stimuli such as a light touch, a breeze, touching the face, shaving, brushing teeth, or movement of the tongue (Rubin, 2019). This type of pain can be so debilitating that patients may not want to eat or drink for fear of bringing on a new episode of pain. Other examples of episodic neuropathic pain conditions include nervus intermedius neuralgia and glossopharyngeal neuralgia. Neuropathic pain typically does not respond to regular analgesics such as acetaminophen, nonsteroidal anti-inflammatory agents, or narcotics. Thankfully, the lifetime prevalence of trigeminal neuropathic pain conditions in the general population is low 0.16% to 0.3% (Maarbjerg, et al., 2017). Referred pain When jaw function and dental provocation tests do not reproduce the jaw pain about which the patient is complaining, the dental practitioner should look for other sources of pain that can present as facial pain. As previously mentioned, a myocardial infarction can present as pain in the mandible or mandibular molars, but also as throat pain, face pain, or temporomandibular joint pain. Differences between pain of cardiac origin and pain of dental origin may be the quality (pressure or burning in the case of cardiac origin versus throbbing or aching) and location (bilateral for cardiac origin versus unilateral). In about 6% of cases, craniofacial pain may be the sole symptom of a cardiac event (Kikuta, et al., 2019). Local and systemic diseases may also cause pain in the orofacial region. These conditions include thyroid disease, pain of otologic origin (from the ear), sinusitis, multiple sclerosis, giant cell arteritis, autoimmune diseases, hypertension, neoplasms, and of course generalized muscle or joint disorders. The cervical spine and the cervical muscles are structures that frequently refer pain to the head and the face (Khalili, et al., 2021; Castien and De Hertogh, 2019).The facet joints in the upper cervical spine can radiate pain to the ear or preauricular area and the forehead. In some cases ear pain has been associated with upper cervical spondylosis (Zacharia and Dec, 2020). The sternocleidomastoid muscle can radiate pain to the entire face, and the trapezius muscles can radiate pain to the mandible (Jain et al., 2019; Moule and Hicks,2016). The dental practitioner should rule out referred pain before initiating dental therapies on a tooth that does not display the normal characteristics for pain of dental origin. Likewise, the dentist should rule out pain from other sources before initiating therapy for temporomandibular disorders if jaw function does not influence or create the orofacial pain. Disrupted physical activity In a state of chronic pain, an individual may limit what he or she does, to avoid either present pain or anticipated increased pain or re-injury (depicted earlier in the case of the schoolteacher in Box 3; (Dong. et al.; Bonakdar, 2017). In older people with pain, falling may also be added to the list of feared outcomes (Wetherell, 2016). Limiting activity to prevent pain is called guarding . Although guarding is a reasonable strategy for managing acute pain (e.g., avoiding walking on a painfully sprained ankle), it is a poor strategy for managing chronic pain, since it leads to a cycle of restricted activities and therefore greater disability (Senba and Kami,2017). With limited activity, the individual now struggles with a secondary issue – not burning the calories he or she once did and possibly putting on weight. Should weight gain begin to get out of hand, it could lead to obesity, which is often associated with more pain, especially in the knees, hips, and lower back (Schwarze, et al. 2019; Rodriguez, 2016; Chou, Lousia, 2016). If severe obesity is present, chronic pain is also frequently present, existing in about 80% of the severely obese (Rodriguez, 2016). Sleep disruption Chronic pain is associated with both excessive sleep and disrupted sleep. Individuals with chronic pain are more than twice as likely to sleep longer; however, they also have more trouble initiating sleep and remaining asleep (Mathias et al., 2018; Nijs, et al., 2018). The extra weight described above
to 4% and usually involves people in the 30-44 year old age range. It originates as a unilateral pain that begins in the neck after neck movement and is usually accompanied by a reduced range of motion. (Khalili, et al., 2020 and B Wu, et al., 2019). The cervicogenic headache stems from a disorder in the neck, but may be felt as a headache and/or face pain. If the headache stems from the cervical spine (i.e., the facet joints), the pain may be felt in the forehead as well as in the preauricular areas. If the headache stems from the cervical musculature, it may be felt in the frontal, temporal, periorbicular, maxillary, mandibular, and/or preauricular areas. The location of the pain could lead the patient and/or the practitioner to believe that the jaw joint or jaw muscles are involved. However, this pain is not usually aggravated by jaw function, which should prompt the practitioner to search for a cause of pain outside the masticatory system. Details concerning primary headaches and features of secondary headaches fall outside the scope of this course; the student is referred to the latest publications by the International Headache Society (http://www.ihs-headache.org) for more information. Neuropathic pain The International Association for the Study of Pain defines neuropathic pain as “pain that arises as a direct consequence of a lesion or diseases affecting the somatosensory system” (IASP, 2017). Orofacial neuropathic pain is usually divided into continuous and episodic pain forms. Much debate exists about the terminology for continuous neuropathic pain. Terms frequently used include atypical odontalgia, atypical face pain, persistent idiopathic face pain, and persistent dentoalveolar pain disorder (Van Deun L., 2020). This pain is usually described as a dull, gnawing, nagging sensation of low to moderate fluctuating intensity with few or no identifiable modulating factors, meaning that the patient usually cannot describe factors that make the pain better or worse. Another type of continuous neuropathic pain the dental practitioner might encounter is called burning mouth syndrome . The disorder is characterized by a burning superficial pain in the oral mucosa in the absence of any local or systemic pathology. Postherpetic trigeminal neuropathy, a complication of shingles, is also a type of continuous neuropathic pain that may occur in the face, and is usually described as burning, tingling, or shooting/stabbing. Episodic neuropathic pain such as trigeminal neuralgia, on the other hand, is typically described as sudden, short-lasting bursts of shooting, electric-shock-like pain of excruciating intensity, brought on by normally non-painful Impact of pain Chronic pain can create considerable suffering. However, it is important to emphasize that great variability exists in the ability of individuals with chronic pain to function in daily life. The degree to which pain limits participation in key activities is called pain interference , and even in samples with high rates of pain, there are great differences in the amount of pain interference that individuals experience (Duenas, et al., 2019). It is hard to predict who will be completely disabled by chronic pain and who will live a full, if occasionally restricted, life. It is important to remember that individuals experiencing mild, moderate, or severe pain, and even those who are most disabled by pain, may not present for care. Therefore, much of the information gathered to better understand pain is generalizable only to individuals seeking help for their pain along with other health- related conditions. To understand and treat chronic pain problems, it is necessary to appreciate exactly how chronic pain can lead to pain interference and disability. Although chronic pain can eventually disrupt almost any area of an individual’s life, it is chronic pain’s effects in two areas – physical activity and sleep – that cause the most disruption. In addition to being problems in their own right, disruptions in physical activity and sleep contribute to further difficulties, including social disruption and problems with mood. It should be remembered that cause and effect are interrelated and cyclical, interdependent and mutually causative.
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