Treatment of Persistent Idiopathic Facial Pain (PIFP) with a Low-Level Energy Diode Laser

Atypical odontalgia and trigeminal neuralgia: psychological, behavioral and psychopharmacological approach in a dental clinic – an overview of pathologies related to the challenging differential diagnosis in orofacial pain

Orofacial pain represents a challenge for dentists, especially if it does not have an odontogenic origin. Orofacial neuropathic pain may be chronic, is arduous to localize and may develop without obvious pathology. Comorbid psychiatric disorders, such as anxiety and depression, coexist and negatively affect this condition. This article presents one case of atypical odontalgia and one of trigeminal neuralgia treated with psychological and psychopharmacological tailored and adapted therapies, after conventional medications had failed. Additionally, an overview of the pathologies related to the challenging differential diagnosis in orofacial pain is given. 

A 68-year-old man complained of chronic throbbing and burning pain in a maxillary tooth, which worsened upon digital pressure. Symptoms did not abate after amitriptyline therapy; psychological intervention along with antianxiety drug were supplemented and antidepressant agent dosage were incremented. The patient reported improvement and satisfaction with the multidisciplinary approach to his pathology.

A 72-year-old man complained of chronic stabbing, intermittent, sharp, shooting and electric shock-like pain in an upper tooth, radiating and following the distribution of the trigeminal nerve. Pain did not recur after psychological intervention and a prescription of antidepressant and antianxiety agents, while carbamazepine therapy had not been sufficient to control pain. Due to concerns with comorbid psychiatric disorders, we adopted a patient-centered, tailored and balanced therapy, favorably changing clinical outcomes.

Comorbid psychiatric disorders have a negative impact on orofacial pain, and dentists should consider adopting tailored therapies, such as psychological counselling and behavioral and psychopharmacologic strategies, besides conventional treatments. They also must be familiar with the signs and symptoms of orofacial pain, obtaining a comprehensive view of the pathologies concerning the differential diagnosis. A prompt diagnosis may prevent pain chronicity, avoiding an increase in complexity and a shift to orofacial neuropathic pain and legal claims.

Predictive role of gnathological techniques for the treatment of persistent idiopathic facial pain (PIFP)

INTRODUCTION/BACKGROUND

Persistent idiopathic craniofacial pain (PIFP) is a heterogeneous group of pain syndromes whose main characteristic is the daily presence of persistent pain for at least 3 months. The pathophysiology of PIFP is still not entirely known and probably related to biological and psychological factors. Although PIFP has been attributed to the central neuron activity, the importance of masticatory muscles as a possible pathogenic mechanism was recently demonstrated. The main purpose of our paper was to identify the physiological rest position of the mandible with minimal tonus of both the elevator and depressor muscles and the neuromuscular trajectory of mouth closing obtained by transcutaneous electrical stimulation (TENS) and maintained with the use of an occlusal device, known as orthotic.

MATERIALS AND METHODS

The VAS scale for facial pain and the migraine disability assessment score (MIDAS) index for patient quality of life were evaluated at the beginning of the study for the 38 subjects that came to our attention. Our research included two phases. The first phase consisted of kinesiographic and electromyographic (EMG) examinations of the masticatory muscles and a 45-min application of TENS in order to deprogram the muscular activity. Kinesio-electromyographic examinations were repeated in the second phase. The main evaluated parameter was jaw deflection or deviation on the sagittal and frontal planes before and after TENS during patient tooth occlusion. Patients that showed a significant modification of this parameter were treated with orthotics for 12 months.

RESULTS

The results of a 12-month follow-up show a sharp reduction of the VAS (pre-orthotic 9.05, range 8-10, SD 0.8; post-orthotic 5.87, range 1-5, SD 0.7) and an improvement in the quality of life (MIDAS).

CONCLUSIONS

Our study demonstrated the usefulness of TENS as a screening method for the application of orthotics. This non-invasive and/or non-painful procedure could be a useful complementary treatment in this patient population. The results of the study also confirm the role of masticatory muscle dynamics as a possible pathogenic mechanism in patients with PIFP.

Treatment of non-odontogenic orofacial pain using botulinum toxin-A: a retrospective case series study

BACKGROUND

The purpose of this study was to evaluate the clinical outcomes of treatment of non-odontogenic atypical orofacial pain using botulinum toxin-A.

METHODS

This study involved seven patients (seven females, mean age 65.1 years) who had non-odontogenic orofacial pain (neuropathic pain and atypical orofacial pain) and visited the Seoul National University Bundang Hospital between 2015 and 2017. All medication therapies were preceded by botulinum toxin-A injections, followed by injections in the insignificant effects of medication therapies. Five of the seven patients received intraoral injections in the gingival vestibule or mucosa, while the remaining two received extraoral injections in the masseter and temporal muscle areas.

RESULTS

In five of the seven patients, pain after botulinum toxin-A injection was significantly reduced. Most of the patients who underwent surgery for dental implantation or facial nerve reconstruction recovered after injections. However, the pain did not disappear in two patients who reported experiencing persistent pain without any cause.

CONCLUSIONS

The use of botulinum toxin-A for the treatment of non-odontogenic neuropathic orofacial pain is clinically useful. It is more effective to administer botulinum toxin-A in combination with other medications and physical therapy to improve pain.

Neuropathic Orofacial Pain

Neuropathic pain of the orofacial region can cause much distress in individuals presenting with this condition. It may be easily mistaken for dental pain, and hence many individuals may undergo unnecessary dental work. Knowledge of the types of neuropathic orofacial pain may assist in timely diagnosis and improvement of a patient's quality of life.

Therapeutic and Analgesic Efficacy of Laser in Conjunction With Pharmaceutical Therapy for Trigeminal Neuralgia

Introduction: Trigeminal neuralgia (TN) is the most common neuralgia in the head and neck region and a common cause of orofacial pain. It is routinely treated with carbamazepine. Laser, acupuncture and radiofrequency are among other treatment modalities for this condition. This study sought to assess the efficacy of laser therapy in conjunction with carbamazepine for treatment of TN. Methods: A total of 30 patients who met the inclusion criteria were divided into 2 groups of cases and controls (n=15) by double blind randomized controlled clinical trial. All patients received 100 mg carbamazepine at baseline and another 100 mg after 2 days for pain control. In the case group, low level laser therapy (LLLT) was also performed in addition to pharmaceutical therapy. Sham laser was used in the control group instead of LLLT. Treatment was continued for 9 sessions (3 days a week). The intensity of pain was measured and compared in the 2 groups using visual analog scale (VAS) in 3 period. The qualitative variables among the groups were compared using the repeated measures analysis of variance (ANOVA). Results: The severity of pain was lower at the end of treatment in the case compared to the control group so this difference was statistically significant (P=0.003). The severity of pain decreased in both groups over time. Significant difference was noted in this regard between the 2 groups either (P=0.003). At the end of treatment pain intensity dropped in the intervention group from 6/8 to 1/2 and control group from 6/6 to 2/7. Conclusion: Laser therapy did add to the value of pharmaceutical therapy for treatment of TN. Both groups experienced significant improvement over time. So it is better to used laser complementary therapy to reduce side effects and the medicine dosage.

Persistent idiopathic facial pain

Background

Persistent idiopathic facial pain (PIFP) is a chronic disorder recurring daily for more than two hours per day over more than three months, in the absence of clinical neurological deficit. PIFP is the current terminology for Atypical Facial Pain and is characterized by daily or near daily pain that is initially confined but may subsequently spread. Pain cannot be attributed to any pathological process, although traumatic neuropathic mechanisms are suspected. When present intraorally, PIFP has been termed ‘Atypical Odontalgia’, and this entity is discussed in a separate article in this special issue. PIFP is often a difficult but important differential diagnosis among chronic facial pain syndromes.

Aim

To summarize current knowledge on diagnostic criteria, differential diagnosis, pathophysiology and management of PIFP.

Methods

We present a narrative review reporting current literature and personal experience. Additionally, we discuss and differentiate the common differential diagnoses associated with PIFP including traumatic trigeminal neuropathies, regional myofascial pain, atypical neurovascular pains and atypical trigeminal neuropathic pains.

Results and conclusion

The underlying pathophysiology in PIFP is still enigmatic, however neuropathic mechanisms may be relevant. PIFP needs interdisciplinary collaboration to rule out and manage secondary causes, psychiatric comorbidities and other facial pain syndromes, particularly trigeminal neuralgia. Burden of disease and psychiatric comorbidity screening is recommended at an early stage of disease, and should be addressed in the management plan. Future research is needed to establish clear diagnostic criteria and treatment strategies based on clinical findings and individual pathophysiology.

Pain Part 5a: Chronic (Neuropathic) Orofacial Pain

Neuropathic pain is a significant social and economic burden. Back pain, joint pain and headaches affect over 30% of the population. Chronic orofacial pain is a common condition and is difficult to diagnose and manage. This two-part paper aims to provide an overview of novel understanding of neuropathic pain, and furnish clinical teams with an update on the less common and less well-recognized chronic orofacial conditions. Headaches and temporomandibular disorders are the most common conditions and are covered in separate papers (6 and 10). Trigeminal neuralgia, burning mouth, and trigeminal autonomic cephalgias are also covered in separate papers (7, 8 and 9). The remaining conditions: post-traumatic neuropathy (nerve injury); and persistent idiopathic facial pain and atypical odontalgia are discussed in this and the following paper. Clinical Relevance: Neuropathic pain, though rare, is a consequence of dental treatment. Nerve injury in relation to M3M surgery, dental implants, endodontics and local anaesthesia result in 70% of affected patients experiencing chronic neuropathic pain.

The adjunct therapeutic effect of lasers with medication in the management of orofacial pain: double blind randomized controlled trial

OBJECTIVE

This study aimed to evaluate the efficacy of laser therapy in conjunction with a pharmaceutical approach to alleviate myofascial pain dysfunction syndrome.

BACKGROUND DATA

A few clinical studies have evaluated the analgesic effect of laser therapy on orofacial pain, most of which reported controversial results. Myofascial pain dysfunction syndrome (MPDS), trigeminal neuralgia, and atypical facial pain are the most common facial pain.

METHODS

A double-blind randomized controlled trial was designed to evaluate the therapeutic effect of GaAs laser (peak power 10 W; pulse frequency 3000 Hz; average power 0.012 W; wavelength 980 nm; irradiation duration 300 sec; and dose 12.73 J/cm(2)) on the management of common orofacial pain. The laser group (n=30) received 10 sessions of treatment with GaAs laser. The control group (n=30) was treated identically with sham laser. All patients received the appropriate pharmaceutical treatment as well. Visual analog scale (VAS) was recorded for all patients at baseline, and immediately, 2, and 4 months after the final treatment session. The qualitative variables among the groups were compared using the χ(2) test.

RESULTS

Both groups demonstrated a significant reduction in pain with the progression of time (p<0.05). The difference between the two groups was not significant (p>0.05). Whereas laser therapy in the present study failed to show any significance over the control group, the role of covariates such as radiation parameters (wave length, dose) should not be overlooked.

CONCLUSIONS

We found no significant level of efficacy for the GaAs laser in the management of common orofacial pain. Further studies are suggested to evaluate the efficacy of other types of lasers with different parameters in the management of orofacial pains.

Clinical effectiveness of laser acupuncture in the treatment of temporomandibular joint disorder

BACKGROUND/PURPOSE

Temporomandibular joint disorder (TMD) is a general term for diseases of the temporomandibular joint and orofacial muscles. In this study, we tested whether laser acupuncture was effective for the treatment of TMD.

METHODS

Twenty patients with TMD were treated with diode K-Laser (wavelength 800 nm, energy density 100.5 J/cm(2)) once a week at four acupuncture points including three standard ipsilateral local points (ST6, ST7, Ashi point) and one contralateral distal point (LI4). A 10-cm visual analogue scale (0 no pain and 10 the most severe pain) was used for measuring the pain intensity before and after the treatment.

RESULTS

Seventeen out of 20 patients (85%) showed various degrees of pain relief after laser acupuncture treatment. The average pain score was 6.3 ± 1.6 before treatment and 2.5 ± 2.2 after treatment. Significant pain relief after laser acupuncture treatment was achieved (p = 0.0003, Wilcoxon signed rank test). The 17 patients showed an average pain relief of 63 ± 31%. There were six patients who showed no TMD symptoms after an average of four treatments of laser acupuncture. The other 11 patients showed partial relief of TMD symptoms after treatment. Although the pain was still present, it was less and was acceptable. No side effects were reported in any patients during or after laser acupuncture treatments.

CONCLUSION

Laser acupuncture may be an alternative treatment modality for TMD because it is non-invasive, results in partial or total relief of pain, and has no side effects.