Orofacial pain management: current perspectives

Abstract

Some of the most prevalent and debilitating pain conditions arise from the structures innervated by the trigeminal system (head, face, masticatory musculature, temporomandibular joint and associated structures). Orofacial pain (OFP) can arise from different regions and etiologies. Temporomandibular disorders (TMD) are the most prevalent orofacial pain conditions for which patients seek treatment. Temporomandibular disorders include a number of clinical problems that involve the masticatory musculature, the temporomandibular joint (TMJ) or both. Trigeminal neuropathic pain conditions can arise from injury secondary to dental procedures, infection, neoplasias, or disease or dysfunction of the peripheral and/or central nervous system. Neurovascular disorders, such as primary headaches, can present as chronic orofacial pain, such as in the case of facial migraine, where the pain is localized in the second and third division of the trigeminal nerve. Together, these disorders of the trigeminal system impact the quality of life of the sufferer dramatically. A multidisciplinary pain management approach should be considered for the optimal treatment of orofacial pain disorders including both non-pharmacological and pharmacological modalities.

Keywords: TMD; headache; neuropathic; orofacial; pain; trigeminal.

Figure 1

Jaw N-stretch with vapocoolant spray. Notes: The patient is instructed to place the tip of the tongue on the roof of the mouth just behind the frontal teeth (like saying the letter “N”) and to open – stretching the mandible while the spray is directed towards the face (masseter muscle region) in an upward motion.

Figure 2

Temporomandibular joint injection.

Figure 3

Maxillary stabilization splint.

Figure 4

Relationship between temporomandibular disorders and headache. Notes: Extracranial nociceptive inputs arising from craniofacial structures as a result of a temporomandibular disorder, as well as cervical input from the cervical muscles, may influence the activation of the trigeminovascular system. The commonality is that these nociceptive inputs converge on the TNC in the same way as do intracranial nociceptive inputs arising from the dural blood vessels and higher centers. Abbreviations: C2, C2 region of the cervical spinal cord; PAG, ventrolateral periaqueductal gray; RVM, rostral ventromedial medulla; SPG, sphenopalatine ganglion; SuS, superior salivatory nucleus; TG, trigeminal ganglion; TMJ, temporomandibular joint; TNC, trigeminal nucleus caudalis; VII, facial nerve; VI, ophthalmic branch of the trigeminal nerve; V3, mandibular branch of the trigeminal nerve.