OralSurgery

Obi Egbuniwe

Tara Renton

Pain Paper 2b: Classification of

Orofacial Pain and an Update on
Assessment and Diagnosis
Abstract: The classification of chronic orofacial pain remains a contentious area. However, more recently, with the clarification of pain
mechanisms and improved understanding of the underlying neurophysiology and modulation factors, there is more clarity of the possible
division of pain conditions. Interestingly, the pathophysiology provides a basis for classification that has more clinical relevance. The
principles of assessing and managing patients with pain have modified significantly, in line with recent improved understanding of the
affective and emotional components in pain behaviour and suffering.
Clinical Relevance: This paper aims to provide the dental and medical teams with a review of the classification of trigeminal pain with an
overview of how to assess and diagnose patients with trigeminal pain.
Dent Update 2015; 42: 336–345

Classification of chronic Headache Society (International Classification published by the International Association
orofacial pain of Headache Disorders 2nd edn;2 The for the Study of Pain (IASP). The impact of
American Academy of Orofacial Pain;3 trigeminal pain must not be underestimated.
There have been several
and the Research Diagnostic Criteria for Facial pain can be associated with
attempts to classify chronic orofacial pain
Temporomandibular Disorders.4 As one pathological conditions or disorders related
(OFP) conditions by pain associations. The
would expect, critique and suggestions for to somatic and neurological structures.
most used main categories have either
modification for most of these systems has There are a wide range of causes of chronic
been topographical (odontogenic versus
been published.5 orofacial pain and these have been divided
non-odontogenic) and/or chronological
The IASP classification1 into three broad categories by Hapak et al
(chronic versus acute). Several associations
categorized orofacial pain (OFP) into (1991)5 and Woda et al (2006)6 (Table 1):
with interest in pain have published
‘Relatively Localized Syndromes of the 1. Neurovascular;
classifications: The International Association
Head and Neck’ composed of five axes. 2. Neuropathic; and
for the Study of Pain;1 International
The IASP system does not, however, fully 3. Idiopathic.
address the psychosocial aspects of pain, The commonest cause of chronic orofacial
which are required in order to provide a pain are temporomandibular disorders
more comprehensive view of the disorder. (TMDs), principally myofascial in nature, and
Obi Egbuniwe, BDS, MSc, PhD,
There is a suggested modification of the a heterogeneous group including arthritides,
AFHEA, Honorary Clinical Researcher,
classification, which may be applicable to arthromyalgia and dysfunctional groups.7
Department of Oral Surgery,
the IASP (the Multiaxial Assessment of Pain As mechanisms underlying these
Tara Renton, BDS, MDSc, PhD,
[MAP]), as it integrates physical, psychosocial, pains begin to be identified, more accurate
FRACDS(OMS), FDS RCS FHEA, Professor,
and behavioural data. classifications, which are mechanism-
Department of Oral Surgery, King’s
The International Headache based, are being used. A major change in
College London Dental Institute, King’s
Society (IHS)2 has published diagnostic mechanism has been that burning mouth
College Hospital London, Bessemer Road,
criteria for primary and secondary headaches syndrome probably has a neuropathic
London SE5 9RS, UK.
as well as facial pain. Criteria have also been cause, using the newly defined definitions,
336 DentalUpdate May 2015

rather than being a pain resulting from
psychological causes. However, we still fall
short of an established pathophysiologically
based classification system for orofacial pain
that would clarify diagnostics and potentially
be predictive for management outcome.
Incidence
comparable with other pain
conditions in the body, and accounts
for between 20 and 25% of chronic pain
conditions.8 A 6-month prevalence of facial
pain has been reported by between 1%3 and
3%9 of the population. In the study by Locker
and Grushka,10 some pain or discomfort
in the jaws, oral mucosa or face had been
experienced by less than 10% in the previous
4 weeks. In 1980, Bonica11 estimated that
5−7 million Americans suffered from chronic
pain in the face and mouth, and 25−45%
were affected at some time in their lives.
Most population-based studies have shown
that women report more facial pain than
men,8-11 with rates approximately twice as
high among women compared to men.10
In clinic populations, the rates for women
are even higher. On the other hand, other
studies have found no sex difference in the
prevalence of orofacial pain. Several studies
have also shown variability in the prevalence
across age groups. The age distribution of
the facial pain population differs from that of
the most usual pain conditions. In contrast
to chest and back pain, for example, facial
pain has been suggested to be less prevalent
Neurovascular Neuropathic Idiopathic
Tension headache
Migraine
Temporal (giant cell) arteritis
Trigeminal autonomic Cephalgias
 Cluster headache
 SUNCT − Short-lasting, Unilateral,
Neuralgiform headache attacks with
Conjunctival injection and Tearing
 SUNA Short-lasting Unilateral
Neuralgiform headache attacks with
cranial Autonomic symptoms.
Table 1. A suggested classification for chronic orofacial pain modified from Woda et al.6
May 2015
in older age. Consequences include
interruption with daily social function,
such as eating, drinking, speaking, kissing,
applying make-up, shaving and sleeping.
Burning mouth syndrome has been reported
to cause significant psychological impact in
70% of patients with temporomandibular
joint (TMJ) pain; 29% of patients report high
disability resulting in unemployment.7
Assessment and diagnosis of
orofacial pain
Often, patients with OFP will
be seen by a clinician who has experience
in one aspect of orofacial pain. Dentists
will explore dental pain, an ENT surgeon
will assess for sinus and ear-related pain,
etc. Consulting a patient in pain requires
specific skills and excellent communication.
Patients are often anxious visiting the dentist
without pain; whilst in pain their anxiety
levels are potentially increased, related to
the imminent treatment necessary to treat
the cause of their pain. Communication is
key to eliciting an appropriate history from
your patient and the clinician must be a
good listener. The patient must also be able
to communicate clearly and this is often
difficult, for example, children, intellectual
disability in the general population (2.5%),
cerebral palsy, dementia in 8% of people
over 65 years, brain damage (5−1.9 million
head injuries per year with 10% of these
being serious).12 These people are all even
Primary neuralgias
Trigeminal
Glossopharyngeal
Nervus intermedius
Secondary
Post herpetic neuralgia
Diabetes mellitus
Multiple sclerosis
HIV
Post traumatic neuropathy lingual inferior
alveolar nerve injuries
OralSurgery
more vulnerable to pain because of their
inability to communicate how they feel.
In order to provide each patient
with the most suitable treatment plan to
address individual needs, it is essential
to discover as much information as
possible about each patient’s experience,
expectations, health and quality of existing
dentures. Ideally, a multidisciplinary team
should assess complex chronic pain patients
including: dentists, neurologists, clinical
psychologists, psychiatrists, neurosurgeons
and pain management consultants.
Patient presentation with
persistent pain is often complex and may
be driven by many factors. Patients may be
fit and well or have significant co-morbidity,
including psychological, medical history
complexities, or have difficulty managing
their anxieties and fears. Fear and anxiety
will increase the pain experience and
may require adjunctive therapy, including
behavioural and medical techniques. As
pain is multi-dimensional, many aspects
of the impact of pain on the patient must
be assessed. The biopsychosocial model
illustrates the many environmental,
phenotypic and psychological factors
(Figure 1).
These factors must be taken into
account when consulting the pain patient.
The attentive, listening clinician will build
a rapport with his/her patient rapidly and
the ensuing trust will allow the patient to
confide in the attending clinician, providing
Burning mouth syndrome
Persistent idiopathic OFP (eg atypical
facial pain)
Persistent Dento-Alveolar Pain (PDAP)
Non cluster condition
TMD/Temporomandibular joint disorders
RDC.7
 Arthritidies
 Dysfunction
 Arthromyalgia
DentalUpdate 337
 OralSurgery

treatment planning are:

 Thorough history (social, dental and
medical);
 Pain history (Table 2);
 Previous medications and their effect on
the reported pain;
 Previous consultations and with whom;
 Previous investigations;
 Previous interventions and ensuing effect
on the pain;
 Careful examination (Table 3);
 Appropriate special tests (Table 4);
 Radiographic − dental radiographs may be
indicated if not recently performed;
 MRI − useful for patients with recent onset
protracted pain and to exclude:
– Space occupying lesions (intra-
cranial and extra-cranial);
–Vascular compromise (for patients
with trigeminal neuralgia);
–Demyelination (+/- gadolinium
enhancement);
 Psychometrics (Table 5);
 Haematological to exclude systemic
Figure 1. The biopsychosocial model of pain. medical conditions that may contribute to
the development or exacerbation of orofacial
pain (Table 6):
 Histological investigations may be
invaluable information about the Pain is invisible thus diagnosis is based upon indicated if a pathological lesion is
ongoing complaint. Managing patients’ what patients can communicate to their discovered. Neurologists routinely biopsy
expectations is paramount and often a clinicians. Good advice is: tissues to quantify peripheral nerve density
cure is not possible but management  The patient must be heard; in patients presenting with neuropathy,
is; providing the patient with a clear  Careful listening and confirmation of what usually from lower limbs for diabetic
understanding of what is taking place with the patient is trying to convey will elucidate patients. This routine practice is more of a
realistic goals is essential. important features and facts about the challenge for patients with orofacial pain as
patient’s experience. sampling facial skin will leave a scar;
Communication skills Often a careful history will suffice  Adjunctive neurological tests may include
Communication skills underpin in making a diagnosis. The cornerstones of quantitative sensory assessment, nerve
a successful consultation for chronic pain. assessment and establishing a diagnosis and conduction tests and somatosensory evoked
potentials;
 Functional, neurological, psychological
assessment ideally undertaken by a
Site − Where is the pain? Or the maximal site of the pain. multidisciplinary team.
For pain diagnosis the
Onset − When did the pain start, and was it sudden or gradual?
standard history and examination should
(Include also whether it is progressive or regressive.) be augmented with specific questions
relating to the history (Table 2) and specific
Character − What is the pain like? An ache? Stabbing?
examination of the mouth and special tests
Radiation − Does the pain radiate anywhere? (See also Radiation) (Table 3).
A recent report13 on the
Associations − Any other signs or symptoms associated with the pain?
differential diagnosis of orofacial pain (OFP)
Time course − Does the pain follow any pattern? highlights some important strategies to
help distinguish between OFP conditions
Exacerbating/Relieving factors − Does anything change the pain?
and comes to a diagnosis or differential
Severity − How bad is the pain? diagnoses. History-taking remains of
paramount importance in facilitating
Table 2. Pain history-taking is often taught as using SOCRATES. the diagnostic process. There are specific

338 DentalUpdate May 2015

 OralSurgery

guidelines for the assessment and diagnosis

 Inspection of the head and neck, skin, topographic anatomy, and swelling or other of neuropathic pain.14-15 Several recent
orofacial asymmetry; studies have made further recommendations
regarding neurological assessment of
 Palpation of the temporomandibular joint and masticatory muscles, tests for patients presenting with orofacial pain.16-17
strength and provocation. With assessment and measurement of the range of However, it remains a challenge to assess
these often complex patients fully and a
mandibular movement; multidisciplinary team is essential.18
 Palpation of soft tissue (including lymph nodes); There are many systemic
conditions that can and must be excluded
 Palpation of cervical muscles and assessment of cervical range of motion; in order to make diagnoses, for example
 Cranial nerve examination (usually excluding cranial nerve 1 (olfactory) and VII burning mouth syndrome is a diagnosis by
exclusion. Neoplasia can occasionally mimic
(vestibule cochlear) and include examination of C2 and C3 as cervicogenic referred or masquerade as orofacial pain; though rare
pain is not uncommon; this must always be excluded and fear of
cancer is likely to be a prominent reason for
 General inspection of the ears, nose and oropharyngeal areas; the patient seeking care.19 Risk factors or RED
 Examination and palpation of intra-oral soft tissue; Flags for occult neoplasia include:
 Age over 50 years;
 Examination of the teeth and periodontium (including occlusion).  Sudden recent onset and intense pain,
motor or sensory neuropathy;
Table 3. The clinical evaluation of the patient presenting with orofacial pain.

Diagnostic requirements:

Identify signs of:  Redness swelling heat pain (tenderness)

Inflammation  Response to anti-inflammatories
 Response to antibiotics if initiated by infection
 Tenderness to percussion of a tooth-indication of periapical periodontitis

Loss of function  Trismus, inability to bite on tooth, difficulty swallowing

 Neuropathy

 Non response does not signify pulpal necrosis, positive response may be complicated in
Pulpal testing (ethyl chloride)
multi-rooted teeth with varying rates of pulpal death in different canals
 Hyper-responsiveness to cold may indicate that the pulp is inflamed reversibly and
hyperaemic
 Hyper-responsiveness to heat may indicate irreversible pulpitis
 Pain with sweetness may indicate leakage into the pulpal cavity via caries or fractured
breached crown
 Intermittent hypersensitivity on biting may indicate ‘cracked tooth syndrome’ using a ‘tooth
sleuth’ or simply a mirror handle between the tooth cusps. Pain will often be elicited on biting
down on the instrument

Neuropathic sign  Mechanical allodynia (pain to touch)

 Thermal allodynia (pain with hot or cold)
 Hyperalgesia (increased pain to painful or noxious stimulus)

Radiographs  Long cone periapical for individual to 3 teeth in single quadrant

 If multiple quadrants or impacted teeth use DPT
 Rarely additional radiographs are required (spreading infection covered in Oral Surgery
section)

Table 4. Examination with reference to pain and special tests required for pain patients.

May 2015 DentalUpdate 341

 OralSurgery

 Painless persistent lymphadenopathy; Measuring pain bi-temporal palpation, sharing your pain
 Painless trismus; Measuring pain is near experience will depend upon your clinician’s
 Worsening trismus despite therapy; impossible. The pain experience is an entirely talent for listening and empathizing which
 Developing spontaneous asymmetry; individual response. No other person can may, in part, allow him/her to begin to
 Trigeminal neuralgia in patients under derive your own experience of pain because understand your pain. We attempt to gain
50 years can be suspected to be multiple you alone experience it and, owing to an idea of the affective component of your
sclerosis. Conversely, some orofacial its complexity, conveying your total pain pain experience using questionnaires for
pain conditions may masquerade or experience to others is impossible. Unless psychometrics and we use questionnaires
be misdiagnosed or misinterpreted your clinician is equipped with Dr Spock’s to assess your functionality, disability and
as toothache, for example trigeminal (from Starship Enterprise not paediatrics) behaviour. Scoring pain using a Lickhert
neuralgia. ability to key into your experience using scale is standard practice but it massively
oversimplifies the complex pain experience.
A pain diary may provide both
clinician and patient with an extremely
 McGill Pain questionnaire short version (Dworkin et al (2009) developed the useful adjunct to the initial pain history,
SF-MPQ-2)20 particularly by clarifying the response of
the pain to various medications, avoidance
 Chronic Pain Acceptance Questionnaire (CPAQ-8)21 strategies taken by the patient, and
 HADS Hospital Anxiety Depression Score22 identifying factors that exacerbate the pain.
Daily changes in the pain are important, for
 Pain catastrophizing score23 example:
 OHIP 14 Health Impact Profile (also known as the OHIP-14 Questionnaire), which  Does the patient wake up at night with
asks about the frequency of 14 functional and psychosocial impacts that people the pain? This is very rare for neuropathic
have with oral functional problems24 pain disorders (trigeminal neuralgia);
 Is the pain worst in the morning? This
 Pain detect and question survey to detect neuropathic pain versus may be an indication of nocturnal bruxism
inflammatory pain25 precipitating TMJ pain;
 EuroQOL (EQ-5D™) is a standardized instrument for use as a measure of health  Is the pain worse with stress or anxiety
outcome26 (symptomatic of neuropathic pain)? Does
the pain respond to anti-inflammatories
 PCS score (Pain Catastrophizing Scale Scoring Information)27 (including paracetamol and ibuprofen)? If
 PCL (Brief version) post-traumatic stress disorder assessment28 the pain does NOT respond it is likely to be
neuropathic rather than inflammatory pain.
 PSEQ (Pain Self Efficacy Questionnaire)29

Table 5. Commonly used psychometric evaluation for patients with chronic OFP.

Full blood count with haematinics Deficiency in haematinics may cause peripheral neuropathies and burning type
(Fe (Iron), B12, Folate) sensations

Zinc level Required for Fe absorption

Haemoglobin A1C or HbA1C The more glucose in the blood, the more haemoglobin A1C or HbA1C will be present in
the blood. Exclude Diabetes, a common cause for painful neuropathy

Thyroid function tests Hypothyroidism may be associated with sensory neuropathy

Autoantibody screen When connective tissue disease is suspected (rheumatoid, systemic erythematosis,
Extractible nuclear antibodies and Lupus, Sjögrens, Polymyositis)
anti-nuclear antibodies NAs

Table 6. Haematological tests to exclude systemic conditions that may contribute to the development of, or facilitate, chronic OFP.

342 DentalUpdate May 2015

 OralSurgery
Psychological assessment of
the pain patient (Table 5)
In the introductory section to
this series the significant component of
the affective and emotional role in pain
perception, behaviour and suffering is
highlighted. As pragmatic clinicians we
tend to focus on ‘mechanical/medical’
interventions to prevent the nociceptive
pain and forget the ‘holistic’ management
of pain. With simple acute inflammatory
conditions that can be simply managed with
a swift and effective surgical intervention,
less understanding of the affective burden
is required. However, in chronic pain the
emotional components of persistent pain, its
social, functional and resultant psychological
sequelae, cannot be underestimated.20,29
The biopsychosocial model of pain (Figure
1) emphasizes the complexity of managing
pain patients. Many authors have made
recommendations regarding the preferred
psychological assessment of the pain
patient.30-35 Our local orofacial pain team,
which includes liaison psychiatrist, clinical
psychologist, health psychologist, dental
clinicians, neurosurgeon, neurologist and
pain management consultant, use the
questionnaires in Table 5. Using these
questionnaires we are able to elicit anxiety
and depression that may be contributory to
the patient’s pain condition. We can identify
his/her ability to cope and how impactful
the pain is in relation to daily function. Red
flags including self-harming tendency and
suicidal ideation can also be identified early
on, precipitating an expeditious referral to
the psychiatrist. Overall, the patients are
extremely co-operative with completing
these questionnaires and the data collected
is undoubtedly facilitating the development
of tailored cognitive behavioural techniques
for specific orofacial pain conditions.
Summary
Most importantly, the clinician
must keep a broad perspective of the
patient’s presentation and complaint.
Systemic diseases, psychological and
environmental factors all play a potential
role in the patient’s pain experience and
thus must be considered in order to provide
effective pain alleviation and education.
The subsequent papers provide an update
on the management of acute and specific
chronic trigeminal pain conditions. Pain
344 DentalUpdate
management procedures, including local
anaesthesia and the management of
anxiolysis (behavioural techniques and
medical techniques − sedation), are not
included in this series.
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