Equity of African American Men in Headache in the United States: A Perspective From African American Headache Medicine Specialists (Part 1).

Migraine and severe headache affect approximately 1 in 6 U.S. adults and migraine is one of the most disabling disorders worldwide. Approximately 903,000 to 1.5 million African American (AA) men are affected by migraine in the United States. Racial disparities in headache medicine exist. In addition, there are limited headache studies that attest to the inclusion of or have robust data on AA men in headache medicine in the United States. Racial concordance between provider and patient may ameliorate some aspects of care disparities. Moreover, it has been demonstrated that diversity and inclusion particularly in leadership of organizations has consistently produced positive change, increased innovation, and long-term success. Most national headache organizations strive to improve the care and lives of people living with headache disorders yet only ~0.5% of their physician members are AA men. Herein, we provide an observation of equity issues from the perspective of AA men in the headache medicine subspecialty. Part 1 of this manuscript explores inherent and potential challenges of the equity of AA men in headache medicine including headache disparities, mistrust, understudied/lack of representation in research, cultural differences, implicit/explicit bias, and the diversity tax. Part 2 of this work offers possible solutions to achieve equity for AA men in headache including: (1) addressing head and facial pain disparities and mistrust in AA men; (2) professionalism and inclusion; (3) organizational/departmental leadership buy-in for racial diversity; (4) implicit/explicit and other bias training; (5) diversity panels with open discussion; (6) addressing diversity tax; (7) senior mentorship; (8) increased opportunities for noteworthy and important roles; (9) forming and building alliances and partnerships; (10) diversity leadership training programs; (11) headache awareness, education, and literacy with focus to underrepresented in medicine trainees and institutions; and (12) focused and supported the recruitment of AA men into headache medicine. More work is needed for equity of AA men in headache medicine.

Equity of African American Men in Headache in the United States: A Perspective From African American Headache Medicine Specialists (Part 2).

In part 1 of this opinion piece, we described inherent and potential challenges of the equity of African American (AA) men in headache medicine including headache disparities, mistrust, understudied/lack of representation in research, cultural differences, implicit/explicit bias, and the diversity tax. We shared personal experiences related to headache medicine likely faced due to the color of our skin. In part 2, we offer possible solutions to achieve equity for AA men in headache including: (1) addressing head and facial pain disparities and mistrust in AA men; (2) professionalism and inclusion; (3) organizational/departmental leadership buy-in for racial diversity; (4) implicit/explicit and other bias training; (5) diversity panels with open discussion; (6) addressing diversity tax; (7) senior mentorship; (8) increased opportunities for noteworthy and important roles; (9) forming and building alliances and partnerships; (10) diversity leadership training programs; (11) headache awareness, education, and literacy with a focus to underrepresented in medicine trainees and institutions; and (12) focused and supported the recruitment of AA men into headache medicine.

Demographic Predictors of Pain Sensitivity: Results From the OPPERA Study.

The demographic factors of sex, age, and race/ethnicity are well recognized as relevant to pain sensitivity and clinical pain expression. Of these, sex differences have been the most frequently studied, and most of the literature describes greater pain sensitivity for women. The other 2 factors have been less frequently evaluated, and current literature is not definitive. Taking advantage of the large Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) study cohort, we evaluated the association of sex, age, and self-reported race with 34 measures of pressure, mechanical, and thermal pain sensitivity encompassing threshold and suprathreshold perception. Women were significantly more pain-sensitive than men for 29 of 34 measures. Age effects were small, and only significant for 7 of 34 measures, however, the age range was limited (18-44 years of age). Race/ethnicity differences varied across groups and pain assessment type. Non-Hispanic white individuals were less pain-sensitive than African-American (for 21 of 34 measures), Hispanic (19 of 34), and Asian (6 of 34) individuals. No pain threshold measure showed significant racial differences, whereas several suprathreshold pain measures did. This suggests that racial differences are not related to tissue characteristics or inherent nociceptor sensitivity. Rather, the differences observed for suprathreshold pain ratings or tolerance are more likely related to differences in central nociceptive processing, including modulation imposed by cognitive, psychological, and/or affective factors. PERSPECTIVE: The influence of sex, age, and race/ethnicity on various aspects of pain sensitivity, encompassing threshold and suprathreshold measures and multiple stimulus modalities, allows for a more complete evaluation of the relevance of these demographic factors to acute pain perception.

Relato de caso oobre o uso da acupuntura no tratamento da dor orofacaal / Case reprt on thhe use of acupuncture in an orofacial treatmntt

A DTM (Disfunção temporomandibular) é considerada uma doença de etiologia multifatorial. Seus sintomas mais comuns são dor funcional da mandíbula, cefaleia, tensão muscular na região cervical, limitação na abertura da boca, desvio mandibular. Os tratamentos mais indicados são as terapias não invasivas e reversíveis. Acupuntura tem se mostrado tão eficiente no controle de dores facial quanto as terapias convencionais, principalmente, tratando-se de dores de origem muscular. Acupuntura é uma terapia chinesa milenar que consiste na inserção de agulhas descartáveis para promover o equilíbrio das energias que circulam pelo corpo humano. Este trabalho descreve o caso clínico da paciente C. G., 29 anos, que apresentava dor generalizada na face ao acordar, desgastes nas superfícies dentárias oclusais, tensão muscular na região cervical. O tratamento foi realizado de acordo com o desequilíbrio energético apresentado pela paciente, que desde a primeira sessão relatou diminuição da sintomatologia.

TMD is considered a multifactorial etiology disease. Its most common symptoms are functional jaw pain, headaches, muscular tension in the neck, mouth opening limitation, mandibular deviation. The most suitable treatments arenon-invasive and reversible therapies. Acupuncture has provento be effective in controlling facial pain as conventional therapies, especially in the case of muscular pain. Acupuncture is an ancient Chinese therapy that involves inserting fine needles to promote energy balance around the body. This study describes the clinical case of a 29-year-old patient that showed widespread pain in the face in the morning, abrasion on the occlusal teeth surfaces, muscular tension in the neck. The treatment was performed according to the energy unbalance diagnosis and symptoms which decreased since the first session.

Racial/Ethnic and gender prevalences in reported common pains in a national sample.

AIMS: To compare prevalences of self-reported temporomandibular joint and muscle disorders (TMJMD)-type pain, headaches, and neck and back pains in the 2000 to 2005 US National Health Interview Survey (NHIS) by gender and age for non-Hispanic Whites (Whites), Hispanics, and non-Hispanic Blacks (Blacks). METHODS: Data from the 2000 to 2005 NHIS included information on gender, age, race, ethnicity, and different common types of pain specifically: TMJMD-type pain, severe headaches/migraine, neck, and low back pains. RESULTS: A total of 189,992 people were included: 52% female and 48% male, 73% White, 12% Hispanic, 11% Black, and 4% "Other." The overall prevalence of TMJMD-type pain was 4.6%; severe headaches/migraine was 15.4%; neck, 14.9%; and low back, 28.0%. Survey logistic regression models estimating race-specific, age-adjusted curves revealed race by age pain differences. For TMJMD-type pain, White females presented the highest prevalence at younger ages, decreasing after age 40. Prevalences for Hispanic and Black females, although lower at younger ages, increased up to age 60 and remained higher than Whites. Males showed less racial/ethnic and age variation. Severe headaches/migraines presented an age pattern similar to TMJMD-type pain for White females and little overall variation for males, but without racial differences. Neck pain showed some similarities to TMJMD-type pain: higher in Whites at younger ages, lower at older ages, with Hispanics having the highest rates after their 60's. For low back pain, the rates peaked around the sixth decade for all racial/ethnic groups. CONCLUSION: The patterns of TMJMD-type pain varied greatly within and across racial/ethnic groups by gender and across the adult lifespan. Similarities and differences for the other pains were noted.

Self-report of alcohol use for pain in a multi-ethnic community sample.

UNLABELLED: This study examined the occurrence of alcohol use to manage pain in community-dwelling adults with tooth pain, jaw joint/face pain, and arthritis. Race/ethnicity, sex, and age were examined to determine their associations with alcohol use for pain. Community-dwelling adults from South Florida with tooth pain (n = 1,767), jaw joint/face pain (n = 1,199), or arthritis pain (n = 1,355) completed a structured telephone interview. Logistic regression models indicted that, similar to population rates, nonHispanic whites and males were the most likely to use alcohol to manage pain. In addition, alcohol use for pain was highest in younger adults. Individuals who self-managed oral pain with alcohol were more likely to use prescription and over-the-counter pain medications, but this association was not found for arthritis. Additional characteristics of individuals who self-medicated regardless of pain condition included greater pain frequency, depression, and higher levels of education. Being married was protective against the use of alcohol to manage pain symptoms. Use of alcohol for pain should be assessed during treatment evaluation so that physicians and other health care providers are aware of their patient's concomitant use of alcohol and pain medication, assess for psychosocial impairment, and make the appropriate referrals and adjustment to treatment. PERSPECTIVE: Self-medication of pain with alcohol is most common among younger nonHispanic white males and associated with pain frequency, depression, and use of pain medications. Alcohol use for pain needs to be assessed so that health care providers can make appropriate referrals and adjustments to treatment.

Depression and diffuse physical symptoms in southern Chinese with temporomandibular disorders.

The study investigated the experience of depressive symptoms and the relationship with diffuse physical symptoms reporting in southern Chinese seeking professional care for temporomandibular disorders (TMD) in Hong Kong. Eighty-seven new patients [77 females/10 males; mean age 39.3 years (SD 12.7)] referred to the specialist TMD clinic at the Prince Philip Dental Hospital, Hong Kong participated in this study. The Research Diagnostic Criteria (RDC)/TMD history questionnaire was used to derive Axis II psychological data. Psychological status was assessed through depression and non-specific physical symptoms (NPS) scores (pain items included and excluded) measured with RDC/TMD Axis II instruments; 42.5% of patients experienced moderate/severe depression symptoms; 59.8% and 57.5% had moderate/severe NPS scores when pain items were included and excluded, respectively. Strong, positive and statistically significant correlations were noted between depression scores and the NPS scores that included pain items (r = 0.80) and those that did not (r = 0.80). The correlations remained consistent and were of similar magnitude when male patients were excluded from the computation and also when the possible effect of patient age was controlled. While taking into account the modest patient sample which was related to a low rate of treatment seeking, depressive symptoms were common and similar to other western and Chinese patient groups. NPS reports were higher than in Singapore Chinese patients. There appeared to be a clear association between depression and diffuse physical symptoms. The findings should be considered in the holistic care of Chinese people with TMD.

Ethnic background as a factor in temporomandibular disorder complaints.

AIMS: To examine the associations between the ethnic backgrounds of temporomandibular disorder (TMD) patients in the Netherlands and the level of TMD pain complaints and psychological/behavioral factors and whether these associations are influenced by socioeconomic factors. METHODS: A sample of 504 consecutive patients from a TMD clinic completed the Research Diagnostic Criteria for TMD (RDC/TMD) Axis II questionnaire (pain intensity, pain-related disability, somatization, depression, ethnic background, and socioeconomic status), an oral parafunctions questionnaire, and questions related to stress. Ethnic background was classified, following the method of Statistics Netherlands (CBS), using the country of birth from subject and both parents. This resulted in a classification into three subgroups: Native Dutch (ND; 69.6%), Non-Native Western (NNW; 14.8%), and Non-Native Non-Western (NNNW; 15.6%). Statistics used were chi-square, one- and two-way ANOVA, and Kruskall-Wallis tests; for post-hoc interpretation, standardized residual values, Bonferroni, and Mann-Whitney U tests were used. RESULTS: No differences in age or gender were found between the three ethnic groups, nor were there any differences in characteristic pain intensity or oral parafunctions. However, TMD patients from the NNNW subgroup had significantly higher scores on psychological factors, namely pain-related disability, disability days, somatization, depression, and stress. These patients had a lower incidence of employment, a lower level of education, and a lower income level than patients from the ND and NNW ethnic backgrounds. Analysis of variance showed no interaction effects between ethnic background and socioeconomic factors in relation to the psychological variables mentioned. CONCLUSION: Ethnic background of TMD patients in the Netherlands is associated with psychological factors, regardless of socioeconomic status, but not with TMD pain complaints or oral parafunctions.

Acculturation and orofacial pain among Hispanic adults.

UNLABELLED: This study examined the associations between acculturation and orofacial pain and healthcare among Hispanic adults. Understanding the effects of acculturation on Hispanic oral health may improve understanding of oral health disparities in the United States. Data were collected from 911 Hispanic adults reporting tooth pain and painful oral sores who were part of a larger study of South Florida residents conducted using random-digit dialing methodology. The survey was conducted in Spanish or English by bilingual interviewers per the choice of each respondent. Greater use of the Spanish language was associated with disparities in healthcare visits for orofacial pain, not having a usual dentist, having greater pain, increased difficulty eating and sleeping, and more depression. Respondents' and their parents' nativity (families that had been in the United States longer) and those identifying more closely to Hispanic culture were also predictive of several of the outcomes. Gender, financial status, and age, independent of acculturation, were also associated with orofacial pain, accessing health care, and pain-related loss of functioning among Hispanics. The data support the hypothesis that Hispanics with less acculturation are less able to access needed oral health care. This study highlights the need for outreach programs targeting recent Hispanic immigrants focusing on oral health care. PERSPECTIVE: This study found that lower levels of acculturation, particularly less frequent use of English, were associated with greater oral pain and depression for Hispanics adults. This emphasizes the need to provide Hispanic patients with information in Spanish and the importance of having bilingual materials and staff in dental clinics.

Diagnostic sub-types, psychological distress and psychosocial dysfunction in southern Chinese people with temporomandibular disorders.

The study aimed to assess the distribution of temporomandibular disorders (TMD) sub-types, psychological distress and psychosocial dysfunction in southern Chinese people seeking treatment for TMD using Research Diagnostic Criteria for TMD (RDC/TMD) and investigate potential cross-cultural differences in sub-type prevalence and psychosocial impact. Eighty-seven consecutive patients (77 females; 10 males) with a mean age of 39.3 years (s.d. 12.8) newly referred to the specialist TMD clinic at the Prince Philip Dental Hospital, Hong Kong over a 20-month period took part in the study. RDC/TMD history questionnaire and clinical assessment data were used to derive Axis I and II findings. Group I muscle disorders were the most common and found in 57.5% of patients. Group II (disc displacement) disorders were found in 42.5% and 47.1% of the right and left temporomandibular joints (TMJ) respectively. Group III disorders (arthralgia/arthrosis/arthritis) were revealed in 19.5% and 23.0% of right and left TMJ's respectively. In the Axis II assessment, 42.5% of patients had moderate/severe depression scores, 59.7% had moderate/severe somatization scores and based on graded chronic pain scores 15.0% had psychosocial dysfunction (grade III and IV). While acknowledging the small sample size, the distribution of RDC/TMD Axis I and II diagnoses was fairly similar in Chinese TMD patients compared with Western and other Asian patient groups. However, in Chinese patients, myofascial pain with limited jaw opening and TMJ disc displacement with reduction were more common and a significant number experienced psychological distress and psychosocial dysfunction. The findings have implications for the management of TMD in Chinese people.

Race/ethnic differences in health care use for orofacial pain among older adults.

The purpose of this study was to describe race/ethnic differences in the use of formal health care services for painful oral symptoms by older adults. We also considered the sex of the respondent rather than assuming that males and females within a specific racial group would use health care services similarly. To our knowledge, these specific utilization patterns have never been reported before in the pain literature.Telephone interviews were conducted on a stratified random sample of 1,636 community dwelling older (65+) north Floridians. A total of 5,860 households were contacted and screened, with 75.3% participating to the point where their eligibility for the study could be determined. Overall race/ethnic differences in patterns of health care use for orofacial pain were not found. However, when we stratified race/ethnicity by sex, Black females (37.6%) were the least likely to have visited a health care provider, followed by non-Hispanic White females (47.2%), non-Hispanic White males (49.3%), and Black males (62.7%). Point estimates of odds ratio, adjusting for financial differences, indicate that more non-Hispanic White males (OR=1.79) and Black males (OR=2.74) visited a health care provider than Black females. Our results also suggest that for older Black adults, financial constraints have a more significant impact on decisions about health care for orofacial pain than they do for non-Hispanic Whites. For non-Hispanic White respondents, characteristics of the pain symptoms were significant determinates of health care use for their painful oral symptoms. Pain at its worst was a positive predictor for four of the five analyses (jaw joint pain, painful oral sores, temperature sensitivity, and toothache pain). The duration variable (years with pain) was a negative predictor of health care use. This is consistent with the conclusion that individuals seek care early in the course of the symptom, i.e. an active care seeking phase, make emotional or physical adjustments, and then resign themselves to the symptoms.

Orofacial pain: racial and sex differences among older adults.

OBJECTIVES: This study investigated racial differences in orofacial pain symptoms in a sample of older adults. Orofacial pain prevalence, persistence, severity, and behavioral impact were assessed. We also tested whether sex and race interact, such that racial differences are only observed for a single sex, or whether sex differences only occur within a single racial group. METHODS: Telephone interviews were conducted with a stratified random sample of 1,636 community-dwelling older (age 65+ years) north Floridians. RESULTS: Racial differences were not found for 12-month prevalence or pain ratings for any painful oral symptom, or in the total number of symptoms. The most consistent racial differences were in behavioral impact associated with pain. Blacks reported greater behavioral impact as defined by pain having reduced their daily activities or motivating them to take some action in response to pain. For toothache pain, that action was more likely to have been some form of self-medication. These relationships persisted after controlling for socioeconomic status, approach to health care, and pain intensity in multivariable models. CONCLUSION: Although pain prevalence is an important public health variable, this study suggests that other pain-related variables, such as behavioral impacts, are useful when describing disparities associated with orofacial pain.

Race and gender as TMD risk factors in children.

The aim of this study was to record the prevalence in preschool children of oral/facial pain symptoms of clinical interest in the diagnoses of temporomandibular disorders (TMD) and to analyze the association with the race and gender factors. Children, 525 4-6 year olds, mean age 5.1 +/- 0.65 (SD), 326 Caucasian and 199 African American, from a preschool and kindergarten program in a low income industrial area, who participated in a voluntary oral health examination, were examined. Comparisons were made using Chi-Square test. An alpha-level of 5% was chosen, and the effect of making multiple comparisons was compensated for by Bonferroni correction. No gender differences were found, but racial differences were observed regarding six of the 10 variables. Twenty-five percent of the children had recurrent (at least one to two times per week) headache. Thirteen percent had recurrent earache, African-American children more often than Caucasian children (p approximately 0.0038). Thirteen percent had recurrent temporomandibular joint (TMJ) pain, and 11% had recurrent neck pain. Pain or tiredness in the jaws during chewing was reported by 29% of the children, more often by African-American than by Caucasian (p < 0.00001). Pain at jaw opening occurred in 13% of the children, more often in the African-American than in the Caucasian children (p approximately 0.00004). Palpation pain was found in the posterior TMJ area in 28%, in the lateral TMJ area in 22%, in the masseter area in 19%, in the anterior temporalis area in 15% and was found more often in all of those regions in the African-American than in the Caucasian children (p approximately 0.00001), except for the temporalis area. In conclusion, this study showed that mild, but distinct, TMD-related oral/facial pain symptoms occur already by ages 4-6 with significant differences in distribution observed between the African-American and the Caucasian races. While gender seems to play a negligible role in this age group, this does not necessarily mean that race is a causative factor. The pain symptoms may be caused by other factors with different distribution in the two racial subgroups.