Orofacial pain and neurosensory disorders and dysfunction in cancer patients

Recent advances in cancer therapy-associated oral mucositis

Oral mucositis (OM) is a common and debilitating toxicity of cancer treatments - chemotherapy, radiotherapy, hematopoietic cell transplant, or combinations. OM is associated with severe oral pain and has negative impacts on patient function and quality of life. Additionally, OM has accompanying systemic complications that may have critical implications. These local and systemic consequences can alter cancer treatment, and add an economic burden. This review covers the clinical presentation and course of OM, differential diagnosis, clinical and economic impacts, pathogenesis, risk factors, assessment measures, biomarkers and prediction of OM, management, research advances in the development of new drugs and treatments, and big data.

Dental Management of Patients Who Have Undergone Oral Cancer Therapy

Oral cancer therapies are associated with orofacial complications that could result in dose-limiting cancer treatment and consequent suboptimal tumor control. Oral cancer treatment complications include oral mucositis, salivary gland hypofunction, odontogenic infections, pain, dermatitis, neurotoxicity, soft tissue fibrosis, trismus, osteoradionecrosis, and potential cancer recurrence. These complications significantly affect cancer survivorship, quality of life, and psychosocial status. Effective dental management of patients with oral cancer involves the coordination of care among several health care professionals before, during, and after cancer therapy. The goal is to minimize complications, and establish optimal quality of life for survivors.

Management of Skull Base Tumor-Associated Facial Pain

Cancer-associated facial pain can be caused by a variety of pathologic conditions. Here the authors describe the symptoms and incidence of facial pain secondary to three separate anatomic subcategories of cancer. The authors subsequently discuss the effectiveness and drawbacks of the most common methods of treatment.

Adenoid Cystic Carcinoma of Maxillary Sinus Misdiagnosed as Chronic Apical Periodontitis

Sometimes pain originating from a non-odontogenic pathologic condition is mistaken as endodontic illness, leading to misdiagnosis. The patient can misinterpret the pain as originating from a site different from the actual site, which is known as referred pain. However, the clinician managing pain in the orofacial region needs to be well-informed about the typical signs and symptoms of non-odontogenic diseases and to be able to make the correct referral when necessary for proper diagnosis and treatment. A 43-year-old man presented to the department of conservative dentistry complaining of dental pain. Despite nonsurgical root canal treatment and curettage, he complained that the pain had spread to an area inclusive of the right side of the head and face and the right eye. The patient's pain differed from the typical endodontic pain. Therefore, the patient received a diagnosis of non-odontogenic pain and was referred to the pain clinic. Brain magnetic resonance imaging and parotid contrast images showed a mass in the right maxillary sinus. In addition, destruction in the hard palate and alveolar recess adjacent to the sinus floor was found. Infiltration into the cavernous sinus through the pterygopalatine fossa was seen. A neurosurgeon partially removed the mass by performing an osteoplastic craniotomy on the right occipital bone with the patient under general anesthesia. On the basis of the biopsy results, an adenoid cystic carcinoma was diagnosed.

Cancer and orofacial pain

BACKGROUND

Cancer pain is a devastating condition. Pain in the orofacial region, may be present as the single symptom of cancer or as a symptom of cancer in its later stages. This manuscript revises in a comprehensive manner the content of the conference entitled "Orofacial Pain and Cancer" (Dolor Orofacial y Cancer) given at the VI Simposio International "Advances in Oral Cancer" on the 22 July, 2016 in San Sebastioan-Donostia, Spain.

MATERIAL AND METHODS

We have reviewed (pubmed-medline) from the most relevant literature including reviews, systematic reviews and clinical cases, the significant and evidence-based mechanisms and mediators of cancer-associated facial pain, the diverse types of cancers that can be present in the craniofacial region locally or from distant sites that can refer to the orofacial region, cancer therapy that may induce pain in the orofacial region as well as discussed some of the new advancements in cancer pain therapy.

RESULTS

There is still a lack of understanding of cancer pain pathophysiology since depends of the intrinsic heterogeneity, type and anatomic location that the cancer may present, making more challenging the creation of better therapeutic options. Orofacial pain can arise from regional or distant tumor effects or as a consequence of cancer therapy.

CONCLUSIONS

The clinician needs to be aware that the pain may present the characteristics of any other orofacial pain disorder so a careful differential diagnosis needs to be given. Cancer pain diagnosis is made by exclusion and only can be reached after a thorough medical history, and all the common etiologies have been carefully investigated and ruled out. The current management tools are not optimal but there is hope for new, safer and effective therapies coming in the next years.

A novel lozenge containing bupivacaine as topical alleviation of oral mucositis pain in patients with head and neck cancer: a pilot study

Introduction: Oral mucositis induces severe oral pain in head and neck cancer patients. There is at this point no effective pain treatment without considerable side effects.

Objective: The aim of this pilot study was to investigate pain reduction in oral cavity and pharynx in patients with head and neck cancer (HNC) with oral mucositis, the location of anesthetic effect, and duration of pain relief, after a single-dose administration of a 25 mg bupivacaine lozenge.

Methods: Ten patients with HNC suffering from oral mucositis pain were included. The patients assessed pain in the oral cavity and pharynx on a visual analogue scale (from 0 to 100 mm) at baseline and up to 3 hours after the lozenge was dissolved. Possible adverse events were registered.

Results: The baseline pain was 51 mm (range: 30–73 mm) in the oral cavity and 58 mm (range: 35–70 mm) in the pharynx. When the lozenge was dissolved, both oral (−27 mm; range: −3 to −52 mm; P = 0.0003) and pharynx pain (−20 mm; range: −3 to −45 mm; P = 0.008) were significantly reduced. After 180 minutes, the mean reduction in pain was significant in the oral cavity (−18 mm; range: −8 to −30 mm; P < 0.0001) but not in the pharynx (−8 mm; range: +4 to −23 mm; P = 0.12). No adverse events were observed.

Conclusion: The results indicate that the bupivacaine lozenge has a clinically significant and long-lasting pain-relieving effect on pain because of oral mucositis in patients with HNC.

Cancer and Referred Facial Pain

Orofacial pain may be a symptom of diverse types of cancers as a result of local or distant tumor effects. The pain can be presented with the same characteristics as any other orofacial pain disorder, and this should be recognized by the clinician. Orofacial pain also can arise as a consequence of cancer therapy. In the present article, we review the mechanisms of cancer-associated facial pain, its clinical presentation, and cancer therapy associated with orofacial pain.

Review of the complications associated with treatment of oropharyngeal cancer: a guide for the dental practitioner

OBJECTIVES

Oropharyngeal cancer (OPC) is the sixth most common cancer worldwide. Focus on risk factors, improved diagnostic methods and effective management strategies have made it possible to successfully treat OPC. However, the 5-year survival rate has not improved for several years due to multiple treatment complications, tissue morbidity, loss of function, and diminished quality of life. Survivors are faced with complications like oral mucositis, hyposalivation, osteoradionecrosis, tissue fibrosis, morbidity from jaw resection, disfigurement, and loss of function that further diminish quality of life. The aim of this review is to highlight major complications associated with treatment of OPC via a literature search and review of available options for identification and management of these complications.

DATA SOURCES

Relevant publications on oral complications of OPC therapy were thoroughly reviewed from the literature published between the years 1988 and 2012. We evaluated reported incidence, prevalence, and risk factors for oral complications of chemotherapy and radiotherapy for OPC. The authors conducted an electronic search using English language databases, namely PubMed Plus, Medline (Pre-Medline and Medline), Cochrane Database of Systematic Reviews (evidence-based medicine), Dentistry & Oral Sciences Source, A ccessScience, Embase, Evidence-Based Medicine Reviews Multifile, Google Scholar, ISI Journal Citation Reports, and Ovid Multi-Database.

CONCLUSION

We identified the most common complications associated with the treatment of oral cancers. Based on the information gathered, there is evidence that survival of OPC extends beyond eradication of the diseased tissue. Understanding the potential treatment complications and utilizing available resources to prevent and minimize them are important. Caring for OPC survivors should be a multidisciplinary team approach involving the dentist, oncologist, internist, and social worker to improve the currently stagnant 5-year survival rate of OPC. More emphasis on improved quality of life after elimination of the cancer will ultimately improve OPC survivorship.

Limited mouth opening secondary to diffuse systemic sclerosis

Systemic sclerosis (SSc) is a relatively rare condition with an immunologically mediated pathogenesis. For reasons that are not clearly understood, dense collagen is deposited in the connective tissues of the body in extraordinary amounts. Although its dramatic effects are seen in association with the skin, the disease is often quite serious with visceral organ involvement. We describe a case of limited mouth opening secondary to diffuse SSc, improvement in mouth opening with passive jaw stretch exercises, and the challenges involved in performing dental procedures for such patients.

Clinical assessment of patients with orofacial pain and temporomandibular disorders

Accurate diagnosis of chronic pain disorders of the mouth, jaws, and face is frequently complex. It is common for patients with chronic orofacial pain to consult multiple clinicians and receive ineffective treatment before a correct diagnosis is reached. This problem is a significant public health concern. Clinicians can minimize error by starting the diagnostic procedure with a careful, accurate history and thorough head and neck examination followed by a thoughtfully constructed differential diagnosis. The possibility that the patient has symptoms of a life-threatening underlying disease rather than a more common dental, sinus, or temporomandibular disorder must always be considered.

Regional cerebral blood flow in patients with orally localized somatoform pain disorder: a single photon emission computed tomography study

AIM

Somatoform pain disorder is characterized by persistent and chronic pain at one or more sites without an associated general medical condition and in which psychological factors are thought to play a role. This study aimed to investigate the pathological features of somatoform pain disorder localized to the oral region by single photon emission computed tomography (SPECT).

METHODS

Ten patients (nine females and one male; average age 55.0 ± 14.4 years) having somatoform pain disorder with oral symptoms participated. SPECT was performed using N-isopropyl-4-[(123) I] iodoamphetamine intravenous injections, and regional cerebral blood flow (rCBF) was assessed by three-dimensional stereotactic surface projections. We also selected 12 healthy individuals (seven females and five males; average age 61.8 ± 13.2 years) to act as controls.

RESULTS

Both the patient and control groups showed no atrophy or infarction on CT or magnetic resonance imaging. The patient group showed higher rCBF in the subcortical area, especially in the thalamus and cingulate gyri, than the control group. In contrast, the patient group showed lower rCBF in the bilateral frontal and occipital lobes as well as in the left temporal lobe.

CONCLUSIONS

These results suggest that the biological process involved in somatoform pain disorder of the oral region is characterized by changes in limbic and cortical functions. The finding that somatoform pain disorder with oral symptoms is associated with brain functional changes will help to develop treatment regimes for this disorder and clarify the underlying pathology.

Interindividual differences in the perception of dental stimulation and related brain activity

For identical diagnoses in the trigeminal innervation territory, individual differences have been clinically observed among the symptoms reported, such as dysesthesia and pain. Different subjective perceptions of unpleasantness and pain intensity may have different cortical substrates. The aim of this study was to identify brain areas in which activation depends on the subjective perception (intensity and unpleasantness) of electric dental stimulation. Electrical stimuli of increasing intensity were applied to maxillary canines in 14 healthy volunteers. Ratings for stimulus intensity and unpleasantness perceived across the stimulation session were reported postscan on 11-point numerical scales. The rating values were then included as covariates in the functional magnetic resonance imaging (fMRI) group analysis. Interindividual differences of intensity ratings were reflected in differential activity of the following brain areas: superior parietal lobule, superior temporal gyrus/anterior insula, inferior and middle temporal gyrus, lingual gyrus, anterior cingulate, and caudate nucleus. Differences related to unpleasantness ratings were reflected in the lingual gyrus. In conclusion, differences of perceived intensity between individuals are reflected in the differential activity of a set of brain areas distinct from those regions, reflecting rating differences of unpleasantness.