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Acute Orofacial Pain OralSurgery Nadine Khawaja Tara Renton Pain Part 3: Acute Orofacial Pain Abstract: Acute trigeminal pain is a common presentation in the dental surgery, with a reported 22% of the US adult population experiencing orofacial pain more than once during a 6-month period.1 This article discusses the mechanisms underlying the pain experience, diagnosis and subsequent management of acute trigeminal pain, encompassing pre-, peri- and post-operative analgesia. The dental team spend most of their working lives managing patients and acute pain. The patient may present to the clinician in existing pain, which may often provide a diagnostic challenge. Prevention and managing intra-operative and post-surgical pain are implicit in providing your patient with optimum care. CPD/Clinical Relevance: This paper aims to provide an overview of conditions that may present with acute orofacial pain and their management using the most recent evidence base. Intra-operative and post-surgical pain management are also scrutinized and evidence- based treatment is recommended. Dent Update 2015; 42: 442–462 ‘A toothache, or a violent passion, is not empathy and patience. Oral analgesics trigeminal nerve. Pain has a dramatic necessarily diminished by our knowledge are commonly prescribed for a few days physiologic impact that can adversely of its causes, its character, its importance or following oral surgery or other procedures, affect the health and well-being of dental insignificance’ wrote T S Eliot. after which patients are typically pain-free patients.5 Furthermore, if acute pain is not Acute pain management is or can switch to over-the-counter (OTC) treated adequately, there is a risk that it integral to the provision of optimal dental medications (ie either lower doses of the may become chronic in nature. Therefore, care and supporting the well-being of same analgesics or different OTC drugs). adequate pain control is a medical and patients. Any patient attending a dentist Acute trigeminal pain is a dental necessity and not merely an issue of will be experiencing some degree of anxiety distressing, common encompassing pain patient comfort. and stress. These emotions will lower from the orofacial region and head.2 It is now understood that the patient’s pain tolerance and further A cross-sectional population study in early control of acute pain can shape its compound pain management. Anyone in Cheshire, England, reported that orofacial subsequent progression, by preventing this field recognizes that pain is complex, pain (OFP) affected a quarter of the nociceptive input and, hence, preventing particularly in the dental environment population, of whom only a half sought persistent pain.6 Good pain management where fear, phobia and poor expectations help.3 The prevalence was higher in women can help prevent the negative physiological compound the patient’s pain experience. and younger adults (18–25 years) with 17% (tachycardia, hypertension, myocardial Dentists require an armamentarium of of the population having time off work ischaemia, decrease in alveolar ventilation, psychological, communication, medical and or unable to carry out normal activities and poor wound healing) and psychological technical skills. Managing operative pain due to the pain.3 The impact of pain on (anxiety, sleeplessness, phobia) outcomes.5 under local anaesthesia requires expertise, the economy is demonstrated by a cross- Management of acute dental sectional survey in eight countries in Europe pain includes management of patients which estimated the total annual cost of undergoing surgery (peri- and post- headache among adults, aged 18 to 65 operative) and those presenting with pain Nadine Khawaja, BDS, MJDF years, as €173 billion.4 as a result of underlying pathology (eg MSurgDent, Specialist Academic Trainee, The dental profession, since its pulpitis, ulcer). Patients with trigeminal pain Department of Oral Surgery and Tara infancy, has been a pioneer in the fields may often present to dental practitioners. Renton, BDS, MDSc, PhD, FARCDS(OMS) of anaesthesia and pain control. This Successful management of acute trigeminal FDS, RCS FHEA, Professor of Oral stems from the need for these modalities pain is dependent on obtaining a correct Surgery, King’s College London Dental to render painless dental care in an diagnosis of the source of pain.7 This is Institute, King’s College Hospital London, anatomic region that is highly innervated achieved through comprehensive history- Bessemer Road, London SE5 9RS, UK. by the second and third divisions of the taking, examination and appropriate 442 DentalUpdate June 2015 OralSurgery special tests (Table 1). Initial history- taking into account associated signs Management of acute taking should include determining the and symptoms, radiation, functionality, trigeminal pain site, onset, character (type of pain), disability, psychological effects and time The management of acute 7 severity (verbal/numerical, Table 2) and course. Management of acute pain as a trigeminal pain can be divided into three any exacerbating/relieving factors. A presentation symptom is discussed in later areas: intra-operative, post-operative and thorough assessment can be completed articles. acute symptomatic pain (usually acute Diagnostic Requirements Identify signs of inflammation Redness, swelling, heat pain, loss of function Response to anti-inflammatory drugs (eg NSAIDs) Response to antibiotics if initiated by infection Loss of function Trismus, inability to bite on tooth, difficulty swallowing Special tests (Endofrost/ Electric pulp NB Surrogate measure of vitality as it measures nerve response rather than condition of test/heat) blood supply Non response does not always signify pulpal necrosis Positive response may be complicated in multi-rooted teeth with varying pulpal conditions in different canals Short sharp pain, which doesn’t linger (ie Ad fibre mediated) suggests inflammation is superficial in the pulp and, therefore, can be reversible Lingering, dull, aching poorly localized pain (ie C-fibre mediated pain) is suggestive that the inflammatory process has spread to the central part of the pulp and, therefore, the pulp is irreversibly inflamed Pain on release of biting may indicate ‘cracked tooth syndrome’ using a ‘tooth sleuth’ or simply a cotton roll between the tooth cusps Neuropathic signs Mechanical allodynia (pain to stimulus which is not normally painful eg light touch) Hyperalgesia (increased pain to painful or noxious stimulus) Radiographs Long Cone periapical using paralleling technique for individual to three teeth in single quadrant Bitewing radiographs If multiple quadrants or impacted teeth use dental panoramic tomography (DPT) Cone beam computerized tomography (CT) for localization of high risk teeth or impacted teeth Haematological investigations CRP levels in acute spreading infections ESR for chronic pain, pain of unknown aetiology FBC with Haematinics (Fe, B12, Folate) Zinc (required for Fe absorption) Thyroid function tests HBA1c (exclude Diabetes) Auto-antibody screen (ENAs and ANAs) Biopsy Punch, classical, laser biopsy for lesions of unknown aetiology for histopathological diagnosis Signs of sinister disease Over 50 years Sudden recent onset, intense pain Painless trismus, worsening trismus despite therapy Neuropathy Asymmetry Table 1. History, examination and special tests. June 2015 DentalUpdate 443 OralSurgery Pain assessment tool Assessment Category rating scale Choice of five categories: None, Mild, Moderate, Severe, Unbearable Visual analogue scale (VAS) Draw a line from no pain to worst pain No pain Worst pain Numerical rating scale Choose a number from 1–10 1 2 3 4 5 6 7 8 9 10 No pain Worst pain Table 2. Summary of pain assessment tools. infection). They are quick and easy to use (Table of nerve depolarization and firing. The 1. Management of intra-operative pain: 2),8 whereas pain questionnaires can membrane expansion theory suggests management of anxiolysis, non-medical often assess the quality and character of non-specific swelling of the cell membrane (behavioural) and medical (sedation) is not the pain (eg McGill Pain Questionnaire by absorption of the LA, whilst the newer covered in depth in this article; (MPQ)), as well as its intensity.9 The MPQ specific binding theory describes binding of 2. Management of post-surgical pain; consists primarily of three major classes LA to a specific binding site of the sodium 3. Management of acute orofacial pain: of word descriptors; sensory, affective and channel. Discovery of specific drug binding patient presenting with dental pain as a evaluative to specify the pain experience.8 sites allows for the possibility of developing symptom. anaesthetics with greater sensitivity for The mechanism, peripheral specific sodium channels with reduced side- mediators, central modulation and the Management of intra-operative pain effects.12 trigeminal anatomy of pain have been Local anaesthesia (LA) is Lidocaine is the most commonly covered in Part 1 of this series. fundamental for pain control in outpatient administered local anaesthetic by dental oral surgery and dental procedures. Local practitioners, although other available anaesthetic is defined as a drug which solutions (prilocaine, mepivacaine and Pain assessment reversibly prevents transmission of the articaine) offer advantages in certain The clinician is beholden to nerve impulse in the region to which it is situations (Table 3). In the severely medically- 10 take a full and comprehensive history applied, without affecting
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