Pain is possibly the most common reason for patients to seek dental help, and is, therefore, a phenomenon with which dentists are frequently confronted. This special issue of the Dutch Dental Journal considers several aspects of orofacial pain as they are presented by patients. Both common and less frequent disorders causing pain in the orofacial area are described and discussed.

In accordance with current views on pain, a distinction is made, on a physiological basis, among ´normal´, or nociceptive pain, inflammatory pain and neuropathic pain. ´Normal´, nociceptive pain is a reaction to possible or actual tissue damage. Inflammatory pain is a response to actual tissue damage, in which not only nociception occurs but the sensitivity of nocisensors changes through morphological transformation. This phenomenon is called sensitization and lies at the root of multiple types of chronic pain. Sensitization also plays an important role in neuropathic pain as a result of damage to the neuronal structures themselves.

Dental practitioners as well as general practitioners are frequently confronted with patients complaining of pain in the orofacial region. Diagnosing these pains often poses a challenge to the clinician. Currently, the diagnosis of orofacial pains is biaxial. In determining a diagnosis, it is important to consider, in addition to the condition which is causing the pain (axis Idiagnosis), the impact of the pain on the patient’s ability to function (axis IIdiagnosis). The compilation of a thorough medical history represents the most important diagnostic tool and basis for clinical examination. Based on the axis I-diagnosis several treatment options are suggested; the strategy for managing the pain is, however, largely determined by the axis II-diagnosis.

Orofacial pain is a source of misery, especially when it is persistent. The odds are that it will transmute into chronic atypical facial pain. As it takes a long time before the right diagnosis has been made, the patients find themselves wandering off the right track and get lost in the maze of medical and paramedical attendants. The magic spell to help these weary wanderers professionally runs: multidisciplinary approach.

A patient’s pain history is the primary source of information in case of toothache (dentoalveolar pain); revealing its location, its main characteristics and its course, both from the onset and during the day. Clinical diagnostic tests that provoke (such as pulp testing or percussion) or eliminate (such as local anaesthesia) pain are most useful. Several mechanisms may underlie dentoalveolar pain. Pain caused by pulpitis shows characteristics of visceral types of pain, whereas pain originating from the periodontal ligament is characterized by musculoskeletal features. It also happens fairly often that the pain is found to originate from a different tooth than the one in which it is perceived, or from an even more distant source (referred pain). These mechanisms emphasize the importance of differential diagnostics.

In daily social life, orofacial pain is strongly associated with teeth. However, edentulousness is no lifetime guarantee of being pain-free in the orofacial region. Common oral pains in edentulous people are caused by denture misfits or occlusal errors, by alveolar ridge atrophy, by (sharp) exostoses, and by non-denture-related mucosal lesions. Less common or hard to diagnose pains are caused by burning mouth syndrome, toxic or allergic reactions, nerve injuries, mucosal or skin grafts, and ischaemic heart disease.

Pain or fatigue in the masticatory muscles or pain in the temporomandibular joints are well-known complaints. Diagnosing these complaints, that have a relation with mandibular movements, can be challenging since they can arise from the teeth and surrounding tissues, the temporomandibular joints or other musculoskeletal structures. Also referred pains are a common finding in this area. Pain history and clinical examination are crucial for a comprehensive diagnosis. Besides the disorders underlying the pain (so called axis I), the impact of the pain on the patient’s physical and psychosocial functioning can play an important role in the diagnosis (axis II).

Paroxysmal orofacial pains can cause diagnostic problems, especially when different clinical pictures occur simultaneously. Pain due to pulpitis, for example, may show the same characteristics as pain due to trigeminal neuralgia would. Moreover, the trigger point of trigeminal neuralgia can either be located in a healthy tooth or in the temporomandibular joint. Neuralgic pain is distinguished into trigeminal neuralgia, glossopharyngeal neuralgia, Horton’s neuralgia, cluster headache and paroxysmal hemicrania. In 2 cases trigeminal neuralgia is successfully managed with a neurosurgical microvascular decompression procedure according to Jannetta. Characteristic pain attacks resembling neuralgic pain result from well understood pathophysiological mechanisms. Consequently, adequate therapy, such as a Janetta procedure and specific pharmacological therapy, is available.

The Platform Pain and Pain Control provides a meeting point for representatives of professional organizations concerned with pain control and chronic pain patients associations. This start page gives access to various sites providing information on various manifestations of pain and methods of pain control.