Chronic orofacial pain
The definition of chronic orofacial pain is pain that appears to originate from - and continues to emanate from - the mouth area, for more than three months. It can be difficult to know if the pain is actually coming from the teeth, from other structures in the head or neck, or pain referred from a more distant site.
Anatomically, physiologically, emotionally and functionally, the face is a busy and complex area!
Once confirmed by medical and dental pain specialists, chronic pain is a formal diagnosis, but it can be a real problem arriving at that correct diagnosis. Unfortunately chronic orofacial pain has to be diagnosed by exclusion, after considering more common possible causes.
Differentiating chronic pain and pain of dental origin
If the pain appears to originate from the head and neck region, the following pathologies may need investigation:
• Dental causes e.g. pulpitis or dental infections;
• Cracked teeth;
• Temporomandibular joint disorders (TMD);
• Muscle disorders;
• Cervicogenic causes e.g. from neck and cervical spine;
• Neurological causes e.g., trigeminal neuralgia;
• Vascular disorders e.g., cranial arteritis;
• Viral causes e.g. post herpetic neuralgia (nerve pain following an outbreak of shingles);
• Neuropathic causes e.g., trigeminal neuropathic orofacial pain;
• Atypical odontalgia, also termed phantom tooth pain, psychogenic toothache, or persistent dentoalveolar pain disorder;
• Persistent Idiopathic Facial Pain (PIFP) (Atypical Facial Pain);
• Referred pain e.g., cardiac pain.
The dental examination to rule out if your ‘pain is of dental origin’
A suggested course of action
If you feel confident and comfortable with your current dentist, explain your situation to the receptionist - that you have experienced chronic pain for over three months. Ask that your dentist be made aware of your ongoing pain and that .... the purpose of your dental visit is that you are a patient who hopes to rule out (or rule in) if your ‘Pain is of Dental Origin.’
If you do not have a dentist, or have little confidence in your current private dentist, ask your friends who their dentist is and make an appropriate appointment to see that dentist.
If you are an eligible holder of a current Health Care Card, inform the receptionist that you have been suffering severe dental pain and that it has been present for over three months. This should give you priority and allow you to be seen as an “Emergency patient.” Once you are seen by the dentist have them understand that ..... the purpose of your dental visit is that you are a patient who hopes to rule out (or rule in) if your persistent ‘Pain is of Dental Origin.’
Trying to diagnose the source of obscure dental pain is difficult! The initial examination needs time and completeness. Every tooth needs to be individually scrutinised and tested for partial or incomplete fractures through the crown of the tooth. Unfortunately cracks in teeth do not necessarily show up on radiographs. Individual pulp vitality tests are mandatory. Also mandatory are good quality dental radiographs of every tooth, including its apical (root) area.
An Orthopantomogram (OPG) is usually required, and also - if available - a full mouth Cone Beam 3D dental radiograph. These are special X-ray techniques which give a panoramic view of the teeth and the bones of the upper and lower jaws. These diagnostic radiographic tests normally include a specialist radiologist’s report. All relevant history, including the dentist’s consideration of the above dot points should be listed in the referral to the radiologist.
It is better to have your general dentist refer you to a specialist dental radiologist, rather than a general radiologist. Specialist dental radiologists have specific knowledge and interests in interpreting dental pathology. There are some of these specialists in Australian capital cities. These specialists can help in ruling in – or out – if your pain is of ‘Dental Origin.’
Referral to oral specialists
If the thorough dental examination and all the investigations are not conclusive, a referral for diagnosis to dental specialists with an interest in pain diagnosis is necessary. This can be an Endodontist, an Oral Pathology or Oral Medicine specialist, or a Maxillofacial Surgeon. Naturally all the current results must be included with the referral. It is important to have the original referring dentist keep copies of all the reports and, where appropriate, keep copies of all the radiographic images. (Sometimes the original radiographs are better than the duplicates. If so, ensure that the originals are returned back to your general dentist.) The dentist will then have all information from all the relevant dental specialists and then, if necessary, you can be referred to a Chronic Pain Specialist for further diagnosis or management.
Unfortunately, arriving at the sum total of these investigations is a long, tedious, worrying and often expensive process. However the facts are that for the pain medicine specialist physicians to make their diagnosis that the pain is not of ‘dental origin’, the patient has had to “jump through all the head and neck investigative hoops.”
It is only after this entire analytical marathon is finished can you be diagnosed as not having ‘pain of dental origin,’ and can then be confidently referred to a pain medicine specialist. What is important to consider is that not all chronic orofacial pain can be cured quickly. Pain management may be required to keep the pain under control.
Written for APMA by Dr Pat Jackman & reviewed by Dr Alex Moule, President of the International Association of Dental Traumatology.