Orofacial Pain

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Orofacial Pain. A relatively common symptom. Sources of orofacial pain include caries, periodontitis, neuropathic, and musculoskeletal conditions. Symptoms of pain may represent different phases of acute or chronic conditions.
Orofacial Pain

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Orofacial Pain

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  • A relatively common symptom.

  • Sources of orofacial pain include caries, periodontitis, neuropathic, and musculoskeletal conditions.

  • Symptoms of pain may represent different phases of acute or chronic conditions.

  • Based on NHIS data from 1989, survey participants representing 39 million adults reported experiencing at least one of five orofacial pain symptoms in the past 6 months:

    • tooth pain,

    • mouth sores,

    • jaw joint pain,

    • facial pain,

    • burning mouth

      (Lipton et al., 1993).

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  • Orofacial pain is often divided into two categories.chronic and acute.

  • The National Center for Health Statistics generally uses a cut off point of 3 months to distinguish between acute and chronic pain.

  • Currently, there are no national data on orofacial pain for children.

  • Data sources other than the 1989 NHIS include studies on a population of elderly adults (65+) living in 10 northern Florida counties (Riley et al., 1998); studies of adults 45 and older, also located in northern Florida (Gilbert et al., 1997); a survey of adults in Toronto (Locker & Grushka, 1987); and studies on temporomandibular joint disorder, or TMD, reviewed by LeResche (1997).

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What types of orofacial pain do we see?

  • Community

    • Macfarlane et al 2004 – n = 125 total 1510

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Prevalence orofacial pain no TMJ

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Prevalence TMJ pain in adults

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Prevalence of selected pain conditions by poverty status: US adults, 18 years and over

Adjusted for age

SOURCE: Lethbridge-Cejku M, Rose D, Vickerie J. Summary health statistics for US Adults: National Health Interview Survey, 2004. National Center for Health Statistics.Vital Health Stat 10 (228). Hyattsville, MD 2006

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Chronic Orofacial pain

  • The cost of chronic pain is estimated to be about $80 billion per year, 40% associated with orofacial pain (Israel & Scrivani, 2000; Friction & Schiffman, 1995).

  • The two most prevalent sources of chronic orofacial pain are temporomandibular joint disorder (TMD) and burning mouth syndrome.

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Chronic Orofacial pain

  • TMD consists of jaw joint pain and dull facial pain in the temporomandibular joint and the muscles of mastication. Chronic TMD is estimated to affect from 3% to 12% of the U.S. population (Klausner, 1995).

  • Burning mouth syndrome is characterized as a burning, tender, or annoying sensation in the mouth with no apparent mucosal lesion.

  • In 1989, the prevalence of jaw joint pain, burning mouth, and dull facial pain in the U.S. population was 5.3%, 0.7%, and 1.5%, respectively.

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Acute orofacial pain

  • Acute orofacial pain includes tooth pain and painful sores or irritations of the mouth.

  • Tooth pain is often caused by dental caries but may also be due to periodontal disease.

  • Tooth pain can interfere with work and social activities, promote anxiety, and result in economic costs.

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Acute orofacial pain

  • Data from the 1989 NHIS Orofacial Pain Supplement indicate that the overall prevalence of tooth pain and of mouth sores in the United States was 13.6% and 8.4%, respectively.

  • The prevalence of tooth pain was higher among adults 20 to 64 years of age than among those 65 and older, those with lower education, poorer people, and those who visited a dentist within the past 12 months. (Vargas et al. 2000 and Lipton et al. 1993)

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Prevalence of orofacial pain in a sample of adults in the USA during a 6-month period (Lipton 1993)

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Percentage of oral facial pain among adults in USA and Canada (Goulet et al., 1995; Lipton et al., 1993; & Ripley et al., 2001)

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Proportion of subjects with no, mild, moderate and severe jaw pain reporting sleep problems, difficulty in opening and joint clicking in Quebec (Goulet et al., 1995)

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Other studies

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“The subject’s conscious perception of modulated nociceptive impulses that generate an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”

(IASP definition, 1994)

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History and Description of Pain

  • Compliant

  • Site of pain

  • What starts the pain

  • Duration of attack

  • Pain intensity

  • Quality of pain

  • When pain was first noted

  • When pain occurs

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History Examination ofOrofacial Pain

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History Ex. of Orofacial Pain

C. Characteristics of pain

  • Quality of pain

  • Behaviour of pain

    • Temporal

    • Frequency

    • Duration

  • Intensity

  • Concomitant symptoms

  • Flow of pain

1. Chief complaints

A. Location of pain

B. Onset of pain

  • Association with other factors

  • Progression

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History Ex. of Orofacial Pain

  • E. Past consultation and/or treatment

  • F. Relationship to other complaints

  • 2. Past medical history

  • 3. Review of systems

  • 4. Psychological assessment

  • 1. Chief complaints (cont.)

    D. Aggravating and alleviating factors

    • Physical modalities

    • Function and parafunction

    • Sleep disturbances

    • Medications

    • Emotional stress

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    Clinical Examination of Orofacial Pain

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    Clinical Examination

    E. Cervical evaluation

    F. Balance and co-ordination

    2. Muscle examination

    A. Pulpation

    • Pain and tenderness

    • Trigger points and pain referal

    1. General examination

    A. Vital signs

    • Blood pressure

    • Pulse rate

    • Respiratory rate

    • Temperature

      B. Cranial nerve evaluation

      C. Eye evaluation

      D. Ear evaluation

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    Clinical Examination

    C. Oral structures

    • Mucogingival tissues

    • Teeth

    • Periodontium

    • Occlusion

      4. Other diagnostic tests

      A. Imaging

      B. Laboratory tests

      C. Psychologic provocation tests

    3. Masticatory evaluation

    A. Range of mandibular movement

    • Measurement

    • Pain

      B. Temoromandibular joint evaluation

    • Pain

    • Dysfunction

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    The Erlanger/Gasser classification of nerve fibres (1939)

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    Characteristics of pulpal sensory fibres (Trowbridge and Kim, 1991)

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    Orofacial Pain

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    Signs and Symptoms of Stress

    • Physical Signs and Symptoms

    • Emotional Signs and Symptoms

    • Cognitive/Perceptual Signs and Symptoms

    • Behavioral Signs and Symptoms

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    1. Physical Signs and Symptoms of Stress

    increased heart rate; pounding heart; elevated blood pressure; sweaty palms; tightness of the chest, neck, jaw and back muscles; headache; diarrhea; constipation; urinary hesitancy; trembling, twitching;

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    1. Physical Signs and Symptoms of Stress

    stuttering and other speech difficulties; nausea; vomiting; sleep disturbances; fatigue; shallow breathing; dryness of the mouth or throat; susceptibility to minor illness, cold hands, itching; being easily startled; chronic pain and dysponesis

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    2. Emotional Signs and Symptoms of Stress

    • irritability, angry outbursts, hostility,

    • depression, jealously, restlessness, withdrawal,

    • anxiousness, diminished initiative,

    • feelings of unreality or overalertness,

    • reduction of personal involvement with others, lack of interest, tendency to cry,

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    2. Emotional Signs and Symptoms of Stress

    • being critical of others, self-deprecation,

    • nightmares, impatience,

    • decreased perception of positive experience opportunities,

    • narrowed focus, obsessive rumination,

    • reduced self-esteem, insomnia,

    • changes in eating habits and weakened positive emotional response reflexes

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    3. Cognitive/Perceptual Signs and Symptoms of Stress

    • forgetfulness, preoccupation, blocking,

    • blurred vision, errors in judging distance,

    • diminished or exaggerated fantasy life, reduced creativity,

    • lack of concentration, diminished productivity,

    • lack of attention to detail,

    • orientation to the past,

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    3. Cognitive/Perceptual Signs and Symptoms of Stress

    • decreased psychomotor reactivity and coordination,

    • attention deficit, disorganization of thought,

    • negative self-esteem,

    • diminished sense of meaning in life,

    • lack of control/need for too much control,

    • negative self-statements and negative evaluation of experiences

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    4. Behavioral Signs and Symptoms of Stress

    • increased smoking,

    • aggressive behaviors (such as driving),

    • increased alcohol or drug use,

    • carelessness,

    • under-eating, over-eating,

    • withdrawal, listlessness,

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    4. Behavioral Signs and Symptoms of Stress

    • hostility,

    • accident-proneness,

    • nervous laughter,

    • compulsive behavior and impatience

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    Sensory Arousal

    Respiratory control

    Pituitary gland

    Sympathetic NS

    GI system

    Adrenal cortex


    Adrenal medulla

    Cardiovascular system


    Immune-Inflam response

    Electrolyte water control



    Limbic system

    Metabolic and Haemostatic changes

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    • Stress ส่งผลให้มีการเพิ่มการหลั่งACTH, GH, PRL, beta-endorphine, ADH, insulin and glucagonACTH --> cortisol --> NE --> E

    • Stress stimulate sympathetic nervous systemCardiac Output, Stroke Volume, systolic Blood Pressure blood flow to muscle, skin blood glucose rate of blood coagulation

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    Cardiovascular responses

    • Increase Heart rate, Cardiac output, Blood pressure, muscle blood flow

    • ผู้ป่วยที่มีภาวะ hypertension, obesity, high fat dietStress --> cortisol or epihephine --> cholesterol --> coronary artery disease Arteriosclerosis Myocardial infarction Other

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    Gastrointestinal responses

    • อาหารติดคอ, ปวดท้อง, diarrhea, fullness, nausea หลังอาหารincrease gastric acid, mobility --> peptic ulcer

    • Respiratory responses Hyperventilation --> hypocapnea Cerebral vasoconstriction dizziness, confusion, paraesthesia, tetany

      Cooling --> trigger --> asthmatic attack

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    Immunological responses

    • Cortisol CMI – cancer HMI – allergy

    • Metabolic – haemostatic changes Lipolysis Insulin hyperglycemia ระวังใน DM Glucagon Adrenaline

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    ความเครียด – โรคทางช่องปาก

    • โรคฟันผุ – โพรงประสาทฟัน – ปลายรากฟันStress decrease saliva flowวัยรุ่น – salivary flow + immune ถูกกดความกดอากาศ – aerodontalgia RCT --> stress --> pain from blood pressure Experimental animal stress --> caries

    • โรคปริทันต์NUG = stress

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    ความเครียด – โรคทางช่องปาก

    • Clenching – bruxism –TMDฟันสึก, โรคปริทันต์, ฟันแตก, masseter muscle เกร็งโต, ปวดหัวผู้ป่วยที่มี TMD = stress ปานกลาง ถึง สูง

    • Bad habitดูดนิ้ว กัดแก้ม, กัดปาก, กัดเล็บ --> malocclusionTongue thrusting

    • Aphthous – herpetic lesionExperimental animal (stress from noise) --> herpetic lesion

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    Sign and symptoms of depression

    Fatigue Muscle achesAlcohol-substance abuse Behavioral disturbancesPessimism (มองโลกแง่ร้าย) Marital problemsHeadache DiarrheaAnxiety Excessive perspirationConstipation(ท้องผูก) HyperventilationPhobias Blurred visionCrying episodes Dry or flushed skinIrritability Slurred speechVertigo Urinary tract disturbancesParesthesias Work inhibition, weakness

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