Atypical facial pain ( AFP ) is a type of chronic facial pain that does not meet other diagnoses. There is no consensus on the globally accepted definition, and there is even controversy over whether the term should continue to be used. Both the International Headache Society (IHS) and the International Association for Pain Study (IASP) have adopted the term persistent idiopathic facial pain ( PIFP ) to replace AFP. In the 2nd Edition of the International Classification of Headache Disorders (ICHD-2), PIFP is defined as "persistent facial pain that has no characteristics of cranial neuralgias [...] and is not associated with other disorders." However, the term AFP continues to be used by revisions of 10 International World Organizations on the Classification of Disease Statistics and Health Related Issues and remains in general use by doctors to refer to chronic facial pain that does not meet diagnostic criteria and does not respond to most treatments.
The main features of AFP are: no objective signs, negative results with all investigations/tests, no clear explanation for the cause of the pain, and poor response to treatment efforts. AFP has been described differently as a medically unexplained symptom, a diagnosis of exclusion, the cause of psychogenic pain (eg, manifestation of somatoform disorder), and as neuropathy. AFP is usually burned and continuous in nature, and can last for years. Depression and anxiety are often associated with AFP, which is described as the cause of pain, or the emotional consequences of suffering with chronic pain that is not diminished. For unknown reasons, AFP is significantly more common in middle-aged or elderly people, and in women.
Atypical odontalgia ( AO ) is very similar in many respects to AFP, with some sources treating them as the same entity, and others describing the former as AFP sub-types. Generally, the term AO can be used where the pain is limited to teeth or gums, and AFP when the pain involves other parts of the face. Like AFP, there is a lack of standardization of terms and there is no consensus on the globally accepted definition of AO. Generally the definition of AO states that it is a pain without a provable cause that is thought to come from teeth or multiple teeth, and is not eradicated by standard treatments to relieve toothache.
Depending on the exact presentation of atypical facial pain and atypical odontalgia, it may be regarded as craniofacial pain or orofacial pain. It has been argued that, in fact, AFP and AO are umbrella terms for heterogeneous groups that are misdiagnosed or not fully understood conditions, and they may not each represent a single, discrete condition.
Video Atypical facial pain
Classification
AFP has also been described as a phenomenon that can not be medically explained, which some perceive as psychogenic. However, true psychogenic pain is considered rare. Some sources have established or categorized AFP as a psychosomatic manifestation of somatoform disorder, as defined in the American Psychiatric Association's Diagnostic and Statistical Manual. Differences must be made between somatoform disorders, in which the affected individual does not create symptoms for some of the benefits, and other conditions such as artificial disorders or pretending to be sick.
Recent evidence in the study of chronic facial pain shows that the proportion of individuals who have been diagnosed with AFP have neuropathic pain,
AFP is described as one of 4 recognizable symptom complexes of chronic facial pain, along with burning mouth syndrome, temporomandibular joint dysfunction (TMD) and atypical odontalgia. However, there is an overlap between these diagnostic features, e.g. between AFP and TMD and burning mouth syndrome.
Atypical ocontalgia is similar in nature to AFP, but the latter term is commonly used where pain is restricted to teeth or gums, and AFP when pain involves other parts of the face. Other sources use atypical odontalgia and AFP as synonyms, or describe atypical odontalgia as sub-type, variant, or AFP intra-oral equivalent. Sometimes "phantom toothache" is listed as a synonym for AO, and sometimes it is defined as persistent toothache after the tooth has been extracted. It has been argued that it is likely that these terms do not represent a single, discrete condition, but the collection is misdiagnosed and as the cause has not been identified. The pain is often similar to the pain of organic tooth disease such as periapical periodontitis, or pulpitis (toothache), but unlike normal toothache, it is not relieved in the long term by dental treatment such as endodontic treatment (root canal treatment) or tooth extraction , and may even worsen, return shortly thereafter, or simply migrate to other areas of the mouth after dental treatment.
Definition
Atypical facial pain
There is no universally accepted definition of AFP, and it is defined less by what it is like what it is not. Various definitions of AFP include:
- "nonmuscular or joint pain that has no detectable neurological cause."
- "a condition characterized by the absence of other diagnoses and causing ongoing pain, variables-intensity, migration, disruption, internalization, and spread."
- "unilateral continuous pain pain sometimes with burnt components."
- "facial pain does not meet other criteria" (previous IHS definition, which now uses the term "Persistent idiopathic facial pain", see below).
- "persistent pain in the maxillofacial region that is incompatible with the diagnostic criteria of any other orofacial pain and has no identifiable cause." (Neville et al. )
Atypical odontalgia
No AO definitions are accepted globally, but some suggested definitions are listed below:
- "persistent pain in the tooth or in the tooth socket after extraction without the identification of identifiable teeth," (Society of international headache, description included as side note "persistent idiopathic facial pain" at ICHD -2, ie with no separate diagnosis for atypical odontalgia).
- "Severe throbbing pain in teeth without major pathology" (IASP definition in "Chronic Pain Classification", listing AO as "toothache not related to lesion").
- "pain and very sensitive teeth in the absence of detectable pathology".
- "the pain of an unidentifiable cause that comes from teeth or teeth".
Name the controversy and propose a replacement term
The term "atypical facial pain" has been criticized. Initially, AFP was intended to describe a group of individuals whose response to neural surgical procedures was not typical. Some experts in facial pain have suggested that AFP terminology is discarded, as it may serve as a catchall phrase to describe individuals who do not yet have adequate diagnostic assessment or individuals who are psychogenically ill. AFP is also described as an incorrect term because many cases in this category correspond to recognizable patterns. Another reason cited for stopping the use of the AFP term is that some cases seem to follow surgery or injuries involving the face, teeth and gums, possibly indicating an infection or traumatic etiology. Some classifications of facial pain avoid terms that support other similar terms.
IHS now uses the term "persistent idiopathic facial pain" in ICHD-2, defining it as "persistent facial pain that has no characteristic neuralgia of the skull [...] and is not associated with other disorders." The IASP classification of Chronic Pain does not have a diagnosis compatible with AFP, although it is listed in the differential diagnosis of "Glossodynia and mouthache" (Burning mouth syndrome). However, in other IASP publications from 2011, the term PIFP is used and defined almost identically to the above. Although there is controversy surrounding the use of the term, it has a long history, and is still commonly used by doctors to refer to chronic facial pain that does not meet diagnostic criteria and does not respond to most treatments.
Re-classification of trigeminal neuralgia
Trigeminal neuralgia is another example of the cause of facial pain. Neuralgia refers to pain in the distribution of nerves (or nerves), and generally implies paroxysmal pain (suddenly), although the accepted IASP definition establishes that the term should not be limited to mean paroxysmal pain. Classical trigeminal neuralgia refers to sudden, facial pain, which is usually short-lived and is caused by the stimulation of accidental trigger points on the face, as may occur during washing. Trigeminal neuralgia has been described as one of the most painful conditions. Trigeminal neuralgia and AFP are traditionally considered separately, because AFP usually involves constant pain, often burning and classic trigeminal neuralgia showing paroxismal, painful firing, but in reality there is some overlap in their features. In 2005 researchers proposed a new classification of trigeminal neuralgia that describes a type of trigeminal neuralgia in which the pain is constant and burning. They theorize that this species is a development of untreated trigeminal neuralgia, and represents worsening nerve damage. There are seven sub-types of trigeminal neuralgia (TN) proposed in this classification (see table), and the last category is reserved for facial pain caused by somatoform disorders. This latter category (TN7) is called atypical facial pain, although many cases that would traditionally be labeled AFP fall into other groups in this classification, especially into the second group. In a publication of the Trigeminal Neuralgia Association (TNA), the following is said about this new classification and AFP:
The term neuralgia or atypical facial pain is a rubbish term applied by a serious contributor from an earlier era to a group of patients he does not understand.Some of these patients are our trigeminal type of neuralgia. that many of these people are told they have psychological problems. Many develop psychological problems after the fact when told by everyone that it is their problem. Over the years, the area of ​​our ignorance has narrowed.] A term that does not degrade and, hopefully, make sense for a group of facial facial pain issues that have never been diagnosed: Facepain of Obscure Etiology (FOE or POE) to replace atypical facial pain in the Burchiel classification. "
As a result, some sources mention terms such as "atypical trigeminal neuralgia," "trigeminal neuropathic pain" and "atypical facial neuralgia" as synonyms of AFP.
Maps Atypical facial pain
Signs and symptoms
Some sources include some non-specific signs that may be related to AFP/AO. This includes an increase in the temperature and softness of the mucosa in the affected area, which is otherwise normal in all respects.
Patients often report symptoms of paresthesia, pain, and throbbing. Physical examination may be normal, but hypoesthesia, hyperesthesia, and allodynia may be present.
The characteristics of atypical facial pain may be considered in accordance with Socrates' pain assessment method (see table).
Cause
Iatrogenic
Sometimes dental treatment or surgical procedures in the mouth appear to precede the onset of AFP, or sometimes people with AFP will blame doctors for their pain.
Organic disease
Many people with AFP blame organic disease because of their pain.
Research on individuals with AFP shows that there is an increase in brain activity (shown during positron emission tomography), possibly indicating that there is an overactive mechanism of warning against peripheral stimulation. It has been suggested that this can trigger neuropeptides to be released, and the formation of free radicals (capable of damaging cells), eicosanoid release (eg prostaglandins). There are several opinions that AFP is the earliest form of trigeminal neuralgia.
Pain can be referred from other parts of the head or other parts of the body to cause facial pain. No place in the body called pain is described better than in the face, and this is because the rich, complex nature of the head and neck is innervated.
"Neuralgia-induces osteonecrosis of cavitation"
Neuralgia-induced osteonecrosis of the cavity (NICO) is a controversial term, and is questioned by many. Osteonecrosis of the jaw refers to bone marrow mortality in the maxilla or mandible due to inadequate blood supply. This is not always a painful condition, usually there will be no pain at all unless the necrotic bone becomes exposed to the mouth or through the facial skin, and even then this continues to be painless in some cases. When pain occurs, it varies in severity, and may be neuralgiform or neuropathic in nature. The term NICO is used to describe the pain caused by jaw ischemic osteonecrosis, where the degenerative extracellular crystalline chamber (cavity within the bone) is said to develop as a result of ischemia and infarction in the bone marrow, possibly in relation to other factors such as predisposing offspring to formation thrombus in blood vessels, low chronic dental infections and use of vasoconstrictors in local anesthesia during dental procedures. This proposed phenomenon has been postulated to be the cause of pain in some patients with AFP or trigeminal neuralgia, but this is controversial. NICO is said to be significantly more common in women, and lesions may or may not be seen on radiography. When they look, the appearance varies greatly. Approximately 60% of lesions appear as "hot spots" on technetium bone scan 99. NICO proponents recommend decortication (surgical removal of parts of cortical plates, originally described as treatment for osteomyelitis of the jaw) and curettage of the necrotic bone of cavitation, and in some cases reportedly, this has eliminated chronic pain. However, NICO seems to exhibit a tendency to recur and develop elsewhere in the jaw. The American Association of Endodontists Research and Scientific Affairs Committee published a position statement on NICO in 1996, stating:
"Most of the sites affected by postoperative NICO diagnosis have been in the edentulous region [where the tooth has disappeared], but some patients with a long history of pain and frustration associated with endodontically treated teeth have been given treatment options teeth extraction followed by periapical curettage in an effort to relieve pain The American Endodontist Association can not justify this practice when NICO is suspected. Due to the lack of clear etiologic data, the NICO diagnosis should be considered only as a last resort when all local possibilities of odontogenic causes for facial pain has been eliminated. If NICO lesions are suspected in relation to endodontically treated teeth, where possible, periradicular surgery and curettage should be attempted, not extraction. In addition, the practice recommends endodontic treated dental extraction for the prevention of NICO, or other illness, unethical and should immediately reported to the gods n appropriate state dentistry. "
Atypical trigeminal neuralgia
Some people argue that AFP is the earliest form of trigeminal neuralgia.
Psychological
There is strong evidence to suggest that chronic orofacial pain (including AFP) is associated with psychological factors. Sometimes stressful life events appear to precede the onset of AFP, such as mourning or illness in family members. Hypochondriasis, especially cancerophobia, is also often called involved. Most people with AFP are "normal" people who are under extreme pressure, but others with AFP have neurosis or personality disorders, and a small minority has psychosis. Some have been separated from their parents as children.
Depression, anxiety and changed behaviors are highly correlated with AFP. It is said whether this is a single cause or contribute to AFP, or the emotional consequences of suffering with chronic and never-lost pain. It has been suggested that more than 50% of people with AFP develop depression or hypochondria simultaneously. Furthermore, about 80% of people with psychogenic facial pain report other chronic pain conditions as listed in the table.
Diagnosis
- Migraine
- Dental disease
- Neoplasia
- Infection
AFP and AO can be difficult to diagnose, and are often misdiagnosed with inappropriate outcomes, eg. root canal therapy that may have only temporary benefits, or at worst causes increased pain. Excluding organic causes for pain is the most important part of the diagnosis. Odontogenic pain should be mainly excluded, as this accounts for more than 95% of cases of orofacial pain.
There are fairly overlapping symptoms between atypical facial pain and temporomandibular joint dysfunction.
Diagnosis nyeri wajah umumnya sering multidisiplin.
Kriteria ICHD-2 Diagnostik
The ICHD-2 lists the diagnostic criteria for "persistent idiopathic facial pain" (a term that supersedes AFP in this classification):
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- A. Pain in the face, present every day and last for all or most days, meet the criteria B and C,
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- B. Pain is confined to onset to a confined area on one side of the face, and deep and less localized,
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- C. Pain is not associated with loss of senses or other physical signs,
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- D. Investigations including x-rays of face and jaw show no relevant abnormalities.
There are currently no accepted medical tests that consistently distinguish between facial pain syndromes or differentiate Atypical Facial Pain from other syndromes. However, normal Radiography, CT, and MRI may help exclude other pathologies such as arterio-veinous malformations, tumors, temporomandibular joint disorders, or MS.
Management
Psychosocial interventions for AFP include cognitive behavioral therapy and biofeedback. A systematic review reported that there is weak evidence to support the use of these treatments to improve long-term outcomes in chronic orofacial pain, but these results are primarily based on temporomandibular joint dysfunction and burning mouth syndrome rather than ATP and AO.
Psychosocial interventions assume 2 models of chronic face pain, ie "inactive" and "over activity". The first is where people with pain become conditioned to avoid physical activity as a result of aggravating their pain. These negative thoughts and behaviors actually prolong and intensify their symptoms. Some psychosocial interventions work on this fear-averse behavior to improve function and thereby reduce symptoms. The model of over activity involves factors such as anxiety, depression or anger that act to increase pain by triggering autonomic, visceral and skeletal activity.
Medication
- Analgesics
- Antidepressants
- Central work muscle relaxant
- Anticonvulsants
Surgery
Some have suggested that surgery is not appropriate for treatment for AFP, but frequent medical care failures to relieve pain sometimes cause surgeons to try surgical treatments. Surgery can provide temporary remissions from pain, but there is rarely any long-term cure achieved through these steps. Sometimes the pain can be increased or simply migrate to adjacent areas after the surgical procedure. Description of procedures such as partial removal of affected trigeminal nerve branches, or direct injection of caustic substances (eg phenol, glycerol, alcohol) into the nerves have been reported. Proponents of "Neuralgia induce cavitary necrosis" suggest exploration of bone marrow surgery that surrounds the affected neural intra-bone pathway to find a diseased marrow.
Prognosis
Research shows that people with AFP are not much assisted by health care professionals. One study reported that on average, individuals had consulted with 7.5 different doctors. 91% have seen dentists, 80% doctors, 66% neurologists, 63% of ear, nose and throat surgeons, 31% of orthopedic and maxillofacial surgeons, 23% psychiatrists, 14% neurosurgeon and 6% ophthalmologists and dermatologists. In this study, individuals have undergone a variety of different treatments, from surgery, antidepressants, analgesics, and physical therapy. None of the people reported that the operation was useful, and in many cases the pain was exacerbated by surgery. The article placed as a source of this information was withdrawn from the publication, saying that the information was out of date and did not meet the Cochrane methodology standards.
It has been suggested that chronic face onset is likely to be a developmental change of life for those affected.
Epidemiology
AFP is sometimes described as fairly common, and an estimated prevalence is about 1-2% of the general population. However, the IASP describes PIFP as rare, less common than trigeminal neuralgia (which has a prevalence of about 0.01-0.3% in the general population), and lacks epidemiological data available for estimation of prevelence in the general population. The dominant age group is 30-50, and females are more frequently affected than men, with most reports suggesting that about 80% of people with AFP are women.
References
Source of the article : Wikipedia
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