Bell's Orofacial Pain, 5th ed.

Okeson JP Carol Stream, IL 60188, Quintessence Publishing Co, 1 995, hardback, 500 pp, illus, $68.

Before Dr Welden Bell died he asked Dr Jeffrey Okeson to write the fifth edition of Bell's Orofacial Pain. Dr Okeson, Director of the Orofacial Pain Center at the University of Kentucky, responded to this large task by extensively revising and rewriting the fourth edition. He accomplished his goal of introducing the most up-to-date research on pain to health professionals involved in diagnosis and treatment of orofacial pain.

The sequence of the text is clear, starting with a review of normal neuroanatomy and function of the trigeminal system. In this section, a review of pain mechanisms is discussed. Diagrams and text show the progression of Melzack and Wall's initial gate-control theory of pain and include several pain modulation models that show more involvement of the central nervous system.

The author then presents a classification system for orofacial pain disorders and explains the diagnostic approach for differentiating these pain disorders. Throughout the text and case studies, the message is emphasized that the major reason for treatment failures is misdiagnosis--treating the wrong problem. In this classification system, Axis I (physical conditions) and Axis II (psychological conditions) can be used by the clinician as a road map to the proper diagnosis. Analgesic blocking is one of the best tools used to confirm a clinical diagnosis and differentiate primary from secondary pain. For example, if stellateganglion blocking alleviates the primary pain, then the diagnosis would certainly include a sympathetic component that might be missed without a trial injection. Physical therapy is covered generally in this section but more specifically in the following chapters, which deal with specific orofacial pain disorders.

Management of the various disorders is covered in the last section. The pain classification chart is continued throughout these chapters. On this chart, each specific disorder is highlighted to show where it stands in relation to the overall classification of orofacial pain.

At least six of the nine chapters on management will be of great interest to physical therapy professionals who treat orofacial pain disorders. The chapter "Pains of Muscular Origin" covers many possible causes, including Travell's referred-pain patterns of the orofacial region. The case studies are informative concerning chief complaint, history, examination, impressions, and diagnosis, but do not go into specific management. Treatment is delegated to a list of what's available.

The text covers some of the changes in management of the temporal mandibular joint. Due to long-term studies that suggest that internal derangements may be self-limiting, resulting in no significant disability, aggressive treatment is questionable and therapy such as physical therapy is encouraged.

The in-depth chapter on neuropathic pains is excellent. As with all chapters, the references are extensive and current. Because this type of pain is difficult to manage, this chapter is of special interest. The figures assist in understanding the complex mechanism of neuropathic pain.

Throughout the book, the author continues to remind clinicians to care for the whole person. He says this clearly in his final paragraph: "Perhaps the most important concern for the clinician to remember when managing pain is to: listen carefully, consider all possibilities, cure if you can, manage if you cannot, but always console."