Clinical Cases in Orofacial Pain

Malin Ernberg, Per Alstergren

• Publisher: Wiley-Blackwell
• Year: 2017
• ISBN:
  9781119194828
• Edition: 1
• Topic: Medicine
• Subtopic: Dentistry

Expand your knowledge and put it into practice with this unique, case-based guide

Clinical Cases in Orofacial Pain is a valuable resource for undergraduate dental students as well as residents working towards board certification. Individual cases cover temporomandibular joint disorders, masticatory muscle disorders, headache, neuropathic pain, dental pain, tooth wear, and dystonia. Following the popular Clinical Cases series style, cases are presented with associated academic commentary, including background information, diagnostic criteria and fundamental points that might influence the diagnosis, treatment planning or management of the case.

Well-illustrated throughout, each chapter features self-assessment study questions to help foster independent learning. Clinical Cases in Orofacial Pain is an excellent primer for undergraduate dental students and an invaluable study guide for postgraduate students and residents. Dental practitioners will also want to keep this unique, case-based guide as a ready reference in their working libraries.

Chapter 1
Diagnostics of Orofacial Pain and Temporomandibular Disorders

Thomas List and Richard Ohrbach

Temporomandibular disorders (TMDs) and orofacial pain occur in about 5–12% of the adult population and in approximately 4–7% of youth and adolescents (Drangsholt, 1999; Nilsson et al., 2005; NIDCR, 2014). About half of the individuals with TMD and orofacial pain perceive a need for treatment and seek consultation (Nilsson et al., 2009; NIDCR, 2014). The consequences of TMD and orofacial pain for the patient are often a limitation in daily activities, lower quality of life, and personal suffering; the consequences for society include high economic costs for treatment and loss of productivity (NIDCR, 2014).

Although several professional groups routinely encounter patients with TMD and orofacial pain, it is the general practicing dentist who will initially manage the care of these patients. One problem is that general dentists are often unsure about diagnosing patients with TMD and orofacial pain (Tegelberg et al., 2001). Thus, there is great need for a simplified and reliable diagnostic classification with clear instructions on how to conduct the clinical examination and which questions to ask in the history to get an overall picture of the patient's difficulties and choose suitable therapy. In addition to determining diagnoses through the examination of subjective symptoms and clinical findings, it is important to assess the patient's psychosocial status, including the consequences of chronic pain, in order to reveal an overall picture of the patient. The clinical condition (Axis I) and the psychosocial assessment (Axis II) together provide the information necessary for planning and executing suitable therapy with an optimal prognosis.

Diagnostic Classifications

There are many diagnostic systems for TMD and orofacial pain (Dworkin and LeResche, 1992; de Leeuw and Klasser, 2013; Headache Classification Committee of the International Headache Society (IHS), 2013; Peck et al., 2014; Schiffman et al., 2014). Of these, the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and the American Academy of Orofacial Pain (AAOP) diagnostic criteria for TMD-related masticatory disorders have been the ones most used internationally (Dworkin and LeResche, 1992; de Leeuw and Klasser, 2013). The RDC/TMD standardized assessment of the most common TMD diagnoses and the AAOP criteria, while not as strictly defined, covered a larger range of conditions.

The RDC/TMD has been translated into more than 20 languages, and the publication that introduced it is one of the most cited in the dental literature (Dworkin and LeResche, 1992; List and Greene, 2010). After identification of some limitations of the system, the RDC/TMD was revised and the new classification system Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) (Schiffman et al., 2014) was developed, which was also incorporated into the newest edition of the AAOP guidelines (de Leeuw and Klasser, 2013), thereby bringing research and clinical practice together.

The most common temporomandibular disorders

The DC/TMD is based both on extensive multicenter clinical studies, including studies funded by the National Institutes of Health in the USA, and on international consensus conferences (Schiffman et al., 2014). It is important to point out here that the DC/TMD only covers the most commonly occurring TMD conditions. The DC/TMD is comprised of two domains: a physical Axis I and a psychosocial Axis II.

The strength of the DC/TMD Axis I protocol includes reliable and valid diagnostic criteria for the common pain-related disorders and for the intraarticular disorders. The Axis I protocol provides standardized evaluation of subjective symptoms, contains clearly defined examination methods, and utilizes specific diagnostic criteria based on the clinical findings. The Axis II protocol, a psychosocial assessment, is simplified compared with the RDC/TMD version and has two options: a brief assessment and a comprehensive set of instruments for expanded assessment. The AAOP guidelines, in parallel, include the 12 common DC/TMD diagnoses.

Less common temporomandibular disorders: the expanded taxonomy

The DC/TMD covers the most common TMD conditions for which data were readily available. This created a need to expand the taxonomy to cover less common but still clinically relevant conditions. The expanded taxonomy (Peck et al., 2014) is a consolidation of the common disorders in the DC/TMD and the less common disorders described in the fourth edition of the AAOP guidelines for TMD (De Leeuw, 2008). The expanded taxonomy defines the diagnostic criteria for the less common TMD conditions and includes a total of 37 disorders; for example, temporomandibular joint (TMJ) arthritis in cases of systemic inflammatory diseases, local TMJ arthritis, ankylosis, myositis, and orofacial dyskinesia (Peck et al., 2014) (Table 1.1). Note that while the diagnostic criteria for the less common disorders are clearly stated such that each disorder is defined without overlap, the criteria have not yet been operationalized; in addition, there is at present no informa...