Orofacial phantom pain: theory and phenomenology

The phenomenological approach in dentistry - a narrative review

PURPOSE

Phenomenology is a branch of philosophy that focuses on human lived experience. Illness including dental diseases can affect this living experience. Within the dental literature, there is very little reported on the use of phenomenology compared to other healthcare sciences. Hence, the aim was to review the literature and provide an overview of various applications of phenomenology in dental research.

METHODS

This study was a narrative review using literature in the last 10 years identified by web-based search on PubMed and Scopus using keywords. A total of 33 articles that were closely related to the field and application in dentistry were included. The methodology, main results, and future research recommendations, if applicable, were extracted and reviewed.

RESULTS

The authors in this study had identified several areas such as orofacial pain and pain control research, dental anxiety, dental education, oral healthcare perceptions and access, living with dental diseases and dental treatment experience in which the phenomenological method was used to gain an in-depth understanding of the topic.

CONCLUSIONS

There are several advantages of using the phenomenological research method, such as the small sample size needed, the diverse and unique perspective that can be obtained and the ability to improve current understanding, especially from the first-person perspective.

Effectiveness of root canal treatment for vital pulps compared with necrotic pulps in the presence or absence of signs of periradicular pathosis: A systematic review and meta-analysis

BACKGROUND

Preoperative pulpal status may influence the outcomes of root canal treatment (RCTx) according to various measures used.

OBJECTIVES

To compare the effectiveness of RCTx of teeth with a vital pulp versus a necrotic pulp, using a range of clinical and patient-related outcomes proposed for the development of S3-level clinical practice guidelines.

METHODS

A search was conducted in the PubMed-MEDLINE, Scopus, EMBASE, Google scholar databases and available repositories, followed by hand searches, until 29 March 2022. Clinical studies published in the English language comparing the stipulated outcomes of RCTx of teeth with vital versus necrotic pulp were included. The Newcastle-Ottawa Scale was adapted to assess study quality. Effects of pulpal status were estimated and expressed as risk ratio (RR) using fixed- and random-effect meta-analyses. The quality of evidence was assessed through the Grading of Recommendations Assessment, Development and Evaluation tool.

RESULTS

Twenty-eight studies published between 1961 and 2021 were included. Five studies have investigated the "tooth survival" outcome, four reported pulpal status was not a significant predictor, consistent with meta-analysis findings (RR: 1.00; 95% CI: 1.00, 1.00; n = 3). Seven studies reported pulpal status had no significant influence on postoperative pain, regardless of duration after treatment. Sixteen studies have analysed "periapical health," and 11 revealed pulpal status had no significant influence. Meta-analyses revealed the influence was not significant if preoperative periapical radiolucency was absent (RR: 0.95; 95% CI: 0.90, 1.00; n = 9) but significant if it was present (RR: 1.12; 95% CI: 1.05, 1.19; n = 11). Most studies were classified as "some concerns" (n = 17) to "low" (n = 9) risk of bias RoB.

DISCUSSION

Evidence is limited and only available for three outcomes when comparing the effectiveness of RCTx in permanent teeth with vital pulp versus pulp necrosis. Nevertheless, the quality of available evidence was moderate to high. The "periapical health" data heterogeneity could be explained by preoperative radiolucency, thus RCTx was found more effective for prevention than the resolution of apical periodontitis.

CONCLUSIONS

There was no significant difference in the "tooth survival," "postoperative pain" and "evidence of apical radiolucency" outcomes of RCTx in teeth with vital or necrotic pulps.

REGISTRATION

PROSPERO database (CRD42021260280).

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.

Phantom bite syndrome: Revelation from clinically focused review

Phantom bite syndrome (PBS), also called occlusal dysesthesia, is characterized by persistent non-verifiable occlusal discrepancies. Such erroneous and unshakable belief of a “wrong bite” might impel patients to visit multiple dental clinics to meet their requirements to their satisfaction. Subsequently, it takes a toll on their quality of life causing, career disruption, financial loss and suicidal thoughts. In general, patients with PBS are quite rare but distinguishable if ever encountered. Since Marbach reported the first two cases in 1976, there have been dozens of published cases regarding this phenomenon, but only a few original studies were conducted. Despite the lack of official classification and guidelines, many authors agreed on the existence of a PBS “consistent pattern” that clinicians should be made aware. Nevertheless, the treatment approach has been solely based on incomplete knowledge of etiology, in which none of the proposed theories are fully explained in all the available cases. In this review, we have discussed the critical role of enhancing dental professionals’ awareness of this phenomenon and suggested a comprehensive approach for PBS, provided by a multidisciplinary team of dentists, psychiatrists and exclusive psychotherapists.

Bildgebende Untersuchungen des neuronalen Schmerznetzwerks

Der vorliegende Artikel soll eine Übersicht über bildgebende Untersuchungen im Bereich chronischer Schmerzsyndrome bieten. Auf die einleitenden Worte zur allgemeinen Phänomenologie des Schmerzes folgt ein umfassender Einblick in die gegenwärtige Anwendung funktioneller und struktureller Bildgebungstechniken am Beispiel ausgewählter Schmerzsyndrome (Chronischer Rückenschmerz, Fibromyalgiesyndrom (FMS), Phantomschmerz und Komplexes regionales Schmerzsyndrom (CRPS)). In diesem Zusammenhang werden Gemeinsamkeiten und Besonderheiten der spezifischen neurologischen Korrelate verschiedener chronischer Schmerzerkrankungen diskutiert.

Occlusal dysesthesia-A clinical guideline

Background

The diagnosis and management of patients suffering from occlusal dysesthesia (OD) remain a major challenge for dental practitioners and affected patients.

Objectives

To present the results of a literature‐based expert consensus intended to promote better understanding of OD and to facilitate the identification and management of affected patients.

Methods

In 2018, electronic literature searches were carried out in PubMed, Cochrane Library and Google Scholar as well as in the archives of relevant journals not listed in these databases. This approach was complemented by a careful assessment of the reference lists of the identified relevant papers. The articles were weighted by evidence level, followed by an evaluation of their contents and a discussion. The result represents an expert consensus.

Results

Based on the contents of the 77 articles identified in the search, the current knowledge about clinical characteristics, epidemiology, aetiology, diagnostic process, differential diagnosis and management of OD is summarised.

Conclusions

Occlusal dysesthesia exists independently of the occlusion. Instead, it is the result of maladaptive signal processing. The focus should be on patient education, counselling, defocusing, cognitive behavioural therapy, supportive drug therapy and certain non‐specific measures. Irreversible, specifically an exclusively dental treatment approach must be avoided.

Comparison of Cerebral Blood Flow Patterns in Patients with Phantom Bite Syndrome with Their Corresponding Clinical Features

BACKGROUND

Phantom bite syndrome (PBS) is characterized by an uncomfortable sensation during occlusion without any evident abnormality. A recent case-control study with single-photon emission computed tomography (SPECT) using ^99mTc-ethyl cysteinate dimer could not find the specific features of regional cerebral blood flow (rCBF), which might be due to the heterogeneity of PBS. We analyzed the brain images of PBS corresponding to the clinical features by studying PBS subgroups.

METHODS

This study contributes to elucidating the pathophysiology of PBS by evaluating regional brain perfusion on SPECT and its clinical features. We performed SPECT using ^99mTc-ethyl cysteinate dimer in 44 patients with PBS. The SPECT images were analyzed qualitatively and quantitatively.

RESULTS

Asymmetrical rCBF patterns were detected, corresponding to symptom laterality. Patients with PBS with right-side symptoms showed right-side-predominant rCBF asymmetry in the parietal region and left-side-predominant rCBF asymmetry in the thalamus, and vice versa. Moreover, the analysis of the association between rCBF and patient behaviors revealed that patients who blamed their dentists for their symptoms tended to have a symmetrical rCBF pattern.

CONCLUSION

Patients with PBS showed blood flow imbalance in the thalamus and parietal region corresponding to symptom laterality. There are two types of symmetrical and asymmetrical rCBF patterns in the pathophysiology of PBS despite similar clinical manifestations.

Neuroimaging the pain network - Implications for treatment

In this chapter, we provide an overview of neuroimaging studies in chronic pain. We start with an introduction about the phenomenology of pain. In the following section, the application of functional and structural imaging techniques is shown in selected chronic pain syndromes (chronic back pain, fibromyalgia syndrome (FMS), phantom limb pain, and complex regional pain syndrome (CRPS)), and commonalities and peculiarities of imaging correlates across different types of chronic pain are discussed. We conclude this chapter with implications for treatments, with focus on behavioral interventions, sensory and motor trainings, and mirror and motor imagery trainings.

Prevalence, predictive factors and clinical course of persistent pain associated with teeth displaying periapical healing following nonsurgical root canal treatment: a prospective study

AIMS

To investigate the prevalence, pain catastrophizing and other predictive factors and clinical course of persistent pain/discomfort associated with teeth displaying periapical healing following nonsurgical root canal treatment (NSRCT).

METHODOLOGY

One hundred and ninety-eight patients (264 teeth) who had NSRCT were reviewed at 5-14 months, postoperatively. Teeth with persistent post-treatment pain or discomfort, plus evidence of periapical healing were further monitored 0.5, 4 and 10 years later. Pain Catastrophizing Scale (PCS) and Short Form of the McGill Pain Questionnaire (SF-MPQ) were completed. Predictive factors were investigated using logistic regression models.

RESULTS

Twenty-four per cent (60/249) of teeth displaying periapical healing at first review were associated with persistent pain or discomfort. Fifty-five teeth monitored 6-7 months later were associated with reduction in pain (17/30) or discomfort (7/25). Cone beam computed tomography (CBCT) of eight teeth with persistent symptoms and complete periapical healing (by conventional radiographs) revealed distinct, small apical radiolucencies (n = 3) or root apex fenestration through the buccal plate (n = 2). History of chronic pain (headache, temporo-mandibular joint, masticatory muscle, neck, shoulder or back pain; P = 0.005), preoperative pain (P = 0.04), responsive pulp (P = 0.009), tooth crack (P = 0.05) and small periapical radiolucency (P = 0.005) were significant predictive factors. The PCS revealed 16 patients (22 teeth) were catastrophizers (PCS ≥ 30), but this had no influence on post-treatment symptoms (P = 0.5).

CONCLUSIONS

Persistent pain or discomfort associated with teeth showing periapical healing at the first review after NSRCT, decreased in intensity in most cases over the following 6 months. Longer-term follow-up revealed spontaneous improvement or symptom resolution in the majority of those with confirmed radiographic the absence of periapical disease. Five predictive factors (history of chronic pain, teeth with responsive pulps, association with pain, diagnosis of tooth crack before treatment and diameter of preoperative radiolucency) were identified.

Evaluating Burning Mouth Syndrome as a Comorbidity of Atypical Odontalgia: The Impact on Pain Experiences

OBJECTIVE

This study aimed (1) to investigate the differences in clinical characteristics of patients between 2 groups, those who have atypical odontalgia (AO) only and those who have AO with burning mouth syndrome (BMS), and (2) to assess the influence of psychiatric comorbidity factors on patients' experiences.

METHOD

Medical records and psychiatric referral forms of patients visiting the Psychosomatic Dentistry Clinic of Tokyo Medical and Dental University between 2013 and 2016 were reviewed. The final sample included 2 groups of 355 patients: those who have AO only (n = 272) and those who have AO with BMS (AO-BMS; n = 83). Clinicodemographic variables (gender, age, comorbid psychiatric disorders, and history of headache or sleep disturbances) and pain variables (duration of illness, pain intensity, and severity of accompanying depression) were collected. Initial pain assessment was done using the Short-Form McGill Pain Questionnaire, and depressive state was determined using the Zung Self-Rating Depression Scale.

RESULTS

The average age, female ratio, and sleep disturbance prevalence in the AO-only group were significantly lower than those in AO-BMS group. AO-BMS patients rated overall pain score and present pain intensity significantly higher than did the AO-only patients (P = 0.033 and P = 0.034, respectively), emphasizing sharp (P = 0.049), hot-burning (P = 0.000), and splitting (P = 0.003) characteristics of pain. Patients having comorbid psychiatric disorders had a higher proportion of sleep disturbance in both groups and a higher proportion of depressive state in the AO-only group.

CONCLUSIONS

AO-BMS patients have different epidemiological characteristics, sleep quality, and pain experiences compared to AO-only patients. The presence of psychiatric comorbidities in both groups may exacerbate sleep quality. We suggest that BMS as a comorbid oral disorder in AO patients contributes to a more intensively painful experience.

Altered pain modulation in patients with persistent postendodontic pain

Persistent pain may follow nerve injuries associated with invasive therapeutic interventions. About 3% to 7% of the patients remain with chronic pain after endodontic treatment, and these are described as suffering from painful posttraumatic trigeminal neuropathy (PTTN). Unfortunately, we are unable to identify which patients undergoing such procedures are at increased risk of developing PTTN. Recent findings suggest that impaired endogenous analgesia may be associated with the development of postsurgical chronic pain. We hypothesized that patients with PTTN display pronociceptive pain modulation, in line with other chronic pain disorders. Dynamic (conditioned pain modulation, temporal summation) and static (response to mechanical and cold stimulation) psychophysical tests were performed intraorally and in the forearm of 27 patients with PTTN and 27 sex- and age-matched controls. The dynamic sensory testing demonstrated less efficient conditioned pain modulation, suggesting reduced function of the inhibitory endogenous pain-modulatory system, in patients with PTTN, mainly in those suffering from the condition for more than a year. The static sensory testing of patients with PTTN demonstrated forearm hyperalgesia to mechanical stimulation mainly in patients suffering from the condition for less than a year and prolonged painful sensation after intraoral cold stimulus mainly in patients suffering from the condition for more than a year. These findings suggest that PTTN is associated more with the inhibitory rather than the facilitatory arm of pain modulation and that the central nervous system has a role in PTTN pathophysiology, possibly in a time-dependent fashion.

Psychiatric comorbidities and psychopharmacological outcomes of phantom bite syndrome

OBJECTIVE

Phantom bite syndrome (PBS) is characterized by a persistent uncomfortable sensation of occlusion without an evident occlusal discrepancy. The aims of this retrospective cross-sectional study were to assess psychiatric comorbidities and evaluate psychopharmacological outcomes of PBS.

METHODS

The database of the Psychosomatic Dentistry Clinic of Tokyo Medical and Dental University Dental Hospital was reviewed for cases of PBS diagnosed between April 2009 and March 2012. Clinical Global Impression indices were used to assess psychopharmacological outcomes.

RESULTS

The review revealed 130 patients (107 women, 23 men) with a mean age of 53.0 ±13.1 years. They previously visited 4.4 ±3.4 dental clinicsand had a mean symptom duration of 5.3 ±5.4 years. Only 24 (18.5%) of 63 (48.5%) patients with psychiatric comorbidities had schizophrenia, major depressive disorder, or bipolar disorder. The frequency of psychiatric comorbidities was significantly lower in PBS with a dental trigger than that without a specific trigger. Moreover, patients without a psychiatric comorbidity showed significantly better outcomes than those with a psychiatric comorbidity. Forty patients (30.8%) showed remarkable clinical improvement after receiving amitriptyline, mirtazapine, or aripiprazole.

CONCLUSION

PBS is generally not associated with severe psychiatric disorders. Absence of a dental trigger predicts a psychiatric comorbidity, which affects the psychopharmacological outcome. Antidepressant or antipsychotic therapy may be effective for symptom management in PBS.

Orofacial pain syndromes: evaluation and management

Patients will often visit their primary medical practitioner with orofacial pain complaints. Hence, it is important to recognize and have an understanding of these conditions to properly evaluate and potentially manage these disorders. If the practitioner is uncertain or uncomfortable with these conditions, then patient referral to a knowledgeable health care practitioner should be considered for further evaluation and management. In this article, the evaluation and management of various neuropathic, neurovascular, and vascular pains are discussed.

The psychosomatic disorders pertaining to dental practice with revised working type classification

Psychosomatic disorders are defined as disorders characterized by physiological changes that originate partially from emotional factors. This article aims to discuss the psychosomatic disorders of the oral cavity with a revised working type classification. The author has added one more subset to the existing classification, i.e., disorders caused by altered perception of dentofacial form and function, which include body dysmorphic disorder. The author has also inserted delusional halitosis under the miscellaneous disorders classification of psychosomatic disorders and revised the already existing classification proposed for the psychosomatic disorders pertaining to dental practice. After the inclusion of the subset (disorders caused by altered perception of dentofacial form and function), the terminology "psychosomatic disorders of the oral cavity" is modified to "psychosomatic disorders pertaining to dental practice".

Occlusal dysesthesia: a qualitative systematic review of the epidemiology, aetiology and management

Occlusal dysesthesia refers to a persistent complaint of uncomfortable bite sensation with no obvious occlusal discrepancy. This systematic review aimed to draw a picture of such patients, to present an agreement of previously reported diagnostic criteria and to analyse the evidence level of the recommended management approaches. An electronic search for all relevant reports on occlusal dysesthesia was thoroughly performed based on previous nomenclatures (e.g. phantom bite, occlusal hyperawareness) in PubMed and The Cochrane Library in July, 2011. A total of 84 reports were matched, among which only 11 studies were included after a two-step (abstract and detailed full-text revision) screening process. Additionally, a thorough manual review of reference lists of the included reports enabled the inclusion of two additional studies. Data analysis revealed that 37 occlusal dysesthesia patients presented a mean age of 51.7 ± 10.6 years and were predominantly women (male/female: 1/5.1) with symptom duration of more than 6 years (average: 6.3 ± 7.5 years) and with concomitant psychological disturbances (e.g. mood disorders, somatoform disorders, personality disorders). Only four authors presented diagnostic criteria for occlusal dysesthesia, which served as the basis for an agreement in the diagnostic criteria. Treatment approaches included psychotherapy, cognitive/behaviour therapy, splint therapy and prescription of anti-depressants or anti-anxiety drugs. Classification of evidence level of management approaches, however, revealed that most of them were expert opinions with single- or multiple-case report(s). Future studies are necessary for a deeper understanding of the mechanisms behind the occlusal dysesthesia symptoms, and consequently, for improvements in evidence-based management approaches.

Phantom pain after eye amputation

PURPOSE

To characterize the quality of phantom pain, its intensity and frequency following eye amputation. Possible triggers and relievers of phantom pain are investigated.

METHODS

The hospital database was searched using surgery codes for patients who received ocular evisceration, enucleation, orbital exenteration or secondary implantation of an orbital implant in the period between 1993 and 2003. A total of 267 patients were identified and invited to participate; of these, 173 agreed to participate. These patients' medical records were reviewed. A structured interview focusing on pain was conducted by a trained interviewer.

RESULTS

Of the 173 patients in the study, 39 experienced phantom pain. The median age of patients who had experienced phantom pain was 45 years (range: 19-88). Follow-up time from eye amputation to participation in the investigation was 4 years (range: 2-46). Phantom pain was reported to be of three different qualities: (i) cutting, penetrating, gnawing or oppressive (n = 19); (ii) radiating, zapping or shooting (n = 8); (iii) superficial burning or stinging (n = 5); or a mixture of these different pain qualities (n = 7). The median intensity on a visual analogue scale, ranging from 0 to 100, was 36 (range: 1-89). One-third of the patients experienced phantom pain every day. Chilliness, windy weather and psychological stress/fatigue were the most commonly reported triggers for pain.

CONCLUSIONS

  Phantom pain after eye amputation is relatively common. The pain appears to be similar to the phantom pain suffered by limb amputees. Patients should be informed about this potential complication before surgery.

The eye amputated - consequences of eye amputation with emphasis on clinical aspects, phantom eye syndrome and quality of life

In this thesis the term eye amputation (EA) covers the removing of an eye by: evisceration, enucleation and exenteration. Amputation of an eye is most frequently the end-stage in a complicated disease, or the primary treatment in trauma and neoplasm. In 2010 the literature is extensive due to knowledge about types of surgery, implants and surgical technique. However, not much is known about the time past surgery.

THE PURPOSE OF THE PHD THESIS WAS

To identify the number of EA, the causative diagnosis and the indication for surgical removal of the eye, the chosen surgical technique and to evaluate a possible change in surgical technique in Denmark from 1996 until 2003 (paper I); To describe the phantom eye syndrome and its prevalence of visual hallucinations, phantom pain and phantom sensations (paper II); To characterise the quality of phantom eye pain, including its intensity and frequency among EA patients. We attempted to identify patients with increased risk of developing pain after EA and investigated if preoperative pain is a risk factor for a later development of phantom pain (paper III); In addition we wanted to investigate the health related quality of life, perceived stress, self rated health, job separation due to illness or disability and socio-economic position of the EA in comparison with the general Danish population (paper IV).

THE STUDIES WERE BASED ON

Records on 431 EA patients, clinical ophthalmological examination and an interview study of 173 EA patients and a questionnaire answered by 120 EA patients.

CONCLUSIONS

The most frequent indications for EA in Denmark were painful blind eye (37%) and neoplasm (34%). During the study period 1996-2003, the annual number of eye amputations was stable, but an increase in bulbar eviscerations was noticed. Orbital implants were used with an increasing tendency until 2003. The Phantom eye syndrome is frequent among EA patients. Visual hallucinations were described by 42% of the patients. The content were mainly elementary visual hallucinations, with white or colored light as a continuous sharp light or as moving dots. The most frequent triggers were darkness, closing of the eyes, fatigue and psychological stress. Fifty-four percent of the patients had visual hallucinations more than once a week. Ten patients were so visually disturbed that it interfered with their daily life. Approximately 23% of all EA experience phantom pain for several years after the surgery. Phantom pain was reported to be of three different qualities: (i) cutting, penetrating, gnawing or oppressive (n=19); (ii) radiating, zapping or shooting (n=8); (iii) superficial burning or stinging (n=5); or a mixture of these different pain qualities (n=7). The median intensity on a visual analogue scale, ranging from 0 to 100, was 36 [range: 1-89]. One-third of the patients experienced phantom pain every day. Chilliness, windy weather and psychological stress/fatigue were the most commonly reported triggers for pain. Factors associated with phantom pain were: ophthalmic pain before EA, the presence of implant and a patient reported high degree of conjunctival secretion. A common reason for EA is the presence of a painful blind eye. However, one third of these patients continue to have pain after the EA. Phantom sensations were present in 2% of the patients. The impact of an eye amputation is considerable. EA patients have poorer health related quality of life, poorer self-rated health and more perceived stress than does the general population. The largest differences in health related quality of life between the EA patients and the general population were related to role limitations due to emotional problems and mental health. Patients with the indication painful blind eye are having lower scores in all aspects of health related quality of life and perceived stress than patients with the indication neoplasm and trauma. The percentage of eye amputated which is divorced or separated was twice as high as in the general population. Furthermore, 25% retired or changed to part-time jobs due to eye disease and 39.5% stopped participating in leisure activities due to their EAs.

Treatment of phantom bite syndrome with milnacipran - a case series

Phantom bite syndrome is characterized by an uncomfortable sensation mainly affecting corrected dentition in which no abnormality is clinically detectable. Despite repeated failures of dental surgery, sufferers persist in seeking bite correction from a succession of dentists. The etiology-pathogenesis of phantom bite is unknown but some consider the syndrome to be a psychosomatic disorder. Seven patients with this syndrome were treated with the serotonin and norepinephrine reuptake inhibitor milnacipran for 4 weeks. One patient withdrew after 2 weeks because he was feeling "well". At the end of the study, 5 of the 6 patients completing the study reported significant improvements, with a mean decrease in occlusal discomfort of 55.3%, as indicated by a visual analogue scale. This result appeared to be independent of any antidepressant effect. Only minor and transient side-effects were observed. It is suggested that milnacipran may be a helpful treatment for phantom bite but this needs to be confirmed by further and longer term studies.

Phantom bite revisited

The term 'phantom bite' is used to describe an uncommon condition in which patients are preoccupied with their dental occlusion, believing that it is abnormal. The condition is remarkable for the nature of the involved explanations and interpretations that the patients give and for their persistence in trying to find a solution to what appears to be a relatively minor problem. Three clinical cases that illustrate the nature of this condition are presented and problems associated with the management of affected patients are discussed. Phantom bite can be a disabling disorder which is difficult to treat. Available evidence suggests that the symptoms cannot be improved by occlusal treatments. It is therefore essential to avoid extensive irreversible restorative treatment. General dental practitioners should refer patients for specialist opinion and management. Psychiatric assessment with recommendations for management should be obtained if possible. The prognosis is poor for symptom elimination but need not necessarily be poor for patients' overall functioning and well-being. It is suggested that emphasis should be placed on building adaptive coping skills. Further research is needed to elucidate the nature of the condition to improve treatment.

Atypical Odontalgia: A Review of the Literature

OBJECTIVE

To review previous reports of cases of atypical odontalgia to examine its epidemiological and clinical characteristics and to explore the etiology and pathophysiology of the disease.

BACKGROUND

Atypical odontalgia is one of many painful conditions that affect the oral cavity and is often overlooked in the differential diagnosis.

METHODS

A search of the literature was performed for all cases of atypical odontalgia reported from 1966 to the present.

RESULTS

The typical clinical presentation of atypical odontalgia that has been reported involves pain in a tooth in the absence of any sign of pathology; the pain may spread to areas of the face, neck, and shoulder. The existing literature suggests that this condition occurs in 3% to 6% of the patients who undergo endodontic treatment, with high female preponderance and a concentration of cases in the fourth decade of life. Deafferentation seems to be the most likely mechanism to initiate the pain, but psychological factors, alteration of neural mechanisms, and even an idiopathic mechanism have been implicated. Not all reported cases were preceded by trauma to the teeth or gums. The treatment of choice is a tricyclic antidepressant, alone or in combination with a phenothiazine. The outcome is usually fair, with many patients obtaining complete relief from pain. Especially in the absence of overt pathology, particular attention should be paid to avoiding any unnecessary and potentially dangerous dental intervention on the teeth.

CONCLUSION

Atypical odontalgia is surprisingly common, of uncertain origin, and potentially treatable.

Phantom bladder sensations: a new concern for stoma care workers

The phenomena of phantom limb pain and sensations are well recognized in the medical literature. However, historically, there has been little more than passing reference to phantom pain and sensations of visceral organs. In particular, phantom bladder pain has been barely recognized. This article describes the result of a small survey of urostomists (n=50) who experienced bladder pain and sensations that were described by the respondents as being a perpetuation of the pain and sensations that they experienced before cystectomy or urinary bladder diversion surgery. Respondents reported a varied frequency of sensations, unhelpful healthcare professional responses and a range of strategies that they employed to deal successfully with the pain and sensations. The findings of this study are important because they have identified significant issues for stoma care patients that need to be addressed by those involved in stoma care and which could lead to significant quality of life improvements. This research has shown that stoma care workers need to include the possibility of the occurrence of phantom bladder sensations in preoperative counselling, acknowledge and support postoperative patients by confirming the validity of their experience and by using interventions, identified in this study, that can minimize the effects.

The use of SPECT bone scans to evaluate patients with idiopathic jaw pain

OBJECTIVE

The purpose of this study was to investigate the potential usefulness of single photon emission computed tomography (SPECT) bone scanning with technetium-99m methylene diphosphonate (Tc-99m MDP) in the diagnosis of idiopathic jaw pain. Unlike planar bone scanning, SPECT uses tomographic technology to provide 3-dimensional images, which are more useful in localizing small lesions.

STUDY DESIGN

Twenty patients, each with a diagnosis of chronic idiopathic jaw pain, were compared after SPECT bone scanning with 20 age-matched and gender-matched normal controls. Uptake was identified and compared in sites with previously detected jaw pathoses and jaw pain.

RESULTS

Nineteen of 20 patients with jaw pain evaluated with SPECT had positive scans, in contrast with 12 of 20 control subjects (P <.04). Positive scans were correlated with painful sites in 15 of 20 patients, with the remaining 5 patients demonstrating no uptake in painful locations. Patients with jaw pain demonstrated 37 of 80 mouth quadrants with positive scans, in contrast with 21 of 80 mouth quadrants in the controls (P <.01). Nineteen of 24 painful mouth quadrants had uptake in the pain group. Of the 21 quadrants positive in the controls, 17 were correlated with previously detected jaw pathoses. The sensitivity and specificity for detecting painful sites were 0.79 and 0.68, respectively. The sensitivity and specificity for detecting previously identified pathoses in the jaws of normal controls were 0. 80 and 0.93, respectively.

CONCLUSION

Patients with idiopathic jaw pain had a significantly greater frequency of positive SPECT bone scans when compared with normal controls. However, the sensitivity and specificity of SPECT bone scans in detecting painful sites were low. These findings suggest that SPECT bone scanning with Tc-99m MDP is not indicated as a routine imaging procedure for the detection of jaw pathoses, but may be considered as a potential research tool in the future study of chronic idiopathic jaw pain.

Need for occlusal therapy and prosthodontic treatment in the management of temporomandibular disorders. Part II: Tooth loss and prosthodontic treatment

The second part of this review, evaluating the literature on the relationship between dental occlusion and temporomandibular disorders (TMDs), focuses on the aetiological importance of tooth loss and the place of prosthodontic replacement in the treatment of TMD. Loss of teeth and lack of posterior occlusal support seem to have little influence on the development of TMD, which calls into question the use of prosthodontic restoration as prevention or treatment for TMD. In addition, there are practically no studies assessing the benefit of instrumental analysis in diagnosis or comparing the outcome of prosthodontic treatment with simple reversible methods in the management of TMD. There is a trend in the current literature to abandon any treatment, including positioning appliances and prosthodontic measures, to 'recapture the disk' in patients with disk displacements because of the favourable, long-term results achieved after using more simple methods. It is concluded that prosthetic therapy in TMD patients is not appropriate for initial TMD treatment and should only be carried out on prosthodontic indications after reversible treatment has alleviated pain and dysfunction.

Phantom Tooth Pain: A New Look at an Old Dilemma

The aim of this paper is to review the current knowledge of phantom tooth pain, a neuropathic facial pain disorder, thought to result from peripheral nerve injury. Phantom tooth pain is a deafferentation pain disorder of persistent toothache in teeth that have been denervated (usually by root canal treatment) or pain in the area formerly occupied by teeth prior to their extraction. The pain usually extends to the facial structures adjacent to tissues that have undergone deafferentation. The clinical characteristics, differential diagnosis, epidemiology, and treatment of phantom tooth pain are reviewed. Suggestions for further research include the need for controlled treatment trials and modification of current criteria.

CONCLUSIONS

Phantom tooth pain has much in common with other phantom pain disorders. In the absence of controlled clinical trials specifically directed to phantom tooth pain, treatment should be guided by standards used for other neuropathic pain disorders. Revised diagnostic criteria for phantom tooth pain are proposed.

Medically unexplained chronic orofacial pain. Temporomandibular pain and dysfunction syndrome, orofacial phantom pain, burning mouth syndrome, and trigeminal neuralgia

Orofacial pain syndromes pose a dilemma for physicians. Even when the patient is referred, quality medical care requires that the physician be acquainted with current evidence-based practice. Such practice may be radically different from the traditional view. This article reviews the differential diagnosis and treatment of the most common medically unexplained orofacial syndromes.

Management of chronic orofacial pain: attitudes among patients and dentists in a Swedish county

The purpose was to survey attitudes towards management of chronic orofacial pain (COP). Questionnaires were mailed to 30 randomized dentists and to 30 consecutive COP patients, examined 16 months earlier by a pain group of dental specialists. Fifty-seven per cent of the patients reported that their pain was the same as or worse than before and was disturbing. Few were dissatisfied with the examinations. Fifty-nine per cent thought that the consultations had been good. The surveyed dentists judged the most common causes of COP to be neurogenic and psychogenic in origin; they were overwhelmingly positive to the idea of a pain group (93%) and could consider referring patients (97%). Pain-inducing local diseases occurred but were not dominant among these COP patients. We concluded that management of COP in a pain group appears to be meaningful, as reflected by the respondents' attitudes but would gain by a closer collaboration with medical expertise.

Temporomandibular pain and dysfunction syndrome. History, physical examination, and treatment

A stepwise method for treating TMPDS is presented. Step 1-start patient on a regimen of chloroethane or chlorofluorocarbon spray and exercise. Step 1A--if a clicking joint is the chief complaint, start with click exercise. Step 1B--if restricted mouth opening is the chief complaint, start with range of motion exercise; employ exercises sequentially, not simultaneously. Step 2--if pain is moderate to severe, start with amitriptyline 10 mg at bedtime, increasing the dose in 10-mg increments to 40 mg. Step 3--for nonresponders, add injections of tender points with lidocaine and consider a trial of a different tricyclic. Step 4--for nonresponders, consider a trial of tender point injections combining dexamethasone with local anesthetic. Start by injecting the three most painful tender points with 0.5 mL of a solution of 1 mg of dexamethasone combined with two thirds bupivacaine and one third lidocaine to reach the desired volume. Repeat injections, varying the sites as required. Do this once weekly for 4 to 6 weeks for an adequate trial. This regimen can be continued for an extended period of time with appropriate precautions in place. The value of judgment-free psychosocial support cannot be overemphasized. Patients with TMPDS are faced with long-term problems of pain management. An understanding clinician can provide the sustained support required to prevent the cycle of ever more invasive treatments with their potential for harm.