Orofacial Pain

A Guide for the Headache Physician

Martina K. Shephard, BDent(Hons), MBBS(Hons), FRACDS; E. Anne MacGregor, MD, FFSRH; Joanna M. Zakrzewska, MD, FDSRCS, FFPMRCA

Disclosures

Headache. 2014;54(1):22-39. 

In This Article

Abstract and Introduction

Abstract

Orofacial pain represents a significant burden in terms of morbidity and health service utilization. It includes very common disorders such as toothache and temporomandibular disorders, as well as rare orofacial pain syndromes. Many orofacial pain conditions have overlapping presentations, and diagnostic uncertainty is frequently encountered in clinical practice. This review provides a clinically orientated overview of common and uncommon orofacial pain presentations and diagnoses, with an emphasis on conditions that may be unfamiliar to the headache physician. A holistic approach to orofacial pain management is important, and the social, cultural, psychological and cognitive context of each patient needs to be considered in the process of diagnostic formulation, as well as in the development of a pain management plan according to the biopsychosocial model. Recognition of psychological comorbidities will assist in diagnosis and management planning.

Introduction

Orofacial pain may be defined as pain localized to the region above the neck, in front of the ears and below the orbitomeatal line, as well as pain within the oral cavity.[1] It includes pain of dental origin and temporomandibular disorders (TMDs), and thus is widely prevalent in the community. Up to a quarter of the population reports orofacial pain (excluding dental pain), and up to 11% of this is chronic pain.[2] Patients with orofacial pain present to a variety of clinicians, including headache physicians, dentists, maxillofacial surgeons, otolaryngologists, neurologists, chronic pain clinics, psychiatrists, and allied health professionals such as physiotherapists and psychologists.[3,4] Orofacial pain is associated with significant morbidity and high levels of health care utilization.[5]

This review presents a clinically orientated overview of orofacial pain presentations and diagnoses. The scope of orofacial pain includes common disorders such as dental pain and TMDs, as well as a number of rare pain syndromes. Pain in the orofacial region is derived from many unique tissues such as teeth, meninges, and cornea. This results in several unique physiological mechanisms that have been well reviewed.[6] Because of these unique mechanisms and the requirement for specialist knowledge of the complex anatomy and physiology of the orofacial region, diagnosis may be difficult. Many patients have consulted multiple clinicians for their condition yet remain undiagnosed or with an incorrect diagnosis.[7,8] Our aim is to provide the headache physician with a guide to orofacial pain presentations and diagnoses informed by our clinical experience in the fields of medicine as well as dentistry, and to review the literature relevant to these conditions. We provide an overview of the common presentations of orofacial pain including dental causes of pain, non-dental causes of intraoral pain, and extraoral facial pain syndromes, as the signs and symptoms of many of these conditions can overlap significantly, causing diagnostic difficulty.

We also present a discussion of history, diagnosis, and management considerations relating to the biopsychosocial model of diagnostic formulation and management. This approach is particularly relevant and important in the field of orofacial pain given the significant level of psychological distress and social dysfunction that is associated with these disorders.[9,10] As with other types of chronic pain, there is often a mismatch between the patient's expectation of a cure for their pain, and the reality that for many types of chronic pain, a cure is seldom possible. Medicine alone does not have the tools to manage a condition that has a neurophysiological cause but is also experienced emotionally, socially, financially, and spiritually.[11] Recognition of psychological comorbidities is essential for appropriate diagnosis and successful pain management.

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