Chronic orofacial pain

The Gothenburg Trismus Questionnaire in China: Cross-cultural adaptation and measurement invariance

OBJECTIVES

The Gothenburg Trismus Questionnaire (GTQ) is a comprehensive scale for screening and assessing trismus in head and neck (H&N) cancer and temporomandibular joint disorders (TMD) patients. This study aimed to translate and cross-culturally adapt the GTQ in China, and to test its measurement invariance.

METHODS

This study comprised 278 H&N cancer, 245 TMD, and 507 control patients. Internal consistency and test-retest reliability were tested to assess the GTQ's reliability. The validity was evaluated through composite reliability (CR), average variance extracted (AVE), and correlation tests. Multi-group confirmatory factor analysis (CFA) was used to investigate the GTQ's measurement invariance across clinical status and gender. T tests were employed to compare score differences across clinical status and gender.

RESULTS

The Chinese version of GTQ scale shows excellent internal consistency and test-retest reliability. The CR, AVE, and correlation values demonstrate the good validity of GTQ. The multi-group CFA supported configural invariance across clinical status but not metric invariance, while it supported strict invariance across gender. Additionally, t tests revealed that patients with H&N cancer and TMD scored higher than the control group, while males scored higher than females.

CONCLUSIONS

The Chinese version of GTQ serves as an effective tool for screening and assessing trismus.

Association between oxidative stress and chronic orofacial pain and potential druggable targets: Evidence from a Mendelian randomization study

BACKGROUND

Oxidative stress indicators affect chronic orofacial pain (COFP), but how to reduce these effects is uncertain.

OBJECTIVES

11 oxidative stress biomarkers were collected as exposures, while four forms of COFP were chosen as outcomes for Mendelian randomization (MR) study.

METHODS

The effect estimates between oxidative stress and COFP were calculated using inverse variance-weighted MR (IVW-MR). Then, functional mapping and annotation (FUMA) was utilized in order to carry out SNP-based functional enrichment analyses. In addition, the IVW-MR method was applied to combine effect estimates when using genetic variants associated with oxidative stress biomarkers as an instrument for exploring potential druggable targets.

RESULTS

The results indicated that oxidative stress biomarkers (causal OR of uric acid (UA), 0.998 for myofascial pain, 95% CI 0.996-1.000, p < .05; and OR of glutathione transferase (GST), 1.002 for dentoalveolar pain, 95% CI 1.000-1.003, p < .05) were significantly linked with the probability of COFP. Functional analysis also demonstrated that UA and myofascial pain genes were prominent in nitrogen and uracil metabolism, while GST and dentoalveolar pain genes were enriched in glutathione metabolism. Also, the study provided evidence that solute carrier family 2 member 9 (SLC2A9) and glutathione S-transferase alpha 2 (GSTA2) cause discomfort in the myofascial pain (OR = 1.003, 95% CI 1.000-1.006; p < .05) and dentoalveolar region (OR = 1.001, 95% CI 1.000-1.002; p < .05), respectively.

CONCLUSIONS

In conclusion, this MR study indicates that genetically predicted myofascial pain was significantly associated with decreased UA and dentoalveolar pain was significantly associated with increased GST level. SLC2A9 inhibitor and GSTA2 inhibitor were novel chronic orofacial pain therapies and biomarkers, but clinical trials are called to examine if these oxidative biomarkers have the protective effect against orofacial pain, and further research are needed to explore the underlying mechanisms.

Reappraising the psychosomatic approach in the study of "chronic orofacial pain": looking for the essential nature of these intractable conditions

As burning mouth syndrome (BMS) and atypical odontalgia (AO) continue to remain complex in terms of pathophysiology and lack explicit treatment protocol, clinicians are left searching for appropriate solutions. Oversimplification solves nothing about what bothers us in clinical situations with BMS or AO. It is important to treat a complicated phenomenon as complex. We should keep careful observations and fact-finding based on a pragmatic approach toward drug selection and prescription with regular follow-up. We also need to assess the long-term prognosis of treatment with a meticulous selection of sample size and characteristics. Further investigation of BMS and AO from a psychosomatic perspective has the potential to provide new insight into the interface between brain function and "chronic orofacial pain."

Enhancing nerve regeneration in infraorbital nerve injury rat model: effects of vitamin B complex and photobiomodulation

Orofacial nerve injuries may result in temporary or long-term loss of sensory function and decreased quality of life in patients. B vitamins are required for DNA synthesis and the repair and maintenance of phospholipids. In particular, vitamins B1, B6, and B12 are essential for neuronal function. Deficiency in vitamin B complex (VBC) has been linked to increased oxidative stress, inflammation and demyelination. Photobiomodulation (PBM) has antioxidant activity and is neuroprotective. In addition, a growing literature attests to the positive effects of PBM on nerve repair. To assess the effect of PBM and VBC on regenerative process we evaluated the expression of brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF), myelin basic protein (MBP), laminin and neurofilaments (NFs) using Western blotting to identify regenerative pattern after chronic constriction injury of the infraorbital nerve (CCI IoN) treated by PBM, VBC or its combination. After CCI IoN, the rats were divided into six groups naive, sham, injured (CCI IoN), treated with photobiomodulation (904 nm, 6.23 J/cm2, CCI IoN + PBM), treated with VBC (containing B1, B6 and B12) 5 times, CCI IoN + VBC) and treated with PBM and VBC (CCI IoN + VBC + PBM). The treatments could revert low expression of BDNF, MBP and laminin. Also reverted the higher expression of neurofilaments and enhanced expression of NGF. PBM and VBC could accelerate injured infraorbital nerve repair in rats through reducing the expression of neurofilaments, increasing the expression of BDNF, laminin and MBP and overexpressing NGF. These data support the notion that the use of PBM and VBC may help in the treatment of nerve injuries. This finding has potential clinical applications.

The Association Between Orofacial Pain and Depression: A Systematic Review

Background

The occurrence of orofacial pain is often accompanied by comorbid conditions such as depression. Even though previous studies suggested a bidirectional correlation between orofacial pain and psychological factors, some studies still provided contradictory results.

Objective

This systematic review aimed at providing scientific evidence regarding the association between orofacial pain and depression in published literature.

Methods

The current study is a systematic literature review (PROSPERO registration no. CRD42023438596) that was conducted by reviewing cross-sectional studies that investigated the association between orofacial pain and depression. Article selection was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Articles searching was performed by using three databases, namely PubMed, ScienceDirect, and Scopus using the Boolean operator method. Article screening was carried out by applying the inclusion and exclusion criteria, as well as duplication checking, suitability checking, and compatibility checking. Reviewed articles went through the risk of bias evaluation form from the Joanna Briggs Institute (JBI). Extracted data were analyzed in a qualitative method.

Results

Twelve studies that were conducted on 5557 participants were included in the final review. After all articles were analyzed, the correlation between orofacial pain and depression was revealed. Most articles revealed a positive correlation between orofacial pain and depression, and the rest showed how orofacial pain patients showed significantly higher depression scores compared to those individuals without orofacial pain.

Conclusion

The results of this systematic review suggested a correlation between orofacial pain and depression with varying degrees. Incorporating potential depressive symptoms' treatment, when treating orofacial pain patients, should be part of the treatment plan.

Sex differences in descending control of nociception (DCN) responses after chronic orofacial pain induction in rats and the contribution of kappa opioid receptors

Descending control of nociception (DCN), a measure of efficiency of descending pain inhibition, can be assessed in animals by the combined application of test and conditioning noxious stimuli. Evidence from pre-clinical and clinical studies indicates that this mechanism of pain control may differ between sexes and might be impaired in many chronic pain states. However, little is known about sex differences in DCN efficiency in models of acute and chronic orofacial pain. Herein, we first evaluated DCN responses in male and female rats by the applying formalin into the upper lip or capsaicin into the forepaw as the conditioning stimulus, followed by mechanical stimulation (Randall-Selitto) of the hind paw as the test stimulus. The same protocol (i.e., capsaicin in the forepaw followed by mechanical stimulation of the hind paw) was evaluated in male and female rats on day 3 after intraoral incision and on day 15 and 30 after chronic constriction injury of the infraorbital nerve (CCI-ION). Additionally, we assessed the effect of the kappa opioid receptor (KOR) antagonist Norbinaltorphimine (nor-BNI) on DCN responses of female nerve-injured rats. This study shows that naïve female rats exhibit less efficient DCN compared to males. Postoperative pain did not alter DCN responses in female and male rats, but CCI-ION induced loss of DCN responses in females but not in males. Systemic pretreatment with nor-BNI prevented the loss of DCN induced by CCI-ION in female rats. The results reveal sex differences in DCN responses and female-specific impairment of DCN following chronic orofacial pain. Moreover, the findings suggest that, at least for females, blocking KOR could be a promising therapeutic approach to prevent maladaptive changes in chronic orofacial pain.

Clinical aspects of mastication myalgia-an overview

Mastication myalgia is the most common cause of non-odontogenic pain in the orofacial region and is often associated with a reduced quality of life. The purpose of this review is to provide an overview of the clinical aspects of myalgia based on available research. The review includes epidemiological, diagnostic, and etiological aspects. In addition, the potential risk factors related to the transition from acute to chronic myalgia are explored and treatment strategies are presented for its management. As a result, this review may increase clinical knowledge about mastication myalgia and clarify strategies regarding prevention, diagnostics, and management to improve prognosis and reduce patient suffering.

Advancements in Understanding and Classifying Chronic Orofacial Pain: Key Insights from Biopsychosocial Models and International Classifications (ICHD-3, ICD-11, ICOP)

In exploring chronic orofacial pain (COFP), this review highlights its global impact on life quality and critiques current diagnostic systems, including the ICD-11, ICOP, and ICHD-3, for their limitations in addressing COFP's complexity. Firstly, this study outlines the global burden of chronic pain and the importance of distinguishing between different pain types for effective treatment. It then delves into the specific challenges of diagnosing COFP, emphasizing the need for a more nuanced approach that incorporates the biopsychosocial model. This review critically examines existing classification systems, highlighting their limitations in fully capturing COFP's multifaceted nature. It advocates for the integration of these systems with the DSM-5's Somatic Symptom Disorder code, proposing a unified, multidisciplinary diagnostic approach. This recommendation aims to improve chronic pain coding standardization and acknowledge the complex interplay of biological, psychological, and social factors in COFP. In conclusion, here, we highlight the need for a comprehensive, universally applicable classification system for COFP. Such a system would enable accurate diagnosis, streamline treatment strategies, and enhance communication among healthcare professionals. This advancement holds potential for significant contributions to research and patient care in this challenging field, offering a broader perspective for scientists across disciplines.

The Chinese version of the brief pain inventory-Facial (BPI-F) among different populations: Factor structure and measurement invariance

OBJECTIVE

This study aimed to translate and adapt the Brief Pain Inventory-Facial (BPI-F) into Chinese, proposing a validated Chinese version for clinical application.

METHODS

To evaluate the applicability of Chinese BPI-F, this study included two groups: clinical sample (406 patients with OFP) and non-clinical sample (514 college students without OFP medical history). Content validity was improved through patient interviews. Cronbach's α was used to evaluate the reliability of BPI-F in both groups. The best-fit factor structure was tested on clinical sample via exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Convergent and discriminant validity of BPI-F was evaluated by Spearman's coefficient. Serial CFA was used to assess measurement invariance between the two groups.

RESULTS

Content validity and reliability of BPI-F were verified. EFA results support a two-factor structure, interference with general activities (1-7 items) and face-specific pain interference (8-14 items). CFA results demonstrated this two-factor structure is appropriate for different populations. Spearman results showed that BPI-F had good convergent and discriminant validity. Full measurement invariance is observed across the two groups.

CONCLUSION

The Chinese BPI-F, with two-factor structure (interference with general / orofacial functions), enables accurate assessment of functional interference caused by OFP. BPI-F has the same significance in different clinical populations, which expands its application.

CLINICAL SIGNIFICANCE

This manuscript proposed the Chinese version of the BPI-F and examined its psychometric characteristics for the first time. This validated scale provides a favorable instrument for aiding individual diagnosis and treatment for OFP patients in China.

Revolutionizing orofacial pain management: the promising potential of stem cell therapy

Orofacial pain remains a significant health issue in the United States. Pain originating from the orofacial region can be composed of a complex array of unique target tissue that contributes to the varying success of pain management. Long-term use of analgesic drugs includes adverse effects such as physical dependence, gastrointestinal bleeding, and incomplete efficacy. The use of mesenchymal stem cells for their pain relieving properties has garnered increased attention. In addition to the preclinical and clinical results showing stem cell analgesia in non-orofacial pain, studies have also shown promising results for orofacial pain treatment. Here we discuss the outcomes of mesenchymal stem cell treatment for pain and compare the properties of stem cells from different tissues of origin. We also discuss the mechanism underlying these analgesic/anti-nociceptive properties, including the role of immune cells and the endogenous opioid system. Lastly, advancements in the methods and procedures to treat patients experiencing orofacial pain with mesenchymal stem cells are also discussed.

Involvement of Oxidative Stress and Nutrition in the Anatomy of Orofacial Pain

Pain is a very important problem of our existence, and the attempt to understand it is one the oldest challenges in the history of medicine. In this review, we summarize what has been known about pain, its pathophysiology, and neuronal transmission. We focus on orofacial pain and its classification and features, knowing that is sometimes purely subjective and not well defined. We consider the physiology of orofacial pain, evaluating the findings on the main neurotransmitters; in particular, we describe the roles of glutamate as approximately 30-80% of total peripheric neurons associated with the trigeminal ganglia are glutamatergic. Moreover, we describe the important role of oxidative stress and its association with inflammation in the etiogenesis and modulation of pain in orofacial regions. We also explore the warning and protective function of orofacial pain and the possible action of antioxidant molecules, such as melatonin, and the potential influence of nutrition and diet on its pathophysiology. Hopefully, this will provide a solid background for future studies that would allow better treatment of noxious stimuli and for opening new avenues in the management of pain.

Craniofacial disorders and headaches. A narrative review

OBJECTIVES

Craniofacial- and headache disorders are common co-morbid disorders. The aim of this review is to provide an overview of the research discussing craniofacial pain, especially temporomandibular disorders, and its relationship and impact on headaches, as well as suggestions for diagnostic assessment tools and physical therapeutic management strategies.

METHOD

A narrative structured review was performed. A search was conducted in MEDLINE using terms related to craniofacial pain and headaches. Additionally, papers regarding this topic were also extracted from the authors' personal libraries. Any study design (i.e., RCT, observational studies, systematic review, narrative review) that reported the concepts of interest was included, using Covidence. Results were narratively synthesized and described.

RESULTS

From an epidemiological perspective, craniofacial pain and headaches are strongly related and often co-existing. This may be due to the neuroanatomical connection with the trigeminal cervical complex, or due to shared predisposing factors such as age, gender, and psychosocial factors. Pain drawings, questionnaires, and physical tests can be used to determine the cause of pain, as well as other perpetuating factors in patients with headaches and craniofacial pain. The evidence supports different forms of exercise and a combination of hands-on and hands-off strategies aimed at both the craniofacial pain as well as the headache.

CONCLUSION

Headaches may be caused or aggravated by different disorders in the craniofacial region. Proper use of terminology and classification may help in understanding these complaints. Future research should look into the specific craniofacial areas and how headaches may arise from problems from those regions. (249 words).

Patterns of Third-Molar-Pericoronitis-Related Pain: A Morphometrical Observational Retrospective Study

BACKGROUND

Mandibular third molar (M3M) removal and the management of postoperative complications represent a common matter of interest in oral and maxillofacial surgery. Pain represents a great symptom for patients affected by pericoronitis and it is the most common indication for third molar removal. The aim of the present article is to search for patterns of pre-operative pain in patients before undergoing third molar surgery and to test for a relation between some patterns of symptoms, such as pain intensity, site of symptomatic tooth, and referred area of pain.

METHODS

This retrospective observational study enrolled a total of 86 patients, aged (mean ± SD) 34.54 ± 13.62 years (range 17-78 years), scheduled for outpatient third molar extraction at the Oral Surgery School, Department of Medical Biotechnologies, Policlinico "Le Scotte", University of Siena. Pericoronitis and pain were the symptoms of the patients and the indication of extraction. Inclusion criteria were the presence of partially impacted third molars, confirmed with a preoperative panoramic radiograph, and preoperative pain. Exclusion criteria were known neurological disease (such as previous trigeminal or facial nerve injuries), impaired communicative or cognitive disease, diagnosed diabetes mellitus, and oral surgical intervention within 30 days before data collection. Patients were visited and asked to answer a morphometric analytic questionnaire about their perception of pain referred to the third molar. Analyses were performed on statistical evaluation on age, age ranges, patient gender, prior third molar extraction, site of pericoronitis, pain score (1-10), and pain area. Two-tailed p values of less than 0.05 were considered significant if not otherwise specified.

RESULTS

No correlations were found between age, gender, previous extraction, tooth site (maxillar on mandible), pain score, and pain area. Patterns of third molar pericoronitis pain among 86 patients were reported. A significant correlation was found between pain score and pain area (p = 0.0111, r_s = 0.3131).

CONCLUSIONS

Pain intensity has indeed some kind of responsibility in determining the orofacial distribution of pain. The pain area referral patterns of the present article could be considered as a pain model resulting from the pericoronitis of maxillar and mandibular third molars.

A systematic review of the efficacy of ketamine for craniofacial pain

Background

Craniofacial pain (CFP) poses a burden on patients and health care systems. It is hypothesized that ketamine, an N-methyl-d-aspartate (NMDA) receptor antagonist, can reverse central sensitization associated with causation and propagation of CFP. This systematic review aims to assess the role of ketamine for CFP.

Methods

Databases were searched for studies published up to September 26, 2022, investigating the efficacy of ketamine for adults with CFP. Primary outcome was the change in pain intensity at 60 min postintervention. Two reviewers screened and extracted data. Registration with PROSPERO was performed (CRD42020178649).

Results

Twenty papers (six randomized controlled trials [RCTs], 14 observational studies) including 670 patients were identified. Substantial heterogeneity in terms of study design, population, dose, route of administration, treatment duration, and follow-up was noted. Bolus dose ranged from 0.2-0.3 mg/kg (intravenous) to 0.4 mg/kg (intramuscular) to 0.25-0.75 mg/kg (intranasal). Ketamine infusions (0.1-1 mg/kg/h) were given over various durations. Follow-up was short in RCTs (from 60 min to 72 h) but longer in observational studies (up to 18 months). Ketamine by bolus treatment failed to reduce migraine intensity but had an effect by reducing intensity of aura, cluster headache (CH), and trigeminal neuralgia. Prolonged ketamine infusions showed sustainable reduction of migraine intensity and frequency of CH attacks, but the quality of the evidence is low.

Conclusion

Current evidence remains conflicting on the efficacy of ketamine for CFP owing to low quality and heterogeneity across studies. Ketamine infusions are suggested to provide sustained improvement, possibly because of prolonged duration and higher dosage of administration. RCTs should focus on the dose-response relationship of prolonged ketamine infusions on CFP.

Targeted Therapy for Orofacial Pain: A Novel Perspective for Precision Medicine

Orofacial pain (OFP) is a dental specialty that includes the diagnosis, management and treatment of disorders of the jaw, mouth, face, head and neck. Evidence-based understanding is critical in effectively treating OFPs as the pathophysiology of these conditions is multifactorial. Since OFP impacts the quality of life of the affected individuals, treating patients successfully is of the utmost significance. Despite the therapeutic choices available, treating OFP is still quite challenging, owing to inter-patient variations. The emerging trends in precision medicine could probably lead us to a paradigm shift in effectively managing the untreatable long-standing pain conditions. Precision medicine is designed based on the patient's genetic profile to meet their needs. Several significant relationships have been discovered based on the genetics and genomics of pain in the past, and some of the notable targets are discussed in this review. The scope of this review is to discuss preclinical and clinical trials that include approaches used in targeted therapy for orofacial pain. Future developments in pain medicine should benefit from current trends in research into novel therapeutic approaches.

Assessing Orofacial Pain Behaviors in Animal Models: A Review

Orofacial pain refers to pain occurring in the head and face, which is highly prevalent and represents a challenge to clinicians, but its underlying mechanisms are not fully understood, and more studies using animal models are urgently needed. Currently, there are different assessment methods for analyzing orofacial pain behaviors in animal models. In order to minimize the number of animals used and maximize animal welfare, selecting appropriate assessment methods can avoid repeated testing and improve the reliability and accuracy of research data. Here, we summarize different methods for assessing spontaneous pain, evoked pain, and relevant accompanying dysfunction, and discuss their advantages and disadvantages. While the behaviors of orofacial pain in rodents are not exactly equivalent to the symptoms displayed in patients with orofacial pain, animal models and pain behavioral assessments have advanced our understanding of the pathogenesis of such pain.

Headache and orofacial pain: A traffic-light prognosis-based management approach for the musculoskeletal practice

Introduction

Headache (HA) is one of the most prevalent disabling conditions worldwide and is classified as either primary or secondary. Orofacial pain (OFP) is a frequent pain perceived in the face and/or the oral cavity and is generally distinct from a headache, according to anatomical definitions. Based on the up-to-date classification of the International Headache Society, out of more than 300 specific types of HA only two are directly attributed to the musculoskeletal system: The cervicogenic HA and HA attributed to temporomandibular disorders. Because patients with HA and/or OFP frequently seek help in the musculoskeletal practice, a clear and tailored prognosis-based classification system is required to achieve better clinical outcomes.

Purpose

The aim of perspective article is to suggest a practical traffic-light prognosis-based classification system to improve the management of patients with HA and/or OFP in the musculoskeletal practice. This classification system is based on the best available scientific knowledge based on the unique set-up and clinical reasoning process of musculoskeletal practitioners.

Implications

Implementation of this traffic-light classification system will improve clinical outcomes by helping practitioners invest their time in treating patients with significant involvement of the musculoskeletal system in their clinical presentation and avoid treating patients that are not likely to respond to a musculoskeletal based intervention. Furthermore, this framework incorporates medical screening for dangerous medical conditions, and profiling the psychosocial aspects of each patient; thus follows the biopsychosocial rehabilitation paradigm.

Cannabis Bioactive Compound-Based Formulations: New Perspectives for the Management of Orofacial Pain

The management of orofacial pain to alleviate the quality of life of affected patients is becoming increasingly challenging for scientific research and healthcare professionals. From this perspective, in addition to conventional therapies, new alternatives are being sought, increasingly looking at the use of both natural and synthetic products. Cannabis sativa L. represents an interesting source of bioactive compounds, including non-psychoactive cannabinoids, flavonoids, and terpenes, many of which are effective in improving pain intensity. Here, we aim to analyze the possible mechanisms of action of the bioactive natural and synthetic hemp-derived compounds responsible for the modulatory effects on pain-related pathways. The ability of these compounds to act on multiple mechanisms through a synergistic effect, reducing both the release of inflammatory mediators and regulating the response of the endocannabinoid system, makes them interesting agents for alternative formulations to be used in orofacial pain.

"No One Truly Understands What We Go through and How to Treat It": Lived Experiences with Medical Providers among Patients with Orofacial Pain

Orofacial pain affects 10-15% of adults, yet treatments are limited. The gaps in care are frustrating for both patients and providers and can negatively impact patient-provider interactions. These interactions are key because they impact patient-reported outcomes and satisfaction with care.

PURPOSE

Our study aims to understand the nuanced experiences with medical providers among patients with orofacial pain.

METHODS

In a cross-sectional survey, 260 patients provided written responses describing their experiences with medical providers. Using an inductive-deductive approach to thematic analysis, we identified themes and subthemes and organized them into four domains based on the Patient-Centered Model of Communication.

RESULTS

Patients reported feeling hopeless about treatment options, frustrated with lack of provider knowledge, disappointed in ineffective care, and stigmatized and dismissed by providers. Patients also said they learned to advocate for their health, were grateful for effective care, and felt lucky when providers listened and showed compassion. Patients identified key barriers that interfere with care (e.g., insurance, transportation, limited providers, lack of team coordination).

CONCLUSIONS

Findings can help inform training programs and psychoeducation that target patient-provider communication to improve patient-reported outcomes, the quality of care delivered, and health care utilization and costs.

Effect of Botulinum Toxin Injection on EMG Activity and Bite Force in Masticatory Muscle Disorder: A Randomized Clinical Trial

Botulinum toxin type A (BoNT-A) is increasingly used in treating masticatory muscle pain disorder; however, safe doses and reinjection intervals still need to be established. The purpose of this randomized clinical trial was to evaluate the degree and duration of the impairment of masticatory muscle performance. Fifty-seven subjects were randomly divided into two groups: one of which received BoNT-A first (n = 28) while the other received saline first (n = 29), with the cross-over being in week 16, and a total follow-up period of 32 weeks. A total dose of 50 U of BoNT-A was injected in the masseter and temporal muscles bilaterally. Electromyographic (EMG) activity and bite forces were assessed. A significant reduction in EMG activity was observed up to week 18 (p ≤ 001), with total recovery at week 33. A significant reduction in maximum bite force was observed up to week 11 (p ≤ 005), with total recovery at week 25. In conclusion, when treating masticatory muscle pain disorder with 50 U of BoNT-A, a reinjection interval of 33 weeks can be considered safe since the recovery of muscle function occurs by that time.

“I Still Suffer Every Second of Every Day”: A Qualitative Analysis of the Challenges of Living with Chronic Orofacial Pain

Objective

Chronic orofacial pain is prevalent and debilitating. Psychological and social factors place a heavy burden on this population but are often overlooked. Here, we offer the first comprehensive qualitative conceptualization of the challenges of living with chronic orofacial pain through a biopsychosocial perspective to inform multifaceted care for this population.

Design

We employed a qualitative thematic analysis of open text responses using a hybrid inductive-deductive approach and a biopsychosocial framework.

Methods

Two hundred and sixty participants with chronic orofacial pain responded to an open-ended question: “What is the biggest challenge you face in managing your condition?” by typing their responses into a text box as part of an online survey. We mapped responses onto biomedical, psychological, and social themes (deductive) and concurrently identified findings within each theme that emerged directly from the data (inductive).

Results

Subthemes within the biomedical theme included challenges with biomedical pain management, medication side effects, sensory triggers, physical symptoms of stress/tension, and biological functions and related activities of daily living. Subthemes within the psychological theme included anxiety, depression, emotional symptoms of stress, unpredictability/uncertainty of pain, and psychological and cognitive aspects of medication management. Subthemes within the social theme included social relational, experience with providers, socioeconomics and access to care, and roles and responsibilities.

Conclusion

Chronic orofacial pain is associated with multifaceted challenges. Consideration of individuals’ experiences of biomedical, psychological, and social challenges in the assessment, referral, and treatment of chronic orofacial pain holds the potential to promote more comprehensive, patient-centered care for this population.

Orofacial Pain: Molecular Mechanisms, Diagnosis, and Treatment 2021

The Special Issue “Orofacial Pain: Molecular Mechanisms, Diagnosis, and Treatment 2021” contains 6 articles published by 41 authors from different countries focusing on nucleus accumbens core GABAergic neurons, receptor-interacting serine/threonine-protein kinase 1, pannexin 1-mediated ATP signaling, ultra-low-frequency transcutaneous electrical nerve stimulation, and triamcinolone acetonide. The content covers several pain models, including neuropathic pain caused by peripheral nerve constriction or malpositioned dental implants, tongue cancer, myogenous temporomandibular dysfunction, and oral ulcerative mucositis. In addition, a review paper on trigeminal neuralgia is included.

A Review of Medical and Surgical Options for the Treatment of Facial Pain

Facial pain is a common medical complaint that is easily misdiagnosed. As a result, this pain often goes mistreated. Despite this, there are a variety of pharmacologic, surgical, and neuromodulatory options for the treatment of facial pain. In this review, the authors detail the forms of facial pain and their treatment options. They discuss the common medications used in the first-line treatment of facial pain and the second-line surgical and neuromodulatory options available to patients when pharmacologic options fail.

Pediatric Chronic Orofacial Pain: A Narrative Review of Biopsychosocial Associations and Treatment Approaches

Pediatric chronic orofacial pain (OFP) is an umbrella term which refers to pain associated with the hard and soft tissues of the head, face, and neck lasting >3 months in patients younger than 18 years of age. Common chronic pediatric OFP diagnoses include temporomandibular disorder, headaches, and neuropathic pain. Chronic OFP can adversely affect youth's daily functioning and development in many areas of well-being, and may be associated with emotional stress, depression, functional avoidance, and poor sleep, among other negative outcomes. In this mini-review, we will discuss common psychological comorbidities and familial factors that often accompany chronic pediatric OFP conditions. We will also discuss traditional management approaches for pediatric orofacial pain including education, occlusal appliances, and psychological treatments such as relaxation, mindfulness-based interventions, and cognitive-behavioral treatments. Finally, we highlight avenues for future research, as a better understanding of chronic OFP comorbidities in childhood has the potential to prevent long-term pain-related disability in adulthood.

[Studies on the psychodynamics of Chronic Orofacial Pain Disorder]

Studies on the psychodynamics of Chronic Orofacial Pain Disorder Objectives: Psychodynamic factors play an important role in its emergence and development of Chronic Orofacial Pain Disorder (COP), which is also known as Chronic Primary Orofacial Pain. This factors form the basis for differentiated psychotherapy. Methods: Seven female and two male patients with COP who had visited the Dental School, University Hospital, Ludwig Maximilian University of Munich, and the dental surgery of a practising dentist over the year were included in the study. Following a detailed dental examination, a psychodynamic interview was videotaped, reconstructing the connections between the life history and the development of the illness. Psychosomatic data were assessed by 3 psychotherapists based on a consensus model with regard to symptom trigger mechanisms such as conflicts and pressure, the development of symptoms, and the personality structure. Pathogenetically, we differentiated among conversion, somatization and projection. Results: The patients had a mean age of 57 years (range: 44-67) and an average illness duration of three (1-5) years. The average age where the illness had manifested was 54 (43-64). All patients showed clear psychodynamic factors in the development and course of the illness. The symptoms developed mainly during transitional situations during the life history, predominately in midlife. During this phase, dental treatment undertaken for whatever reason could trigger the chronic symptoms, which could then be further exacerbated by further dental interventions. The mode of symptom development by equal number of patients related to a somatoform disorder, such as a somatization of affect, a conversion with conflict symbolism and a projective-hypochondriac disorder. In the remaining patients, COP was an accompanying symptom of depressive disorder or the consequence of a posttraumatic stress disorder with self-mutilating tendencies. Conclusion: The consideration of psychosomatic connections and pathogenetic differentiation is helpful for the understanding and management of COP. This diagnostic differentiation could serve as a basis for prognosis and for specific therapeutic indications. Despite numerous general researches about chronic pain syndromes, there is a lack of intervention studies which take into account the specific conditions of COP on a larger sample.

Physical therapist guided active intervention of chronic temporomandibular disorder presenting as ear pain: A case report

This case report describes the successful physical therapy management of a 40-year-old female who presented with left ear pain referred from the temporomandibular joint. Diagnosis was primarily based on clinical examination findings and ruling out of red flags. Guidance was given on active self-care approaches consisting of pain neuroscience education designed with individualized pain curriculum, exercise therapy, manual therapy, and breathing exercises for a period of  sixweeks. Clinically meaningful improvements were obtained in the outcome measures of Numeric Pain Rating Scale (NPRS), Patient-Specific Functional Scale (PSFS), and Global Rating of Change (GROC) scale and progress in Pain-Self Efficacy Questionnaire (PSEQ) and Tampa Scale for Kinesiophobia (TSK) scores. Positive changes were achieved with functional activities (chewing, eating, yawing, brushing teeth and physical intimacy), and the patient was pain-free on discharge, which was maintained at a six-month follow-up.

Review of Literatures: Physiology of Orofacial Pain in Dentistry

The objective of this review of the literature is to summarize the physiology of orofacial pain in dentistry, particularly physiology of the pain pathway and molecular mechanisms on pathophysiology of pain, on account of new insights into classification of orofacial pain related diseases. This article will also focus on possible mechanisms of neuropathic orofacial pain which is distinguished from other types of pain.

Perceived Practitioner Barriers to the Management of Orofacial Pain in the Kingdom of Saudi Arabia: A Cross-sectional Study

Background:

Orofacial Pain (OFP) is a group of non-dental painful conditions affecting the oral cavity and facial area.

Objectives:

The objective of this study was to explore which barriers to manage the patient with chronic OFP as perceived by general dentists versus dental specialists and to investigate whether if professionals with degrees from their home country versus another country or number of years of professional experience differ in their perceptions.

Methods:

A closed-end questionnaire was hand-delivered to 600 participants [300 general dentists and 300 dental specialists] in four major provinces in Saudi Arabia. Demographic data were expressed as frequency. Proportional t-tests and chi-square tests were used to analyse intergroup differences. Statistical significance for all analyses was set at P-value < 0.05.

Results:

Overall, the response rate was 56.6% (340/600). Around two-thirds of the participants were general dentists (60.9%), while the remainder were dental specialists (39.1%). There was an obvious consensus by the participants that “Low payment/reimbursement” and “Lack of OFP knowledge” were among the most common barriers (85% and 83.5%, respectively). In contrast, “Legal risks” were the least frequently reported factor (38.8%). The most commonly reported barrier by general dentists was “Shortage of patients/lack of demand;” this was significantly different from the experience of dental specialists (87% vs. 72.2%; P- value < 0.01). In terms of the country of graduation or years of experience, there were no significant differences.

Conclusion:

The study demonstrates the existence of many significant barriers other than OFP knowledge, such as reimbursement, facility and demand that could present obstacles and challenges to the management of OFP by general dentists and dental specialists. Most participants believed that dentists should manage this condition and that OFP courses should be included in the dental school curriculum.