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Chronic Facial Pain: a Multidisciplinary Problem

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Chronic Facial Pain: a Multidisciplinary Problem 716 J Neurol Neurosurg Psychiatry 2001;71:716–719 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.71.6.716 on 1 December 2001. Downloaded from NOSOLOGICAL ENTITIES? Chronic facial pain: a multidisciplinary problem G Madland, C Feinmann Abstract to diVerent specialists providing diVerent treat- Atypical facial pain is an unrecognised ments, including dentists, neurologists, otorhi- and unhelpful diagnosis but one which nologists, osteopaths, chiroporacters, and psy- describes chronic pains that do not fit the chiatrists, with little collaboration. present classification system. Due to the There are additional important problems site of the pain, patients may seek and, concerning the recognition and definition of indeed, receive treatment from dental underlying psychiatric disturbances. Emotional practitioners and specialists, but the pain disturbance, when present, is often mild and of is often unresponsive and may have more brief duration and psychiatric classification has in common with unexplained medical proved an inadequate measure. symptoms aVecting other areas of the body, than with other dental symptoms. Chronic symptoms This review suggests a need for a diagnos- Chronic symptoms and syndromes pose a tic category of “chronic facial pain”, major challenge to medicine: they are com- which demands a multidisciplinary ap- mon, often persistent, and are associated with proach to diagnosis and management. significant distress, disability, and unnecessary (J Neurol Neurosurg Psychiatry 2001;71:716–719) expenditure of medical resources. In United Kingdom primary care, somatic symptoms and Keywords: chronic pain; facial pain syndromes account for 20% of consultations. copyright. Among medical outpatients, somatic com- plaints accounted for 35% of new referrals in a Chronic idiopathic orofacial pain is an ill United Kingdom study.2 Even among medical understood group of conditions, which may inpatients, a substantial proportion have com- involve the whole of the mouth and face. plaints that are found to be functional. The Unfortunately descriptions of disorders and prevalence of emotional distress and disorder treatment tend to be influenced by the in patients who attend hospital with unex- background of the specialist assessing the plained syndromes (such as irritable bowel patient. Thus patients who see maxillofacial syndrome) is higher than in patients with com- surgeons have symptoms described in terms of parable medical conditions (such as inflamma- clicking, sticking, and locking of the temporo- Behavioural Sciences tory bowel disease) and many such patients are and Dentistry, mandibular joint and pain in the associated severely disabled.3 http://jnnp.bmj.com/ Eastman Dental musculature. Ear, nose, and throat surgeons Wessely et al3 suggest that each medical spe- Institute and Hospital, may retain Costen’s outdated notion that the cialty has defined its own syndrome or 256 Gray’s Inn Road, pain is due to missing molar teeth and may syndromes in terms of symptoms that relate to London WC1X 8LD, refer on to maxillofacial surgeons or restorative UK their organ or interest, despite similarities in G Madland dental specialists. Despite advice from the case definition, reported symptoms, sex, out- C Feinmann National Institute of Health that “there is no look, and response to treatment. Patients seek evidence linking occlusal abnormalities with help from doctors for symptoms, and doctors Department of pain”, patients’ occlusions continue to be diagnose diseases to explain them. Symptoms on September 26, 2021 by guest. Protected Psychiatry and adjusted by ill informed practitioners, often are the patient’s subjective experience of Behavioural Sciences, leading to more problems for patients.1 University College changes in his or her body, diseases are objec- London, UK The NIH conference in 1996 reviewed the tively observable abnormalities in the body. G Madland issues on the management of orofacial pain, DiYculties arise when the doctor can find no C Feinmann concluding that major problems hampered objective changes to explain the patient’s present diagnostic classifications and treat- subjective experience. The symptoms are then 48 Riding House ment. Five years later, there is no greater clar- referred to as medically unexplained or func- Street, London ity in classification. W1N 8AA, UK tional. Atypical facial pain is relegated to the G Madland Current diagnoses include tension headache, dental rather than neurological domain. C Feinmann migraine, neckache, temporomandibular disor- Wessely et al postulate that “the existence of der (temporomandibular joint pain dysfunction specific somatic syndromes is largely an Correspondence to: syndrome, facial arthromyalgia), and atypical artefact of medical specialisation. That is to say G Madland [email protected] facial pain. These pains seem to arise from blood that the diVerentiation of specific syndromes vessels, muscles, and joint capsules rather than reflects the tendency of specialists to focus on Received 19 December 2000 conforming to the distribution of sensory nerve only those symptoms pertinent to their and in revised form 5 March 2001 branches, as in trigeminal neuralgia. Artificial specialty, rather than any real diVerences Accepted 7 March 2001 distinctions in clinical presentation lead patients between patients” (p 936). www.jnnp.com Chronic facial pain 717 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.71.6.716 on 1 December 2001. Downloaded from Symptoms and signs activity), in response to both heat and nocicep- There are four recognisable symptom com- tive stimuli, in patients with atypical facial pain plexes of chronic orofacial pain, which may, relative to controls.9 This is suggestive of an however, coexist: temporomandibular disorder exaggerated perception of pain in response to (myofascial face pain); atypical facial pain peripheral stimuli but how this might develop (atypical facial neuralgia); atypical odontalgia remains a matter for speculation. The authors (phantom tooth pain); and burning mouth thought it likely that the mechanism for the syndrome (oral dysaesthesia, glossodynia, glos- diVerences found is related to anxiety and sopyrosis). They may be considered as medi- attention and therefore that the pain might be cally unexplained symptoms aVecting four brought under conscious control. However, the regions of the mouth and face. cross sectional nature of this evidence pre- Atypical facial pain is no longer included in cludes any conclusions as to whether such cen- the International Association for the Study of tral changes are primary or secondary to pain. Pain’s “classification of chronic pain”.4 The term originated to distinguish the condition Epidemiological considerations from “typical” trigeminal neuralgia, as the pain Although the prevalence of joint related and neither follows the distribution of the periph- muscle related symptoms has been studied, the eral nerve, nor responds to antiepileptic agents. epidemiology of chronic facial pain remains However, the categorisation of patients with unclear. An obvious explanation for why some similar pain histories into a diagnostic pigeon people choose to consult whereas others do not hole labelled “atypical” is self contradictory, is the severity of their symptoms. Sadly, epide- and the definition of a condition by what it is miological studies of facial pain have tended to not, rather than what it is, is unsatisfactory. A ignore intensity and frequency of symptoms better term might be “chronic facial pain”, as and recorded only their presence or absence. Orofacial pain is a common problem a ect- the defining characteristics are longevity and V ing at least 10% of the adult population and site, as distinct from temporomandibular 50% of the elderly population, and its inad- disorder which aVects the jaw rather than the equate recognition and management present (mid-)face, and intraoral pains. an enormous problem to the health service. The pain is usually a continuous dull ache The sex distribution is thought to be equal in with intermittent severe episodes, primarily the general population, but four times as many aVecting areas of the face other than joints and women as men seek help.10 Barksy and Borus muscles of mastication, such as the zygomatic have described how changes in social attitudes copyright. maxilla. Pain may be bilateral and will often have reduced the public tolerance to mild have been present for several years. Analgesics symptoms and benign infirmities, physiological are ineVective. responses to anxiety are also misinterpreted as Atypical odontalgia has a similar character illness. Isolated symptoms are then identified but is localised to one or more premolar or as disease by patients.11 molar teeth, simulating pulpitis.5 There may be a history of inappropriate dental treatment, Associated personality and psychiatric including extraction, and subsequent recur- problems rence of symptoms apparently from another There is a long standing association in the tooth. literature between chronic facial pain and psy- Patients often attribute their pain to an ante- chological distress, particularly depression.12 cedent event such as a dental procedure, or This is consistent with other chronic pain http://jnnp.bmj.com/ minor trauma to the face. Despite the notori- groups, in which the prevalence of depressive ous unreliability of such retrospective reports, symptoms is consistently higher than in the these attributions have led to the suggestion general population and many
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