We examined two cases in which patients with orofacial pain were referred to a pain clinic after dental treatment, what they complained of, and what they looked like. When a patient visits a physical doctor complaining of physical symptoms, it is common to be treated from the physical side first. Since pain is a sensory experience and an unpleasant emotional experience, it is both a physical symptom and an emotion. Focusing on emotions may advance diagnosis and treatment. In the dental treatment of older adults, if pain or numbness occurs after implant placement for aesthetic purposes, the response to remove it is a conflict situation in which the unpleasant thing （pain） is reduced for the patient, but the good thing is also lost （loss of beauty）. If nerve damage occurs for purposes other than aesthetics, it may develop into a dispute, and anger may accumulate. In such a situation, pain treatment is not effective, and repeated further medical treatment is likely to result in secondary injury. Treating emotions first, rather than pain sensations, is beneficial in such cases. Interviews for unpleasant emotions such as anger and sadness were shown as simulated cases.

View full abstract

Purpose: Nociplastic pain arises in the body including the orofacial region despite no clear evidence of tissue damage, for which currently available therapeutics do not provide adequate relief. This review extracts pathophysiology and potential therapeutic approaches suggested by research using disease model animals.
Study selection: Fibromyalgia is a typical disease exhibiting nociplastic pain as a main symptom. This review collects and discusses findings in studies using reserpine-induced myalgia （RIM） model animal （rat etc.）, which has been constructed based on the hypothesis that fibromyalgia is triggered by disruption of the antinociceptive regulation by monoamines in the brain.
Results: RIM model animals, simulating patients with fibromyalgia, exhibit nociplastic pain （stimulus-evoked and spontaneous pain symptoms）. It has been shown that pathophysiological changes, including increase of oxidative stress, upregulation of pronociceptive neurotransmitters, and activation of brain immune cells, occur after the chronic reduction of brain monoamines. Potential therapeutic approaches, i.e., 1） functional modification of specific molecules which expression is altered following the monoamine reduction, 2） targeting the molecules which are responsible for other categories of chronic pain （e.g., neuropathic pain）, 3） supplementation of nutrition to correct the disrupted nutritional balance, 4） improvement of physical constitution by natural substances, and 5） nonpharmacological interventions., have been proposed in studies using RIM model animals.
Conclusions: It is expected that translation of findings in RIM model animals to patients would lead to elucidation of pathophysiological mechanisms and development of effective therapeutic approaches to nociplastic pain in the body including the orofacial region.

View full abstract

Pain and/or occlusal discomfort are common issues that dentists frequently encounter and can’t avoid. In some cases, patients exhibit a lack of improvement or even a negative response to treatment. It is, therefore, necessary to distinguish between cases in which nonreversible treatments should be avoided and cases in which reversible treatments are effective for improvement. In order to facilitate the management of patients who complain of orofacial pain and/or occlusal discomfort, a classification based on causes has been proposed which takes into account both organic and psychosocial factors. It is important to understand the underlying causes.

View full abstract

Patient: A 72-year-old male presented to our hospital with complaints of experiencing severe pain in his right mandibular molar upon taking the first bite of a meal. Tenderness was noted in the upper right parotid gland during his initial visit to our department. Based on the clinical symptoms, the patient was suspected of being affected by first bite syndrome, and pregabalin 50mg/day was prescribed. Additionally, the patient was referred to the Department of Diabetes and Endocrinology at our facility due to the non-treatment of hyperglycemia. Consequently, the patient’s treatment was initiated for diabetes mellitus. As the hyperglycemia resolved, the pain at the first bite of a meal and the degree of tenderness in the right upper parotid gland were mitigated. A cataract was diagnosed during an ophthalmology examination, and surgery was conducted. Furthermore, atrial fibrillation and colorectal polyps were detected and treated. As the pain at the first bite of food resolved and the tenderness improved after the initiation of medication for diabetes mellitus, pregabalin administration and patient follow-up were discontinued. However, other treatments were maintained, and the patient did not experience an exacerbation of pain.
Discussion: Idiopathic FBS is believed to be caused by aberrant sympathetic innervation to the parotid gland. In the present case, the dysautonomia caused by diabetes mellitus may have induced FBS and atrial fibrillation. In addition to treating diabetes, pregabalin, which acts on calcium ion channels, a significant intracellular messenger involved in the regulation of water and electrolyte secretion in the salivary glands, was effective in alleviating symptoms.
Conclusion: It is crucial to consider the potential presence of diabetes mellitus when treating idiopathic FBS.

View full abstract

Patients: A 63-year-old woman presented with right facial pain and numbness. Two years ago, she had a fall, which resulted in right facial fracture. Gradually, she experienced a throbbing pain triggered by touch. The patient then consulted the Orofacial Pain Clinic of Tokyo Medical and Dental University Hospital due to continuous pain. Allodinia and hyposentibility of the right face, innervated by the second branch of trigeminal nerve were observed on physical examination. Additionally, based on the semmes-Weinstein monofilament test, we diagnosed her condition as trigeminal neuropathy/post-traumatic trigeminal neuropathic pain （ICOP-1 4. 1. 2. 3）. After treatment with 7.5g/day of Keishikajutubuto, a type of Kampo medicine, near-infrared light therapy, iontophoresis, and needle energization, the duration of pain reduced and the intensity of pain attenuated. Long-term vitamin B12 supplementation and a total of 24 near-infrared light therapy sessions were performed. Two years after the start of the treatment, her pain intensity had reduced and the range of abnormal sensations had reduced compared to that at the first hospital presentation; however, the abnormal sensations still persisted．
Discussion: Post-traumatic trigeminal neuropathic pain was in defined in ICOP-1 in 2020, as “pain, in a neuroanatomically plausible area within the distribution（s） of one or both trigeminal nerve（s）,” and “Onset within 6 months after the injury．” Somatosensory symptoms are characterized by the presence of negative signs such as hypoesthesia or hyperalgesia, or positive signs such as hyperalgesia or allodynia, or both, as noted in the footnote. In this case of trigeminal neuropathy of the infraorbital nerve, long-term use of vitamin B12 supplements and near-infrared therapy reduced the pain and abnormal sensations such as allodynia and hypoesthesia in a case of trigeminal neuropathy of the infraorbital nerve after a long period of onset．
Conclusions: Our case suggests that even late onset of treatment of post-traumatic trigeminal neuropathic pain in the infraorbital nerve region with continuous pharmacotherapy and physical therapy can successfully alleviate the symptoms．

View full abstract

Patients: We present the case of a 36-year-old woman at 29 weeks of gestation. She had contracted coronavirus disease 2019 （COVID-19） twice: once before the pregnancy, where the only symptom was a severe headache, and then at 25 weeks of gestation. After the second infection, she experienced a new onset of facial pain and clenching that exacerbated her pre-existing headache and gingival pain. Before the second infection, the gingival pain area was localized to the anterior teeth in the maxilla. Afterward, it expanded to the anterior teeth in the mandible. Moreover, the headache and gingival pain were worse than those she experienced before she fell pregnant. After delivery, she used a night guard to prevent clenching. She was followed up for 7 months postpartum, during which her headache and gingival pain ceased from months 1 to 3. Her chief complaint of clenching and gingival pain disappeared at 7 months postpartum, but her headache and fatigue persisted.
Discussion: The pre-existing headache was believed to be a combination of migraine and tension-type headache, and the gingival pain was possibly related to tension-type headache and myofascial toothache. Exacerbation of pre-existing symptoms after COVID-19 was considered due to a weakened antiviral immune system during pregnancy and differences between the COVID-19 delta and omicron variants.
Conclusions: COVID-19 infection during pregnancy exacerbated pre-existing symptoms in our patient. Thus, pregnant women should take care and avoid viral infections. Furthermore, if a patient experiences various orofacial pains, multiple symptoms may be involved. Therefore, dentists should suspect odontogenic and nonodontogenic toothache and carefully monitor the patient’s progress.

View full abstract

Purpose: While online dental consultations are partially accepted, including some covered by health insurance, they are still not widespread. It is essential to recognize the limitations and values before utilizing them. This report discusses the experience of utilizing D to P with D （Doctor to Patient with Doctor） online consultations, gaining insights from specialists while highlighting considerations crucial in online dental consultations.
Materials and Methods: Presented is a case where despite three months of consultation by the primary physician, no improvement in symptoms was observed. Transition to online consultation using the D to P with Doctor approach was made. The primary physician adequately conveyed patient information to the specialist, who provided real-time instructions and guidance. After two months of treatment under specialist supervision, symptom improvement was achieved, and the treatment concluded.
Discussion: In online consultations, compensating for the lack of information compared to face-to-face consultations is necessary. In this case, thorough information transfer from initial face-to-face consultations and establishing the physician-patient relationship over time was crucial. Each stakeholder—specialists, primary physicians, and patients—in the D to P with Doctor approach has its pros and cons, necessitating careful organization to leverage them effectively in treatment.
Conclusion: While considerations exist in utilizing online consultations, there are significant benefits in dentistry. For patients, learning from specialist consultations is advantageous, and this holds true for physicians as well, making online consultations valuable.

View full abstract

Objective: To evaluate nociceptive modulation pain in a patient with Persistent Idiopathic Dentoalveolar Pain （PIDAP） using a novel approach involving Intraepidermal Electrical Stimulation （IES）.
Methods: A 43-year-old female patient with PIDAP underwent IES applied to the upper limb, with a noxious heat stimulus （47℃） applied to the palm as a conditioning stimulus. Temporal Summation （TS） and Conditioned Pain Modulation （CPM） effects were observed. Additionally, TS, CPM, and central sensitization-related symptoms were assessed during the treatment course.
Results: At the initial visit, the patient’s visual analogue scale （VAS） was 60/100, CSI was 25, TS value was 6, and CPM value was 6. Amitriptyline 10mg/day was prescribed. One month later, VAS improved to 50, CSI to 20, TS value to 8, and CPM decreased to 1. The dose of amitriptyline was increased to 20mg/day. Three months later, VAS improved to 40, CSI to 19, TS reached 10, and CPM decreased to −4. Treatment was maintained with amitriptyline 10mg/day.
Conclusion: The use of IES in evaluating nociceptive modulation pain in a PIDAP patient demonstrated a decrease in CPM, with subsequent improvement following treatment, suggesting the potential of this approach in managing pain modulation.

View full abstract