Welcome to another session of DocScopy. This session will provide you with great insights into one of the most comprehensive subjects in Dentistry, ''OROFACIAL PAIN'' (OFP). Although it is a vast topic, our speaker, Dr. Karthik Kommuri has made it effortless for us to understand the basic concepts of diagnosis, management, and treatment modalities in OFP.

Get ready for the fruitful discussion between Dr. Karthik Kommuri, Dr. Meghana Pasala (BDS, MDS, Content Writer at MedBound Times), and Himani Negi (Copy Editor at MedBound Times).

Dr. Karthik Kommuri completed his bachelor’s degree (B.D.S.) from St. Joseph Dental College and Hospital in Andhra Pradesh. He practiced as a clinician for about 5 years in cities like Vishakhapatnam, Hyderabad, Mumbai, and Goa in India. In 2014, he moved to the US to pursue his MBA from the University of Findlay. He also pursued a dual specialty - post-doctoral training in Orofacial Pain and Temporomandibular Disorders from the University of Rochester and a degree in Orthodontics and Dentofacial Orthopaedics from the same university. Currently, he’s practicing as a full-time orthodontist in the state of Texas.

Dr. Meghana: What exactly is the term orofacial pain (OFP), and which region of the face does it include?

Dr. Karthik: To answer this question in a simple manner, orofacial pain is something that is related to the structures extending between the head and neck region, not just restricted to the oral cavity. Examples that can classify in this category include headaches, neuralgias, lesions, and infections related to head and neck regions. It can be odontogenic (related to dental structures) or non-odontogenic (not related to dental structures) in origin. So OFP can be classified as anywhere from the entirety of the head, face, oral cavity, and neck region.

One more thing that we have to understand from a dental standpoint about this complex specialty is that it is in a budding stage. There is a long way to go and we will need several multi-centered trails at a national level to identify the voids and uncertainties encountered in this field. This will enable us to efficiently diagnose, manage and treat orofacial pain patients in the future.

Dr. Meghana: What is the incidence and prevalence of OROFACIAL PAIN in the general population (in the US & INDIA)? Any RCTs?

Dr. Karthik: According to a study published by Gaskin DJ et al. in The Journal of Pain in 2012, at least 100 million people in the US (which is around one-third of the American population), are found to suffer from chronic pain. I recently come across a research article where the study was conducted in Indore City by Dr. Sandeep Kumar (https://pubmed.ncbi.nlm.nih.gov/27542197/). The study results showed that the overall prevalence of orofacial pain was found to be 17.9% in the study sample. However, this is just an indication of the prevalence of orofacial pain in the study subjects in Indore City. I believe that larger multicentred studies should be undertaken to understand the occurrence of orofacial pain at a national level.

Dr. Meghana:  Is OFP particular to any age group or gender?

Dr. Karthik: OFP is more commonly seen in the middle-aged group and elderly population, but it's not uncommon to diagnose orofacial pain in teenagers, adolescents, and/or young adults. Interestingly, for one reason or the other, apart from odontogenic complications, not many reports of orofacial pain are encountered in children.

Gender predilection: Generally, it is observed that women/females are more prone to orofacial pain.

Dr. Meghana:  How do we diagnose Orofacial pain?

Dr. Karthik: Diagnosis is an important aspect and should be established in a systematic and step-by-step fashion. Ideally, this should be started by thoroughly going over the general medical and dental history of the patient, followed by an elaborate clinical examination. This consists of assessing several components; for example, the cranial nerves, muscles of the head and neck, the oral cavity, jaw joint health, etc. Certain investigations like bitewings, periapical and panoramic x-rays, CBCT/CT, MRI, bone scans, EMG, and lab tests should also be adequately pursued to support the clinical examination. We can also gather more information from the patient using various tools like questionnaires and pain scales/measurement aids to better understand the nature of pain/discomfort. Apart from this, as part of diagnosis, we can also use several diagnostic aids like local anesthesia, pharmacotherapy, and vapor coolants to confirm our diagnosis.

The objective behind these investigations is to identify the nature and source of pain: whether odontogenic, non-odontogenic, myogenic, myopathic, neurogenic, headaches (what is the root cause of these headaches), TMDs (Temporomandibular disorders), etc. This helps us better understand factors like the intensity, frequency, duration, spread, and the acute or chronic nature of the discomfort; and accordingly, design a management and treatment protocol that is tailored to meet individual patient needs. For example, during a physical exam, a TMD (Temporomandibular disorder) condition can present with signs and symptoms like pain, clicking and popping, crepitus, and any deviations and /or limitations of the jaw while opening or closing. Based on the extent and severity of these presentations we can design a treatment plan that can range anywhere between palliative care to surgical intervention.

Signs like restlessness, lack of focus and irritability also give us more information on the impact of pain/discomfort on the mental or emotional well-being of the patient.

During examination, the provider should also look for presentations' indicative of parafunctional habits like clenching and bruxism, and the quality of patients’ sleep to establish a diagnosis. In chronic cases, these factors can result in psychological stress which may further worsen the condition for these patients. 

Dr. Meghana: What are the symptoms and signs of orofacial pain?

Dr. Karthik: Signs and symptoms:

Some of the other obvious signs that can also be observed during the clinical examination are, limited range of muscle motion (due to spasms of any orofacial muscles like masticatory muscles, neck muscles, etc.), headaches, clenching, bruxism, and sleep apnea. Based on the severity and duration of the pain, the patient may also present general signs of depression and irritability. During history taking, we may also observe patient presentations like underperformance at work or school, lack of focus, and inability to efficiently perform everyday chores. These factors ultimately lead to having a poor quality of life, eventually hindering having a normal and productive life. In short, based on the primary reason for discomfort, there can be a wide range of symptoms that can be associated with OFP.

Dr. Meghana: What are the general etiological factors for a pain episode?

Dr. Karthik: A wide range of factors can cause OFP. Some of the commonly encountered etiological factors (but not limited to) can be trauma, pathological lesions, any underlying infections, tumors, and systemic diseases. From a purely dental perspective, odontogenic pathologies can also contribute to OFP. Based on individual conditions, clenching, bruxism, poor quality of sleep, overuse of certain orofacial muscles, overuse of certain medications, poor quality of life, decreased physical activity, anxiety, and stress can also be the reason for OFP. We may find it surprising, but genetics can also play a role in certain OFP conditions.

Dr. Meghana: Differential diagnosis of OFP?

Dr. Karthik: Primarily, the differential diagnosis for OFP depends on the diagnosis, the nature and location of the pain. Generally speaking, conditions that may be considered in this category can range between ear pain, arthritis, Burning Mouth Syndrome (BMS), neurovascular conditions, tendonitis, mucositis, muscle spasms, degenerative disc disorders, and different types of headaches, to viral infections (Herpes Zoster, Shingles, etc.). Some other conditions that can be considered during differential diagnosis in OFP are related to the diseases of the cranial nerves, for example, trigeminal and glossopharyngeal neuralgias; and neuropathies.

 Dr. Meghana: Therapeutic Management of Orofacial Pain?

Dr. Karthik: The management depends on the diagnosis, the etiology, the site of pain, and the nature and intensity of pain/discomfort. For example, in a TMD case, the general protocol would be prescribing adequate rest, hot/cold compressions, a soft diet, avoiding hard/chewy foods, focusing on identifying and eliminating all possible etiological factors, physical therapy (massage therapy), pharmacological management (analgesics, anti-depressants), prescribing a customized occlusal splint (hard/soft) and follow up visits as needed to monitor the progress. Besides therapeutic management, patient education would also be an important step in the management of OFP.

Himani Negi: What’s your take on self-medication or over-the-counter (OTC) medicines in a country like the USA?

Dr. Karthik: Self-medication is not appropriate as it is unsafe for patients. I will encourage patients to seek medical advice before using any medications. In the United States, it is not easy to just get your hands on any medication; there is a clear classification of what is over-the-counter (OTC) and what is not. For example, basic pain medication drugs like Ibuprofen-200 mg can be OTC, but for higher-grade medications, one needs a prescription from a certified provider. This system would probably come into place keeping patient safety in mind. There is an existing condition of medication overload in the US. Coming to OFP, sometimes over usage of drugs like antipsychotics, or even simple analgesics can lead to conditions like medication overuse headaches, also commonly known as rebound headaches. Therefore, one has to be extremely cautious when using unprescribed medications.

Dr. Meghana: Where do you prefer hard splints from soft splints and also what is the thickness of the splint you recommend?

Dr. Karthik: Depending on the patient’s condition, I prefer using a soft splint that may provide the individual with some degree of oro-facial muscle relaxation. Based on the severity of the condition, I may also choose to use a hard splint - for moderate to moderately-severe cases of TMDs. In my opinion, the provider should be cognizant of when and where to use a splint for patients.

Coming to thickness, it again depends on the amount of clearance required to suit the patient’s needs, comfort, and overall treatment approach. I believe that for hard splints, a range of around 4-5 mm thickness will provide good results.

Dr. Meghana:  We usually preferred a thickness of around 2 mm or more, but it again depends on the type of case. There is no universal standard, I think.

Dr. Meghana: What cases end up with surgical intervention?

Dr. Karthik: In severe cases of TMDs, a surgical intervention for jaw joint replacement is necessary when there is extensive deterioration of the articulating surfaces of the jaws. In these cases, other modes of management usually do not show much success as the jaw joints exhibit significant erosion. Based on need, procedures like arthroplasty, arthrocentesis, and arthroscopy may also show benefit. Some other situations where surgery may be necessary in treating OFP cases are the removal of tumors and certain nerve-related conditions where procedures like nerve root sectioning and microvascular decompressions (MVD), etc. may be undertaken.

Dr. Meghana: How often follow-up visits are required?

Dr. Karthik: The follow-up usually depends on the diagnosis and treatment that is planned to meet individual patient needs. For example, in myogenic pain cases, the follow-up may be based on the pain severity and intensity. Usually, in mild cases, after designing a patient-specific treatment plan, the patient can be recalled within a 4-6 month period for evaluation of progress.

The follow-up varies from patient to patient and depends on the diagnosis and severity of the condition.

Dr. Meghana: What are the challenges you encountered during your study on orofacial pain?

Dr. Karthik: Basically, being strong in basic anatomy and cranial structures related to the head and neck is a prerequisite. Educating the patient, understanding what the patient is going through, and identifying the key etiological factors/problem are the challenging parts. Additionally, the ability to make fluent patient referrals is critical in managing OFP cases. Therefore, the availability of adequate specialists in the area of practice is a challenge that one may come across.

Through this Interview session with MedBound Times, Dr. Karthik Kommuri has shed light on the fundamental aspects of diagnosing, managing, and treating OFP, emphasizing the need for extensive research and multicenter trials to bridge the gaps in this evolving specialty. 

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