TWO days ago, a woman visited the Clinic suffering from chronic facial pain, which is a problem that affects a patient’s quality of life significantly, because it interferes with their ability to function at home, work, or social setting. The gravity of this problem presents a tremendous challenge to health professionals in their attempt to investigate and treat this disorder. The average patient with this problem seeks care from four to six clinicians, and spends thousands of dollars in search of relief.
It is not surprising that patients seek so many different health professionals for treatment, when you consider the confusion among dentists and physicians as to exactly what constitutes chronic facial pain, and how it should be treated. Unfortunately, this has resulted in leaving many patients with irreversible damage and even more pain, which has contributed to a growing number of malpractice cases.
In general, the problem lies in the fact that many clinicians are trying to manage problems that are beyond their expertise. So, most of the literature on this subject has been derived from clinical data instead of from a research basis. As a result, many currently accepted theories for treatment exist without the benefit of research that employs well-defined control groups, minimal bias, and the use of appropriate statistical methods.
At this time, there are no standardized diagnostic criteria for researchers to use to compare results. Thus, progress in improving therapy has been hindered by the acceptance of treatments and theories that lack scientific basis. Too many times, complicated, unnecessary, and expensive treatments are used when more conservative treatment would achieve similar or even better results.
Most authorities agree the most effective approach to treating chronic facial pain of muscle origin seems to be multidisciplinary. The focus should be on identifying all possible contributing factors, and managing them by using physical, dental, and behavioral therapies. At this time, most authorities are in agreement that all therapies should be reversible and conservative. Irreversible therapy is seldom recommended.
The complexity of the head and neck and the potential for numerous pathological conditions that can cause pain makes it mandatory for the health provider to consider carefully all possible answers to the patient’s problem. Clinicians should begin by taking a detailed medical/dental history and a physical examination to rule out any medical disorders (systemic diseases that manifest in the head).
If the results are negative, the next step is to rule out any dental problems (e.g. filling or root canal therapy is needed, periodontal disease, etc.) that could be causing the pain. If these results are negative, then the clinician should examine the temporomandibular joint, keeping in mind that joint ‘clicking noises’ do not necessarily eliminate other structures as the cause of symptoms.
A diagnosis of masticatory pain can only be considered after all other options have been exhausted. Muscle splinting is an appropriate diagnosis if pain begins from the date of a placement of a restoration or prosthesis (i.e. full or partial denture). Acute myositis is considered if there has been a recent trauma to the face, as long as infection, a systemic disease, or a jaw fracture has been ruled out as the problem.
When pain has been present more than a month, a tentative diagnosis of myofascial pain or masticatory myalgia may be appropriate. Chronic pain can be treated with several reversible procedures, physical therapy (including massage), ultrasound, acupuncture, application of moist heat or ice to the area, prescribing anti- inflammatory agents, electrical (electro-galvanic) stimulation, active and passive exercises of the affected areas, spraying with an aerosol skin coolant in combination with stretch techniques to treat trigger points, transcutaneous electrical nerve stimulation (TENS), and biofeedback. The most common treatment for chronic pain is a flat-pane splint that covers the entire arch.
It is a well-accepted fact that the diagnosis of chronic facial pain is difficult; and once it has been diagnosed, it is always best to take the conservative, reversible approach to treatment.