Israel Howard A, Ward John Desmond, Horrell Brenda, Scrivani Steven J
Clinical Surgery, Cornell University Weill Medical College, New York Presbyterian Hospital, New York, NY 10021, USA.
J Oral Maxillofac Surg. 2003 Jun;61(6):662-7. doi: 10.1053/joms.2003.50133.
In this investigation, we evaluated a population of patients with chronic orofacial pain who sought treatment at a pain center in an academic institution. These patients were evaluated with respect to 1) the frequency and types of previous oral and maxillofacial surgery procedures, 2) the frequency of previous significant misdiagnoses, and 3) the number of patients who subsequently required surgical treatment as recommended by an interdisciplinary orofacial pain team. The major goal of this investigation was to determine the role of oral and maxillofacial surgery in patients with chronic orofacial pain.
The study population included patients seen at the Center for Oral, Facial and Head Pain at New York Presbyterian Hospital from January 1999 through April 2001. (120 patients; female-to-male ratio, 3:1; mean age, 49 years; average pain duration, 81 months; average number of previous specialists, 6). The patient population was evaluated by an interdisciplinary orofacial pain team and the following characteristics of this population were profiled: 1) the frequency and types of previous surgical procedures, 2) diagnoses, 3) the frequency of previous misdiagnoses, and 4) treatment recommendations made by the center team.
There was a history of previous oral and maxillofacial surgical procedures in 38 of 120 patients (32%). Procedures performed before our evaluation included endodontics (30%), extractions (27%), apicoectomies (12%), temporomandibular joint (TMJ) surgery (6%), neurolysis (5%), orthognathic surgery (3%), and debridement of bone cavities (2%). Surgical intervention clearly exacerbated pain in 21 of 38 patients (55%) who had undergone surgery. Diagnoses included myofascial pain (50%), atypical facial neuralgia (40%), depression (30%), TMJ synovitis (14%), TMJ osteoarthritis (12%), trigeminal neuralgia (10%), and TMJ fibrosis (2%). Treatment recommendations included medications (91%), physical therapy (36%), psychiatric management (30%), trigger injections (15%), oral appliances (13%), biofeedback (13%), acupuncture (8%), surgery (4%), and Botox injections (1%) (Allergan Inc, Irvine, CA). Gross misdiagnosis leading to serious sequelae, with delay of necessary treatment, occurred in 6 of 120 patients (5%).
Misdiagnosis and multiple failed treatments were common in these patients with chronic orofacial pain. These patients often have multiple diagnoses, requiring management by multiple disciplines. Surgery, when indicated, must be based on a specific diagnosis that is amenable to surgical therapy. However, surgical treatment was rarely indicated as a treatment for pain relief in these patients with chronic orofacial pain, and it exacerbated and perpetuated pain symptoms in some of them.
在本研究中，我们评估了在一所学术机构的疼痛中心寻求治疗的慢性口面部疼痛患者群体。对这些患者进行了以下方面的评估：1）既往口腔颌面外科手术的频率和类型；2）既往严重误诊的频率；3）随后按照跨学科口面部疼痛团队建议接受手术治疗的患者数量。本研究的主要目的是确定口腔颌面外科手术在慢性口面部疼痛患者中的作用。
研究群体包括1999年1月至2001年4月在纽约长老会医院口腔、面部和头部疼痛中心就诊的患者（120例患者；男女比例为3:1；平均年龄49岁；平均疼痛持续时间81个月；既往平均看诊专科医生数量为6名）。由跨学科口面部疼痛团队对患者群体进行评估，并分析该群体的以下特征：1）既往手术的频率和类型；2）诊断情况；3）既往误诊的频率；4）中心团队给出的治疗建议。
120例患者中有38例（32%）有口腔颌面外科手术史。在我们评估之前进行的手术包括牙髓治疗（30%）、拔牙（27%）、根尖切除术（12%）、颞下颌关节（TMJ）手术（6%）、神经松解术（5%）、正颌手术（3%）以及骨腔清创术（2%）。在38例接受过手术的患者中，有21例（55%）手术干预明显加重了疼痛。诊断包括肌筋膜疼痛（50%）、非典型面部神经痛（40%）、抑郁症（30%）、TMJ滑膜炎（14%）、TMJ骨关节炎（12%）、三叉神经痛（10%）以及TMJ纤维化（2%）。治疗建议包括药物治疗（91%）、物理治疗（36%）、精神科管理（30%）、触发点注射（15%）、口腔矫治器（13%）、生物反馈（13%）、针灸（8%）、手术（4%）以及肉毒杆菌毒素注射（1%）（Allergan公司，加利福尼亚州欧文市）。120例患者中有6例（5%）出现严重误诊并导致严重后果，延误了必要的治疗。
在这些慢性口面部疼痛患者中，误诊和多次治疗失败很常见。这些患者通常有多种诊断，需要多学科管理。手术如有必要，必须基于适合手术治疗的特定诊断。然而，在这些慢性口面部疼痛患者中，很少将手术作为缓解疼痛的治疗方法，而且手术在一些患者中加剧并使疼痛症状持续存在。
