1 - Faculdade de Odontologia de Bauru - Universidade de São Paulo - USP, SP - Brazil.
2 - Faculdade de Odontologia de Araraquara - Universidade Estadual Paulista - UNESP, - Araraquara - São Paulo - Brazil.
After the extraction of a third molar tooth, and after the normal healing period, Mrs. Maria started to experience constant, burning, and sometimes electric shock-like pain at the surgery site. She was treated by several professionals that offered different treatment options, including surgical procedures, the use of various painkillers, as well as psychological support. However, none of the approaches was able to ease her suffering. Only after many tentative during several months she got an accurate diagnosis and adequate therapy. This trajectory brought her anxiety, suffering, and loss of quality of life. Unfortunately, cases like Mrs. Maria’s are not rare in Dentistry, and perhaps symbolize the same scenario of headache patients 30 years ago, before the establishment of validated diagnostic criteria1.
Chronic Orofacial Pain (OFP) comprises a diverse group of extraoral and intraoral painful manifestations that may include dental pain, muscle, and articular (temporomandibular joint - TMJ) pain, as well as post- traumatic neuralgias, which are difficult to diagnose and control. Beyond the potential negative impact on patients’ quality of life, these conditions are also frequently associated with other comorbidities, such as primary headache, fibromyalgia, neck pain, and others.2,3,4
As illustrated in the case above mentioned, dentists daily deal with critical challenges and difficulties in the recognition and diagnosis of such conditions. Such problems are often shared with other health professionals, such as physicians, psychologists and physical therapists, who may be involved in the care of patients with such conditions. These facts perhaps are related to the complexity of the Trigeminal System, which is composed of three nerve branches, sharing neural pathways with many other cranial and cervical nerves5. Another critical problem is the absence of a worldwide accepted and comprehensive classification able to reflect in appropriate and evidence-based management strategies. An unrecognized and unclassified condition cannot be treated!
An inherent characteristic of human beings is the tendency to group objects or creatures with similar characteristics. Primitive man, for example, already divided living beings into two groups: edible and inedible. In other words, classifying and differentiating is part of the evolution of the human race.
Some classification systems consider the OFP conditions, such as the “International Classification of Headaches Disorders” (ICHD)6, and the “Diagnostic Criteria for Temporomandibular Disorders” (DC/DTM)7. However, none of them encompass, in an organized and hierarchical manner, all possible painful manifestations of the face and oral cavity.
Thus, a joint initiative was launched with the participation of several entities, such as the Special Interest Group in Orofacial Pain and Headache (SIG-OFHP) of the IASP (International Association for the Study of Pain), the International Network for Orofacial Pain & Related disorders Methodology (INfORM) of the IADR (International Association for Dental Research), the American Academy of Orofacial Pain (AAOP) and the International Headache Society (IHS). Accordingly, several professionals, including dentists, neurologists, and psychologists, worked together during a few years to propose a new classification system that would be helpful in the practice of all health professionals. Thereby, the “International Classification of Orofacial Pain” - version 1.0 Beta, has emerged8.
This document represents a significant improvement for all professionals involved in the diagnosis and treatment of OFP and associated morbidities. It aims to increase the integration among all these specialists in research and clinical settings, hospitals, and other health services. It also must be incorporated into ICD-11, representing the recognition of chronic orofacial pain as a public health problem to be considered and controlled.
ICOP has a format already established by neurology through ICHD and embraces the pain from dental and associated structures, which are the most prevalent types of OFP and are not considered in the other classification systems. It also includes the Temporomandibular Disorders (TMD), based on the well-known DC/TMD, besides the disorders involving injuries of the cranial nerves, facial manifestations similar to the primary headaches, as well as facial and oral idiopathic pain.
It is well known that some primary headaches may include facial manifestations during the pain phase. However, some of them may manifest exclusively in the face, and sometimes, in the teeth9. Although rare, such conditions represent a major challenge for all of us. They are also listed in the new ICOP, which may improve our research opportunities, understanding leading to a more scientific clinical practice.
As aforementioned, there are many similarities, interests, and intersections between Dentistry, Neurology, Psychology, and other areas regarding the recognition and integrated treatment of patients with OFP and chronic headaches. The kickoff for the ICOP translation into Portuguese has already been given, and we hope to make it available soon. Thus, we invite everyone to use, interact, and discuss these new pathways of the OFP. Our patients who has endlessly and desperately looking for proper diagnosis and treatments to alleviate their suffering will be the most benefited and thankful. And perhaps, cases like Mrs. Maria’s may become increasingly rare....
- May A. Facial Pain is coming home. Cephalagia. 2020; 40: 227-228.
- Ferreira MP, Waisberg CB, Conti PCR, et al. Mobility of the upper cervical spine and muscle performance of the deep flexors in women with temporomandibular disorders. J Oral Rehabil. 2019; 46: 1177-1184.
- Costa YM, Conti PC, de Faria FA, et al. Temporomandibular disorders and painful comorbidities: clinical association and underlying mechanisms. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017; 12: 288-297.
- Conti PC, Costa YM, Gonçalves DA, et al. Headaches and myofascial temporomandibular disorders: overlapping entities, separate managements? J Oral Rehabil. 2016; 43: 702-15
- May A, Svensson One nerve, three divisions, two professions and nearly no crosstalk? Cephalalgia. 2017; 37: 603. https://doi.org/10.1177/0333102417704605
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders. 3rd ed. Cephalalgia. 2018; 38: 1 –211.
- Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache. 2014; 28: 6-27.
- The ICOP classification International Classification of Orofacial Pain. Cephalalgia. 2020; 40: 1 29–221.
- Ziegeler C , May Facial presentations of migraine, TACs, and other paroxysmal facial pain syndromes. Neurology. 2019; 93: e1138.