Atypical odontalgia and trigeminal neuralgia: psychological, behavioural and psychopharmacologic approach – an overview of the pathologies related to the challenging differential diagnosis in orofacial pain

Introduction

In clinical dental practice there are difficult situations to be managed by the practitioner, but the most challenging and gratifying are those related to the diagnosis and treatment of pain, especially if with a non-odontogenic basis.¹

In the orofacial region, aesthetic, biological, emotional and relational importance and psychological sphere prominence have to be considered.²

Pre-existing pre-treatment, especially long-lasting, inflammatory pain seems to have paramount importance and might represent a key factor to evolve into orofacial neuropathic pain in the same area.³ Therefore, it is advisable to avoid an increase in complexity and a shift to chronic pain, conditions which may dispose to psychological distress² and may magnify the degree of pain and its characteristics.

The patient may become deprived of confidence and hope due to diagnostic procrastination, irreversible dental treatments and lack of knowledge and may experience frustration up to clinical depression.^4,5

Prevention, early diagnosis, and treatment of inflammatory pain may thus have utility in avoiding the development of neuropathic pain³ and consequent anxiety.^2,6

Depression is a mood disorder characterized by persistent sadness associated with other symptoms. The four most common types of depression are major depression (a bad temper associated with reduction in psychological vitality, or even inability to experience pleasure, and a decrease of other physiological functions, such as sleep), persistent depressive disorder (a form of depression which has lasted for at least two years without reaching the magnitude of major depression), bipolar disorder (a form characterized by episodes of depression, alternating with intervals of unusually high energy or vitality) and seasonal affective disorder (a mental condition which characteristically arises in autumn and winter as a consequence of alterations in the body’s natural daily rhythms, in the eyes’ sensitivity to light, or in changes in serotonin and melatonin chemical messages).

Two other depression types, unique to women, are those influenced by reproductive hormones: perinatal depression and premenstrual dysphoric disorder.⁷

Anxiety is a mental state that arises spontaneously rather than through conscious effort and is characterized and often accompanied by stress, worried thoughts and physical changes.⁸

Based on available psychometric evidence, the Beck depression inventory – version two (BDI-II) can be viewed as a cost-effective, reliable tool to measure depression intensity of a patient, with broad applicability for research and clinical practice. It can easily discriminate between depressed and non-depressed subjects.⁹

It is also of paramount importance to understand the intensity of patient anxiety since this allows appropriate management. However, anxiety level is not easily measured. There are different methods accessible to dentists to measure patient dental anxiety; for example, the modified dental anxiety scale (MDAS).¹⁰

There are also many strategies available to the dental team to safely provide comprehensive care to quell patient anxiety and depression.

When patients afflicted with orofacial pain and associated comorbid psychiatric disorders cannot be treated by conventional therapies, reassuring them by providing an explanation and comforting professional empathy, counselling and psychological therapy should be considered, and well-tolerated and effective antidepressants and antianxiety drugs should be prescribed.

In many cases of orofacial pain, due to the absence of radiographic signs and clinical symptoms of endodontic or restorative dentistry related pathologies, or other identifiable causes,^11,12 the dental practitioner should be very well trained and also aware of the difficult differential diagnostic process (a mental activity and computing, following logical methods, which utilizes the combination of knowledge and reasoning about current symptoms, medical history, results from physical and possibly laboratory or other examinations and discriminates amongst different diseases which partially share signs or symptoms, specific signs or symptoms of the pathology intended to be diagnosed).

The differential diagnostic process and treatment are extremely important while dealing with these pathologies, to avoid diagnostic delays, useless and superfluous dental treatments⁴ and risks of legal claims.

Amongst other orofacial pain, atypical odontalgia (AO), also termed persistent dentoalveolar pain disorder,⁴ and trigeminal neuralgia (TN) are the main diagnosed neuropathic pains.²

AO can affect up to 6% of patients after they have undergone endodontic therapies^4,13 and usually leads to tooth extraction without recovery of the pain.¹¹

There is heterogeneity in the classification proposed in the literature but, in accordance with the third edition of the international classification of headache disorders (ICHD-3), this condition is now classified as a subtype of persistent idiopathic facial pain or, due to occasional presence of traumatic trigger, may also be considered a subdivision of post-traumatic painful trigeminal neuropathy.¹⁴

Patients affected by AO describe the pain as localized to the tooth, or to the tooth surrounding bone, generally continuous, with periods of relief, aching, dull, throbbing, sometimes sharp, with a mild to moderate intensity. Paraesthesia or dysesthesia may be detected during examination.¹ Sometimes touching of the area may represent an aggravating factor.

The pathophysiological mechanisms to justify the onset and persistence of the condition are not fully elucidated,⁴ but the most endorsed hypothesis is that of a neuropathic origin, assuming that injuries to teeth and/or periodontal tissues may modify health status, leading to alteration in the periodontal nerve plexus and resulting in peripheral sensitization.¹⁵

In the pathophysiological mechanisms of AO, comorbid psychiatric disorders should also be taken into account. In a recent study,¹⁶ 46.2% of patients with AO showed comorbid psychiatric disorders. Of those patients, 15.4% showed depressive disorders and 10.1% showed anxiety disorders. Serious mental disorders like bipolar disorder and schizophrenia were present only in 3.0% and 1.8% of the cases, respectively. Thus, pain might have a significant emotional basis, besides the previously discussed sensory one.¹⁶

TN is reportedly the most frequent condition (82.1%) amongst patients with neuropathic pain.²

TN is characterized by paroxysmal, sharp, severe unilateral pain in the distribution of the trigeminal nerve, although patients may experience a variety of symptoms that simulate pain of odontogenic origin.¹

Trigger areas around the nose and the mouth characterize the condition, provoking the sudden onset of the pain which can lasts seconds to minutes, giving relief to patients with pain free intervals.¹⁷

From a pathophysiological standpoint, as the most supported theory, it is assumed that tumour or vascular compression may lead to partial and focal nerve demyelination and consequent abnormal transmission and processing of impulses along the trigeminal nerve.^1,18,19

Chronic irritation or trauma have also been thought to be involved in the origin of TN¹.

In the development of TN, magnetic resonance imaging (MRI) supported the most recent evidence of superior cerebellar artery aneurysms²⁰ and venous compression,²¹ but also revealed benign or malignant lesions and plaques of multiple sclerosis.²⁰

Pain characteristics of TN often have unfavourable effects on the daily life of patients. Patients are affected by disruptive pain with a consequent poor quality of life and significantly reduced working performance.²² For these reasons, it is also important to evaluate the psychological aspects of patients affected by TN.

In this article, due to the above mentioned comorbid psychiatric disorders, one case of AO and one case of TN are presented and discussed taking into consideration patient-centered, tailored and adapted therapies, compared to conventional treatment: strategies for psychological suffering managing were introduced, combining psychological counselling and cognitive behavioural therapies with antidepressants and antianxiety drugs while managing patients affected with these diseases, after conventional therapy had exhibited limited efficacy.

There are several available data on single form of orofacial pain but there is still a lack of knowledge and a lack of up to date available data summarizing, or fully describing, different pain arising from the regions of the face and mouth, which would enable dental practitioners to become familiar with the signs and symptoms of orofacial pain, especially if related to non-odontogenic pain.^4,23

On the bases of these reasons the two case reports acted as stimuli to accomplish also an overview of the pathologies concerning the difficult and challenging differential diagnosis in orofacial pain, which might be a helpful tool for the dental practitioner to broaden the clinical view and bear in mind more information during practice: in fact, a prompt diagnosis prevents pain chronicity, avoiding an increase in complexity and a shift to orofacial neuropathic pain and legal claims.

Case presentation

Discussion

Orofacial pain always represents a demanding and stimulating situation for the practitioner. Treatment can be troublesome.² Long lasting pre-existing pre-treatment pain can represent a risk factor for the pain to become chronic.³

Persistent pain tends to magnify the degree of pain and pain characteristics² and can cause stress in both the patient and the clinician.

Eventually, lack of knowledge, diagnostic procrastination and possible useless irreversible dental treatment can lead to frustration⁴ up to real psychological distress, becoming a more complex condition to be managed.

Dealing with a wide range of patients, from the relaxed and collaborative to the anxious and depressed, the dental team should have a patient-centered approach and optimize and tailor the treatment, considering patients’ psychological profiles, pathology and pain characteristics. Therefore, a comprehensive anamnesis, including psychological assessment, and history listening is necessary and has been advocated.^3,29 Drug history also has to be included²⁹. According to patient’s characteristics and needs, a combination of reassurance, psychological counselling and psychopharmacologic treatment should be considered in cases of psychological distress. The proposed psychological, behavioural and psychopharmacologic approach has demonstrated advantages to control pain magnitude and peculiarities in AO and TN case reports, drastically reducing pain duration over time, ameliorating the clinical scenario and improving the patient’s psychological profile with patient satisfaction.

The limitation in our approach to these cases is that the evaluation and treatment of the comorbid psychiatric disorders were made by scheduled psychiatric consultation, clinical observation and patient self-report, but were not based on a standardized evaluation scale or a questionnaire, since these are not habitually available in a dental office.

In TN clinical case, the diagnosis and treatment was challenging and demanding: the pain was neuropathic in origin and therefore uncommonly managed in a dental clinic. Despite correct diagnosis and initial treatment, the severity and distinctive features of the pain did not significantly ameliorate after carbamazepine had been prescribed, which is considered an effective drug. Associated comorbid psychiatric disorders made a shift to a more complex condition to be managed.

Some patients find relief in the treatment provided, others experience a chronic, severe pain, affecting the psychological sphere²⁸. In this case report of TN, a multi-disciplinary approach to treatment radically improved the symptoms of the condition and enhanced the psychological state of the patient. After we had prescribed a psychiatric consultation and after we had also explained to the patient the planned treatment, we adopted a more patient-centered approach and we used all the appropriate behavioural techniques, psychiatric counselling and antidepressant and antianxiety drugs for the patient to remain emotionally balanced in his daily life and confident with the professional team.

For these reasons, dentists who frequently deal with orofacial pain should be well trained in recognising and interpreting the signs and symptoms of a specific pathology for an early diagnosis to avoid unnecessary psychological suffering and possible unwanted legal claims.

The diagnostic process might be particularly difficult, especially in cases of neuropathic pain with a non-odontogenic basis.^1,2

Moreover, the medical diagnosis can vary tremendously if a patient with pain below the imaginary line drawn between the eyes is assessed by a dentist or another medical specialist: in fact, orofacial pain in a dental environment is probably attributed to dental pathology, in contrast to orofacial pain patients in another medical environment likely being referred to a neurologist or to a maxillo-facial surgeon.²⁹

In regard to the diagnostic process, a comprehensive record of pain history and extraoral and intraoral examination of the head and neck region is mandatory. Laboratory investigations and imaging can sometimes be helpful.²⁹

Eventually, for an overview of the pathologies related to the challenging differential diagnosis in orofacial pain, several factors have to be taken into account.

As a general summary, comorbid psychiatric disorders are more frequent clinical findings in patients whose pathologies have shifted from an acute form to a chronic condition¹⁶ and all types of diagnosed orofacial pain are more prevalent in females than males,² with myofascial pain remarkably more frequent. The peak age of prevalence is 50-67. Manual palpation of the muscles thought to be the origin of the pain must be carried out and must be bilateral. The pain is generally acute and can be unilateral or bilateral. Careful investigation of potential myofascial trigger points seems to be of paramount importance in migraine-associated neck and shoulder muscle pain.³⁰ Mental health comorbidity has been recently investigated.³¹

Myofascial pain usually positively responds to benzodiazepines and muscle relaxants² and this may help in the diagnostic process.

Temporomandibular disorders are also predominant in females³² and are very frequent, affecting 5% to 12% of the population. The peak age of prevalence is 20-40.²⁹ Pain is related to the muscles used for mastication and of the neck. Being the only double joint of the human body, the pain is usually bilateral and all clinical investigations must be performed bilaterally. For the diagnostic process it is of primary importance that pain onset, during bilateral palpation, matches pain characteristics previously experienced by the patient. Clicking, locking, crepitus and limited opening (<40 mm) may be present and can lead to correct diagnosis.²⁹ Imaging of both joints can be helpful. Generally, with an acute onset, comorbid psychiatric disorders can increase the risk of chronicity. Hard full arch splints are advantageous. Non-steroidal anti-inflammatory drugs, benzodiazepines²⁹ and muscles relaxants have been considered controversial as medications to treat these patients, although in a more recent study the above-mentioned medications and opioids, corticosteroids, anticonvulsants, anxiolytics and antidepressants were considered efficacious in alleviating pain.³³

Temporal tendinosis is an underestimated musculoskeletal pathology inadequately studied, reported and comprehended.³⁴ It is a chronic condition and causes orofacial pain.

Emphasis has been placed on the diagnostic and differential diagnostic process, as well as on proper treatment and clinical care. Nevertheless, there is still a lack of agreement on the most effective therapeutic management. Clinically, it can appear as unilateral facial pain accompanied, or not, by temporal headache; the second, most frequent clinical presentation is orofacial pain radiating from the distal temporalis tendon to the temporalis muscle.

Despite symptom similarity with temporomandibular disorders and giant cell arteritis, temporal tendinosis should be identified by means of anamnesis, proper related history, physical examination and dedicated imaging, such as ultrasound or MRI.³⁴

Dental causes evoke acute pain and they are in all probability unilateral. Dental caries and periodontal diseases affect approximately 20-50% of the world’s population, with childhood prevalence but no gender prevalence for caries, and with no gender prevalence for periodontal diseases, which can affect patients from childhood to adulthood. Both pathologies represent the main reason for tooth loss.³⁵

In most cases, the involved tooth is identifiable by the patient. Other times, e.g. in cases of pulpal involvement, the pain is more radiating and difficult to pinpoint to a specific tooth. Nevertheless, these conditions and the others related to dental problems are generally easily diagnosed and managed by dentists.

A simple initial screening by periapical X-ray is very effective in the diagnostic process in the case of a decayed tooth, or to evaluate the alveolar bone and to recognize a periodontal disease. A comprehensive periodontal evaluation by gingival sulcular probing depth should always be undertaken.

For therapeutic or prophylactic reasons antibiotics are still largely prescribed to these patients, despite the known increasingly critical situation of antimicrobial resistance.³⁵

Non-steroidal anti-inflammatory drugs are also widely used for pain relief.

An accurate intraoral inspection to detect lesions related to diseases of the oral mucosa is also mandatory.³⁶ A histological examination of the oral mucosae can be supportive to more specifically identify a suspected pathology. After the diagnostic process is completed, the patient undergoes appropriate therapy²⁹ or is referred to the oral pathologist.

Maxillary sinusitis can be acute or chronic. Generally unilateral, it can also be bilateral. There is not age nor gender prevalence. There is an odontogenic and a non-odontogenic form.³⁷ The acute form is usually accompanied by pain and slight to moderate swelling of the cheek. Extraoral palpation of the skin, or intraoral palpation of the mucosa of the maxillary sinus area may provoke slight pain. Acute sinusitis is usually due to bacteria³⁷ and viruses. If a bacterial infection is suspected, it is advisable to prescribe antibiotics, decongestants, and nasal saline solution rinses. In cases of acute sinusitis related to pathologies affecting the premolars or molars, proper dental care therapy solves signs and symptoms. Acute sinusitis can also follow dental extractions. In these cases, possible oral antral fistula must be identified and all surgical efforts need to be done to close the fistula.²⁹

Chronic sinusitis can be unexpectedly detected by 3D X-ray imaging, for example when a better anatomical study of the surgical area is needed to detect possible septa, as in implantology, when an associated sinus lift procedure is planned.³⁸ Chronic sinusitis is not usually associated with pain. Transnasal endoscopy done by an otolaryngologist is likely to be a useful and quick method for the diagnostic process.

In implantology, in case of a surgical complication during a sinus lift procedure due to dental implant displacement into the maxillary sinus, psychological distress can possibly be displayed by patients. This emotional condition is primarily due to the increasing length of the treatment planning for the diagnostic process to detect the foreign body position and for transnasal endoscopy removal. Proper treatment of distress needs to be accomplished.

In salivary gland disorders, a reduced volume of secretion or a change in the chemical composition of the saliva may be caused by salivary gland disfunction and can affect 5% to 46% of the population.³⁹ This is usually a chronic condition, difficult to treat, known as xerostomia and may negatively affect patients’ quality of life, thus causing psychological suffering. Acute pain in the region of the salivary glands can be elicited by salivary stones, characteristically at the sight of food or immediately before eating. In the case of tumours or duct obstruction of a salivary gland, pain in the trigeminal nerve can follow. Bimanual palpation can allow the clinician to recognize the stone. More frequently, it is a unilateral condition and can be non-invasively diagnosed by ultrasounds and possibly with associated sialendoscopy⁴⁰ or imaging.

Many new cases of AO following relatively common dental procedures have been reported in industrialized countries. It is an increasingly recognized condition affecting up to 6% of patients after they have undergone endodontic therapies¹³ that has as an endpoint therapy the extraction of the involved tooth, without recovery of the pain.¹¹

It can be diagnosed in both sexes in adulthood, although women around mid-40s are singularly more affected by the condition.⁴¹ It is a chronic condition, sleep can be undisturbed and pain can remit, with pain-free intervals, during the day.¹ It is a neuropathic pain,²⁹ characterized by continuous toothache following root canal therapy, apicoectomy, tooth extraction, implantology and even local analgesia administration.^11,42–44 AO can also follow facial trauma and inferior alveolar nerve block.⁴⁵ Poor analgesia at the time of the dental procedure has been regarded as an etiologic factor.²⁹

Prior long history of pain seems to have paramount importance since may represent a risk factor, and thus may increase the possibility of progression and origination of orofacial neuropathic pain in the same area.³

Characteristically, patients with AO describe the pain as continuous, non-paroxysmal, throbbing, sometimes burning or stabbing,^11,15 which may make the differential diagnosis with trigeminal neuralgia difficult. The pain is referred to teeth or to the alveolar process, in the absence of any identifiable dental cause on clinical or radiographic examination.¹¹

Maxillary molars and premolars are more frequently affected.⁴¹

Pain can spread and be diffused unilaterally or bilaterally⁴² and thus difficult to localize for the patient.⁴⁵ As already mentioned above, chronicity is at the base of demoralization, but it is unclear if this is the cause or the effect of the condition.⁴²

AO now seems to have various psychiatric comorbidities, having a great impact on treatments.¹⁶

Amitriptylina has been reported to be helpful in treating AO,^1,11,16 but an association with cognitive-behavioural therapy is highly recommended,² especially for those patients experiencing impaired social and occupational function and relationships with others.

TN is the most frequent cause of orofacial neuralgia, affecting four to five people per 100,000 population with the highest prevalence in women, with a reported proportion in women and men of three to one, aged between 37 and 67. Pain follows the distribution of one or more branches of the trigeminal nerve with a predilection for the maxillary and mandibular branches.¹

It is a chronic condition. The pain is described as sudden, usually unilateral, brief, severe and stabbing. It can also be presented as a shooting, burning or paraesthesia sensation.¹²

These paroxysmal attacks can last seconds to minutes. Other variants report pain for hours. Patients may experience as many as 10 to 30 attacks daily, although attacks may remit for weeks or months.²⁹ Pain rarely occurs during sleep.¹²

Trigger points are characteristics of TN and attacks are provoked by light touch, washing, cold wind, eating, brushing teeth, talking, chewing.¹²

From a pathophysiological stand point, tumour or vascular compression, leading to partial and focal nerve demyelination and consequent abnormal transmission and processing of impulses along the trigeminal nerve, or chronic irritation or trauma, have been thought to be involved in the origin of TN.^1,18,19 More specifically, superior cerebellar artery aneurysms²⁰ and venous compression²¹ have been taken into account in the development of TN. Moreover, TN affects 1% of patients with multiple sclerosis and 2% to 8% of patients with TN are affected by multiple sclerosis.¹⁸

MRI can be used to reveal juxtaposition of vessels to the trigeminal nerve,¹² benign or malignant lesions and plaques of multiple sclerosis.²⁰

As a result of the fact that carbamazepine is very often able to alleviate the pain, the logical conclusion in the diagnostic process of these clinical cases might be that the pathology faced and tackled by the practitioner might match the criteria of TN.

Although carbamazepine remains the most commonly used drug and is sometimes used as a diagnostic tool, many others have therapeutic coherence.¹⁸

In cases of unbearable drug side-effects or uncontrolled pain, surgical management should be considered,¹ even if possibly followed by complications. TN has a profound impact on quality of life of affected patients.¹

The act of concentrating during working hours can become very difficult and social relationships can be impaired too.

For these reasons a multidisciplinary approach can be helpful for the management of the neuropsychologic aspect of chronic pain, such as in TN⁴⁶.

A branch of the trigeminal nerve can also be involved in a neuro cutaneous viral infection, known as herpes zoster, which can sometimes lead to trigeminal post-herpetic neuralgia. It is a fairly frequent event in the elderly and immunocompromised patients, and is less frequently observed amongst children.⁴⁷

The distribution of vesicles along nerves represents a diagnostic aid. Differential diagnosis can involve herpes simplex virus infection, recurrent aphthae, lichen planus, pemphigoid, pemphigus and immune defect consequent to drugs.⁴⁷

Although glossopharyngeal neuralgia may mimic TN due to paroxysmal pain attacks of two seconds to minutes, recurrent throughout the day, characteristically remitting for weeks or months, a difference in pain location is advantageous for the differential diagnosis: in fact, the pain is usually unilateral deep in the ear and/or back of the tongue, tonsils or neck.⁴⁸

It may be confused at the beginning with a temporomandibular disorder because pain is referred in the auditory meatus,²⁹ but a description of the pain as sharp, shooting electric shock, moderate to very severe, and the presence of evoking factors such as swallowing, coughing and touch of an ear, are likely to lead to the diagnosis of glossopharyngeal neuralgia.

Syncope is a rare complication due to anatomical propinquity with the vagus.²⁹

MRI may be indicated to identify areas of vascular compression and surgery may be used to treat the condition.⁴⁹

Percutaneous radiofrequency thermocoagulation is another option to treat glossopharyngeal neuralgia.⁵⁰

The trigeminal autonomic cephalalgias are a group of unilateral episodic pains²⁹ characterized by prominent headache and ipsilateral cranial signs controlled by the autonomic nervous system, like conjunctival injection, lacrimation, tearing and rhinorrhoea. Some trigeminal autonomic cephalalgias share their short-lasting painful characteristics with TN and thus they must be distinguished and eventually treated differently.⁵¹

Affecting the oral cavity, burning mouth syndrome is a ubiquitous oral rare chronic condition with a burning sensation of the oral mucosa and tongue, without relation to clinical causes; a unique and elucidating symptom for a prompt diagnosis.⁵² The syndrome usually affects peri- and post-menopausal women²⁹ often wearing removable prosthesis.

This condition is often chronic and, due to unexplained oral symptoms, the patient usually experiences psychological distress and frustration, as it happens in neuropathic pain patients. Reassurance of no worsening of the symptoms can act as a helpful factor.

Giant cell arteritis is the most frequent primary vasculitis of the elderly.

Patients complain about pain in the temporal region and this fact can be confusing, leading to a misdiagnosed temporomandibular disorder or vice versa.

If not rapidly treated, giant cell arteritis can result in blindness and sometimes in stroke with associated extreme pain of part or of the whole face.

Temporal artery biopsy as a diagnostic test is recommended, as well as other laboratory examinations. Steroids are the most credited therapy for patient management, but other efficacious therapies are now available.²⁹

Persistent idiopathic facial pain (PFIP), previously termed atypical facial pain, is a chronic condition and a rare disorder with an incidence rate of 4.4 per 100.000 persons per year.⁵³ Females are more affected by the condition compared to males and the mean age of onset is in the mid 40s⁵⁴.

The International Classification of Headache Disorders, 3rd edition, published by the Headache Classification Committee of the International Headache Society (IHS)¹⁴ presents PIFP as a continuous daily pain, lasting for more than two hours per day over a period of more than three months, but in the absence of clinical neurological deficit. Rarely, some patients report hours or days without pain. The pain is described as dull, aching, burning, throbbing and often stabbing and sharp. The pain is difficult to localize; most of the time it is radiating and unilateral, but sometimes bilateral.⁵⁴

Comorbid psychiatric disorders and psychosocial impairments have frequently been associated with PIFP, jeopardizing personal relationships of the patient.²⁹

PIFP patients affected by higher pain intensity frequently experience anxiety and depression.

Due to the complexity of the pathophysiology of the condition and comorbid psychiatric disorders, it has been concluded that an interdisciplinary approach is mandatory for the diagnostic process and management.⁵⁵ Treatment may include tricyclic antidepressants; more recent antidepressants such as duloxetine⁵⁶ and venlafaxine;⁵⁷ anticonvulsants;⁵⁸ low-level laser treatment;⁵⁹ and high-frequency repetitive transcranial magnetic stimulation.⁶⁰ From a psychological standpoint, it is important for the patient that the pain is acknowledged by the clinician as real.²⁹

Since comorbid psychiatric disorders may be frequently associated with orofacial pain, due to the effect of emotional states on pain perception and modulation, psychiatric and/or psychological counselling and proper drug management, together with an empathic attitude, might be determinant in patient compliance and an improvement in the clinical condition.

Moreover, the diagnosis and treatment of orofacial pain, especially if with a non-odontogenic basis, is difficult and challenging for the dental practitioner and, thus, they must be familiar with the signs and symptoms related to these conditions.

Dentists need to be well trained in this specific field to avoid diagnostic delays and multiple, irreversible and ineffective dental treatments.

It is imperative that dentists have a patient comprehensive, health-centered approach during the differential diagnostic process, refraining from focusing on ordinary, common sources of tooth pain, thus aggravating the clinical condition of the patient and exposing themselves to the risk of legal claims.

Data availability

All data underlying the results are available as part of the article and no additional source data are required.

Consent

Written informed consent for publication of their clinical details was obtained from the patients.