Differential diagnosis of orofacial pain.

Orofacial pain, especially if the problem is chronic, presents a diagnostic and management challenge to all health practitioners. This paper suggests how clinicians might simplify the diagnosis of orofacial pain. First, the pain is classified into one of the three basic pain categories: somatic, neuropathic, or psychogenic pain. Somatic pain results from noxious stimulation of normal neural structures. Neuropathic pain is caused by a structural abnormality in the nervous system. Psychogenic pain arises from psychic causes; there is no apparent physiologic or organic basis for the pain. The next step is to determine the tissue system from which the pain arises: intracranial, extracranial, musculoskeletal, neurovascular, neurogenous, or psychological. Finally, some of the more common orofacial pain syndromes within each category are discussed.

Topical capsaicin-pharmacology and potential role in the treatment of temporomandibular pain.

Capsaicin is an over-the-counter topical analgesic marketed at 0.025% and 0.075% concentrations. It is currently approved by the United States Food and Drug Administration for the topical relief of pain due to rheumatoid arthritis, osteoarthritis and various neuralgias. This paper will review the basic and clinical pharmacology of capsaicin, and discuss its potential role in the management of pain in the temporomandibular joint region.

Chronic orofacial pain. A practical approach to differential diagnosis.

Successful diagnosis of chronic orofacial pain is a difficult task. This article attempted to simplify diagnosis by first classifying the orofacial pain on the basis of clinical characteristics into three basic pain categories: somatic, neurogenous, and psychogenic, and then according to the tissue system affected. An accurate and thorough history is essential, along with a detailed physical examination. In addition, an awareness of the local, systemic, and psychological causes of orofacial pain is necessary. The adage "what you don't know, you don't diagnose" is especially apt in regard to orofacial pain.

Occlusal splint therapy in MPD and internal derangements of the TMJ.

Although occlusal splints are useful in the treatment of MPD and internal derangements, they must be used in a rational manner. Two basic appliances are employed in Phase I palliative therapy: a maxillary full coverage (MAR) and a mandibular orthopedic repositioning appliance (MORA). The MAR is used in MPD patients primarily to disengage the occlusion and reduce parafunctional activity. In many cases of internal derangement, protrusive mandibular repositioning is indicated. By using the MORA during the day and the MAR at night, the disadvantages of each appliance are minimized.

Management of the acute TMJ emergency.

The urgent or after hours phone call to the dentist's office usually indicates a dental, traumatic, infectious, or pain emergency relating to the teeth or adjacent supporting structures. One subject not discussed at length in the professional literature is the emergency patient with acute pain or dysfunction of the orofacial musculoskeletal system, primarily the muscles of mastication and the temporomandibular joint (TMJ). The practitioner should be able to rapidly and efficiently diagnose and manage these emergency patients, or make adequate referral as necessary. Essential features in the diagnosis involve distinguishing muscle problems from intracapsular disorders. Knowledge of general medical-dental differential diagnosis is essential to rule out those problems masquerading as muscle or TMJ disorders. Proper emergency management is directed at controlling the pain or hypomobility disorder and stabilizing the patient. Contrary to most other aspects of dental practice, rapid and complete elimination of symptomatology may not be possible at this visit. Subsequent management should further define the pathologic process and direct the patient to additional phases of care. This report suggests a series of diagnostic and therapeutic guidelines.

Cervical strain and mandibular whiplash: effects upon the craniomandibular apparatus.

One of the most common injuries that can lead to a multitude of problems is cervical strain and mandibular whiplash resulting from a motor vehicle accident. Many individuals do not fully recover from such injuries, develop additional areas of pain and dysfunction weeks or months after the accident, and/or sustain major trauma that may require surgical intervention. Other than fractures or dislocations of cervical vertebrae, which are usually easily discerned from radiological analysis, two prime factors frequently lead to a prolongation of pain, a long rehabilitation course, and the development of problems at adjacent structures such as the craniomandibular region. These two factors are: 1) the lack of early comprehensive evaluation and referral for definitive therapeutic intervention, and 2) a minimal awareness of the relationship of upper quarter structures to one another. The purpose of this paper is to foster within the reader an appreciation of the interrelationship of the cervical and craniomandibular architectures as well as the significance of proper evaluation and treatment of cervical strain and mandibular whiplash injuries.