any known trigger pattern — not even headaches36 compared to 20 to 23 those of the neuropathic conditions. percent of the general population.37 Sinus Likewise, the history does not follow They also share common aggravators, Eleven percent of patients with a known pattern, such as progressive such as stress and inadequate sleep. sinusitis report maxillary toothache.39 worsening (in the case of infection) or Primary headaches can be To further confuse the diagnostic pain coming in clusters (in the case of distinguished by several features. They process, tenderness to percussion,40 some and headaches). Any usually are not worsened with palpation or hypersensitivity to cold and intraoral quality and any intensity is possible. jaw usage, while TMDs are. They also do mucosa tenderness, edema and erythema Despite this wide range of not limit range of motion.3 The following in the area overlying the infl amed sinus41 characteristics, the one common theme associated signs and symptoms also greatly can accompany sinusitis. The PDL may is that the pain does not match any of increase the likelihood of a headache:38 even appear widened because of the the previously mentioned conditions’

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descriptions. But the clinician must be alleviating pain, they must be able to 3. Yatani H, Komiyama O, Matsuka Y, et al. Systematic review careful not to defi nitively diagnose or recognize a nondental pain presentation and recommendations for nonodontogenic toothache. J Oral Rehabil 2014;41(11):843–852. doi:10.1111/joor.12208. dismiss unusual pains as psychogenic, as such. Forty-four percent of patients 4. Schiff man E, Ohrbach R, Truelove E, et al. Diagnostic Criteria because the pain could actually be with nonodontogenic orofacial pain for Temporomandibular Disorders (DC/TMD) for Clinical and a neuralgia or headache that the have at least one root canal treatment Research Applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special clinician is simply unaware of. It is or extraction prior to the appropriate Interest Group. J Oral Facial Pain Headache 2014;28(1):6– best to refer such unusual pain to an referral.17 It is our hope that with articles 27. doi:10.11607/jop.1151. orofacial pain dentist or a neurologist such as this, and increased dental school 5. Huang GJ, LeResche L, Critchlow CW, Martin MD, Drangsholt MT. Risk factors for diagnostic subgroups to fi rst assess for those possibilities. and continuing education sessions, that of painful temporomandibular disorders (TMD). J Dent While purely psychogenic pain is percentage will be greatly reduced. Res 2002;81(4):284–288. www.ncbi.nlm.nih.gov/ extremely rare, psychologically affected The average dental practice is pubmed/12097315. Accessed Sept. 10, 2015. 6. de Leeuw R, Klasser G, eds. Orofacial Pain: Guidelines 44 pain is extremely common. In fact, busy, with numerous pressing issues to for Assessment, Diagnosis and Management. 5th ed. because all pain signals are processed attend to. Nonodontogenic conditions Quintessence Publishing Co. 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Baltimore: Lippincott Williams & Wilkins; 1998. (also known as phantom bite syndrome treatment is better than being hasty. 10. Okeson JP, de Leeuw R. Diff erential Diagnosis of or occlusal dysesthesia), which is “a In such cases, if the true cause is dental Temporomandibular Disorders and Other Orofacial Pain persistent hyperawareness of their (e.g., pulpal necrosis), palliative care Disorders. Dent Clin North Am 2011;55(1):105–120. doi:10.1016/j.cden.2010.08.007. occlusion with few or no objective (e.g., medication) could keep symptoms 11. Merskey H, Bogduk N, eds. Classifi cation of : fi ndings to support their beliefs.”46 When at bay until the follow-up visit, at which Descriptions of Chronic Pain Syndromes and Defi nition of Pain considering making occlusal adjustments time the dental cause may be more Terms. 2nd ed. Seattle: IASP Press; 2002. 12. Dworkin RH, Portenoy RK. Pain and its persistence in herpes specifi c to the patient’s request, the clear (e.g., formation of an abscess) zoster. Pain 1996;67(2-3):241–251. www.ncbi.nlm.nih.gov/ dentist should exercise caution, as such, with no appreciable loss. If the true pubmed/8951917. Accessed Sept. 10, 2015. adjustments may not satisfy the patient cause is nonodontogenic, that too 13. Rasmussen P. Facial pain. III. A prospective study of the localization of facial pain in 1052 patients. Acta Neurochir 46 and may worsen the condition. The will become more evident with time, (Wien) 1991;108(1-2):53–63. www.ncbi.nlm.nih.gov/ condition should fi rst be addressed by followed by the appropriate referral. pubmed/2058427. Accessed Sept. 14, 2015. a psychologist or psychiatrist.47-51 Both are far preferable to premature 14. Katusic S, Beard CM, Bergstralh E, Kurland LT. Incidence and clinical features of trigeminal neuralgia, Rochester, dental treatment for a nonodontogenic Minn., 1945–1984. Ann Neurol 1990;27(1):89–395. Conclusion pain, with no resultant relief and doi:10.1002/ana.410270114. With a modest amount of instruction, possible worsening. The cautious, 15. Tacconi L, Miles JB. Bilateral trigeminal neuralgia: A therapeutic dilemma. Br J Neurosurg 2000;14(1):33-39. either from dental school or continuing contemplative dentist can thereby spare http://www.ncbi.nlm.nih.gov/pubmed/10884882. Accessed education, dentists can effectively some patients unnecessary suffering. Sept. 28, 2015. treat mild to moderate TMDs. The age-old adage even holds true for 16. Kuncz A, Vörös E, Barzó P, et al. Comparison of clinical symptoms and magnetic resonance angiographic (MRA) results This article hopefully sheds some dentistry: “Slow and steady wins the race.” ■ in patients with trigeminal neuralgia and persistent idiopathic light on those other causes of pain facial pain. Medium-term outcome after microvascular in the face and mouth. 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