Orofacial Pain: An Interprofessional Effort

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Dentistry is truly in a golden age. 

Technological advances coupled with a rapidly growing foundation of scientific knowledge have brought the field of dentistry to the forefront with regard to the provision of evidence-based care. 

Over the past several decades the general population has gained an increasing appreciation for the importance of quality oral health as a significant component of optimum overall health. Never in the history of dentistry have we enjoyed the demand for our services associated with the recognition that poor oral health is potentially associated with diabetes, cardiovascular disease, cerebral vascular accidents, and low birth weight babies.

We also are better able to blend the science with the art of dentistry. However, it must be appreciated that pain is the primary symptom for which patients seek medical or dental care. Coincidental to pain are cultural, economic, psychosocial and pathophysiological conditions that demand consideration as potential etiologic, influencing, or sustaining factors.  

Health care providers are obligated to ascertain an accurate diagnosis prior to the initiation of definitive treatment modalities. For the “pain patient,” this is best achieved by meticulous assessment incorporating a comprehensive history, detailed clinical examination and indicated additional diagnostic procedures and/or laboratory studies.

Since pain is a subjective experience for which there are no accurate objective measurements, patient-derived information regarding their pain experience is important to analyze. One must appreciate the various factors such as patient reporting style and clinician/patient biases that may negatively influence interpretation of diagnostic information.Additionally, the frequent occurrence of referred pain in the head and neck, sometimes associated with seemingly unrelated autonomic changes, may contribute to diagnostic confusion. Therefore, it is critical that those involved in the treatment of pain develop basic problem solving skills that heretofore have not been emphasized in primary medical or dental training.

One of the more common areas in the human body in which pain is experienced is in the head, face and neck region, as was elucidated by a study published by the University of North Carolina Pain Center - not Orofacial Pain Center - but Anesthesia Pain Center, in which they assessed the primary pain complaints of a successive group of patients seen there. They reported that the most common area in which pain was experienced with that population of individuals was the head, face, and neck. 

Another study published in the Journal of American Dental Association1 reported the data assimilated from a telephone survey of 45,711 U.S. households regarding pain in the craniofacial region. The study, which did not include headache as a choice, determined that the five most common orofacial pain conditions were: odontogenic pain/tooth ache; oral ulcerations, temporomandibular-related pain; facial pain; and, burning mouth. It must be kept in mind that accurate and complete diagnosis is critical to achieving optimal treatment/care outcomes.

We are fortunate to be practicing at a time in which there has been a rapid expansion of diagnostic and treatment capabilities as a result of the explosion of scientific knowledge. 

Physical medicine modalities and techniques for the management of musculoskeletal conditions provide invaluable adjuncts to patient care. Pharmacotherpeutics have made tremendous advances over the last several decades as we are better able to target specific pathology with target specific medications. Recognizing that many patients presenting with orofacial pain suffer from musculoskeletal conditions, physical medicine must be considered as a component of the management protocol. 

With an enhanced appreciation for the mind/body connection and potential impact for those suffering with pain, psychotherapeutics have been demonstrated to provide positive effects through relaxation training and cognitive behavioral therapy.  Importantly, the advent of dentistry's role and the expansion of dentistry's role in sleep medicine, sleep dentistry. 

Clearly, orofacial pain is not purely in the domain of dentistry but may require an interprofessional effort to include, but not limited to, otolaryngology, neurology, physical medicine, rheumatology, and recognizing the mind/body experience, psychology. 

It is important to recognize that while dentists may be the entry point for patients who are suffering from orofacial pain, orofacial pain is not discipline-specific. It is time for those in dentistry to appreciate the need to expand our knowledge in the areas of anatomy, physiology, neurology and psychology, so that we can best diagnose and develop individualized plans of care for those individuals who suffer from the wrath of orofacial pain.  We will have to wear many hats. 

Our responsibilities have dramatically expanded over the last several decades with the tremendous explosion of knowledge with regard to pain and its many ramifications.

Henry A. Gremillion, DDS, is the Dean at Louisiana State University School of Dentistry.To learn more about assessing and diagnosing facial pain conditions, visit this site. 

Reference

1. Lipton, JA,  Ship, JA,  Larach-Robinson, DJADA. 1993;124,(10):115-121.

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