Understanding Common Causes of Orofacial Pain

Temporomandibular Disorder, Burning Mouth Syndrome, and Dry Eye Disease


Although common, orofacial pain—pain that occurs in the mouth, jaw, face, or head—often poses several diagnostic challenges. Patients with chronic pain in these areas that is not diagnosed as headache- or migraine-related require a comprehensive medical evaluation for the best treatment path forward. This assessment typically includes a physical and providing your doctor with a general medical history as well as details of your pain symptoms.

As orofacial pain is often complicated by co-existing psychiatric, psychosocial, or other health disorders, a multidisciplinary treatment plan involving a few types of doctors is usually advised. Below is a look inside some of common types of orofacial pain conditions: temporomandibular disorder (TMD), burning mouth syndrome, and dry-eye disease.


Temporomandibular Disorder (TMD)

The most common acute, or short-lasting, causes of orofacial pain are related to dental issues and can be successfully relieved by a dentist or oral surgeon. Depending on the cause, primary care clinicians may also refer you to an otolaryngologist (ear, nose and throat doctor), neurologist, or pain specialist for treatment. Chronic facial pain, on the other hand, can be unilateral—meaning it occurs on one side of the head—or bilateral, meaning it occurs on both sides of the head. Chronic orofacial pain can be continuous or occur in episodes, or flashes.

Pain felt on one side of the face may be caused by a temporomandibular disorder (TMD), especially if it involves your chewing muscles. TMDs comprise a group of disabling conditions characterized by dysfunctions in the jaw muscles and/or the temporomandibular joint (that is the jaw joint that connects the lower jaw to the skull), with chronic orofacial pain as a typical feature. TMDs are the most common non-dental cause of facial pain and affects up to 12% of the population, mostly between the ages of 20 and 40. Early diagnosis and simple physical therapy are usually effective. If needed, patient might also seek the help of orthopedists that treat musculoskeletal disorders (muscles, bones, and joints) or, in severe cases, neurologists or rheumatologists.

TMDs have been linked to back pain, fibromyalgia, and headaches. Pain management usually focuses on decreasing the instances of pain and the patient’s functional limitations to improve quality of life. Diet, splints, physical therapy, medications, psychological interventions, and surgery may be involved depending on the severity of the case.

Burning Mouth Syndrome

Another type of orofacial pain is burning mouth syndrome (BMS), described as a burning sensation in the mouth, usually on the tip of the tongue while often affecting other areas. It is classified by the International Headache Society as a painful cranial neuropathy that occurs daily for at least two hours and has been present for more than three months.

The pain is usually considered moderate to severe. Over half of patients affected by BMS also experience taste alterations and xerostomia. Although estimates vary, approximately 1% of the population suffers from this condition, with women outnumbering men, and postmenopausal women particularly affected.

Burning mouth syndrome has been noted as a “diagnosis of exclusion,” meaning that it is diagnosed after all other possible conditions have been eliminated. The pain is not immediately visible, which often causes practitioners to dismiss the syndrome. While originally considered a painful condition caused, increased, or prolonged by mental, emotional, or behavioral factors (also called psychogenic pain), current evidence indicates that BMS is a chronic neuropathic pain condition that can be treated as such.

For proper diagnosis, a thorough dental examination and detailed medical history will be necessary. In certain cases, a neurological examination and psychiatric consultation may also be useful. Doctors may use sensory testing to detect certain neuropathic issues and search for factors that can lead to BMS, such as nutritional deficiencies (iron, zinc, vitamin B), allergies, Type 2 Diabetes, acid reflux, oral diseases, or psychological factors (anxiety, depression, and stress), which can then be treated accordingly.

Using advanced methods to diagnose the condition, most BMS cases can be classified as occurring in the body’s peripheral or central nervous system, or a combination of both types. Such differentiation is important for determining treatment options. For example, the central nervous system type does not respond to local treatments and is often associated with depression or anxiety, whereas the peripheral nervous system type of BMS responds to lidocaine blocks and topical clonazepam. Patients with central nervous system BMS may best be treated with non-invasive brain stimulation therapies or dopamine medications.

Dry-Eye Disease

Dry-eye disease (DED) is a chronic, multifactory inflammatory disorder of the lacrimal gland, or tear ducts, characterized by pain, visual disturbances, and in severe cases, blindness. It affects as many as 9% of US adults, with twice as many women as men experiencing the condition. The prevalence of this disease increases with age and is more than three times higher in individuals over age 50.

If you have dry eyes accompanied by pain, are over the age of 50, wear contact lenses, have had refractive surgery, or have an immune disease, it is possible you have DED. The cause of DED remains unknown, but inflammation around the eye area and tear ducts may play a key role. Tears are a mixture of fatty oils, mucus, water, and proteins. Dry eye occurs when the quantity or quality of the tears fails to keep the surface of the eye adequately lubricated.

Until recently, the only approved therapy for DED was the immunosuppressant drug cyclosporin A (CsA), but the medication’s effectiveness was shown to be limited. Corticosteroids may also provide relief, but only in the short-term as they can cause serious side effects.

A new therapy recently approved by the FDA, lifitegrast, has been shown to significantly improve symptoms of DED without major side effects. Yet, there is still a need for a fast-acting, effective, safe, and well-tolerated therapy to address both the signs and symptoms of DED. New research is being conducted to determine the potential of narrow spectrum kinase inhibitors (NSKIs), which are proteins that regulate the inflammatory process in the body, to treat DED and inflammatory eye disorders.Recent studies have shown that NSKIs may have the potential to relieve a number of inflammatory conditions as well as arthritis. NSKIs are thought to offer an approach that targets the chronic inflammation in both the early and later stages of DED.



Updated on: 05/24/18
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