David C. Rainwater, DDS, Pllc
Diplomate, American Board of Orofacial Pain
Fellow, American Academy of Orofacial Pain
Master of The Academy of General Dentistry
Mentorship committee of the AAOP
Seema Kurup MDS, MS, FAAOM
Assistant Professor; Section: Oral Medicine, Orofacial Pain & TMD
School of Dental Medicine
University of Connecticut Health
General dentists have many skills in their armamentarium to not only relieve pain but also repair and replace disease dentition to natural form and function. These invaluable services offered by general dentists are essential in providing overall health and well-being to the patient population. From my personal experience one of the most rewarding areas of dentistry is having the ability to alleviate pain especially acute tooth pain.
Generally speaking, diagnosis and the management of tooth pain is very straightforward. Most tooth pain characteristics tend to fit the classic pattern of side of pain equals source of pain. However it’s the side of pain that is not the source of pain that can humble us. Dentists are often challenged with pain complaints from teeth and oral structures that show no visual signs of pathology with pain characteristics that seem to break the textbook rule of our perception of dental pain.
Dr. Bell’s third edition textbook entitled Oralfacial Pain’s Classification Diagnosis Management. He writes:
Some pain sources are easy to identify accurately and therefore present no diagnostic problem. Such complaints calls a minimum of alarm on the part of the patient and the doctors have little difficulty managing them successfully. Other pain however, are less easily related to the actual site of the noxious stimulation that induces them so that both patient and doctor may have trouble determining the true source of the complaint. It is in this area of obscure pain that professional training experience and skill especially count.
Dr. Weldon Bell.
Unfortunately the inability to recognize the characteristics of head and neck complex pain patterns can result in misdiagnosis and in some instances the performing of unnecessary irreversible dental treatment.
To illustrate an example a patient presents to a dental office chief complaint of toothache. Patient states that she is in severe pain and she is convinced that the pain is from the upper bicuspid. Because of the severity of her pain she is adamant that the dentist do something to get rid of her pain. It is often the case the dentist performs root canal therapy on the bicuspid only to have the patient returned the next day with the same tooth pain. A decision is then made to perform aa Apicoectomy on the same tooth.
When the patient returns to the dentist office a week later the patient again states that she still has the same tooth pain. The decision is then made to remove the tooth. However, following the extraction the tooth the pain complaint continues. But now the pain has worsened. The question is why?
Without the understanding of a typical pain characteristics in the head neck area the clinician through confusion and/or frustration may mistakenly conclude that the origin of the patient’s pain is due to psychological factors.
This is where the Oralfacial pain specialist comes in. One of the differences between the general dentist and the oralfacial pain specialist is in the area of education and training. Most undergraduate dental school curriculum the diagnosis and management of oralfacial pain including temporomandibular disorders & sleep disorders is either lightly touched on or not covered at all. The bio psycho social modeling of pain is not adequately addressed. Instead the emphasis is on doing.
As clinicians we must realize that sometimes less is more. Also it can be difficult for busy general practice to allocate amount of chair of time necessary for an adequate patient interview and comprehensive head neck examination. Another difference is the oral facialpain specialists will have an enhanced knowledge of pharmacology due to the use of medications not typically prescribed in general dentistry medications that may have greater risks due to potential side effects and drug interactions.
Consider the above example of the patient with the “toothache”. In this case had the dentist been aware of the complexities and types of oralfacial pain a timely referral to the oralfacial pain specialist most likely would have provided the correct diagnosis. Maybe saving the tooth, not to mention avoiding unnecessary anxiety frustration and time lost.
As stated in the American Board of Oralfacial Pain Web site the oralfacial pain dentist must be competent in the diagnosis treatment and rehabilitation and prevention of oralfacial pain disorders. Which include being knowledgeable in areas such as neuropathic pain, masticatory, cervical pain, musculoskeletal pain, neurovascular pain, psychosocial concerns and sleep disorders to mention a few. In many cases the management of the oral facial pain patient will require a multidisciplinary approach in order to achieve successful management which results in pain reduction.
In conclusion. The rapidly evolving field of Oralfacial pain is a vital dental specialty. Recognizing and knowing when to refer a patient to an oralfacial pain specialist will be a win win situation for the dental profession as well as the overall patient population.
Discover more from the AAOP