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Orofacial Pain
Introduction
The specialty of Orofacial Pain Dentistry is concerned with the prevention, evaluation, diagnosis, treatment, and rehabilitation of orofacial pain disorders. Such disorders may have pain and associated symptoms arising from a discrete cause, such as postoperative pain or pain associated with a malignancy, or may be syndromes in which pain constitutes the primary problem, such as neuropathic pains or headaches.
The diagnosis of painful syndromes relies on interpretation of historical data; review of laboratory studies, imaging, and electrodiagnostic studies; behavioral, social, occupational and avocational assessment; interview and examination by the orofacial pain dentist; and may require specialized diagnostic procedures, including central and peripheral neural blockade or monitored drug infusions. The special needs of the pediatric and geriatric populations are considered when formulating a comprehensive treatment plan for these patients.
At global dental care, the orofacial pain dentist serves as a consultant to other dentists and physicians but is often the principal treating health care provider and may provide care at various levels, such as direct treatment, prescribing medication, prescribing rehabilitative services, performing pain relieving procedures, counseling of patients and families, direction of a multidisciplinary team, coordination of care with other healthcare providers and consultative services to public and private agencies pursuant to optimal healthcare delivery to the patient suffering from a painful disorder.
At the present time the orofacial pain encompasses:
  • Masticatory musculoskeletal pain
  • Cervical musculoskeletal pain
  • Neurovascular pain
  • Neuropathic pain
  • Sleep disorders related to orofacial pain
  • Orofacial Dystonias
  • Intraoral, intracranial, extracranial, and systemic disorders that cause orofacial pain
Orofacial Pain is a complaint that around the world affects millions of people on a daily basis. It constitutes any symptom that occurs from a large number of disorders and diseases that result in a sensation of discomfort or pain felt in the region of the face, mouth, nose, ears, eyes, neck, and head. When a person experiences pain in any other part of the body, often that pain or discomfort can be ‘tolerated, endured, or ignored’ to some level until symptoms become bad enough that the person seeks treatment. When pain occurs in the Orofacial region however, it often sparks an immediate attention response consisting of a significant level of concern and worry.
The Orofacial region exists to perform many functions vital to human life support and therefore it is the most anatomically complex of all body systems, and has an enormous level of brain function and nerve supply dedicated to its daily operation.
The region performs functions such as breathing and smell, taste, sight, mastication (eating and chewing), swallowing, and communication (verbal and non-verbal).
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Often, patients suffering from an Orofacial Pain Disorder or Headache have undergone numerous dental procedures, have seen multiple Doctors and Specialists, have tried or are on many different prescription and non-prescription medications, and have had many medical tests, x-rays, CT scans, and MRI’s before being successfully diagnosed and treated.
Chronic Orofacial Pain presents very challenging diagnostic problems that are typically complicated by a variety of psychological and distressing factors, sleep disturbances, employment and family breakdowns, marriage and relationship difficulties, and complex medical conditions. Therefore, patients with Orofacial Pain often require multidisciplinary treatment approaches, whilst a correct diagnosis requires time, understanding, and listening to the patients chief complaints and their thorough description of the pain history.
Orofacial Pain Categories
The vast array of Orofacial Pain categories may be intracranial (within the skull) or extracranial (outside of the skull) in origin and include.
1. Idiopathic - of unknown origin
  • Atypical facial pain
  • Atypical odontalgia
  • Burning mouth syndrome
2. Musculoskeletal - arising from dysfunction of the muscles and / or bones and joints
  • Masticatory muscle disorders
    • Myofascial pain
    • Myospasm
    • Local myalgia
  • Temporomandibular joint disorders
    • Synovitis/capsulitis
    • Osteoarthritis / Rheumatoid arthritis
    • Disc displacement with reduction
    • Disc displacement without reduction
  • NICO (Neuralgia Inducing Cavitational Osteonecrosis) Lesions
  • Tension-type and Cervicogenic (neck origin) headaches.
3. Neuropathic - functional change in the peripheral or central nervous system
  • Episodic (occurs with periods of remission)
    • Trigeminal neuralgia
    • Glossopharyngeal neuralgia
  • Continuous
    • Herpetic neuralgia
    • Postherpetic neuralgia
    • Traumatic neuralgia
    • Eagle’s syndrome
4. Vascular
  • Giant cell (Temporal) arteritis
  • Carotid artery dissection
5 . Neurovascular – arising from nerves and the blood vessels they supply
  • Migraine
  • Cluster headache
  • Chronic paroxysmal hemicrania
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6. Psychogenic - containing an emotional or psychological component
  • Somatoform disorders
  • Factitious disorders
  • Malingering
7. Diseases that can cause facial pain
  • Local pathology – Dental decay and abscess, Periodontal disease, tumours, and ulcers in the mouth
  • Xerostomia (dry mouth syndrome
  • Trauma and / or surgery to the face
  • Distant pathology (referred pain)
  • Systemic diseases
Aetiology of Orofacial Pains
As described, pain is commonly a response to local tissue damage, which is termed acute pain. Specifically, in the orofacial region, the damage could have a variety of origins. The most frequent cause is dental caries, resulting in pulpitis . However, the differential diagnosis of pain in the face of non-odontogenic origin can be complex due to the multitude of possible causes.
Some Common Causes of Orofacial Pain
Dental Pulpitis, cracked tooth
Peroidontal Gingivities, Periodontitis, Periocoronitis
Mucosal Ulceration
Temporomandibular (TMJ) Traumatic acute dysfunction
Maxillary sinus Sinusitis and carcinoma
Salivary glands Sialadenitis, obstruction
Ear Otitis externa
Tonsils Quinsy
Referred Pain Angina, Cercvical spondylosis, lung cancer, eyes
A second form of pain is chronic, or neuropathic pain. Chronic pain is defined as pain lasting longer than three months, or pain that outlasts the inflammatory stimulus. As with acute orofacial pain, there are a plethora of possible causes for chronic orofacial pains.
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Some Common Causes of Chronic Pain in the Orofacial Region
Neurological Trigeminal neuralgia (tic douloureux). multiple sclerosis, post-herpetic and HIV.
Nociceptive Cancer, osteoarthritis
Imflammatory Rhematoid arthritis
Temporomandibular (TMJ) Facial athromyalgia
Vascular Migrane
Muscular Tension headache
Idiopathic Atypical odontalgia, idiopathic facial pain, burning mouth syndrome
Idiopathic and Atypical Facial Pains
Trigeminal neuralgia is a well known example of an idiopathic facial pain, in that the exact aetiology of the disorder is currently unknown. The pain however, is well described, being sudden, sharp or electric shock-like with non-painful stimuli frequently triggering the pain . It is observed that demyelination of the root entry zone of the trigeminal nerve is a common factor, which could be caused either vascular compression, or a mass lesion compression of the nerve . The disease can present in its atypical form , particularly following surgery to the oral cavity, head and neck, or ear nose and throat and is associated with an underlying, persistent burning pain in addition to the paroxysmal lancing pains associated with typical trigeminal neuralgia . After the exclusion of other differential diagnoses (particularly multiple sclerosis or intracranial masses) a diagnosis of trigeminal neuralgia is possible, and the patient can often be managed with carbamazepine, or referred for surgery. However, as described, some patients can present with pains that do not fulfil the criteria any known cause for orofacial pain, this makes their diagnosis one of exclusion of all other possible causes . Atypical facial pains are frequently referred to as being psychosomatic in Origin although they may well erroneously include unusual presentations of facial pains with known causes .
Persistent Idiopathic Orofacial Pain
As described, they include all clinical manifestations of pain which cannot be categorised, and have no known organic cause. Four main subgroupings of this pain can be identified which can present themselves clinically:
  • Atypical facial pain,
  • Atypical odontalgia,
  • Stomatodynia
  • Temporomandibular disorders.
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In addition to the stated difficulties associated with the differential diagnosis of facial pains and the exclusion of all possible organic causes, the disorders are situated at the interface of several medical specialities. Persistent idiopathic facial pain describes several unclassified symptoms of orofacial pain .
Atypical Odontalgia
Atypical odontalgia is defined as prolonged or throbbing pain in the teeth or alveolar process, but has no identifiable odontogenic cause. Patient whose atypical odontalgia was incorrectly diagnosed as being of endodontic origin and then as trigeminal neuralgia, which results in various unnecessary treatments and surgery by dental and oral surgeons, neurologists and a neurosurgeon. Unfortunately, such case histories are common. These treatments can exacerbate the pain and psychological anguish and frustration felt by the patient . In the absence of any identifiable cause, it is frequently assumed that patients must have a psychological disorder. An assumption for which little objective evidence exists . While atypical odontalgia and depression are clearly linked . It thought that the pain precedes depression, rather than being its cause . It is important to note that tricyclic antidepressants are frequently prescribed for patients with persistent idiopathic orofacial pains, but in lower doses than would be normal in patients with depression . While there are some purely psychosomatic pain syndromes are described, and must continue to be considered when diagnosing patients with persistent idiopathic orofacial pain, it is also worth considering various theories concerning the aetiology of atypical odontaligas.
Atypical odontalgia can be thought of as a “phantom tooth pain” and would therefore have a neuropathic cause, akin to the phantom sensations and stump pains, which are frequently felt by amputees . This mechanisms underlying amputees' phantom pains are not completely understood, but involve peripheral ectopic activities, neuroplasticity including central sensitisation, and cerebral organisation , which are also cited as possible pathological mechanisms for atypical odontalgias .
It is cited that invasive (dental, ent or maxillofacial) surgical procedures can lead to the partial or complete severing of primary afferent trigeminal nerve fibres, which can lead to neuropathic iatrogenic pain . a theory of bacterial infection in the region of the trigeminal nerve is has also been suggested . the damage may also have been preceded by a facial trauma . The initial surgical procedure may well have been carried out in order to relieve pain: pre-existing pain and infection are possible indicators of post-amputation pain .
Psychological issues cannot be ignored. patients may be pre-disposed, for example patients in a pain clinic were found to have high rate of sexual abuse histories , and is fully consistent with the “gate theory” . Atypical odontalgia is therefore likely to be a grouping of several disorders, some of which may be purely somatisation disorders (of psychological aetiology), others may involve neuropathies, or central sensitisation in the subnucleus caudalis of the trigeminal nerve . In each case, a perjorative labelling of the patient's pain as being purely “imagined” – which was the experience of 52% of patients – is only likely to add to the patient's psychological difficulties, the stigma attached to the disorder and their frustration with those treating them.
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Stomatodynia
This sensation of burning in the mouth is also termed glossopyrosis, glossodynia or oral dysaesthesia, and involves a burning sensation in the tongue, buccal mucosa, gingivae, palate and pharynx . The persistent, burning sensation is also associated with: “jaw pain, taste changes and subjective dry mouth, geographic and fissured tongue, painful teeth, loss of a comfortable jaw position, uncontrollable jaw tightness, headache, neck and shoulder pain, increased parafunctional activity, difficulty speaking, nausea, gagging and swallowing difficulties” . The pain is reported as being sufficient to cause difficulties in sleeping. there are various pathological causes for stomatodynia, including bacterial infections, xerostomia, irritation from dental prosthetics and materials .
In the absence of pathology, such patients are frequently thought, as with atypical odontalgia, to be suffering from depression, anxiety or hypochondria . The aetiology of the disorder is unclear, with a variety of local and systemic factors. Psychological factors are so often associated with the syndrome. That it is frequently viewed as being psychological in origin . Patients often erroneously receive various treatments and (dental) surgical procedures in the belief that there is a pathological cause for the disease . Various treatments have been proposed for idiopathic stomatodynia, including antidepressants, local treatment with capsaicin and local anaesthetics. The patient should be reassured that the pain is not caused by a grave illness, and that in some cases the symptoms can spontaneously go into remission . Possible neurological mechanisms in idiopathic stomatodynia have been implicated, including endogenous reduced dopamine . Understanding such neuropathologic mechanisms could lead to more effective treatments.
Temporomandibular Disorders and Phantom Bite Syndromes
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Temporomandibular disorders or craniomandibular disorders are a complex group of disorders whose origin lie in the musculoskeletal structures of the masticatory system, which can involve the structures of the temoromandibular joint (TMJ), the muscles and ligaments associated with the TMJ . In a number of cases, the systemic or traumatic aetiology of the disorder is known. However, in the majority of cases – estimated at 90 to 95% - the aetiology or pathological mechanism remains unclear. In these cases psychological factors have frequently been implicated, and not without good reason, since muscle tension or parafunctional oral habits, for example, form part of the disorder's aetiology . Other evidence shows that, as with other idiopathic facial pains, it is a stress related disorder . Stress related hormones of the hypothalamic-pituitary-adrenal axis are shown to have a significant psycho-neuro-endocrine effect, and serum serotonin levels have been shown to correlate inversely with tmj pain sensitivity. The role of oestrogen receptors present in the tmj musculature has been suggested as a reason why the disorder affects women more frequently . The muscles are innervated by the trigeminal nerve , which can lead to periphery and central sensitisation of the pain, which has been discussed also in previous sections. Pain responses in the tmj system are also related to the motor function of the muscles, leading to pain-spasm reponses or changes in the muscle tonicity. Although historically thought to be the case , malocclusion is not known to be a cause of or predisposing factor to tmj pain, and therefore orthodontic treatment to correct the occlusion is not indicated.). In addition to being a cause, the psychological consequences of the disorder should not be underestimated; the tmj is intimately involved with eating and speaking, which can lead to the avoidance of talking and eating in public, causing social isolation and strained relationships .
The limited knowledge of TMJ disorder pathologies also has an important medico-legal consequence in litigation for pain associated with whiplash injuries sustained in motor-vehicle accidents .
Phantom bite syndrome describes an interesting subgroup of temporomandibular disorders. In these cases the patient becomes preoccupied with his or her dental occlusion and complains that this leads to pain and discomfort. It was first described by Marbach as a psychiatric condition – monosymptomatic hypochondriacal psychosis. In such disorders, which are rare, the patient becomes fixated on one specific delusion . The syndrome has also been associated with body dysmorphic syndromes . However, recent research casts doubt on whether the syndrome is truly a pyschosis , and may be more akin to phantom pains felt by amputees. In this case, the pain is not a stump pain caused by trigeminal nerve damage as with atypical odontalgia, but instead is related to plasticity of brain function , involving changes in the somatotopic map at the amputation site and brain, possibly caused by the removal of inhibiting existing neurons . Given the orofacial structure's rich innervation and representation in the cortex. It is not surprising that subtle adjustments in occlusion during orthodontic or restorative dental treatment can result in significant sensual perception .
Know More about TMJ Disorders.
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‘Temporomandibular Joint’ Disorders
TMJ is an abbreviation for ‘Temporomandibular Joint’ (the jaw joints). Located just in front of both ears, each person has two TMJ’s that hinge the lower jaw to the rest of the skull. The TMJ has 2 movements: a rotation or hinge action that occurs as you open your mouth, and a gliding action, which is a movement that allows your mouth to open wider. The coordination of these two actions allows you to perform many functions with your mouth and teeth such as chew, yawn, shout, whistle, talk, and sing. To keep the movements of the jaw smooth, a disc lies in between the head of the jaw joint (condyle) and the bone of your skull (temporal bone). The disc prevents the bones of the jaw joint and skull from rubbing against each other, and provides a shock absorber to the forces created when chewing.
The abbreviations TMD, TMJD, and CMD are all used interchangeably to describe a condition or dysfunction involving the jaw joints and the head and neck region. Most health practitioners involved in treating jaw joint problems use the term TMD that stands for Temporomandibular Joint Disorder.
Normal Jaw Function
In the normal healthy functioning TMJ, the disc is situated on the top of the condyle in the 2 o’clock position. When the mouth opens and closes, or the jaw moves from side to side, the disc stays in contact with the condyle at all times and provides smooth and pain free range of motion. No clicking, grating, popping, or other jaw joint noises are heard when the disc is in its correct position and remains there during all jaw movements.
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Disc Displacement With Reduction
When a jaw joint problem has been occurring long enough for example either through chronic tooth clenching/grinding (micro trauma) or from an injury (macrotrauma), often the disc will become displaced, or positioned forward to the condyle.
When the mouth opens or is moved from side to side, the disc bunches up against the condyle and gets stretched until it ‘pops, cracks, or clicks’ and recaptures into its correct position. This can happen every time the jaw is opened or moved, or only occasionally. It typically is much worse in the mornings on waking. It can either be very quiet and heard only by the person themselves, or sometimes it can be loud enough to be heard across the table and by everyone in the room.
When the mouth opens or is moved from side to side, the disc bunches up against the condyle and gets stretched until it ‘pops, cracks, or clicks’ and recaptures into its correct position. This can happen every time the jaw is opened or moved, or only occasionally. It typically is much worse in the mornings on waking. It can either be very quiet and heard only by the person themselves, or sometimes it can be loud enough to be heard across the table and by everyone in the room.
Disc displacement Without Reduction
When a jaw joint problem has been present for long enough, or following a fall or sudden blow to the jaw, often the person is suddenly unable to open their mouth or move their jaw very far from side to side. Most commonly patients report that their jaw “has clicked all my life then suddenly stopped”, or “I woke up this morning and my jaw was locked shut”. When this occurs, the disc no longer is able to be recaptured back onto the condyle during normal jaw movements. It becomes trapped forward of the condyle and bunches up restricting jaw movement and mouth opening. Often a lot of pain is associated with this condition and urgent correct repositioning and stabilisation treatment is vital to prevent a long term and chronic problem from developing.
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Progression of TMJ Diseases and Disorders:
When symptoms arise many TMJ problems improve on their own within days or weeks without treatment by following simple conservative self-management techniques. This is particularly true for people who suffer with ‘muscle only’ causes of pain. For others however, symptoms worsen over time and develop into long-term, persistent and debilitating pain that often has a major impact on a persons quality of life.
What are the Common Signs and Symptoms?
People whom suffer from TMD most often report:
Medical –
  • Headaches and migraines
  • Neck stiffness
  • Ear problems (tinnitus, pain, stuffiness)
  • Dizziness
  • Facial pain and soreness
  • Tiredness and insomnia
  • Excessive daytime sleepiness
  • Snoring and Sleep Apnoea
  • Lower back problems
  • Shoulder and muscle tenderness
  • Postural problems
  • Sinus problems
  • Cold hands and feet
  • Poor circulation
  • Depression
Dental –
  • Sore or sensitive teeth
  • Teeth and fillings that continually crack or break
  • Teeth grinding
  • Jaw clenching
  • Chewing difficulties
  • Loose teeth
  • Limited mouth opening
  • Jaw joint pain and stiffness
  • Jaw noises such as clicking and grating
  • Jaw locking open or closed..
Why Should you Fix it?
Often, the person and health care provider may not even realise that a TMD is present and is contributing to or is the cause of the existing health complaints and symptoms. This makes treatment very frustrating for both the patient and the practitioner.
In these cases the symptoms do not resolve completely, or they keep returning and thus the patient needs to be placed on a ‘maintenance’ schedule, or are told they need to ‘learn to live with it’. In many other cases long-term medications are prescribed to mask or reduce symptoms as the cause of the condition cannot be found or isolated.
In the majority of these cases, without treating the TMD many symptoms cannot be stabilised and allowed to heal. And vice versa, without treating the other symptoms, we often cannot alleviate the TMD.
Diagnosis of a person suffering from TMD can be very complicated and confusing. The disorder and resultant symptoms and dysfunction often results in significant pain and impairment because the disorder transcends many boundaries of health professions – in particular dentistry, neurology, general medicine, physiotherapy, osteopathy, and psychology.
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Therefore, in many cases treatment may involve a ‘team’ of people with specialised skills and may occur over a period of months rather than days or weeks. This is especially true for those patients that have a chronic long-term condition that has developed into a ‘pain cycle’.
A correct diagnosis involves the use of highly specialised and computerised diagnostic equipment, x-rays, CT scans, MRI’s, jaw measurements, plaster models of your teeth, airway assessment, photographs, and a very thorough medical history.
Treament Of TMD
Only after a confirmed diagnosis of TMD will any form of treatment be suggested.
Treatment is aimed at reducing muscle pain, improving sleep quality, ‘decompressing’ the TMJ, and improving body posture. By positioning your lower jaw and teeth in an orthopedic relationship with the upper jaw that is termed ‘neuromuscular’ so your head and neck muscles are in a relaxed state, they automatically will guide you into a comfortable corrected bite. This position is then recorded and confirmed using various tests and computerised equipment.
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Depending on the diagnosis made and the severity of the TMD, a night orthosis (splint), and/or a day orthosis are then constructed. Your new bite relationship is held in place by the custom made plastic orthosis that fits over the teeth for wear during waking hours, and one that is worn during sleep.
In the majority of cases however (70%), only a night orthotic is needed, and in other’s, the use of partial dentures, overlay dentures, or other custom designed appliances may also be used to hold and maintain your new bite position. And in many other cases simple exercises and self-management techniques are prescribed. The exact nature of the treatment is based entirely on the diagnosis for each individual.
Trigeminal Neuralgia
Trigeminal neuralgia is the most common facial pain syndrome and is often described as "the most terrible pain known to man". Trigeminal neuralgia is characterized by a sudden (paroxysmal) attack of facial pain described as intense, sharp, like an electric-shock, or stabbing. The pain is most commonly felt in the cheekbone, most of the nose, upper lip and upper teeth and, in some people, it also extends to the lower lip, teeth, and chin. Pain is usually felt on one side of the face (unilateral) and lasts from a few seconds to two minutes. Trigeminal neuralgia is the most frequently occurring nerve pain disorder.
Trigeminal neuralgia is also called tic douloreux because there is a characteristic muscle spasm that typically accompanies a pain attack. Patients with trigeminal neuralgia report that the intermittent pain attacks and the anticipatory anxiety from not knowing when they will occur result in a significant deterioration of their quality of life and interfere with daily activities such as eating and sleeping.
There are 12 pairs of nerves, called cranial nerves, which provide the nerve supply (innervate) to the right and left side of the head and neck. The trigeminal nerve is the 5th and largest of the cranial nerves and is designated as cranial nerve number V. It provides nerve sensation to the face, mouth, and the front of the scalp as well as controlling the muscles involved in chewing (mastication). The trigeminal nerve also enables us to feel sensations in the mouth and face such as taste, touch, and pain.
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The trigeminal nerve has three branches.
  • The ophthalmic branch runs through the eye, forehead and nose.
  • The maxillary branch runs through the upper teeth, gums, lips, cheek, lower eyelid and side of the nose.
  • The mandibular branch runs through the lower teeth, gums and lip. It also controls jaw movement for mastication or chewing.
Trigeminal neuralgia most often affects the maxillary branch or the mandibular branch of the trigeminal nerve. Most patients complain of pain in both the maxillary and mandibular branches.
The average age of onset is between 50 and 70 years old, though it can be seen in younger people as well. The incidence of trigeminal neuralgia gradually increases with age. Almost twice as many women are affected by trigeminal neuralgia as men.
The Primary Goals of Treatment for Patients with Trigeminal Neuralgia Include:
  • Controlling the symptoms.
  • Relieving severe facial pain.
  • Treating the underlying cause of trigeminal neuralgia in cases where an underlying cause has been identified.
  • Enabling the patient to function and lead a reasonably good quality of life.
Understanding the standard treatments - and the treatment options - is critical for successfully achieving the goals of treatment for trigeminal neuralgia.
  • The major types of medications that are commonly prescribed to relieve pain in patients with trigeminal neuralgia including anticonvulsants,antidepressants, and muscle relaxants.
  • The role of nerve blocks with drugs such as local anesthetics or ethanol in the management of trigeminal neuralgia.
  • The surgical treatment options that are available for patients with intractable trigeminal neuralgia that cannot be adequately controlled with medications, which include:
    • Microvascular decompression surgery
    • Percutaneous rhizotomy (gangliolysis)
  • Non-surgical treatment option called stereotactic radiosurgery (Gamma Knife) that has recently become available and has been shown to be effective for the treatment of trigeminal neuralgia in many patients.
Conclusion
Patients suffering from idiopathic orofacial pain as described may well present to a dental surgeon in the first instance. However, in these cases dental treatment is inappropriate, and may serve to exacerbate the pain . The anatomic complexity of the orofacial region overlaps several medical specialities . It is therefore wrong to perceive idiopathic facial pains as primarily a “dental” problem. Although orofacial pain and dentistry are synonymous. orofacial pains have a notable prevalence in the population, affecting around 10% of the adult population at any one time . The diagnosis of atypicial orofacial pain is one of exclusion , which means the patient must undergo a battery of tests, often carried out by several medical specialities. a mechanistic dogma. Which views pain as being the result of a peripheral stimulus frequently led to the description of such pains as being purely psychosomatic: it shown that more recent research into the neurobiology of pain casts doubt on this conclusion and there are a number of putative causes for these pains, though the link between the patient's mental state and sensation of pain cannot be ignored. The patient quoted shows just how distressing and pejorative it is to label the patient's pain as being purely mental: chronic orofacial pain is anything but “all in the mind” .
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