Development and preliminary evaluation of a new screening instrument for atypical odontalgia and persistent dentoalveolar pain disorder.

AIM: To develop and preliminarily evaluate a new screening instrument for atypical odontalgia (AO) or persistent dentoalveolar pain disorder (PDAP). To evaluate the instrument's performance in detecting AO/PDAP amongst a heterogeneous group of orofacial pain conditions and pain-free controls and empirically compare its performance with an established neuropathic screening instrument (S-LANSS), which is the best available standard. METHODS: The study design was cross-sectional; subjects recruited included a convenience sample of pain-free controls (n = 21) and four groups of orofacial pain conditions: AO/PDAP (n = 22); trigeminal neuralgia (n = 21); temporomandibular disorder (n = 41); and acute dental pain (n = 41). The instrument's internal reliability and factor structure were examined alongside its sensitivity and specificity and ROC-determined threshold score. RESULTS: The 9 AO/PDAP-specific items were found to moderately correlate with the S-LANSS (r = 0.58; P < 0.01). The 14-items of the full instrument were examined using exploratory factor analysis and reduced to ten items in a two-factor structure that explained 96% of the variance. This 10-item final instrument had a ROC area of 0.77 (95% CI: 0.67; 0.88), sensitivity of 77% (95% CI: 55; 92%), and specificity of 69% (95% CI: 60; 77%) with an intentionally higher false-positive rate than false-negative rate. In contrast, the S-LANSS exhibited sensitivity of 32% (95% CI: 14;55%) and specificity of 78% (95% CI: 70;85%) with less optimal false-positive versus false-negative rates. CONCLUSION: This preliminary study confirms the new screening instrument for AO/PDAP merits progression to field testing.

Self-management programmes in temporomandibular disorders: results from an international Delphi process.

Self-management (SM) programmes are commonly used for initial treatment of patients with temporomandibular disorders (TMD). The programmes described in the literature, however, vary widely with no consistency in terminology used, components of care or their definitions. The aims of this study were therefore to construct an operationalised definition of self-management appropriate for the treatment of patients with TMD, identify the components of that self-management currently being used and create sufficiently clear and non-overlapping standardised definitions for each of those components. A four-round Delphi process with eleven international experts in the field of TMD was conducted to achieve these aims. In the first round, the participants agreed upon six principal concepts of self-management. In the remaining three rounds, consensus was achieved upon the definition and the six components of self-management. The main components identified and agreed upon by the participants to constitute the core of a SM programme for TMD were as follows: education; jaw exercises; massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. This Delphi process has established the principal concepts of self-management, and a standardised definition has been agreed with the following components for use in clinical practice: education; self-exercise; self-massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. The consensus-derived concepts, definitions and components of SM offer a starting point for further research to advance the evidence base for, and clinical utility of, TMD SM.

What is the impact of acute and chronic orofacial pain on quality of life?

OBJECTIVES: Orofacial pain (OFP) is thought to substantially reduce oral health-related quality of life (OHRQoL). Little has been reported about the impact of acute dental pain and persistent (chronic) orofacial pain conditions, other than temporomandibular disorders (TMD), on OHRQoL. The aim of this study was to examine and compare OHRQoL impairment among four OFP conditions: TMD, acute dental pain (ADP), trigeminal neuralgia (TN) and persistent dentoalveolar pain disorder (PDAP). METHODS: OHRQoL was measured using the OHIP-49 in a convenience sample of subjects with four OFP conditions (TMD (n=41), ADP (n=41), TN (n=21), PDAP (n=22) and a pain-free control group (n=21)). The mean OHIP-49 summary score described the level of impact and inferential and descriptive statistics were used to examine any differences inter-condition. The mean of the OHIP-14 and 5 were also measured by extracting the corresponding items from the OHIP-49. RESULTS: All pain conditions presented with statistically significant (P<0.001) and clinically relevant (measured by effect sizes and the OHIP's minimal important difference) impairment when compared to the control group (P<0.001). The OHRQoL for the four OFP conditions had similar levels of impairment (TMD=62.3, ADP=55.5, TN=58.1 and PDAP=69.8). CONCLUSION: TMD, ADP, TN and PDAP have substantial impact on OHRQoL as measured by the OHIP-49 and the extracted items for the OHIP-14 and 5. Differences among the four groups of orofacial pain conditions are likely not to be substantial.

Oro-facial pain and nutrition: a forgotten relationship?

Oro-facial pain (OFP) is known to exert profound impacts on quality of life including functionally and psychosocially mediated changes in dietary intake and thereby nutrition. This commentary explores the evidence base available on chronic oro-facial pain, diet and nutrition and discusses current dietary guidance for individuals with chronic OFP; potential impact of chronic OFP on eating and nutritional status; impact of nutritional status on pathophysiology of chronic OFP; and potential role of nutrition in the management of chronic OFP.

Predicting severe pain after root canal therapy in the National Dental PBRN.

Some patients experience severe pain following root canal therapy (RCT) despite advancements in care. We sought to identify factors, which can be measured preoperatively, that predict this negative outcome so that future research may focus on preemptive steps to reduce postoperative pain intensity. Sixty-two practitioners (46 general dentists and 16 endodontists) who are members of the National Dental Practice-Based Research Network enrolled patients receiving RCT for this prospective observational study. Baseline data collected from patients and dentists were obtained before treatment. Severe postoperative pain was defined based on a rating of ≥7 on a scale from 0 (no pain) to 10 (pain as bad as can be) for the worst pain intensity experienced during the preceding week, and this was collected 1 wk after treatment. Multiple logistic regression analyses were used to develop and validate the model. A total of 708 patients were enrolled during a 6-m period. Pain intensity data were collected 1 wk postoperatively from 652 patients (92.1%), with 19.5% (n = 127) reporting severe pain. In multivariable modeling, baseline factors predicting severe postoperative pain included current pain intensity (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07 to 1.25; P = 0.0003), number of days in the past week that the subject was kept from their usual activities due to pain (OR, 1.32; 95% CI, 1.13 to 1.55; P = 0.0005), pain made worse by stress (OR, 2.55; 95% CI, 1.22 to 5.35; P = 0.0130), and a diagnosis of symptomatic apical periodontitis (OR, 1.63; 95% CI, 1.01 to 2.64; P = 0.0452). Among the factors that did not contribute to predicting severe postoperative pain were the dentist's specialty training, the patient's age and sex, the type of tooth, the presence of swelling, or other pulpal and apical endodontic diagnoses. Factors measured preoperatively were found to predict severe postoperative pain following RCT. Practitioners could use this information to better inform patients about RCT outcomes and possibly use different treatment strategies to manage their patients (Clinicaltrials.gov NCT01201681).

Healthcare pathway and biopsychosocial impact of persistent dentoalveolar pain disorder: a qualitative study.

AIM: To examine persistent dentoalveolar pain disorder (PDAP) patients' reported experiences of the biopsychosocial impacts of the condition and its healthcare pathway. METHODS: Qualitative semi-structured interviews were conducted with a university-based cohort of PDAP patients. One interviewer used an open-ended, evolving, topic guide, and all interviews were recorded and transcribed verbatim. Data collection and analysis continued until saturation (n = 20). The principles of the constant comparative method were followed, and frameworks were used to help organize and analyse the data. RESULTS: PDAP exerts significant biopsychosocial impacts on the individual. These impacts occur across a wide variety of everyday activities including employment, personal relationships and social activities. The conceptualization and acceptance of PDAP are difficult for patients given the reinforcement of multiple ineffective dental treatments perceived as targeting the source of their pain. CONCLUSION: There is an urgent need for earlier identification of PDAP cases in order to minimize the negative biopsychosocial effects of multiple dental interventions incorrectly applied to treat the symptom of pain.

Classifying orofacial pains: a new proposal of taxonomy based on ontology.

We propose a new taxonomy model based on ontological principles for disorders that manifest themselves through the symptom of persistent orofacial pain and are commonly seen in clinical practice and difficult to manage. Consensus meeting of eight experts from various geographic areas representing different perspectives (orofacial pain, headache, oral medicine and ontology) as an initial step towards improving the taxonomy. Ontological principles were introduced, reviewed and applied during the consensus building process. Diagnostic criteria for persistent dento-alveolar pain disorder (PDAP) were formulated as an example to be used to model the taxonomical structure of all orofacial pain conditions. These criteria have the advantage of being (i) anatomically defined, (ii) in accordance with other classification systems for the provision of clinical care, (iii) descriptive and succinct, (iv) easy to adapt for applications in varying settings, (v) scalable and (vi) transferable for the description of pain disorders in other orofacial regions of interest. Limitations are that the criteria introduce new terminology, do not have widespread acceptance and have yet to be tested. These results were presented to the greater conference membership and were unanimously accepted. Consensus for the diagnostic criteria of PDAP was established within this working group. This is an initial first step towards developing a coherent taxonomy for orofacial pain disorders, which is needed to improve clinical research and care.

Psychometric properties of the modified Symptom Severity Index (SSI).

The psychometric properties of the modified Symptom Severity Index were investigated to assess the relationships among dimensions of pain in temporomandibular disorders (TMD). The 15-item instrument is composed of ordinal scales assessing five pain dimensions (intensity, frequency, duration, unpleasantness and difficulty to endure) as experienced in three locations (temple, temporomandibular joint (TMJ), masseter). In 108 closed-lock subjects, Cronbach's alpha was used to measure internal consistency resulting in 31 of the 105 pair-wise comparisons >or=0.71. Multilevel exploratory factor analysis was used to assess dimensionality between items. Two factors emerged, termed temple pain and jaw pain. The jaw pain factor comprised the TMJ and masseter locations, indicating that subjects did not differentiate between these two locations. With further analysis, the jaw pain factor could be separated into temporal aspects of pain (frequency, duration) and affective dimensions (intensity, unpleasantness, endurability). Temple pain could not be further reduced; this may have been influenced by concurrent orofacial pains such as headache. Internal consistency was high, with alphas >or=0.92 for scales associated with all factors. Excellent test-retest reliability was found for repeat testing at 2-48 h in 55 subjects (Intra-class correlation coefficients = 0.97, 95%CI 0.96-0.99). In conclusion, the modified Symptom Severity Index has excellent psychometric properties for use as an instrument to measure pain in subjects with TMD. The most important characteristic of this pain is location, while the temporal dimensions are important for jaw pain. Further research is needed to confirm these findings and assess relationships between dimensions of pain as experienced in other chronic pain disorders.

Self-reported severity of taste disturbances correlates with dysfunctional grade of TMD pain.

Altered central neural processing of sensory information may be associated with temporomandibular disorders (TMD) pain. The objectives of this study were to compare the prevalence of self-reported taste disturbances in TMD pain patients and in a control population, and to determine whether frequency of taste disturbances was correlated with dysfunctional grade of TMD pain. Subjects were 2026 people within a German population sample and 301 consecutive TMD patients diagnosed using the Research Diagnostic Criteria. Taste disturbances were measured using two questions from the Oral Health Impact Profile. Dysfunctional grade of TMD pain was measured with the Graded Chronic Pain Scale. A two-sample test of proportions revealed that TMD patients reported a greater frequency of taste disturbances, 6%, than did the general population subjects, 2% (P < 0.001). Moreover, the frequency of taste disturbances correlated with the dysfunctional grade of TMD pain. For each 1 unit increase in taste disturbance, the odds of observing a higher grade of TMD pain increased by 29% (95% CI: 3-63%, P = 0.03). Analysis by individual taste question and adjustment for age and gender did not substantially affect the results. These findings are consistent with a central neural dysfunction in TMD pain and suggest that a common neural substrate may underlie sensory disturbances of multiple modalities in chronic pain patients. Further research regarding taste disturbances and trigeminally mediated pains such as in TMD is warranted.