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INTRODUCTION TO OROFACIAL PAIN

Patients affected by orofacial pain disorders suffer from significant disability. Even mild pain or dysfunction has a profound effect on their social life. A withdrawal from social events such as meals and social gatherings that necessitate chewing, talking, and smiling is common. Absenteeism is high, and intimacy activities such as oral sex and kissing can become uncomfortable.

Orofacial pain relates to the structures innervated by the trigeminal nerve. Branches of C2 and C3, such as the greater and lesser occipital nerve, which innervate the scalp area, also contribute to facial pain (particularly the forehead and orbits) (Fig. 44–1). Orofacial pain disorders originate from or affect the mouth, teeth, face, head, and neck. As such, orofacial pain conditions fall within the scope of several medical specialties, hence diagnosis and management are complex. For this reason, it is important to evaluate the patient in an integrative multidisciplinary setting where physiatrists, pain physicians, dentists, neurologists, physical therapists, life coaches, sleep physicians, ear/nose/throat (ENT) and pain psychologists can work together.1

Figure 44–1

Innervation of pain-sensitive intracranial compartments (A) and corresponding extracranial sites of pain radiation (B). The trigeminal (V) nerve, especially its ophthalmic (V1) division, innervates the anterior and middle cranial fossae; lesions in these areas can produce frontal headache. The upper cervical nerve roots (especially C2) innervate the posterior fossa; lesions here can cause occipital headache. (Reproduced with permission from Cranial Nerves and Pathways. In: Waxman SG, eds. Clinical Neuroanatomy, 28e New York, NY: McGraw-Hill; 2017.)

Mood disorders, depression, anxiety, catastrophizing, and lack of coping skills negatively affect the emotional burden caused by all chronic pain conditions, including temporomandibular disorders (TMD).24

Evidence has also suggested that psychological problems can manifest as somatic symptoms, sometimes referred to as “masked depression” or in extreme cases, somatization.2,57 An increased propensity to report orofacial pain is seen in individuals with higher levels of psychological distress and with a perception of unhappiness in childhood.

It is widely accepted that the best results for all pain conditions are obtained with conservative modalities that include both pharmacologic and nonpharmacologic aspects, with an emphasis on patient education and involvement. Procedural and surgical interventions are mostly reserved for select patients or patients refractory to conservative treatments. This equally applies to the treatment of orofacial pain.8

TEMPOROMANDIBULAR DISORDERS

Overview

In a Canadian epidemiologic study, 48.8% of orofacial pain patients responded positively to one or more of the nine questions concerning TMD symptoms. Joint sounds (clicking, crepitus, popping), tiredness or stiffness of jaw muscles, and an uncomfortable bite were the symptoms most frequently reported. Functional pain or pain while at rest was reported by 12.9%. Sex and age ...

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