Endogenous pain modulation in chronic temporomandibular disorders: Derivation of pain modulation profiles and assessment of its relationship with clinical characteristics.

BACKGROUND: Endogenous pain modulation (EPM) reflects the brain's ability to modulate incoming nociceptive inputs, and deficient EPM was implicated as a chronic pain mechanism. EPM status has been investigated in temporomandibular disorders (TMD) patients with conflicting results, and its relationship with clinical characteristics in this population is not well known. OBJECTIVES: (a) Determine EPM responses in chronic TMD cases and pain-free controls; (b) Derive pain modulation profiles (PMP) based on individual EPM responses; and (c) Categorise clinical characteristics of TMD cases and pain-free controls based on their individual PMP. METHODS: Twenty-two chronic TMD cases and 17 age-matched pain-free controls, all females, were comprehensively characterised regarding clinical characteristics and underwent EPM testing using temporal summation of pain (TSP) and conditioned pain modulation (CPM) protocols over the face and hand. Individuals were categorised into PMPs (I-IV) based on predetermined cut-off points for TSP and CPM responses. RESULTS: Between-group comparisons showed similar TSP and CPM responses (P > 0.23) in the face, while TMD cases showed significantly increased TSP (P = 0.04) but similar CPM responses (P > 0.17) in the hand relative to controls. Similar distribution across PMPs and clinical characteristics when categorised into PMPs was found for both groups. Body mass index was associated with increased TSP and reduced CPM in the face in TMD cases. CONCLUSION: Endogenous pain modulation responses over the face were similar between groups. TMD cases showed increased hand TSP compared to controls while both groups showed no significant hand CPM. PMP classification showed similar results between groups, and further refinement of PMP determination is warranted.

Pharmacological treatment of oro-facial pain - health technology assessment including a systematic review with network meta-analysis.

This health technology assessment evaluated the efficacy of pharmacological treatment in patients with oro-facial pain. Randomised controlled trials were included if they reported pharmacological treatment in patients ≥18 years with chronic (≥3 months) oro-facial pain. Patients were divided into subgroups: TMD-muscle [temporomandibular disorders (TMD) mainly associated with myalgia]; TMD-joint (TMD mainly associated with temporomandibular joint pain); and burning mouth syndrome (BMS). The primary outcome was pain intensity reduction after pharmacological treatment. The scientific quality of the evidence was rated according to GRADE. An electronic search in PubMed, Cochrane Library, and EMBASE from database inception to 1 March 2017 combined with a handsearch identified 1552 articles. After screening of abstracts, 178 articles were reviewed in full text and 57 studies met the inclusion criteria. After risk of bias assessment, 41 articles remained: 15 studies on 790 patients classified as TMD-joint, nine on 375 patients classified as TMD-muscle and 17 on 868 patients with BMS. Of these, eight studies on TMD-muscle, and five on BMS were included in separate network meta-analysis. The narrative synthesis suggests that NSAIDs as well as corticosteroid and hyaluronate injections are effective treatments for TMD-joint pain. The network meta-analysis showed that clonazepam and capsaicin reduced pain intensity in BMS, and the muscle relaxant cyclobenzaprine, for the TMD-muscle group. In conclusion, based on a limited number of studies, evidence provided with network meta-analysis showed that clonazepam and capsaicin are effective in treatment of BMS and that the muscle relaxant cyclobenzaprine has a positive treatment effect for TMD-muscle pain.

Depressive symptoms account for differences between self-reported versus polysomnographic assessment of sleep quality in women with myofascial TMD.

Patients with temporomandibular disorder (TMD) report poor sleep quality on the Pittsburgh Sleep Quality Index (PSQI). However, polysomnographic (PSG) studies show meagre evidence of sleep disturbance on standard physiological measures. The present aim was to analyse self-reported sleep quality in TMD as a function of myofascial pain, PSG parameters and depressive symptomatology. PSQI scores from 124 women with myofascial TMD and 46 matched controls were hierarchically regressed onto TMD presence, ratings of pain intensity and pain-related disability, in-laboratory PSG variables and depressive symptoms (Symptoms Checklist-90). Relative to controls, TMD cases had higher PSQI scores, representing poorer subjective sleep and more depressive symptoms (both P < 0·001). Higher PSQI scores were strongly predicted by more depressive symptoms (P < 0·001, R2 = 26%). Of 19 PSG variables, two had modest contributions to higher PSQI scores: longer rapid eye movement latency in TMD cases (P = 0·01, R2 = 3%) and more awakenings in all participants (P = 0·03, R2 = 2%). After accounting for these factors, TMD presence and pain ratings were not significantly related to PSQI scores. These results show that reported poor sleep quality in TMD is better explained by depressive symptoms than by PSG-assessed sleep disturbances or myofascial pain. As TMD cases lacked typical PSG features of clinical depression, the results suggest a negative cognitive bias in TMD and caution against interpreting self-report sleep measures as accurate indicators of PSG sleep disturbance. Future investigations should take account of depressive symptomatology when interpreting reports of poor sleep.

Treatment needs and therapy experiences in patients with temporomandibular disorders: a retrospective survey.

OBJECTIVES: This study investigated a patient population suffering from temporomandibular disorders (TMD) with respect to their need for treatment, satisfaction with the information received, and the treatment provided. METHODS: A survey was sent by post to 1011 patients. RESULTS: Almost one-third of the patients had used analgesics prior to the start of any treatment. Having pain and functional jaw complaints was a risk factor for patients experiencing social restrictions. Subjects with severe complaints needed a range of conservative treatment modalities in combination with more follow-up appointments in agreement with the practitioners. Persons with remaining functional limitations were often unsatisfied with information and care they had received. The rate of compliance with prescribed treatment modalities and advice corresponded significantly higher with patient contentment with final outcome. DISCUSSION: Patient satisfaction is often determined by a qualitative doctor-patient relationship. The influence of complaints and pain on daily functioning was illustrated. Pain medication use at baseline seems to be predictive for persistent orofacial pain (OFP).

Assessment of Pain Drawings and Self-Reported Comorbid Pains as Part of the Biopsychosocial Profiling of Temporomandibular Disorder Pain Patients.

AIMS: To assess drawings of pain sites and self-reported comorbid pains as a part of the biopsychosocial profiling of tertiary care referral patients with temporomandibular disorder (TMD) pain. METHODS: A total of 135 consecutive patients referred to tertiary care for TMD pain participated. Patients drew all the sites where they had pain on whole-body pain drawings. Other assessments included self-reported comorbid pains in the head and body regions, the Finnish Research Diagnostic Criteria for TMD (RDC/TMD_FIN Axis II), and additional biopsychosocial and treatment-related variables. Patients were grouped into pain drawing profiles (localized, regional, and widespread) and the associations between these profiles and the biopsychosocial variables were statistically evaluated using Bonferroni adjusted P values and with logistic regression using SAS 9.3. RESULTS: A total of 21% of the patients reported localized TMD pain, 20% reported regional pain (headaches and neckaches), and the majority, 59%, reported widespread pain (local/regional and multiple bodily pain sites). Patients with widespread pain profiles formed a heterogenous group in which 28.2% reported severe and 30.8% reported moderate pain-related disability. The widespread pain patients reported significantly higher levels of depression and somatization, lower levels of general health, more sleep dysfunction, decreased ability to control pain, and greater health care needs compared to patients with localized pain (P < .05). Patients with regional pain profiles reported moderate scores on psychosocial functioning compared to the patients with localized or widespread pain. CONCLUSION: The majority of tertiary care referral patients with TMD pain reported comorbid pains. Pain drawings were found a useful adjunctive tool for screening and as a part of comprehensive biopsychosocial assessment and treatment planning for patients with TMD pain.

Design, construction, and technical implementation of a web-based interdisciplinary symptom evaluation (WISE) - a heuristic proposal for orofacial pain and temporomandibular disorders.

BACKGROUND: Medical symptoms independent of body location burden individuals to varying degrees and may require care by more than one expert. Various paper and computer-based tools exist that aim to comprehensively capture data for optimal clinical management and research. METHODS: A web-based interdisciplinary symptom evaluation (WISE) was newly designed, constructed, and technically implemented. For worldwide applicability and to avoid copyright infringements, open source software tools and free validated questionnaires available in multiple languages were used. Highly secure data storage limits access strictly to those who use the tool for collecting, storing, and evaluating their data. Concept and implementation is illustrated by a WISE sample tailored for the requirements of a single center in Switzerland providing interdisciplinary care to orofacial pain and temporomandibular disorder patients. RESULTS: By combining a symptom- burden checklist with in-depth questionnaires serving as case-finding instruments, an algorithm was developed that assists in clarifying case complexity and need for targeted expert evaluation. This novel modular approach provides a personalized, response-tailored instrument for the time- and cost-effective collection of symptom-burden focused quantitative data. The tool includes body drawing options and instructional videos. It is applicable for biopsychosocial evaluation in a variety of clinical settings and offers direct feedback by a case report summary. CONCLUSIONS: In clinical practice, the new instrument assists in clarifying case complexity and referral need, based on symptom burden and response -tailored case finding. It provides single-case summary reports from a biopsychosocial perspective and includes graphical symptom maps. Secure, centrally stored data collection of anonymous data is possible. The tool enables personalized medicine, facilitates interprofessional education and collaboration, and allows for multicenter patient-reported outcomes research.

Assessment of knowledge on temporomandibular disorders among Mexican dental educators / Evauación del conocimiento sobre trastornos temporomandibulares en docentes de odontología en México

Temporomandibular disorders (TMDs) is an umbrella term that embraces a group of musculoskeletal and neuromuscular conditions that involve the temporomandibular joints, muscles and all associated tissues. Because of the relatively high number of patients with TMDs in the population, instruction in this area of health care should be included on all dental curricula. Although levels of knowledge among dentists have been evaluated in several countries, they have not been in Mexico. This study evaluates the dental faculty's range of knowledge about TMD at five dental schools in Puebla, Mexico. Using an observational design, a survey was administered to 161 educators in order to assess their knowledge of TMD. Four domains were assessed, including: a) pathophysiology; b) psychophysiology; c) psychiatric disorders; and d) chronic pain. Overall knowledge of TMD was measured using a consensus of TMD experts' answers as a reference standard1The results show that educators' overall knowledge had 55% agreement with the reference standard. Individually, the psychophysiological domain was correctly recognized by 77.7% of the educators; correct responses on the other domains ranged from 38% to 56%. This study demonstrates the need to incorporate standardized TMDs instruction into the dental curricula at Mexican Universities, without which graduating dentists will lack the necessary knowledge or experience to diagnose and manage their TMD patients.

Los Trastornos Témporomandibulares (TTM) incluyen un grupo de condiciones musculoes que léticas y neuromusculares que afectan a la Articulación Temporomandibular (ATM), los músculos masticadores y otros tejidos asociados. Debido al número relativamente alto de pacientes con TTM en la población, la educación en esta área de la salud debe ser incluida en las currículas de las escuelas de odontología. A pesar de que el nivel de conocimiento sobre TTM ha sido evaluado en diversos países, esto no ha sido realizado en México, por lo que el objetivo del presente estudio fue evaluar el nivel de conocimiento sobre los TTM de los profesores de odontología en cinco universidades de Puebla, México. Bajo un diseño observacional, se administró una encuesta a 161 docentes de odontología para evaluar el nivel de conocimiento sobre los TTM. La encuesta incluyó cuatro dominios: a) patofisiología; b) psicofisiología; c) trastornos psiquiátricos y d) dolor crónico. Se usaron las respuestas otorgadas con un consenso de expertos como estándar de referencia1 para evaluar el nivel global de conocimiento sobre los TTM. Los resultados mostraron que los docentes tuvieron un nivel global de conocimiento del 55% de acuerdo al estándar de referencia. El dominio psicofisiológico indivi dualmente fue el mejor reconocido con el 77% de acuerdo con los expertos; las respuestas correctas en los otros dominios oscilaron entre el 38% y el 56%. El presente estudio demostró la necesidad de incorporar educación sobre los TTM estandarizada en la currícula de las escuelas o facultades de odontología en las universidades mexicanas. Hasta que esto suceda, las generaciones de odontólogos no tienen el conocimiento ni la experiencia necesarios para diagnosticar y manejar a los pacientes con Trastornos Temporomandibulares.

Pain paper 2b: classification of orofacial pain and an update on assessment and diagnosis.

The classification of chronic orofacial pain remains a contentious area. However, more recently, with the clarification of pain mechanisms and improved understanding of the underlying neurophysiology and modulation factors, there is more clarity of the possible division of pain conditions. Interestingly, the pathophysiology provides a basis for classification that has more clinical relevance. The principles of assessing and managing patients with pain have modified significantly, in line with recent improved understanding of the affective and emotional components in pain behaviour and suffering. Clinical Relevance: This paper aims to provide the dental and medical teams with a review of the classification of trigeminal pain with an overview of how to assess and diagnose patients with trigeminal pain.

Study on self-assessment regarding knowledge of temporomandibular disorders in children/adolescents by Swedish and Saudi Arabian dentists.

OBJECTIVE: To estimate the degree of self-assessed knowledge among dentists in Sweden and Saudi Arabia regarding temporomandibular disorders (TMD) in children and adolescents using a summative form of assessment and further to investigate the possible factors that may influence the self-assessed knowledge. MATERIALS AND METHODS: A questionnaire survey covering four domains (Etiology; Diagnosis and classification; Chronic pain and pain behavior; Treatment and prognosis) regarding TMD knowledge was used. Out of 250 questionnaires (125 in each country) a total of 65 (52%) were returned in Sweden and 104 (83%) in Saudi Arabia. RESULTS: Self-assessed individual knowledge was significantly associated to the level of actual knowledge among the Swedish groups in the domains Etiology; Diagnosis and classification and Treatment and prognosis (p < 0.05). However, in the Saudi Arabian groups a corresponding significant association was only found in the domain Diagnosis and classification (p < 0.05). CONCLUSIONS: This study showed that there is a difference in the accuracy of self-assessment of own knowledge between the dentists in Sweden and Saudi Arabia. The Swedish dentists have a better ability to assess their level of knowledge compared to Saudi Arabian dentists regarding TMD in children and adolescents. This difference could be related to several factors such as motivation, positive feedback, reflection, psychomotor, and interpersonal skills, which all are more dominant in the Swedish educational tradition.

Orofacial pain symptoms and associated disability and psychosocial impact in community-dwelling and institutionalized elderly in Hong Kong.

OBJECTIVE: The study investigated the experience of orofacial pain (OFP) symptoms and associated disability and psychosocial impact in community dwelling and institutionalized elderly people in Hong Kong. METHODS: A community-based cross-sectional survey involving elders aged 60 years and above. Participants were recruited at social centres for the elderly and homes for the aged throughout Hong Kong. Elders who reported OFP symptoms in the previous four weeks took part. Standard questions were asked about OFP conditions in the previous month and the Manchester Orofacial Pain Disability Scale (MOPDS), the Oral Health Impact Profile (OHIP-14) and the General Health Questionnaire (GHQ-12) were administered. The MOPDS was translated and validated for use in Chinese elders. RESULTS: 200 community dwelling and 200 institutionalized elders participated. Toothache was the most common symptom (62.0%) and burning sensation in the tongue was least common (0.5%). The distribution of pain symptoms, pain duration and severity and pain ratings were similar in both groups. The MOPDS (Chinese elders version) had good reliability and construct validity. The MOPDS and OHIP-14 summary scores was significantly higher in the institutionalized elderly (p < 0.001 and p < 0.013, respectively). Psychological distress (GHQ-12 score > or = 4) was more common among the institutionalized elderly (11%) than the community dwelling elderly (4.0%, p = 0.002). CONCLUSIONS: Orofacial pain symptoms were associated with significant disability and had a detrimental impact on psychological distress level and quality of life, particularly in the institutionalized elderly. There is a need to improve access to professional care and health-related outreach services generally for elderly people in Hong Kong.

Translation and validation of the Hindi version of the Geriatric Oral Health Assessment Index.

PURPOSE: To translate the original English version of the Geriatric Oral Health Assessment Index (GOHAI) into Hindi and assess its validity and reliability for use among people in India. MATERIALS AND METHOD: After translation into Hindi, a total of 385 participants aged 55+ demonstrated acceptable validity and reliability when used for people in India. Individual GOHAI items were recorded and summed as originally recommended. The questionnaire sought information about socio-demographic characteristics and self-reported perception of general and oral health. Clinical examination included assessment of periodontal status and number of decayed teeth, missing teeth, filled teeth and crowned teeth. RESULT: Mean GOHAI score was 40.9 (SD, 10.6; range, 12-60). Cronbach's alpha for the GOHAI score was 0.88, indicating a high degree of internal consistency and homogeneity between the GOHAI items. The test-retest correlation coefficient for add-GOHAI scores was 0.72, indicating good stability. Add-GOHAI scores increased with poorer perceived general and oral health. Convergent validity, construct validity and discriminant validity of the GOHAI were demonstrated. CONCLUSION: It could therefore be used as a valuable instrument for measuring oral health-related quality of life for people in this region.

The Oral Health Impact Profile: ranking of items for temporomandibular disorders.

The study aimed to rank the Oral Health Impact Profile (OHIP-49) items by relevance to temporomandibular disorders (TMD). A modified version of the OHIP-49 was completed by 110 patients with TMD and by age- and gender-matched TMD-free individuals. Patients were diagnosed using the Research Diagnostic Criteria (RDC) for TMD. The modified OHIP included a reference to the 'jaw' and a 1-month reference period. The difference in item prevalence for problems reported fairly/very often (FOVO) between the two groups was calculated for each OHIP item. The FOVO prevalence differences were ranked to reveal the most relevant problems for TMD. Patients' total OHIP scores were higher (60.6, SD = 31.6) than those of controls (17.1, SD = 18.1). Patients scored higher on all items, with 41 items showing a statistically significant difference between the patient score and the control score. The patient-control difference in FOVO item prevalence varied considerably between different items, ranging from 1 to 67%. Substantial differences were noted between patients and controls for a number of specific items, including those relating to pain and physical impact. Smaller differences across most items were also noted, even those not expected to have an impact. The OHIP provides a starting point for a measure of TMD treatment outcome, once items less attributable to TMD are excluded.

Objective and subjective assessment of masticatory function for patients with temporomandibular disorder in Korea.

This study examined the differences in the masticatory function of patients with temporomandibular disorder (TMD) in Korea. The experimental groups were as follows: 23 patients with painful arthralgia classified as pain group according to the research diagnostic criteria for temporomandibular disorder (RDC/TMC) and 28 patients with pain-free disc displacement and reduction classified as clicking group. The subjects were obtained from those who had visited Yonsei University Dental Hospital from 2007 to 2008. Twenty dental students without TMD symptoms were enroled as the normal control group. The Mixing Ability Index (MAI) was used as the objective index, and the Food Intake Ability (FIA) Index, Visual Analogue Scale (VAS) and oral health impact profile (OHIP) were used as the subjective indices. The MAI, FIA and VAS were significantly lower in the pain group than in the normal and clicking groups (P<0·05). The pain group showed a MAI, FIA and VAS of 16%, 81% and 67%, respectively, compared to that of the normal group. However, there were no significant differences in the MAI, FIA and VAS between the clicking and normal groups. The pain and clicking groups showed a 1·7 and 1·4 times higher OHIP value than the normal group (P<0·05). The MAI and subjective indices, such as the FIA (r=0·40) and VAS (r=0·48), showed a moderate correlation (P<0·01). In conclusion, pain is the main factor for the reduced masticatory function in patients with TMD in Korea, and the joint sound, not the masticatory function, affects the declining OHIP.

Assessment and further development of RDC/TMD Axis II biobehavioural instruments: a research programme progress report.

A symposium was held in Toronto, 2008, in which research progress regarding the biobehavioural dimension of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) was presented. An extended workshop was held in April 2009 in which further recommendations were made from an expert panel, using the 2008 symposium material as a base. This paper is a summary of the 2008 symposium proceedings with elaborations based on further developments. Seven studies were conducted between 2001 and 2008, in which the following were investigated: (i) basic properties of Axis II instruments, (ii) reliability and criterion validity of Axis II instruments, (iii) expansion of predictors, (iv) metric equivalence of the depression and non-specific physical symptoms subscales in the RDC/TMD, (v) laboratory investigation of oral behaviours, (vi) field data collection of oral behaviours, and (vii) functional limitation of the jaw. Methods and results for each of these studies are described. Based on the results of these studies that have been published, as well as the direction of interim results from the few studies that await completion and publication, the biobehavioural domain of the RDC/TMD, as published in 1992, is reliable and valid. These results also provide strong evidence supporting the future growth of the biobehavioural domain as the RDC/TMD matures into subsequent protocols for both clinical and research applications.

Comparison of subjective symptoms among three diagnostic subgroups of adolescents with temporomandibular disorders.

AIM: To compare subjective symptoms among three diagnostic subgroups of young patients with temporomandibular disorders (TMDs). DESIGN: We comprehensively examined 121 patients with TMDs (age ≤20 years; 90 female patients and 31 male patients) who completed self-reported forms for assessing subjective symptoms, which consisted of five items on pain intensity in the orofacial region and six items on the level of difficulty in activities of daily living (ADL) (rating scale, 0-10). They were divided into three diagnostic subgroups: temporomandibular joint (TMJ) problem (JT) group, masticatory muscle pain (MM) group, and the group with a combination of TMJ problems and masticatory muscle pain (JM group). Their symptoms were compared using the Kruskal-Wallis and Mann-Whitney U-tests. RESULTS: The intensity of jaw or face tightness and difficulty in talking and yawning were not significantly different among the groups. However, the MM and JM groups had a significantly higher rating for jaw or face pain, headache, neck pain, tooth pain, and difficulty in eating soft foods (P < 0.01). CONCLUSIONS: Young patients with MM or JM report more intense pain in the orofacial region and have more difficulties in ADL than those with JT problems alone.

Satisfaction with teeth and life-course predictors: a prospective study of a Swedish 1942 birth cohort.

This study aimed to assess the stability or change in satisfaction with teeth among Swedish adults between the ages of 50 and 65 yr, and to identify the impact of socio-demographics and of clinical and subjective oral health indicators on participants' satisfaction with teeth during that period. Self-administered standardized questionnaires were used as part of a longitudinal study. In 1992, 1997, 2002, and 2007 all residents (born in 1942) of two Swedish counties were invited to participate in the study. A total of 63% women and 66% men reported being satisfied with their teeth between 50 and 65 yr of age. The corresponding figures, with respect to dissatisfaction, were 7% and 6% respectively. Generalized estimated equation models revealed a decline in the odds of being satisfied with advancing age, which was particularly important in subjects with lower education, tooth loss, and smokers. Consolidation in oral health perceptions starts before age 50, suggesting early intervention before that age. Promotion of a healthy adult lifestyle and improved access to quality oral healthcare might increase the likelihood of people being satisfied with their teeth throughout the third age-period in both genders.

Psychological correlates of medical comorbidities in patients with temporomandibular disorders.

BACKGROUND: Medical comorbidities are common among patients with temporomandibular disorders (TMDs). The authors examined the relationship between the medical comorbidities in patients with TMDs and their psychological functioning. METHODS: The sample consisted of 1,060 adults with TMDs, of whom 85 percent (n = 901) were female. At the time patients were evaluated at a university orofacial pain center, from 1997 through 2007, they completed medical history and psychological questionnaires. On the basis of retrospective chart reviews, the authors assessed the relationship between medical comorbidities and psychological functioning, controlling for pain severity, by using multivariate analyses of covariance. RESULTS: The mean total number of medical comorbidities was 3.49 (standard deviation [SD] = 2.87; range, 0-16). The authors found a linear relationship between number of medical comorbidities and overall psychological distress (t[1, 959] = 16.79, P < .001) and interference owing to pain (t[1, 1,028] = 18.03, P < .001). CONCLUSIONS: Patients with TMDs who have medical comorbidities may be at increased risk of experiencing poor psychological functioning. Further study is needed to investigate whether the observed relationship changes across time. CLINICAL IMPLICATIONS: The physical and psychological health of patients with TMDs may influence the course of their pain condition. When treating these patients, dentists routinely should assess not only the symptoms of their TMDs but also their general health status.