Differences in the Clinical Characteristics of Persistent Idiopathic Facial Pain (Atypical Odontalgia) Patients with or Without Neurovascular Compression of the Trigeminal Nerve.

BACKGROUND: Persistent idiopathic facial pain (PIFP) is the unexplained pain along the territory of the trigeminal nerve, including nonorganic tooth pain called atypical odontalgia (AO). Though PIFP is debilitating to patients' livelihood and well-being, its pathophysiology remains poorly understood. Although neurovascular compression (NVC) of the trigeminal nerve is known to be associated with trigeminal neuralgia (TN), the relationship between NVC and other orofacial pains has not been fully elucidated. METHODS: In this study, we investigated the differences in the characteristics of PIFP (primarily AO) patients in the presence or absence of NVC. A retrospective analysis was performed on data from 121 consecutive patients who had been diagnosed with unilateral PIFP according to the criteria of the International Classification of Headache Disorders (ICHD)-3 and underwent magnetic resonance imaging scans of the head. RESULTS: In the group without NVC, characteristic findings were significant for psychiatric morbidity, somatization, and pain disability, when compared with the group with NVC. Furthermore, the group without NVC exhibited significant headache, noncardiac chest pain, shortness of breath, and pain catastrophizing. CONCLUSIONS: These results suggest that PIFP patients can be divided into two groups: one consistent with a neuropathic pain phenotype when NVC is present and a functional somatic symptom phenotype when presenting without NVC. Our findings may enable a more precise understanding of pathophysiology of PIFP and lead to better treatment strategies.

The effects of levetiracetam, sumatriptan, and caffeine in a rat model of trigeminal pain: interactions in 2-component combinations.

BACKGROUND: Levetiracetam is an antiepileptic drug with analgesic efficacy shown in pain models and small clinical trials. Sumatriptan is used in acute migraine treatment. Caffeine is widely consumed in some beverages/foods and is also an adjuvant in analgesic formulations. We examined the effects of systemic levetiracetam, sumatriptan, and caffeine and their interactions in 2-component combinations in the rat orofacial formalin test, a model of trigeminal pain. METHODS: Rats received a subcutaneous injection of formalin solution into the perinasal area, and the total time spent in nociceptive behavior (face rubbing) was quantified. The antinociceptive effect of drugs/drug combinations was assessed 1 hour after per os administration. The type of interaction between levetiracetam/sumatriptan and caffeine was examined by comparing the effects of a fixed, effective dose of levetiracetam/sumatriptan alone with the effects of the same dose applied with increasing, subeffective doses of caffeine. The type of interaction between levetiracetam and sumatriptan was determined by isobolographic analysis. RESULTS: Levetiracetam (1-50 mg/kg) and sumatriptan (0.5-5 mg/kg) produced significant and dose-dependent antinociceptive effects in both phases of the orofacial formalin test (P ≤ 0.001). Caffeine (7.5-100 mg/kg) produced significant antinociception in the second phase of the test (P = 0.04). Caffeine (1-7.5 mg/kg) significantly reduced the antinociceptive effects of levetiracetam (25 mg/kg) (first phase P = 0.002, second phase P < 0.001) and sumatriptan (2.5 mg/kg) (first phase P = 0.014, second phase P = 0.027); dose-dependent inhibition was observed in the second phase. Levetiracetam and sumatriptan exerted an additive interaction in the second phase of the orofacial formalin test. CONCLUSIONS: Results indicate that levetiracetam may be useful for treatment of pain in the trigeminal region. Dietary caffeine might decrease the effects of levetiracetam and sumatriptan; this needs to be considered in clinical settings. A levetiracetam-sumatriptan combination could also be useful in trigeminal pain treatment. Its efficacy and adverse effects should be examined clinically.

Pain Part 5b: Non-Odontogenic Dysfunctional Pain.

UNLABELLED: Orofacial chronic pain provides a significant challenge to all clinicians and the patients seeking treatment for it. Due to the anatomical and regional complexities, diagnosis can be extremely difficult, and due to the lack of cross specialty training, patients will undergo a variety of treatment under different disciplines. Dysfunctional pain provides a unique challenge for patient management and requires a multidisciplinary team. CLINICAL RELEVANCE: Lack of recognition of dysfunctional chronic pain can result in inappropriate dental treatment and further damage. to the patient. Appropriate patient reassurance and referral to an orofacial pain multidisciplinary team is recommended as most of these conditions require medical management.

The relationship between serum trace elements, vitamin B12, folic acid and clinical parameters in patients with myofascial pain syndrome.

BACKGROUND: Myofascial pain syndrome (MPS) is characterized by myofascial trigger points in a palpable taut band of skeletal muscle. OBJECTIVE: We aimed to investigate serum trace elements, vitamin B12, folic acid levels and their correlations with clinical findings and functional status in patients with MPS. METHODS: Thirty eight patients with at least one trigger point located on shoulder muscles, and at least 6 months duration, were included in this study. The demographic data, disease duration of patients were noted. Serum copper, zinc, magnesium and iron levels, vitamin B12 and folic acid levels were measured. Visual analogue scale (VAS) was implemented to estimate daily severity of pain. Pain pressure threshold of subjects and control groups were assessed by using Fischer's tissue compliancemeter. The Turkish version of the Beck Depression Inventory (BDI) was administered for the presence of any depressive disorder. RESULTS: The mean age of patients in MPS group and control group were 33.1 and 37.8 years respectively. Serum levels of zinc (p< 0.006) were significantly decreased in patients with MPS. VAS, total myalgic and BDI scores of patients were significantly higher than the control group (Respectively p< 0.000, p< 0.012, p< 0.000). Association between TMS and magnesium, vitamin B12 levels was found statistically significant. BDI score correlated significantly with the serum zinc level (r:-0.548, p< 0.001) and VAS in patients with MPS (r:0.641, p< 0.000). CONCLUSION: According to the results of this study, it was asserted that trace elements, vitamins may play an important role in the pathophysiology of MPS and psychological factors may also have additional effect.

[An abbreviated version of RDC/TMD]. / Eine Kurzversion der RDC/TMD.

BACKGROUND: The aim of this study was to develop a short diagnostic test for pain-related craniomandibular disorders (CMD) based on the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). MATERIAL AND METHOD: Participants included 1,177 CMD patients and 896 general population subjects who were examined according to the RDC/TMD. This new diagnostic short test consisted of a combination of the least amount of RDC/TMD items that distinguished between patients and subjects with a sensitivity of > or =70% and a specificity of > or =90%. The diagnostic test items were selected from all available RDC/TMD items using best subset logistic regression. RESULTS: The question about the presence of facial pain achieved a sensitivity of 96% and a specificity of 95%. The lower limits of the confidence interval for test accuracy measures exceeded the postulated thresholds specified for test development. Assuming a CMD pain prevalence of 10% in the general population this short test resulted in a positive predictive value of 80% and a negative predictive value of >99%. CONCLUSION: A single question about facial pain is a strong predictor for a pain-related CMD disorder and could provide an effective CMD short test.

An up-to-date view on persistent idiopathic facial pain.

Previously called atypical facial pain, persistent idiopathic facial pain (PIFP) is a common, but poorly defined entity. The cause of PIFP is unknown, but surgery or injury in the distribution of the trigeminal nerve could be reported as early event. Treatment is often unsatisfactory and quality research relating management of this condition is missing. Psychologi-cal distress is frequently observed in patients suffering from persistent idiopathic facial pain. The present review aims at presenting the available knowledge of this elusive orofacial pain condition.

Psychosocial profiles of painful TMD patients.

The aim of the present investigation is to test the null hypothesis that the presence of psychopathology in patients with temporomandibular disorders (TMD) is related to the presence of pain, independent of its location [(i.e. myofascial and/or temporomandibular joint (TMJ) pain]. Ninety-six (n = 96) patients affected by painful TMD underwent a clinical assessment in accordance with the research diagnostic criteria for TMD (RDC/TMD) guidelines and filled out the Symptoms Check List - Revised (SCL-90-R) instrument to investigate the presence of symptoms of psychopathology. Patients with myofascial pain, alone or combined with TMJ pain, endorsed the highest scores in all SCL-90-R scales and showed the highest percentage of abnormal values in the depression (DEP) and somatization (SOM) scales for the assessment of depressive and somatization symptoms. Nonetheless, anova revealed no significant differences between groups in any of the SCL-90-R scales, except than in the Positive Symptom Total Index (F = 3.463; P = 0.035), and the chi-squared test did not detect any significant differences between groups for the prevalence of abnormal scores in the DEP and SOM scales. The existence of a close association between pain and psychosocial disorders in TMD patients was supported by the present study. The null hypothesis is that no differences exist between patients with different painful TMD cannot be fully accepted for the presence of psychosocial disorders because of the trend evidencing higher SCL-90-R scores for myofascial pain patients, alone or combined with TMJ pain, with respect to TMJ pain alone.

Unexplained orofacial pain - is an early diagnosis possible?

Aim To identify distinct characteristics of unexplained orofacial pain that could be used by dental practitioners in making an early diagnosis.Methods Subjects reporting orofacial pain in a postal questionnaire-based cross-sectional survey were invited for clinical examination. The interviewer was blinded to the questionnaire responses of the subjects. A diagnosis was made following the examination and subjects were assigned into two groups: unexplained pain and dental pain. The questionnaire responses of subjects who had consulted a healthcare professional within these two groups were then compared with particular attention to demographics, orofacial pain characteristics, consultation behaviour and relationship with other unexplained syndromes.Results Subjects who had consulted for their pain and were assigned to the unexplained orofacial pain group were significantly (p <0.05) more likely to report the following characteristics: pain descriptors (nagging, aching, tingling), pain pattern (worse with stress), site (poorly localised), duration (persistent/chronic), high disability, multiple consultations and co-morbidities (teeth grinding, reporting of other unexplained syndromes).Conclusion This study has shown that unexplained orofacial pain has distinct characteristics that differentiate it from other common dental conditions. This provides a good evidence base which can reduce uncertainty among dental practitioners, allowing them to make an early diagnosis.

The relationship between clinical parameters and depression level in patients with myofascial pain syndrome.

OBJECTIVE: Several studies and reviews have documented the high degree of comorbidity between depression and chronic pain. It was reported that chronic muscle pain is frequently accompanied by symptoms of depression. The purpose of this study was then to investigate the prevalence of major depression in chronic pain patients (CPP) with myofascial pain syndrome (MPS) and to investigate the relationship between some clinical parameters and level of depression, utilizing a healthy control group without MPS. DESIGN/SETTING/PATIENTS: The study group consisted of 77 MPS patients (65 female, 12 male) and 72 healthy volunteers (60 female, 12 male). The diagnosis of MPS was based on clinical characteristics, examination findings, and ruling out other diagnoses. Major depressive disorder was diagnosed by a psychiatrist utilizing DSM-IV criteria. Levels of depression were obtained from the Beck Depression Inventory (BDI). RESULTS: There was no significant difference between MPS patients and controls with respect to age and gender (P > 0.05). The mean age of the patients was 31.1 years (SD 9.8) and the mean age of controls was 29.7 years (SD 7.1). Major depression was more frequently found in CPPs with MPS (P < 0.001). BDI scores were higher in the MPS group than in controls (P < 0.001). There was a significant correlation between the severity of pain and depression level in patients with MPS (r = 0.654, P < 0.001). CONCLUSION: Major depression is found in MPS CPPs at a rate previously noted in the literature in mixed diagnoses CPPs. In addition, the severity of the depression may be related to perceived pain severity.

Typical facial neuralgias.

Neuralgia denotes a sharp, shooting, lancinating pain that is momentary but characteristically recurs. It may be precipitated by touch to a sensitive area ("trigger zone"), or may occur spontaneously. Cranial neuralgias are commonly distinct in two groups: typical neuralgias and atypical facial pain. Unlike headache syndromes, which are mediated centrally, neuralgias are more characteristic of peripheral nerve localisation. Neuralgias may follow nerve trauma, herpes zoster infections or may arise spontaneously. The management of this group of painful conditions is complicated by the area of the body involved and the interaction of organic and psychological factors.

Can one predict the likely specific orofacial pain syndrome from a self-completed questionnaire?

To estimate the prevalence of orofacial pain (OFP) by specific diagnostic subgroups in the general population. Cross-sectional population study. General medical practice in South East Cheshire, UK. Participants of baseline investigation who completed the full postal questionnaire (1510, adjusted study participation rate 81%). Clinical examination was attended by 126 (43%) of all the participants who reported OFP in the questionnaire. These individuals were classified as musculoligamentous/soft tissue type, dentoalveolar or neurological/vascular. OFP duration, location, descriptors and statements on OFP were predictors of classification group. The estimated prevalence in the general population of musculoligamentous/soft tissue type of OFP was 7%, dentoalveolar 7% and neurological/vascular 6%. This study has derived a statistical model to classify participants with OFP into three broad groups (musculoligamentous/soft tissue, dentoalveolar and neurological/vascular) based on questionnaire information about OFP (OFP chronicity, location and verbal descriptors of pain). It is potentially useful in large population studies of OFP, where a clinical examination is not possible, however, further validation of its performance in large populations are necessary.

[Interviewing the patient--an "impossible" task]. / Die Anamneseerhebung--ein "unmögliches" Unterfangen.

A patient with atypical facial pain (conversion symptom) is presented, who had to suffer for more than 10 years, because physicians were unable to conduct a biopsychosocial interview. The characteristics of hard and soft data are mentioned. The significance of empathy for the data collection is stressed. The relationship between empathy and countertransference feelings is briefly discussed.

[Differential and common characteristics of patients with atypical facial pain and craniomandibular dysfunction]. / Differenzielle und gemeinsame Merkmale bei Patienten mit atypischem Gesichtsschmerz und kraniomandibularer Dysfunktion.

BACKGROUND: Craniomandibular disorders (CMD) and atypical facial pain (AFP) represent a clinical challenge. Whereas CMD patients respond to somatic approaches, somatization should be strictly avoided in AFP. The aim of this study was to establish prognostic criteria to identify an aggravated risk of a chronic course in CMD and AFP. METHOD: A total of 124 consecutive patients with CMD ( n=108) or AFP ( n=16) were examined by two interdisciplinary academic pain centers. Psychometric evaluation was conducted with standardized questionnaires (SCL-90R, STAXI, modified SBAS-IV). All patients were clinically assessed by a maxillofacial surgeon or specialized dentist. RESULTS: The following variables proved to be significant: age (risk for AFP vs CMD increased by 6% p.a.), decreased dysfunction index (13% higher risk for AFP vs CMD), and low scores concerning outwardly directed anger (12% higher risk for AFP vs CMD). There was no correlation between initial pain intensity and somatic parameters of disease as assessed by the standardized clinical examination. Low educational status proved to be the best predictor ( p<0.001) for patients presenting high initial pain with a marked discrepancy between somatic findings and subjective status. CONCLUSIONS: CMD patients differ from AFP patients regarding age, psychosocial isolation, outwardly directed anger, and a decreased dysfunction index. Additionally, initial pain intensity in patients presenting indistinct CMD/AFP can be considered as a valid predictor for a chronic course in pain.

Contributing factors to chronic myofascial pain: a case-control study.

This case-control study was designed to investigate the contributing factors for chronic masticatory myofascial pain (MFP). Eighty-three patients with MFP, selected from the dental clinics of the Jewish General and Montreal General Hospitals, Montreal, Canada, and 100 concurrent controls selected only at the first clinic, participated in this study. The association with MFP was evaluated for bruxism, head-neck trauma, psychological factors (symptom check list 90 revised questionnaire, SCL-90R) and sociodemographic characteristics by using unconditional logistic regression. Clenching-grinding was associated with chronic MFP in multiple models including anxiety (OR=8.48; 95% CI: 2.85; 25.25) and depression (OR=8.13; 95% CI: 2.76; 23.97). This association also remained for MFP, excluding all other temporomandibular disorders (TMD). Clenching-only (OR=2.54; 95% CI: 1.10; 5.87) and trauma (OR=2.10; 95% CI: 1.0; 4.50) were found to be associated with the chronic MFP, when the level of anxiety was adjusted in the model. No significant change was noted when the effects of clenching-only (2.76; 95% CI: 1.20; 6.35) and trauma (OR=2.08; 95% CI: 1.03; 4.40) were adjusted for depression. Clenching-only and clenching-grinding remained related to MFP regardless of patients being informed about these habits. A higher score of anxiety (OR=5.12; 95% CI: 1.36; 19.41) and depression (OR=3.51; 95% CI: 1.07; 11.54) were associated with MFP, as well as other psychological symptoms. In addition, female gender had almost three times the risk of chronic MFP than males when the model was also adjusted for psychological symptoms. Grinding-only, age, household income and education were not related with chronic MFP. Tooth clenching, trauma and female gender may contribute to MFP even when other psychological symptoms are similar between subjects.

Psychiatric perspectives on headache and facial pain.

For a subset of headache patients, an understanding of psychological antecedents and interpersonal difficulties is an important part of the headache evaluation. This subset includes patients with chronic headache, frequent headache, treatment-refractory headache, analgesic misuse problems, and serious compliance issues. Inadequate coping with stress is central to the persistence of headache in many such patients. Other patients present to the headache specialist but actually suffer from a serious comorbid psychiatric disorder, such as major depression, panic disorder, substance abuse, or personality disorder. For successful treatment of headache, it is important that these related problems be detected and either treated (as outlined here) or referred to a specialist for treatment.

Chronic facial pain: a multidisciplinary problem.

Atypical facial pain is an unrecognised and unhelpful diagnosis but one which describes chronic pains that do not fit the present classification system. Due to the site of the pain, patients may seek and, indeed, receive treatment from dental practitioners and specialists, but the pain is often unresponsive and may have more in common with unexplained medical symptoms affecting other areas of the body, than with other dental symptoms. This review suggests a need for a diagnostic category of "chronic facial pain", which demands a multidisciplinary approach to diagnosis and management.

The interdisciplinary approach to oral, facial and head pain.

BACKGROUND: Chronic oral, facial and head pain is a common clinical problem, and appropriate diagnosis and management are a challenge for health care professionals. Patients often will first seek the care of dentists because of the pain's localization in the oral cavity and surrounding structures. This article emphasizes the importance of establishing accurate diagnoses and conducting appropriate triage of the patient with complex orofacial pain. CASE DESCRIPTIONS: The authors present two case reports illustrating the complex nature of oral, facial and head pain, and the potential and actual pitfalls in management of this condition. These representative cases demonstrate how orofacial pain--which appears to be localized in the peripheral dental and oral structures--can have extremely complex etiologies involving other anatomical structures, the central nervous system and psychological factors. The reports point to the need for the expertise of a number of specialists in such cases. CLINICAL IMPLICATIONS: If the symptoms and clinical findings do not appear to be consistent with typical oral disease, or if standard treatments do not alleviate the pain, the dental clinician must consider other, more complex orofacial pain diagnoses. The dental professional should not hesitate to make referrals to key specialists or to members of an interdisciplinary team at a pain treatment center who have the expertise to appropriately diagnose and manage chronic oral, facial and head pain.