Constructing the brief diagnostic criteria for temporomandibular disorders (bDC/TMD) for field testing.

BACKGROUND: Despite advances in temporomandibular disorders' (TMDs) diagnosis, the diagnostic process continues to be problematic in non-specialist settings. OBJECTIVE: To complete a Delphi process to shorten the Diagnostic Criteria for TMD (DC/TMD) to a brief DC/TMD (bDC/TMD) for expedient clinical diagnosis and initial management. METHODS: An international Delphi panel was created with 23 clinicians representing major specialities, general dentistry and related fields. The process comprised a full day workshop, seven virtual meetings, six rounds of electronic discussion and finally an open consultation at a virtual international symposium. RESULTS: Within the physical axis (Axis 1), the self-report Symptom Questionnaire of the DC/TMD did not require shortening from 14 items for the bDC/TMD. The compulsory use of the TMD pain screener was removed reducing the total number of Axis 1 items by 18%. The DC/TMD Axis 1 10-section examination protocol (25 movements, up to 12 sets of bilateral palpations) was reduced to four sections in the bDC/TMD protocol involving three movements and three sets of palpations. Axis I then resulted in two groups of diagnoses: painful TMD (inclusive of secondary headache), and common joint-related TMD with functional implications. The psychosocial axis (Axis 2) was shortened to an ultra-brief 11 item assessment. CONCLUSION: The bDC/TMD represents a substantially reduced and likely expedited method to establish (grouping) diagnoses in TMDs. This may provide greater utility for settings requiring less granular diagnoses for the implementation of initial treatment, for example non-specialist general dental practice.

Examination of Conditioned Pain Modulation in Myofascial TMD With Consideration of Temporal Summation.

Research on myofascial temporomandibular disorder (mTMD) has often focused on potential dysfunction in endogenous pain modulation. However, studies on the specific inhibitory and facilitatory components of endogenous pain modulation using conditioned pain modulation (CPM) and temporal summation of second pain (TSSP) have shown mixed results. This study aimed to 1) examine whether women with mTMD demonstrated efficient CPM compared to controls; 2) explore the association between independent measures of CPM and TSSP in women with mTMD relative to controls; and 3) determine whether resulting modulatory profiles differentially predicted pain intensity among cases. All participants were recruited from dental clinics. Cases were women who met the research diagnostic criteria for mTMD. Controls did not have facial pain on exam and were selected to be sociodemographically similar to cases. CPM and TSSP were assessed via independent psychophysical protocols. CPM was examined in linear mixed models predicting pain thresholds adjusted for age and stratified by TSSP. Mean CPM was estimated at a 2.2 (SD = 2.8) degree increase in pain thresholds (P ≤ .001), similar in cases and controls (P = .67). CPM was less efficient in cases with enhanced TSSP (P = .031), but not in controls. Although the double-pronociceptive profile of both low CPM and high TSSP trended higher among cases than controls, it did not predict higher levels of pain intensity among cases. This study does not support deficient inhibitory endogenous pain modulation in mTMD, but results suggest that inhibitory and facilitatory pain modulation should be examined concomitantly in the study of endogenous pain modulation. PERSPECTIVE: This manuscript presents a novel examination of inhibitory modulation by the level of facilitatory modulation in mTMD. The findings and approach may prove useful for mechanistic researchers studying endogenous pain modulation and clinical researchers seeking to jointly examine conditioned pain modulation and temporal summation in future research on chronic pain.

Temporal Summation and Aftersensations of Second Pain in Women with Myofascial Temporomandibular Disorder Differ by Presence of Temporomandibular Joint Pain.

Purpose: Mechanisms underlying myofascial temporomandibular disorder (mTMD) are poorly understood. One theory is dysfunction in the central mediation of pain, specifically in enhanced facilitatory pain modulation. Because mechanisms leading to central sensitization may differ for joint and muscle pain, this study of mTMD addressed phenotypic heterogeneity by temporomandibular (TM) joint pain in the examination of quantitative sensory testing (QST). Patients and Methods: The stimulus dependent increase in second pain (temporal summation (TS)) and associated aftersensations (AS) were examined across groups of women with mTMD with TM joint pain and without, and a demographically matched control group. Results: TS was slightly more evident in mTMD without joint pain vs with (p = 0.035), but AS were most robustly persistent in the group with joint pain vs without (p < 0.002). Conclusion: While both subgroups demonstrated evidence of central sensitization relative to controls on one of two measures, differences in QST results, if replicated, may point to possible differences in the mechanisms that yield central sensitization. Alternatively, it may represent methodological artifacts that need to be addressed. Therefore, greater consideration should be given to symptom-based phenotypes in studies examining TS and AS.

Painful Truth: The Need to Re-Center Chronic Pain on the Functional Role of Pain.

Pain is undesirable, whether it is a symptom of mild or severe illness or instead indicates disorder in the nervous system's ability to perceive and process sensory information. Nonetheless, pain is part of the body's ability to defend itself and promote its own survival-this is its fundamental evolutionary function. This normal expression of pain is not limited to what is considered useful because it alerts us to the initiation of illness. It also applies to pain that continues when illness or noxious stimuli persist. However, the parameters of what is here termed functional pain are not fully understood and are seldom explicitly the focus of research. This paper posits that failure to appreciate the functional role of pain in research has had significant unintended consequences and may be contributing to inconsistent research findings. To that end, the paper describes the misclassification issue at the core of chronic pain research-whether a given pain reflects functional or pathological processes-and discusses research areas where reconsidering the functional role of pain may lead to advancements.

Effect of multiple injections of botulinum toxin into painful masticatory muscles on bone density in the temporomandibular complex.

BACKGROUND: Adverse effects of masticatory muscle injections of Botulinum Toxin (Btx) have been noted in animal and, less dramatically, human studies. OBJECTIVE: Among women treated in multiple community-based private practices, to compare TMJ bone density and mandibular condylar volume between patients with myofascial TMJD receiving multiple masticatory muscle Btx treatments and similarly diagnosed women not receiving such treatment. METHODS: Cohorts consisted of women whose treatment charts indicated a diagnosis of myofascial TMJD: 35 received at least 2 Btx treatment cycles; 44 received none. Bone density at pre-specified regions of interest (ROI) was defined by grey scale values from Cone Beam CT, adjusting for a fixed density phantom included in each scan. Mean bone density and mandibular condyle volume were compared between groups. Dose-response effects were tested within the Btx-exposed group. RESULTS: The mean density of primary and secondary ROIs was similar between exposure groups, as was condylar volume. Among Btx-exposed women, increasing dose of Btx to the temporalis muscle was inversely proportional to the density of the trabecular area of the mandible body. Many Btx-exposed women received smaller doses of Btx to the masseter muscles than in most TMJD Btx clinical trials. CONCLUSION: Masticatory muscle injections of Btx failed to produce clinically significant TMJ bone-related changes. Should Btx receive regulatory approval for treatment of myofascial TMJD, a phase IV study is recommended to evaluate potential adverse effects of Btx on bone and muscle when administered at higher doses and/or for more treatment cycles.

Absence of joint pain identifies high levels of sleep masticatory muscle activity in myofascial temporomandibular disorder.

Although the development of reliable diagnostic criteria for temporomandibular disorders (TMDs) has operationalised identification of a subgroup with myofascial pain (mTMD), causal mechanisms remain elusive. This study examines masticatory muscle activity (MMA) in more homogenous research subgroups of mTMD. Data from an existing case-control study of women were used to subcategorise mTMD cases based on joint pain with palpation to isolate muscle-only pain (M-pain) vs muscle and joint pain (MJ-pain). Differences in laboratory indicators of MMA, specifically research diagnostic criteria for sleep bruxism (SB) and high background EMG activity, and other clinical and sociodemographic indicators were examined between groups. Compared to controls, the MJ-pain subgroup did not show elevated background EMG or sleep bruxism. In contrast, the M-pain subgroup showed significantly higher background EMG and a trend towards elevated prevalence of sleep bruxism. These results may explain why it has been difficult for studies of SB in mixed TMD and even mTMD samples to find a consistent positive association, since a positive association may be limited to mTMD without joint pain. The subcategorising of mTMD based on joint pain with palpation (ie M-pain, MJ-pain) appears to reveal subgroups with relatively high and low sleep masticatory muscle-specific activity. Findings need replication in a larger study with updated mTMD diagnostic criteria, but may prove useful for understanding mechanism of pain maintenance in mTMD with and without joint pain.

Perceived helpfulness of treatments for myofascial TMD as a function of comorbid widespread pain.

OBJECTIVE: This study examined whether patients with myofascial temporomandibular disorder (mTMD) comorbid with fibromyalgia (FM) receive different treatments or respond differently to these treatments than mTMD-only patients. MATERIALS AND METHODS: A total of 125 mTMD+ women were enrolled (26 FM+ and 98 FM-). mTMD and FM were assessed via clinical research examinations. Treatment histories and self-reported treatment-related improvement were obtained via interview. RESULTS: The top 3 most common treatments reported were oral appliances (59%), physical therapy (54%), and jaw exercises at home (34%). Use of alternative medicine was reported more frequently among FM+ women, but self-reported improvement did not differ by comorbid FM. Physical therapy was as likely reported by FM status but self-reported improvement scores trended higher for FM+ women. CONCLUSIONS: Oral appliances were as likely to be reported by FM comorbid as FM- women. Oral appliances did not outperform self-management treatments on self-reported improvement of facial pain. CLINICAL RELEVANCE: Results support the use of self-management as first-line treatment for mTMD and potential utility of inquiring about widespread pain for treatment planning.

Single-Item, Self-Rated Health is a Useful Indicator of Health in Myofascial Temporomandibular Disorders.

AIMS: To (1) examine differences in self-rated health (SRH) between a group of women with myofascial temporomandibular disorders (mTMD) and controls; (2) determine the extent to which pain, mental health, and physical function mediate these differences; and (3) explore specific mTMD symptoms and impairments explaining SRH among mTMD cases. METHODS: An existing dataset of a sample of women with mTMD (n = 125) and a group of demographically similar controls (n = 49) was used. SRH was measured via a single item with 5 answer options ranging from poor (SRH = 1) to excellent (SRH = 5). Bodily pain, mental health, and physical function were measured with the Short-Form Health Survey. Regression analyses with SRH as the outcome were conducted. RESULTS: mTMD cases reported poorer SRH compared to controls, and bodily pain score fully mediated these lower scores. Physical function partially mediated the association between mTMD and SRH, while mental health did not explain much of the variance in SRH. This pattern held in case-only analyses. The association was not explained by mTMD-specific symptoms or by localized mTMD pain severity, although mTMD disability was independently associated with lower SRH. CONCLUSION: SRH is a simple and useful tool to consider in mTMD research, as it discriminates between cases and controls based on pain and physical function and is associated with mTMD disability.

Adapting Evidence-Based Teen Pregnancy Programs to Be LGBT-Inclusive: Lessons Learned.

CONTEXT: Lesbian, gay, bisexual, and transgender (LGBT) youth show higher rates of sexual risk behaviors than heterosexual and cisgender youth; yet, most school-based sexual health education is largely heteronormative and cisnormative and does not recognize the spectrum of sexual and gender identity. New York City's Departments of Health and Education collaborated to create an LGBT-inclusive supplement to the Reducing the Risk curriculum and implement it in 21 South Bronx high schools. METHOD: Teachers completed an electronic survey to report the number of students reached and an online log to measure curriculum adherence. Students were administered an anonymous 74-item pre- and posttest to measure demographics, sexual health knowledge, and student satisfaction with the curriculum. Chi-square and t tests were used to assess differences in student demographics and changes in knowledge scores. RESULTS: Reducing the Risk was implemented in 21 schools reaching 230 classes and 5,673 students; with 161 classes receiving the supplement. Teachers reported completing an average of 70% of LGBT supplement activities. Students who received the supplement reported higher satisfaction and greater knowledge scores than students who did not. CONCLUSION: New York City experience shows that being more inclusive of LGBT teens while implementing preexisting evidence-based sexual and reproductive health programs is possible and replicable.

Bronx Teens Connection's Clinic Linkage Model: Connecting Youth to Quality Sexual and Reproductive Health Care.

PURPOSE: Teen pregnancy and birth rates in the Bronx have been higher than in New York City, representing a longstanding health disparity. The New York City Department of Health and Mental Hygiene implemented a community-wide, multicomponent intervention to reduce unintended teen pregnancy, the Bronx Teens Connection. The Bronx Teens Connection Clinic Linkage Model sought to increase teens' access to and use of sexual and reproductive health care by increasing community partner capacity to link neighborhood clinics to youth-serving organizations, including schools. METHODS: The Bronx Teens Connection Clinic Linkage Model used needs assessments, delineated the criteria for linkages, clarified roles and responsibilities of partners and staff, established trainings to support the staff engaged in linkage activities, and developed and used process evaluation methods. RESULTS: Early results demonstrated the strength and feasibility of the model over a 4-year period, with 31 linkages developed and maintained, over 11,300 contacts between clinic health educators and teens completed, and increasing adherence to the Centers for Disease Control and Prevention-defined clinical best practices for adolescent reproductive health. For those eight clinics that were able to provide data, there was a 25% increase in the number of teen clients seen over 4 years. There are many factors that relate to an increase in clinic utilization; some of this increase may have been a result of the linkages between schools and clinics. CONCLUSIONS: The Bronx Teens Connection Clinic Linkage Model is an explicit framework for clinical and youth-serving organizations seeking to establish formal linkage relationships that may be useful for other municipalities or organizations.

Pain Predicts Function One Year Later: A Comparison across Pain Measures in a Rheumatoid Arthritis Sample.

Background. Guidance is limited on best measures and time periods to reference when measuring pain in order to predict future function. Objective. To examine how different measures of pain predict functional limitations a year later in a sample of rheumatoid arthritis patients. Methods. Logistic regression analyses were conducted using baseline and one-year data (n = 262). Pain intensity in the last 24 hours was measured on a 0-10 numerical rating scale and in the last month using an item from the Arthritis Impact Measurement Scale 2 (AIMS2). AIMS2 also provided frequency of severe pain, pain composite scores, and patient-reported limitations. Physician-rated function was also examined. Results. Composite AIMS2 pain scale performed best, predicting every functional outcome with the greatest magnitude, a one-point increase in pain score predicting 21% increased odds of limitations (combined patient and physician report). However, its constituent item-frequency of severe pain in the last month-performed nearly as well (19% increased odds). Pain intensity measures in last month and last 24 hours yielded inconsistent findings. Conclusion. Although all measures of pain predicted some functional limitations, predictive consistency varied by measure. Frequency of severe pain in the last month provided a good balance of brevity and predictive power.

Involvement of monoaminergic system in the antidepressant-like effect of riparin I from Aniba riparia (Nees) Mez (Lauraceae) in mice.

In past studies conducted by our group, riparin I (rip I) isolated from the green fruit of Aniba riparia presented antianxiety effects in mice, while its analogs rip II and III showed anxiolytic and antidepressant-like actions. This time around, we investigated a possible antidepressant activity of rip I using the forced swimming test (FST) and tail suspension test (TST) as predictive tests for antidepressant activity in rodents. In addition, the involvement of the monoaminergic system in this effect was also assessed. rip I was acutely administered by intraperitoneal (i.p.) and oral (p.o) routes to male mice at doses of 25 and 50 mg/kg. Results showed that rip I at both tested doses and administration routes produced a significant decrease in immobility time in FST and TST. The pretreatment of mice with prazosin (1 mg/kg, i.p., an α1 -adrenoceptor antagonist), yohimbine (1 mg/kg, i.p., an α2 -adrenoceptor antagonist), SCH23390 (15 µg/kg, i.p., a dopamine D1 receptor antagonist), sulpiride (50 mg/kg, i.p., a dopamine D2 receptor antagonist), p-chlorophenylalanine (100 mg/kg, an inhibitor of serotonin synthesis) or ritanserin (4 mg/kg, a serotonin 5-HT2(A)/2(C) receptor antagonist) blocked the anti-immobility effects elicited by rip I (50 mg/kg, p.o.) in the FST. Taken together, results indicate that rip I produces significant antidepressant-like activity in the FST and TST, and this effect seems to be dependent on its interaction with noradrenergic, dopaminergic and serotonergic systems.

Gestão da assistência farmacêutica do Brasil: revisão integrativa da literatura / Management of pharmaceutical services in Brazil: integrative literature review

Com a Política Nacional de Medicamentos, a assistência farmacêutica (AF) tornou-se parte integrante de um conjunto de práticas voltadas para a promoção, prevenção e recuperação de saúde, tendo o medicamento como principal insumo, porém contemplando atividades que extrapolam o simples abastecimento de medicamentos, compreendendo seleção, programação, aquisição, armazenamento, distribuição, prescrição, dispensação e uso. O presente estudo tem como objetivo realizar uma revisão integrativa da literatura no sentido de fornecer um documento de atualização e compilação de dados recentes acerca da gestão da AF do Brasil nos últimos anos. Para a busca dos artigos foram consultadas as bases de dados LILACS, SciELO e MEDLINE, com os descritores “gestão da assistência farmacêutica” e “assistência farmacêutica e gestão”. Os  critérios de inclusão considerados foram: os artigos eletrônicos estarem disponíveis na íntegra, em língua portuguesa e que foram publicados no período compreendido entre 2006 e 2013. Para a coleta de dados dos artigos selecionados, foram utilizados os itens: ano, tipo de estudo, título e objetivo. Foram selecionados oito artigos científicos. Observou-se que, apesar de todos os trabalhos apresentarem objetivos diferentes dentro de uma mesma temática, todos trouxeram à tona um problema comum: a falta de estruturação adequada da AF no Brasil. Ficou evidenciado que a AF é ainda vista como um mero setor de fornecimento de medicamentos. Sugere-se, portanto, uma gestão voltada para atividades de natureza administrativa com AF voltada para o medicamento e usuário...

With the National Drug Policy, the pharmaceutical care (PC) has become an integral part of a set of practices for the promotion, prevention and health recovery, having the drug as the main ingredient, but contemplating activities that extrapolate the mere supply of drugs, including selection, programming, acquisition, storage, distribution, prescription, dispensing and use. This study has as an objective to carry out an integrative literature review in order to provide an updated document and compilation of recent data on the management of the PC in Brazil in recent years. For the search of articles were consulted the databases LILACS, SciELOand MEDLINE with the descriptors “management of pharmaceutical care” and “pharmaceutical care and management”. Inclusion criteria were: electronic articles are available in full in Portuguese and which were published in the period between 2006 and 2013. To collect the data of the selected articles, the following items were used: year, type of study, title and objective. Eight scientific articles were selected. It was observed that, despite all the articles have different objectives within the same theme, all brought to light a common problem: the lack of proper structuring of PC in Brazil. The study revealed that PC is still seen as a mere drug supply sector. Therefore, it is suggested the management focused on administrative activities with PC facing the drug and user...

Magnetic nanosystem for cancer therapy using oncocalyxone a, an antitomour secondary metabolite isolated from a Brazilian plant.

This paper describes the investigation and development of a novel magnetic drug delivery nanosystem (labeled as MO-20) for cancer therapy. The drug employed was oncocalyxone A (onco A), which was isolated from Auxemma oncocalyx, an endemic Brazilian plant. It has a series of pharmacological properties: antioxidant, cytotoxic, analgesic, anti-inflammatory, antitumor and antiplatelet. Onco A was associated with magnetite nanoparticles in order to obtain magnetic properties. The components of MO-20 were characterized by XRD, FTIR, TGA, TEM and Magnetization curves. The MO-20 presented a size of about 30 nm and globular morphology. In addition, drug releasing experiments were performed, where it was observed the presence of the anomalous transport. The results found in this work showed the potential of onco A for future applications of the MO-20 as a new magnetic drug release nanosystem for cancer treatment.