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ORAL PATHOLOGY

15 DENTAL NEWS, VOLUME V, NUMBER II, 1998

CHRONIC OROFACIAL PAINCase Reports

Dr. K. Rifai1 - Dr. Z. K. Salloum2

INTRODUCTION

P ain is recognized as being more an experience than a sensation, it does have a sensory dimension

that registers the nature of the initiating stimulus, including its quality, intensity, location and dura-

tion. But it has other dimensions also: cognitive, which represents the subject's ability to comprehend

and evaluate the significance of the experience, emotional, which represents the feelings that are gener-

ated, and motivated, which has to do with the drive to terminate it. Pain is a very personal experience

with complex psychological and physical overtones1, 2, 3. It is always subjective. It cannot be accurately

measured and may be strongly influenced by sociological and cultural factors4, 5, 6.

Chronic pain must be differentiated from acute pain for the purpose of management. Chronic pain can

be defined as pain endured for more than 6 months. Chronic pain does not serve any biological purpose,

is not self limiting, and appears to be permanent. As the duration of pain continues, the pain may become

centralized and its clinical characteristics intensified by psychological factors7, 8.

1- Khaldoun Rifai, D.D.S, D.SO, H.D.R. Associate Professor,

Chairman Department of Prosthodontics, L.U.

2- Ziad Kayssar Salloum B.D.S, D.U.A., D.U.B.P. Attaché Clinique

Department of Removable Prosthodontics, L.U.

For Correspondence:

Dr. Ziad Salloum, PO Box 113-5463 Beirut, Lebanon

Tel: 01-346117 - Fax: 01-442028

KEY WORDS: Chronic Pain,

Psychogenic Factor,

Craniomandibular Disorders,Management.

Abstract

Pain is the most important of the various masticato-

ry symptoms, because it is the symptom that causesthe patient the greatest concern and for which the most

frequently seeks treatment. Therefore, pain is the pri-

mary issue in the management of temporomandibular

disorders and orofacial pain.

Temporomandibular Disorder and Orofacial Pain

should be controlled by designated members of an

established multidisciplinary team.



ORAL PATHOLOGY


ETIOLOGY, DIAGNOSIS AND MANAGEMENT

In patients with chronic orofacial pain, diagnostic problemsmay arise, especially when there is a psychologic componentinvolved. It is sometimes difficult to find a dental origin of pain even when patients insist their pain is emanating from theteeth or surroundings areas9. Lately, it has been accepted thatpatients with chronic pain need psychologic or psychiatriccare. Some authors consider that the chronic pain arises fromthe psychiatric disorder that existed before the pain started,while others claim that the psychiatric disorder is a conse-quence of the chronic pain. The role of psychological factorsin the cause, perpetuation, treatment and prognosis of the painand dysfunction of the temporomandibular joint (TMJ) andmasticatory system has been widely discussed. Until recently

however, there was no agreement on the issue and many con-troversial reports where made10, 11, 12, 13, 14. There is fairly gener-al agreement about the multifactorial etiology of TM disor-ders, disagreement still persists as to the relevance of differentfactors15, 16, 17, 18, 19.

There are several reasons for this:1- Different etiologic factors may be present in the same

patient20, 21.2- The same etiologic factors may lead, in different patients,

to different consequences22, 23.3- Problems arising from craniomandibular structures may

be complicated by the superimposition of systemic disor-ders 24, 25, 26.

The complex nature of temporomandibular disorders(TMD) and oral facial pain (OFP) requires a multidisciplinaryapproach. The management goals for the dentist as a memberof a TMD team are patient comfort, occlusal stability and / orthe complex restoration of teeth27, 28, 29.

TMD and OFP patients are more efficiently treated in aninterdisciplinary setting at a single facility with dental andmedical specialist or by a multidisciplinary team whose mem-bers, working in different facilities, coordinate diagnosis andtreatments. The objectives of treatment, common to all mem-bers of the team, are to relax the muscles of mastication, reduceadverse loading of the TMJ, stabilize the craniomandibularrelationship, and have a normal productive life30, 31, 32, 34.

Combining traditional dental treatments with psychologi-

cally based treatments may be the most efficacious approachfor the successful treatment of TMD and OFP, and important-ly the long term maintenance of initial treatment success35, 36, 37.

Ideally, TMD should be controlled by designated membersof an established multidisciplinary team.

CASE REPORTS

Case Report 1:Patient R.C. is a 20-year-old female, single. Her chief com-

plaint was pain on the right TMJ for a period of 7 years dur-ing opening. She first presented herself on August 15, 1997and ended on September 16, 1997.

Clinical examination revealed pain precipitated by function(after a clicking period) on the right TMJ. History of jointnoises and limitation of mandibular opening. The maximal

interincisal opening was 22 mm. The mandible was deviatedto the right side on opening.

It was diagnosed disc displacement without reduction. Thedisc is nonreducing or permanently displaced and does notimprove its relation with the condyle on translation; in fact,the relation may become worse. It sometimes is referred to asa “closed lock”38.

The manipulation of the mandible was unsuccessful. Theunloading appliance combined with jaw exercises and physio-therapy ameliorated slightly the symptoms.

Since there was no significant improvement of the symp-toms, we decided to stop the treatment after one month(September 19, 1997).

Case Report 2:Patient N. A. is a 45-year-old housewife. Her chief com-

plaint was constant pain of the masticatory muscles withchronic headache. The pain was deep, aching, and constant.

Clinical examination revealed hypertrophy, edema, spasmand tenderness (on palpation) in the right and left temporalis,the body and mandibular angle of the right and left massetermuscles; the right and left internal and external pterygoidmuscles. Localized tenderness on palpation over entire regionof the masticatory muscles. Increased pain with mandibularmovement. Moderately to severely limited range of motiondue to pain and swelling.

A diagnosis of myositis was made and treatment initiated.

There are five main avenues of treatment:1- Physiotherapeutic treatment to eliminate muscle tension

and pain, the logical first step in treatment.2- Elimination of occlusal and jaw imbalance through the

use of an orthopedic repositioning appliance, which willpermit the muscles to close the mandible in the muscularposition without the teeth directing the closure into a dif-ferent position (with elimination of the trigger areas andspasm, the occlusion should be corrected).

3- Control of oral habits and associated exercisetherapy.

4- Assisting the patients in the control of their tension andstress.

5- Medication and systemic therapy (Anti-inflammatorydrug).Within 4 months a slight amelioration was noticed, which

was not constant. The patient was oriented to medical exami-nation.

Case Report 3:Patient N. I. Is a 53-year-old housewife. Her chief complaint

was bilateral headache. There was a constant pain in her tem-ples and ears. The pain was deep, aching, and constant. Therewere secondary complaints, stuffiness in both ears.

The clinical examination revealed, bruxism, and the evi-dence of psychological stress. The pattern of pain was



PROSTHETIC DENTISTRY


REMARKS AND DISCUSSION

From these 4 case reports, we can classify them into twogroups:

Group 1: Case 1 and Case 2 have craniomandibular disor-ders without any psychological factors.

Group 2: Case 3 and Case 4, have craniomandibular disor-ders with psychological factors.

The most important initial step in therapy is an accuratediagnosis. Diagnosis always precedes treatment.

The complex nature of temporomandibular disorders andorofacial pain requires a multidisciplinary approach. The painis treated irrespective of the cause and localization of the pain.The aim of the treatment is not primarily to attain a completereduction of the pain, but rather to teach the patient how tolive with and alleviate the pain44, 45, 46, 47.

A major frustration of clinical orofacial practice is the failureof some patients to improve with standard treatment protocolsbecause of factors out of the clinician's awareness and control.

The importance of psychological factors in TMDs andchronic pain is not clear, and these factors may play a role inpredisposition, perpetuation, or mediation of treatment outcome49.

described as pressure inconsistent on intensity and durationand it is not well-defined, it does not follow the anatomicaldistribution of the nerves.

A diagnosis of craniofacial muscle disorder was made andtreatment initiated.

An occlusal appliance for muscle relaxation was used. Thepain decreased during the first 3 months. But the painrecurred after 3 months, more acute, intense and inconsistent.

We decided to stop the treatment after 6 months and thepatient referred to medical and psychological consultation.

Case Report 4:Patient F. H. 47-year-old housewife. Her chief com-

plaint was bilateral headache with pressure on ears when shepresented herself on March 11, 1996. She generally awak-ened with a headache every morning. The pain was lancinat-

ing and deep.Clinical examination revealed mild clicking on both TMJon the beginning of the opening movement. Evidence of bruxism. Bilateral upper edentation class III of Kennedy.

Radiographic examination, transcranial X-ray, revealedposterior position of the condyles on intercuspal position.

A diagnosis of craniofacial muscle disorders associatedwith internal derangement39, 40.

Management of patient began with occlusal appliance formuscle relaxation41, 42. For 3 months the symptoms decrease. Butafter 3 months, bilateral headaches recurred, and it was constantfor 4 months. We tried to equilibrate the appliance in a moreanterior position to decrease the pressure on ears, but there wasno significant improvement. The patient was referred to anoth-

er specialist who diagnosed a psychological problem andadministrated her an anti-depressant (Amitriptyline)43.

Concerning the case report 1, the management requiresimmediate manipulation and an unloading appliance50, 51, 52. If this fails, manipulation under general anesthesia will confirm

whether realignment is possible. It might require surgicaltherapy, followed by post operative maintenance program.

For the case report 2, a medical consultation is necessary.Laboratory tests and dosage of Ca and Mg could reveal atetanic problem. Otherwise an anti inflammatory drug thera-py for a long period must be under control with medical assis-tance53, 54, 55, 56, 57, 58, 59.

Concerning the 2nd group patients (case reports 3, 4), wenotice the following:

Both patients are female, age between 45-55 years, whichcould or might indicate hormonal influence.

The persistent pain is associated with psychological factors(greater than 6 months).

The depression and anxiety may alter patient's perceptionand tolerance for pain. These patients seek more care.Moreover, the occlusal factor can reveal the problem. Neitherthe elimination of these factors resolve the problem.

In general patients report inconsistent and vague description of pain.Some of them over dramatize the pain.Inconsistent response to analgesics and muscle relaxant.Many chronic orofacial pain patients have psychological

and behavioral problems coexisting with their pain complaintsthat often intensify the clinical characteristics. These psycho-logical factors may also cause the pain to persist even whenthe original tissue damage has diminished or disappeared60.

In conclusion, personality, emotional, and attitudinal char-acteristics can be interpreted as psychologic predisposing fac-

tors. Structural predisposing factors related to biomechanicalrelationships can be genetic, development or iatrogenic.Perpetuating factors that often complicate the management of chronic pain include behavioral, social, emotional, and cogni-tive difficulties.

The evaluation of the psychological and emotional status of a patient provides insight into any possible emotional compo-nents of the patient's problem, and its result may be useful inpatient management. In addition, psychological assessment isfundamental to developing good communication and motiva-tion strategies61. Rugh has recommended that assessment of chronic TMD patients should include a behavioral and psy-chological evaluation. The etiology of TM disorders appears

to be multifactorial rather than unifactorial. Emotional andpsychological factors are known to be important in that emo-tional tension may cause muscular hyperactivity and para-function62.

Knowledge or understanding of illness behavior is indeedimportant, because both, diagnosis and treatment of patients,require adequate assessment of the factors contributing to thepatient's recognition of their symptoms quest for professionalcare, and response to therapy. It is therefore assumed that moredetailed studies of social, cultural, and demographic backgroundof TMD and OFP patients should be accomplished.

CONCLUSION



ORAL PATHOLOGY


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