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Karachi government hospitals: Hub for trauma-related orofacial pain

By Dr Saqba Alam

Orofacial pains are unique in their presentation. This is attributed to the complex head and neck anatomy and the trigeminal V nociceptive pathway. This anatomic and physiologic construct has crucial implication with regards to pain patterns in the head and neck region, making the diagnosis of Orofacial pain difficult.

Head and neck trauma noted to be the most prevalent and most common cause of Orofacial Pain reported at Abbasi Shaheed Hospital, Karachi, Pakistan.

Karachi is the largest city of Pakistan with a population of around 16,094000 according to the 2020 consensus. The Abbasi Shaheed Hospital is one of the only three big government-funded hospitals in the city, including the Civil Hospital, Jinnah Hospital. It serves residents of the northern part of the city (Nazimabad, North Nazimabad, North Karachi, Federal B area, Orangi Town etc.). People from all over Pakistan visit this hospital for the treatment of their various ailments without any charge. Our study carried out at The Abbasi Shaheed Hospital that is the third-largest hospital of the city after Civil and Jinnah and is the main government hospital for the Central and West districts of Karachi.

Orofacial pain is defined as pain restricted to the region above the neck, in front of the ears and below the orbitomeatal line, also within the oral cavity. 

Orofacial pain includes odontalgia, neuralgia, psychogenic, traumatic, vascular, myofascial joint-related or other idiopathic variants. Chronic Orofacial pain may be correlated with psychological stress, social impairment, reduced quality of life, economic crisis and high cost for healthcare service. With regards to gender, studies have shown a higher number of females seeking

Orofacial pain treatment in contrast to males with a steady increase in the last several decades. Some of the most widespread and disabling pain conditions arise from the structures innervated by the trigeminal system (head, face, masticatory musculature, temporomandibular joint and associated structures). According to Okeson Classification of Orofacial Pain, pain can be branched into physical (Axis 1) and psychological (Axis 2) conditions. Physical conditions include disorders of the Temporomandibular Joint (TMJ) and diseases of the Musculoskeletal structures (masticatory muscles and cervical spine); Neuropathic pains, episodic (trigeminal neuralgia [TN]) and continuous (peripheral/centralized mediated) pains and Neurovascular disorders (migraine). Psychological conditions include mood and anxiety disorders1,2-3. Myofascial pain syndromes, temporomandibular disorders (TMD), neuralgias, ENT diseases, dental pain, tumours, neurovascular pain or psychiatric conditions frequently present with overlapping signs and symptoms with diverse characteristics making the diagnosis challenging. Identifying the actual cause of pain thus goes a long way in the clinical diagnosis and treatment planning.

Challenging to diagnose and manage, Orofacial pain can follow a myriad of factors worldwide. It is the most common complaint in the general population worldwide, causing chewing dysfunction, dental pain, intraoral pain, facial pain, jaw pain, earaches, headache, oral ulceration pain, salivary gland dysfunctions, oral candidiasis, temporomandibular joint disorders, oral pathologies of cysts and tumours, oral cancer and lesions, burning mouth. Syndromes, neurosensory disturbances are the complains commonly presented in dental and medical practices. The latest risk assessment diagram of orofacial pain (RADOP) describes essential insights about the underlying mechanisms procedure.

A persons’ self-reporting system such as The Visual Analogue Scale describes the actual intensity of pain is the most valuable means of reaching to the diagnosis of pain and its correct management and choosing specific analgesics and setting right doses of medications. 

The scale used in the study shows markings from 0 to 10 on which the patient’s pain intensity is represented by a point between the extremes of “no pain at all”, “Moderate pain” and “worst pain imaginable.” The scale used for the study also shows expressive faces describing emotions and pain perceived by the individual in picture format. Its simplicity, reliability, and validity, as well as its ratio scale properties, make the VAS the optimal tool for describing pain severity or intensity. 

We used the Visual Analogue Pain Scoring System; to avoid any operator related bias or misinterpretation on the clinicians’ side.

DIAGNOSIS

The diagnosis can only be reached after complete history taking, psychosocial evaluation and physical examination. The physical examination includes intraoral examination of dental hard and soft tissues, buccal and vestibular mucosa, lips, tongue, gingivae, salivary glands, tonsils and faucial pillars. The extraoral analysis comprises of detailed muscle examinations, temporomandibular joint examination, cranial nerve examination, neurologic and vascular examination. Immediate attention must always be given to problems associated with extreme pain and anxiety, which may trigger stress-related cardiovascular sequel. Remarkably few patients scored a 9 or 10 on the Visual Analogue Score. Once the airway, breathing and circulation have been adequately assessed, a quick neurologic function evaluation should be performed. Elective trauma cases which present in the outpatient department usually don’t need emergency protocols and advanced trauma life support. Patients who sustain fractures involving the mandible will often report paresthesia, or an “uncomfortable pain” or pain of a “different kind” The patient’s past medical and surgical history, medication use and known drug allergies should also be reviewed. Temporomandibular joint dysfunction and any previous non-surgical or surgical treatment should be carefully documented. When a mandibular fracture is suspected, meticulous clinical examination of the maxillofacial region is critical and should be carried out before the ordering of radiographic imaging studies.

Diagnostic studies used to help in confirmation of the diagnosis in this study were blood tests, diagnostic anaesthetic injections, biopsies of suspicious lesions, ultrasonography, plain radiographs from peri-apical dental views, Orthopentamogram, PA face to specialized CT,

Contrast sialograms and three-dimensional reconstruction CT imaging.

A randomized clinical trial study was carried out for six months. Informed consent was obtained from all study subjects. Following the selection criteria, some 289 patients complaining of Orofacial Pain have selected a sealed envelope method of randomization. All patients were treated by the same surgeon, the same set of questions were asked for pain in history taking and based on clinical examination specific radiographic investigation were carried out if at all necessary to confirm the diagnosis. 

All patients were asked to Self Score their severity of pain experienced by using the same VAS (Visual Analogue Pain) Chart with scores listed from 1 to 10, with number 1 being the mildest kind of pain experienced and number 10 the most severe and bitter pain one can experience. 

We concluded that trauma associated orofacial pain is the most frequent pattern recorded at Dental and Maxillofacial outpatient department of Abbasi Shaheed, a tertiary care hospital located in District North, Karachi. The hospital serves the residents of the northern part of the city (Nazimabad, North Nazimabad, North Karachi, F. B. Area, Orangi Town, etc.) with an estimated population of nearly 1 million. The tool used to measure the severity is the VAS pain scale with scores of 1 to 10 assessing the seriousness of pain in a step ladder ascending manner.

Using the Visual Pain Analogue Score is a better and more natural method of determining pain severity by patients’ oneself instead of predicting and judging severity by a clinician and prescribe medications based on wrong measurement analysis. The study generated evidence that significant bulk of trauma patients with injuries associated with head and neck region ranging from minor injuries like a bruise, hematoma, abrasions, lacerations and small bleeds in the head and neck region to major trauma causing bony fractures, life-threatening vascular bleeding and degloving injuries complaining of mild to severe orofacial pain are being presented more in the maxillofacial outpatient clinics both directly and after emergency treatment for followup reasons than other causes related to orofacial pain.

July 4, 2020

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