Jens C. Türp

Pain maps from facial pain patients indicate a broad pain geography.

Two hundred consecutive female patients, who were referred to a university-based facial pain clinic, were asked to mark all painful sites on sketches showing the contours of a human body in the frontal and rear views. The drawings were analyzed with transparent templates containing 1875 (frontal view) and 1929 (rear view) square cells of equal size. The average patient scored 71.8 cells in the frontal and 99.7 cells in the rear view (corresponding to 3.8% and 5.2% of the maximum possible scores). In individual patient drawings, however, up to 42.7% and 44.9% of all cells were marked. Only 37 cases (18.5%) exhibited pain that was limited to the trigeminal system. An analysis of the pain distribution according to the arrangements of dermatomes revealed three distinct clusters of patients: (1) pain restricted to the region innervated by the trigeminal nerves (n = 37); (2) pain in the trigeminal dermatomes and any combination involving the spinal dermatomes C2, C3, and C4, but no other dermatomes (n = 32); and (3) pain sites involving dermatomes in addition to the ones listed above (n = 131). Mean ages in the three clusters were 38.7, 35.5, and 37.5 years, respectively (p = 0.62, n.s.). Widespread pain existed for longer durations (median, 48 months) than conditions involving local and regional pain (median, 24 months) (p = 0.02, s.). Our findings showed that among a great percentage of persistent facial pain patients the pain distribution is more widespread than commonly assumed, and that the persistence of pain in the regional and widespread pain presentations is significantly greater than in cases with pain limited to the trigeminal system.

Trigeminal neuralgia versus atypical facial pain. A review of the literature and case report.

Trigeminal neuralgia and atypical facial pain are common conditions of facial pain. Although these two pain conditions are classically well separated in textbooks, a straightforward diagnosis may not always be possible because of the overlapping clinical signs and symptoms. In this article, a comparison and differentiation between the clinical and diagnostic features of these two pain conditions are presented. The general characteristics, etiologic characteristics, pathophysiology, differential diagnostic criteria, and therapeutic options of trigeminal neuralgia and atypical facial pain are described. A case report demonstrates the difficulties that can arise in the diagnosis and differentiation between the two disease entities. The article underscores the responsibility clinicians have in correctly diagnosing and managing patients with facial pain conditions.

Temporomandibular disorders--pain outside the head and face is rarely acknowledged in the chief complaint.

STATEMENT OF PROBLEM With diagnostic and therapeutic procedures being heavily influenced by the patients chief complaint, the question arises whether this information alone represents a solid basis for clinical action. PURPOSE The aim of this investigation was to assess the agreement between pain complaints and patient generated paper-and-pencil drawings of the distribution of pain in patients suffering from temporomandibular disorders. METHODS The study included 140 adult female patients with temporomandibular disorders. Pain drawings served as a standard, against which the oral reports were compared. In 40 (29%) of the patients, pain was limited to the head and face; in the remaining subjects, it exceeded the boundaries of these regions. Nine potential pain sites were distinguished (head, face, neck, shoulders, arms, chest, abdomen, back, and legs). Whenever one of these regions was part of the drawing or the pain complaint, it was counted. Sensitivity, specificity, and kappa indices were computed for each site. RESULTS Patients with pain limited to the head and face showed a close correspondence between pain report and drawing. On the other hand, patients with temporomandibular disorders with concomitant pain sites outside the head and face frequently did not mention these additional pain locations. This was reflected in low sensitivities (minimum: 0.00; maximum: 0.48) and low kappa values (minimum: -0.02; maximum: 0.19). CONCLUSIONS This study showed that the chief complaint frequently underestimates the real extent of pain involvement.

Prosthetic rehabilitation in patients with temporomandibular disorders

Decision-making in prosthetic dentistry and in the management of patients suffering from temporomandibular disorders is strongly influenced by the clinical and educational background of the dentist. The prosthetic rehabilitation of patients affected by one of the various subsets of temporomandibular disorders is a particularly challenging task, and the literature about this topic is limited. This article reviews the current situation and gives suggestions on how the dentist should proceed in the prosthetic treatment of these patients.

Fibrosarcoma misdiagnosed as a temporomandibular disorder: a cautionary tale.

Because of the abundance of articles on temporomandibular disorders in the dental literature, other sources of facial pain and mandibular dysfunction do not receive adequate diagnostic attention. The case report in this article describes a female patient who appeared for treatment with symptoms and signs similar to those encountered in subsets of temporomandibular disorders. Her condition was misdiagnosed, and she was treated for a temporomandibular disorder over an extended period before the correct diagnosis of high-grade pharyngeal fibrosarcoma was established. Once diagnosed, the tumor was treated aggressively with preoperative and postoperative combinations of chemotherapy and radiation. Despite the intensive therapy, the patient died. This case should remind the clinician that nonmusculoskeletal sources of persistent facial pain and dysfunction, including tumors, may be masked by or mimic temporomandibular disorders. If therapy does not produce the expected outcome, the diagnosis should be reexamined.