Int. J. Odontostomat.

,
8(2):247-252, 2014.

Periodontal Treatment and Quality of

Life of Chronic Facial Pain Patients

Tratamiento Periodontal y Calidad de Vida en Pacientes con Dolor Facial Crónico

Gisele Maria Campos Fabri*; Cynthia Savioli* & José Tadeu Tesseroli Siqueira*

FABRI, G. M. C.; SAVIOLI, C. & SIQUEIRA, J. T. T. Periodontal treatment and quality of life of chronic facial pain patients.
Int. J. Odontostomat., 8(2):247-252, 2014.

ABSTRACT: The aim of this research is to determine the impact of periodontal treatment on the quality of life of
patients with concomitant chronic headache or facial pain and periodontal disease. Thirty-eight consecutive patients with
chronic periodontal disease were divided according to the presence of chronic craniofacial pain (CFP):Study Group-with
CFP and Control Group-without CFP. They were evaluated with the Clinical protocol of the Orofacial Pain Clinic, the WHOQOL-
bref and the McGill Pain Questionnaire. All patients received periodontal treatment. The Study Group presented worst
quality of life than the Control Group. Nevertheless, the Study Group showed trend improvement in the psychological score
(p=0.06) and affective descriptors at the McGill Pain Questionnaire improved (p=0.014) after periodontal treatment. There
were no significant changes in quality of life from pre- to post- operatory evaluations in both groups (p>0.05). We conclued
that chronic craniofacial pain sufferers presented worst score at physical and psychological domain of quality of life, however
there was an improvement in their psychological state 180 days after periodontal treatment.

KEY WORDS: quality of life, periodontal disease, facial pain, headache.

INTRODUCTION

Quality of life is defined as individuals’ Nobrega et al., 2007), and patients with chronic pain
perceptions of their position in life in the context of have more complaints of physical and psychiatric co-
culture and value systems in which they live and in morbidities, central sensitization and neuroplastic
relation to their goals, expectations, standards and changes (Nóbrega et al., 2007; Sessle, 2000; Ren &
concerns (WHOQOL Group, 1994). Dubner, 2002).

Orofacial pain is very common in the general Periodontal disease (PD) is a group of frequent
population (Lipton et al., 1993). Its etiology is chronic inflammatory diseases at the adult population
multifactorial and there are many possible diagnoses, (Albandar & Rams, 2002; Ministério da saúde, Secre-
including myofascial pain syndromes, neurovascular taria de Atenção à Saúde, 2003; Bartold et al., 2000),
disorders, dental pain, neuralgias, temporomandibular characterized by gingival and/or alveolar bone infection
disorders (TMD), atypical facial pain, etc. (International (Bartold et al.), with different levels of severity
Classification of Headache Disorders, 2004; (American Academy of Periodontology, 2000).
Zakrzewska, 2004). These patients usually receive
multiple treatments and are often misdiagnosed, and It is generally painless, except during mechanical
for the assessment, special training of health care irritation (chewing or teeth brushing) or acutization
professionals is necessary because of overlapping of periods, and patients have gingival bleeding, dental
signs and symptoms of these multiple diagnosis mobility and growing tooth sensation (Lundy & Linden,
(Fricton et al., 1982; Marbach, 1996). It is much more 2004). Experiences like “gum swelling”, “gum pain”,
common when the pain symptom is persistent or “gum recession”, “dental mobility”, “dental inclination”,
considered atypical facial pain (Siqueira et al., 2004; “halitosis” and dental pain are associated with PD and

*Dentistry Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, Brazil.

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 FABRI, G. M. C.; SAVIOLI, C. & SIQUEIRA, J. T. T. Periodontal treatment and quality of life of chronic facial pain patients. Int. J. Odontostomat., 8(2):247-252, 2014.

with poor quality of life (McGrath & Bedi, 2001; Were included patients with PD, in accordance
Needleman et al. 2004). Several studies demonstrated with the classification criteria of the American Academy
its envolvement with cardiovascular, metabolic, or of Periodontology, and only for Study Group: patients
neurovascular diseases (Amar et al., 2003; Tonetti et with CFP (Merskey & Bogduk, 1994).
al., 2007; Yamazaki et al. 2004). Despite the existence
of these studies there is a lack of papers about the Patientes with presence of chronic systemic
role of untreated chronic PD in patient sufferers of diseases that did not fit into the attendance protocol
chronic headache or facial pain (CFP), maybe because used in this study, psychiatric patients with cognitive
it is not routinely evaluated during medical assessment deficiency, pregnant women, epileptic patients,
of chronic pain(Siqueira et al.). hematological diseases or tumors of the head and neck
were excluded.
A central focus of dental care is to improve the
quality of life, to increase survival (absence of oral Instruments of evaluation. A standardized diagnostic
cancer, presence of teeth) and enable appropriated protocol was applied to all patients equally by an
physical, emotional and social functioning at normal experienced and trained dentist. It consisted of an
daily tasks (McGrath & Bedi). Therefore, recent studies interview and systematic evaluation of cervical, cranial,
showed an interaction between the immune system facial, dental and other oral structures in accordance
and pain, also at the trigeminal system (Xie et al., 2006), to the following instruments or specialized exams:
but until now there are no studies about chronic PD in
chronic pain sufferers, despite its infectious and 1- The Clinical Protocol of the Orofacial Pain Clinic, a
inflammatory nature. standardized orofacial pain evaluation to detail: (a) the
chief complaint, (b) the general pain characteristics
Thus, the aim of this study was to verify the (location, intensity, quality, duration, time of pain
quality of life characteristics before and after periodontal worsening) (c) the presence of headache or body pain
treatment of patients with PD and concomitant CFP. complaints, (d) the oral and dental condition and (e)
the medical history.

MATERIAL AND METHOD 2- WHOQOL Questionnaire in the validated Portuguese

version to assess quality of life (Fleck et al., 2000).
3- McGill Pain Questionnaire in the validated
Patients that had concomitant CFP (Headache Portuguese version only for patients with CFP (Study
Classification Subcommittee of the International group).
Headache Society) and chronic PD (American
Academy of Periodontology) were seleted and received Periods of evaluation. All patients were evaluated in
periodontal treatment comparatively with another group two periods:
of patients that had only PD and sought attendance 1.- Baseline, before periodontal treatment (up to 15
for routine dental evaluation. All the patients gave days before);
informed consent to procedures approved by the Ethics 2.- 180 days (6 months) after the end of periodontal
Committee of the Medical School. treatment, completing a follow-up of 6 months.

The CFP (headache or facial pain) patients were Statistical analysis. Data were analyzed by parametric
referred to the Orofacial Pain Clinic for evaluation and non-parametric tests. The Fisher and Chi-squared
because of non improvement of pain. They were tests were used to compare the nominal data, such
referred by the Interdisciplinary Pain Center of the as, sex, race and presence of co-morbid conditions.
Neurology Division of Hospital das Clínicas of the To compare weight, height and Body Mass Index
Medical School of the University of São Paulo (EDOF- between the groups we used the T student’s test.
HC), from June 2003 to July 2005. Variations in the mean WHOQOL scores intergroup
were explored with Mann-Whitney non-parametric test
Patients were divided into two groups: and variations in WHOQOL scores intragroup were
assessed with the Wilcoxon test. Changes in
1. Study Group: sufferers of chronic craniofacial pain descriptors of the McGill Pain questionnaire were
with concomitant PD. examined with the Wilcoxon test. The level of
2. Control Group: patients with only PD. significance was 5%.
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 FABRI, G. M. C.; SAVIOLI, C. & SIQUEIRA, J. T. T. Periodontal treatment and quality of life of chronic facial pain patients. Int. J. Odontostomat., 8(2):247-252, 2014.

RESULTS

Forty patients with chronic periodontal disease Mann-Whitney test, p = 0,006). The Study Group
were assessed and treated. Two patients did not fulfill showed significantly lower scores than those of the
criteria and were excluded, the remaining 38 patients, control group in both evaluations.
08 men e 30 women, with a mean of 45.38±12 years
old (range to 28–73 y). The Study Group, which Psychological Domain. There was a significant
included patients with CFP, was composed by 4 difference between the groups in the initial score
(20%) men and 16 (80%) women and the mean ages (non-parametric Mann-Whitney test, p = 0.007),
were 48.95±13.03 years old (28–73 y). The Control however there was no difference at 180 days after
Group was composed by 4 (22.2%) men and 14 periodontal treatment (non-parametric Mann-Whitney
(77.8%) women with a mean age of 42.38±9.51 years test, p = 0.217). The Study Group showed significant
old (29–62 y). There was no statistical difference lower scores than the Control Group at the baseline.
between the two groups in relation to these These differences disappeared 180 days after
parameters, showing homogeneity between them. periodontal treatment.
The general characteristics are presented in Table I.
Social Relationships Domain. There was no
Co-morbidities. The Study Group showed 19 (95%) significant difference between the groups at the
patients that had one or more co-morbidities, and baseline score (non-parametric Mann-Whitney test,
the Control Group showed 11 (61.1%) patients with p =0.290) or at 180 days after the periodontal
these findings. There was a significantly higher treatment (non-parametric Mann-Whitney test, p
percentage of co-morbidities in the Study Group =0.251).
(Fisher exact test, p = 0.016).
Environment Domain. There was no significant
Quality of life. In all domains evaluated there were difference between the groups at the baseline score
no significant differences between baseline scores (non-parametric Mann-Whitney test, p =0.828) or at
and scores at 180 days after periodontal treatment 180 days after periodontal treatment (non-parametric
in both groups. The data show, however, the following Mann-Whitney test, p =0.633). These data are
interesting findings: demonstrated in Table II

Physical Domain. There was a significant difference For the question "How satisfied are you with
between the groups at the baseline score (non- your health?" the groups did not differ at the baseline
parametric Mann-Whitney test, p<0.001) and at 180 (p = 0.081, Fisher's test) but differed at 180 days
days after periodontal treatment (non-parametric after periodontal treatment (p = 0.020,
Fisher's test). At the Study Group, there
was significant change in health
Table I. Demographic characteristics of patients with periodontal disease
satisfaction (McNemar's test p = 0.025),
of the Study and the Control Groups
Study group Control group
where 31.4% of the cases that were not
p satisfied at baseline became satisfied after
(n= 20) (n= 18)
Sex F = 16 F = 14 treatment. We also observed it in 71.4%
1.000_
M= 4 M= 4 of the Control Group (McNemar's test
Race B = 15 B = 10 p=0.025).
0.207_
N =5 N = 08
Age (mean) ±SD 48.9±13.0 42.4±9.5 0.0878_ McGill pain questionnaire. Descriptors of
(Minimum–Maximum) (28-73) (29-62) pain according to the McGill Pain
Weight ±SD 65.9±13.63 61.8±12.5 0.3409_ questionnaire for the Study Group are
(Minimum–Maximum) (43-90) (45-93) shown in Table III. Patients had an
Height ± SD 1.61±0.07 1.61±0.1 0.8083_ improvement in affective indexes
(Minimum–Maximum) (1.5-1.77) (1.5-1.8) descriptors (p = 0.024 p = 0.014,
BMI±SD 25.11±4.43 23.7±3.83 0.3134_ respectively).
(Minimum–Maximum) (17.9-35.4) (22.7-32.8)
∂= Fisher’s Test; ∑= Chi-Square Test; ∏= Student t Test; SD= standard deviation.

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 FABRI, G. M. C.; SAVIOLI, C. & SIQUEIRA, J. T. T. Periodontal treatment and quality of life of chronic facial pain patients. Int. J. Odontostomat., 8(2):247-252, 2014.

Table II. Evaluation of the quality of life at the Study (headache and
facial pain) and the Control (only periodontal disease) groups in physical,
social, psychological and environment domains of the WHOQOL
Questionnaire.
Domains Groups Moment Mean p* p**
Baseline 11.95±3.12
0.252 <0.0011
Study 180 days 12.50±3.99
Physical Baseline 15.67±1.78 0.709 0.006
2

Control 180 days 15.83±2.26

Baseline 13.25±3.75 0.293
0.2901
Social Study 180 days 14.15±3.05
2
Baseline 14.33±3.83 0.165 0.251
Control 180 days 15.22±2.69
Baseline 12.40±2.56 0.060 1
180 days 13.70±2.92 0.007
Study
Psychological Baseline 14.72±2.19 0.928 0.2172
Control 180 days 14.67±2.38
Baseline 11.90±2.34 0.757
180 days 12.10±3.24 0.8281
Study
Enviroment Baseline 11,61±2.97 0.182 0.633
2

Control 180 days 12,28±2.63

* p= comparative intragroup at baseline and 180 days after periodontal treatment
(non-parametric Wilcoxon test).
**p= comparative intergroup at baseline (1) and 180 days after periodontal
treatment (2) (non-parametric Mann-Whitney test).

Table III. Pain descriptors and indexes by the McGill Pain Questionnaire.
McGill Pain Questionnaire Baseline (Mean) 180 days (Mean)
Sensorial Index_ 17.2±7.31 (6–32) 13.35±8.89 (0-33)
Affective Index_ 6.4±3.56 (0–11) 4.2±4.32 (0-13)
Avaliative Index_ 2.7±1.45 (1–5) 1.9±1.44 (0-5)
Miscelaneous Index4 6.25±3.87 (0–14) 4.35±3.99 (0-16)
5
Sensorial descriptors 7.3±2.79 (2–10) 6.05±3.28 (0-10)
Affective descriptors6 3.8±1.64 (0–5) 2.5±2.03 (0-5)
Avaliative descriptors7 1.0±0.00 (1–1) 0.85±0.36 (0-1)
8
Miscelaneous descriptors 2.85±1.22 (0–4) 2.15±1.35 (0-4)
Wilcoxon Test: ∂p=0.059; ∑p=0.024; ∏p=0.040; 4p=0.082; 5p=0.076; 6p=0.014; 7p=0.083; 8p=0.041.

DISCUSSION

Although there were no statistically significant On the other hand, physical scores in both
changes intragroups in quality of life, it is interesting moments of evaluation were different between groups
that the psychological domain showed difference (p <0.001 and p = 0.006, respectively), which means
between groups at 180 days, compared to baseline (p that the physical debilitation of patients with chronic
= 0.007 and p = 0.217, respectively). The reason for headache and facial pain is worse than the control
that is the psychological improvement of patients patients, independently of periodontal disease. It is
suffering from chronic craniofacial pain after periodontal known that patients with chronic pain have more
treatment (p = 0.060). This date can be enhanced by tendency to have physical and / or psychiatric co-
the improvement in the affective indexes and morbidities (McWilliams et al., 2003), especially this
descriptors of the questionnaire McGill of pain (p = group in this study, which are patients referred because
0.024 and p = 0.014, respectively). of non improvement during earlier treatments.

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These data suggest that the control of The scores of social relations and environment
periodontal disease and concomitant improvement in domains didn’t change nor were different between
oral health brought some emotional comfort for patients groups. Possibly, all patients in this sample had simi-
suffering from craniofacial chronic pain. The reasons lar values, aspirations, and concerns, perhaps because
for this improvement are not clear and we cannot they are from a single sample (all patients treated at
discard the placebo effect because of frequent contact the Hospital das Clinicas). It is controversial with other
with the dentist during treatment, but it had not been studies that demonstrated affection in all quality of life
evaluated. The care received may have influenced the domains for patients with chronic pain. Exercises,
improvement in some emotional aspects (body image, domestic activities, food, family and social relationships
appearance, self-esteem, positive and negative are often compromised by the painful condition
feelings), which did not occur in other aspects (thinking, (Teixeira & Yeng, 2006). In Brazil, more than 1 / 3 of
learning, memory, concentration and spirituality / the population feels that chronic pain declines usual
religion / personal beliefs). Moreover, the dental activities and more than 3 / 4 believe that chronic pain
treatment is associated with perceptions of health and limits recreational activities, social and family relations
quality of life. Patients understand that the health of (Teixeira & Yeng).
their mouth often affects their quality of life by symptoms
and signs produced, especially those patients with the In conclusion, these data showed that there was
experience of chronic pain. an improvement at the emotional aspects of chronic
craniofacial pain sufferers after periodontal treatment
Experiences like "gum swelling," "gingival pain”, in comparison to baseline. The affective indexes and
"gingival retraction," "dental mobility", "bad breath" and descriptors at the McGill Pain Questionnaire also
" tooth pain " are associated with a reduction in quality reduced, which reflected in quality of life.
of life (McGrath & Bedi; Needleman et al.). Thus, the
perception of health improvement after periodontal
treatment, in this study, reinforces these data in the ACKNOWLEDGMENTS
literature. There was partial improvement of the degree
of satisfaction with the health of patients 180 days after
periodontal treatment. When asked about the degree This study was supported by Fundação de Am-
of satisfaction with health, we observed that in both paro à Pesquisa do Estado de São Paulo - FAPESP
groups there was a significant change (McNemar's test (grant Nº 2007/00934-2) and CAPES
p=0.025). It is probably due to oral health perception (33001010177P7). Our acknowledgments to Samia
after treatment. Simurro, Andréa Portnoi and Adriana Peraro.
FABRI, G. M. C.; SAVIOLI, C. & SIQUEIRA, J. T. T. Tratamiento periodontal y calidad de vida en pacientes con dolor facial crónico.
Int. J. Odontostomat., 8(2):247-252, 2014.

RESUMEN: El objetivo fue determinar el impacto del tratamiento periodontal sobre la calidad de vida de los pacientes con
cefalea crónica concomitante o dolor facial y enfermedad periodontal. Treinta y ocho pacientes consecutivos con enfermedad
periodontal crónica fueron divididos de acuerdo a la presencia de dolor craneofacial crónico (CFC); grupo de estudio con CFC y el
grupo control, sin CFC. Fueron evaluados con el protocolo clínico de la Clínica del Dolor Orofacial, el WHOQOL-bref y el cuestio-
nario de dolor McGill. Todos los pacientes recibieron tratamiento periodontal. El grupo estudio presentó peor calidad de vida que el
grupo control. No obstante, el Grupo de estudio mostró una tendencia de mejoría en la puntuación psicológica (p=0,06 ) y los
descriptores afectivos en el cuestionario de dolor de McGill tambien mejoraron (p=0,014 ) después del tratamiento periodontal. No
hubo cambios significativos en la calidad de vida de las evaluaciones pre y postoperatorias en ambos grupos (p>0,05). Concluimos
que los pacientes de dolor crónico craneofaciales presentaron peor puntuación en el dominio físico y psicológico de la calidad de
vida, sin embargo, hubo una mejoría en su estado psicológico 180 días después del tratamiento periodontal.

PALABRAS CLAVE: calidad de vida, enfermedad periodontal, dolor facial, dolor de cabeza.

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