Referred Pain: Clinical Significance, Pathophysiology, and Treatment

Visceral pain, mechanisms, and implications in musculoskeletal clinical practice

The global impact of visceral pain is extremely high, representing a significant portion of all forms of chronic pain. In musculoskeletal practice, at least one-third of people with persistent noncancerous pain report recurrent abdominal, pelvic, or chest pain symptoms. Visceral pain can be felt in several different areas of the body and can migrate throughout a region, even though the site of origin does not appear to change. Traditionally, clinicians have examined musculoskeletal pain through a reductionist lens that ignores the influence of the visceral system on musculoskeletal pain. The hypothesis presented is that visceral pain has an important influence on developing and maintaining different types of musculoskeletal pain through processes within the peripheral or central nervous systems, as a result of a visceral nociceptive stimulus generated by pathoanatomical or functional alterations. The hypothesis predicts that a consideration of the function of the visceral system in musculoskeletal pain conditions will improve clinical outcomes, moving beyond a linear model and adopting a more holistic approach, especially in the more complex groups of patients.

Pulpalgia contributing to temporomandibular disorder-like pain: a literature review and case report

BACKGROUND

Dentists need to be cognizant that temporomandibular disorder (TMD) -like pain can be caused by a tooth pulpalgia. The author provides suggestive symptom characteristics and definitive diagnostic techniques.

CASE DESCRIPTION

A patient had severe bilateral TMD-like pain, which increased when something cold touched a premolar and when the patient lay down, and which awakened her several times every night. The author identified the offending tooth and administered a ligamentary injection along the tooth, which eliminated her bilateral TMD-like pain. Occlusal adjustment of her tooth reduced her pain, and subsequent endodontic therapy eliminated her pain. To the author's knowledge, this is the first report of a pulpalgia in a posterior tooth causing bilateral TMD-like pain.

CLINICAL IMPLICATIONS

Pulpalgia may cause symptoms that mimic TMD or may contribute to TMD signs and symptoms. When patients with TMD-like pain report feeling increased pain due to a cold stimulus' coming into contact with a tooth, practitioners should ensure that a pulpalgia is not contributing to their pain.

Referred craniofacial pain patterns in patients with temporomandibular disorder

BACKGROUND

Referred pain is prevalent in the craniofacial region, and it would be helpful for dental practitioners to have drawings delineating regions with a high probability for a patient's referred pain source.

METHODS

The author applied firm pressure for approximately five seconds to trigger points, nodules of spot tenderness, and selected masticatory structures within the head and neck region on 230 patients with temporomandibular disorder, or TMD. As firm pressure was being applied, subjects were asked whether pain was developing or intensifying in a location different than that being palpated.

RESULTS

One hundred ninety-six subjects (85 percent) reported that referred pain was being generated. The cheek area, ear and forehead were the most frequently reported sites of referred pain generation; palpation over the trapezius muscle, lateral pterygoid area and masseter muscle were the most common sources of referred pain to the craniofacial region. The author provides figures displaying common referred pain sites and their sources.

CONCLUSIONS

Patients with TMD often report referred craniofacial pain arising from palpation of the head and neck region. The author found that the pattern between referred pain source and site was consistent and predictable.

PRACTICE IMPLICATIONS

Practitioners should consider craniofacial pain's propensity for referral when treating patients with TMD. Practitioners can use the figures presented to determine regions of high probability for a patient's referred pain source.