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Thursday November 27, 2014

When a 'Toothache' is Really a Migraine

When a 'Toothache' is Really a Migraine

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Rutgers strives to raise global awareness of dentists trained in orofacial pain to diagnose elusive pain syndromes

Benoliel (right), Heir examine patient
Photo: Jeff Tolvin
Rafael Benoliel, right, and Gary Heir demonstrate to students how to search for a patient's source of pain. 

The U.S. Surgeon General cited facial pain as a major component of trigeminal neuralgia, facial shingles, temporomandibular disorders and fibromyalgia. The report said 22 percent of U.S. adults reported some form of oral or facial pain in the previous six months.

When Maria, then 22, began experiencing pain, she felt it intermittently, mostly in the left upper jaw area. Thinking she had sinusitis, she visited an ear, nose and throat specialist. The ENT found no explanation for the pain. With the pain intensifying and lasting hours and sometimes days at a time, she also consulted her dentist, who suspected that faulty restorations were to blame.

Maria, not her real name, eventually underwent four root canals, an extraction and multiple sinus explorations, and yet nearly eight years after it began, the pain had become excruciating and constant. Finally, her ENT referred her to specially trained dentists whom he had heard lecture about orofacial pain.

“When we took her medical history, we learned that her mother and grandmother suffered from migraine headaches,” Rafael Benoliel, a professor at Rutgers School of Dental Medicine (RSDM) where he is director of the Center for Orofacial Pain and Temporomandibular Disorders. “Migraines are genetic in nature but I still wasn’t certain until we looked at the whole picture and considered everything we had observed.”

Maria’s pain stemmed from an atypical migraine, “atypical” because of its mid-face location, rather than in the forehead region where most migraines occur. The technical diagnosis: “neurovascular orofacial pain,” generally treatable with medication. Maria was prescribed Depakote, an anti-convulsant medication often used for such pain, and remains pain-free as long as she sticks to the regimen.

Her case is used at the dental school to explain “atypical” mid-face migraines but also to illustrate the value of interdisciplinary care, particularly when the evidence for a diagnosis and treatment plan is not clear.

Rutgers School of Dental Medicine, which has taught orofacial pain management for 25 years, is one of only 10 dental schools in the nation with a post-graduate pain management program approved by the American Dental Association’s Commission of Dental Accreditation.  It is also one of the few dental schools with an extensive undergraduate pain management program. Though not recognized as a specialty by the American Dental Association, orofacial pain management is a specialty area in several countries and emerging as one in others.

Led by Benoliel and Gary Heir, a professor who directs the center’s division of orofacial pain, Rutgers has a central role in the global orofacial pain community’s efforts to raise awareness – among dentists, physicians and other health care providers – of the value of a multidisciplinary approach to patient care to prevent cases such as Maria’s from lingering.  

“A misdiagnosis not only may lead to inappropriate treatment and expense, it can delay reaching an accurate, timely diagnosis of conditions with potentially severe consequences,” Heir said.

Orofacial pain is defined generally as pain felt in the face or mouth caused by disease or by various problems in the nervous system.  In a report on oral health in 2000, the U.S. Surgeon General cited facial  pain as a major component of trigeminal neuralgia, facial shingles, temporomandibular disorders and fibromyalgia. The report said 22 percent of U.S. adults reported some form of oral or facial pain in the previous six months.

In a notable development, the International Headache Society last month accepted orofacial pain specialists’ recommended criteria which define certain pain caused by nerve injury in the facial area – technically referred to as painful traumatic trigeminal neuropathy.

Benoliel, lead author of the paper outlining the recommendations, said it is valuable to provide internationally accepted terms and criteria to enhance understanding among a variety of professionals encountering similar symptoms.

Acceptance of the recommendations is seen as another step toward increasing collaboration in health care. “Pain caused by nerve injury in the facial area might require treatment by a pain specialist, by a dentist trained in orofacial pain or by a neurologist trained in headache,” Benoliel said.

Separately, Benoliel and Heir are serving on a task force of the International Association for the Study of Pain, which has declared October 2013-October 2014 the “Global Year Against Orofacial Pain” to expand the knowledge of orofacial pain. The association has more than 12,000 members in 94 countries.

For the yearlong campaign, Benoliel and Heir developed background materials explaining the criteria and recommendations for treating various types of orofacial pain and pain disorders.

Benoliel and Heir will also continue awareness-raising in a series of lectures, including at the American Academy of Orofacial Pain’s 2014 meeting where both will make presentations. Heir is an academy past president and scientific chair of the meeting. Benoliel co-edited the award-winning textbook Orofacial Pain and Headache, published in 2008, which is used extensively. He is working on a second edition.

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