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* How can TMD and idiopathic facial pain be distinguished in practice?
* What management options are available to the GP?
* What is the burning mouth syndrome?
JOANNA M ZAKRZEWSKA MD, FDSRCS, FFDRCSI
Senior Lecturer and Honorary Consultant in Oral Medicine, Institute of Dentistry, St Bartholomew's and the London Queen Mary's School of Medicine and Dentistry, London
By far the commonest cause of orofacial pain is dental, and so any patient presenting with this type of pain needs to have a dental check-up. Most dental pain is acute and the characteristic signs and symptoms enable a dentist to make a rapid diagnosis.
However, if the history is not indicative of a dental cause, the dentist needs to refrain from invasive dental work and consider other options (listed in table 1).
Patients may become disillusioned with their dentist if they fail to make a diagnosis and improve symptoms, and in these circumstances patients frequently seek help from their GP.
Dental pain aside, over 80 per cent of diagnoses of orofacial pain are made on history alone. It is therefore crucial that you spend time with a patient who complains of orofacial pain, as the psychosocial aspects of the history will be crucial.
* Non-dental causes Once dental causes have been eliminated, chronic orofacial pain is most likely due to either temporomandibular diseases (TMD) or idiopathic facial pain (atypical facial pain).
TMD are divided into three groups:
* Masticatory myofascial pain
* Internal derangements
* The arthritides
The first of these is by far the commonest. The international collaboration TMD research site http://www.rdc-tmdinternational.org/ also classifies these patients by pain intensity, pain-related disability and emotional symptoms, as this latter classification appears to have a significant influence on outcome.
Recent classification research suggests that there is little difference between TMD and idiopathic facial pain, except for the location.
Neurological or vascular causes are rare, and most have clear diagnostic criteria, although few have been proven by case-control studies.
The diagnostic criteria of the more common non-dental causes are shown in table 2. More details can be found on the International Headaches Society website, which has recently revised its classification and diagnostic criteria for head and facial pain: http://216.25.100.131