Invasive dental treatment, pain reports, and disease conviction in chronic facial pain patients. A retrospective study

Percutaneous Radiofrequency Rhizotomy in Treatment of Trigeminal neuralgia: A Prospective Study

INTRODUCTION

Trigeminal neuralgia (TN) often called as "Tic douloureux" is a syndrome characterized by paroxysmal facial pain, is one of the most painful and debilitating craniofacial pain disorders. The controversy regarding the etiology and treatment of TN still exists.

OBJECTIVE

To evaluate the effectiveness of percutaneous radiofrequency rhizotomy (PRR) for TN, after failure of pharmacological management.

METHOD

A nonrandomized, non comparative, descriptive, in vivo study of 15 patients with TN of maxillary and mandibular divisions of trigeminal nerve and patients with pain refractory to pharmacological management were done. It was performed as an O.P.D procedure. A routine follow up was done in all cases for 1 year.

RESULTS

In a total of 15 patients, 8 female and 7 male patients were enrolled for the study. Early pain relief (immediately, postoperatively to 6 month) classified as excellent or good (successful), occurred in 12 of 15 patients (80 %). Fair or poor pain relief (unsuccessful) occurred in three patients (20 %).There was no mortalities and no major morbidity.

SUMMARY

It was found that surgical treatment with PRR is a safe and effective way to manage patients with TN in whom pharmacologic therapy is either ineffective or not tolerated, with low side effects which are well tolerated.

Chronic idiopathic orofacial pain. A long-term follow-up study

Patients suffering facial pain that does not fit with the traditional diagnostic criteria and which does not respond to dental treatment constitute a clinical problem. These patients lack a proper diagnosis and are frequently exposed to excessive and inadequate invasive treatment. The aim of this investigation was to study the long-term development of pain and the result of treatment in a cohort of patients suffering chronic idiopathic facial pain. The 74 patients referred to the Facial Pain Diagnostic Group at the Karolinska Institute School of Dentistry between 1981 and 1992 were invited to take part in a follow-up study. As 16 subjects were unwilling or unable to take part in the study and 13 had died, the remaining 45 were interviewed either in accordance with a standard protocol or by filling out a questionnaire mailed to them. The interview revealed that 10 were free of orofacial pain, but only 2 were totally free of pain. Over the 9-19 years' follow-up period the relationship between facial pain and pain in the rest of the body had changed substantially. Of 14 patients and more than 100 extractions, permanent pain relief was felt by only 3 patients. It is concluded that a diagnosis was given in only 2 cases. The distribution of the pain has changed dramatically. The low success rate of invasive treatments suggests that such therapeutic methods are to be considered contraindicated in patients suffering from idiopathic orofacial pain.

Percutaneous stereotactic differential radiofrequency thermal rhizotomy for the treatment of trigeminal neuralgia

PURPOSE

The purpose of this study was to evaluate the effectiveness of radiofrequency thermal rhizotomy (RTR) for trigeminal neuralgia, after failure of pharmacological management.

PATIENTS AND METHODS

Two hundred fifteen patients underwent RTR from 1991 to 1996 and were prospectively evaluated. These patients were characterized by age, sex, side of the face, and division(s) involved. Patients were evaluated for pain relief, recurrence requiring or not requiring reoperation, and the type and rate of complications. They were followed-up by serial clinical evaluation and telephone interview. Patients were categorized into groups: 1) Successful result: excellent, good pain relief; and 2) Unsuccessful result: fair, poor, or no pain relief. The RTR group was compared with historical controls. Follow-up ranged from 9 to 68 months (mean, 32 months) and results were evaluated at early and long-term follow-up.

RESULTS

At early follow-up (defined as immediately postoperatively to 6 months), pain relief of excellent or good quality (successful result) occurred in 198 of 215 patients (92%). Fair or poor or no pain relief (unsuccessful result) occurred in 17 (8%) patients. At long-term follow-up (>6 months to 68 months), recurrence of pain that required reoperation occurred in 24 patients (11%) and recurrence of pain that did not require reoperation (medically managed) occurred in 34 patients (16%). Dysesthesia developed in 18 patients (8%); seven patients (3%) had dysesthesia alone (medically managed) and 11 patients (5%) had dysesthesia with recurrence of pain (medically or surgically managed). "Anesthesia/analgesia dolorosa" developed in four patients (1.8%) and was medically managed. At long-term follow-up, 83% of patients had good to excellent pain relief (successful result). There were no mortalities, no significant morbidity, and a low rate of minor complications.

CONCLUSION

With the use of this specific diagnostic approach and management algorithm, patients with trigeminal neuralgia can be successfully managed.

The possible role of nitric oxide in the physiopathology of pain associated with temporomandibular joint disorders

Temporomandibular joint disorders (TMD) pose a significant challenge to the practice of oral and maxillofacial surgery. When painful, TMD are generally associated with hyperthermia of the overlying skin. It is hypothesized that this skin hyperthermia, caused by regional vasodilation, is induced by nitric oxide (NO) produced in the extravascular space of the joint. Extravascular NO can be produced by osteoblasts, chondrocytes and macrophages, or by stimulated neurons. It is suggested that this kind of pain is associated with NO-enhanced sensitivity of the peripheral nociceptors. Verification and clinical implications of the proposed mechanism are discussed.

Role of nitric oxide in the physiopathology of pain

Many painful disorders, including joint dysfunctions such as rheumatoid arthritis (RA) or temporomandibular joint disorders (TMD), are associated with hyperthermia of the overlying skin. The same is true of certain intractable chronic pain conditions, such as chronic orofacial pain, which may be associated with TMD. We suggest that this skin hyperthermia, caused by regional vasodilation, is induced by extravascular nitric oxide (NO). Extravascular NO can be produced in the affected joint by osteoblasts, chondrocytes, and macrophages, by mechanical stimulation of endothelial cells, or by stimulated neurons. In view of a strong correlation between pain and skin hyperthermia in these disorders, and the evidence that NO enhances the sensitivity of peripheral nociceptors, we also suggest that at least this kind of pain is associated with excessive local level of NO. This hypothesis can be verified by dynamic area telethermometry, assessing the effect of NO on the sympathetic nervous function. This mechanism, which is in line with the general role of NO as a mediator between different organ systems, also may be relevant to any pain associated with enhanced immune response. Clinical implications of the proposed mechanism are discussed.

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.

Lack of disability in patients with chronic orofacial pain. a retrospective study

Although patients with chronic orofacial pain are frequently disabled, the disability is not necessarily due to the orofacial pain: various other factors may contribute. This retrospective study investigated the possible relationship between reports of pain, fatigue, disease conviction (DC), and denial of psychologic factors as explanation of the suffering (P-S) and limitations in occupational, domestic, physical, social, and sexual activities. The subjects comprised 30 patients referred to the Facial Pain Diagnostic Group at the Karolinska Institute, School of Dentistry, Huddinge, Sweden. None of the disability measures were significantly (p < or = 0.01) correlated with the facial pain reports. Fatigue was not correlated with degree of reported pain. DC was significantly (p < or = 0.01) correlated only with the minimum pain intensity. P-S was negatively correlated (p < or = 0.01) with maximum pain intensity and pain distribution (number of zones) outside the face. In 50% of the patients chronic orofacial pain was the formal reason for their occupational disability. However, such disability was related only to pain distribution (number of zones) outside the face. Social activity was negatively correlated (p < or = 0.01) with fatigue and positively correlated (p < or = 0.01) with P-S. It is suggested that the findings could be satisfactorily explained by a symptom perception hypothesis.