Evidence Based Approach to Patient Care

Facial Pain

Causes of facial pain

Evidence based approach to patient care

PICO -patient intervention comparison outcome

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Evaluate the evidence

Apply to the clinical situation

Trigeminal neuropathic pain/ atypical odontalgia / persistent dento alveolar pain

Management neuropathic pain according to NICE guidelines

· Tricyclic antidepressant – nortriptyline

· Gabapentin

· Pregablin

· Cognitive Behaviour Therapy

· Education – information

Burning mouth syndrome

Management BMS

· Exclude other causes of burning

· Reassure – especially nil serious

· Information

· May require drug therapy and or CBT

Chronic (persistent) idiopathic facial pain

Management of CIFP

· Tricyclic antidepressant – nortriptyline

· Cognitive Behaviour Therapy CBT

· Education – information

TMD

Management of TMD systematic reviews

· Acupuncture – needs confirmation of efficacy

· Occlusal adjustment – no evidence that treats or prevents TMD

· Stabilisation splint therapy may be some evidence for use

· Physiotherapy – may be useful

· CBT vs splints and education - unproven

Trigeminal Neuralgia

Carbamazepine – can be prescribed by dentists

· 3 RCT studies (total 160 patients)

· Number needed to treat - NNT 1.4- 2.1 i.e over 70% patients respond

· Usual dose 300-1,200 mg but start very low e.g 100 mg bd for low weight

· One dose increase every three days – slow and low

· Maximum up to 2.4g/day

· Immediate: rash (genetic variation) especially Orientals

· Idiosyncratic: affects bone marrow

· “Minor”: drowsiness, unsteadiness, dizzy

· Drug interactions common especially to note warfarin

· Monitor Hb, WBC, U& E especially in first six months and when on higher doses

· Long term use: may increase risk of osteoporosis

Surgical management of trigeminal neuralgia, data on 5 years not available for some procedures.

Procedure / % Probability of being pain free / Mortality / Morbidity
Peripheral neurectomy, cryotherapy, alcohol, / Two years – 22 / Nil / Low, sensory loss, transient heamatoma, oedema
Radiofrequency thermorhizotomy (RFT) / Two years - 68
Five years- 48 / Low / dyseasthesia, anesthesia dolorosa, eye problems, masticatory problems, sensory loss over 50%
Percutaneous glycerol rhizotomy / Two years – 63
Five years – 45 / Low / complications as for RFT but fewer cases of sensory loss
Balloon microcompression / Two years –79 / Low / complications as for RFT , fewer sensory loss but temporary masticatory problems common
Microvascular decompression / Two years – 81
Five years – 76
Ten years- 70 / 0.4% / Overall 75% no complications, 16% peri-operative complications, 2% transient cranial nerve 4th, 6th, 4% 8th dysfunction with 2 % permanent deafness
Gamma Knife surgery / Five years – 58 / Nil / Late onset of relief, may only be partial, 7% sensory loss up to two years post treatment

Psychosocial aspects of pain

Social history elements

· School & childhood: overall assessment, lonely, history of bullying, truant, illness, relationships
· Education: level of education, satisfaction
· Work including housework and satisfaction: previous posts, present, stress factors
· Leisure activity: how relax physical, cognitive, alone, team activities
· Marital status: past and present, stress factors
· Children: number, ages, problems, worries
· Finance: worries
· Housing: type, quality, satisfaction

There is evidence to show that some patients are less resistant to stress which then impacts on their pain experience. At risk factors include childhood problems, fear, sleep, moods, purpose in life.

Impact of pain

References

Books Orofacial Pain Ed J Zakrzewska Oxford University Press 2009

· Baad-Hansen L. Atypical odontalgia – pathophysiology & clinical management. J Oral Rehabil 2008;35:1-11.

· Nixdorf DR, Drangsholt MT, Ettlin DA, Gaul C, De Leeuw R, Svensson P, Zakrzewska JM, DE Laat A, Ceusters W Classifying orofacial pains: a new proposal of taxonomy based on ontology. J Oral Rehabil. 2011 Aug 18. doi: 10.1111/j.1365-2842.2011.02247

· Shephard MK, Macgregor EA, Zakrzewska JM. Orofacial Pain: A Guide for the Headache Physician Headache. 2013 Nov 21. doi: 10.1111/head.12272.

· Zakrzewska JM Facial neuralgias Faculty Dental Journal 2011: 2(4) ;152- 157

· Zakrzewska JM Differential diagnosis of facial pain and guidelines for management. BrJ Anaesthesia 2013: 111: 95-104; doi: 10.1093/bja/aet125

TMD

· Ernberg M, Hedenberg-Magnusson B, List T, Svensson P. Efficacy of botulinum toxin type A for treatment of persistent myofascial TMD pain: a randomized, controlled, double-blind multicenter study. Pain 2011; 152(9):1988-1996.

· Fricton JR, Ouyang W, Nixdorf DR, Schiffman EL, Velly AM, Look JO. Critical appraisal of methods used in randomized controlled trials of treatments for temporomandibular disorders. J Orofac Pain 2010; 24(2):139-151

· List T, Axelsson S. Management of TMD: evidence from systematic reviews and meta-analyses. J Oral Rehabil 2010; 37(6):430-451.

· Michelotti A, Iodice G, Vollaro S, Steenks MH, Farella M. Evaluation of the short-term effectiveness of education versus an occlusal splint for the treatment of myofascial pain of the jaw muscles. J Am Dent Assoc 2012; 143(1):47-53.

· Ohrbach R, Bair E, Fillingim RB, Gonzalez Y, Gordon SM, Lim PF et al. Clinical orofacial characteristics associated with risk of first-onset TMD: the OPPERA prospective cohort study. J Pain 2013; 14(12 Suppl):T33-T50.

· Roldan-Barraza C, Janko S, Villanueva J, Araya I, Lauer HC. A systematic review and meta-analysis of usual treatment versus psychosocial interventions in the treatment of myofascial temporomandibular disorder pain. J Oral Facial Pain Headache 2014; 28(3):205-222.

· .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.

· Schiffman E, et al Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. Journal of Oral & Facial Pain and Headache 2014: 28:6-27. doi: 10.11607/jop.1151

· Slade GD, Sanders AE, Bair E, Brownstein N, Dampier D, Knott C et al. Preclinical episodes of orofacial pain symptoms and their association with health care behaviors in the OPPERA prospective cohort study. Pain 2013; 154(5):750-760.

1. Cruccu, G., Gronseth, G., Alksne, J., Argoff, C., Brainin, M., Burchiel, K., Nurmikko, T., & Zakrzewska, J.M. 2008. AAN-EFNS guidelines on trigeminal neuralgia management. Eur.J.Neurol., 15, (10) 1013-1028 available from: PM:18721143

2. Tolle, T., Dukes, E., & Sadosky, A. 2006. Patient Burden of Trigeminal Neuralgia: Results from a Cross-Sectional Survey of Health State Impairment and Treatment Patterns in Six European Countries. Pain Practice, 6, (3) 153-160

3. Zakrzewska, J.M. & Coakham, H.B. 2012. Microvascular decompression for trigeminal neuralgia: update. Curr.Opin.Neurol., 25, (3) 296-301 available from: PM:22547101

4. Zakrzewska, J.M., Palmer, J., Ettlin, D.A., Obermann, M., Giblin, G.M., Morisset, V., Tate, S., & Gunn, K. 2013. Novel design for a phase IIa placebo-controlled, double-blind randomized withdrawal study to evaluate the safety and efficacy of CNV1014802 in patients with trigeminal neuralgia. Trials, 14, 402

5. Zakrzewska, J.M. Linskey, M.E. 2014. Trigeminal neuralgia. Clin.Evid.(Online), 2014), 10:pii 1207

6. Zakrzewska JM, Linskey ME Trigeminal Neuralgia BMJ 2014 348:g474. doi: 10.1136/bmj.g474

Books/ booklets patients

1. Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain

Michael Nicholas, Allan Molloy, Lois Tonkin and Lee Beeston, Souvenir Press Ltd,

2. Overcoming Chronic Pain

Frances Cole, Helen Macdonald, Catherine Carus, Hazel Howden-Leach, Robinson,

3. Brain and Spine Foundation – booklet on facial pain – can download off website

Psychological/ general pain / communication

· Morley S. Psychology of pain. Br J Anaesth 2008; 101(1):25-31

· Chrousos Stress and disorders of the stress system Nat Rev Endoc 2009: 5: 374-381

· Feder A et al Psychobiology and molecular genetics of resilience Nature 2009: 446- 457

Narrative Medicine

· Divinsky M. Stories for life. Introduction to narrative medicine. Can Fam Physician 2007;53:203-5, 209-11. (Eng)

· Charon R. Narrative medicine: honoring the stories of illness. New York, NY: Oxford University Press; 2006. p. 155-74.

· DasGupta S. Between stillness and story: lessons of children’s illness narratives. Pediatrics 2007;119(6):e1384-91, 1391

· Stanley P. The patient’s voice: a cry in solitude or a call for community. Lit Med 2004;23(2):346-63

Cochrane Library – systematic reviews e.g.

· Cochrane reviews on TMD , carbamazepine, non epileptic drugs for TN, surgical treatments TN

· Zakrzewska JM , Akram H Neurosurgical interventions for classical trigeminal neuralgia Cochrane Database Syst Rev. 2011 Sep 7;9:CD007312

Web sites

· e-learning modules non dental facial pain, trigeminal neuralgia both free hosted on http://www.paincommunitycentre.org or e brain www.ebrainJNC.com

· Guidelines TN www.aan.com

· Clinical knowledge summaries http://cks.nice.org.uk/trigeminal-neuralgia TMJ

· British Pain Society good selection of material open access including this generic booklet http://www.britishpainsociety.org/book_understanding_pain.pdf

· Pain Clinical Updates The Patient’s Journey Through Trigeminal Neuralgia May 2014 (Volume 22, Issue 1)

· J M. Zakrzewska D Padfield http://www.iasp-pain.org/PublicationsNews/PainNewsletterList.aspx

· http://www.efic.org/ Year against orofacial pain patient and professionals leaflets

Patient sites

· trigeminal neuralgia support group http://www.tna.org.uk , http://www.tna-support.org/

· migraine trust , http://www.migrainetrust.org/

· video on YouTube: Understanding Pain and what to do about it in less than five minutes
http://www.youtube.com/watch?v=4b8oB757DKc&feature=youtube_gdata_player

· for music for relaxation http://www.paincd.org.uk/

· Mindfulness for Pain, Stress and Illness -http://breathworks-mindfulness.org.uk

· Patient.co.uk

· Pain Association Scotland www.chronicpaininfo.org

· www.Paintoolkit.org

Professor Joanna M. Zakrzewska

Facial Pain Unit Eastman Dental Hospital,

UCLH NHS Foundation Trust Jan 2015