Orofacial Pain

A relatively common symptom. Sources of orofacial pain include caries, periodontitis, neuropathic, and musculoskeletal conditions. Symptoms of pain may represent different phases of acute or chronic conditions. Based on NHIS data from 1989, survey participants representing 39 million adults reported experiencing at least one of five orofacial pain symptoms in the past 6 months:
tooth pain, mouth sores, jaw joint pain, facial pain, burning mouth (Lipton et al., 1993).

http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf

 Orofacial pain is often divided into two categories.chronic and acute. The National Center for Health Statistics generally uses a cut off point of 3 months to distinguish between acute and chronic pain. Currently, there are no national data on orofacial pain for children. Data sources other than the 1989 NHIS include studies on a population of elderly adults (65+) living in 10 northern Florida counties (Riley et al., 1998); studies of adults 45 and older, also located in northern Florida (Gilbert et al., 1997); a survey of adults in Toronto (Locker & Grushka, 1987); and studies on temporomandibular joint disorder, or TMD, reviewed by LeResche (1997).

http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf

What types of orofacial pain do we see?

Community
Macfarlane et al 2004 n = 125 total 1510 Dental 33% ML/ soft tissue 39% Neuro/vasc 28%

Prevalence orofacial pain no TMJ

Sample, Author
UK Aggarwal 2005 UK, Macfarlane 2002 USA, Lipton 1993 Canada, Locker 1987 UK, Richards 1996 France, Munoz 1988

Sample

Type of pain

2299 Chronic facial pain 2504 Facial pain 45711 Facial pain 1014 Orofacial pain 997 Orofacial pain 1144 Head , face

Prevalence % 7
26 1.4 4.9 3.1 2.7

Prevalence TMJ pain in adults

Sample authors Finland Helkino 1974 USA Von Korff 1988 USA Lipton 1993 Size of sample 600 1016 42370 Type of pain Prevalence ranges % Face and jaw pain Muscle and joint pain Jaw pain 12-15 12 3.9-6.5

Japan Matuska 1996

672

TMJ, face pain

5.7-15.2

Prevalence of selected pain conditions by poverty status: US adults, 18 years and over
40

30

Percentage

20

10

0 Migraine Neck Pain Poor Near Poor Back Pain Not Poor Face/Jaw Pain

Adjusted for age

SOURCE: Lethbridge-Cejku M, Rose D, Vickerie J. Summary health statistics for US Adults: National Health Interview Survey, 2004. National Center for Health Statistics.Vital Health Stat 10 (228). Hyattsville, MD 2006

Chronic Orofacial pain

The cost of chronic pain is estimated to be about $80 billion per year, 40% associated with orofacial pain (Israel & Scrivani, 2000; Friction & Schiffman, 1995). The two most prevalent sources of chronic orofacial pain are temporomandibular joint disorder (TMD) and burning mouth syndrome.

http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf

Chronic Orofacial pain

TMD consists of jaw joint pain and dull facial pain in the temporomandibular joint and the muscles of mastication. Chronic TMD is estimated to affect from 3% to 12% of the U.S. population (Klausner, 1995). Burning mouth syndrome is characterized as a burning, tender, or annoying sensation in the mouth with no apparent mucosal lesion. In 1989, the prevalence of jaw joint pain, burning mouth, and dull facial pain in the U.S. population was 5.3%, 0.7%, and 1.5%, respectively.

http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf

http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf

http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf

Acute orofacial pain

Acute orofacial pain includes tooth pain and painful sores or irritations of the mouth. Tooth pain is often caused by dental caries but may also be due to periodontal disease. Tooth pain can interfere with work and social activities, promote anxiety, and result in economic costs.

Acute orofacial pain

Data from the 1989 NHIS Orofacial Pain Supplement indicate that the overall prevalence of tooth pain and of mouth sores in the United States was 13.6% and 8.4%, respectively. The prevalence of tooth pain was higher among adults 20 to 64 years of age than among those 65 and older, those with lower education, poorer people, and those who visited a dentist within the past 12 months. (Vargas et al. 2000 and Lipton et al. 1993)

http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf

http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf

http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf

OROFACIAL PAIN in CANADA

Prevalence of orofacial pain in a sample of adults in the USA during a 6-month period
(Lipton 1993)
Female
14 12 10 8 6 4 2 0 toothache oral sores jaw pain face/cheek burning mouth

Male

Percentage of oral facial pain among adults in USA and Canada (Goulet et al., 1995; Lipton et al., 1993; & Ripley et al., 2001)

20 15 10 5 0 Quebec USA USA

Female Male

14

8.8 4.4

9.6 6.2

Proportion of subjects with no, mild, moderate and severe jaw pain reporting sleep problems, difficulty in opening and joint clicking in Quebec (Goulet et al., 1995)
Difficulty in opening Joint clicking Sleep porblems

70 60 50 40 30 20 10 0 None Mild Moderate 1 4 13 7 14 20 16 24 32 27 31

59

Severe

OROFACIAL PAIN in Other studies

Pain
The subjects conscious perception of modulated nociceptive impulses that generate an unpleasant

sensory and emotional experience associated with

actual or potential tissue damage, or described in

terms of such damage

(IASP definition, 1994)

History and Description of Pain

Compliant Site of pain Pain intensity Quality of pain

What starts the pain

Duration of attack

When pain was first noted

When pain occurs

History Examination of Orofacial Pain

History Ex. of Orofacial Pain

1. Chief complaints
A. Location of pain B. Onset of pain Association with other factors Progression C. Characteristics of pain Quality of pain Behaviour of pain Temporal Frequency Duration Intensity Concomitant symptoms Flow of pain

History Ex. of Orofacial Pain

1. Chief complaints (cont.) D. Aggravating and alleviating factors Physical modalities Function and parafunction Sleep disturbances Medications Emotional stress

E. Past consultation and/or treatment F. Relationship to other complaints 2. Past medical history 3. Review of systems 4. Psychological assessment

Clinical Examination of Orofacial Pain

Clinical Examination
1. General examination E. Cervical evaluation A. Vital signs F. Balance and coordination Blood pressure 2. Muscle examination Pulse rate A. Pulpation Respiratory rate Pain and tenderness Temperature Trigger points and B. Cranial nerve evaluation pain referal C. Eye evaluation D. Ear evaluation

Clinical Examination
3. Masticatory evaluation C. Oral structures A. Range of mandibular Mucogingival tissues movement Teeth Measurement Periodontium Pain Occlusion B. Temoromandibular joint 4. Other diagnostic tests evaluation A. Imaging Pain B. Laboratory tests Dysfunction C. Psychologic provocation tests

The Erlanger/Gasser classification of nerve fibres (1939)

Type Function Avg. (m) 15 8 5 <3 3 1.0 Avg. C.V. (m/s) 70-120 30-70 15-30 12-30 3-15 0.5-2 A Primary muscle-spindle afferent, motor to skeletal muscles A Cutaneous touch and pressure afferents A Motor to muscle spindles A Cultaneous temperature and pain afferents B C Sympathetic pre-ganglionic Cutaneous pain afferents, sympathetic post-ganglionic(unmyelinated)

Characteristics of pulpal sensory fibres (Trowbridge and Kim, 1991)

Type Myelination Location of terminal Pain characteristics Stimulation threshold

Yes

Principally in region of Sharp, pricking Relatively low pulp-dentine junction Probably distributed throughout pulp Burning, aching, less bearable than A fibre sensations Relatively high, usually associated with tissue injury

No

Stress and Orofacial Pain

ENVIRONMENT
BEHAVIOUR NERVOUS SYSTEM HOMEOSTASIS

IMMUNE SYSTEM
ENDOCRINE SYSTEM

IL-1

STRESS
HIPPOCAMPUS
HYPOTHALAMUS

BRAIN

CRH

IMMUNE CELL ADRENAL GLAND ACTH PITUITARY

glucocorticoids

glucocorticoids

Signs and Symptoms of Stress

1. Physical Signs and Symptoms
2. Emotional Signs and Symptoms

3. Cognitive/Perceptual Signs and Symptoms

4. Behavioral Signs and Symptoms

1. Physical Signs and Symptoms of Stress

increased heart rate; pounding heart; elevated blood pressure; sweaty palms; tightness of the chest, neck, jaw and back muscles; headache; diarrhea; constipation; urinary hesitancy; trembling, twitching;

1. Physical Signs and Symptoms of Stress

stuttering and other speech difficulties; nausea; vomiting; sleep disturbances; fatigue; shallow breathing;
dryness of the mouth or throat; susceptibility to minor illness, cold hands, itching; being easily startled; chronic pain and dysponesis

2. Emotional Signs and Symptoms of Stress

irritability, angry outbursts, hostility, depression, jealously, restlessness, withdrawal, anxiousness, diminished initiative, feelings of unreality or overalertness, reduction of personal involvement with others, lack of interest, tendency to cry,

2. Emotional Signs and Symptoms of Stress

being critical of others, self-deprecation, nightmares, impatience, decreased perception of positive experience opportunities, narrowed focus, obsessive rumination, reduced self-esteem, insomnia, changes in eating habits and weakened positive emotional response reflexes

3. Cognitive/Perceptual Signs and Symptoms of Stress

forgetfulness, preoccupation, blocking, blurred vision, errors in judging distance, diminished or exaggerated fantasy life, reduced creativity, lack of concentration, diminished productivity, lack of attention to detail, orientation to the past,

3. Cognitive/Perceptual Signs and Symptoms of Stress

decreased psychomotor reactivity and coordination, attention deficit, disorganization of thought, negative self-esteem, diminished sense of meaning in life, lack of control/need for too much control, negative self-statements and negative evaluation of experiences

4. Behavioral Signs and Symptoms of Stress

increased smoking, aggressive behaviors (such as driving), increased alcohol or drug use, carelessness, under-eating, over-eating, withdrawal, listlessness,

4. Behavioral Signs and Symptoms of Stress

hostility, accident-proneness, nervous laughter, compulsive behavior and impatience

Memory

Psyche Limbic system

Sensory Arousal

Respiratory control Pituitary gland Sympathetic NS GI system

Adrenal cortex
Immune-Inflam response

Kidney

Adrenal medulla
Cardiovascular system

Adrenaline

Electrolyte water control

Metabolic and Haemostatic changes

Metabolism Haemostasis-fibrinolysis


Stress ACTH, GH, PRL, beta endorphine, ADH, insulin and glucagon ACTH --> cortisol --> NE --> E Stress stimulate sympathetic nervous system Cardiac Output, Stroke Volume, systolic Blood Pressure blood flow to muscle, skin blood glucose rate of blood coagulation

Cardiovascular responses
Increase Heart rate, Cardiac output, Blood pressure, muscle blood flow hypertension, obesity, high fat diet Stress --> cortisol or epihephine --> cholesterol --> coronary artery disease Arteriosclerosis Myocardial infarction Other

Gastrointestinal responses
, , diarrhea, fullness, nausea increase gastric acid, mobility --> peptic ulcer Respiratory responses Hyperventilation --> hypocapnea Cerebral vasoconstriction dizziness, confusion, paraesthesia, tetany Cooling --> trigger --> asthmatic attack

Immunological responses
Cortisol CMI cancer HMI allergy Metabolic haemostatic changes Lipolysis Insulin hyperglycemia DM Glucagon Adrenaline


Stress decrease saliva flow salivary flow + immune aerodontalgia RCT --> stress --> pain from blood pressure Experimental animal stress --> caries

NUG = stress


Clenching bruxism TMD , , , masseter muscle , TMD = stress Bad habit , , --> malocclusion Tongue thrusting Aphthous herpetic lesion Experimental animal (stress from noise) --> herpetic lesion

Sign and symptoms of depression

Fatigue Alcohol-substance abuse Pessimism ( ) Headache Anxiety Constipation () Phobias Crying episodes Irritability Vertigo Paresthesias Muscle aches Behavioral disturbances Marital problems Diarrhea Excessive perspiration Hyperventilation Blurred vision Dry or flushed skin Slurred speech Urinary tract disturbances Work inhibition, weakness

Thank you