Bell's Orofacial Pains: The Clinical Management of Orofacial Pain, ed 6.

Bell's Orofacial Pains: The Clinical Management of Orofacial Pain, ed 6 Okeson JP. Carol Stream, IL 60188, Quintessence Publishing Co Inc, 2005, hardcover, 567 pp, illus, ISBN: 0-86715-439-X, $78.

This is the sixth edition of a classic textbook on orofacial pain written for dental practitioners and other clinicians and researchers interested in the phenomenon of pain. This edition was written mainly to update readers on the latest research findings on the subject. It is illustrated by numerous helpful line drawings, photographs, and radiographs.

The book consists of 18 extensively referenced chapters divided into 3 sections. The first section, "The Nature of Pain," reviews the neuroanatomy and neurophysiology of general pain pathways. It includes discussions of primary and heterotopic (eg, referred) pain and some less frequently appreciated excitatory effects of pain on the central nervous system (eg, secondary hyperalgesia at sites of pain, muscle co-contractions and the development of myofascial trig get points, and autonomic nervous system responses). This section describes the modulation of pain by the body's antinociceptive systems and how these systems are activated clinically (eg, transcutaneous electrical nerve stimulation, acupuncture) to treat pain. Psychological factors that influence pain--such as a patient's anxiety, mood, level of stress, attention to the pain, and prior experiences--also are discussed. This section also explores the possible secondary gains from experiencing pain, such as avoiding responsibility or attracting attention, along with their effect on therapy. The treatment of acute pain resulting from tissue trauma or disease is contrasted with the management of chronic pain, which may cause intense suffering disproportionate to somato-sensory input.

Section 2, "Clinical Considerations of Orofacial Pain," presents the principles of pain diagnosis and management. The author makes distinctions between various types of pain, including distinctions between somatic pain transmitted by healthy nervous tissue and neuropathic pain that originates in abnormal (eg, demyelinated) nervous tissue. Because neuropathic pain occurs in the seeming absence of tissue injury, the author emphasizes the importance of not assuming a psychogenic origin for pain without an immediately apparent cause. This section makes a useful distinction between inflammatory and noninflammatory pain, but I found the author's classification of visceral pain as a form of somatic pain somewhat confusing.

The book's discussion of the role of the sympathetic nervous system in maintaining or enhancing some forms of pain serves as a reminder of the potential aggravating effect of emotional stress. Neuroplastic changes in afferent neurons can contribute to the development of chronic pain conditions, and these also are described. The author acknowledges that some of the pain classifications in this book may be flawed, but argues that their use still provides diagnostic advantages for the clinician.

The largest section in the book, "Clinical Pain Syndromes," describes the differential diagnosis and treatment of specific orofacial pain syndromes and probably will be of limited interest to physical therapists. An exception may be the clear, concise discussion of myofascial pain and trigger points in chapter 12: "Pains of Muscle Origin." Therapists who treat patients with temporomandibular joint (TMJ) disorders also may want to read chapter 13, which is devoted to TMJ disorders and includes a discussion of the role of cervical extension injuries in producing TMJ symptoms. The 35 case histories presented in this section are intended for dental professionals, but anyone who reads a few cases will appreciate the complexity of pain syndromes. For example, one patient had cardiac pain that was referred first to the left shoulder (and treated as bursitis) and then later referred to the mandible as a "toothache." Another patient had preauricular pain referred from a trigger point in the sternocleidomastoid muscle.

Although written primarily for dental professionals and pain researchers, this textbook should be of interest to physical therapists who specialize in the treatment of pain. Clinicians and educators may find the general review of pain and its associated signs in the first section worth reading. The book's emphasis that pain, especially chronic pain, is more than a simple sensation resulting from the noxious stimulation of sensory receptors can be a helpful reminder when treating patients whose symptoms and signs fail to respond to conventional therapies. This is a well-written, well-illustrated text on a difficult topic.

William A Roy, PT, PhD

Touro University-Nevada

Henderson, Nev

Dr Roy is Associate Professor in the Department of Basic Sciences. He has been a faculty member for 27 years and has taught physical therapist, occupational therapist, dental, and medical students.