This study has shown that chronic syndromes that are frequently unexplained co-occur in the general population and share common associated factors. Primary care practitioners need to be aware of these characteristics so that management is appropriate at the outset.

Current management of COFP is ineffective and unsatisfactory for patients and practitioners, which impacts on their relationship. Fundamental barriers to accessing and implementing psychological interventions for COFP arise from ineffective communication between physicians and patients, and between medical and dental practitioners. Statement of contribution What is already known on this subject? COFP is characterized by persistent pain in the face, mouth, or jaws that are not the result of organic disease or physical trauma. Patients with COFP present to both medical and dental services and receive sub-optimal care. No studies have examined the experiences of managing this problem from the perspectives of dentists, general practitioners and patients. What does this study add? Patients, dentists, and GPs recognize the role that psychological factors have in maintaining and addressing facial pain symptoms, yet principally manage it through biomedical interventions. Challenges exist over arriving at a diagnosis and managing the problem, and challenges are exacerbated by poor communication between doctors and medical services. Improvements are needed in liaison between medical and dental services and further training to support primary care clinicians to facilitate a stepped care approach to managing COFP.

Due to the cross-sectional nature of previous studies, whether mechanical factors predict the onset of Chronic oro-facial pain remains unclear. Aims of the current study were to test the hypotheses that self-reported mechanical factors would predict onset of Chronic oro-facial pain and that any observed relationship would be independent of the confounding effects of psychosocial factors and reporting of other unexplained symptoms. About 1735 subjects who had completed a baseline questionnaire were assessed at 2 year follow-up for the presence of Chronic oro-facial pain, psychosocial factors (anxiety and depression, illness behaviour, life stressors and reporting of somatic symptoms), mechanical dysfunction (facial trauma, grinding, phantom bite and missing teeth) and reporting of other unexplained symptoms (chronic widespread pain, irritable bowel syndrome and chronic fatigue). About 1329 subjects returned completed questionnaires (adjusted response rate 87%). About 56 (5%) reported new episodes of Chronic oro-facial pain at follow-up. Univariate analyses showed that age, gender, reporting of other unexplained symptoms, psychosocial factors and two self-report mechanical factors predicted the onset of Chronic oro-facial pain. However multivariate analysis showed that mechanical factors did not independently predict onset. The strongest predictors were health anxiety (Relative Risk (RR) 2.8, 95% CI 1.3–6.2), chronic widespread pain (RR 4.0 95% C.I. 2.2–7.4) and age (RR 0.2, 95% CI 0.1–0.7). The findings from this prospective study support the hypothesis that psychosocial factors are markers for onset of Chronic oro-facial pain. The efficacy of early psychological management of Chronic oro-facial pain to address these factors should be a priority for future investigations.

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Changes to financial incentive structures can produce large and abrupt changes in professional behaviours. In the context of multiple and conflicting goals, greater thought needs to be given to policies to change incentive structures to mitigate their unintended consequences.