Abstract
Dear Sir We want to thank Benoliel and Sharav for the constructive comment on our paper on facial pain in a neurological tertiary care centre (1). The comment points directly to the dilemma in diagnosing and treating patients suffering from facial pain. Straightforward cases are usually treated successfully in primary care, and complex cases, especially when the pain cannot be attributed to a specific disorder, are referred to specialized centres. Among the latter, the proportion of patients with unrecognized well-defined disorders is small, as shown in our study (1). In the majority of patients, the cause of the pain remains uncertain and many of them are clinically classified as atypical facial pain or persistent idiopathic facial pain. However, applying the current IHS criteria (2) in a strict sense shows that a considerable number of patients even do not fulfil these criteria.
Benoliel and Sharav confirm our findings from the perspective of the orofacial pain specialist. We agree totally with them in stressing the importance of cooperation between orofacial and neurological pain specialists in elucidating the aetiology and pathogenesis of idiopathic facial pain in order to improve the management of these patients. A prerequisite is the use of uniform, standardized diagnostic criteria. Accordingly, the differences between the IHS criteria (2) and the Guidelines of the American Academy of Orofacial Pain (3) should be surmounted. Our study aimed at pointing out the dimensions of the problem. The patients with persistent idiopathic and unclassifiable facial pain, respectively, did not fulfil the IHS criteria for other diagnoses, nor did they meet the criteria for myofascial pain or temporomandibular disorders (1, 2). Similarly, the patients did not fulfil the diagnostic criteria for TAC or post-traumatic pain which were discussed as possible diagnoses by Benoliel and Sharav. As pointed out in our paper, the interval between a possible causative trauma or operation and the patient's presentation to a pain centre often amounts to many years, making it impossible to establish a definite causal relation retrospectively. This problem can be overcome only by prospective studies.
The letter by Benoliel and Sharav demonstrates that orofacial pain specialists such as neurologists are aware of the substantial number of patients with chronic facial pain which cannot be diagnosed accurately. The crucial point is that a broad basis of both specialties should be willing to cooperate in developing improved diagnostic tools. We will be quite content if our paper, the comment by Benoliel and Sharav and this reply contribute to a closer, constructive cooperation between orofacial specialists and neurologists.