IASP Curriculum Outline on Pain for Dentistry and Oral Health

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Task Force Members

Peter Svensson (chair), Antoon De Laat, Rafael Benoliel, Barry J. Sessle

Outline Summary

Introduction
Principles
Objectives
Curriculum Content Outline

1. Multidimensional Nature of Pain
2. Pain Assessment and Measurement
3. Management of Pain
4. Clinical Conditions

References

Appendix: Curriculum Outline on Orofacial Pain
Additional Resource: Postdoctoral Outline

Introduction

Pain is a multidimensional and complex phenomenon that requires comprehensive and ongoing assessment and effective management. The multidimensional nature of orofacial pain requires an interdisciplinary approach to assessment and management. All health-care professionals need to serve as advocates for the person in pain and must ensure that pain management is based on evidence-based standards, guidelines, and ethical principles. Traditionally, the field of Dentistry and Oral Health has focused on the prevention, diagnosis, and management of intraoral and orofacial pain.

IASP encourages all Dentistry and Oral Health programs to consider the following curriculum outline to embed pain education and training. As is the case in all health professions, an objective of a curriculum such as this one is to instill the knowledge and skills necessary to advance the science and management of pain as part of an interprofessional team. The desired outcomes of education emphasize critical competencies that support the humanistic aspects of health care and the learner’s capacity to carry out tasks successfully in the real world. The fundamental concepts and complexity of pain include how pain is observed and assessed, collaborative approaches to treatment options, and the application of pain competencies across the lifespan in the context of various settings, populations, and care team models.

In dentistry and oral health, this means that dental students should be knowledgeable about orofacial pain mechanisms, the epidemiology of pain, prevention of pain, barriers to effective pain control, the variety of orofacial pain conditions, and variables that influence the patient’s perception of and response to pain. Students should be trained to apply validated and reliable methods of clinical pain assessment and master the range of available methods for the alleviation and control of orofacial pain.

Principles

The following principles guide the pain curriculum for the entry-level dentist:

1. Pain is a multidimensional biopsychosocial experience requiring comprehensive and ongoing assessment and effective management.
2. Dentists play an essential role in the prevention, diagnosis, and management of intraoral and orofacial pain conditions.

Objectives

Dentists at the completion of this pain curriculum will be able to:

1. Provide an accurate diagnosis of the most common intraoral and orofacial pain conditions, be able to recognize the more complex orofacial pain conditions, and initiate referrals to appropriate experts in managing such patients
2. Perform a comprehensive pain assessment, including its impact on the patient
3. Manage the pain based on best-available evidence and good clinical practice and to evaluate the effectiveness of those actions

Curriculum Content Outline (Entry-level, Predoctoral)

1. Multidimensional Nature of Pain
   1. Introduction
      1. Pain as a public health problem
      2. Pain as an obstacle to optimal dental and oral care
      3. Epidemiology, personal, familiar, and societal consequences
      4. Economic impact
      5. Medico-legal, ethical, and compensation issues
   2. Definition of Pain
      1. Relationship between acute, incident, breakthrough, and chronic pain
      2. Pain terms
      3. Philosophical issues
      4. Historical aspects of the study of pain
      5. Biological significance of acute pain (survival value) versus chronic pain (disease)
   3. Peripheral and Central Mechanisms of Pain Transmission and Pain Modulation
      1. Theories of pain and etiology
      2. Distribution of the trigeminal nerve and other nerves of the head and neck, the anatomic relations of the structures that they innervate, and their primary central connections
      3. Receptors and afferents of the trigeminal system, peripheral sensitization, non-neural (e.g., glia) mechanisms
      4. Brainstem, thalamus, and cerebral cortex and central sensitization processes
      5. Features that distinguish the trigeminal system from the spinothalamic and dorsal column lemniscal systems; e.g., the proportion of myelinated to unmyelinated fibers, the occurrence of sites (e.g., tooth pulp, cornea) predominantly or exclusively innervated by nociceptive afferents, the bilateral and disproportionately large representation of the orofacial region in higher levels of the somatosensory system, the nuclear and subnuclear organization of the trigeminal brainstem complex
      6. Related motor centers and mechanisms underlying orofacial movements
      7. Segmental and brain centers modulating pain transmission
      8. Chemical mediators and non-neural (e.g. glia) mechanisms involved in pain transmission and control
      9. Genetic and epigenetic aspects and sex differences
      10. Affective, cognitive, behavioral, developmental, and aging aspects
      11. Interpersonal and psychosocial issues; illness behavior; the influence of political, governmental, and social welfare programs
2. Pain Assessment and Measurement
   1. Measurement of pain, as well as disability, associated distress, and suffering
   2. Measurement of impact of pain on orofacial and general function, well-being, and quality of life
   3. Assessment of pain relief
   4. Patient evaluation (psychological and physical status including comorbidities such as depression, sleep disturbances, and pain elsewhere in the body)
   5. Objective tests and procedures; e.g., physical exam, tooth vitality tests, radiographs, microbiology, hematology, serology, nerve blocks, chair-side sensory tests, etc.
3. Management of Pain
   1. Control of preoperative and operative pain and apprehension
      1. Non-pharmacological methods
         1. Psychological and behavioral methods
         2. Interpersonal strategies of patient management
         3. Hypnosis, acupuncture, etc.
      2. Pharmacological methods—analgesics
         1. Review of physiologic and pharmacologic considerations
         2. Selection of agents
         3. Techniques of administration
         4. Prevention, recognition, and management of complications, side effects, and emergencies, including principles of advanced life support
      3. Pharmacological methods—local anesthesia
         1. Review of anatomic and physiologic considerations
         2. Selection of agents
         3. Technique of injections
         4. Prevention, recognition, and management of complications and emergencies, including principles of advanced life support
      4. Pharmacological methods—conscious sedation (anti-anxiety treatments)
         1. Review of related cardiovascular, respiratory, and central nervous system physiology and pathophysiology and psychopathology
         2. Selection of agents
         3. Techniques of administration
         4. Prevention, recognition, and management of complications and emergencies, including the principles of advanced life support
      5. Overview of general anesthesia and deep sedation
      6. Interaction of pharmacological and psychological methods
   2. Control of postoperative pain and apprehension
      1. Use of appropriate instructions and interpersonal strategies
      2. Selection of appropriate pharmacological agents based on procedures and patient’s psychological background
4. Clinical Conditions
   1. Taxonomy of orofacial pain
      1. Familiarity with the classification of acute pain and chronic orofacial pain and headache conditions, the principles upon which it is based, and the application to specific cases is required (Bogduk and Merskey 1994; ICHD-3 2013; Schiffman et al. 2014; Treede et al. 2015) and DSM IV Classification of Somatoform Disorders (Diagnostic and Statistical Manual of Mental Disorders (4th Ed).
   2. Diagnostic features, etiology, mechanisms, and management of orofacial pain associated with:
      1. Specific sites; e.g., tooth, TMJ, muscle, mucosa, skin, sinus, bone
      2. Infections; e.g., herpes, candidiasis
      3. Non-dental referral; e.g., earache, cardiac, headache
      4. Orofacial pain referral patterns
      5. Orofacial pain conditions
         1. Trigeminal neuralgia
         2. Glossopharyngeal neuralgia
         3. Postherpetic neuralgia
         4. Temporomandibular disorders
         5. Oral dysesthesia, burning mouth syndrome
         6. Primary, idiopathic, orofacial pains
         7. Orofacial malignancy (e.g., primary/metastatic/referred)
         8. Facial variants of headaches; e.g., tension-type headache, migraine, cluster headache
         9. Peripheral nerve injury and deafferentation pain; post-traumatic trigeminal neuropathic pain
         10. Others; e.g., carotidynia

References

Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet J-P, List T, Svensson P, Gonzalez Y, Lobbezoo F, Michelotti A, Brooks S.L, Ceusters W, Drangsholt M, Ettlin D, Gaul C, Goldberg L, Haythornthwaite J, Hollender L, Jensen R, John MT, de Laat A, deLeeuw R, Maixner W, van der Meulen M, Murray GM, Nixdorf DR, Palla S, Petersson A, Pionchon P, Smith B, Visscher CM, Zakrzewska J, Dworkin SF. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache 2014;28:6-27.

Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, Cohen M, Evers S, Finnerup NB, First MB, Giamberardino MA, Kaasa S, Kosek E, Lavandʼhomme P, Nicholas M, Perrot S, Scholz J, Schug S, Smith BH, Svensson P, Vlaeyen JW, Wang SJ. A classification of chronic pain for ICD-11. Pain 2015;156:1003-1007.

Peck CC, Goulet JP, Lobbezoo F, Schiffman EL, Alstergren P, Anderson GC, de Leeuw R, Jensen R, Michelotti A, Ohrbach R, Petersson A, List T. Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. J Oral Rehabil 2014;41:2-23.

Sessle B.J., Lavigne, G., Lund J.P. Dubner, R. Orofacial Pain: From Basic Science to Clinical Management (2^nd edition). Quintessence Publishing 2008.

de Leeuw, R., Klasser, G.D. Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management (5^th edition). Quintessence Publishing 2013.

Sessle BJ, Baad-Hansen L, Svensson P. Orofacial Pain. In: Clinical Pain Management: A Practical Guide. Lynch M, Craig K, Peng P (Eds.) Wiley Blackwell, 2010.

Sessle B.J. Orofacial Pain. Recent Advances in Assessment, Management, and Understanding of Mechanisms. IASP Press 2014.

Sharav Y, Benoliel R Orofacial Pain and Headache (2^nd edition). Quintessence Publishing 2015.

Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia Int J Headache 2013; 33: 629–808.

Appendix

Curriculum Outline on Orofacial Pain

1. Anatomical, physiological, and psychological aspects of orofacial pain
   1. Have a broad general knowledge of the anatomy and physiology of the orofacial structures, particularly of the peripheral nerve distribution of the major trigeminal nerve trunks and other cranial nerves, the anatomic relations of the structures they innervate, and their primary central connections.
   2. Be familiar with the similarities between the trigeminal system and the spinal and lemniscal systems that make current concepts of neurobiology, peripheral and central sensitization processes, nociceptive transmission and its control applicable to the trigeminal system.
   3. Similarly, be aware of features that distinguish these systems; e.g., in the trigeminal system, the proportion of myelinated to unmyelinated fibers and the properties of some of these fibers that are different from those in spinal nerves; the occurrence of sites (e.g., tooth pulp, cornea) in the orofacial region that are predominantly or exclusively innervated by nociceptive afferents; the bilateral and disproportionately large representation of the orofacial region in higher levels of the somatosensory system; the exquisite sensibility of orofacial tissues.
   4. Be familiar with psychological, psychosocial, genetic, and environmental factors associated with orofacial pain and other pain conditions.
2. Diagnosis of orofacial pain
   1. To have a broad general knowledge of the major diagnostic features, differential diagnosis and possible etiological, epidemiological, and pathophysiological aspects of pain associated with:
      1. Specific sites: tooth and surrounding structures, temporomandibular joint, muscle, mucosa, sinus, bone, salivary glands
      2. Orofacial pain conditions, including cranial neuralgias and neuropathic pain, temporomandibular disorders, neurovascular and other primary and secondary headaches, primary idiopathic pain conditions such as burning mouth syndrome, persistent idiopathic facial pain, and persistent idiopathic dentoalveolar pain (formerly known as atypical facial pain and atypical odontalgia, respectively)
   2. Be familiar with the general principles of taking a structured orofacial pain history and carrying out a clinical examination of the orofacial region and adjacent structures.
   3. Be aware that there are objective and validated tests and procedures used for differential diagnosis of many of the above (e.g., de Leeuw and Klasser 2013; Schiffman et al. 2014; Peck et al. 2014), but that some diagnostic approaches still lack reliability, validity, specificity, or sensitivity. Tests and procedures include tooth pulp vitality and tooth percussion tests, muscle palpation tests, salivary tests, quantitative sensory and neurophysiological tests, and other physical exams; behavioral and psychosocial assessments; radiographs and other imaging techniques; microbiological and serological tests; biopsies; and controlled nerve blocks.
   4. Be aware of the common orofacial patterns of pain referral. Also be aware that orofacial pain may sometimes be referred from remote sites (e.g., earache, cardiac pain, intracranial lesions).
3. Management of orofacial pain
   1. Be aware of the current evidence-based management approaches, and their indications and contra-indications, for the different types of orofacial pain noted in Section II. Some of the commonly used therapeutic approaches include pharmacological agents, surgery, physical medicine, and multidisciplinary management, including cognitive behavioral approaches, as well as the use of support groups. Be able to inform the patient on these topics.

Additional Resource

Postdoctoral Curriculum

Objectives

Dentists and other health-care providers at the completion of this pain curriculum should have an advanced understanding and training in orofacial pain and overlapping headache conditions and will be able to:

1. Provide an accurate diagnosis of complex intraoral and facial pain conditions, including overlapping headache conditions and to initiate appropriate management based on an interdisciplinary approach
2. Perform a comprehensive pain assessment using evidence-based techniques, such as quantitative sensory testing and differential nerve blocks, and establish the full impact of the orofacial pain condition on the patient (e.g., physical functioning, emotional functioning, cognitive functioning, sleep)
3. Manage the pain based on best-available evidence and good clinical practice and to evaluate the effectiveness of those actions based on an interdisciplinary effort.

1. Multidimensional Nature of Pain
   1. Representative and associated non-dental syndromes and conditions; e.g., phantom pain, causalgia, cancer pain, arthritis, complex regional pain syndromes, fibromyalgia, visceral pain, etc. (Treede et al. 2015)
   2. Pain in special contexts
      1. Primary and secondary headaches
      2. Postoperative pain (including prophylaxis)
      3. The harmful effects of unrelieved severe acute pain
      4. Children and infants (signs of pain, evaluation and management, physiology, acute and chronic pain)
      5. Cancer-related pain (death and dying, palliative care)
      6. Aged patients
      7. Intellectually and cognitive impaired patients
      8. Occupational issues (e.g., overuse syndromes, post-traumatic stress disorders)
   3. General anesthesia and deep sedation
      1. Survey of agents used and their proper selection
      2. Survey of adjunctive agents and rationale for their use
         1. Anticholinergics
         2. Sedatives
         3. Analgesics
         4. Muscle relaxants
      3. Indications and contraindications for use of general anesthesia in ambulatory patients
      4. Patient selection and preparation
      5. Complications associated with use of general anesthesia and deep sedation
2. Pain Assessment and Measurement (Examination, Differential Diagnosis, and Clinical Decision Analysis in Orofacial Pain)
   1. Fundamental examination and diagnostic principles in medicine and dentistry
   2. Radiological and MRI interpretation of soft and hard tissue components of the masticatory system
   3. Neurological interpretation of acute and chronic pain disorders including quantitative sensory testing
   4. Predictors of and treatment outcome measures in orofacial pain disorders
3. Management of Chronic Pain
   1. General principles
      1. The measurement, quantification, and recording of pain
      2. The multiperspective approach (multidisciplinary pain clinics)
      3. The clinician-patient relationship
   2. Clinical pharmacology
      1. Nonsteroidal anti-inflammatory drugs
      2. Systemic and spinal opioids
      3. Local anesthetics
      4. Other drugs (anticonvulsants, antidepressants, agents influencing 5-HT, endorphins, and other endogenous neurochemicals)
   3. Neurostimulation techniques
      1. Transcutaneous nerve stimulation
      2. Acupuncture
   4. Nerve blocks
      1. Local anesthesia
      2. Neurolytic solutions
   5. Neurosurgical techniques
      1. Microvascular decompression
      2. Neurectomy
      3. Sympathectomy
      4. Peripheral nerve decompression
      5. Tractotomy
      6. Others
   6. Psychosocial and behavioral approaches
      1. Individual, family, and group psychotherapy
      2. Cognitive-behavioral therapy
      3. Relaxation techniques (biofeedback, etc.)
      4. Hypnotherapy, operant approach, stress management
   7. Physical therapy
      1. Exercise, massage, heat, hydrotherapy, etc.

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