GAP Australasian-Dentist Issue 80 Jul-Aug 19

Category 72 AustrÀlÀsiÀn Dentist À he possible causes of orofacial pain are considerable and form a grey area between medicine and dentistry. An enigmatic condition formerly known as atypical facial pain has been renamed persistent idiopathic facial pain (PÀFP) with defined diagnostic criteria. After the common causes of orofacial pain have been ruled out, then a diagnosis of PÀFP can be considered. Orofacial pain is common, with an estimated incidence in the general population of up to 26%. 1 Orofacial pain can be severe and debilitating, resulting in serious effects on patients’ quality of life. Àuccessful management of a patient seeking care for orofacial pain requires the clinician to first establish a diagnosis. 2 Orofacial pain may be a symptom of disease of local structures, most commonly the teeth and sinuses, or of musculoskeletal, rheumatological, neuroÀ vascular, neuropathic and psychological causes. Pain can also be referred from distant structures, most commonly the neck, but even including the heart. Given this complexity, there are myriad causes of orofacial pain, and correct diagnosis begins with the GP at least being familiar with the most common conditions that may account for their findings on examination of the patient. Detailed history taking, intra- and extraoral physical examination and appropriate diagnostic tests are required for all patients presenting with orofacial pain. An interdisciplinary approach is often required to establish a correct diagnosis and thereby institute appropriate treatment. Chronic orofacial pain symptoms that differ from those more commonly encountered have been described previously as atypical facial pain (AFP), often as a diagnosis of exclusion. Àhe condition is now termed persistent idiopathic facial pain (PÀFP). Àt is poorly defined and presents as both a diagnostic and therapeutic challenge for clinicians, as well as being a significant challenge for long-suffering patients with the condition. Àntil recently, a lack of understanding of the underlying pathophysiological mechanisms of PÀFP has underpinned the difficulties in diagnosing and managing the condition. Àt is not unusual for patients to consult multiple healthcare providers from different disciplines to find a solution for their orofacial pain problem. Patients presenting to a specialist orofacial pain clinic in Àcandinavia had, on average, already consulted seven healthcare profesÀsionals including dentists, GPs, neurologists, specialists, ophthalÀ mologists, oral/maxillofacial surgeons and psychiatrists. 3 Patients often become convinced that the pain is caused by an infection or cancer and that the clinicians thus far have been incapable of making a diagnosis. Hence, patients may seek out specialist after specialist in the hope of finding someone to diagnose and cure the pain. During this quest, a number of invasive dental and surgical treatments may have been attempted without benefit, and possibly with perpetuation or aggravation of symptoms. Àhe term AFP was first described in 1924 to differentiate it from trigeminal neuralgia. 4 As the name implies, the diagnosis was typically made after excluding typical causes of orofacial pain such as local dental disease, cranial neuralgias and primary and secondary headache disorders. Àndeed, absence of objective findings from the clinical examination, laboratory tests and medical imaging were considered to be the diagnostic criteria for AFP. Owing to the vagueness of the term AFP and the proliferation of synonymous terms such as atypical facial neuralgia, atypical odontalgia, phantom tooth pain and migratory odontalgia, the Ànternational Association for the Àtudy of Pain and the Ànternational Headache Àociety replaced the term AFP with PÀFP. Àn 2013 the Ànternational Headache Àociety classification redefined PÀFP (Box), 5 but none of the published or proposed diagnostic criteria have yet been universally accepted or validated. PÀFP is therefore best viewed as an idiopathic pain condition. Àhe pain Persistent idiopathic facial pain Not just a diagnosis of exclusion By Robert Delcanho BDÀc, MÀ, CertOrofacialPain, FPMAÀZCA, FÀCD, FAAOP International Headache Society classification of persistent idiopathic facial pain* Previously used term Atypical facial pain Description Persistent facial and/or oral pain, with varying presentations but recurring daily for more than 2 hours per day over more than 3 months, in the absence of clinical neurological deficit. Diagnostic criteria A.À Facial and/or oral pain fulfilling criteria B and C. B.À Recurring daily for >2 hours per day for >3 months C.À Pain has both of the following characteristics: 1. poorly localized, and not following the distribution of a peripheral nerve 2. dull, aching or nagging quality D.À Clinical neurological examination is normal E.À A dental cause has been excluded by appropriate investigations F.À Not better accounted for by another ICHD-3 diagnosis. * ÀClassification 13.11. Reproduced with permission from the International Headache Society. The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 2013; 33: p. 782.5 Abbreviation: ICHD = International Classification of Headache Disorders. n aÀ