Temporomandibular joint pain-dysfunction in patients suffering from atypical facial pain

[Differential and common characteristics of patients with atypical facial pain and craniomandibular dysfunction]

BACKGROUND

Craniomandibular disorders (CMD) and atypical facial pain (AFP) represent a clinical challenge. Whereas CMD patients respond to somatic approaches, somatization should be strictly avoided in AFP. The aim of this study was to establish prognostic criteria to identify an aggravated risk of a chronic course in CMD and AFP.

METHOD

A total of 124 consecutive patients with CMD ( n=108) or AFP ( n=16) were examined by two interdisciplinary academic pain centers. Psychometric evaluation was conducted with standardized questionnaires (SCL-90R, STAXI, modified SBAS-IV). All patients were clinically assessed by a maxillofacial surgeon or specialized dentist.

RESULTS

The following variables proved to be significant: age (risk for AFP vs CMD increased by 6% p.a.), decreased dysfunction index (13% higher risk for AFP vs CMD), and low scores concerning outwardly directed anger (12% higher risk for AFP vs CMD). There was no correlation between initial pain intensity and somatic parameters of disease as assessed by the standardized clinical examination. Low educational status proved to be the best predictor ( p<0.001) for patients presenting high initial pain with a marked discrepancy between somatic findings and subjective status.

CONCLUSIONS

CMD patients differ from AFP patients regarding age, psychosocial isolation, outwardly directed anger, and a decreased dysfunction index. Additionally, initial pain intensity in patients presenting indistinct CMD/AFP can be considered as a valid predictor for a chronic course in pain.

Collagen type in dysfunctional temporomandibular joint disks

Controlled studies were undertaken to ascertain the nature of the fibrous tissue component of surgically removed dysfunctional human temporomandibular joint disks. Each disk was divided into several parts and dissociative methods were used to extract collagenous residues. The resultant residues were digested with cyanogen bromide and the obtained soluble peptides were characterized by their electrophoretic mobility on polyacrylamide slab gels. The separated peptides were then scanned on a laser densitometer. Type III collagen was identified in samples taken from both the women's and the men's posterior disk attachment tissues. The amount of type III collagen in the women's attachments was approximately twice that found in the men's and both of these quantities were greater than those previously found in nondysfunctional tissues. The finding that there was more type III collagen in the posterior attachments of the women's chronically damaged disks may indicate that these tissues in women are less able to withstand functional loading.

[Diagnosis and treatment of atypical facial pain-a review.]

Atypical facial pain is a collective term used for otherwise unclassifiable pain syndromes of the face. It describes mostly unilateral lancinating and burning pain, which is constantly present but fluctuating in intensity and may be accompanied by dys-or paraesthesias over a period of several years. Women are more often affected than men. A strikingly large number of invasive investigative procedures are performed before the final diagnosis is established. Psychopathological abnormalities are frequent and do not consist solely in masked depression. To date there is no cure for atypical facial pain. Most frequently tricyclic antidepressants such as amitriptyline and imipramine, MAO inhibitors or anticonvulsives such as carbamazepine and phenytoin are used, which only alleviate the pain. This also holds true for behaviour therapy, which should be the first-line treatment. Any invasive intervention should be avoided. In the differential diagnosis atypical facial pain should be distinguished from cervicogenic or cluster headache, and also from intracranial tumours of the trigeminal nerve or the cerebellar-pontine angle, erosive tumors of the base of the skull, orbitas and nasopharynx.

Facial pain and muscle atrophy secondary to an intracranial tumour

Orofacial pain rarely arises from a distant site. It is unusual for orofacial pain to be associated with wasting of the facial musculature and diminished sensation. This case report describes a patient who presented with temporomandibular joint pain dysfunction syndrome which was initially successfully managed with splint therapy. She re-presented later with unilateral wasting of the muscles of mastication, facial pain and diminished sensation ipsilaterally. An intracranial meningioma was diagnosed following an extensive series of investigations.

Facial pain. 'Why does my face hurt, doctor?'

In addition to sinus and dental abnormalities and stress, several different neurologic conditions can cause facial pain. These include various neuroalgias (trigeminal, vagoglosso-pharyngeal, cranial), carotodynia, and optic neuritis. Pain characteristics and results of specific neurologic tests establish the diagnosis. While carbamazepine (Tegretol) is the treatment of choice in many of these conditions, other drugs may also be beneficial. If drug therapy fails to relieve the pain, specific surgical procedures may be warranted.

Presence of type III collagen in disc attachments of human temporomandibular joints

Samples of discs and disc attachments were extracted by dissociative methods and the resultant collagenous residues cleaved with cyanogen bromide. Soluble peptides thus released were characterized by their electrophoretic mobility following SDS-PAGE and by Western blot staining with specific antibodies against type I and type III collagens. Type III collagen was identified in samples taken from the posterior discal attachments. This may explain why this disc is prone to detachment and internal derangement and the high incidence of patients with temporomandibular joint dysfunction.