orofacial pain. a relatively common symptom. sources of orofacial pain include caries,...

Orofacial PainOrofacial 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. •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).

http://drc.hhs.gov/report/pdfs/section10-orofacialpain.pdf

• 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).


What types of orofacial pain What types of orofacial pain do we see?do we see?

• Community Community – Macfarlane et al 2004 – n = 125 total 1510Macfarlane et al 2004 – n = 125 total 1510

DentalDental ML/ soft tissueML/ soft tissue Neuro/vasc Neuro/vasc

33%33% 39%39% 28%28%

Prevalence orofacial pain no TMJ

Sample, AuthorSample, Author SampleSample Type of painType of pain Prevalence Prevalence %%

UK Aggarwal 2005UK Aggarwal 2005 22992299 Chronic facial Chronic facial painpain

77

UK, Macfarlane 2002UK, Macfarlane 2002 25042504 Facial painFacial pain 2626

USA, Lipton 1993USA, Lipton 1993 4571145711 Facial painFacial pain 1.41.4

Canada, Locker 1987Canada, Locker 1987 10141014 Orofacial painOrofacial pain 4.94.9

UK, Richards 1996UK, Richards 1996 997997 Orofacial painOrofacial pain 3.13.1

France, Munoz 1988France, Munoz 1988 11441144 Head , faceHead , face 2.72.7

Prevalence TMJ pain in adults

SampleSample

authorsauthors

Size of Size of samplesample

Type of painType of pain Prevalence Prevalence ranges %ranges %

FinlandFinland

Helkino 1974Helkino 1974

600600 Face and Face and jaw painjaw pain

12-1512-15

USAUSA

Von Korff 1988Von Korff 1988

10161016 Muscle and Muscle and joint painjoint pain

1212

USAUSA

Lipton 1993Lipton 1993

4237042370 Jaw painJaw pain 3.9-6.53.9-6.5

JapanJapan

Matuska 1996Matuska 1996

672672 TMJ, face TMJ, face painpain

5.7-15.25.7-15.2

0

10

20

30

40

Migraine Neck Pain Back Pain Face/Jaw Pain

Pe

rce

nta

ge

Poor Near Poor Not Poor

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

Chronic Orofacial painChronic 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.


Chronic Orofacial painChronic 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.


Acute orofacial painAcute 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.

Acute orofacial painAcute 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)

OROFACIAL PAINOROFACIAL PAINin in

CANADACANADA

Prevalence of orofacial pain in a sample of Prevalence of orofacial pain in a sample of adults in the USA during a 6-month period adults in the USA during a 6-month period

(Lipton 1993)(Lipton 1993)

0

2

4

6

8

10

12

14

toothache oral sores jaw pain face/cheek burning

mouth

Female Male

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

al., 1993; & Ripley et al., 2001)al., 1993; & Ripley et al., 2001)

14

8.89.6

4 4.46.2

0

5

10

15

20

Quebec USA USA

Female

Male

Proportion of subjects with no, mild, moderate Proportion of subjects with no, mild, moderate and severe jaw pain reporting sleep problems, and severe jaw pain reporting sleep problems,

difficulty in opening and joint clicking in difficulty in opening and joint clicking in Quebec (Goulet et al., 1995)Quebec (Goulet et al., 1995)

17

16

27

4

14

2431

1320

32

59

0

10

20

30

40

50

60

70

None Mild Moderate Severe

Diffi culty in opening J oint clicking Sleep porblems

OROFACIAL PAINOROFACIAL PAINin in

Other studiesOther studies

““The subject’s conscious perception of The subject’s conscious perception of

modulated nociceptive impulses that generate an modulated nociceptive impulses that generate an

unpleasant sensory and emotional experience unpleasant sensory and emotional experience

associated with actual or potential tissue associated with actual or potential tissue

damage, or described in terms of such damage”damage, or described in terms of such damage”

PainPain

(IASP definition 1,994)

History and Description of PainHistory and Description of Pain

• CompliantCompliant

• Site of painSite of pain

• What starts the What starts the painpain

• Duration of attackDuration of attack

• Pain intensityPain intensity

• Quality of painQuality of pain

• When pain was first When pain was first notednoted

• When pain occursWhen pain occurs

History Examination History Examination ofof

Orofacial Pain Orofacial Pain

History Ex. of Orofacial Pain History Ex. of Orofacial Pain 1. Chief complaints

A. Location of painB. Onset of pain

– Association with other factors– Progression

C. Characteristics of pain– Quality of pain– Behaviour of pain

– Temporal– Frequency– Duration

– Intensity– Concomitant symptoms– Flow of pain

History Ex. of Orofacial Pain History Ex. of Orofacial Pain

1. Chief complaints (cont.)

D. Aggravating and alleviating factors

– Physical modalities– Function and parafunction– Sleep disturbances– Medications– Emotional stress

E. Past consultation and/or treatmentF. Relationship to other complaints

2. Past medical history3. Review of systems4. Psychological assessment

Clinical Examination Clinical Examination of of


Clinical Examination Clinical Examination 1. General examination

A. Vital signs– Blood pressure– Pulse rate– Respiratory rate– Temperature

B. Cranial nerve evaluationC. Eye evaluationD. Ear evaluation

E. Cervical evaluationF. Balance and co-ordination

2. Muscle examinationA. Pulpation

– Pain and tenderness– Trigger points and pain referal

Clinical Examination Clinical Examination

3. Masticatory evaluationA. Range of mandibular movement

– Measurement– Pain

B. Temoromandibular joint evaluation

– Pain– Dysfunction

C. Oral structures– Mucogingival tissues– Teeth– Periodontium– Occlusion

4. Other diagnostic testsA. ImagingB. Laboratory testsC. Psychologic provocation tests

The Erlanger/Gasser classification of The Erlanger/Gasser classification of nerve fibres (1939)nerve fibres (1939)

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

Stress Stress and and


ENVIRONMEENVIRONMENTNT

BEHAVIOURBEHAVIOUR

NERVOUS NERVOUS SYSTEMSYSTEM

HOMEOSTASIHOMEOSTASISSIMMUNE IMMUNE SYSTEMSYSTEM

ENDOCRINE ENDOCRINE SYSTEMSYSTEM

STRESS

PITUITPITUITARY ARY ADREADRE

NAL NAL GLANGLAN

DD

IMMIMMUNE UNE CELLCELL

BRAIBRAINN

HYPOTHAHYPOTHALAMUSLAMUS

HIPPOCAHIPPOCAMPUSMPUS

IL-1IL-1

glucocoglucocorticoidsrticoids

ACACTHTH

glucocoglucocorticoidsrticoids

CRHCRH

Signs and Signs and Symptoms of Symptoms of

StressStress1.1.Physical Signs and SymptomsPhysical Signs and Symptoms

2.2.Emotional Signs and Emotional Signs and SymptomsSymptoms

3.3.Cognitive/Perceptual Signs Cognitive/Perceptual Signs and Symptomsand Symptoms

4.4.Behavioral Signs and Behavioral Signs and SymptomsSymptoms

1. Physical Signs and 1. Physical Signs and Symptoms of StressSymptoms of Stress

increased heart rate; pounding increased heart rate; pounding heart; elevated blood pressure; heart; elevated blood pressure; sweaty palms; tightness of the sweaty palms; tightness of the

chest, neck, jaw and back chest, neck, jaw and back muscles; headache; diarrhea; muscles; headache; diarrhea;

constipation; urinary hesitancy; constipation; urinary hesitancy; trembling, twitching; trembling, twitching;

1. Physical Signs and 1. Physical Signs and Symptoms of StressSymptoms of Stressstuttering and other speech stuttering and other speech

difficulties; nausea; vomiting; difficulties; nausea; vomiting; sleep disturbances; fatigue; sleep disturbances; fatigue;

shallow breathing; dryness of the shallow breathing; dryness of the mouth or throat; susceptibility to mouth or throat; susceptibility to minor illness, cold hands, itching; minor illness, cold hands, itching; being easily startled; chronic pain being easily startled; chronic pain

and dysponesisand dysponesis

2. Emotional Signs 2. Emotional Signs and Symptoms of and Symptoms of

StressStress• irritability, angry outbursts, hostility, irritability, angry outbursts, hostility, •depression, jealously, restlessness, depression, jealously, restlessness,

withdrawal, withdrawal, •anxiousness, diminished initiative, anxiousness, diminished initiative, •feelings of unreality or overalertness, feelings of unreality or overalertness, •reduction of personal involvement reduction of personal involvement

with others, lack of interest, with others, lack of interest, tendency to cry, tendency to cry,

2. Emotional Signs 2. Emotional Signs and Symptoms of and Symptoms of

StressStress•being critical of others, self-deprecation, being critical of others, self-deprecation, •nightmares, impatience, nightmares, impatience, •decreased perception of positive decreased perception of positive

experience opportunities, experience opportunities, •narrowed focus, obsessive rumination, narrowed focus, obsessive rumination, •reduced self-esteem, insomnia, reduced self-esteem, insomnia, •changes in eating habits and weakened changes in eating habits and weakened

positive emotional response reflexespositive emotional response reflexes

3. 3. Cognitive/Perceptual Cognitive/Perceptual

Signs and Signs and Symptoms of StressSymptoms of Stress•forgetfulness, preoccupation, blocking, forgetfulness, preoccupation, blocking, •blurred vision, errors in judging distance, blurred vision, errors in judging distance, •diminished or exaggerated fantasy life, diminished or exaggerated fantasy life,

reduced creativity, reduced creativity, • lack of concentration, diminished lack of concentration, diminished

productivity, productivity, • lack of attention to detail, lack of attention to detail, •orientation to the past, orientation to the past,

•decreased psychomotor reactivity and decreased psychomotor reactivity and coordination, coordination,

•attention deficit, disorganization of attention deficit, disorganization of thought, thought,

•negative self-esteem, negative self-esteem, •diminished sense of meaning in life, diminished sense of meaning in life, • lack of control/need for too much control, lack of control/need for too much control, •negative self-statements and negative negative self-statements and negative

evaluation of experiencesevaluation of experiences

3. 3. Cognitive/Perceptual Cognitive/Perceptual

Signs and Signs and Symptoms of StressSymptoms of Stress

4. Behavioral Signs 4. Behavioral Signs and Symptoms of and Symptoms of

StressStress• increased smoking, increased smoking, •aggressive behaviors aggressive behaviors (such as driving), (such as driving),

• increased alcohol or drug increased alcohol or drug use, use,

•carelessness, carelessness, •under-eating, over-eating, under-eating, over-eating, •withdrawal, listlessness, withdrawal, listlessness,

4. Behavioral Signs 4. Behavioral Signs and Symptoms of and Symptoms of

StressStress•hostility, hostility, •accident-proneness, accident-proneness, •nervous laughter, nervous laughter, •compulsive behavior compulsive behavior and impatienceand impatience

Metabolic and Metabolic and Haemostatic Haemostatic

changeschanges

Memory PsycheSensory Arousal

Limbic system

Respiratory controlPituitary glandSympathetic NSGI system

Adrenal cortexKidneyAdrenal medulla

Immune-Inflam Immune-Inflam responseresponse

AdrenalineAdrenaline Cardiovascular Cardiovascular systemsystem

Electrolyte water control

MetabolismHaemostasis-fibrinolysis

ความเครี�ยดกั�บโรีคทางความเครี�ยดกั�บโรีคทางรี�างกัายรี�างกัาย

• Stress Stress ส่�งผลให้�ม�กัารีเพิ่��มกัารีห้ล��งส่�งผลให้�ม�กัารีเพิ่��มกัารีห้ล��ง ACTH, GH, ACTH, GH, PRL, beta-endorphine, ADH, insulin PRL, beta-endorphine, ADH, insulin and glucagonand glucagon

ACTH --> cortisol --> NE --> EACTH --> cortisol --> NE --> E• Stress stimulate sympathetic Stress stimulate sympathetic

nervous systemnervous system Cardiac Output, Stroke Volume, Cardiac Output, Stroke Volume,

systolic Blood Pressuresystolic Blood Pressure blood flow to muscle, skin blood flow to muscle, skin blood glucose blood glucose rate of blood coagulation rate of blood coagulation

Cardiovascular Cardiovascular responsesresponses

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

• ผ��ป่�วยท��ม�ภาวะ ผ��ป่�วยท��ม�ภาวะ hypertensionhypertension , , obesity, obesity, high fat diethigh fat dietStress --> cortisol or epihephine --> Stress --> cortisol or epihephine --> cholesterol --> coronary artery cholesterol --> coronary artery diseasedisease

ArteriosclerosisArteriosclerosisMyocardial infarctionMyocardial infarctionOtherOther

Gastrointestinal Gastrointestinal responsesresponses

• อาห้ารีติ�ดคออาห้ารีติ�ดคอ , , ป่วดท�องป่วดท�อง , , diarrhea, fullness, diarrhea, fullness, nausea nausea ห้ล�งอาห้ารีห้ล�งอาห้ารี

increase gastric acid, mobility --> increase gastric acid, mobility --> peptic ulcerpeptic ulcer

• Respiratory responsesRespiratory responsesHyperventilation --> hypocapneaHyperventilation --> hypocapneaCerebral vasoconstrictionCerebral vasoconstrictiondizziness, confusion, dizziness, confusion,

paraesthesia, tetanyparaesthesia, tetany

Cooling --> trigger --> asthmatic attackCooling --> trigger --> asthmatic attack

Immunological Immunological responsesresponses

• Cortisol Cortisol CMI – cancerCMI – cancerHMI – allergyHMI – allergy

• Metabolic – haemostatic Metabolic – haemostatic changeschanges

LipolysisLipolysisInsulinInsulin

hyperglycemia hyperglycemia รีะว�งใน รีะว�งใน DMDMGlucagonGlucagonAdrenalineAdrenaline

– ความเครี�ยด โรีคทางช่�อง – ความเครี�ยด โรีคทางช่�องป่ากัป่ากั

• โรีคฟั%นผ& โพิ่รีงป่รีะส่าทฟั%น ป่ลายรีากัฟั%น– –โรีคฟั%นผ& โพิ่รีงป่รีะส่าทฟั%น ป่ลายรีากัฟั%น– –Stress decrease saliva flowStress decrease saliva flowว�ยรี&�น –ว�ยรี&�น – salivary flowsalivary flow + + immune immune

ถู�กักัดถู�กักัด ความกัดอากัาศ –ความกัดอากัาศ – aerodontalgiaaerodontalgia

RCT --> stress --> pain from RCT --> stress --> pain from blood pressureblood pressure

Experimental animal stress --Experimental animal stress --> caries> caries

• โรีคป่รี�ท�นติ)โรีคป่รี�ท�นติ)NUG = stressNUG = stress

ความเครี�ยด โรีคทางช่�อง–ความเครี�ยด โรีคทางช่�อง–ป่ากัป่ากั• Clenching – bruxism –TMDClenching – bruxism –TMD

ฟั%นส่*กัฟั%นส่*กั , , โรีคป่รี�ท�นติ)โรีคป่รี�ท�นติ) , , ฟั%นแติกัฟั%นแติกั , , masseter masseter muscle muscle เกัรี,งเกัรี,ง โติโติ , , ป่วดห้�วป่วดห้�ว

ผ��ป่�วยท��ม� ผ��ป่�วยท��ม� TMD = stress TMD = stress ป่านกัลาง ถู*ง ส่�งป่านกัลาง ถู*ง ส่�ง• Bad habitBad habit

ด�ดน�-วด�ดน�-วกั�ดแกั�มกั�ดแกั�ม , , กั�ดป่ากักั�ดป่ากั , , กั�ดเล,บ กั�ดเล,บ --> malocclusion--> malocclusionTongue thrustingTongue thrusting

• Aphthous – herpetic lesionAphthous – herpetic lesionExperimental animal (stress from Experimental animal (stress from

noise) --> herpetic lesionnoise) --> herpetic lesion

Sign and symptoms Sign and symptoms of depressionof depression

FatigueFatigue Muscle achesMuscle achesAlcohol-substance abuseAlcohol-substance abuse Behavioral Behavioral disturbancesdisturbancesPessimism Pessimism ((มองโลกัแง�รี�ายมองโลกัแง�รี�าย)) Marital Marital problemsproblemsHeadacheHeadache DiarrheaDiarrheaAnxietyAnxiety Excessive perspirationExcessive perspirationConstipationConstipation ((ท�องผ�กัท�องผ�กั)) HyperventilationHyperventilationPhobiasPhobias Blurred visionBlurred visionCrying episodesCrying episodes Dry or flushed skinDry or flushed skinIrritabilityIrritability Slurred speechSlurred speechVertigoVertigo Urinary tract Urinary tract disturbancesdisturbancesParesthesiasParesthesias Work inhibition, Work inhibition, weaknessweakness

Thank youThank you

orofacial pain. a relatively common symptom. sources of orofacial pain include caries,...

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jaw pain

orofacial pain slide

face pain

symptoms of pain

prevalence orofacial

tooth pain

sources of orofacial

chronic facial pain