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

A Holistic Approach to Facial Pain

The History

Accurate and comprehensive history-taking is essential in order to gather sufficient information in order to formulate a diagnosis and treatment plan.[99] The medical consultation has been described as "a transaction that involves translation," and further that "the physician's concern is to translate the subjective experience of illness into the recognizable discourse of medicine."[100] It has also been suggested that we should not be "taking" a history but "receiving it."[100] Inaccurate or inappropriate "translation" can lead to inaccuracy of diagnosis and impair the therapeutic relationship.

Our unit advocates the use of a structured or semistructured history in order to ensure consistency in history-taking and documentation, and to assist in diagnostic accuracy. An open-ended style of history-taking, rather than an interrogative approach, often yields important information and ensures that patients feel they have been listened to and their health beliefs understood.[101,102] Building a therapeutic relationship is essential in the assessment and management of chronic pain. Ensuring sufficient duration for the initial consultation, allowing the patient time to speak and express their ideas regarding the pain, and eliciting and understanding patient expectations are all essential for successful pain management.[103] A recent study of 12 patients interviewed preconsultation and post-consultation in a pain clinic, without the knowledge of the clinicians involved, provided some of these comments:

I guess what the appointment has done is drawn a line under it and made me think, well, that's fine but nothing can be done about it so I just need to get on with things.

Even though I haven't come away with a cure, I feel in a better position to cope with my symptoms.

I felt xxx listened to me more than the other healthcare professionals I have seen and took into account the effects the pain was having on my life in general, rather than just treating me as a diagnosis.[104]

In addition to the standard pain history, psychiatric comorbidities must be identified and addressed early in the therapeutic relationship, as they may have been present before the onset of the pain.[15] It is also essential to elicit detailed information regarding social history, major life events, psychosocial stressors, and the impact of pain on the patient's ability to participate in the activities of daily living. Many patients with facial pain who present to secondary care or pain clinics have attended consultations with a large number of primary and secondary care providers, and may have had multiple investigations or interventions for their pain.[7,102,105] This is illustrated by the following patient quotation: "A lot of people would think [that consulting a] dentist, max facs [maxillo-facial surgery], neurologist was already over the top but I wanted to be certain that I'd tried everything."

These patients often have a significant level of psychological distress, and this can impact negatively on the therapeutic relationship and management strategies. Understanding the patient's expectations and illness beliefs, and assessing negative prognostic factors such as catastrophizing or low self-efficacy levels is essential in order to formulate an appropriate treatment plan using the biopsychosocial model that will then require a multidisciplinary team approach.[106]

Psychological screening tools such as the National Institutes of Clinical Excellence depression screening questions, the Hospital Anxiety and Depression Scale, Patient Health Questionnaire, and the Beck Depression Inventory are useful for quantifying the degree of psychological comorbidity.[107] The inclusion of an objective measure of pain impact on quality of life is essential in every facial pain consultation; the Graded Chronic Pain Scale, Brief Pain Inventory (including the extended version),[108] the Pain Catastrophizing Scale, and the EuroQoL scale are useful tools. However, these measures need to be carefully interpreted in the context of the patient's comorbidities. As 1 patient commented: "And if you're very depressed and it's hard to verbalize how you feel about things, or whether you can't just mark on a scale between nought and ten what your pain is like, you know, what's your pain, is it nought or is it ten?"[31]

Diagnostic Considerations

There is also the propensity for clinicians to "label" patients with a diagnosis, with the expectation that this will enable the patient to accept the condition and progress with treatment. This approach may be helpful for some patients – 1 patient stated: "I was quite relieved to have a diagnosis … although I had hoped I would come away with a solution for a cure, I am happy now that I know the cause and that it is not serious."[104]

However, our experience is that this is often not the case. Some facial pain presentations are diagnostically challenging, and the evolution of symptoms over time may either clarify, or rule out, the diagnosis initially given. Extant classification systems may also hinder diagnosis or result in inaccurate labeling. It has been found that the number of patients whose symptoms could not be classified as a specific diagnosis was larger in ICHD-II than in ICHD-I, with particular difficulty experienced in patients with persistent idiopathic facial pain.[109] In a study examining the usefulness of the ICHD-II classification criteria, only 56% of patients were successfully diagnosed with orofacial pain using ICHD-II.[2] Applying American Academy of Orofacial Pain (AAOP)/Research Diagnostic Criteria for Temporomandibular Disorders (RDCTMD) criteria, a further 37% were diagnosed with masticatory myofascial pain (MMP), and further published criteria enabled the remaining patients to be allocated to other predefined diagnoses. The authors concluded that while MMP is clearly defined by AAOP and the RDCTMD, expansion of ICHD-II was needed so as to integrate more orofacial pain syndromes.

It may be better to give no diagnosis rather than the wrong diagnosis, as revising a diagnosis that has previously been presented to the patient as definitive can be damaging to the therapeutic relationship and the patient's confidence in the clinician. The use of a grading system such as "definite," "probable," or "possible" has been suggested for use when diagnosing neuropathic pain.[110] This classification could be extended to other orofacial pain diagnoses as a means of managing the uncertainty in providing diagnoses for conditions that have varied clinical presentations. Ontological approaches to the diagnosis and classification of facial pain syndromes aim to reduce the problems associated with "labeling" and focus on the use of purely descriptive terms with no inferences made regarding mechanism or etiology.[27]

"Labeling" or compartmentalizing patients into diagnostic categories also ignores the multifaceted nature of chronic pain syndromes, particularly orofacial pain. The patient is not the diagnosis – rather the pain condition has occurred in a patient who exists within a milieu of social, cultural, psychological, and cognitive influences. Patients' beliefs about their condition will also affect their disability and outcome,[111] as the quote in Figure 3 — illustrates. Recognizing the significance of these contributory factors to the overall presentation is essential for effective therapeutic dialogue as well as good management of pain.

Figure 3.

Extract from a patient letter about treatment of her orofacial pain.

This concept has been further explored in a recent series of qualitative studies examining patients' experience and perception of orofacial pain.[26,102,105] As with any other chronic pain psychological factors will increase pain disability.[112] Orofacial pain syndromes often co-exist with significant psychological morbidity, probably more so than other types of chronic pain,[10,113] and are risk factors for chronicity.[114] Addressing these factors is essential for appropriate management of the orofacial pain, as treatment outcome has been shown to be related to psychological comorbidity.[49] Affective as well as interpretative and cognitive factors play an important role in the patient's perception of pain. One small qualitative study found that their patients perceived their orofacial pain to "have no limits and to repressively permeate all aspects of their existence: social, practical, and emotional."[105] This illustrates the significant impact that orofacial pain can have on quality of life, and provides a focal point for assessment of pain management outcomes. Patients need to know that although the sensation of pain may not be completely alleviated by treatment, the impact of pain upon their daily life can certainly be modulated.

Management

Chronic pain management should be holistic in nature and approach, and involves addressing all the factors that modulate the pain experience.[7] Addressing unrealistic patient expectations is important for setting achievable treatment goals. There remains a common perception that pain should always be curable, as demonstrated in this quote from a patient: "Many don't understand the pain I feel. They think I should be over this pain by now. Others feel I should seek other doctors. They feel there should be something to relieve this terrible pain and ask me why I'm not trying to find it, if it is so bad."

Pain as defined by International Association for the Study of Pain is both a "sensory and emotional experience," and it should be managed as such. A recent study has shown that chronic musculoskeletal pain can be experienced as a "constant adversarial struggle," and the researchers suggest that patient and clinician expectations of a diagnosis and cure need to be challenged.[115] Beliefs, coping strategies, and catastrophizing predict functioning in patients with chronic pain, and this should be considered when individualizing pain management programs.[116] This extends to patients' beliefs about medication as these will influence adherence.[117]

Successful pain management is also related to the patient's self-efficacy beliefs and ability to learn and use positive coping strategies.[118] Recognition of the contribution of social, psychological, and lifestyle factors to the pain experience, as expressed in the patient quote earlier, is essential for taking the next steps in chronic pain management and achieving a reduction in the impact of pain on quality of life. The provision of support for these next steps is a fundamental part of multidisciplinary pain management. Pain management programs delivered in group settings normalizes the pain experience, and the concept of an improved pain experience because of observation of others with a similar complaint is also expressed by the patient quoted earlier. Newer techniques such as an e-learning cognitive behavioral therapy model can be helpful.[119] Supported but self-directed pain management focused around lifestyle change and reducing the impact of pain on quality of life is a more effective management approach in chronic pain than the traditional, didactic biomedical model, but these strategies need to be tailored appropriately.[120]

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