The purpose of this study is to profile patients with NO pain, to investigate the relationship between NO pain and previous dental treatments, and to gain helpful information about the diagnosis and treatment of NO pain.
Based on the obtained results, we report the following findings:
1. NO pain was diagnosed mainly as neuropathic pain (53.8%) and MFP (23.3%).
2. There were 65.7% without medical history, 20.5% cardiovascular diseases, 6.7% with GI troubles and 4.3% with psychogenic diseases. And only few of them have smoking (male 6.7%, female 1.0%) and drinking habits (male 8.6%, female 5.7%).
3. The common site of NO pain is left maxilla (30.0%), and right maxilla (27.6%).
Distribution of affected area were generally in accordance with previous reports but was not predominant in maxillary posterior region. Single area was affected in 90 patients (42.9%) with similar occurrence with multiple lesions (41.0%).
4. 17 patients (8.1%) had referred pain. 63.8% of patients have spontaneous pain. And the number of patients who have severe pain and who have moderate pain were 24.3%, 51.9%
each. The average period of treatment was 6.7 months.
5. NO pain occurs more often to the female (74.8%) than to the male (25.2%). The average age is 49.0 years and the average pain duration is 31 months.
6. Considering the departments referring to the Department of Orofacial Pain and Oral Medicine, treatments related to NO pain, previous dental treatment history, and visiting dental departments, NO pain is very closely related to the RCT. 48.6% of patients have treated more than 3 dentists.
7. The used drugs were mainly antidepressants (42.9%) and anticonvulsants (38.9%). And the effectiveness of anticonvulsants (79.2%) is better than that of antidepressants (75.3%).
8. Mainly the treatment drugs of neuropathic pain used amitriptyline (18.9%) and gabapentin (14.1%). And topical capsaicin has a limited effect.
9. Mainly the treatment drugs of MFP used eperisone HCl (24.3%) and cyclobenzaprine HCl (13.6%).
In conclusion, patients in Korea suffering from NO pain often visit multiple dental practitioners and receive unnecessary treatments before arrival to the correct diagnosis. In this study, such NO patients were largely diagnosed to have neuropathic pain and MFP. Rather than performing irreversible treatments, such as RCT or extraction, this study provides grounds for encouraging reversible treatments such as medications or physical therapy that will better benefit NO patients. With the continual publishing of future studies, we believe that a guideline will eventually be made for the treatment of NO patients in Korea.
REFERENCES
Ram S, Teruel A, Kumar SK, Clark G: Clinical characteristics and diagnosis of atypical odontalgia: implications for dentists. J Am Dent Assoc. 2009 Feb;140(2):223-8.
Mattscheck D, Law AS, Nixdorf DR: Diagnosis of non-odonogentic toothache. In: Hargreaves KM, Cohen S, eds. Cohen’s Pathways of the Pulp, 10th ed. St Louis: Mosby; 2011:49–70.
Melis M, Lobo SL, Ceneviz C, Zawawi K, Al-Badawi E, Maloney G, Mehta N: Atypical odontalgia: a review of the literature. Headache. 2003;43:1060-74.
Yatani H, Komiyama O, Matsuka Y, Wajima K, Muraoka W, Ikawa M, Sakamoto E, De Laat A, Heir GM: Systematic review and recommendations for NO toothache. J Oral Rehabil. 2014 Nov;41(11):843-52.
Pigg M, Svensson P, Drangsholt M, List T: Seven-year follow-up of patients diagnosed with atypical odontalgia: a prospective study. J Orofac Pain. 2013 Spring;27(2):151-64.
List T, Leijon G, Helkimo M, Oster A, Dworkin SF, Svensson P: Clinical findings and psychosocial factors in patients with atypical odontalgia: a case-control study. J Orofac Pain.
2007 Spring;21(2):89-98.
Dougall AL, Jimenez CA, Haggard RA, Stowell AW, Riggs RR, Gatchel RJ: Biopsychosocial factors associated with the subcategories of acute temporomandibular joint disorders. J Orofac Pain. 2012;26:7–16.
Turk DC, Audette J, Levy RM, Mackey SC, Stanos S: Assessment and treatment of psychosocial comorbidities in patients with neuropathic pain. Mayo Clin Proc. 2010;85:S42–
S50.
Polycarpou N, Ng YL, Canavan D, Moles DR, Gulabivala K: Prevalence of persistent pain after endodontic treatment and factors affecting its occurrence in cases with complete radiographic healing. Int Endod J. 2005 Mar;38(3):169-78.
Nixdorf DR, Moana-Filho EJ, Law AS, McGuire LA, Hodges JS, John MT: Frequency of nonodontogenic pain after endodontic therapy: a systematic review and meta-analysis. J Endod.
2010 Sep;36(9):1494-8.
Pogrel MA: Damage to the inferior alveolar nerve as the result of root canal therapy. J Am Dent Assoc. 2007;138(1):65-9.
Blondeau F, Daniel NG: Extraction of impacted mandibular third molars: postoperative complications and their risk factors. J Can Dent Assoc. 2007;73(4):325.
Pigg M, List T, Abul-Kasim K, Maly P, Petersson A: A comparative analysis of magnetic resonance imaging and radiographic examinations of patients with atypical odontalgia. J Oral Facial Pain Headache. 2014 Summer;28(3):233-42.
Israel HA, Ward JD, Horrell B, Scrivani SJ: Oral and maxillofacial surgery in patients with chronic orofacial pain. J Oral Maxillofac Surg. 2003;61(6):662-667.
List T, Leijon G, Helkimo M, Oster A, Svensson P: Effect of local anesthesia on atypical odontalgia--a randomized controlled trial. Pain. 2006 Jun;122(3):306-14.
de Leeuw R (ed). The American Academy of Orofacial Pain. Orofacial pain – guidelines for assessment, diagnosis, and management. Chicago (IL): Quintessence, 2013.
Tomoyasu Y, Higuchi H, Mori M, Takaya K, Honda Y, Yamane A, Yabuki A, Hayashi T, Ishii-Maruyama M, Jinzenji A, Maeda S, Kohjitani A, Shimada M, Miyawaki T: Chronic orofacial pain in dental patients: retrospective investigation over 12 years. Acta Med Okayama.
2014;68(5):269-75.
Wirz S, Ellerkmann RK, Buecheler M, Putensen C, Nadstawek J, Wartenberg HC:
Management of chronic orofacial pain: a survey of general dentists in german university hospitals. Pain Med. 2010 Mar;11(3):416-24.
Martin WJ, Perez RS, Tuinzing DB, Forouzanfar T: Efficacy of antidepressants on orofacial pain: a systematic review. Int J Oral Maxillofac Surg. 2012 Dec;41(12):1532-9.
Baad-Hansen L: Atypical odontalgia -- pathophysiology and clinical management. J Oral Rehabil. 2008;35:1-11
Vedula SS, Bero L, Scherer RW, Dickersin K: Outcome reporting in industry-sponsored trials of gabapenitn for off-label use. N Engl J Med. 2009 Nov 12;361(20):1963-71.
O’Connor AB, Dworkin RH: Treatment of neuropathic pain: an overview of recent guidelines.
Am J Med. 2009 Oct;122(10 Suppl):S22-32.
Napeñas JJ, Zakrzewska JM: Diagnosis and management of trigeminal neuropathic pains. Pain Manag. 2011 Jul;1(4):353-65.
Lynch ME, Clark AJ, Sawynok J, Sullivan MJ: Topical amitriptyline and ketamine in neuropathic pain syndromes: an open-label study. J Pain. 2005 Oct;6(10):644-9.
Handa T, Fukuda K, Ichinohe T: Effect of combination of trigger point injection and stellate ganglion block on non-odontogenic mandibular molar pain referred from masseter muscle: a case report. Bull Tokyo Dent Coll. 2013;54(3):171-5.
Al-Ani Z, Gray RJ, Davies SJ, Sloan P, Glenny AM: Stabilization splint therapy for the treatment of temporomandibular myofascial pain: a systematic review. J Dent Educ. 2005 Nov;69(11):1242-50.
Fricton J: Current evidence providing clarity in management of temporomandibular disorders:
summary of a systematic review of randomized clinical trials for intra-oral appliances and occlusal therapies. J Evid Based Dent Pract. 2006 Mar;6(1):48-52.
ABSTRACT (in Korean)
비치성 통증으로 안면통증 클리닉에 내원한 환자의 특성
<지도교수 김 성 택>
연세대학교 대학원 치의학과 서 정 일
비치성 통증에 대한 원인 및 진단, 치료는 아직 명확하게 밝혀진 바는 없다.
일반적으로 비치성 통증을 호소하는 환자는 비교적 복잡한 치과치료 병력을 가지고 있으나 증의 변화가 없다. 결국 환자는 불필요한 치과치료를 받으면서도 주소부위에 대한 해결은 이루어지지 않고 만성적인 동통에 시달려 고통을 받게 된다. 그러나 우리나라에서는 아직 이러한 비치성 통증 환자에 대한 체계적인 연구조사가 부족한 상태이다.
이에 본 연구에서는 비치성 통증 환자의 임상적 특징과 병력조사를 통해 다양한 연관성을 조사하여 비치성 통증 환자가 불필요한 치과치료를 받지 않도록 진단과 치료에 새로운 지침을 마련하고자 다음과 같은 연구를 시행하였다
2003 년 5 월부터 2013 년 4 월까지 연세대학교 치과대학병원 구강내과에 내원한 비치성 통증으로 여겨지는 환자 남자 53 명, 여자 157 명, 총 210 명을
대상으로 비치성 통증 환자의 진료기록부를 통하여 성별, 연령, 동통기간,
전신질환, 증상발현부위, 증상발현의 다발성 여부 등에 대해 조사하였다. 또한 구강내과에서 사용된 진단방법, 진단명, 치료 방법, 사용된 약물의 빈도, 그리고 치료 효과에 대해 분석을 시행하였다.
이 연구를 통해 다음과 같은 결과를 알 수 있었다.
1. 비치성 통증의 흔한 임상적 진단은 신경병증성 통증(53.8%)과 근막동통 (23.3%)이었다.
2. 전신질환 병력이 없는 환자가 65.7%로 가장 많았고, 다음으로 심혈관질환 20.5%, 위장장애 6.7%의 비유로 나타났다. 정신과 질환 병력은 4.3%로 연관성은 낮은 것으로 보이고 흡연은 7.6%, 음주는 14.3%이었다.
3. 증상 발현부위는 좌측상악구치부(30.3%)와 우측상악구치부(27.6%)에서
비슷하게 나타났고 대부분이 구치부에서 나타났다. 증상발현의 다발성
여부는 단독 부위에만 나타난 경우는 42.9%로 단독으로 나타나는 경우와 다발성으로 나타나는 경우가 비슷하다.
4. 연관통은 8.1%로 적게 나타났으며, 자발통은 63.8%로 다소 높게 나타났다.
통증양상은 중간의 동통이 51.9%로 많았으며, 평균 치료기간은
6.7 개월이었다.
5. 대상 환자 중 여자 157 명, 남자 53 명으로 여자에게 더 많이 발생하였으며, 평균연령은 49.0 세였고 동통기간은 평균 31 개월이었다.
6. 구강내과로 협의진료를 의뢰한 과, 증상발현과 연관된 치료, 이전 치과 병력 및 그 동안 환자가 내원한 과를 종합하여 보면 근관치료와의 연관성이 가장 높다고 볼 수 있다.
7. 약물의 사용은 다양하지만 항우울제(42.9%)와 항경련제(38.9%)가 주로
사용되고, 효과는 항경련제(79.2%)가 항우울제(75.3%)보다 다소 높게
나타났다.
8. 신경병증성 통증에는 항우울제인 amitriptyline(18.9%)과 항경련제인
gabapentin(14.1%)의 사용빈도가 높았고 capsaicin 도포제도 제한적이지만 효과를 보였다.
9. 근막동통에는 근이완제인 eperisone HCl(24.3%)과 cyclobenzaprine HCl (13.6%)의 사용빈도가 높았다.