NEUROPATHIC OROFACIAL PAIN: Authors' response

NEUROPATHIC OROFACIAL PAIN: Authors' response

COMMENTARY of gun control in the United Kingdom versus in the United States, since the homicide by firearm rate in the United Kingdom is a tiny fract...

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COMMENTARY

of gun control in the United Kingdom versus in the United States, since the homicide by firearm rate in the United Kingdom is a tiny fraction of the gun-related homicide rate in the United States, it is impossible to discount the impact of access to firearms as a major driver in the different rates. In addition to a behavior change by practicing physicians or dentists to reduce the number of prescriptions and quantity of opioids dispensed, it became glaringly clear from the proceedings that the pharmacology core knowledge in medical and dental schools is inadequate. Even though physicians receive constant reinforcement in pharmacology, comments were made by physicians themselves during the hearing on their lack of knowledge regarding the unintended consequences of opioids. Dental school pharmacology courses vary as to number of hours and content, and whether it is a “therapeutics or pharmacology” course at a time when the numbers of drugs keep increasing on the market and many disease states are now termed “chronic,” thereby exacerbating the need for a strong core knowledge base in pharmacology. Pain is one of the principal symptoms that patients present on visiting a dentist, and the knowledge level of pharmacology on prescribing opioids should not differ between a physician and dentist. There is no such term as “dental analgesics.” Therapeutic courses do not cover appropriately the concepts of pharmacokinetics and pharmacodynamics that is warranted at the professional school education level. The root cause Dr. Liewehr seeks, as I see it, is a need for higher prioritization of pharmacology in the dental curriculum to a level commensurate with the responsibilities of the term “doctor.” In-

deed, such prioritization should become one of the hallmarks in separating dentists from the midlevel providers. The number of deaths and the overprescribing of these drugs in the United States has reached proportions to warrant the FDA’s taking some action, if only to raise the level of concern to the populace. I have worked with the FDA many times, and the agency sits in a position that often can be criticized from all sides, and no decision can satisfy all the interest groups. The FDA strives to base its decisions on data and to be responsive to the needs of the nation. I believe it acted in this manner in addressing this issue. It is a first step to solving a complex problem to which no single attempted control will be the solution. Frederick A. Curro, DMD, PhD

Director Practitioners Engaged in Applied Research and Learning (PEARL) Network New York University New York City

NEUROPATHIC OROFACIAL PAIN

Dr. Prashanth Konatham Haribabu and colleagues’ June JADA article, “Topical Medications for the Effective Management of Neuropathic Orofacial Pain” (Konatham Haribabu P, Eliav E, Heir GM. JADA 144[6]:612-614), was relevant and entertaining. Unfortunately, I was uncomfortable with one aspect of the article: the lack of a thorough evaluation of the pulpal status of the maxillary right first molar, premolar and canine. The authors elected to focus their examination on the neurological status of cranial nerve–V2. This was based on the presence of discomfort in the right zygomatic region and

LETTERS

the system of hyperesthesia, not typical findings with pulpal disease. It also was based on the absence of clinical or radiographic signs of pulpal disease. So they elected not to perform or document thermal, electric or percussion tests of teeth nos. 3 through 6. I agree with the authors that neuropathic orofacial pain can occur subsequent to oral surgical procedures, but pulpal disease and discomfort also can be linked to these procedures, particularly if the surgery is associated with the apexes of the teeth. For that reason, I feel that an evaluation of the pulpal status of these teeth was warranted. Their treatment resulted in a significant reduction of the patient’s discomfort, but maybe an evaluation of the pulpal status and treatment would have resulted in the elimination of her discomfort. Otherwise, it was an exceptional article. James E. Newman Jr., DDS Orting, Wash.

Authors’ response: We thank Dr. Newman for his observations regarding the diagnosis of neuropathic orofacial pain (NOP) in our case report published in the June issue of JADA. We certainly agree that a full dental examination, including pulpal evaluation, is an essential step necessary to eliminate the possibility of dental pathology. Hence, we routinely perform all the necessary pulpal evaluation tests as a standard procedure at our center. However, other considerations often are required in these often confusing and complex cases. Dr. Newman’s question raises an essential point in differential diagnosis. If patients such as those described in our article are subjected to root canal therapy or extractions, assuming that their pain is of dental ori-

JADA 144(8)  http://jada.ada.org  August 2013  877 Copyright © 2013 American Dental Association. All Rights Reserved.

COMMENTARY

LETTERS

gin, there is the probability that complaints would not resolve or could be further aggravated. A history of the current complaint is essential in determining not only the location, duration, frequency, quality and intensity of the complaint, but also the chronology of onset and temporal relationship to other conditions or events. This patient reported residual pain that began after a surgical procedure and, according to the patient, was constant, dull and achy. The patient described a persistent background pain in the right zygomatic region with brief, episodic sharp attacks that were minimally responsive to analgesics. This presentation is not consistent with pulpal pathology but is for NOP. The cranial nerve screening examination was positive for abnormal findings in the area of the surgery. Of utmost im-

portance, and in response to the point raised by Dr. Newman, was the equivocal response to a diagnostic anesthetic infiltration. A diagnostic local anesthetic infiltration of teeth nos. 3 through 6 was performed. If the primary source of pain was of pulpal origin, pain should have been arrested completely. The effects were equivocal, with the patient still reporting pain arising from the anesthetized area. Therefore, in response to Dr. Newman’s appropriate observation, pulpal pathology was tested and eliminated as a possible etiology of pain. In addition to performing routine dental (pulpal) evaluation tests, persistent noxious input from the teeth was essentially eliminated via the diagnostic anesthetic injection, thereby eliminating pulpal pathology as a potential source of pain. The elimination of pulpal pathology

in this manner led to the diagnosis of NOP, specifically NOP considered secondary to deafferentation of cranial nerve-V2 during the cyst enucleation procedure. The patient’s favorable response to topical medications was reported, also demonstrating the absence of a primary dental etiology. Prashanth Konatham Haribabu, BDS, MDS Resident

Eli Eliav, DMD, Msc, PhD

Chairman and Program Director

Gary Heir, DMD

Clinical Program Director The Center for Temporomandibular Disorders and Orofacial Pain Department of Diagnostic Science Rutgers School of Dental Medicine Rutgers, The State University of New Jersey Newark

878 JADA 144(8) http://jada.ada.org August 2013 Copyright © 2013 American Dental Association. All Rights Reserved.