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Facial pain: an update

Zakrzewska, Joanna M

Current Opinion in Supportive and Palliative Care: June 2009 - Volume 3 - Issue 2 - p 125–130
doi: 10.1097/SPC.0b013e32832b7d75
Pain: nonmalignant disease: Edited by Richard Langford
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Purpose of review Review current literature in the field of chronic nondental facial pain as recent clinical research findings need to be put into practise.

Recent findings The areas covered include epidemiology and risk factors for facial pain, management of temporomandibular disorders, burning mouth syndrome, atypical odontalgia and trigeminal neuralgia.

Summary There is an increasing awareness that facial pain is common and has similar risk factors to other chronic pain conditions. Some oral pain conditions are now being recognized as being probably neuropathic in origin rather than being due to psychological factors. A more biopsychosocial approach to management of these conditions is essential. The first international guidelines on management of trigeminal neuralgia have now been published and should help all clinicians seeing these patients.

Division of Diagnostic, Surgical and Medical Sciences, Eastman Dental Hospital, UCLH NHS Foundation Trust, London, UK

Correspondence to Professor Joanna M. Zakrzewska MD, FDSRCS, FFDRCSI, FFPMRCA, Consultant/Hon Professor Facial Pain, Head Division of Diagnostic, Surgical and Medical Sciences, Eastman Dental Hospital, UCLH NHS Foundation Trust, 256 Gray's Inn Road, London WC1X 8LD, UK Tel: +44 20 7915 1195; fax: +44 20 7915 1105; e-mail: jzakrzewska@nhs.net

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Introduction

Facial pain includes both oral and facial components. In order to exclude headaches facial pain is often defined as pain, which is experienced in the area below the meatal line, above the neck and up to the ear [1]. The major oral causes of pain are dental with the majority being acute. Of the facial causes of pain the most common are temporomandibular disorders (TMD). The causes for facial pain have been divided into three broad categories by Hapak el al.[2] and adopted by many epidemiological studies: musculoligamentous, dentoalveolar and neurological and vascular. As the mechanisms underlying these pains begin to be identified so more accurate classifications will become possible.

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Methodology

A search of the literature using search terms of facial pain, burning mouth and trigeminal neuralgia and limited to the period 2007–2008, the English language and human material yielded over 500 articles. Thus in this short review I will highlight some clinical relevant findings and will not cover the expanding field of trigeminal nerve injury and trigeminal neuropathic pain.

Patients with orofacial pain often face the dilemma of whether they need to see a dentist or a general medical practitioner and their choice will dictate the type of treatment received. There is good evidence to show that many patients with nondental causes of pain nevertheless are given dental treatments. Many patients in their frustration to get relief of pain will eventually go to a doctor and when they finally come to a facial pain service they will have seen several healthcare providers. It is, therefore, important that medical practitioners are aware that not all oral pain is dental in origin and that they may be better placed to manage these patients holistically.

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Diagnosis and classification

The European Academy of Craniomandibular Disorders (EACD) has published guidelines and recommendations for the examination, diagnosis, and management of patients with TMD and other facial pain for use by general dentists but which could be useful for other primary care physicians [3•]. They suggest four screening questions.

  1. Ability to open the mouth and eat without pain.
  2. Location of pain.
  3. Locking of the jaw.
  4. Presence of weekly headaches.

The questions really focus on TMD pain, are not sensitive for other forms of facial pain and lack emphasis on biopsychosocial factors.

We have shown that [4•] on the basis of a few characteristics patients with nondental facial pain can be differentiated from those with dental causes by:

  1. pain descriptors (nagging, aching, tingling),
  2. pain pattern (worse with stress),
  3. site (poorly localized),
  4. duration (persistent/chronic),
  5. high disability,
  6. multiple consultations,
  7. comorbidities (teeth grinding, reporting of other unexplained syndromes).

This has resulted in the development of a self-complete questionnaire for use in epidemiological studies that still needs further evaluation [5•].

Several groups have published criteria for facial pain to aid in diagnosis and management:

  1. International Headache Society (IHS)
  2. International Association for the Study of Pain (IASP)
  3. American Academy of Orofacial Pain (AAOP)
  4. Research Diagnostic Criteria for Temporomandibular Disorders (RDCTMD).

The latter are used extensively in studies pertaining to TMD. However, there are still a number of entities that cannot be clearly allocated and proposals are put forward for new criteria and terminology that becomes very confusing for the nonexpert; for example, atypical facial pain has been renamed persistent idiopathic facial pain in the IHS classification.

Benoliel et al.[6•] assessed 328 of their referrals to a specialist clinic over a 2-year period using the above classifications and could place all but 8% of their patients into a category. Thirty-four were allocated to the IHS category of persistent idiopathic facial pain. By using a new category of neurovascular orofacial pain (facial migraine) they were able to allocate the remaining 8%. The patients had throbbing facial pain with autonomic and/or systemic features and attack duration of more than 60 min. It could be argued that these patients are really migraine sufferers in whom the location of pain has changed from upper face to lower face as they often also complain of nausea. It is unfortunate that they had submitted their study prior to the publication by Zebenholzer et al.[7] who used the same methodology and suggested some changes to the criteria of persistent idiopathic facial pain. They argue for the use of terminology of ‘probable’ in those cases where an accurate ‘fit’ is not possible.

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Epidemiology

There have been several epidemiological studies on pain in the last 2 years that have included data on orofacial pain. Trigeminal neuralgia is often included in studies on neuropathic pain or headache. Recent studies are showing increasing prevalence of trigeminal neuralgia and Dieleman et al.'s study [8] based on Dutch primary care practices showed an incidence rate per 100 000 person years of 28.9 (CI 25.8–32.1) and this was very similar to that reported in the United Kingdom general practices: 27 (CI 26–27) [9]. The Bruneck study [10••] in people aged 55–94 years who were diagnosed by specialist neurologists showed a lifetime prevalence of 1.6 (CI 0.6–2.6) which is higher than those reported 40 years ago (4.7). This difference could be related to a number of factors. General practitioners may be diagnosing dental pain (which can be unilateral, sharp, shooting and light touch provoked) as trigeminal neuralgia. Improved diagnostic skills and awareness could also lead to more patients being diagnosed. TMD pain predominates in secondary care facial pain centres [6•].

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Risk factors for facial pain

It is essential that healthcare professionals appreciate that patients who report a variety of mechanical problems (such as teeth grinding, facial trauma, missing teeth and the feeling that the teeth did not fit together properly) often have underlying psychological factors and other frequently unexplained syndromes in other areas and do not require dental treatment [11•].

Anxiety and depression have been shown to increase the number of reported muscle tender spots, it does not correlate with diagnosis [12] and explains why in Von Korff and Dunn's study [13••] patients with chronic pain (455 had orofacial pain) the duration was not as reliable a predictor of pain outcomes as a risk score made up of pain intensity, pain related activity limitation, depressive symptoms, number of pain sites and pain days. This risk score would be easily used in pain centres and could improve triaging of patients.

Orofacial pain has a considerable impact on quality of life: 20% report the pain interfering with daily life activities, and in 10% it affects work [14]. In patients with TMD impairment of quality of life was higher in those with musculoskeletal causes than those with disc derangements [15].

Wolf et al.[16••] through their qualitative methods have provided evidence that patients with chronic facial pain lack an understanding of their pain that results in hopelessness, resignation, and a lack of faith. Healthcare professionals need to be aware of these factors when managing these patients.

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Risk factors temporomandibular disorders

In 2002 the United States National Health Interview Survey TMD had a prevalence of 4.6%, was more prevalent in women and showed that white women had TMD earlier than black women [17•]. Studies in Swedish adolescence have also supported the finding that TMD is more common in women and increases with age [18••]. The condition fluctuates with less than 1% having continued pain over 1 or 2 years [18••], however, a 20-year follow-up study has shown that 38% continue to suffer intermittently but less severely [19••]. TMD patients need to be told that the natural history of the disorder is that it is intermittent but continues for many years.

It is increasingly being recognized that TMD is not a unique type of orofacial pain and that it may reflect an underlying vulnerability to musculoskeletal pain. LeResche et al.[20•] have shown in adolescents that the risk factors for onset of clinically significant TMD pain are similar to risk factors for onset of TMD and other pain problems in adults. These are female sex, negative somatic and psychological symptoms including somatization, number of other pain complaints and life dissatisfaction. There is increasing evidence that TMD is linked to many other chronic pain conditions and in the last couple of years there have been a number of case–control studies carried out to show the relationship of TMD with other conditions, headaches, posttraumatic stress disorder, fibromyalgia [21•–25•].

Many dentists will tell patients that their TMD pain is related to a clenching habit or bruxism (parafunctional habits) and that this occurs during the night or at times of stress. This is far more complex and the relationship between bruxism and pain is far from being simple or even linear [26••]. Daily variations in pain do not correlate with self-reports of clenching or grinding but pain levels during weekends were significantly lower [27•]. However, reduced tooth contact can result in greater pain relief [28].

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Investigations

Many patients with orofacial pain expect to have imaging studies done and yet these are rarely indicated. Degenerative changes of the TMJ are not correlated to pain but rather to age (increasing), sex (female) and coarse crepitus in all movements of the TMJ [29••]. Patients need to be told that these changes can rarely be treated and do not require reduction in activity.

Validated questionnaires are useful to assess psychosocial aspects of facial pain and they often do not relate to location or severity of pain but provide a useful insight for further management [30].

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Treatment of temporomandibular disorders

From a meta-analysis of the literature it has been estimated that 15% of those with TMD may require some form of treatment [31•]. It is crucial that only those patients who have moderate or severe signs and symptoms of TMD and seek help should be given active management. The rest can be reassured and given advice re self care [32], but supplementation with exercises does not improve outcomes probably due to low compliance [33•]. As in back pains early biopsychosocial intervention reduces chronicity and costs [34••].

The EACD guidelines on TMD management [3•] stress the importance of providing adequate information and counselling. However, they are advocates of early use of occlusal splints despite stating that there is a lack of robust data on this topic. The literature is very clear that irreversible procedures including the use of prosthetic reconstructions or orthodontic treatments do not prevent or treat TMD.

There are numerous studies on the effect of low-level light amplification by stimulated emission of radiation (LASER) therapy in the treatment of TMD and one good quality study showed that LASER therapy was not better than placebo [35••].

Small pilot randomized controlled trials (RCTs) on acupuncture and traditional Chinese medicine and naturopathic medicine [36,37•] indicate that they may be useful especially in patients who do not want conventional medications.

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Atypical odontalgia

These patients are defined as having pain in a tooth or tooth region in which no clinical or radiological findings can be detected. Several studies have now been done to try and define this group more clearly and most of the recent work has come from the Scandinavian countries. Atypical odontalgia patients when compared with controls have:

  1. comorbid pain conditions,
  2. higher scores for depression and somatization,
  3. significant limitation in jaw function,
  4. significantly lower scores on quality of life [38•].

When these patients are compared with those with TMD it is shown that they are more likely to describe their pain as aching, find rest relieving but cold and heat aggravating. Over 80% relate the onset of their pain to dental treatment. Both groups show worsening of symptoms on chewing but more patients with TMD have other chronic pain [39•]. These patients have somatosensory abnormalities suggesting that generalized sensitization of the nociceptive mechanism may be occurring [40•]. Baad-Hansen [41••] has written a well balanced review of this condition and shown that due to lack of RCTs evidence based care is difficult. She stresses, as all of us seeing these patients report, that one of the major problems with this condition is convincing the patient that there are no dental causes for this pain and then ensuring that dentists are aware of this diagnosis and do not perform irreversible treatments. These patients are often diagnosed late [39•] and, therefore, need a multidisciplinary approach with psychological counselling and avoidance of any invasive treatments. She presents a very sensible approach to management in this sequence:

  1. topical lidocaine or capsaicin,
  2. tricyclic antidepressants,
  3. gabapentin, pregabalin,
  4. tramadol or oxycodone.
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Burning mouth syndrome

Burning mouth syndrome (BMS), or stomatodynia, is defined as a chronic, idiopathic oral mucosal pain/discomfort in which no clinical lesions or systemic diseases are identified. A recent world workshop in oral medicine resulted in a review article [42•]. Clinical evidence (clinicalevidence.bmj.com) maintains a regularly updated article on management of BMS and there is also a Cochrane Systematic review on this topic [43••].

There are increasing numbers of studies to suggest that this condition is not due to psychological factors alone but may be a form of neuropathic pain that then results in psychological effects. Studies have noted that not only do patients have a sensation of burning in their mouths but also there are often changes in taste and salivation. Eliav et al.[44•] showed that BMS patients had a dysfunction of their chorda tympani. Of the RCTs it would appear that clonazepam used topically may be helpful as well as cognitive behaviour therapy [43••,42•]. In the last 2 years a well designed RCT reporting under Consolidated Standards of Reporting Trials (CONSORT) methodology showed that Hypericum perforatum did not result in a positive response [45•]. Once these patients are given a physiological explanation for their pain and reassurance that they are not developing cancer many learn to cope with their symptoms.

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Trigeminal neuralgia

We recently published jointly between the American Academy of Neurology and the European Federation of Neurological Societies [46••,47••] international guidelines on trigeminal neuralgia. Evidence based methodology was used and they where approved by both Societies. The data are based on the literature up to 2006. There are also Cochrane reviews and I regularly update an article in Clinicalevidence.bmj.com on trigeminal neuralgia.

The following is a summary of the findings, more details of which can be found at www.aan.com:

  1. Routine head imaging identifies structural causes in up to 15% of patients and may be considered useful. The presence of trigeminal sensory deficits, bilateral involvement, and abnormal trigeminal reflexes may indicate the presence of symptomatic trigeminal neuralgia (STN) that is due to multiple sclerosis, tumours or malformations. Younger age of onset, involvement of the first division and unresponsiveness to treatment do not correlate consistently with symptomatic trigeminal neuralgia.
  2. There is good evidence to support measuring trigeminal reflexes in order to distinguish symptomatic trigeminal neuralgia from classical trigeminal neuralgia. These tests may not always be available.
  3. There is still insufficient evidence to support or refute the usefulness of MRI to identify neurovascular compression of the trigeminal nerve.
  4. Carbamazepine remains the gold standard drug but there is now evidence that oxcarbazepine (RCTs have not been published in full) is equally effective and has improved tolerability.
  5. Baclofen and lamotrigine may be considered useful if the first line drugs cannot be used.
  6. There are only limited data to help patients decide when to have surgery but often the factors used are refractoriness to medical therapy and loss of tolerability.
  7. A wide variety of surgical techniques are available but most data are of low quality evidence and so it is difficult to provide guidelines. Gasserian ganglion percutaneous techniques, gamma knife and microvascular decompression may be considered. Microvascular decompression may be considered over other surgical techniques to provide the longest duration of pain freedom; it is the most invasive procedure but does not damage the trigeminal nerve.
  8. The role of surgery versus pharmacotherapy in the management of trigeminal neuralgia in patients with multiple sclerosis remains uncertain.

More recently a randomized control trial (reported using CONSORT guidelines) of gabapentin together with weekly injections of ropivacain into the trigger area yielded a number needed to treat of 2.4 (50% reduction of pain) at 4 weeks [48•]. In clinical use we have not found gabapentin to be effective but we have not combined its use with a local anaesthetic.

There is now increasing literature on the use of Gamma knife and what is becoming increasingly clear is that Gamma knife therapy although noninvasive results in nerve damage and sensory loss can be expected to occur sometimes 6 months after the procedure has been done. It can be bothersome in 5% of patients and there are patients I have treated who have developed anaesthesia dolorosa after its use [49].

I encourage patients to have an early discussion with a neurosurgeon so they have more time to consider their options and at a time when their pain is still tolerable and this led to our study on how 156 trigeminal neuralgia patients make decisions on treatment. In hypothetical scenarios surgical techniques narrowly offer the highest chance of maximizing patient quality of life. However, surgery is not right for everyone, and patients should be informed about their full range of choices [50••]. Patients are keen to gain more knowledge as shown by their attendance at conferences [51•]. There is a need to provide jargon-free information and this has recently been done in a book called Insights: facts and stories behind trigeminal neuralgia[52].

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Persistent idiopathic facial pain

There remains a group of patients who are classified as persistent idiopathic orofacial pain (atypical facial pain) and who are generally treated with tricyclic antidepressants. However, many of the patients do not want to use drug therapy so the recently well conducted controlled study with patient blinding using hypnosis provides a useful addition to therapies [53•]. Those individuals who were susceptible to hypnosis noted an improvement in pain relief outcomes but the authors point out that other psychological factors need to be addressed. This is something we have also noted in our patients using hypnotherapy.

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Conclusion

Although TMD dominates the field of orofacial pain there is now some promising work emerging in this area. Although TMD has been reasonably well characterized there is an urgent need to accurately phenotype other facial pains that would enable improved research into determining the aetiology of this group of disorders. There is an increasing understanding that orofacial pain shares the same mechanisms as other chronic pain conditions and that a holistic approach is required. It is thus essential that dentists take a more biopsychosocial approach rather than a purely mechanistic one.

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References and recommended reading

Papers of particular interest, published within the annual period of review, have been highlighted as:

• of special interest

•• of outstanding interest

Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 146–147).

1 Zakrzewska JM, Hamlyn PJ. Facial pain. In: Crombie IKCPR, Linton SJ, LeResche L, Von Korff M, editors. Epidemiology of Pain. Seattle: IASP; 1999. pp. 171–202.
2 Hapak L, Gordon A, Locker D, et al. Differentiation between musculoligamentous, dentoalveolar, and neurologically based craniofacial pain with a diagnostic questionnaire. J Orofac Pain 1994; 8:357–368.
3• De Boever JA, Nilner M, Orthlieb JD, Steenks MH. Recommendations by the EACD for examination, diagnosis, and management of patients with temporomandibular disorders and orofacial pain by the general dental practitioner. J Orofac Pain 2008; 22:268–278. Internationally agreed guidelines using evidence-based resources.
4• Aggarwal VR, McBeth J, Zakrzewska JM, Macfarlane GJ. Unexplained orofacial pain: is an early diagnosis possible? Br Dent J 2008; 205:E1–E6. This is the first community-based survey to provide the characteristics of unexplained facial pain.
5• Aggarwal VR, McBeth J, Lunt M, et al. Development and validation of classification criteria for idiopathic orofacial pain for use in population-based studies. J Orofac Pain 2007; 21:203–215. Provides a useful self-complete questionnaire for epidemiological work.
6• Benoliel R, Birman N, Eliav E, Sharav Y. The International Classification of Headache Disorders: accurate diagnosis of orofacial pain? Cephalalgia 2008; 28:752–762. Provides a comprehensive survey of types of facial pain seen in secondary care centres using established criteria.
7 Zebenholzer K, Wober C, Vigl M, et al. Facial pain and the second edition of the international classification of headache disorders. Headache 2006; 46:259–263.
8 Dieleman JP, Kerklaan J, Huygen FJ, et al. Incidence rates and treatment of neuropathic pain conditions in the general population. Pain 2008; 137:681–688.
9 Hall GC, Carroll D, Parry D, McQuay HJ. Epidemiology and treatment of neuropathic pain: the UK primary care perspective. Pain 2006; 122:156–162.
10•• Schwaiger J, Kiechl S, Seppi K, et al. Prevalence of primary headaches and cranial neuralgias in men and women aged 55-94 years (Bruneck Study). Cephalalgia 2009; 29:179–187. Very carefully conducted study and all the patients' diagnoses were validated by trained neurologists.
11• Aggarwal VR, McBeth J, Zakrzewska JM, et al. Are reports of mechanical dysfunction in chronic oro-facial pain related to somatisation? A population based study. Eur J Pain 2008; 12:501–507. Based on the same data as other papers quoted in this review providing further evidence of the link of facial pain with other chronic pain.
12 Mongini F, Ciccone G, Ceccarelli M, et al. Muscle tenderness in different types of facial pain and its relation to anxiety and depression: a cross-sectional study on 649 patients. Pain 2007; 131:106–111.
13•• Von Korff M, Dunn KM. Chronic pain reconsidered. Pain 2008; 138:267–276. A very useful risk factor can be derived to help predict prognosis.
14 Wong MC, McMillan AS, Zheng J, Lam CL. The consequences of orofacial pain symptoms: a population-based study in Hong Kong. Community Dent Oral Epidemiol 2008; 36:417–424.
15 John MT, Reissmann DR, Schierz O, Allen F. No significant retest effects in oral health-related quality of life assessment using the Oral Health Impact Profile. Acta Odontol Scand 2008; 66:135–138.
16•• Wolf E, Birgerstam P, Nilner M, Petersson K. Nonspecific chronic orofacial pain: studying patient experiences and perspectives with a qualitative approach. J Orofac Pain 2008; 22:349–358. Rare piece of work in that this is qualitative and provides data on patients who have become very difficult to manage.
17• Isong U, Gansky SA, Plesh O. Temporomandibular joint and muscle disorder-type pain in U.S. adults: the National Health Interview Survey. J Orofac Pain 2008; 22:317–322. Useful study in that it includes large numbers.
18•• Nilsson IM, List T, Drangsholt M. Incidence and temporal patterns of temporomandibular disorder pain among Swedish adolescents. J Orofac Pain 2007; 21:127–132. Cohort study over 3 years with excellent response rate.
19•• Bergstrom I, List T, Magnusson T. A follow-up study of subjective symptoms of temporomandibular disorders in patients who received acupuncture and/or interocclusal appliance therapy 18–20 years earlier. Acta Odontol Scand 2008; 66:88–92. Remarkable in that they managed to get a high response rate after so long a period; only study of its kind.
20• LeResche L, Mancl LA, Drangsholt MT, et al. Predictors of onset of facial pain and temporomandibular disorders in early adolescence. Pain 2007; 129:269–278. Very carefully conducted study that provides clinicians with data on prognosis.
21• Glaros AG, Urban D, Locke J. Headache and temporomandibular disorders: evidence for diagnostic and behavioural overlap. Cephalalgia 2007; 27:542–549. Provides important evidence that TMD is not a localized pain and uses TMD/RDC criteria.
22• Bertoli E, de Leeuw R, Schmidt JE, et al. Prevalence and impact of posttraumatic stress disorder symptoms in patients with masticatory muscle or temporomandibular joint pain: differences and similarities. J Orofac Pain 2007; 21:107–119. Provides important evidence that TMD is not a localized pain and uses TMD/RDC criteria.
23• Afari N, Wen Y, Buchwald D, et al. Are posttraumatic stress disorder symptoms and temporomandibular pain associated? Findings from a community-based twin registry. J Orofac Pain 2008; 22:41–49. Provides important evidence that TMD is not a localized pain and uses TMD/RDC criteria.
24• Balasubramaniam R, de Leeuw R, Zhu H, Nickerson RB, et al. Prevalence of temporomandibular disorders in fibromyalgia and failed back syndrome patients: a blinded prospective comparison study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104:204–216. Provides important evidence that TMD is not a localized pain and uses TMD/RDC criteria.
25• Wiesinger B, Malker H, Englund E, Wanman A. Back pain in relation to musculoskeletal disorders in the jaw-face: a matched case-control study. Pain 2007; 131:311–319. Provides important evidence that TMD is not a localized pain and uses TMD/RDC criteria.
26•• Svensson P, Jadidi F, Arima T, et al. Relationships between craniofacial pain and bruxism. J Oral Rehabil 2008; 35:524–547. Excellent review of the complexity of mechanism involved in bruxism and clenching.
27• Glaros AG, Williams K, Lausten L. Diurnal variation in pain reports in temporomandibular disorder patients and control subjects. J Orofac Pain 2008; 22:115–121. By using electronic pagers able to accurately document pain fluctuations.
28 Glaros AG, Owais Z, Lausten L. Reduction in parafunctional activity: a potential mechanism for the effectiveness of splint therapy. J Oral Rehabil 2007; 34:97–104.
29•• Wiese M, Svensson P, Bakke M, et al. Association between temporomandibular joint symptoms, signs, and clinical diagnosis using the RDC/TMD and radiographic findings in temporomandibular joint tomograms. J Orofac Pain 2008; 22:239–251. Highlights that pain is not a major predictor of TMJ changes.
30 Reissmann DR, John MT, Wassell RW, Hinz A. Psychosocial profiles of diagnostic subgroups of temporomandibular disorder patients. Eur J Oral Sci 2008; 116:237–244.
31• Al-Jundi MA, John MT, Setz JM, et al. Meta-analysis of treatment need for temporomandibular disorders in adult nonpatients. J Orofac Pain 2008; 22:97–107. A thorough review highlighting that not all patients with TMD come forward for treatment.
32 Riley JL III, Myers CD, Currie TP, et al. Self-care behaviors associated with myofascial temporomandibular disorder pain. J Orofac Pain 2007; 21:194–202.
33• Mulet M, Decker KL, Look JO, et al. A randomized clinical trial assessing the efficacy of adding 6 × 6 exercises to self-care for the treatment of masticatory myofascial pain. J Orofac Pain 2007; 21:318–328. An RCT reporting an essentially negative result.
34•• Stowell AW, Gatchel RJ, Wildenstein L. Cost-effectiveness of treatments for temporomandibular disorders: biopsychosocial intervention versus treatment as usual. J Am Dent Assoc 2007; 138:202–208. Important study that highlights the importance of early psychological therapy for TMD and shows its cost effectiveness.
35•• Emshoff R, Bosch R, Pumpel E, et al. Low-level laser therapy for treatment of temporomandibular joint pain: a double-blind and placebo-controlled trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105:452–456. A negative RCT using CONSORT guidelines.
36 Smith P, Mosscrop D, Davies S, et al. The efficacy of acupuncture in the treatment of temporomandibular joint myofascial pain: a randomised controlled trial. J Dent 2007; 35:259–267.
37• Ritenbaugh C, Hammerschlag R, Calabrese C, et al. A pilot whole systems clinical trial of traditional chinese medicine and naturopathic medicine for the treatment of temporomandibular disorders. J Altern Complement Med 2008; 14:475–487. Large pilot study done by one of the large insurance companies in the United States.
38• List T, Leijon G, Helkimo M, et al. Clinical findings and psychosocial factors in patients with atypical odontalgia: a case-control study. J Orofac Pain 2007; 21:89–98. First case–control study of atypical odontalgia.
39• Baad-Hansen L, Leijon G, Svensson P, List T. Comparison of clinical findings and psychosocial factors in patients with atypical odontalgia and temporomandibular disorders. J Orofac Pain 2008; 22:7–14. A useful comparison between a common and rare condition.
40• List T, Leijon G, Svensson P. Somatosensory abnormalities in atypical odontalgia: a case-control study. Pain 2008; 139:333–341. Carefully conducted study showing that sensory changes are present.
41•• Baad-Hansen L. Atypical odontalgia - pathophysiology and clinical management. J Oral Rehabil 2008; 35:1–11. A thoroughly done review based on the highest quality evidence available, excellent overview with practical help.
42• Patton LL, Siegel MA, Benoliel R, De Laat A. Management of burning mouth syndrome: systematic review and management recommendations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103(Suppl):S13–S39. Consensus and evidence based review based on world workshop in oral medicine.
43•• Zakrzewska JM, Forssell H, Glenny AM. Interventions for the treatment of burning mouth syndrome. Cochrane Database Syst Rev 2005;CD002779. A Cochrane systematic review with a lay summary.
44• Eliav E, Kamran B, Schaham R, Czerninski R, et al. Evidence of chorda tympani dysfunction in patients with burning mouth syndrome. J Am Dent Assoc 2007; 138:628–633. First paper to provide evidence for the symptom of altered taste in patients with BMS.
45• Sardella A, Lodi G, Demarosi F, et al. Hypericum perforatum extract in burning mouth syndrome: a randomized placebo-controlled study. J Oral Pathol Med 2008; 37:395–401. A negative result RCT using St John's wort in BMS and reported using CONSORT guidelines.
46•• Cruccu G, Gronseth G, Alksne J, et al. AAN-EFNS guidelines on trigeminal neuralgia management. Eur J Neurol 2008; 15:1013–1028. First internationally agreed guidelines of two neurological societies based on evidence and experts.
47•• Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology 2008; 71:1183–1190. First internationally agreed guidelines of two neurological societies based on evidence and experts.
48• Lemos L, Flores S, Oliveira P, Almeida A. Gabapentin supplemented with ropivacain block of trigger points improves pain control and quality of life in trigeminal neuralgia patients when compared with gabapentin alone. Clin J Pain 2008; 24:64–75. RCT using CONSORT guidelines: first study to show the synergistic effect of two drugs.
49 Little AS, Shetter AG, Shetter ME, et al. Long-term pain response and quality of life in patients with typical trigeminal neuralgia treated with gamma knife stereotactic radiosurgery. Neurosurgery 2008; 63:915–923.
50•• Spatz AL, Zakrzewska JM, Kay EJ. Decision analysis of medical and surgical treatments for trigeminal neuralgia: how patient evaluations of benefits and risks affect the utility of treatment decisions. Pain 2007; 131:302–310. First paper to ask patients how they view the diffrent treatment options for trigeminal neuralgia.
51• Zakrzewska JM, Jorns TP, Spatz A. Patient led conferences: who attends, are their expectations met and do they vary in three different countries? Eur J Pain 2008. [Epub ahead of print] First paper to report from a conference run by patients and document their expectations.
52 Zakrzewska JM. Insights: facts and stories behind trigeminal neuralgia. Gainesville, Trigeminal Neuralgia Association 2006. pp. 1–403.
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Keywords:

burning mouth syndrome; facial pain; temporomandibular disorders; trigeminal neuralgia

© 2009 Lippincott Williams & Wilkins, Inc.