Somatosensory investigation of patients with orofacial pain compared with controls.

The objective of this study was to investigate the sensorial characteristics of orofacial pain in patients compared with control subjects. A total of 336 subjects (282 patients and 54 control subjects) were evaluated to identify their thermal (cold and warm), tactile, and pain thresholds. Numbness was reported by 61.7% of the patients (p<0.001). Patients with trigeminal postherpetic neuralgia and burning mouth syndrome showed loss of thermal perception; patients with postherpetic neuralgia, burning mouth syndrome, and posttraumatic painful neuropathy had a decrease in tactile perception compared with the control subjects (p<0.001). In conclusion, other sensorial modalities besides pain are affected by neuropathic orofacial pain; these findings can help in the understanding of the pathophysiological mechanisms in orofacial pain.

Sorting pain out of salience: assessment of pain facial expressions in the human fetus.

INTRODUCTION: The question of whether the human fetus experiences pain has received substantial attention in recent times. With the advent of high-definition 4-dimensional ultrasound (4D-US), it is possible to record fetal body and facial expressions. OBJECTIVE: To determine whether human fetuses demonstrate discriminative acute behavioral responses to nociceptive input. METHODS: This cross-sectional study included 5 fetuses with diaphragmatic hernia with indication of intrauterine surgery (fetoscopic endoluminal tracheal occlusion) and 8 healthy fetuses, who were scanned with 4D-US in 1 of 3 conditions: (1) acute pain group: Fetuses undergoing intrauterine surgery were assessed in the preoperative period during the anesthetic injection into the thigh; (2) control group at rest: Facial expressions at rest were recorded during scheduled ultrasound examinations; and (3) control group acoustic startle: Fetal facial expressions were recorded during acoustic stimulus (500-4000 Hz; 60-115 dB). RESULTS: Raters blinded to the fetuses' groups scored 65 pictures of fetal facial expressions based on the presence of 12 items (facial movements). Analyses of redundancy and usefulness excluded 5 items for being of low discrimination capacity (P>0.2). The final version of the pain assessment tool consisted of a total of 7 items: brow lowering/eyes squeezed shut/deepening of the nasolabial furrow/open lips/horizontal mouth stretch/vertical mouth stretch/neck deflection. Odd ratios for a facial expression to be detected in acute pain compared with control conditions ranged from 11 (neck deflection) to 1,400 (horizontal mouth stretch). Using the seven-item final tool, we showed that 5 is the cutoff value discriminating pain from nonpainful startle and rest. CONCLUSIONS: This study inaugurates the possibility to study pain responses during the intrauterine life, which may have implications for the postoperative management of pain after intrauterine surgical interventions.

Severe psychosocial compromise in idiopathic trigeminal neuralgia: case report.

OBJECTIVE: This article describes a 60-year-old man with 17 years of idiopathic trigeminal neuralgia (ITN) which affected tooth brushing for 6 years, causing severe dental complications and psychosocial problems. METHODS: Case report. RESULTS: Following ITN diagnosis, this patient underwent neurosurgery (microcompression of the trigeminal ganglion with a balloon) with immediate relief, but after three months, pain recurred and was accompanied by dysesthesia and periodontal disease. After dental treatment, he had complete alleviation of pain and no further need of medication over the following 3 years. The intense suffering of this patient represents the importance of a multidisciplinary evaluation for pain-caused secondary complications. CONCLUSION: ITN is a simple diagnosis but may have complex course. Appropriately trained health professionals are necessary to evaluate and treat these patients.

Orofacial pain and sensory characteristics of chronic patients compared with controls.

OBJECTIVES: To investigate orofacial and sensorial characteristics of patients with orofacial pain and healthy controls. STUDY DESIGN: Case-control. Seventy-five patients (61 women) who had chronic orofacial pain for more than 6 months (i.e., idiopathic trigeminal neuralgia, burning mouth syndrome, persistent idiopathic facial pain, nonidiopathic neuropathic pain, fibromyalgia or temporomandibular disorders were compared with 41 healthy subjects (19 women). They were evaluated with a quantitative sensory testing protocol involving a combination of gustative, olfactory, thermal, mechanical and pain stimuli. Mean pain duration in this population was 6.27 ± 6.06 years. Orofacial characteristics (masticatory and articular abnormalities), oral health and sensitivity to muscular palpation were assessed. RESULTS: The majority of patients (73.3%) had pain upon craniofacial muscle palpation and 46.7% had numbness. High cold thresholds were observed with burning mouth syndrome and nonidiopathic neuropathic pain (P = .017), while high tactile thresholds were observed in persistent idiopathic facial pain patients (P = .048). Persistent idiopathic facial pain and temporomandibular disorders were associated with a low threshold for pain perception (P < .002). Several of these sensorial alterations were associated with positive musculoskeletal findings. CONCLUSIONS: Sensorial abnormalities were observed in neuropathic and somatic pain patients. The masticatory system is associated with and may be a secondary cause of pain in such patients.

Quantitative sensory testing in trigeminal traumatic neuropathic pain and persistent idiopathic facial pain.

The objective of this article was to investigate, with a systematic protocol of quantitative sensory testing, patients with persistent idiopathic facial pain (PIFP) and others with trigeminal traumatic neuropathic pain (TTN) compared to controls. Thirty patients with PIFP, 19 with TTN, and 30 controls were evaluated on subjective numbness and dysesthesia and with a systematic protocol of quantitative sensory testing for thermal evaluation (cold and warm), mechanical detection (touch and pinpricks for mechanical pain), superficial pain thresholds, and corneal reflex. We found that PIFP and TTN had numbness and dysesthesia higher than controls (p<0.001 and p=0.003), and that in both of them mechanical pain by pinpricks detection was abnormal intra and extra orally at the mandibular branch (p<0.001). Cold, warm, and tactile detections and pain thresholds were similar among the groups. Corneal reflex was abnormal in TTN (p=0.005). This study supports neuropathic mechanisms involving pain processing in PIFP and that the criterion on absence of sensorial variations in PIFP should be revised.

High prevalence of orofacial complaints in patients with fibromyalgia: a case-control study.

OBJECTIVE: The aim of this study was to investigate the orofacial complaints and characteristics of patients with fibromyalgia syndrome (FS) compared with controls. STUDY DESIGN: We evaluated 25 patients diagnosed with FS compared with 25 gender- and age-matched controls by using a detailed clinical protocol for orofacial pain diagnosis and dental examination. RESULTS: FS patients had a higher frequency of temporomandibular disorders (TMD), masticatory complaints, pain with mandibular movements, and pain upon palpation of the head and neck area. There were no significant differences related to the dental exam. CONCLUSIONS: Orofacial complaints including TMD may be present either as symptoms of FS or as a comorbidity associated with this condition. A comprehensive evaluation of patients with FS is necessary to identify the need for specific treatments for orofacial complaints. Future studies, especially those with longitudinal design, should clarify whether a cause-effect relationship exists between orofacial complaints and fibromyalgia.

Xerostomia and salivary flow in patients with orofacial pain compared with controls.

OBJECTIVES: Pain in the orofacial region is frequently reported by patients in dental and medical offices. Facial pain, headache, masticatory abnormalities and other complaints often become chronic and may be associated with local disturbances, such as xerostomia and teeth abnormalities. The objective of this study was to investigate salivary flow and xerostomia in patients with orofacial pain. DESIGN: This was a case-control study; we evaluated 82 patients with chronic orofacial pain compared with 56 healthy subjects using a Clinical Pain Questionnaire (pain characteristics, duration, intensity and descriptors), complete dental examination (including static and dynamic evaluation of the jaw) and a Xerostomia Inventory. The salivary flow was quantitatively evaluated. Data was compared through Pearson's chi-square, Fisher's exact, analysis of variance (ANOVA) 1 factor and Mann-Whitney tests. RESULTS: Patients often had temporomandibular disorder (TMD) (P=0.001) and pain during facial (P<0.001) and neck palpation (P=0.002). There were no differences in dental examination or other structural aspects of the jaw between the groups. There were more complaints associated with xerostomia in the study group, including burning sensation in the oral mucosa (P=0.003), in the throat (P=0.035) and in the stomach (P=0.050). Patients had lower salivary flow (P=0.008). CONCLUSIONS: Orofacial pain patients need to be evaluated with regard to their salivary function, which was often found abnormal in this sample and may have contributed to the complaints of these patients. Assessing salivary flow and xerostomia may help in the treatment of chronic orofacial pain.

Trigeminal pain and quantitative sensory testing in painful peripheral diabetic neuropathy.

OBJECTIVE: To evaluate patients with Diabetes Mellitus type 2 and painful peripheral neuropathy in order to investigate oral complaints and facial somatosensory findings. RESEARCH DESIGN AND METHODS: Case-control study; 29 patients (12 women, mean age 57.86 yo) with Diabetes Mellitus type 2 and 31 age-gender-matched controls were evaluated with a standardized protocol for general characteristics, orofacial pain, research diagnostic criteria for temporomandibular disorders, visual analogue scale and McGill Pain questionnaire, and a systematic protocol of quantitative sensory testing for bilateral facial sensitivity at the areas innervated by the trigeminal branches, which included the thermal detection by ThermoSensi 2, tactile evaluation with vonFrey filaments, and superficial pain thresholds with a superficial algometer (Micromar). Statistical analysis was performed with Wilcoxon, chi-square, confidence intervals and Spearman (p<0.05). RESULTS: Orofacial pain was reported by 55.2% of patients, and the most common descriptor was fatigue (50%); 17.2% had burning mouth. Myofascial temporomandibular disorders were diagnosed in 9 (31%) patients. The study group showed higher sensory thresholds of pain at the right maxillary branch (p=0.017) but sensorial differences were not associated with pain (p=0.608). Glycemia and HbA(1c) were positively correlated with the quantitative sensory testing results of pain (p<0.05) and cold (p=0.044) perceptions. Higher pain thresholds were correlated with higher glycemia and glycated hemoglobin (p=0.027 and p=0.026). CONCLUSIONS: There was a high prevalence of orofacial pain and burning mouth was the most common complaint. The association of loss of pain sensation and higher glycemia and glycated hemoglobin can be of clinical use for the follow-up of DM complications.

Clinical characteristics of patients with trigeminal neuralgia referred to neurosurgery.

OBJECTIVES: To investigate the clinical characteristics of patients with trigeminal neuralgia referred to surgery in a center of reference. METHODS: We evaluated the general characteristics of 395 patients with trigeminal neuralgia referred to neurosurgery as treatment. They corresponded to 2 samples of 1984 and 2004. The EDOF-HC protocol (Orofacial Pain Questionnaire) and the medical profile were used. RESULTS: In the first study (1984), with 290 patients, the higher prevalence was: women (57.3%), white (95.5%), with mean age of 62.5. The most affected trigeminal branches were the maxillary and/or mandibular branches (65.5%), and the right side was the most affected (57.6%). From the second study (2004), with 105 patients, 57.1% were women, 75.2% white, with a mean age of 60.8. The maxillary and/or mandibular branches (79.0%) and the right side (69.5%) were the most affected. Both samples had neurological abnormalities and systemic diseases (mainly cardiovascular). CONCLUSIONS: General characteristics of these patients were similar to other samples of trigeminal neuralgia. Neurological findings were also present in patients with no previous surgical treatment for TN. Hypertension and cardiac diseases were also frequent and make the monitoring of the patients during crises necessary.

Quantitative sensory testing in trigeminal traumatic neuropathic pain and persistent idiopathic facial pain / Teste sensitivo quantitativo em dor neuropática trigeminal pós-traumática e dor facial idiopática persistente

The objective of this article was to investigate, with a systematic protocol of quantitative sensory testing, patients with persistent idiopathic facial pain (PIFP) and others with trigeminal traumatic neuropathic pain (TTN) compared to controls. Thirty patients with PIFP, 19 with TTN, and 30 controls were evaluated on subjective numbness and dysesthesia and with a systematic protocol of quantitative sensory testing for thermal evaluation (cold and warm), mechanical detection (touch and pinpricks for mechanical pain), superficial pain thresholds, and corneal reflex. We found that PIFP and TTN had numbness and dysesthesia higher than controls (p<0.001 and p=0.003), and that in both of them mechanical pain by pinpricks detection was abnormal intra and extra orally at the mandibular branch (p<0.001). Cold, warm, and tactile detections and pain thresholds were similar among the groups. Corneal reflex was abnormal in TTN (p=0.005). This study supports neuropathic mechanisms involving pain processing in PIFP and that the criterion on absence of sensorial variations in PIFP should be revised.

O objetivo deste artigo foi investigar, com um protocolo sistemático de testes sensitivos quantitativos, pacientes com dor facial idiopática persistente (DFIP) e outros com dor neuropática trigeminal traumática (DNTT) comparado aos controles. Trinta pacientes com DFIP, 19 com DNTT e 30 controles foram avaliados quanto à dormência e à disestesia subjetiva e por meio de um protocolo sistemático de testes sensitivos quantitativos, que incluiu avaliação térmica (frio e quente), detecção mecânica (táctil e alfinetes), limites de dor superficial e reflexo córneo-palpebral. Foi observado que os pacientes apresentaram mais dormência e disestesia do que os controles (p<0,001 e p=0,003), além de mais anormalidades intra e extraorais no ramo mandibular (p<0,001). As alterações de calor, frio, dor e tato foram semelhantes entre os grupos. O reflexo córneo-palpebral foi anormal somente no grupo com DNTT (p=0,005). Este estudo suporta mecanismos de dor neuropática envolvidos no processamento da DFIP, e o critério de ausência de variações sensoriais nesta deve ser revisto.