Orofacial pain - an update on diagnosis and management

Multidisciplinary approach and the Self-Training Educative Pain Sensation (STEPS) model for managing orofacial complex regional pain syndrome

Orofacial complex regional pain syndrome (O-CRPS) presents a diagnostic challenge due to its overlap with other orofacial pain conditions. This case report highlights the value of a multidisciplinary approach in managing a patient with chronic and unexplained facial pain.This case report aims to illustrate: (1) the application of a multidisciplinary approach in diagnosing and managing O-CRPS within the Saudi healthcare system, and (2) the effectiveness of the Self-Training Educative Pain Sensation (STEPS) model in managing O-CRPS.

CASE DESCRIPTION

A woman in her early 20s presented with left-sided facial pain and motor/autonomic symptoms following a facial injury. Extensive evaluations by various specialists excluded underlying structural pathology. A diagnosis of O-CRPS was established based on Budapest criteria. The STEPS model was implemented for treatment.

INTERVENTION

The STEPS model, a four-component intervention (pain education, graded motor imagery, sensory exposure, facial muscle exercises), aimed to reduce allodynia, normalise motor control and restore important functional activities.

OUTCOMES

Initial pain medications were ineffective. The STEPS model intervention significantly improved pain, function and overall quality of life.This case report emphasises the importance of a multidisciplinary approach to diagnosing O-CRPS and the potential benefits of the STEPS model in managing this complex condition.

Enhancing orofacial pain relief: α-phellandrene complexed with hydroxypropyl-β-cyclodextrin mitigates orofacial nociception in rodents

Orofacial pain affects 10-15% of adults and can severely impact quality of life. Despite ongoing treatment challenges, monoterpene alpha-phellandrene (PHE) shows potential therapeutic benefits. This study aimed to develop and evaluate an inclusion complex of PHE with hydroxypropyl-beta-cyclodextrin (PHE-HPβCD) for treating orofacial pain. The PHE-HPβCD complex was created using physical mixing and characterized by differential scanning calorimetry (DSC) and high-performance liquid chromatography (HPLC) to determine encapsulation efficiency. The complex exhibited a 70.45% encapsulation efficiency. Male Swiss mice were used in models of orofacial pain induced by formalin, cinnamaldehyde, glutamate, and corneal nociception by hypertonic saline. Additionally, cytokine levels (TNF-α and IL-1β) were measured in the upper lip tissue of mice subjected to the formalin model. Both PHE and PHE-HPβCD showed significant antinociceptive effects at a 50 mg/kg dose during formalin-induced pain, reducing both neurogenic and inflammatory phases of pain. PHE-HPβCD also reduced TNF-α and IL-1β levels. For cinnamaldehyde and glutamate-induced nociception, both treatments reduced pain behavior, but only PHE-HPβCD decreased eye wipes in corneal nociception. These results suggest that PHE, especially in complexed form, alleviates orofacial pain by potentially modulating pain-related receptors (TRPA1 and TRPV1), mediators, like glutamate, and reducing pro-inflammatory cytokines. Further research is needed to explore the precise mechanisms of PHE in chronic orofacial pain models, but the study indicates promising avenues for new pain treatments.

Evaluating amitriptyline's role in chronic TMD management: a placebo-controlled trial

BACKGROUND

To assess the effectiveness of low-dose amitriptyline in reducing pain and improving oral health-related quality of life in individuals with chronic temporomandibular disorders (TMD) over a 2-month period, compared to placebo.

METHODS

Forty participants were randomly assigned to receive either 25 mg of amitriptyline or a placebo pill for 2 months. The primary outcome was pain intensity, measured using a visual analogue scale (VAS). The secondary outcome was the impact of pain on oral health-related quality of life, assessed by the Oral Health Impact Profile questionnaire (OHIP-14). Evaluations were conducted at baseline and after the 1st and 2nd months of treatment.

RESULTS

No statistically significant differences were observed between the treatment groups at baseline (p > 0.05). After 2 months of treatment participants in amitriptyline group experienced a significantly greater reduction in spontaneous pain, with a 63.3% decrease in VAS scores. Participants in placebo group showed a much smaller reduction in spontaneous pain, with only a 16.2% decrease in VAS scores. Additionally, the amitriptyline group demonstrated a significant improvement in OHIP-14 scores (p < 0.001), whereas the placebo group showed no significant change in oral health-related quality of life (p = 0.184).

CONCLUSION

This study highlights low-dose amitriptyline as an effective treatment for chronic TMD, showing significant pain reduction and improved quality of life, underscoring its value in a multimodal approach despite the need for further research to personalize care.

TRIAL REGISTRATION

This study was registered retrospectively in ISRCTNregistry under the number ISRCTN17622685, on 01/10/2024.

Biomarkers in orofacial pain conditions: A narrative review

Orofacial pain conditions, including temporomandibular disorder, migraine, dental pain, and trigeminal neuralgia, are complex, multifactorial disorders with significant impacts on patients' quality of life. As understanding of the pathophysiology of these conditions has deepened, the role of molecular and genetic biomarkers in diagnosing, monitoring, and potentially treating orofacial pain has garnered increasing interest. This scoping review provides a comprehensive overview of the current state of research on biomarkers associated with orofacial pain conditions. By analyzing existing literature, we identify key biomarkers linked to inflammation, neural activity, and tissue degradation that are common across multiple conditions, as well as those specific to particular disorders. Our findings underscore the potential of these biomarkers to guide the development of personalized therapeutic strategies. However, the review also highlights the challenges faced by current biomarker research, including heterogeneity in study designs, small sample sizes, and a lack of longitudinal data. Addressing these challenges is critical for translating biomarker research into clinical practice and improving outcomes for patients with orofacial pain.

Novel apocynin regulates TRPV1 activity in the trigeminal system and controls pain in a temporomandibular joint neurogenic model

OBJECTIVE

Herein, we investigate the potential analgesic effect of a newly synthesized chalcone-derived apocynin in a neurogenic pain model.

METHODS

Molecular docking was used to foretell the apocynin binding features and dynamics with the TRPV1 channel, and the activity was tested in vitro, using transfected HEK 293T cells with the rat TRPV1 receptor. The analgesic effect of apocynin was investigated using a capsaicin-induced pain model. The expression of TRPV1, TRPA1, TRPM8, and MAPKs was assessed by electrophoresis, and immunosorbent assays were performed to quantify the neurotransmitters Substance P, Glutamate, and CGRP. A survival assay using Galleria mellonella was carried out to determine the toxicity.

RESULTS

We observed that apocynin exhibits greater thermodynamic stability. Upon apocynin ligand binding, it changes the electrostatic potential for a predominantly electronegative state in the interior and neutral in its external vanilloid pocket. Treatment of apocynin induces antinociceptive effects against the noxious challenge of capsaicin. Histologically, apocynin decreased the number of TRPV1+ immunopositive cells. Electrophoresis showed reduced phosphorylation of p44/42 (ERK1/2) and decreased protein levels of substance P, and CGRP. In the survival assay, apocynin showed low toxicity.

CONCLUSIONS

In conclusion, we provide proof-of-principles that the newly synthesized apocynin compound effectively prevented nociception in a neurogenic model of orofacial pain.

Incidence, diagnosis, and management of orofacial pain among new patients receiving tertiary care in Thailand: A 6-year retrospective study comparing before and during the COVID-19 outbreak

BACKGROUND

There is insufficient data on orofacial pain related to the COVID-19 outbreak in Thailand.

OBJECTIVE

To investigate the incidence, diagnosis and management of orofacial pain among new patients over the last 6 years, before and during the COVID-19 outbreak.

METHODS

Medical records from new patients who first visited Chulalongkorn Dental Hospital between 2017 and 2022 were retrospectively investigated. The sample size was determined, and proportional stratified random sampling was employed to distribute the sample number proportionally across each year. The hospital number of each patient was randomised using online software as a sampling strategy. A data collection form was developed and used to gather information from the digital data system.

RESULTS

At the first visit, 770 out of 1359 patients (56.7/100 people, 95% CI: 54.0-59.3) reported orofacial pain defined as acute, chronic and unclassified pain. The most common chief complaints based on the AAOP classification were odontogenic pain (90.00%) and temporomandibular disorders (6.10%). The top three provisional modified ICD-10-TM diagnoses among these patients were pulp diseases (21.95%), impacted teeth (20.65%) and dental caries (9.09%). 81.87% of dental students' provisional diagnoses matched the final diagnoses given by dental specialists. Only 63.38% of orofacial pain patients were completely managed during the COVID-19 pandemic with common procedures being surgical removal, extraction and root canal therapy.

CONCLUSION

Half of Thai dental patients seeking tertiary care at a university dental hospital reported orofacial pain, which was not impacted by the COVID-19 pandemic. In contrast, dysfunction-related problems in the orofacial area significantly increased during the pandemic.

Modern Approaches to the Treatment of Acute Facial Pain

PURPOSE OF REVIEW

Acute facial pain presents a complex challenge in medical practice, requiring a comprehensive and interdisciplinary approach to its management. This narrative review explores the contemporary landscape of treating acute facial pain, delving into pharmacological, non-pharmacological, and advanced interventions. The significance of tailored treatment strategies, rooted in the diverse etiologies of facial pain, such as dental infections, trigeminal neuralgia, temporomandibular joint disorders, sinusitis, or neurological conditions like migraines or cluster headaches, is underscored. We particularly emphasize recent advances in treating trigeminal neuralgia, elucidating current treatment concepts in managing this particular acute facial pain.

RECENT FINDINGS

Recent research sheds light on various treatment modalities for acute facial pain. Pharmacotherapy ranges from traditional NSAIDs and analgesics to anticonvulsants and antidepressants. Non-pharmacological interventions, including physical therapy and psychological approaches, play pivotal roles. Advanced interventions, such as nerve blocks and surgical procedures, are considered in cases of treatment resistance. Moreover, we explore innovative technologies like neuromodulation techniques and personalized medicine, offering promising avenues for optimizing treatment outcomes in acute facial pain management. Modern management of acute facial pain requires a nuanced and patient-centric approach. Tailoring treatment strategies to the individual's underlying condition is paramount. While pharmacotherapy remains a cornerstone, the integration of non-pharmacological interventions is essential for comprehensive care. Advanced interventions should be reserved for cases where conservative measures prove inadequate. Furthermore, leveraging innovative technologies and personalized medicine holds promise for enhancing treatment efficacy. Ultimately, a holistic approach that considers the diverse needs of patients is crucial for effectively addressing acute facial pain.

Muscle oxygenation and pain in different types of temporomandibular disorders

OBJECTIVES

Studies exploring variations in peripheral muscle oxygenation and pressure pain thresholds (PPT) of masticatory muscles in individuals with Temporomandibular Disorders (TMDs) are limited. The purpose of this study was to compare variations in peripheral oxygenation of the masseter muscle; PPT of the masseter and temporal muscles and correlate peripheral muscle oxygenation and PPT of the masseter muscle in individuals with different types of TMDs.

MATERIALS AND METHODS

Cross-sectional study involving 116 participants classified into three groups: muscle group (MG, n = 32), joint group (JG, n = 30) and muscle-joint group (MJG, n = 54). Individuals aged 26.97 ± 6.93, 68.97% female, 31,03% males were included. All participants were evaluated using the Diagnostic Criteria for Temporomandibular Disorders, Near-infrared spectroscopy (NIRS) for peripheral muscle oxygenation and pressure algometer for PPT.

RESULTS

There was no difference in masseter muscle oxygenation among groups. In the masseter muscle, a weakly positive correlation was observed between PPT and variation in tissue saturation index in the MG (rho = 0.365) and JG (rho = 0.317). In addition, the MJG expressed lower PPT (p = 0.004) than JG, demonstrating that MJG had more pain in this muscle.

CONCLUSIONS

MJG have lower PPT in the masseter muscle. Although the PPT is dependent on the type of TMDs, the correlation between PPT and oxygenation is weak. All TMDs groups evaluated (MG, JG, MJG) showed hemodynamic similarities of the masseter muscle.

CLINICAL RELEVANCE

Understanding pain thresholds and the hemodynamic behavior of the masticatory muscles contributes to a more assertive physiotherapeutic assessment in TMDs, serving as a basis for careful and individualized interventions.

Somatic and temporomandibular disorder symptoms - Idioms of psychological distress in Southeast Asian youths

OBJECTIVE

To evaluate the prevalence/severity of somatic and temporomandibular disorder (TMD) symptoms in Southeast Asian youths and determine their associations with psychological distress.

METHODS

Demographic information, Patient Health Questionnaire-15 (PHQ-15), Fonseca Anamnestic Index (FAI), and Depression, Anxiety, Stress Scale-21 (DASS-21) responses were gathered electronically and analyzed using non-parametric statistical and logistic regression analysis (p < 0.05).

RESULTS

Of 400 youths (mean age 18.7 ± 1.7 years; 52.3% females), 65.0%/47.0% reported somatic/TMD symptoms, and 10.5% had TMDs. Significant differences in psychological distress were observed among the varying severity of somatic/TMD symptoms. Correlations between PHQ-15/FAI and DASS-21 scores were weak to moderately strong (rs = 0.30-0.61). Stepwise logistic regression indicated that female gender, TMD symptoms, and stress were risk factors for somatic symptoms, while somatic symptoms and stress were probable factors for TMDs.

CONCLUSION

Somatic and TMD symptoms are common in Southeast Asian youths and may be a manifestation of psychological distress.

Duloxetine improves chronic orofacial pain and comorbid depressive symptoms in association with reduction of serotonin transporter protein through upregulation of ubiquitinated serotonin transporter protein

ABSTRACT

Chronic orofacial pain (COP) is relieved by duloxetine (DLX) and frequently causes depressive symptoms. The aim of this study was to confirm effects of DLX on pain and depressive symptoms, and to associate with their effectiveness in platelet serotonin transporter (SERT) expression, which is a target molecule of DLX and plasma serotonin concentration in COP patients with depressive symptoms. We assessed for the severity of pain and depressive symptoms using the Visual Analog Scale (VAS) and 17-item Hamilton Depression Rating Scale (HDRS), respectively. Chronic orofacial pain patients were classified into 2 groups based on their HDRS before DLX-treatment: COP patients with (COP-D) and without (COP-ND) depressive symptoms. We found that the VAS and HDRS scores of both groups were significantly decreased after DLX treatment compared with those before DLX treatment. Upregulation of total SERT and downregulation of ubiquitinated SERT were observed before DLX treatment in both groups compared with healthy controls. After DLX treatment, there were no differences in total SERT of both groups and in ubiquitinated SERT of COP-D patients compared with healthy controls; whereas, ubiquitinated SERT of COP-ND patients remained downregulated. There were positive correlations between changes of serotonin concentrations and of VAS or HDRS scores in only COP-D patients. Our findings indicate that DLX improves not only pain but also comorbid depressive symptoms of COP-D patients. Duloxetine also reduces platelet SERT through upregulation of ubiquitinated SERT. As the result, decrease of plasma serotonin concentrations may be related to the efficacy of DLX in relieving pain and depression in COP patients.

A woman in her forties with ear pain

Background

A woman in her forties developed intermittent pain in her ear and pharynx which worsened when talking and swallowing. Multidisciplinary approach confirmed a rare diagnosis.

Case presentation

The patient reported left-sided ear fullness, followed by otalgia and burning pain in the palate. Numbness in the palate and nasal cavity, and soreness upon palpation of the external ear canal were noted upon examination. Magnetic resonance imaging (MRI) with contrast showed a vessel located in close proximity to the glossopharyngeal nerve on the left side. A diagnosis of glossopharyngeal neuralgia was made, and the patient was treated with antiepileptic medications without substantial effect. Microvascular decompression of the glossopharyngeal nerve was therefore performed. A large vein located along the glossopharyngeal nerve was separated and fixated away from the nerve. The patient reported pain alleviation after the operation, which has continued to improve on follow-ups.

Interpretation

Glossopharyngeal neuralgia is a rare condition characterised by intermittent, unilateral pain in the base of the tongue, oropharynx, and/or angle of the mandible which radiates to the ipsilateral ear. The condition should be treated medically, but open surgical treatment should be considered in refractory cases. Early diagnosis and treatment are essential.

Naringenin modulates GABA mediated response in a sexdependent manner in substantia gelatinosa neurons of trigeminal subnucleus caudalis in immature mice

The substantia gelatinosa (SG) within the trigeminal subnucleus caudalis (Vc) is recognized as a pivotal site of integrating and modulating afferent fibers carrying orofacial nociceptive information. Although naringenin (4',5,7-thrihydroxyflavanone), a natural bioflavonoid, has been proven to possess various biological effects in the central nervous system (CNS), the activity of naringenin at the orofacial nociceptive site has not been reported yet. In this study, we explored the influence of naringenin on GABA response in SG neurons of Vc using whole-cell patch-clamp technique. The application of GABA in a bath induced two forms of GABA responses: slow and fast. Naringenin enhanced both amplitude and area under curve (AUC) of GABA-mediated responses in 57% (12/21) of tested neurons while decreasing both parameters in 33% (7/21) of neurons. The enhancing or suppressing effect of naringenin on GABA response have been observed, with enhancement occurring when the GABA response was slow, and suppression when it was fast. Furthermore, both the enhancement of slower GABA responses and the suppression of faster GABA responses by naringenin were concentration dependent. Interestingly, the nature of GABA response was also found to be sex-dependent. A majority of SG neurons from juvenile female mice exhibited slower GABA responses, whereas those from juvenile males predominantly displayed faster GABA responses. Taken together, this study indicates that naringenin plays a partial role in modulating orofacial nociception and may hold promise as a therapeutic target for treating orofacial pain, with effects that vary according to sex.

Advancements in Understanding and Classifying Chronic Orofacial Pain: Key Insights from Biopsychosocial Models and International Classifications (ICHD-3, ICD-11, ICOP)

In exploring chronic orofacial pain (COFP), this review highlights its global impact on life quality and critiques current diagnostic systems, including the ICD-11, ICOP, and ICHD-3, for their limitations in addressing COFP's complexity. Firstly, this study outlines the global burden of chronic pain and the importance of distinguishing between different pain types for effective treatment. It then delves into the specific challenges of diagnosing COFP, emphasizing the need for a more nuanced approach that incorporates the biopsychosocial model. This review critically examines existing classification systems, highlighting their limitations in fully capturing COFP's multifaceted nature. It advocates for the integration of these systems with the DSM-5's Somatic Symptom Disorder code, proposing a unified, multidisciplinary diagnostic approach. This recommendation aims to improve chronic pain coding standardization and acknowledge the complex interplay of biological, psychological, and social factors in COFP. In conclusion, here, we highlight the need for a comprehensive, universally applicable classification system for COFP. Such a system would enable accurate diagnosis, streamline treatment strategies, and enhance communication among healthcare professionals. This advancement holds potential for significant contributions to research and patient care in this challenging field, offering a broader perspective for scientists across disciplines.

Assessing thickness and stiffness of superficial/deep masticatory muscles in orofacial pain: an ultrasound and shear wave elastography study

INTRODUCTION

Sonoelastography has been increasingly used for non-invasive evaluation of the mechanical features of human tissues. The interplay between orofacial pain and regional muscle activity appears clinically paramount, although only few imaging studies have investigated this association. Using shear wave sonoelastography (SWS), this study ascertained whether orofacial pain induced alterations in the stiffness of superficial and deep masticatory muscles.

METHODS

All participants were systematically evaluated for oral/facial-related conditions, including the area and intensity of pain. SWS was applied to measure the stiffness of the bilateral masseter, temporalis, and lateral pterygoid muscles. The association between orofacial pain and muscle stiffness/thickness was investigated using a generalized estimating equation for adjusting the influence of age, sex, laterality, and body mass index on muscle thickness/stiffness.

RESULTS

A total of 98 participants were included in the present study: 48 asymptomatic controls, 13 patients with unilateral pain, and 37 patients with bilateral orofacial pain. The reliability, quantified by the intraclass correlation coefficient for muscle stiffness measurement, ranged from 0.745 to 0.893. Orofacial pain at the individual muscle level was significantly associated with masseter muscle stiffness. A trend of increased stiffness (p = 0.06) was also observed in relation to the painful side of the temporalis muscle. No significant correlation was identified between the numeric rating scales for pain and stiffness measurements.

CONCLUSIONS

SWS provides reliable stiffness measurements for the superficial and deep masticatory muscles. The ipsilateral masseter and temporalis muscles might be stiffer than those on the side without orofacial pain. Future studies using the present sonoelasotography protocol can be designed to investigate the stiffness changes in the target muscles after interventions.

Sex-dependent differences in the genomic profile of lingual sensory neurons in naïve and tongue-tumor bearing mice

Mechanisms of sex-dependent orofacial pain are widely understudied. A significant gap in knowledge exists about comprehensive regulation of tissue-specific trigeminal sensory neurons in diseased state of both sexes. Using RNA sequencing of FACS sorted retro-labeled sensory neurons innervating tongue tissue, we determined changes in transcriptomic profiles in males and female mice under naïve as well as tongue-tumor bearing conditions Our data revealed the following interesting findings: (1) FACS sorting obtained higher number of neurons from female trigeminal ganglia (TG) compared to males; (2) Naïve female neurons innervating the tongue expressed immune cell markers such as Csf1R, C1qa and others, that weren't expressed in males. This was validated by Immunohistochemistry. (3) Accordingly, immune cell markers such as Csf1 exclusively sensitized TRPV1 responses in female TG neurons. (4) Male neurons were more tightly regulated than female neurons upon tumor growth and very few differentially expressed genes (DEGs) overlapped between the sexes, (5) Male DEGs contained higher number of transcription factors whereas female DEGs contained higher number of enzymes, cytokines and chemokines. Collectively, this is the first study to characterize the effect of sex as well as of tongue-tumor on global gene expression, pathways and molecular function of tongue-innervating sensory neurons.

Lingual innervation in male and female marmosets

Several gaps in knowledge exists in our understanding of orofacial pain. Some of these include type of peripheral sensory innervation in specific tissues, differences in innervation between sexes and validation of rodent studies in higher order species. The current study addresses these gaps by validating mouse studies for sensory innervation of tongue tissue in non-human primates as well as assesses sex-specific differences. Tongue and trigeminal ganglia were collected from naïve male and female marmosets and tested for nerve fibers using specific markers by immunohistochemistry and number of fibers quantified. We also tested whether specific subgroups of nerve fibers belonged to myelinating or non-myelinating axons. We observed that similar to findings in mice, marmoset tongue was innervated with nerve filaments expressing nociceptor markers like CGRP and TRPV1 as well as non-nociceptor markers like TrkB, parvalbumin (PV) and tyrosine hydroxylase (TH). Furthermore, we found that while portion of TrkB and PV may be sensory fibers, TH-positive fibers were primarily sympathetic nerve fibers. Moreover, number of CGRP, TrkB and TH-positive nerve fibers were similar in both sexes. However, we observed a higher proportion of myelinated TRPV1 positive fibers in females than in males as well as increased number of PV + fibers in females. Taken together, the study for the first time characterizes sensory innervation in non-human primates as well as evaluates sex-differences in innervation of tongue tissue, thereby laying the foundation for future orofacial pain research with new world smaller NHPs like the common marmoset.

Sex-dependent Differences in the Genomic Profile of Lingual Sensory Neurons in Naïve and Tongue-Tumor Bearing Mice

Mechanisms of sex-dependent orofacial pain are widely understudied. A significant gap in knowledge exists about comprehensive regulation of tissue-specific trigeminal sensory neurons in diseased state of both sexes. Using RNA sequencing of FACS sorted retro-labeled sensory neurons innervating tongue tissue, we determined changes in transcriptomic profiles in males and female mice under naïve as well as tongue-tumor bearing conditions Our data revealed the following interesting findings: 1) Tongue tissue of female mice was innervated with higher number of trigeminal neurons compared to males; 2) Naïve female neurons innervating the tongue exclusively expressed immune cell markers such as Csf1R, C1qa and others, that weren't expressed in males. This was validated by Immunohistochemistry. 4) Accordingly, immune cell markers such as Csf1 exclusively sensitized TRPV1 responses in female TG neurons. 3) Male neurons were more tightly regulated than female neurons upon tumor growth and very few differentially expressed genes (DEGs) overlapped between the sexes, 5) Male DEGs contained higher number of transcription factors whereas female DEGs contained higher number of enzymes, cytokines and chemokines. Collectively, this is the first study to characterize the effect of sex as well as of tongue-tumor on global gene expression, pathways and molecular function of tongue-innervating sensory neurons.

Targeted Therapy for Orofacial Pain: A Novel Perspective for Precision Medicine

Orofacial pain (OFP) is a dental specialty that includes the diagnosis, management and treatment of disorders of the jaw, mouth, face, head and neck. Evidence-based understanding is critical in effectively treating OFPs as the pathophysiology of these conditions is multifactorial. Since OFP impacts the quality of life of the affected individuals, treating patients successfully is of the utmost significance. Despite the therapeutic choices available, treating OFP is still quite challenging, owing to inter-patient variations. The emerging trends in precision medicine could probably lead us to a paradigm shift in effectively managing the untreatable long-standing pain conditions. Precision medicine is designed based on the patient's genetic profile to meet their needs. Several significant relationships have been discovered based on the genetics and genomics of pain in the past, and some of the notable targets are discussed in this review. The scope of this review is to discuss preclinical and clinical trials that include approaches used in targeted therapy for orofacial pain. Future developments in pain medicine should benefit from current trends in research into novel therapeutic approaches.

Photobiomodulation Therapy for the Symptoms Related to Temporomandibular Joint Disk Displacement

Pain related to temporomandibular disorders (TMD) is a common problem that can significantly influence a patient's quality of life. Laser photobiomodulation (PBM) has been reported as a promising method in medicine for wound and bone healing, pain relief, and treatment of the temporomandibular joint (TMJ). Our clinical case aimed to demonstrate the effectivity of PBM using 1064 nm Nd:YAG laser for the treatment of pain and restricted mandible movement in a patient with anterior disk displacement of the left TMJ, using subjective (pain on visual analogue scale - VAS) and objective outcome measures [dynamic magnetic resonance imaging (MRI)]. PBM was performed on the left condyle in four sessions using a 1064 nm Nd:YAG laser with a flat-top handpiece. Results after 10 weeks showed an increase in mouth opening and a painless joint on palpation, with no reported adverse effects. An MRI of the TMJ confirmed the left disk displacement, however, with no signs of inflammation or effusion and with less pronounced disk deformity as compared with the first MRI examination. Use of PBM with Nd:YAG laser may be an efficient method for the management of orofacial pain in patients with acute and chronic TMJ disk displacements and may reduce the recovery time.

Peripheral role of glutamate in orofacial pain

Glutamate is the principal excitatory neurotransmitter in the central nervous system. In the periphery, glutamate acts as a transmitter and involves in the signaling and processing of sensory input. Glutamate acts at several types of receptors and also interacts with other transmitters/mediators under various physiological and pathophysiological conditions including chronic pain. The increasing amount of evidence suggests that glutamate may play a role through multiple mechanisms in orofacial pain processing. In this study, we reviewed the current understanding of how peripheral glutamate mediates orofacial pain, how glutamate is regulated in the periphery, and how these findings are translated into therapies for pain conditions.

A novel implantable device for sensory and affective assessment of orofacial pain in rats

Background and objective

Orofacial pain, in particular, chronic orofacial pain remains a great challenge in clinical practice. To better understand the underlying mechanism of disease, it is essential to apply a feasible and stable preclinical measurement of facial pain. Here, we introduced a novel electrical noxious stimulator in freely behavioral rodents and examined its validation in both naïve and chronic orofacial pain animals.

Methods

One subcutaneous device of electrical stimulator was implanted in the facial region for delivery of the nociceptive input. The sensory component of orofacial pain was assessed by response scoring tool, and conditioned place aversion (CPA) paradigm for pain affect respectively. To confirm its usage in chronic pain state, the chronic constriction injury of the infraorbital nerve (ION-CCI) model was then applied.

Results

We found that responsive scores increased with stimulation intensity, and acted in a dosage-dependent manner, which can be attenuated by the administration of morphine intraperitoneally. Naïve rats displayed significant aversive reaction to the noxious electrical stimulation (25V) in the CPA testing. In addition, an obvious sensory hypersensitivity to electrical stimulation was confirmed by the increased response scores in ION-CCI rats. Furthermore, ION-CCI animal showed significant avoidance to electrical stimulation at relatively low intensity (10V), which was innoxious to naïve rats.

Conclusion

Our findings may provide an alternative pre-clinical measurement of orofacial pain, to quantitively assess both sensory and affective component of orofacial pain.

Salivary Endocannabinoid Profiles in Chronic Orofacial Pain and Headache Disorders: An Observational Study Using a Novel Tool for Diagnosis and Management

The endocannabinoid system is involved in physiological and pathological processes, including pain generation, modulation, and sensation. Its role in certain types of chronic orofacial pain (OFP) has not been thoroughly examined. By exploring the profiles of specific salivary endocannabinoids (eCBs) in individuals with different types of OFP, we evaluated their use as biomarkers and the influence of clinical parameters and pain characteristics on eCB levels. The salivary levels of anandamide (AEA), 2-arachidonoyl glycerol (2-AG), and their endogenous breakdown product arachidonic acid (AA), as well as the eCB-like molecules N-palmitoylethanolamide (PEA) and N-oleoylethanolamide (OEA), were assessed in 83 OFP patients and 43 pain-free controls using liquid chromatography/tandem mass spectrometry. Patients were grouped by diagnosis: post-traumatic neuropathy (PTN), trigeminal neuralgia (TN), temporomandibular disorder (TMD), migraine, tension-type headache (TTH), and burning mouth syndrome (BMS). Correlation analyses between a specific diagnosis, pain characteristics, and eCB levels were conducted. Significantly lower levels of 2-AG were found in the TN and TTH groups, while significantly lower PEA levels were found in the migraine group. BMS was the only group with elevated eCBs (AEA) versus the control. Significant correlations were found between levels of specific eCBs and gender, health-related quality of life (HRQoL), BMI, pain duration, and sleep awakenings. In conclusion, salivary samples exhibited signature eCBs profiles for major OFP disorders, especially migraine, TTH, TN, and BMS. This finding may pave the way for using salivary eCBs biomarkers for more accurate diagnoses and management of chronic OFP patients.

Botulinum toxin A in dentistry and orofacial surgery: an evidence-based review - part 1: therapeutic applications

Objective An evidence-based review on the safety and efficacy of botulinum toxin type-A (BoNTA) in orofacial conditions, focusing on the therapeutic applications and role of BoNTA as an adjuvant treatment.Data source and selection Data was collected using PubMed (Medline), Cochrane Library of Systematic Reviews and Cochrane Central Register of Controlled Trials electronic databases. Having satisfied the search parameters, 32 studies for therapeutic applications and 26 for BoNTA as an adjunctive treatment were included. The quality of relevant studies was assessed using the Best Evidence Topics (BETs) Critical Appraisal Tool.Data extraction The highest level of evidence (LOE) behind BoNTA safety and efficacy was for wound healing and scar management in the orofacial surgery context, where BoNTA was presented as an adjunctive modality. Level-I evidence was controversial for temporomandibular disorders and bruxism. However, it showed promising results for painful temporomandibular disorders of myogenic origin refractory to conservative therapies, and to decrease muscle contraction intensity in sleeping bruxism. There was only one level-II study for persistent recurrent aphthous stomatitis. Data showed limited level-III evidence for orofacial pain conditions (temporomandibular joint recurrent dislocation and pain, burning mouth syndrome or atypical odontalgia), oral cancer complications, or as an adjuvant to maxillofacial and orthognathic surgeries. Benefits of BoNTA in prosthodontics had weak level-IV evidence. No evidence was found among the periodontology field.Conclusion There is growing evidence to support the safety and efficacy of BoNTA in the investigated orofacial pathological conditions, with high levels of satisfaction from the patient and clinician perspective. However, there are some inconsistencies and limited high-quality evidence available. Well-designed controlled clinical trials are necessary to evaluate long-term safety, efficacy and cost-effectiveness before BoNTA is widely adopted with irrefutable evidence-based clinical guidelines.

A Retrospective Study on the Etiological Factors of Orofacial Pain in a Malaysian Sample

OBJECTIVE

 This study aimed to examine the etiological factors of orofacial pain for patients attending dental clinic at Faculty of Dentistry, International Islamic University Malaysia (IIUM).

MATERIALS AND METHODS

 This retrospective study examined the data of 248 patients who have attended dental clinic at Faculty of Dentistry IIUM and suffering from different types of orofacial pain. The data were collected from January 2010 to November 2018. The etiologies of pain were classified according to International Classification of Orofacial Pain, 1st edition (2020).

STATISTICAL ANALYSIS

 The association of age and gender with orofacial pain was evaluated by using the Chi-square test, and the significance level was set to 0.05.

RESULTS

 Collected data showed that orofacial pain has different etiologies among the patients attending the dental clinic at Faculty of Dentistry IIUM. Moreover, a statistically significant relation was observed between orofacial pain toward gender and different age group.

CONCLUSION

 The findings proposed that the orofacial pain has a variety of etiological factors with the highest percentage of orofacial pain attributed to disorders of dentoalveolar and anatomically related structures among patients attending dental clinic at Faculty of Dentistry IIUM.

Pharmacological Approach to Atypical Odontalgia Patients: A Systematic Review of Case Reports

Background:

Atypical odontalgia (AO) is a poorly understood condition of orofacial pain and is often misdiagnosed. The pharmacological approach varies from case to case. This may be due to the differences in etiology, clinical symptoms, as well as comorbidities in each patient.

Objective:

This systematic review aimed at identifying and comprehending the adequate pharmacological approaches in AO management.

Methods:

In this systematic review, case reports that used pharmacological approach(es) as part of the AO management in the last 10 years (2010 to 2020) were reviewed using the PRISMA analysis guidelines. Initial screening was performed using keywords and inclusion criteria in several databases. Subsequently, further screening was carried out by checking for any duplication, followed by an assessment of the title and abstract and the entire content of the case report. All three authors were independently involved in studies selection based on the inclusion criteria, data extraction, and bias assessment.

Results:

Five hundred and ninety-five articles were identified from the initial search. The final result consisted of eleven case reports reviewed in this study. The use of antidepressants in AO management was reported in eight cases, anticonvulsants in five cases, antipsychotic in two cases, opioid analgesics in two cases, and topical analgesics in two cases.

Conclusion:

Based on this systematic review, various pharmacological agents showed adequate results as AO management. Antidepressants seemed to be the most effective ones (PROSPERO registration ID: CRD42021245918).

NOP01, a NOP receptor agonist, produced potent and peripherally restricted antinociception in a formalin-induced mouse orofacial pain model

Orofacial pain is one of the most common medical challenges. A preliminary report indicates that the NOP receptor may act as a therapeutic target in orofacial pain. Previous studies have shown that [(pF)Phe⁴, Aib⁷, Aib¹¹, Arg¹⁴, Lys¹⁵]N/OFQ-NH₂ (NOP01) functions as a potent NOP receptor peptide agonist. This work aims to investigate the antinociception of NOP01 and its possible action mechanisms in a formalin-induced mouse orofacial pain model at different levels. Our results demonstrated that local, intraperitoneal (i.p.) or intrathecal (i.t.) injection of NOP01 produced dose-related antinociception in both phases of the formalin pain, which could be inhibited by the NOP receptor antagonist but not the classical opioid receptor antagonist. Furthermore, the antinociception induced by systemic NOP01 was blocked by local but not spinal pretreatment with the NOP receptor antagonist, suggesting the involvement of the peripheral NOP receptor in NOP01-induced systemic antinociception. Moreover, local injection of NOP01 markedly suppressed the expression of c-Fos protein induced by formalin in ipsilateral trigeminal ganglion (TG) neurons. In conclusion, this work suggests that NOP01 exerts significant antinociception on orofacial pain at both peripheral and spinal levels via the NOP receptor. Notably, NOP01 cannot readily penetrate the blood-brain barrier. Thus, NOP01 may behave as a potential compound for developing peripherally restricted analgesics.

Perspectives on Social and Environmental Determinants of Oral Health

Most oral conditions have a multifactorial etiology; that is, they are modulated by biological, social, economic, cultural, and environmental factors. A consistent body of evidence has demonstrated the great burden of dental caries and periodontal disease in individuals from low socioeconomic strata. Oral health habits and access to care are influenced by the social determinants of health. Hence, the delivery of health promotion strategies at the population level has shown a great impact on reducing the prevalence of oral diseases. More recently, a growing discussion about the relationship between the environment, climate change, and oral health has been set in place. Certainly, outlining plans to address oral health inequities is not an easy task. It will demand political will, comprehensive funding of health services, and initiatives to reduce inequalities. This paper sought to give a perspective about the role of social and physical environmental factors on oral health conditions while discussing how the manuscripts published in this Special Issue could increase our knowledge of the topic.

Risk factor assessments of temporomandibular disorders via machine learning

This study aimed to use artificial intelligence to determine whether biological and psychosocial factors, such as stress, socioeconomic status, and working conditions, were major risk factors for temporomandibular disorders (TMDs). Data were retrieved from the fourth Korea National Health and Nutritional Examination Survey (2009), with information concerning 4744 participants' TMDs, demographic factors, socioeconomic status, working conditions, and health-related determinants. Based on variable importance observed from the random forest, the top 20 determinants of self-reported TMDs were body mass index (BMI), household income (monthly), sleep (daily), obesity (subjective), health (subjective), working conditions (control, hygiene, respect, risks, and workload), occupation, education, region (metropolitan), residence type (apartment), stress, smoking status, marital status, and sex. The top 20 determinants of temporomandibular disorders determined via a doctor's diagnosis were BMI, age, household income (monthly), sleep (daily), obesity (subjective), working conditions (control, hygiene, risks, and workload), household income (subjective), subjective health, education, smoking status, residence type (apartment), region (metropolitan), sex, marital status, and allergic rhinitis. This study supports the hypothesis, highlighting the importance of obesity, general health, stress, socioeconomic status, and working conditions in the management of TMDs.

Referred Orofacial Pain as an Initial Symptom of Distant, Nonmetastatic Cancer: Report of a Case and Review of the Literature

Referred orofacial pain as the first symptom of an otherwise silent distant, nonmetastatic cancer has been reported, but there is sparse literature on the subject. Referred pain may not be considered in the orofacial pain differential diagnosis because of its rarity; however, this may delay a cancer diagnosis. The authors present a case report and a review of the English literature. Peer-reviewed publications were identified through a systematic search of MEDLINE, Embase, and Cochrane CENTRAL. Historic cases were reviewed, and available data regarding demographics, pain characteristics, treatment, cancer diagnosis, and outcome were extracted. Thirty-seven cases were identified. All cancers were intrathoracic. The average age was 54.1 years with a slight female predominance (3:2). Common pain characteristics were (1) diffuse location affecting the ear (76%), jaw (46%), and temple (30%); (2) constant duration (65%); (3) aching quality (74%); (4) severe intensity (94%); and (5) associated systemic symptoms (68%) such as weight loss and digital clubbing. The average time from the onset of facial pain to seeking medical attention was 9 months, and the average time from seeking medication attention to cancer diagnosis was 8 months. Orofacial pain was often attributed to odontogenic (35%) or neuropathic (25%) causes, and treatments for these conditions were also common. The impact of referred orofacial pain on the cancer prognosis was not possible because of the nature of the reviewed studies (case reports with no comparison group). Cancer-associated referred orofacial pain as a first symptom is rare but should be considered in cases with intractable pain and associated systemic symptoms.

An Effective Phytoconstituent Aconitine: A Realistic Approach for the Treatment of Trigeminal Neuralgia

Trigeminal neuralgia pain remains a challenge to treat. Natural compounds may be promising options for relieving pain. This study was aimed at investigating the effects of aconitine in a rat model of trigeminal neuralgia pain. Infraorbital nerve chronic constriction injury was performed in adult Wistar Albino rats. After the neuropathic pain developed, the rats were assigned to one of the treatment groups: carbamazepine 40 or 80 mg/kg; aconitine 0.25, 0.50, or 0.75 mg/kg; or saline injection (control group). Behavioral testing with von Frey filaments and the rotarod test were carried out before the surgical procedure and on the 24th to 29th postoperative days. Following the completion of tests, ipsilateral and contralateral spinal cords were harvested for Western blot analyses to assess NR-1 protein expression. ANOVA followed by Mann-Whitney U test was performed for the statistical analyses. P values of <0.05 were considered significant. Aconitine significantly reduced mechanical sensitivity in a dose-dependent manner. A significant reduction in motor coordination was noted for the higher doses of aconitine which was similar with the 40 and 80 mg/kg doses of carbamazepine. NR-1 expression was reduced in the ipsilateral spinal cord, whereas no significant difference was noted between the groups in the expression of NR-1 in the contralateral spinal cord. Aconitine had a significant pain relieving effect, which was similar to carbamazepine, in a dose-dependent manner. Aconitine may be an alternative pharmacological agent for the control of trigeminal neuralgia pain.

Treatment responses in chronic temporomandibular patients depending on the treatment modalities and frequency of parafunctional behaviour

OBJECTIVES

(i) To evaluate the effect of three different interventions on treatment outcomes and (ii) to determine how the frequency of oral parafunction influences the effectiveness of the different therapeutic modalities.

METHODS

Forty-five participants were randomly assigned into three treatment groups [physical therapy (PT), stabilisation splint (SS) and control therapy (CT)]. According to Oral Behavior Checklist score, participants were divided into "high-frequency parafunction" (HFP) and low-frequency parafunction" (LFP) group. Primary (spontaneous pain and characteristic pain intensity) and secondary outcomes (range of mouth opening, anxiety symptoms, quality of life, perceived stress and global functional limitation) were evaluated during six-month treatment period.

RESULTS

Participants in PT group showed a significant reduction in characteristic pain intensity (p = .047, η²  = 0.243) when compared to SS and CT group, but significant improvement in spontaneous pain was found in all treatment groups. Patients treated with PT and SS exhibited significantly stronger improvement in pain-free mouth opening than patients in CT group (3rd month: p=.037, η2=0.258; 6th month: p = .005, η²  = 0.383). Within-group analyses showed significant decrease of perceived stress, anxiety symptoms and global functional limitation only in PT group over a six-month treatment period. Participants with HFP presented significantly greater levels of anxiety (3rd month: p = .009, η²  = 0.275; 6th month: p = .041, η²  = 0.176) than participants with LFP. Within-group analyses, however, showed significant improvement of anxiety, but also the decrease of perceived stress and improvement of global limitation for the HFP group but not for the LFP group.

CONCLUSION

Although no treatment can be marked as superior in terms of spontaneous pain relief, PT was more effective when observing relief of characteristic pain intensity. In HFP group the reduction of anxiety, stress and functional limitation was present regardless of the applied therapy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04694274. Registered on 01/04/2021.

Comparison of emotional disturbance, sleep, and life quality in adult patients with painful temporomandibular disorders of different origins

OBJECTIVES

This study compared the differences in emotional disturbance, sleep, and life quality among adult patients with temporomandibular (TMD) muscle and/or joint pain.

MATERIALS AND METHODS

The study involved an analytical cross-sectional design. A total of 420 consecutive patients diagnosed with pain-related TMDs based on the Diagnostic Criteria for TMDs (DC/TMD) were recruited from a TMD referral centre and stratified into three groups, namely muscle pain (MP; n = 50), joint pain (JP; n = 329), and combined muscle-joint pain (CP; n = 41). Emotional disturbance, sleep quality, and oral health-related quality of life (OHRQoL) were assessed with the Depression, Anxiety, and Stress Scale-21 (DASS-21), Pittsburgh Sleep Quality Index (PSQI), and Oral Health Impact Profile-TMDs (OHIP-TMDs) respectively. Statistical analyses were performed using the chi-square test, one-way ANOVA, and Pearson's correlation (p < 0.05).

RESULTS

Mean age for the three pain groups (females = 349; males = 71) ranged from 37.15 ± 14.91 to 38.60 ± 14.37 years (p = 0.973). Ranking of depression, anxiety, and stress scores was as follows: CP > MP > JP. Significant differences in emotional disturbances were observed (p < 0.001). CP patients had significantly poorer sleep quality than those with JP (p = 0.004). Moreover, OHRQoL was also significantly more impaired as compared to both MP (p = 0.006) and JP (p < 0.001) patients. Correlations between global PSQI and OHIP-TMDs scores were weak to moderate (r_s = 0.30-0.47).

CONCLUSIONS

Patients with combined muscle-joint pain presented higher levels of emotional disturbance than those with only MP or JP. They also had significantly poorer sleep quality and lower OHRQoL.

CLINICAL RELEVANCE

Emotional and sleep health must be considered in the management of painful TMDs.

Evaluation of orofacial pain and psychological comorbidities in health sciences university students

Introduction: Orofacial pain (OP) is a common public health problem among the general population however, its distribution among the young population like students has not been evaluated so far. The objectives of this study were to investigate the self-reported prevalence, and characteristics of OP, and to evaluate its association with psychological comorbidities such as anxiety and depression. Materials and Methods: A questionnaire-based study was conducted on students studying health sciences programs at SEGi University, Malaysia. A well-designed, structured questionnaire was utilized to assess the prevalence and characteristics of OP. Hospital Anxiety and Depression (HAD) scale was used to evaluate the psychological status of the students. The collected data was subject to statistical analysis by using the SPSS version 22 software. Results: Overall 494 university students had participated in the study of which, 78% (n = 375) of students had suffered from OP and it was significantly higher among the female students (p < 0.03). Headache was the most common type of OP (66.2%) followed by pain in temple region (47.2%), in and around eyes (29.1%), facial region (23.3%), and tooth/gingival pain (20.9%). The association between the prevalence of OP and anxiety was statistically significant (p < 0.019). About 35.4% of the health sciences students had first OP episode started three months ago, 4.2% had daily pain, 14.3% suffered from continuous pain, and only 14% of the students had consulted professionals and 36.1% of them took medication. Conclusion: A significantly higher prevalence of self-reported OP was evident among the health sciences university students and students with different types of OP had higher anxiety and depression scores. Early recognition of OP symptoms and associated comorbidities must be considered for the prevention and successful management of these conditions to circumvent its negative academic impact on the students.

Challenges of Misdiagnosis and Suboptimal Treatment of Persistent Idiopathic Facial Pain and Atypical Odontalgia: A Retrospective Multi-Centric Cross-Sectional Investigation

Purpose

To explore the challenges faced in the diagnosis and treatment of atypical odontalgia (AO) and other persistent idiopathic facial pain (PIFP).

Patients and Methods

This retrospective multi-centric cross-sectional study utilized clinical information (eg, clinical manifestations, history of consultations and treatments prior to correct diagnoses) from patients’ medical records. Their economic parameters were also extracted from medical insurance databases. Each variable collected was statistically analyzed. Differences of variables between AO and other PIFP were statistically tested.

Results

A total of 394 patients were included in this study. On average, the diagnostic delay was 34.8±14.2 months, a median of 7 consultations were performed prior to a correct diagnosis, and 5 ineffective prescriptions were issued. Patients with AO suffered from longer diagnostic delays than patients with other PIFP (38.4±14.3 months vs 31.6±13.4 months) and were more likely to receive invasive dental treatments (73.3% vs 4.3%). The median total cost of treatment for a single patient before correct diagnosis was 8506.3 yuan. Patients with AO spent more than patients with other PIFP (10,146.5 Yuan vs 3864.0 Yuan).

Conclusion

Patients with PIFP were frequently misdiagnosed and the length of diagnostic delay was observed to be long. Ineffective medications, unwarranted procedures, and unnecessary economic burden were imposed on the patients. Patients with AO are in a worse situation than patients with other PIFP. As significantly urgent and unsatisfactory results of misdiagnosis of PIFP have been reported in our study, more attention should be paid on the research and education in this field.

Clinical presentations on a facial pain clinic

Introduction The complex nature of facial pain conditions creates a diagnostic challenge which may necessitate specialist referral.Aim To identify the case mix presenting to a specialist tertiary care facial pain clinic.Methods A retrospective review of 112 patient records was undertaken. Trends in provisional diagnoses from referrers and the correlation to diagnoses made following specialist consultation were reviewed.Results The most common provisional diagnoses recorded in referral letters were painful temporomandibular disorders, trigeminal neuralgia and persistent idiopathic facial pain (PIFP). Over a quarter of referrals did not include a provisional diagnosis. Following assessment, only one case was not given a definitive diagnosis and no patients were diagnosed with PIFP. A causative factor was identified in all the initially queried PIFP cases, and painful post-traumatic trigeminal neuropathic pain was found in multiple patients.Conclusions Painful post-traumatic trigeminal neuropathic pain should be considered if pain onset coincides with dental treatment or other traumatic events. PIFP is a rare facial pain diagnosis and may be over-diagnosed by dental and medical practitioners. It is important to systematically exclude other causes before reaching this diagnosis. This will facilitate effective treatment, manage patient expectations and potentially reduce unnecessary referrals.

Study of the Clinical Efficiency of an Interdisciplinary Approach to the Treatment of Orofacial Pain and Temporomandibular Joint Disorders in Patients with Complete or Partial Edentulism

Objective  The aim of this study is to improve the safety and efficiency of prosthodontic treatment of patients with dental defects. It is necessary to perform a comprehensive assessment of the dentofacial system disorders, including the analysis of the features of pain manifestations. This study also supports to improve the efficiency of prosthodontic rehabilitation of patients with complete dental reconstruction on the basis of an assessment of the severity of orofacial pain manifestations.

Materials and Methods  The study was a single-site prospective open nonrandomized study with the examination and treatment of 452 patients (age = 44.3 ± 15.2 years, including 282 men and 170 women) with partial or total edentulism. The patients were divided into two groups: group 1 (control) of 218 patients treated with a standard prosthodontic approach and group 2 (study) of 234 patients treated which the proposed interdisciplinary approach to prosthodontic rehabilitation.

Results  The study establishes higher safety and clinical efficiency of the proposed interdisciplinary approach. The patients undergoing full-mouth reconstruction with the use of the interdisciplinary approach demonstrated statistically significant decrease in the rate of pain in muscles of the maxillofacial area on palpation, pain, and spasms in the neck area, statistically significantly less frequent pains in the temporomandibular joint (TMJ) during chewing, pain during opening and closing the mouth.

Conclusion  The application of the developed comprehensive approach to prosthodontic rehabilitation planning makes it possible to improve essentially the results of treatment at the expense of reduction of pain manifestations in the area of maxillofacial muscles and pain sensations associated with functioning of the TMJ.

Endodontic microsurgery. Part one: diagnosis, patient selection and prognoses

Historically, surgical endodontics has been viewed as a treatment of last resort, mainly due to poor outcomes as a result of limitations in materials and techniques. Contemporary techniques, modern materials and better visualisation have all led to an improvement in success rates, making endodontic microsurgery a valuable treatment option to certain patients. Such advances, however, are no substitute for skill in endodontic diagnosis and treatment planning, which can often prove challenging. A variety of tools are available to test for fractures and assess both periodontal and pulpal health. More advanced techniques such as cone beam computed tomography are often invaluable in pre-surgical assessment and diagnosis. Once an accurate diagnosis has been established, a favourable prognosis is explicitly linked to careful patient selection. Orthograde treatment, or retreatment, remains the gold standard for the majority of endodontic problems. However, there are a number of indications for surgery where orthograde treatment is either impossible, or less likely to be successful. It is paramount for any clinician undertaking endodontic surgery to have a detailed understanding of the local and systemic factors associated with successful treatment. Whilst there are few absolute medical contraindications, there are a number of conditions which may influence patient management and make treatment more challenging.

Diagnostic delay and suboptimal management in persistent idiopathic facial pain and persistent dentoalveolar pain; a cross-sectional study

OBJECTIVES

The aim of this study was to explore the diagnostic and therapeutic challenges encountered by patients with persistent idiopathic facial pain (PIFP) and to investigate factors influencing its delayed diagnosis.

STUDY DESIGN

In this cross-sectional study, 34 patients with newly diagnosed PIFP were interviewed. Data about diagnostic delay, number and nature of previous consultations, and previous medical and surgical interventions were recorded. Pearson's correlation and Student t test were used to examine the differences among the variables in relation to diagnostic delay.

RESULTS

The average time between the onset of symptoms to correct diagnosis was 19.3 ± 11.1 months. Diagnostic delay was significantly longer in patient with pain localized to intraoral sites (22.6 ± 7.4) compared with patients with extraoral pain (16.1 ± 9.3). The average number of health care professionals consulted before correct diagnosis was 3.7 ± 2.3. General dental practitioners were the most commonly consulted health care professionals (n = 27; 79.4%). On average, patients were given 2.3 ± 0.24 misdiagnoses before the correct diagnosis was determined and were prescribed 3.5 ± 2.4 classes of drugs. Twenty-five patients (73.5%) underwent unnecessary surgical/dental interventions.

CONCLUSIONS

Patients with PIFP are frequently misdiagnosed, leading to prescription of ineffective medications and unnecessary investigations and surgical interventions. Educational efforts should emphasize on improving knowledge and awareness of this condition.

Correlation of somatization, depression, and chronic pain with clinical findings of the temporomandibular disorders in asymptomatic women

Objective: The aim of this study was to correlate degree of depression, somatization, and chronic pain in asymptomatic women with clinical findings, using Research Diagnostic Criteria/Temporomandibular disorders (RDC/TMD). Methods: A total of 200 female participants, ages 18-65, filled out a standard RDC/TMD axis II form for the assessment of chronic pain, disability, depression, and non-specific physical symptoms and underwent clinical examination of the temporomandibular joint. Correlation of clinical findings (axis I) and axis II assessment was performed using Spearman's correlation test, with significance set at p < 0.05. Results: There was a significant correlation between depression scores (p < 0.04), chronic pain (p < 0.001), and non-specific physical symptoms without questions about pain (p = 0.008). Discussion: The highest scores on the Graded Chronic Pain Scale were observed in patients with arthralgia, while patients with myofascial pain scored higher on depression and somatization tests.

Pain Complaints in Patients Undergoing Orthognathic Surgery

The aim of this retrospective study was to assess the frequency of orofacial (nonodontogenic, neuropathic, or atypical) and temporomandibular joint (TMJ) and/or masticatory muscle pain in orthognathic patients in a tertiary institution. A total of 286 consecutive patients undergoing sagittal split osteotomy from 2014 to 2016 were included. Thirty-nine (13.6%) patients presented with TMJ pain and 10 (3.5%) with orofacial nonodontogenic pain before orthognathic surgery; 79.6% (39/49) of these patients had no pain 1 year after surgery. Twenty-nine patients (12.2%) with no preoperative orofacial pain and 22 (9.3%) without preoperative TMJ pain presented with pain 1 year after surgery. Fifty-one (17.8%) of the 286 patients treated for orthognathic cases at our center over the 3-year period presented with pain 1 year after surgery. Most patients were managed conservatively with nonsurgical therapeutic modalities including counseling, physical therapy, warmth application, and bilateral chewing and splint therapy. In patients with TMJ pain refractory to conservative treatment, arthroscopic surgery was advised and successful in all patients for both pain reduction and improvement of the maximal interincisal opening. TMJ symptoms do develop after orthognathic surgery in patients with and without a previous history of TMJ complaints. Most patients can be managed with nonsurgical therapeutic modalities.