Neuropathic orofacial pain patients in need of dental care.

Dental pain is a common complaint among the general population. Most pain is a result of traumatic injury or bacterial infection in pulpal and periapical tissues, and dental practitioners are successful at diagnosing these conditions and providing prompt relief. However, in some cases, patients continue to complain of persistent pain, which may be categorized as neuropathic. These people may avoid or neglect routine dental treatment or interventions to prevent precipitation, perpetuation or exacerbation of their pain condition, and practitioners may have to modify their procedures when managing the dental needs of this unique population.

The pterygospinous and pterygoalar ligaments and their relationship to the mandibular nerve: Application to a better understanding of various forms of trigeminal neuralgia.

INTRODUCTION: Ossification of the pterygospinous and pterygoalar ligaments has been well documented forming pterygospinous and pterygoalar bars. However, the actual ligaments have been rarely shown in the existing literature. Therefore, this study aimed to reveal the anatomy of the pterygoalar ligament/bar and pterygospinous ligament/bar, and its relationship with the branches of the mandibular nerve. METHODS: Thirty sides from fifteen Caucasian fresh frozen cadaveric heads were used in this study. The branches of the mandibular nerve and any ligaments or bony bridges between the lateral plate of the pterygoid process and spine of the sphenoid were observed. RESULTS: A pterygospinous ligament/bar and pterygoalar ligament/bar were defined based on the relationship with the branches of the mandibular nerve. The pterygoalar ligament/bar was further classified into two types. Twenty-seven sides (90%) had at least one pterygoalar ligament/bar or pterygospinous ligament/bar. A pterygospinous ligament/bar was found on 15 sides (50.0%). A pterygoalar ligament/bar was found on 16 sides (53.3%), and a type I on 11 sides and type II on 5 sides. CONCLUSIONS: This finding and classification are simple to understand and easy to apply for future studies, and have important implications regarding the clinical anatomy of trigeminal neuralgia and facial pain.

Patient-centered outcome criteria for successful treatment of facial pain and fibromyalgia.

AIMS: To define treatment success from the facial pain and fibromyalgia pain patient perspective across four domains (pain, fatigue, emotional distress, interference with daily activities) through the use of the Patient-Centered Outcomes (PCO) Questionnaire. METHODS: Participants included 53 facial pain (46 women, seven men) and 52 fibromyalgia (49 women, three men) patients who completed the PCO Questionnaire. The PCO assesses four relevant domains of chronic pain: pain, fatigue, distress, and interference in daily activities. Participants rated their usual levels, expected levels, levels they considered successful improvements, and how important improvements were in each of the four domains following treatment. Repeated-measures analyses of variance were performed to determine whether differences existed across domains and across pain groups. RESULTS: Both groups of participants defined treatment success as a substantial decrease in their pain, fatigue, distress, and interference ratings (all approximately 60%). Fibromyalgia participants reported high levels of pain (mean = 7.08, SD = 2.04), fatigue (mean = 7.82, SD = 1.71), distress (mean = 6.35, SD = 2.46), and interference (mean = 7.35, SD = 2.21). Facial pain participants' ratings of these domains were significantly lower for pain (mean = 5.62, SD = 2.38), fatigue (mean = 5.28, SD = 2.64), distress (mean = 4.34, SD = 2.78), and interference (mean = 4.10, SD = 3.06). CONCLUSION: These results demonstrate the high expectations of individuals with facial pain and fibromyalgia regarding treatment of their symptoms. Health care providers should incorporate these expectations into their treatment plans and discuss realistic treatment goals with their pain patients.

Self-care behaviors associated with myofascial temporomandibular disorder pain.

AIMS: To document the frequency of self-care in a clinical sample of patients with myofascial temporomandibular disorder (TMD) pain; report the perceived relief and control of pain for each of the self-care behaviors; and to test for associations between the frequency and efficacy of each self-care behavior and pain, depression and sleep quality, as assessed during a clinical visit, and to determine whether the frequency was associated with changes in pain intensity, depression, and sleep quality 30 days later. METHODS: The sample consisted of 99 female and 27 male myofascial TMD pain patients who were participants in a multidisciplinary facial pain evaluation program. The subjects participated in a structured interview during a clinical visit and a follow-up telephone interview 30 days later. The interviews included questions about self-care, including resting, relaxation techniques, massage, hot and/or cold packs, home remedies, stretching or exercise, herbal remedies, and the use of vitamins or nutritional supplements for pain. RESULTS: The passive self-care behaviors, such as resting when experiencing pain (66%) and relaxation techniques (62%), were the most commonly used. Patients reported that hot or cold packs (5.3, 0-to-10 scale) and massage (4.7) provided the greatest relief from pain, whereas resting (4.9), relaxation (4.8), and massage (4.8) resulted in the greatest ability to control pain. The most striking finding was that initial levels of pain or change in pain were not consistently associated with self-care use; however, psychosocial outcomes of depression and sleep quality were associated with self-care frequency and reported efficacy and improved in relation to patient-reported self-care frequency. CONCLUSION: Since people with chronic myofascial TMD pain engage in a range of pain self-care strategies, clinicians need to discuss self-care with patients regularly.

Neuropathic orofacial pain: proposed mechanisms, diagnosis, and treatment considerations.

The most common reason patients seek medical or dental care in the United States is due to pain or dysfunction. The orofacial region is plagued by a number of acute, chronic, and recurrent painful maladies. Pain involving the teeth and the periodontium is the most common presenting concern in dental practice. Non-odontogenic pain conditions also occur frequently. Recent scientific investigation has provided and explosion of knowledge regarding pain mechanisms and pathways and an enhanced understanding of the complexities of the many ramifications of the total pain experience. Therefore, it is mandatory for the dental professional to develop the necessary clinical and scientific expertise on which he/she may base diagnostic and management approaches. Optimum management can be achieved only by determining an accurate and complete diagnosis and identifying all of the factors associated with the underlying pathosis on a case-specific basis. A thorough understanding of the epidemiologic and etiologic aspects of dental. musculoskeletal, neurovascular, and neuropathic orofacial pain conditions is essential to the practice of evidence-based dentistry/medicine.

Evidence for sex differences in the relationships of pain, mood, and disability.

UNLABELLED: Disability demonstrates strong univariate associations with pain and negative mood. These relationships are more complex at the multivariate level and might be further complicated by sex differences. We investigated sex differences in the relationships of pain and negative mood to overall disability and to disability in specific functional domains. One hundred ninety-seven consecutive patients with low back, myofascial, neck, arthritis, and fibromyalgia pain were recruited from university pain clinics and completed measures of disability and negative mood. Overall disability and disability in voluntary activities were significantly associated with pain and negative mood (factor score) for both sexes. Significant sex differences emerged in the strength of the disability-mood relationship, with women evincing a stronger relationship. Disability in obligatory activities was also significantly related to pain and negative mood for both sexes; however, there were no sex differences in the strength of these relationships. Mediation analyses indicated that, in men, negative mood partially mediated the relationship between pain and both overall disability and disability in voluntary activities; mediation was not supported for disability in obligatory activities. In women, negative mood fully mediated the relationship between pain and all 3 types of disability. These data suggest that disability is more directly related to pain in men. In women, the effect of pain on disability appears to operate through negative mood. PERSPECTIVE: Results of this study demonstrate that sex differences exist in the relationships of pain, mood, and disability. Men and women might thus benefit from treatment interventions that differentially target these variables.

Sex differences in response to cutaneous anesthesia: a double blind randomized study.

The existing literature on experimentally induced pain indicates that there are sex differences, with females displaying greater sensitivity. In epidemiological studies, sex differences are also noted in the prevalence of a number of pain syndromes, with females reporting more severe pain, more frequent pain, and pain of longer duration. Complicating the interpretation of pain differences between men and women in clinical samples are reports of sex differences in response to pain-reducing medications. Studies in human subjects suggest that women respond better to certain opioid analgesics than men following third molar extraction, but few studies have assessed sex effects in effectiveness of topical anesthetics. The purpose of this study was to test for sex differences in response to a topical anesthetic, Lidocaine, using double blind, placebo controlled experimental methodology, in combination with a magnitude matching psychophysical protocol using a pressure algometer. The subjects were 21 female and 23 male adult volunteers. Twenty-four subjects (12 males and 12 females) were randomly assigned to the Lidocaine condition and 20 subjects were randomly assigned to the placebo control condition (9 males and 11 females). The effect size across sex for subjects in the Lidocaine treatment condition on the response bias variable was large indicating the males rated the stimuli as less painful than the females. Sex differences were not observed for discriminability in the Lidocaine treatment condition. This study did not show sex differences in the placebo condition. These results are particularly interesting in light of previous work that has shown similar pain stimuli (pressure pain) to be the stimulation most sensitive to sex differences. Results of this study suggest that the protocol employed (pressure pain stimulus with magnitude matching task) is sensitive to both anesthetic treatment and sex differences and represents an improvement in pain assessment methodology for use in experimental studies and in the clinic.

Multidisciplinary diagnosis and management of orofacial pain.

Dentistry has enjoyed a remarkable period of technological and scientific growth over the past several decades. With the increase in life expectancy, the number of individuals seeking dental care also has escalated. One of the most common reasons for seeking care is because of pain and/or dysfunction, usually involving the teeth or periodontal tissues. However, musculoskeletal, vascular, and neuropathic causes of orofacial pain occur frequently. The need to understand pain and all of its ramifications is of utmost importance in diagnosis and case-specific, evidence-based management of conditions afflicting the masticatory system. This article reviews current concepts with regard to the multiple etiologic and/or perpetuating factors now thought to be associated with myogenous and arthrogenous orofacial pain. Important distinctions between acute and chronic pain are discussed. The rationale for consideration of multidisciplinary evaluation and management is highlighted.

Psychological considerations in the diagnosis and management of temporomandibular disorders and orofacial pain.

The past several decades have heralded new insights into the many ramifications of pain. The mind-body connection must be appreciated in the assessment and care of the temporomandibular disorder/orofacial pain patient. Recognizing key indicators of psychological distress and their impact on the total pain experience is essential to optimizing treatment outcomes. It currently is understood that pain, especially chronic or recurrent pain, crosses all disciplines of health care with regard to diagnosis and management. This article will discuss the importance of including clinical and health psychology as a part of the health care team.