Care Pathways in Persistent Orofacial Pain: Qualitative Evidence from the DEEP Study

Are orofacial pain assessment tools for adults who cannot self-report pain suitable for dental practice? A scoping review

INTRODUCTION

This study aims to identify and appraise orofacial pain assessment tools designed to score pain in adults who cannot self-report and rate their suitability for dental practice.

METHODS

A protocolled systematic scoping review, in accordance with Joanna Briggs Institute methods was completed. A development panel (n = 7) reviewed attributes of each tool for suitability for use in dental practice, using predefined criteria.

RESULTS

Nine studies were included. Sample size ranged from n = 22 to n = 348; all participants were 65 years plus and had a cognitive impairment or dementia, excluding controls. Four tools were identified: Facial action coding system (FACS), mobilization-observation-behavior-intensity in dementia pain scale (MOBID I & II) and, orofacial pain scale-non-verbal individuals (OPS-NVI). Tools scored between two and thirteen out of twenty according to modified quality assessment criteria. No tool was deemed suitable for use in dental surgery, with the OPS-NVI scoring most favorably.

CONCLUSIONS

No tools were deemed ideal for use within a dental clinic. Elements of some, particularly the OPS-NVI, may be adaptable for this purpose. Despite the difficulties dental practitioners face trying to assess pain in non-speaking patients, there was no suitable tool identified. Pathways need to be designed to facilitate inclusive orofacial pain assessment for those who cannot self-report pain.

Experiences of pain communication in endometriosis: A meta-synthesis

INTRODUCTION

Endometriosis is the leading cause of chronic pelvic pain among women. The pain associated with endometriosis significantly impacts various aspects of patients' quality of life. A notable void in the literature is the absence of a systematic review exploring pain communication between patients with endometriosis and healthcare professionals. Hence, the aim of this qualitative systematic review was to synthesize findings on how patients with endometriosis experience communicating with healthcare professionals about pain and how healthcare professionals experience these interactions.

MATERIAL AND METHODS

A systematic literature search was conducted related to patients with endometriosis and pain communication in CINAHL PLUS with full text and MEDLINE (via EBSCO host) on May 12, 2023, and updated January 26, 2024. Searches were supplemented by backward searching reference lists and forward searching citations of included reports in Scopus and Google Scholar. The review was guided by the four-step meta-synthesis methodology by Sandelowski and Barosso. Critical appraisal of included studies was conducted using Critical Appraisal Skill Program (CASP). Findings were analyzed thematically, using the approach described by Thomas and Harden. The meta-synthesis was based on a registered protocol in PROSPERO (CRD 42023425430), and the study is reported adhering to the PRISMA 2020 checklist.

RESULTS

Overall, 37 reports published from 2003 until 2023 contributed to the review, including 4842 participants. Through thematic analysis, we developed the following themes: "Navigating the double burden," "Lack of mutual understanding," and "The complexities of conveying pain."

CONCLUSIONS

The communication of pain between patients with endometriosis and healthcare professionals is complex, encompassing patterns of disbelief, normalization, and psychological attribution. Engaging in discussions about pain presents diverse challenges stemming from insufficient communication skills and assessment tools. Further research is warranted to comprehensively explore the perspectives of both patients and healthcare professionals, aiming to devise strategies that enhance communication and patient care.

Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Evaluating the Influence of Acute and Chronic Orofacial Pains on the Overall Comprehensive Quality of Life

Background Orofacial discomfort refers to various disorders that affect the mouth, jaws, and face. These conditions may substantially influence a person's quality of life (QoL). This kind of pain may be categorised into two primary classifications: acute and chronic. Acute orofacial pain (OFP) usually occurs suddenly and lasts for a short period. It is commonly caused by specific factors such as dental treatments, traumas, or infections. Hence, this study aimed to assess the influence of acute and chronic orofacial discomfort on the overall QoL. Methodology This research used a convenience sample to gather data from the five groups. It was conducted as a cross-sectional study. Four categories of OFP syndromes were utilised: temporomandibular disorders (TMDs), atypical dental pain (ADP), trigeminal neuralgia (TN), and persistent dentoalveolar pain disorder (PDAP). In addition, a control group consisting of individuals who did not experience any discomfort was also included in the study. Participants received a standardised explanation of the questionnaires utilised, and in most instances, they completed them at the clinic under the supervision of one of the investigators. Results The correlations between each version of the Oral Health Impact Profile (OHIP) were statistically significant (p < 0.001), with correlation values ranging from 0.92 to 0.97. When comparing the occurrence of OHIP items across the four pain types, we identified 18 variations that exceeded the 35% prevalence threshold we established for identifying important items that frequently occur out of the 315 comparisons. The question "Have you had a painful aching in your mouth?" showed a low frequency in patients with TN, TMD, and ADP but a significant prevalence in patients with PDAP (90%). This difference in prevalence across pain types was the biggest seen. The question that seemed to distinguish between the pain categories most effectively was "Have you experienced a toothache?" This question had a high occurrence in PDAP (65%) and ADP (60%), perhaps allowing for differentiating these two diseases from TN and TMD. The highest prevalence differences, over 30%, were most often seen when PDAP was included as one of the disorders being compared. ADP had the fewest variances, over 30%, occurring just seven times. Conclusion Both acute and chronic OFPs have a major negative influence on QoL, but they affect it differently and to differing extents. Injury-related acute pain obviously poses rapid and severe restrictions on physical function and causes temporary psychological distress and temporary social exclusion. On the other hand, chronic pain for the patient always implies being locked in a physical world that does not allow him or her to bypass physical limitations, psychological disorders remain constant, and isolation from other people persists for life.

Trigeminal neuralgia and trigeminal neuropathic pain

It is very important that the dental team are aware of the varied presentations of pain in the mouth, face and other parts of the trigeminal region which are not directly caused by teeth or oral structures. Our understanding of underlying causes in this complex area is evolving. Ultimately, patients who present with what may at first seem to be oral or dental problems will require specialist input in secondary care with potential for use of systemic medications. This article reviews the common non-dental pains encountered in the orofacial region related to dysfunction of the trigeminal nerve.

Presentation and primary care management of temporomandibular disorders: A survey of primary care dentists in Santiago and Newcastle

BACKGROUND

Primary care dentists are often the first point of call for people with temporomandibular disorders (TMD) but it is not known how many people present to their dentist with TMD or the forms of first-line management that are routinely offered.

OBJECTIVES

To report rates of presentation of TMD and management offered in primary care by general dental practitioners in two similarly urban areas, Santiago, Chile and North-East England.

METHODS

An online survey was developed and distributed to primary care dentists in both regions. Descriptive data were presented to quantify presentation rates and forms of management offered.

RESULTS

Responses were received from 215 dentists practising in Chile and 46 in Newcastle. The majority reported seeing 1-2 patients weekly with TMD and less than one new presentation each week. Symptoms were most often treated conservatively and with self-management according to international guidelines. The form of self-management varied however and verbal instructions were often not backed up by written information.

CONCLUSIONS

This research provides a useful starting point in understanding the presentation to, and initial treatment of TMD in primary care internationally. Limitations included the method of recruitment and potentially non-representative samples. Further research could build on this work by including more countries and using more structured sampling methods. The work will be useful in understanding and planning early care pathways for people experiencing TMD.

Chronic temporomandibular disorder pain patients with a history of neuropathic pain treatment: a narrative research on their diagnosis and treatment history

The aims of this qualitative research were (1) to gain more insight in the diagnostic and treatment history of patients with chronic temporomandibular disorder (TMD) pain; (2) to get a deeper understanding of possible factors that are involved in the possible delay in setting a TMD-pain diagnosis and receiving appropriate treatment; and (3) to get a deeper understanding of the perspectives and experiences of chronic TMD-pain patients on the possible improvement of various aspects of their diagnostic and treatment journey.MethodsIn this narrative research, semi-structured interviews took place with patients who experienced chronic orofacial pain (OFP) for at least three years before getting diagnosed with, and treated for, TMD pain by an OFP specialist in an interprofessional setting.ResultsIn total, ten patients were interviewed in-depth. Patients experienced their chronic OFP in different ways, but all reported a significant impact of their pain on their quality of life. All patients visited numerous health care professionals before their TMD diagnosis was set. Among others, they underwent anti-neuropathic pain medication therapies and invasive surgeries, which did not significantly reduce their chronic OFP. The interprofessional TMD-pain treatment reduced the suffering of the chronic OFP substantially, also 6 months after the start of therapy, and improved the quality of life for all patients. In most of them, the OFP intensity was also decreased.ConclusionChronic TMD-pain patients with a history of neuropathic pain treatment may experience a long journey until receiving the appropriate diagnosis and treatment. This stresses the need to improve the implementation of chronic TMD-pain guidelines.

Healthcare priorities in patients with chronic facial pain of temporomandibular disorders

OBJECTIVES

To explore the experiences of patients with temporomandibular disorders (TMDs) with the National Health Service and to discover their healthcare priorities when seeking treatment.

METHODS

Semi-structured interviews were used. They were directed using a topic guide covering subjects such as initial visits in primary care, referrals to secondary care, and the effect on symptoms. The discussions were audiotaped and transcribed verbatim. Thematic analysis was utilised to analyse the data.

RESULTS

In total, 15 participants took part in three focus groups. Six themes were identified: "access to appropriate care", "organised and coordinated care", "receiving a diagnosis and enough information", "interaction with the clinical staff", "treatment strategies and having an 'action plan'" and "support and social networks".

CONCLUSIONS

The participants gave accounts of the difficulties encountered in healthcare in general terms and specific to TMD. Most notable was the struggle to access appropriate care, receive a diagnosis and be understood. Our findings suggest that delays in delivering appointments with people of expertise may have caused the worsening of symptoms. However, when a pleasant experience was encountered, access to care was fast, the clinician was understanding and communication with the clinical team was good. These provided positive experiences and were appreciated by the patients.

Building the foundation for a modern patient-partnered infrastructure to study temporomandibular disorders

Background

Conflicting reports from varying stakeholders related to prognosis and outcomes following placement of temporomandibular joint (TMJ) implants gave rise to the development of the TMJ Patient-Led RoundTable initiative. Following an assessment of the current availability of data, the RoundTable concluded that a strategically Coordinated Registry Network (CRN) is needed to collect and generate accessible data on temporomandibular disorder (TMD) and its care. The aim of this study was therefore to advance the clinical understanding, usage, and adoption of a core minimum dataset for TMD patients as the first foundational step toward building the CRN.

Methods

Candidate data elements were extracted from existing data sources and included in a Delphi survey administered to 92 participants. Data elements receiving less than 75% consensus were dropped. A purposive multi-stakeholder sub-group triangulated the items across patient and clinician-based experience to remove redundancies or duplicate items and reduce the response burden for both patients and clinicians. To reliably collect the identified data elements, the identified core minimum data elements were defined in the context of technical implementation within High-performance Integrated Virtual Environment (HIVE) web-application framework. HIVE was integrated with CHIOS™, an innovative permissioned blockchain platform, to strengthen the provenance of data captured in the registry and drive metadata to record all registry transaction and create a robust consent network.

Results

A total of 59 multi-stakeholder participants responded to the Delphi survey. The completion of the Delphi surveys followed by the application of the required group consensus threshold resulted in the selection of 397 data elements (254 for patient-generated data elements and 143 for clinician generated data elements). The infrastructure development and integration of HIVE and CHIOS™ was completed showing the maintenance of all data transaction information in blockchain, flexible recording of patient consent, data cataloging, and consent validation through smart contracts.

Conclusion

The identified data elements and development of the technological platform establishes a data infrastructure that facilitates the standardization and harmonization of data as well as perform high performance analytics needed to fully leverage the captured patient-generated data, clinical evidence, and other healthcare ecosystem data within the TMJ/TMD-CRN.

Persistent Orofacial Pain Attendances at General Medical Practitioners

Patients with persistent orofacial pain (POFP) can go through complex care pathways to receive a diagnosis and management, which can negatively affect their pain. This study aimed to describe 44-y trends in attendances at Welsh medical practices for POFP and establish the number of attendances per patient and referrals associated with orofacial pain and factors that may predict whether a patient is referred. A retrospective observational study was completed using the nationwide Secure Anonymised Information Linkage Databank of visits to general medical practices in Wales (UK). Data were extracted using diagnostic codes ("Read codes"). Orofacial and migraine Read codes were extracted between 1974 and 2017. Data were analyzed using descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 468,827 POFP and migraine diagnostic codes, accounting for 468,137 patient attendances, or 301,832 patients. The overall attendance rate was 4.22 attendances per 1,000 patient-years (95% confidence interval [CI], 4.21-4.23). The attendance rate increased over the study period. Almost one-third of patients (n = 92,192, 30.54%) attended more than once over the study period, and 15.83% attended more than once within a 12-mo period. There were 20,103 referral codes that were associated with 8,183 patients, with over half these patients being referred more than once. Odds of receiving a referral were highest in females (odds ratio [OR], 1.23; 95% CI, 1.17-1.29), in those living in rural locations (OR, 1.17; 95% CI, 1.12-1.22), and in the least deprived quintile (OR, 1.39; 95% CI, 1.29-1.48). Odds also increased with increasing age (OR, 1.03; 95% CI, 1.03-1.03). The increasing attendance may be explained by the increasing incidence of POFP within the population. These patients can attend on a repeated basis, and very few are referred, but when they are, this may occur multiple times; therefore, current care pathways could be improved.

A Meta-Synthesis of the Experience of Chronic Temporomandibular Disorder Patients Within Health Care Services

Aims: To systematically review the qualitative evidence related to experiences of patients with temporomandibular disorders (TMD) and to explore their journeys within health care services. Methods: A systematic search of the following databases was conducted: MEDLINE, Embase, PsycINFO, Web of Science, CINAHL Complete, and the Cochrane database. Thematic synthesis was used to analyze and synthesize the data from qualitative studies that explored the journeys of TMD patients within health care services. The Critical Appraisal Skills Programme (CASP) tool was used to critically appraise the quality of the included studies. Results: The search strategies yielded 4,563 articles across all databases, and 18 articles were eventually included. Six themes were derived: care-seeking attitudes; expectations and health care experience; the patient-clinician interaction; diagnosis as a stepping stone for improvement; management; and social support. Conclusion: The journey within health care services may play a valuable role in the ability to cope with chronic TMDs. Receiving a diagnosis, being listened to, and being believed are among the most important elements making for a positive clinical experience.

"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.

Effectiveness of and Patient’s Satisfaction with Dental Emergency Unit in Pitié Salpêtrière Hospital (Paris), Focusing on Pain and Anxiety

Background

The Dental Emergency Unit (DEU) of the Pitié Salpêtrière Hospital receives mainly painful emergencies. This study aimed at evaluating the suppression of pain and anxiety as well as the patient's satisfaction after a visit to the DEU. Patients and Methods. A prospective study was carried out in 2019 (NCT03819036) in adult patients. Data was collected on D0 on site and then on D1, D3, and D7 by phone, during daytime. The main objective and secondary objectives were, respectively, to assess the intensity of pain on D1; the intensity of pain on D3 and D7; the evolution of anxiety on D1, D3, and D7; and the patients' satisfaction. They were evaluated with a 0–10 numeric scale (NS) on D1, D3 and D7; mean scores were compared with nonparametric statistics (ANOVA, Dunn's test).

Results

814 patients were contacted and 581 patients included; 87 were lost to follow-up. 376 patients completed all the questionnaires. In the final sample (59% men, 40 ± 16 y.o.), 86% had health insurance. The mean pain scores were as follows: D0: 6.36 ± 0.12; D1: 3.49 ± 0.13; D3: 2.23 ± 0.13; D7: 1.07 ± 0.11—indicating a significant decrease of 45%, 65%, and 93% on D1, D3, and D7, respectively, compared to D0 (p < 0.0001) between D0 and D1, D3, D7. The mean NS anxiety scores were as follows: D0: 3.32 ± 0.15; D1: 3.69 ± 0.16; D3: 2.75 ± 0.16; D7: 1.98 ± 0.15. The decrease was significant between D0 and D7 (p < 0.0001). The perception of general heath improved between D1 and D7. The overall score of satisfaction was 8.64 ± 0.06.

Conclusion

DEU enabled a significant reduction in pain and anxiety with high overall satisfaction.

Temporomandibular disorders cases with high-impact pain are more likely to experience short-term pain fluctuations

Temporomandibular disorders (TMD) patients can present clinically significant jaw pain fluctuations which can be debilitating and lead to poor global health. The Graded Chronic Pain Scale evaluates pain-related disability and its dichotomous grading (high/low impact pain) can determine patient care pathways and in general high-impact pain patients have worse treatment outcomes. Individuals with low-impact TMD pain are thought to have better psychosocial functioning, more favorable disease course, and better ability to control pain, while individuals with high-impact pain can present with higher levels of physical and psychological symptoms. Thereby, there is reason to believe that individuals with low- and high-impact TMD pain could experience different pain trajectories over time. Our primary objective was to determine if short-term jaw pain fluctuations serve as a clinical marker for the impact status of TMD pain. To this end, we estimated the association between high/low impact pain status and jaw pain fluctuations over three visits (≤ 21-day-period) in 30 TMD cases. Secondarily, we measured the association between jaw pain intensity and pressure pain thresholds (PPT) over the face and hand, the latter measurements compared to matched pain-free controls (n = 17). Jaw pain fluctuations were more frequent among high-impact pain cases (n = 15) than low-impact pain cases (n = 15) (OR 5.5; 95% CI 1.2, 26.4; p value = 0.033). Jaw pain ratings were not associated with PPT ratings (p value > 0.220), suggesting different mechanisms for clinical versus experimental pain. Results from this proof-of-concept study suggest that targeted treatments to reduce short-term pain fluctuations in high-impact TMD pain is a potential strategy to achieve improved patient perception of clinical pain management outcomes.

DEEP Study: Modeling Outcomes and Costs of Persistent Orofacial Pain

KNOWLEDGE OF TRANSFER STATEMENT

Despite a substantial number of consultations, individuals experiencing the care pathways in this study continued to have far from perfect health over their life course. The modeling suggests they would only experience 18 y in "perfect health." There is considerable scope to improve current care/outcomes and patient experience.

Implementation of biopsychosocial supported self-management for chronic primary oro-facial pain including temporomandibular disorders: A theory, person and evidence-based approach

BACKGROUND

Aims of the study were to: Implement supported self-management for chronic primary oro-facial pain in a clinical setting. Evaluate its impact on consultation rates, pain severity, interference with life and patient experience.

METHODS

Sixty-six patients with chronic primary oro-facial pain received the intervention at a facial pain clinic at Leeds Dental Institute, UK. Brief Pain Inventory (BPI) scores measured pain severity and interference with life before and after the intervention. Process mining outlined patient care pathways. Monthly consultation rates measured 12 months before and after the intervention were used to evaluate burden on healthcare services and economic impact. Patient feedback was assessed via Patient and Public involvement discussion groups.

RESULTS

Mean BPI scores significantly improved after intervention-from 5.70 (SD 1.89) to 3.78 (SD 2.34) (p < .001); mean pain interference score reduced from 19.95 (SD 9.41) to 12.05 (SD 9.64) (p < .001). Average monthly consultations significantly (p = .001) reduced from 0.42/month before the intervention to 0.16/month after the intervention. Economic assessment showed cost savings of £293 per patient per year. Process mining showed high rates of service usage with 31 patients also attending 51 other specialist services between them. Patient and Public Involvement discussion groups with 5 patients identified that the intervention was a 'constant companion' and should be implemented at the outset in the care pathway.

CONCLUSION

Supported self-management for chronic primary oro-facial pain has a positive impact on health outcomes (physical functioning, pain intensity and patient experience), as well as service usage and healthcare costs when implemented in a secondary care clinical setting. Reconfiguring current care pathways to upscale early implementation of such interventions should be a priority for future testing.

Pain complications of oral implants: Is that an issue?

The use of oral implants as a form of replacing missing teeth in partial or total edentulous patients is considered the gold standard in oral rehabilitation. Although considered a history of success in contemporary dentistry, surgical complications may occur, as excessive bleeding, damage to the adjacent teeth and mandibular fractures. Persistent pain and abnormal somatosensory responses after the surgery ordinary healing time are also potential problems and may lead to the development of a condition named posttraumatic trigeminal neuropathic pain (PTNP). Though relatively rare, PTNP has a profound impact on patient's quality of life. Appropriated previous image techniques, effective anaesthetic procedures and caution during the surgical procedure and implant installation are recommended for the prevention of this condition. In case of the PTNP, different management modalities, including antidepressant and membrane stabilizer medications, as well as peripheral strategies, as the use of topical medication and the botulin toxin are presented and discussed.

Orofacial pain education in dentistry: A path to improving patient care and reducing the population burden of chronic pain

Dentists stand in an optimal position to prevent and manage patients suffering from chronic orofacial pain (OFP) disorders, such as temporomandibular disorders, burning mouth syndrome, trigeminal neuralgia, persistent idiopathic dentoalveolar pain, among others. However, there are consistent reports highlighting a lack of knowledge and confidence in diagnosing and treating OFP among dental students, recent graduates, and trained dentists, which leads to misdiagnosis, unnecessary costs, delay in appropriate care and possible harm to patients. Education in OFP is necessary to improve the quality of general dental care and reduce individual and societal burden of chronic pain through prevention and improved quality of life for OFP patients. Our aims are to emphasize the goals of OFP education, to identify barriers for its implementation, and to suggest possible avenues to improve OFP education in general, postgraduate, and continuing dental education levels, including proposed minimum OFP competencies for all dentists. Moreover, patient perspectives are also incorporated, including a testimony from a person with OFP. General dentists, OFP experts, educators, researchers, patients, and policy makers need to combine efforts in order to successfully address the urgent need for quality OFP education.

Clinical presentations on a facial pain clinic

Introduction The complex nature of facial pain conditions creates a diagnostic challenge which may necessitate specialist referral.Aim To identify the case mix presenting to a specialist tertiary care facial pain clinic.Methods A retrospective review of 112 patient records was undertaken. Trends in provisional diagnoses from referrers and the correlation to diagnoses made following specialist consultation were reviewed.Results The most common provisional diagnoses recorded in referral letters were painful temporomandibular disorders, trigeminal neuralgia and persistent idiopathic facial pain (PIFP). Over a quarter of referrals did not include a provisional diagnosis. Following assessment, only one case was not given a definitive diagnosis and no patients were diagnosed with PIFP. A causative factor was identified in all the initially queried PIFP cases, and painful post-traumatic trigeminal neuropathic pain was found in multiple patients.Conclusions Painful post-traumatic trigeminal neuropathic pain should be considered if pain onset coincides with dental treatment or other traumatic events. PIFP is a rare facial pain diagnosis and may be over-diagnosed by dental and medical practitioners. It is important to systematically exclude other causes before reaching this diagnosis. This will facilitate effective treatment, manage patient expectations and potentially reduce unnecessary referrals.

Selection and application of coils in temporomandibular joint MRI

Objective:

To compare and evaluate the signal-to-noise ratio (SNR) and the contrast-to-noise ratio (CNR) values between a 15-channel phased array head coil and 6-channel dS Flex M surface coil in the MRI of temporomandibular joint.

Methods:

300 patients were randomly assigned to two groups: 150 patients were examined by using a 15-channel phased array head coil and the other 150 patients were scanned by using a 6-channel dS Flex M surface coil. All of the data were set in the same 6 regions of interest including the temporal lobe, condyle neck, lateral pterygoid muscle, parotid gland, the adipose area and an area of the background noise）. SNR and CNR values were measured respectively.

Results:

The numerical variation law of SNR and CNR values measured in regionsof interest of each group was similar, although different coils were used. There were statistically significant differences of SNR values in all of the oblique sagittal (OSag) proton density-weighted imaging, the part of OSag T₂ weighted image (T₂WI) except for SNR₄ and SNR₅. and oblique coronal (OCor) T₂WI sequence except for SNR₂. On the contrary, SNR₄ and SNR₅ values in the OCor T₂WI and SNR₅ values in OSag T₂WI sequences by using the surface coil were higher than those by using the head coil. There were no statistically significant intergroup differences of CNR values in OSag proton density-weighted imaging sequence except CNR₁ and in OSag T₂WI sequence except CNR₅. But, statistically significant differences of all the values in the OCor T₂WI sequence except for CNR₁ were observed.

Conclusion:

Both the phased array head coil and dS Flex M surface coil can be used for temporomandibular joint MRI.

Oral diseases: a global public health challenge

Oral diseases are among the most prevalent diseases globally and have serious health and economic burdens, greatly reducing quality of life for those affected. The most prevalent and consequential oral diseases globally are dental caries (tooth decay), periodontal disease, tooth loss, and cancers of the lips and oral cavity. In this first of two papers in a Series on oral health, we describe the scope of the global oral disease epidemic, its origins in terms of social and commercial determinants, and its costs in terms of population wellbeing and societal impact. Although oral diseases are largely preventable, they persist with high prevalence, reflecting widespread social and economic inequalities and inadequate funding for prevention and treatment, particularly in low-income and middle-income countries (LMICs). As with most non-communicable diseases (NCDs), oral conditions are chronic and strongly socially patterned. Children living in poverty, socially marginalised groups, and older people are the most affected by oral diseases, and have poor access to dental care. In many LMICs, oral diseases remain largely untreated because the treatment costs exceed available resources. The personal consequences of chronic untreated oral diseases are often severe and can include unremitting pain, sepsis, reduced quality of life, lost school days, disruption to family life, and decreased work productivity. The costs of treating oral diseases impose large economic burdens to families and health-care systems. Oral diseases are undoubtedly a global public health problem, with particular concern over their rising prevalence in many LMICs linked to wider social, economic, and commercial changes. By describing the extent and consequences of oral diseases, their social and commercial determinants, and their ongoing neglect in global health policy, we aim to highlight the urgent need to address oral diseases among other NCDs as a global health priority.

DEEP Study: Indirect and Out-of-pocket Costs of Persistent Orofacial Pain

Persistent orofacial pain (POFP) is common and caused by a group of conditions affecting the face, head, or mouth. Recent research highlighted a problematic care pathway with high costs to the health care provider, but the financial impact on patients and employers is not understood. This study aimed to describe patient (out-of-pocket) and employer (indirect) costs of POFP and to identify whether the dichotomized Graded Chronic Pain Scale (GCPS) was predictive of costs. A cohort of 198 patients was recruited from primary and secondary care settings in North East England and followed over a 24-mo period. Patients completed the GCPS and Use of Services and Productivity Questionnaire every 6 mo and a Time and Travel Questionnaire at 14 mo. Questionnaires examined the implications of health care utilization on patients’ everyday lives and personal finances. Time and travel costs were calculated and applied to use-of-services data to estimate out-of-pocket costs, while the human capital method and QQ method (quantity and quality of work completed) were used to estimate absenteeism and presenteeism costs, respectively. Per person per 6-mo period (in 2017 pounds sterling), mean out-of-pocket costs were £333 (95% CI, £289 to £377), and indirect costs were £1,242 (95% CI, £1,014 to £1,470). Regression analyses indicated that over 6 mo, the GCPS was predictive of the following: out-of-pocket costs—a difference of £311 between low and high GCPS per person per 6-mo period (95% CI, £280 to £342; P < 0.01, n = 705 observations over 24 mo); indirect costs—a difference of £2,312 between low and high GCPS per person per 6-mo period (95% CI, £1,886 to £2,737; P < 0.01; n = 352 observations over 24 mo). This analysis highlights “hidden” costs of POFP and supports the use of the dichotomized GCPS to identify patients at risk of higher impact and associated costs and thereby stratify care pathways and occupational health support appropriately.

Orofacial pain - an update on diagnosis and management

The diagnosis and management of orofacial pain may be challenging due to complex histories, pathophysiology and associated psychosocial co-morbidities such as depression and anxiety. Neuropathic facial pain conditions such as burning mouth syndrome (BMS), persistent idiopathic facial pain (PIFP), atypical odontalgia (AO) and trigeminal neuralgia (TN) require early recognition by primary care clinicians and referral to secondary care. Acute pain-related temporomandibular disorder (TMD) may be managed in the primary care setting, with identification of those at risk of developing chronic TMD receiving an early referral to secondary care. Adopting a biopsychosocial approach, consisting of physical therapies, pharmacotherapy and psychological support can lead to effective management and may limit the negative impact of facial pain upon quality of life and daily functioning.