Regulatory barriers ● Regulatory and enforcement practices can reduce patient access to opioid analgesics. ○ Some providers report feeling unfairly criticized for prescribing opioids and describe reductions in their prescription of these medications. Conclusion Pain is an important and adaptive evolutionary mechanism that signals the body when damage has occurred. With chronic pain, these signals persist and remain active, even in the absence of persistent somatic damage. At any given time, chronic pain is present in 10% to 20% of the population. Chronic orofacial pain is a significant physical and psychosocial problem, and its management requires specialized knowledge and training. Thus, many healthcare providers, including dental practitioners, feel inadequately prepared to work with individuals in chronic pain. Acute pain is a concept distinct from chronic pain. Although people with chronic pain can certainly experience incidences of intensified pain (flare-ups) that are similar to acute pain states, the discomfort of chronic pain never fully dissipates. It is not fully understood why acute pain persists and becomes chronic pain for some people, or why, among those suffering from chronic pain, some people experience more pain-related disability than others. However, the transition from acute to chronic pain likely involves a combination of biological, cognitive, and behavioral factors. Several types of chronic orofacial pain have been described. These include temporomandibular disorders, which can be subdivided into muscle and joint disorders; headaches, which can be subdivided into primary (when there is no clear etiology) and secondary (when there is a disorder or a condition to which the headache can be attributed); and neuropathic pains, which can be subdivided into continuous neuropathic pain and episodic (paroxysmal) neuralgias. Each of these chronic pain conditions may contribute to low mood and social problems, primarily through reductions in physical and social activities and disrupted sleep. A complete assessment for chronic pain should therefore include not only the key elements of pain such as pain location, intensity, quality, duration, frequency, modulating factors, and associated
○ Some patients report not filling opioid prescriptions for fear of being in violation of the law or being “flagged in a database.” ddressing these challenges requires an open discussion with patients about barriers to addressing their pain and a personalized approach to removing these barriers. symptoms, but also psychosocial aspects of pain such as pain affect, interference with life, pain behavior, pain coping, and pain cognitions. Treatment for chronic pain should include behavioral modifications (e.g., address parafunctional habits, prescribe a soft diet, and provide sleep hygiene instructions for patients with temporomandibular disorders; teach patients with headaches to avoid foods that trigger headaches and have patients with migraine headaches keep a regular schedule for sleeping and eating) and psychosocial components (e.g., address stressors, mood changes, pain behavior, and coping skills). Two prominent and empirically supported psychosocial approaches to managing chronic pain are cognitive-behavioral therapy and relaxation training. In cognitive-behavioral therapy, the individual with pain works with a therapist to identify beliefs and thoughts that contribute to pain and disability and to challenge and replace those thoughts. The individual will also work to identify environmental and social factors that maintain pain problems and seek to increase well behaviors (such as exercise, independence, and engagement in pleasurable activities). Relaxation training may take a number of forms, with deep breathing, mindfulness meditation, and self-hypnosis training as the most validated approaches for managing chronic pain. Although this course has provided an overview of these treatments, healthcare professionals who are interested in using these techniques clinically are strongly encouraged to complete additional coursework and training. Pharmacological treatment can be used as an adjunct for temporomandibular disorders and headache disorders and is the mainstay of treatment for neuropathic pain. Dental practitioners should prescribe only medications for which they can take full responsibility. In complex chronic pain cases, interprofessional collaboration is important.
APPENDIX A
Commonly used measures of pain intensity Visual Analogue Scale Direction : “Please mark your current level of pain on the line below.”
No Pain
Pain as bad as it can be
Numerical Rating Scale Direction : “Please circle (or say) the number that describes your current level of pain, with 0 indicating no pain and 10 indicating pain as bad as it can be.” 0 1 2 3 4 5 6 7 8 9 10 Verbal Rating Scale (12 Point) Direction : “Please check the box next to the word that best describes your current pain.” or Direction : “Please tell me the word that best describes your current pain.” No pain Weak Strong Severe
Just noticeable
Mild
Intense
Very intense
Very weak
Moderate
Very strong
Excruciting
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