GAP Australasian-Dentist Issue 80 Jul-Aug 19

Category 74 AustrÀlÀsiÀn Dentist than cure is the realistic outcome for patients. 19 Àhis may be difficult for patients to accept, particularly as they often believe there is undiagnosed malignancy or infection causing the problem. As mentioned earlier, these patients attend multiple healthcare practitioners of various backgrounds, frequently followed by invasive, unnecessary and costly procedures that fail. Patients with PÀFP are probably best managed via a multidisciplinary chronic pain team. Ànfortunately, as very few randomised controlled clinical trials for the treatment of PÀFP have been published, the provision of evidence-based treatment is problemat- ic. 20 However, studies have identified vari- ous pharmacological, nonpharmaÀcological and interventional treatments that may provide moderate benefit. Àn general, to date, the advocated treatments for PÀFP are only partially successful and cannot be guaranteed. Patients should therefore be well educated about the nature of the condition and be prepared to live with residual pain. Psychological support is often necessary. Patients can be advised that in some people with the condition the pain ceases spontaneously. Àn others, treatment sees the pain gradually subside and eventually resolve; yet there are many patients in whom the condition persists and who require the continued use of medications and other strategies. Pharmacological treatment As is the case for other neuropathic pain syndromes, the use of tricyclic antidepressant medications (off label) may prove beneficial and is considered by many to be the first-line therapy for PÀFP. Ànless contraindicated, an upwardly tapering dose from 10 to 100 mg per day is prescribed. 20, 21 Àf tricyclics are contraindicated, poorly tolerated or ineffective, the use of a selective noradrenaline reuptake inhibitor (e.g. venlafaxine, duloxetine or mirtazapine; off label) is now advocated as second-line therapy. 22 Alternatively, the alpha-2-delta ligands pregabalin or gabapentin can be trialled. Àome authorities recommend that if a single agent is ineffective, then combinations can be used. Nonpharmacological treatment Considering the chronicity, resultant distress and the known association with psychological morbidity in patients with PÀFP, psychological treatments have been recommended. Cognitive behavioural therapy as an adjunct to antidepressant medication has been shown to provide better outcomes than antidepressant medication alone. 23, 24 Due to a lack of controlled studies, there is limited evidence for psychological treatment for PÀFP. 25 Acupuncture, hypnosis and biofeedback have also been proposed and studied, but the evidence base to date is insufficient to warrant recommendation. 26 More recently, the use of cannabinoids has been proposed but, again, further controlled studies are required. 27 Interventional management Àn recalcitrant cases, interventional procedures can be considered. Àocal anaesthetic block injections and pulsed radiofrequency (PÀF) treatment of the sphenopalatine ganglion have both been shown to have moderate success in reducing PÀFP symptoms. Àn one open trial of 30 patients with PÀFP, 21% obtained complete relief and 65% rated their degree of pain relief between good and moderate. More than 50% of patients reported a 50% reduction in use of opioid medications. 28 As a result of this and other studies, PÀF can be considered as an interventional treatment for PÀFP but higher level evidence is required. 29, 30 Àeuromodulation with implanted peripheral nerve stimulators is also a promising option for patients with PÀFP; but as with PÀF, further randomised controlled trials with larger numbers of patients are needed. 31 Botulinum toxin injections have also been studied as a treatment for patients with PÀFP or other neuropathic pain conditions. Although the studies were small, the results were very promising and this treatment certainly warrants further study. 32 Àesults of a small study in Àaiwan suggest that low- energy (e.g. 800 nm wavelength) diode laser therapy may prove to be a useful alternative treatment for PÀFP. 33 Conclusion PÀFP, and the more localised PDAP, remain enigmatic chronically painful and debilitating conditions. Patients have often seen multiple health care providers and received unnecessary and ineffective or even harmful invasive procedures and costs. PÀFP should no longer be conÀ sidered a ‘waste basket’ facial pain condition affecting patients with comorbid psychological problems. Àecent neurophysiological evidence has confirmed that neuropathic pain mechanisms underlie PÀFP. A diagnostic approach with a combination of thorough history taking, clinical examination and diagnostic testing is recommended. Àt is important for GPs to be familiar with PÀFP and to be able to differentiate it from the far more common causes of orofacial pain. Patients with the condition require interdisciplinary co-operation and conservative management. Àeferral to a multidisciplinary pain clinic, preferably one with an attending orofacial pain expert, is advised. Finding new, more effective treatments for PÀFP will rely heavily on gaining further understanding of its underlying pathophysiology and on undertaking larger controlled trials of pharmacological and nonpharmacological treatments. u Permission granted by Pain Management Today for educational purposes” copyright Medicine Today 2019. Email: gapmagazines@optusnet.com.au for a full list of references for this article. 1800 806 450 www.amalgadent.com.au Presented by: DR TROY SCHMEDDING Assistant Professor Department of Reconstructive Dental Sciences University of Pacific, School of Dentistry, San Francisco, California Brisbane: Friday 18th October Perth: Sunday 20th October Melbourne: Friday 25th October Sydney: Saturday 26th October ADVANCED ADHESION DENTISTRY: New Technologies & Techniques that Solve Clinical Issues FULL DAY 7 ½ CPD POINTS SEMINAR CALL 1800 806 450 TO REGISTER EMAIL: info@amalgadent.com.au 2019 Footer Ad Finals v2.indd 4 10-Jul-19 12:19:12 PM n aÀ