Gary M. Heir

Clinical study of patients with persistent orofacial pain

OBJECTIVE [corrected] To evaluate a sample of patients with persistent facial pain unresponsive to prior treatments. METHODS Hospital records of 26 patients with persistent facial pain were reviewed (20 female and 6 male). RESULTS Patients were classified into three groups according to their presenting symptoms: a)Group I, eight patients (30.7%) with severe, diffuse pain at the face, teeth or head; b)Group II, eight patients (30.7%) with chronic non-myofascial pain and; c)Group III, ten patients with chronic myofascial pain (38.4%). We find 11 different diagnoses among the 26 patients: pulpitis(7), leukemia(1), oropharyngeal tumor(1), atypical odontalgia(1), Eagles syndrome(1), trigeminal neuralgia(4), continuous neuralgia(1), temporomandibular disorders (9), fibromyalgia (2), tension-type headache(1), conversion hysteria(2). After the treatment program all patients had a six-month follow-up period with pain relief, except the patient with tumor. CONCLUSION The wide variability of orofacial pain diagnosis (benign to life-threatening diseases) indicates the necessity to reevaluate patients presenting recurrent pain that is refractory to the usual treatments.

Use of topical medication in orofacial neuropathic pain: a retrospective study.

OBJECTIVE The objective of this study was to evaluate the effect of topical medications as a single treatment or in combination with systemic medications in the treatment of orofacial neuropathic pain conditions. STUDY DESIGN A retrospective chart review of 39 patients treated for orofacial neuropathic pain at the Orofacial Pain Clinic in the New Jersey Dental School was performed. In line with the treatment selection, the subjects were divided into 3 groups: topical medications only (n = 12), systemic medications only (n = 10), and a combination of both (n = 17). RESULTS The starting pain level as expressed in pain Visual Analog Scale for the 3 groups was significantly different. The combined treatment group baseline pain level (7.5 +/- 0.403 SEM; P = .0015) and the systemic treatment only group pain level (8.6 +/- 0.611 SEM; P = .0375) was significantly elevated compared to the topical only group (6.1 +/- 0.716 SEM; P = .1057). Following treatment, pain level was significantly reduced in all 3 groups. The combined group had the highest pain relief (52.0 +/- 6.676 SEM % reduction; P < .0001) followed by the systemic-only group (40.6 +/- 9.727 SEM % reduction; P = .0029) and the topicals-only group (40.9 +/- 10.775 SEM% reduction; P = .0048). The time taken for the topical treatment only to act was significantly shorter (3 weeks +/- 0.479 SEM; P = .0015) when compared with the systemic-only (4 weeks +/- 0.772 SEM; P = .3629) and the combined group (5.5 weeks +/- 0.912 SEM; P = .1738). CONCLUSION Topical medication as single treatment or in combination with systemic medications can reduce orofacial neuropathic pain severity. Further prospective research should be performed to validate this treatment option.

The role of sensory input of the chorda tympani nerve and the number of fungiform papillae in burning mouth syndrome

OBJECTIVE The aim of this study was to evaluate patients suffering from burning mouth syndrome (BMS) and control subjects by means of sensory testing and fungiform papillae count. STUDY DESIGN The left and right anterior two-thirds of the tongue of of 25 BMS subjects and 20 healthy control subjects were evaluated for electric taste and electric detection threshold. The number of fungiform papillae/cm(2) was evaluated by using close-up digital photography. RESULTS The electric taste/tingling detection threshold ratio was significantly higher in BMS compared with control subjects (P = .041). No difference was found between the number of fungiform papillae/cm(2) in the BMS compared with the control subjects (P = .277). Patients suffering from BMS for a prolonged period of time presented with a significantly elevated electric taste/tingling detection threshold ratio (P = .031). CONCLUSIONS BMS may be a neurodegenerative process with chorda tympani nerve hypofunction potentially playing a role in the pathophysiology of this disorder.

Burning mouth complaints: clinical characteristics of a Brazilian sample

OBJECTIVE Evaluation of the clinical characteristics of burning mouth complaints (BMC) in a series of Brazilian patients referred to a large teaching hospital. MATERIALS AND METHODS 66 patients with burning mouth complaints were evaluated through a standardized protocol. RESULTS 56 women and 10 men were examined, ranging in age from 35-83 years. The primary location of the complaints was reported to be the tongue. Thirty-six patients reported a precipitating event. The mean VAS pain levels were 7.5 in women and 6.11 in men. The average estradiol levels in women were low (<13 pg/ml); 80% of all patients reported a concomitant chronic disease, 55% of all patients wore total dentures, 54% of all patients reported subjective xerostomia, 48% of all patients reported sleep disturbances and 66% reported phantom taste. No statistical differences were found between groups with or without a precipitating event in VAS: (p=0.139), in the Number of Words Chosen (NWC) (p=0.259) and Pain Rating Index (PRI) (p=0.276) sections of the McGill Pain Questionnaire (MPQ). CONCLUSION The existence of systemic comorbidities, self-reported sleep disturbances and taste alterations indicates possible correlations and the need for a careful systemic evaluation of each patient; there were no differences between patients with and without precipitating events.

Temporomandibular Joint Osteoarthritis: Diagnosis and Long-Term Conservative Management: A Topic Review

Degenerative joint disease (DJD), a common osteoarthritic problem encountered in clinical practice presents as a chronic debilitating disease resulting in altered joint structure due to degradation and loss of articular cartilage, along with changes in the subchondral bone and other soft tissues. DJD is a frequent finding in the Temporomandibular joints (TMJs). Consequently, a good understanding of the use of a diagnostic algorithm will lead to a better control of DJD in the TMJ. The etiopathogenesis of osteoarthritis is complex, and it is associated with multiple risk factors. The condition progresses slowly through different phases with periods of remission and activity finally reaching the burnout phase. Conservative management forms the cornerstone for the treatment of most of these cases. This review attempts to acquaint the dentist with the diagnosis, pathogenesis and general characteristics of the disease while highlighting and updating them with the current conservative treatment algorithms in order to assist in the formulation of a treatment plan for these patients.

Prolonged gingival cold allodynia: a novel finding in patients with atypical odontalgia

OBJECTIVE The aim of this study was to examine atypical odontalgia (AO) patients with extraoral quantitative sensory testing (EQST) and an intraoral mucosal cold test. STUDY DESIGN Twenty-one subjects with AO and 18 control subjects underwent EQST for electrical and thermal pain and detection thresholds. Cold was applied to painful mucosal areas in AO patients and randomly in control subjects. RESULTS Electrical pain thresholds were higher in AO patients than in control subjects in the same dermatome affected by the pain (P = .03), but no significant differences were observed in electrical detection thresholds and heat pain and detection thresholds at other sites. Cold application was painful in control and AO subjects, but duration of pain sensation was significantly longer in AO patients (P = .019 in contralateral side; P = .029 in affected side). CONCLUSIONS The finding of extended painful aftersensation following cold application in AO patients supports the involvement of central mechanisms. The cold test is clinically easy to apply and of clinically significant value.

Altered pain modulation in patients with persistent postendodontic pain

Abstract Persistent pain may follow nerve injuries associated with invasive therapeutic interventions. About 3% to 7% of the patients remain with chronic pain after endodontic treatment, and these are described as suffering from painful posttraumatic trigeminal neuropathy (PTTN). Unfortunately, we are unable to identify which patients undergoing such procedures are at increased risk of developing PTTN. Recent findings suggest that impaired endogenous analgesia may be associated with the development of postsurgical chronic pain. We hypothesized that patients with PTTN display pronociceptive pain modulation, in line with other chronic pain disorders. Dynamic (conditioned pain modulation, temporal summation) and static (response to mechanical and cold stimulation) psychophysical tests were performed intraorally and in the forearm of 27 patients with PTTN and 27 sex- and age-matched controls. The dynamic sensory testing demonstrated less efficient conditioned pain modulation, suggesting reduced function of the inhibitory endogenous pain-modulatory system, in patients with PTTN, mainly in those suffering from the condition for more than a year. The static sensory testing of patients with PTTN demonstrated forearm hyperalgesia to mechanical stimulation mainly in patients suffering from the condition for less than a year and prolonged painful sensation after intraoral cold stimulus mainly in patients suffering from the condition for more than a year. These findings suggest that PTTN is associated more with the inhibitory rather than the facilitatory arm of pain modulation and that the central nervous system has a role in PTTN pathophysiology, possibly in a time-dependent fashion.

Topical Medications as Treatment of Neuropathic Orofacial Pain

Understanding mechanisms of neuropathic orofacial pain, targets of treatment, and basic pharmacology and working with informed compounding pharmacists may result in significant benefit for patients. The clinical significance of topical medications is improvement of quality of life for patients by providing a unique medication delivery system for neuropathic orofacial pain and other dental and extraoral conditions. The use of this route of administration has decreased or minimized side effects compared with other methods and is especially useful in medically compromised and elderly patients. These innovations, supported and improved by ongoing research, will augment the armamentarium of the clinician treating orofacial pain disorders.

Combined Palliative and Anti-Inflammatory Medications as Treatment of Temporomandibular Joint Disc Displacement Without Reduction: A Systematic Review

Abstract The aim of this study was to evaluate the efficacy of self-care combined with anti-inflammatory medications in the treatment of temporomandibular joint (TMJ) pain associated with disc displacement without reduction (DDWOR). A systematic review of randomized clinical trials was done by the authors. The databases searched were Medline (1966 to July 2012); EMBASE (1980 to July 2012); and LILACS (from 1982 to July 2012). The review authors independently assessed trials for eligibility and methodological quality and also extracted all data. The data was double-checked for accuracy. There was no language restriction in the searches of EMBASE, PubMed, and LILACS databases, or in the manual search. The risk of bias and the heterogeneity of the studies taken into consideration were assessed. Two studies, randomizing 175 patients, were included in this review. The first study (n=106) compared the following interventions: medical treatment, rehabilitation, arthroscopic surgery with postoperative rehabilitation, or arthroplastic surgery with post-operative rehabilitation. The second study (n= 69) compared the use of nonsteroidal anti-inflammatory medications and self-care instructions, nonsteroidal anti-inflammatory medications, occlusal splint, and mobilization therapy. The third group received no treatment; patients were only informed of their prognosis. There is no sufficient evidence regarding efficacy and safety of the palliative treatments associated with anti-inflammatory versus other treatments, or absence of treatment on pain reduction in patients with TMJ DDWOR.

Trigeminal nerve injury following accidental airbag deployment and assessment with quantitative sensory testing

Abstract High velocity motor vehicle accidents are associated with an increase in mortality rates and a significant number of facial injuries. Accidental deployment of airbags and the associated release of hot gases can result in both thermal and mechanical injuries. The more commonly reported maxillofacial injuries include temporomandibular joint fractures and dislocations,1 dental trauma,2 facial nerve paralysis, 3 and other orofacial pain complaints. The following case report describes a patient with facial trauma from the accidental deployment of an airbag resulting in complaints consistent with a neurological injury for which quantitative sensory testing was used in confirming the diagnosis.