Key words: facial pain, myofacial pain dysfunction syndrome, temporomandibular joint dysfunction syndrome psychosomatic disorders.

Chronic idiopathic facial pain is a common problem that confers a real challenge for many medical and dental specialists. There are many symptom complexes of facial pain i.e. myofacial pain dysfunction syndrome, atypical facial pain, atypical odontolgia and oral dysaesthesia [1]. Although described as separate conditions, these symptom complexes are interrelated, and frequently occur at different stages or may coexist in the same patient. Also, the idiopathic facial pain is frequently associated with other chronic pain conditions such as back pain, headache, irritable bowel and pelvic pain; a condition that is described as whole body pain syndrome [2].

Myofacial pain dysfunction syndrome, also known as facial arthromyalgia or temporomandibular joint dysfunction syndrome, presents as a unilateral or bilateral pain in the temporomandibular joint and its associated craniofacial musculature. Other features include clicking and sticking of the joint, limitation of the mouth opening and deviation to the affected side. There might be also a sense of fullness, and popping noises in the ears. Tenderness in the myofacial apparatus is quiet a common finding in the myofacial pain dysfunction syndrome patient, tenderness is most commonly present in the temporalis and masseter muscles. Tenderness can be also found beneath the condylar head adjacent to the lobe of the ear, which is described sometimes as earache. Also tenderness may present over the mastoid process [3].

No organic disease of the temporomandibular joints could be demonstrated. Also there is no evidence that the disease is progressive and goes on to produce permanent damage in the joint itself [4].

Myofacial pain dysfunction syndrome patients include individuals with obsessional perfectionist traits and tendency for self-denial and repression to their personal problems, the thing that accounts for their somatic manifestations [5, 6].

Myofacial pain patients can be considered to a large extent, as psychologically vulnerable patients. In a study done by Feinmann and Harris on such a group of patients, they found 35% of the patients suffered from depressive illness, 22% mixed neurosis and 43% as psychiatrically normal [7].

A biochemical basis for chronic facial pain was suggested because of its association with depression and the response to trycyclic antidepressants. Chronic pain patients have shown hypercortisolaemia and abnormal dexamethasone suppression test responses [8]. Also impaired excretion of tyramine sulphate has been recognised as a trait marker for chronic facial pain [9].

The psychological basis for myofacial pain had been considered because of its considerable response to tricyclic antidepressants in terms of the substantial relief of pain. The precise mode of action is not well known, but it could be due to the central analgesia produced because of increasing concentration of analgesic monoamines in the midbrain [10].

Patients with myofacial pain dysfunction syndrome tested by means of standard psychological scoring methods were found to have significantly higher scores for neuroticism, anxiety and related factors affecting muscle tension, and significantly lower pain threshold than controls [11]. Psychogenic pain may arise as a result of stress, or as a feature of an emotional disturbance such as anxiety or depression. Also it might be a manifestation of psychosis, and there have been several reports of higher levels of stressful life events in idiopathic facial pain patients [12].

The concept of pain vulnerability was underlined by the clinical observation of different pains occurring at different stages of life. In childhood such patients suffer from abdominal pain or earache. In adolescence temporomandibular joint pain or dysmenorrhoea, and later abdominal pain (irritable bowel syndrome), neck and back pain and pruritis [13, 14]. This vulnerability may be genetically transmitted, as siblings of patients suffering myofacial pain have higher incidence of chronic pain conditions [15].

The most important aid to the diagnosis of myofacial pain dysfunction syndrome is the history i.e. medical, family and social history, which must be followed by a careful clinical examination and appropriate investigations including radiographs and where appropriate a computerised or magnetic resonance image. The history taking should be in a way thatestablishes the nature of pain so as to exclude any other condition that may manifest as pain in the head and neck region. Also we have to check for any other associated symptoms such as limitation of mouth opening, clicking in the joint, blurring of vision or any associated phenomena.

This study had been conducted in based on the fact that facial pain is a psychosomatic disorder and patients are believed to be psychologically vulnerable and should benefit from assurance and psychological support rather than from treatment based on occlusal adjustment.

The first twenty patients presented to the outpatient oral surgery clinics referred by either general medical or dental practitioners with complaints suggestive of myofacial pain dysfunction syndrome, have been enrolled in this study. The study was conducted in a double blind fashion, as patients were enrolled into the trial regardless of their age, gender, medical condition, or their socio-economic status and no kind of any selective criteria have been suggested.

All of them presented with pain in the pre-auricular area that radiates to the temporal area and sometimes to the whole side of the face. Some of the patients, 22%, had symptoms of limited mouth opening, while the rest were able to exhibit normal mouth opening. Crepitation, or noises in the joint, were found only in 8% of the patients.

A full medical and social history had been obtained from all patients, with especial emphasis on the family and social history. Also a detailed understanding of the patient's life style and nature of his occupation was an essential part in taking the patients' history. Patients were asked if they think or feel that they are under stress or feel unhappy about their jobs or life style.

My approach to all patients was that of giving them enough time (15-20 min) to explain to them the real nature of the disease, giving great emphasis on the fact that the whole condition lacks any organic change in the joint apart from a very little unlucky minority who might end up with some deformity in the joint. Also the importance of stress and psychological factors had been well emphasised, but it had been made very clear in simple language that it is not necessary to be labelled as a psychologically disturbed patient to encounter such a condition. Also, patients were presented with some numerical facts such as the percentage of people having psychiatric disease or suffering from stress related to their type of career or their life style. Also, the detail of psychosomatic disorders had been described to all patients in very simple words.

Patients were told that such a condition is a long term one that is expected to persist for few months up to few years, but not forever, They were also told about some remissions after which they may start encountering the same symptoms again. Patients were motivated to seek psychiatric counselling, but it was not an essential part of the protocol of this study to do so. It had been made very clear to them that we do expect better results following psychiatric counselling.

No regular medications have been prescribed to the patients, but all have been advised to take non-steroidal anti-inflammatory drugs i.e. Ibuprofen, in case they encounter unbearable pain or discomfort, provided that there is no contraindications to such drugs and not to exceed the daily recommended dosage.

All patients were reviewed on a monthly basis for the next six months following their first attendance to my outpatient clinic, and then all patients were advised to be reviewed on a three months basis.

The patients were between 21-39 years old, and male to female ratio were 1:3. None of the patients had any serious medical illness or were taking any medication on a regular basis. Most of the patients (90%) were found to be well educated, and around 75% of them are employed in jobs of an indoor nature that demand a lot of mental concentration.

As patient counselling was my primary approach, my conversation with the patients revealed that most of the patients (seventy per cent) are under stress that they relate to their jobs or their life style. Two patients admitted poor communication with their surroundings and difficulties in establishing a new relations and both had some psychological treatment at some stage of their life.

On reviewing patients, gradual improvement had been achieved in regard to the pain symptoms, and patients gradually appeared to be adapting well, and their need for analgesia became very little.

By the end of the sixth month after their first attendance, five patients (25%) described complete relief from their aches; 12 patients (60%) described a significant relief regarding their aches, as they describe only an occasional mild pain or discomfort in the pre-auricular area. Only 3 patients (15%) considered not achieving any improvement regarding their pain symptoms, they were convinced of the importance of having psychological advice and so referred to a specialist psychiatrist who has a special interest in facial pain and psychosomatic disorders. Two of them achieved a significant improvement upon using tricyclic antidepressant therapy, but the third one is still experiencing pain in the myofacial structures, and not describing any improvement upon using the medical therapy prescribed for him.

The International Association for the Study of Pain (IASP) defines pain as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage'. From this definition we can conclude that pain is an outcome of different components that lead to the perception of pain, which is believed to be a psychophysiological experience that occurs when a subject is hurt in body or mind.

Pain of emotional origin is common, especially in the orofacial region, and it is clinically and professionally not acceptable to assume that the patients complaints are something they do imagine. Also it is well known now that in most pain conditions the same peripheral structural and biochemical disturbances are responsible for the symptoms of pain whether it is of psychogenic or organic origin, and so it is difficult to distinguish between the quality and the intensity between the two [16].

As clinicians we have to recognise that a long-standing pain condition without specific aggravating or relieving factors, and without any radiological or neurological signs should be classified as pain of psychogenic origin that is lacking any organic structural origin. Myofacial pain dysfunction syndrome is a unique example representing such a group, and so such patients need to be tackled in a very sensitive way, and once diagnosis have been achieved, and the patient found not to be responding to simple analgesics, full psychological work up and professional psychological consultation should be an integral part in the management of such a patient.

Malocclusion had been indicated as an aetiological factor, but it has never been confirmed as a cause, by any controlled trial. Bruxism and other tension relieving habits are commonly found although it seems that these habits do not have a causal relationship but are merely features of the condition. Bruxism, producing muscle cramp and overloading of the joint, had been considered to be difficult to sustain without any pathophysiological evidence, especially when considering the greater percentage of asymptomatic bruxers. Lack of posterior support and minor traumatic injuries to the joint had been claimed to be contributory factors, but there is no strong evidence available to support such claims [17].

An occlusal splint, which provides simultaneous points of contact with smooth lateral guidance to be worn at night, might be elected to treat TMJ pain. Some patients gain relief, but there is no evidence that occlusal adjustment is more effective than any other placebo, but we should keep it in mind that such treatment might lead to a state of occlusal hyperawareness in some patients, the thing that might worsen the condition [2].

For successful and systematic management, a proper and comprehensive medical and family history should be taken, aiming to find out any adverse life events or any emotional disturbance. Also, any dental disease including sensitive carious teeth or pulpal inflammation should be treated, but any major restorative dental procedures such as extensive bridgework should be postponed, because that might complicate the diagnosis and subsequent treatment.

Finally, I have to state that the management of facial pain needs team work, and the best way to apply this is through the establishment of multidisciplinary facial pain clinics that should consist minimally of oral surgeon, restorative dentist, a liaison psychiatrist and a clinical psychologist. Also, training programs for medical and dental practitioners in the field of management of facial pain is very essential because many patients might be misled either at the primary or secondary care levels, and a facial pain patient might end up with unjustified removal of impacted wisdom teeth, or most seriously it may be assumed that the patient is exaggerating, whereby the patients is ignored and left in agony.It is a fallacious practice to assume that the patients' complaint is imaginary.