Interprofessional Management of Chronic Orofacial Pain: A Topic Review, Steps to Improve Collaborative Care, and a Case Example

ABSTRACT

Background

Orofacial pain is a specialty of dentistry that often encounters complex symptoms beyond the scope of dental practice, indicating a role for interprofessional teams in treating chronic orofacial pain.

Discussion

Interprofessional teams often include specialists from neurology, physical therapy, sleep medicine, and behavioral medicine, among others. Interprofessional practices can be difficult to achieve and require a commitment of communication, collaboration, co-location, and organizational support. A complex chronic orofacial pain case exemplifies the challenges for patients receiving sequential or siloed care, including delays in diagnosis, invasive procedures, and worsened disability. Common barriers to collaborative care and possible steps to close these gaps are discussed..

KEYWORDS:

• Pain
• integrated care
• interprofessional care
• orofacial pain
• chronic pain

Introduction

According to American Academy of Orofacial Pain “Orofacial Pain is the specialty of dentistry that encompasses the diagnosis, management, and treatment of pain disorders of the jaw, mouth, face, head, and neck” and “is dedicated to the evidenced-based understanding of the underlying pathophysiology, etiology, prevention, and treatment of these disorders and improving access to interdisciplinary patient care”.¹ Chronic orofacial pain (COFP)-associated disorders include, but are not limited to, temporomandibular muscle and joint disorders, jaw movement disorders, neuropathic and neurovascular pain disorders, headache, and sleep disorders.¹ These definitions, the broadened scope of orofacial pain practice, and an increased understanding of the interplay between the central nervous system and musculoskeletal systems all indicate a new standard for dental professionals to consider collaboration with a range of other healthcare professionals when managing patients with COFP. An understanding of and referral avenues for evidence-based treatment options across disciplines should be considered when managing patients with COFP.

The goals of the treatment are often directed toward decreasing pain and disability while increasing the range of motion and function.² To these ends, the dental professional should understand and move toward collaboration with the healthcare specialists and allied professionals who can deliver evidence-based treatments for COFP. As such, this review and discussion of the levels of collaborative care aims to increase awareness and urgency for dental professionals to collaborate across professions to evaluate and treat patients with COFP. Some of the common barriers to interprofessional collaboration and patient adherence are discussed along with suggestions for tackling these obstacles.

Interprofessional Care in Dentistry

Managing COFP patients can be challenging, especially in those with comorbid conditions. Although most academic programs provide extensive clinical experience in managing pain patients with interventions or pharmacotherapy, very few programs focus on providing interprofessional education.³ There is evidence that interprofessional education can help clinicians improve their knowledge, confidence, and practice toward oral health.⁴ While the foundation of interprofessional practice in dentistry is laid by interprofessional education experiences,⁵ one can pursue interprofessional education at any stage in one’s career. Indeed, as Cole et al. encourage, “interprofessional education occurs when two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.”⁶

The World Health Organization (WHO) provides an extensive framework to implement collaborative care.⁷ Some of the key mechanisms that may help dental professionals in setting up collaborative care with other medical professionals include effective communication strategies, shared decision-making processes, and shared operating resources.⁷ Interprofessional care is described by WHO as a “collaborative practice … when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers, and communities to deliver the highest quality of care across settings.”⁷

Collaborative care is enacted along a continuum, from nonexistent or silo care at one end, to integrated care at the other (Table 1).⁸ For the general dentist in a private or group practice, coordinated care with other dental specialists may already be part of one’s practice, making referrals and having e-mail or phone communication about shared patients. Co-located collaboration may exist for those practicing in a multi-specialty group practice or academic dental center where others are in the same building or department. This creates opportunities for in-person collaboration and consultation, perhaps even stepping into another clinician’s patient visit for a brief evaluation and opinion. However, co-location does not automatically imply there is any collaboration, as some clinicians may stay in their own department with their patient schedules each day, never communicating with others in the same building. Integrated care requires more organizational support, including shared team meeting time, learning opportunities, joint evaluation meetings in the patient schedule, and unified care plans for designated complex populations. Such care would also include integration at all levels of operation, including treatment, program offerings, and payments to staff.⁸ Interprofessional care is an integrated care model across professions (i.e., dentistry, medicine psychology), not only specialties or disciplines (i.e., endodontics, orofacial pain, orthodontics).

Table 1. Levels of collaborative care.

Silo Care	Coordinated Care Key Element: Communication		Co-Located Care Key Element: Proximity		Integrated Care Key Element: Practice Change
LEVEL 0	LEVEL 1	LEVEL 2	LEVEL 3	LEVEL 4	LEVEL 5	LEVEL 6
No Collaboration	Minimal Collaboration	Basic Collaboration at a Distance	Basic Collaboration on Site	Close Collaboration on Site with Some System Integration	Close Collaboration Approaching an Integrated Practice	Full Collaboration in a Transformed/Merged Integrated Practice

Adapted from Getch.⁸

For dental specialists who have not received an opportunity to learn in such ways or practice in interprofessional settings, there may be avenues to increase this collaborative engagement and practice. One can seek continuing education programs that involve a range of disciplines. If you practice in a community healthcare or hospital setting, look for team meetings in related departments, such as psychiatry, neurology, physical medicine, and ask to join the meetings or to present a complex case. If more isolated in one’s practice, then listening to patients for an excellent clinician they have found can lead to an avenue to meet the clinician. For example, if the patient offers “I love my physical therapist, she’s helped me so much with my headaches!” then ask the patient if you might contact the physical therapist to coordinate care. A call to the clinician to discuss your mutual patient can be a starting point for cross-referral and collaborative work on future complex cases.

Data suggest that delays in diagnosis, treatment, and referral of patients suffering from persistent orofacial pain often stem from obstacles in care pathways leading to a negative impact on the lives of these patients due to unmanaged pain.^9,10 Although there is some debate about expanding dentistry’s scope of practice, few disagree that increased collaboration between dentistry and other healthcare professions benefits the patient and the profession.¹⁰

Management of Orofacial Pain

To provide comprehensive care to patients suffering from chronic orofacial pain, assessment, referral, and treatment plans should consider psychological and social challenges.¹¹ Clinicians always need to be cautious about any pathology that can potentially cause COFP and evaluation by dental specialties and medical specialties, such as neurology, is essential. Unfortunately, it is not uncommon for patients with facial pain to go through an arduous journey of seeing multiple providers before finally receiving an accurate diagnosis.¹² During this time many patients undergo irreversible dental treatments due to a lack of understanding of the origin of pain. More complex COFP diagnoses should be considered if symptoms and clinical findings are not consistent with oral disease. Referral to a specialist or interprofessional team with expertise to manage chronic orofacial pain should be considered by the dentist.¹³ The medical literature indicate that interprofessional pain management has not only proven to be cost-effective but also a superior approach when managing patients with chronic pain.^14,15 Even though data supports that there is a benefit in implementing interprofessional care, there are multiple challenges that may prevent various health professionals from collaborating. Inadequate reimbursements, lack of time, and poor communication between healthcare professionals were some of the barriers identified by Rawlinson et al.¹⁶ Patients might also resist an interprofessional team approach for similar reasons such as the cost of multiple evaluations, time commitment, or more psychological reasons such as denial and hoping the symptoms are a simple problem and not requiring a complex treatment plan. To further elaborate on these points, we share a synopsis of a typical case presenting for evaluation at the Craniofacial Pain Clinic at the Tufts School of Dental Medicine. We aim to demonstrate the range of evaluation topics and how treatment planning is formulated in an interdisciplinary setting.

A Case Example

A 45-year-old Caucasian female referred by her general dentist presented for an initial evaluation with an orofacial pain specialist and pain psychologist at the Craniofacial Pain Clinic. She complains of bilateral jaw pain, limited mouth opening, ear pain, and headaches. Pain developed after she started full mouth rehabilitation one year ago after her second sinus surgery. She describes her pain as constant, dull, achy at rest, bilateral, but worse on the right side. She notes that chewing, keeping her mouth open for long dental procedures and stress aggravates the pain. Resting her jaw alleviates symptoms. She notes that the pain is debilitating and has been unable to engage in most recreational activities such as walking for more than 15 min.

She describes headaches that started 5 years ago and are located across the forehead and temples forming a band around the head. She notes that a headache is present upon waking in the morning or develops within an hour after getting out of bed. Headaches progressed in frequency duration, and intensity over the years, currently daily and lasting 8 h after waking. Pain is severe in intensity, ranging from 8 to 10 on a scale of 10. She denies associated nausea, vomiting, or other migraine features. After working with her primary care physician and various medication trials for the first few years, she was referred to otolaryngology for evaluation and was recommended to proceed with sinus surgery. She continues to take medications with little relief, but feels it is the only thing she has to try to make it better.

She reports poor sleep with a total sleep time of 5–6 h, difficulty with falling asleep, and early morning awakenings, often at 3 a.m., where she is unable to return to sleep. She reports that her husband will wake her to tell her she is snoring, but not that she is gasping for air. There is fatigue upon waking in the morning, generally lasting throughout the day.

A Patient Health Questionnaire (PHQ)-9 was completed to assess for depression, and her score of 15 indicates moderately severe depression warranting a referral for a complete psychological evaluation. She shared that she already meets with a psychotherapist for the past 6 months who “listens and empathizes about my situation” but is not a pain specialist. She reports that her recent history is significant for depression and anxiety and attributes this to her pain symptoms. She denies suicidal ideation but is tearful and expresses feeling lonely. She reports stable weight and appetite but much decreased energy. Her history revealed that in her 20’s she also experienced depression for about 1 year “out of the blue” and took medication at that time for 2 years before deciding to taper off. She denies a history of physical, emotional, or sexual traumas.

She reports feeling positive about her marriage and continues to work in marketing but has been starting work late about half of the days due to her headaches and does not speak very much in meetings anymore due to jaw pain. She stopped calling friends due to pain with speaking for too long but does still send text messages to communicate. She denies any history of substance misuse or abuse, but reports that her father and paternal grandfather were alcoholic, never receiving any treatment, but her father stopped drinking about 5 years ago.

Her medical history is significant for asthma, anxiety, depression, headaches, facial pain, and chronic sinusitis. Surgical history is significant for two sinus surgeries in the last 3 years and multiple teeth extractions. She reports taking butalbital/acetaminophen/caffeine four tablets per day for headache for the past 2 years, clonazepam 1 mg 2–3 tablets per day for anxiety and sleep for the past 2 years, duloxetine 40 mg for depression for the past 2 months, and quetiapine 100 mg at bedtime for sleep for the past 6 months. All medications are prescribed by the primary care physician, and she has an evaluation meeting with a psychiatrist in four months. The state prescription drug monitoring program database was checked and is consistent with the patient’s report of controlled substance medications.

Review of systems and physical examination reveals no asymmetry, no swelling, a forward head posture and vital signs are within normal limits. Neuro exam shows patient is alert and oriented, and cranial nerves V and VII are normal. Muscle examination indicates severe tenderness upon palpation of the left deep and superficial masseter muscles, moderate tenderness of temporal tendons and lateral pterygoid muscles of both sides and moderate tenderness of the SCM and trapezius muscles. Jaw opening is restricted with maximum opening of 20 mm without pain and 30 mm with pain, lateral excursions of 5 mm right and left and 3 mm protrusive. There are no joint sounds, and cervical range of motion is within normal limits.

Based on the past medical record and assessment following diagnoses are suggested:

• myofascial pain secondary to dental t/t

• chronic tension type headache, rule-out medication overuse headache

• major depressive disorder, moderate

As we can see from this example, patients with these complex presentations could benefit from additional evaluation with relevant specialists, such as a neurologist, physical therapist, and sleep medicine specialist to further clarify the diagnoses and to develop one comprehensive treatment plan. Additionally, previous medical notes and/or telephone communication should be obtained to understand past and current treatment and to coordinate care amongst all involved. While this may seem a large undertaking for the orofacial pain specialist, the goal is to improve patient outcomes and patient adherence to one comprehensive treatment plan led by the orofacial pain specialist.

This patient has had a typical course of having each specialty evaluating her and offering treatment through only that lens, rather than a multi-specialty and interprofessional comprehensive plan that focuses on overall function as well as symptom reduction. The delays from seeing various specialists and not consulting with the orofacial pain specialist seem to have contributed to worsening symptoms and function. While each clinician working with this patient likely has had the best intentions to reduce her pain and suffering, the more silo approach and leaving the PCP to hold the coordination of each care plan has at a minimum delayed the patient’s recovery and perhaps worsened her disability, functioning, and comorbid sleep and mood symptoms.

Conclusion

Dental professionals are typically the first contact for patients suffering from orofacial pain; however, the location of pain or medical complexity may lead patients to seek care from other medical professionals such as primary care physicians, otolaryngologists, neurologists, or physical therapists for initial evaluation of pain symptoms. Therefore, it is in dentists’ and patients’ best interest that dental professionals in any specialty work to develop collaborative relationships with an orofacial pain center if possible, and/or other community specialists in dentistry, medicine, and mental health. With virtual care options more acceptable to both providers and patients, this opens one’s referral network beyond the local community, to perhaps the entire state or geographic region. While implementing interprofessional care may be challenging, one can take even small steps to increase collaboration and over time and perhaps become a leader in developing interprofessional dental centers, creating opportunities for interprofessional education, such as conferences and continuing education events and advocating for reimbursement structures that support interprofessional work.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Kelly M. Wawrzyniak

Kelly Wawrzyniak is a clinical psychologist with a specialty in behavioral medicine and chronic pain. She is the founder and owner of Kelly Wawrzyniak Psychology, LLC, a behavioral medicine psychotherapy practice, and Lumin Edge Consulting, LLC, a clinical research consulting group. Dr. Wawrzyniak was previously an Assistant Professor and Staff Psychologist at the Tufts School of Dental Medicine Craniofacial Pain Clinic. Before this, she was Head of Department, Behavioral Medicine at Boston Pain Care and Executive Director of MedVadis Research. She has published on topics of chronic pain, opioid-related risk, and functional outcomes in pain management.

Naila Ahmed

Naila Ahmed is a student at Northeastern University pursuing a Bachelor of Science in Psychology.

Ronald J. Kulich

Ronald Kulich is a Professor at TUFTS School of Dental Medicine. He has responsibilities including development and management of opioid risk assessment protocols for the Massachusetts General Hospital Pain Center and Facial Pain/Headache Center at Tufts School of Dental Medicine.

Shuchi Dhadwal

Shuchi Dhadwal is a Clinical Associate Professor at TUSDM. She also maintains a private practice in Newton MA. Her practice is limited to Orofacial Pain and Dental sleep medicine.