Unveiling denture-induced oral lesions: A comprehensive study on classification and pain assessment.

BACKGROUND: Denture-induced oral Lesions (DIOLs) often manifests shortly after the placement or adjustment of new or realigned dentures, frequently resulting in severe pain and discomfort. OBJECTIVES: This study aimed to classify DIOLs placing a particular emphasis on assessing the associated pain. METHODS: A prospective case study was conducted involving 126 patients who were fitted with a total of 193 dentures of various types at the Hadassah School of Dental Medicine. All patients underwent comprehensive intra-oral examinations within 1-8 weeks following denture delivery, completed symptom questionnaires and had their medical records reviewed. Key variables documented included age, gender, overall health status, denture type, and a detailed description of the DIOLs. The description encompassed factors such as lesion location, shape, colour, size, border characteristics, ulcerative appearance, membrane coverage, 3D morphology (elevated, immersed and flat) and patient-reported Verbal Pain Score (VPS) when touching the DIOLs, when wearing the denture, and when not wearing the denture. RESULTS: Notably, 25.4% of denture wearers required no adjustments, while 14.4% necessitated more than three revisions. A majority (71.8%) of DIOLs cases were associated with mandibular complete dentures, primarily situated on the alveolar ridge. The mean VPS indicated a pain intensity of 7 ± 2.1, with temporary dentures in both jaws causing the most discomfort. Implant-supported overdentures were particularly painful when placed in the mandible. Additionally, VPS scores were higher among older individuals and those with prior prosthetic experiences. A significant correlation was observed between pain intensity and presence of chronic health condition (0.036). CONCLUSIONS: This study revealed distinct characteristics of DIOLs and highlighted the multifactorial nature of pain experienced following the development of DIOLs. Insights into the influence of patient and denture characteristics on DIOLs and pain intensity can guide healthcare professionals in optimising patient comfort and satisfaction.

Tic, Triggering, and Tearing: From CTN to SUNHA.

PREMISE: Classical trigeminal neuralgia (CTN) and the short-lasting unilateral neuralgiform headache attacks (SUNHA) are clinically similar. PROBLEM: The SUNHAs include short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA). Shared clinical signs with CTN include severe, unilateral trigeminal pain that is often triggered by innocuous stimuli and accompanied by a dull persistent background pain. Recent reports on trigeminal neuralgia cases with atypical features such as autonomic signs and prolonged attack duration further blur the clinical distinction between CTN and SUNHAs. POTENTIAL SOLUTIONS: Are the similarities greater than their differences? If so, this may reflect a spectrum of disease ranging from typical CTN attacks to typical SUNHAs with a mixed phenotype in the middle. In this review they will summarize the overlap between these entities and contrast the pathophysiology and treatment approach.

An update of management of insomnia in patients with chronic orofacial pain.

In this review, we discuss the management of chronic orofacial pain (COFP) patients with insomnia. Diagnostic work-up and follow-up routines of COFP patients should include assessment of sleep problems. Management is based on a multidisciplinary approach, addressing the factors that modulate the pain experience as well as insomnia and including both non-pharmacological and pharmacological modalities. Parallel to treatment, patients should receive therapy for comorbid medical and psychiatric disorders, and possible substance abuse that may be that may trigger or worsen the COFP and/or their insomnia. Insomnia treatment should begin with non-pharmacological therapy, to minimize potential side effects, drug interactions, and risk of substance abuse associated with pharmacological therapy. Behavioral therapies for insomnia include the following: sleep hygiene, cognitive behavioral therapy for insomnia, multicomponent behavioral therapy or brief behavioral therapy for insomnia, relaxation strategies, stimulus control, and sleep restriction. Approved U.S. Food and Drug Administration medications to treat insomnia include the following: benzodiazepines (estazolam, flurazepam, temazepam, triazolam, and quazepam), non-benzodiazepine hypnotics (eszopiclone, zaleplon, zolpidem), the melatonin receptor agonist ramelteon, the antidepressant doxepin, and the orexin receptor antagonist suvorexant. Chronic orofacial pain can greatly improve following treatment of the underlying insomnia, and therefore, re-evaluation of COFP is advised after 1 month of treatment.

Assessment of interfering factors in non-adherence to oral appliance therapy in severe sleep apnea.

OBJECTIVE: Oral appliances (OA) are recommended for patients with severe obstructive sleep apnea who fail to comply with continuous positive airway pressure (CPAP) therapy. This mixed-methods study aimed to quantify adherence to OA therapy and evaluate subjective reasons associated with non-adherence. MATERIALS AND METHODS: The medical records of 52 patients with an apnea-hypopnea index (AHI) ≥ 40, treated with OA after discontinuation of CPAP treatment, were examined for OA adherence. Patients were divided according to usage at the time of a phone interview. The USER group included all forms of usage, whereas those who completely ceased using the OA were in the NUSE group. The timing of the phone interview was from five months to six years (average 44.63 ± 17.17 months) after OA delivery. RESULTS: The overall adherence rate was 57.7% (30/52 patients). The mean usage times were 10.07 ± 8.96 and 44.30 ± 17.3 months in the NUSE and NUSE groups, respectively. The main factors associated with non-adherence were concerns about the effects of the OA on teeth (22%) and insufficient efficacy (22%). Other factors were discomfort (15%) and improved well-being following weight loss (15%). The overall number of interfering and discontinuity factors was significantly higher in the NUSE group than in the USER group (P = 0.041). Nine (17.3%) of 52 patients resumed CPAP use. Subjective and objective outcomes, determined by using a second sleep test with OA in 69.2% of patients, were related to the continuation of treatment. CONCLUSIONS: On-adherence to OA is strongly associated with patient reservations regarding the effects of the device on teeth, possible lack of efficacy, and discomfort. Clinicians should closely monitor adherence patterns and assess potential interfering factors during their diagnostic workup. Patients should be reassured regarding device safety, particularly following dental work that may interfere with the insertion of the OA.

Trigeminal neuralgia (part I): Revisiting the clinical phenotype.

AIMS: We conducted a cross-sectional study to re-examine the clinical profile of patients with a clinical diagnosis of classical trigeminal neuralgia (CTN). METHODS: Inclusion criteria consisted of the International Headache Society's published classification of CTN. For the specific purposes of the study, features such as autonomic signs, persistent background pain, attack durations of >2 minutes and reports of pain-related awakening were included. The demographic and clinical phenotype of each patient were carefully recorded for analysis. RESULTS: The study cohort consisted of 81 patients and based on reported attack duration these were divided into short (≤ 2 minutes, n = 61) and long (> 2 minutes, n = 20) groups for further analysis. The group with short attack duration neatly fit most of the criteria for CTN while the long attack group presents a more challenging diagnosis. There were no significant differences in pain severity, quality and location between the short and long attack groups. The frequency of persistent background pain was significantly higher in the long (70%) compared to the short attack group (29.5%, p = 0.001). There were significantly more reports of pain-related awakenings in the long (55%) than in the short attack groups (29.5%, p = 0.04). There were no significant differences in the frequency of autonomic signs between the short (21.3%) and long attack groups (40%, p = 0.1). In the short attack group, the presence of autonomic signs was significantly associated with longer disease duration, increased pain-related awakenings, and a reduced prognosis. CONCLUSION: There are clear diagnostic criteria for CTN but often patients present with features, such as long pain attacks, that challenge such accepted criteria. In our cohort the clinical phenotype of trigeminal, neuralgiform pain with or without autonomic signs and background pain was observed across both short and long attack groups and the clinical implications of this are discussed.

Trigeminal neuralgia (part II): Factors affecting early pharmacotherapeutic outcome.

AIMS: We conducted a cohort study to examine demographic and clinical features associated with the pharmacotherapeutic outcome in classical trigeminal neuralgia (CTN) patients. METHODS: Patients with a clinical profile indicating a diagnosis of CTN, as per the International Headache Society's published classification, were enrolled prospectively. Demographic and pain-related characteristics were carefully collected. For the purposes of the study, patients with features such as autonomic signs and longer attack duration were included. All patients were then initiated on a standardised and accepted stepped pharmacotherapeutic protocol for the management of CTN. Initial pain scores and prospectively collected pain scores from pain diaries were used to assess the treatment outcome, with a ≥50% reduction considered significant. RESULTS: A total of 86 patients were seen, of whom five had an underlying disorder that could account for the pain. The study cohort therefore consisted of 81 patients, and based on attack duration these were divided into short (≤2 minutes, n = 61) and long (>2 minutes, n = 20) groups, for further analysis. The features of these patients and a discussion on the differential diagnosis have been presented in part 1 of this report. Employing an accepted stepped pharmacotherapeutic protocol for the management of CTN, significant improvement was more frequent in the short (74%) than in the long attack group (50%, p = 0.05). In the short attack group there were statistically significant associations between a poor treatment response and longer disease duration, the presence of autonomic signs and atypical pain descriptors for pain quality (p < 0.05). CONCLUSION: This report supports previous findings that prolonged disease duration and autonomic signs are negative prognostic indicators. The present study now adds long attack duration as a further negative prognostic sign.

Lifestyle and dental attendance as predictors of oral health-related quality of life.

OBJECTIVES: To evaluate the impact of health-related behaviors and dental attendance on oral health-related quality of life (OHRQoL). METHODS: One hundred and ninety-two individuals presenting for dental treatment were included in a cross-sectional survey using a self-administered questionnaire that assessed demographics, smoking and alcohol consumption, physical activity habits, dental attendance, and dental pain utilizing a numeric rating scale (NRS). Results of the Oral Health Impact Profile (OHIP)-14 questionnaire were considered as the dependent variable. A conceptual hierarchical data analysis model from distal to proximal determinants of the median OHIP-14 total score was adopted. RESULTS: Analysis of the OHIP-14 domains and total score revealed several significant protector characteristics: younger age, academic education, no alcohol consumption, regular physical activity, fewer smoking pack years, routine dental attendance, and lower NRS scores. Routine dental attendance was related to lower NRS scores (P < 0.001) which in turn were associated with lower OHIP-14 scores (P = 0.018). Better health-related behaviors (P = 0.039) and routine dental attendance (P = 0.029) also correlated directly with lower OHIP-14 scores. CONCLUSIONS: Better health-related behaviors and routine dental attendance have a protective effect on OHRQoL. Clinicians should assess these behaviors during routine diagnostic workups. Global health authorities need to integrate oral and general health care and improve both OHrQoL and HrQoL.

The International Classification of Headache Disorders: accurate diagnosis of orofacial pain?

The aim was to apply diagnostic criteria, as published by the International Headache Society (IHS), to the diagnosis of orofacial pain. A total of 328 consecutive patients with orofacial pain were collected over a period of 2 years. The orofacial pain clinic routinely employs criteria published by the IHS, the American Academy of Orofacial Pain (AAOP) and the Research Diagnostic Criteria for Temporomandibular Disorders (RDCTMD). Employing IHS criteria, 184 patients were successfully diagnosed (56%), including 34 with persistent idiopathic facial pain. In the remaining 144 we applied AAOP/RDCTMD criteria and diagnosed 120 as masticatory myofascial pain (MMP) resulting in a diagnostic efficiency of 92.7% (304/328) when applying the three classifications (IHS, AAOP, RDCTMD). Employing further published criteria, 23 patients were diagnosed as neurovascular orofacial pain (NVOP, facial migraine) and one as a neuropathy secondary to connective tissue disease. All the patients were therefore allocated to predefined diagnoses. MMP is clearly defined by AAOP and the RDCTMD. However, NVOP is not defined by any of the above classification systems. The features of MMP and NVOP are presented and analysed with calculations for positive (PPV) and negative predictive values (NPV). In MMP the combination of facial pain aggravated by jaw movement, and the presence of three or more tender muscles resulted in a PPV = 0.82 and a NPV = 0.86. For NVOP the combination of facial pain, throbbing quality, autonomic and/or systemic features and attack duration of > 60 min gave a PPV = 0.71 and a NPV = 0.95. Expansion of the IHS system is needed so as to integrate more orofacial pain syndromes.

Primary vascular-type craniofacial pain.

Primary vascular-type craniofacial pain comprises a group of pain disorders that share common diagnostic features. These are unilateral, episodic, pulsatile, severe pain. Accompanying phenomena include local autonomic (e.g., tearing, rhinorrhea) and systemic signs (e.g., nausea, photophobia). Primary vascular-type craniofacial pain includes migraine, cluster headache, and paroxysmal hemicrania. A new diagnostic entity, vascular orofacial pain, is suggested. Treatment of primary vascular-type craniofacial pain depends on its more specific diagnosis, and may be abortive or prophylactic. Diagnostic features, common pathophysiological mechanisms, and treatment modalities are discussed.

Odontalgia in vascular orofacial pain.

A case of episodic, spontaneous odontalgia, aggravated by ingestion of cold food, with no apparent dental pathology is presented. Attempts at alleviating the pain by means of root canal treatment had failed in previous, similar episodes, and pain and pulpal hyperalgesia had shifted to other locations. Primary vascular orofacial pain was diagnosed and effective control obtained by prophylactic treatment with propranolol, a beta-adrenergic blocker. A prophylactic attempt with nifedipine, a calcium channel blocker, failed to alleviate the pain. This diagnostic entity and possible therapeutic approaches are discussed.

[Ramsay Hunt syndrome--differential diagnosis, pathogenesis and therapy].

Ramsay Hunt syndrome is caused by infection of the geniculate ganglion of the seventh cranial nerve by varicella-zoster virus. A case in an 82-year-old woman is described. She presented with oral lesions, right facial palsy and an eruption and pain in her right ear. Oral examination revealed small circumscribed erosions on the right anterior two-thirds of the tongue, with loss of taste. There were also lesions on her right palate. Early diagnosis and treatment are important as immediate treatment is more likely to prevent irreversible complications affecting the facial and other cranial nerves involved.

Craniofacial pain of myofascial origin: temporomandibular pain & tension-type headache.

Craniofacial pain of myofascial origin is a common chronic disorder. When the pain is unilateral and located periauricularly, masticatory myalgia is likely. Tension-type headache is usually bilateral and affects the upper part of the head. The possible interrelationship with generalized myofascial disorders are discussed. Practical approaches to history-taking, diagnosis, and treatment are suggested.

Paroxysmal hemicrania. Case studies and review of the literature.

Paroxysmal hemicrania is a vascular-type headache that is characterized by short bouts of severe unilateral pain in the area of the orbit and temple. A chronic and episodic form that has been described is similar to cluster headache and reflects a distinctive temporal pattern. Signs associated with paroxysmal hemicrania include ipsilateral conjunctival injection and tearing with nasal congestion and rhinorrhea. The condition's absolute response to indomethacin pharmacotherapy differentiates paroxysmal hemicrania from cluster headache. Typical symptoms usually make for a relatively straightforward diagnosis of paroxysmal hemicrania, but it may masquerade as pulpitic or temporomandibular-joint-related pain and may even herald systemic disease or malignancy. Paroxysmal hemicrania is a rare syndrome; 111 cases have been reported in the literature thus far. All of these cases have been reported by "headache specialists"; no cases of paroxysmal hemicrania were found in the dental literature. In this review, a relatively large series of seven new cases is reported; all seven were seen in an orofacial pain clinic.

Trigeminal neuralgic-type pain and vascular-type headache due to gustatory stimulus.

We present a case of facial pain associated with sweet stimulus. An immediate, electric-like, short, unilateral pain was evoked by strong sweet gustatory stimulation. This was followed 6 to 8 hours later by a bilateral severe headache associated with bilateral tearing, rhinorrhea, periorbital swelling, flushing, and photophobia that lasted up to 2 days. The immediate pain that was experimentally induced with 2.5 grams of sucrose placed on the tongue could be abolished with carbamazepine. However, carbamazepine did not prevent the headache complex that appeared 6 to 8 hours later. Conversely, a trial with indomethacin abolished the late-onset headache, but not the immediate neuralgic-type pain. The independent nature of these pains suggests different pathophysiological mechanisms which are discussed.

Trigeminal neuralgia with lacrimation or SUNCT syndrome?

An intimate relationship between trigeminal neuralgia (TN) and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome, based on similar clinical signs and symptoms and on cases demonstrating possible "transformation" from one entity to the other, has been widely accepted. We evaluated the presence of lacrimation in 22 consecutive cases that had been diagnosed as TN. Ipsilateral lacrimation was reported by 6 such cases (5M, 1F). These cases responded to antineuralgic therapy with concomitant resolution of lacrimation and were clinically very similar to TN. The differential diagnosis and the possibility of lacrimation in TN are discussed.

SUNCT syndrome: case report and literature review.

The case of a woman with short neuralgiform paroxysmal pain of 2 years duration is described. Pain attacks were always accompanied by ipsilateral lacrimation and conjunctival injection. Standard anti-neuralgic therapy, amitriptyline and indomethacin, failed to eliminate or reduce pain. At the end of a 30-month active period the patient seemed to have gone into remission. We believe this to be a case of short-lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), the first reported in the dental literature and the 24th in the general medical literature. The differential diagnosis of the case and relevant literature are discussed.

Neuropathic orofacial pain.

Neuropathic orofacial pain (NOP) is a challenging diagnostic problem. In some cases, symptomatology may be similar to that seen with dental pathology, resulting in unwarranted dental treatment. Rarely, NOP can herald serious disease or central tumors, and early diagnosis can be life-saving. The following review outlines the classification, clinical presentation, pathophysiology, and treatment of the more common NOP entities.

Orofacial pain with vascular-type features.

OBJECTIVE: To examine whether a classifiable primary vascular-type craniofacial pain subgroup exists that predominantly affects intraoral structures. STUDY DESIGN: Fifty-five patients were chosen prospectively according to the following inclusion criteria; periodic craniofacial pain that was unilateral, pulsatile, severe, and that may wake the patient from sleep. Accompanying phenomena could include local autonomic and/or systemic signs. Twenty-six cases could be further classified into one of the categories of vascular craniofacial pain. The remaining 29, all with predominantly intraoral pain, were not readily classifiable. RESULTS: Of the 29 patients 70% were women, with an average onset-age of 42.6 years. All reported severe, episodic pain that was usually unilateral and lasted minutes to hours. In all, 55% of patients had autonomic or systemic signs, 48% had pulsatile pain, and 35.4% of patients were awakened by the pain. CONCLUSION: Although clinical similarities were observed within these patients, further studies are needed to confirm vascular orofacial pain as a clear diagnostic category.