Dental and Musculoskeletal Pain




© Springer International Publishing Switzerland 2016
Dimos D. Mitsikostas and Koen Paemeleire (eds.)Pharmacological Management of HeadachesHeadache10.1007/978-3-319-19911-5_21


21. Dental and Musculoskeletal Pain



Antoon De Laat1, 2   and Tara Renton 


(1)
Department of Oral Health Sciences, KU Leuven, Leuven, Belgium

(2)
Department of Dentistry, University Hospitals KU Leuven, Kapucijnenvoer 7, Leuven, B-3000, Belgium

(3)
Department of Oral Surgery and Oral Medicine, King’s College London Dental Institute, Denmark Hill Campus, Bessemer Road, London, SE5 9RS, UK

 



 

Antoon De Laat (Corresponding author)



 

Tara Renton




21.1 Pain Originating from Teeth and Periodontal Structures


Dental and periapical periodontal (dental abscess) pain is reported by 12–14 % of the population in the last 1–6 months [20]. Interestingly, periodontal disease and gingivitis are painless. Consequently, a thorough dental examination is essential in every patient presenting with orofacial pain in order to exclude dental pathology. Since the patterns of radiating pain can be very puzzling, acute pulpitis has often been confused with typical or atypical forms of trigeminal neuralgia and other orofacial pains. Response to anti-inflammatories and antibiotics may indicate this pathology rather than neuropathic pain. Improved technical investigations including electrical pulp testing, pulpal blood flow assessments, and cone-beam CT-scans assist in investigating teeth for cracks, fractures, or extra roots/pulpal canals, which allowed to decrease the group of patients previously classified as “persistent idiopathic facial pain” or “atypical odontalgia.” Management of dental and periapical pain primarily needs local treatment by the dentist including removal of carious dentine and enamel and restoration, pulpal extirpation with root canal treatment or dental extraction. Pharmacological management of the pain, mostly NSAIDs and paracetamol, is only indicated in the short term prior to or subsequent to surgery. Antibiotic prophylaxis should only be installed in case of abscess or in case of medically compromised patients.


21.2 Pain Associated with Jaw Muscles and Temporomandibular Joints


Pain associated with temporomandibular disorders (TMD) has the highest prevalence in the orofacial region next to dental pain [20] and can clinically be expressed as masticatory muscle pain (MMP), arthritides, and/or TMJ-arthralgia [1]. Joint function and loading of the masticatory system usually aggravates the pain. Often, the pain is also expressed as a (tension-type) headache in the frontal or temporal regions. In part of the patients, limitation of jaw movement, interference during movement, or locking of the TMJ may accompany the pain.

TMD pain is very common: it has been reported in 4–12 % of the general population (especially in the 20–40 years of age range) with a female-to-male ratio of 2:1 [8, 12, 18]. TMD has a benign natural course: the symptoms remit in 33–49 % of cases over a 5-year period [31] and progression to severe and/or chronic pain is rare [21].

Many aspects of the etiology of TMD are unclear. Based upon the biopsychosocial model for pain, Diatchenko et al. [7] proposed a model in which TMD and its associated symptoms would be influenced by the interaction of two sets of intermediate phenotypes: psychosocial distress and pain amplification. Each of these phenotypes was influenced in itself by multiple potential risk factors, that again depend on genetic regulation and are influenced by environmental contributions [37]. The Orofacial Pain Prospective Evaluation and Risk Assessment (OPPERA) study [22, 38] tested this model. Several genetic associations with TMD were confirmed [39], offering promising potential biomarkers. Patients and controls could clearly be discriminated on the basis of pain pressure thresholds and cutaneous mechanical thresholds [16]. In addition, psychometric instruments elucidated higher levels of affective distress, somatic awareness, and pain catastrophizing [11]. TMD appeared also associated with several biological measures illustrative for autonomic dysregulation [23]. These recent findings reinforce the shift from morphological causes like dental occlusion in favor of the biopsychological and multifactorial background [15].

Specifically for MMP, parafunctions like tooth clenching and bruxism have been implicated in the etiology (for review see Lavigne et al. [19]). Strikingly, daytime (low-level) tooth clenching was identified as a risk factor [3, 10]. In TMJ-arthralgia, some kind of trauma or overload of the joint system overrules its adaptive capacity [43] possibly also after whiplash injury (for review see [17]), or in case of intrinsic overloading of the TMJ [26]. As in MMP, genetic factors and gender differences have been identified also in osteoarthritis, [14]. Smoking proved a significant risk factor for the development of TMD in subjects under 30 years of age [32].

MMP is reported as a dull regional pain that aches especially in the jaw closing muscles and around the ear. Some patients report more pain in the morning or the evening [6] but the pattern may be variable [13]. The intensity is rated 3–7/10 on a VAS [42]. The specific relation between MMP and (tension-type) headache is unclear and a cause-effect relationship has not been established. MMP may be part of widespread musculoskeletal pain and there appears to be a significant overlap with fibromyalgia [40].

TMJ-arthralgia appears as a dull or sharp pain of moderate intensity, typically more localized in or around the joint, and irradiating into the ear. Loading, movements of the joint, and stretching of the joint capsule during maximal mouth opening may aggravate the pain. Mouth opening and joint function may be limited as a result of the pain or as a result of articular disk dysfunction (internal derangement of the joint with clicking and locking).

Osteoarthritis of the TMJ is sometimes part of a general arthritis. Where acute phases of arthritis typically are associated with increased pain, it is striking that a “settled” osteoarthrosis of the TMJ, even with significant radiological degeneration of the joint surfaces, often is only characterized by increased crepitation but without pain complaints.

In case chronic TMD pain develops, both MMP and TMJ-arthralgia may be accompanied by central sensitization and psychological problems such as depression, somatization, and anxiety [2].

For the most common subgroups of TMD, research diagnostic criteria (RDC-TMD) were established [9] and soon translated into a clinical classification [41]. Recently, the diagnostic criteria have been refined [34, 35]. Details and decision trees for these diagnoses, as well as numerous translations of the questionnaires and examination sheets, can be readily accessed at the RDC-TMD website (http://​www.​rdc-tmdinternational​.​org/​).

In view of their self-limiting and benign character, management of these problems aims at providing optimal circumstances for the body to adapt and heal. Most treatment approaches are reversible and fit into the biopsychosocial approach:



  • Correct information regarding the benign natural course of TMD is a primary and very important step. Patients have to be instructed in avoiding overload of the system, as in tooth clenching, and in active self-care, using warmth application and massage [25].


  • Systematic review did not find a particular method in physical therapy to be superior [24]. And recent RCTs have indicated that, while in the initial phase physical therapy results in decrease of pain and improved jaw movement there is no specific therapy effect after 1 year [4, 5].


  • The clinical efficacy on pain of intraoral occlusal appliances, widely used in the management of TMD, is poorly documented. They should be designed in order to avoid irreversible changes in the dental occlusion.


  • Pain medication (analgesics, NSAIDs) can be needed to overcome acute pain, and this is for a limited period of time [27].


  • Arthrocentesis of the joint might be considered in patients with persistent TMJ-arthralgia [29]. TMJ-surgery, however, did not prove to be superior to medical management or conservative therapy in case of internal derangement with locking [33, 36].

In patients with chronic TMD pain, these therapies must be accompanied by psychological support, e.g., cognitive behavioral therapy and relaxation therapy [30]. Low-dose tricyclic antidepressants or selective serotonin reuptake inhibitors can be considered, as in other chronic pain syndromes [28].

Jul 22, 2016 | Posted by in PHARMACY | Comments Off on Dental and Musculoskeletal Pain

Full access? Get Clinical Tree

Get Clinical Tree app for offline access