By Dr Saqba Alam
pains are unique in their presentation. This is attributed to the complex head
and neck anatomy and the trigeminal V nociceptive pathway. This anatomic and
physiologic construct has crucial implication with regards to pain patterns in
the head and neck region, making the diagnosis of Orofacial pain difficult.
and neck trauma noted to be the most prevalent and most common cause of
Orofacial Pain reported at Abbasi Shaheed Hospital, Karachi, Pakistan.
is the largest city of Pakistan with a population of around 16,094000 according
to the 2020 consensus. The Abbasi Shaheed Hospital is one of the only three big
government-funded hospitals in the city, including the Civil Hospital, Jinnah
Hospital. It serves residents of the northern part of the city (Nazimabad,
North Nazimabad, North Karachi, Federal B area, Orangi Town etc.). People from
all over Pakistan visit this hospital for the treatment of their various
ailments without any charge. Our study carried out at The Abbasi Shaheed
Hospital that is the third-largest hospital of the city after Civil and Jinnah
and is the main government hospital for the Central and West districts of Karachi.
pain is defined as pain restricted to the region above the neck, in front of
the ears and below the orbitomeatal line, also within the oral cavity.
pain includes odontalgia, neuralgia, psychogenic, traumatic, vascular,
myofascial joint-related or other idiopathic variants. Chronic Orofacial pain
may be correlated with psychological stress, social impairment, reduced quality
of life, economic crisis and high cost for healthcare service. With regards to
gender, studies have shown a higher number of females seeking
pain treatment in contrast to males with a steady increase in the last several
decades. Some of the most widespread and disabling pain conditions arise from
the structures innervated by the trigeminal system (head, face, masticatory
musculature, temporomandibular joint and associated structures). According to
Okeson Classification of Orofacial Pain, pain can be branched into physical
(Axis 1) and psychological (Axis 2) conditions. Physical conditions include
disorders of the Temporomandibular Joint (TMJ) and diseases of the
Musculoskeletal structures (masticatory muscles and cervical spine);
Neuropathic pains, episodic (trigeminal neuralgia [TN]) and continuous
(peripheral/centralized mediated) pains and Neurovascular disorders (migraine).
Psychological conditions include mood and anxiety disorders1,2-3. Myofascial
pain syndromes, temporomandibular disorders (TMD), neuralgias, ENT diseases,
dental pain, tumours, neurovascular pain or psychiatric conditions frequently
present with overlapping signs and symptoms with diverse characteristics making
the diagnosis challenging. Identifying the actual cause of pain thus goes a
long way in the clinical diagnosis and treatment planning.
to diagnose and manage, Orofacial pain can follow a myriad of factors
worldwide. It is the most common complaint in the general population worldwide,
causing chewing dysfunction, dental pain, intraoral pain, facial pain, jaw
pain, earaches, headache, oral ulceration pain, salivary gland dysfunctions,
oral candidiasis, temporomandibular joint disorders, oral pathologies of cysts
and tumours, oral cancer and lesions, burning mouth. Syndromes, neurosensory
disturbances are the complains commonly presented in dental and medical practices.
The latest risk assessment diagram of orofacial pain (RADOP) describes
essential insights about the underlying mechanisms procedure.
persons’ self-reporting system such as The Visual Analogue Scale describes the
actual intensity of pain is the most valuable means of reaching to the
diagnosis of pain and its correct management and choosing specific analgesics
and setting right doses of medications.
scale used in the study shows markings from 0 to 10 on which the patient’s pain
intensity is represented by a point between the extremes of “no pain at all”,
“Moderate pain” and “worst pain imaginable.” The scale used for the study also
shows expressive faces describing emotions and pain perceived by the individual
in picture format. Its simplicity, reliability, and validity, as well as its
ratio scale properties, make the VAS the optimal tool for describing pain
severity or intensity.
the Visual Analogue Pain Scoring System; to avoid any operator related bias or
misinterpretation on the clinicians’ side.
diagnosis can only be reached after complete history taking, psychosocial
evaluation and physical examination. The physical examination includes
intraoral examination of dental hard and soft tissues, buccal and vestibular
mucosa, lips, tongue, gingivae, salivary glands, tonsils and faucial pillars.
The extraoral analysis comprises of detailed muscle examinations,
temporomandibular joint examination, cranial nerve examination, neurologic and
vascular examination. Immediate attention must always be given to problems
associated with extreme pain and anxiety, which may trigger stress-related
cardiovascular sequel. Remarkably few patients scored a 9 or 10 on the Visual
Analogue Score. Once the airway, breathing and circulation have been adequately
assessed, a quick neurologic function evaluation should be performed. Elective
trauma cases which present in the outpatient department usually don’t need
emergency protocols and advanced trauma life support. Patients who sustain
fractures involving the mandible will often report paresthesia, or an
“uncomfortable pain” or pain of a “different kind” The patient’s past medical
and surgical history, medication use and known drug allergies should also be
reviewed. Temporomandibular joint dysfunction and any previous non-surgical or
surgical treatment should be carefully documented. When a mandibular fracture
is suspected, meticulous clinical examination of the maxillofacial region is
critical and should be carried out before the ordering of radiographic imaging
studies used to help in confirmation of the diagnosis in this study were blood
tests, diagnostic anaesthetic injections, biopsies of suspicious lesions,
ultrasonography, plain radiographs from peri-apical dental views,
Orthopentamogram, PA face to specialized CT,
sialograms and three-dimensional reconstruction CT imaging.
randomized clinical trial study was carried out for six months. Informed
consent was obtained from all study subjects. Following the selection criteria,
some 289 patients complaining of Orofacial Pain have selected a sealed envelope
method of randomization. All patients were treated by the same surgeon, the
same set of questions were asked for pain in history taking and based on
clinical examination specific radiographic investigation were carried out if at
all necessary to confirm the diagnosis.
patients were asked to Self Score their severity of pain experienced by using
the same VAS (Visual Analogue Pain) Chart with scores listed from 1 to 10, with
number 1 being the mildest kind of pain experienced and number 10 the most
severe and bitter pain one can experience.
concluded that trauma associated orofacial pain is the most frequent pattern
recorded at Dental and Maxillofacial outpatient department of Abbasi Shaheed, a
tertiary care hospital located in District North, Karachi. The hospital serves
the residents of the northern part of the city (Nazimabad, North Nazimabad,
North Karachi, F. B. Area, Orangi Town, etc.) with an estimated population of
nearly 1 million. The tool used to measure the severity is the VAS pain scale
with scores of 1 to 10 assessing the seriousness of pain in a step ladder
the Visual Pain Analogue Score is a better and more natural method of
determining pain severity by patients’ oneself instead of predicting and
judging severity by a clinician and prescribe medications based on wrong
measurement analysis. The study generated evidence that significant bulk of
trauma patients with injuries associated with head and neck region ranging from
minor injuries like a bruise, hematoma, abrasions, lacerations and small bleeds
in the head and neck region to major trauma causing bony fractures,
life-threatening vascular bleeding and degloving injuries complaining of mild
to severe orofacial pain are being presented more in the maxillofacial
outpatient clinics both directly and after emergency treatment for followup
reasons than other causes related to orofacial pain.
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