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Dental education is moving toward models of education and care that are person-centered. The purpose of this article is to explore and describe the teaching and patient care model (the attending-based model) used for the past 50 years in the oral medicine department at one dental education institution. This article briefly discusses how this teaching model promotes person-centered care and the biopsychosocial model, while highlighting some of the barriers, benefits, and opportunities to wider adoption in dental education.
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AIMS: To investigate the relationship of headache frequency with patient-reported physical functioning and emotional functioning in temporomandibular disorder (TMD) subjects with concurrent temple headache. METHODS: The Research Diagnostic Criteria for TMD (RDC/TMD) Validation Project identified, as a subset of 614 TMD cases and 91 controls (n = 705), 309 subjects with concurrent TMD pain diagnoses (RDC/TMD) and temple headache. The temple headaches were subdivided into infrequent, frequent, and chronic headache according to the International Classification of Headache Disorders, second edition (ICHD-II). Study variables included self-report measures of physical functioning (Jaw Function Limitation Scale [JFLS], Graded Chronic Pain Scale [GCPS], Short Form-12 [SF-12]) and emotional functioning (depression and anxiety as measured by the Symptom Checklist-90R/SCL-90R). Differences among the three headache subgroups were characterized by increasing headache frequency. The relationship between ordered headache frequency and physical as well as emotional functioning was analyzed using linear regression and trend tests for proportions. RESULTS: Physical functioning, as assessed with the JFLS (P < .001), SF-12 (P < .001), and GCPS (P < .001), was significantly associated with increased headache frequency. Emotional functioning, reflected in depression and anxiety, was also associated with increased frequency of headache (both P < .001). CONCLUSION: Headache frequency was substantially correlated with reduced physical functioning and emotional functioning in subjects with TMD and concurrent temple headaches. A secondary finding was that headache was precipitated by jaw activities more often in subjects with more frequent temple headaches.
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Qualidade de Vida , Transtornos da Articulação Temporomandibular/fisiopatologia , Transtornos da Articulação Temporomandibular/psicologia , Cefaleia do Tipo Tensional/fisiopatologia , Cefaleia do Tipo Tensional/psicologia , Adulto , Ansiedade/etiologia , Estudos de Casos e Controles , Lista de Checagem , Dor Crônica/etiologia , Dor Crônica/fisiopatologia , Depressão/etiologia , Feminino , Humanos , Mastigação , Recidiva , Autorrelato , Perfil de Impacto da Doença , Fala , Transtornos da Articulação Temporomandibular/complicações , Cefaleia do Tipo Tensional/etiologiaRESUMO
The purpose of this investigation was to determine the value of adding narrow band (light) imaging (NBI) to the standard oral soft tissue examination process used to detect mucosal change. A total of 620 dental patients who came to the clinic for regular dental evaluation or for treatment of acute dental problems were given a standard oral soft tissue examination by dental students under faculty supervision. The results of the white light examination were recorded after the tissues were examined with NBI, at which point areas with a loss of fluorescence (LOF) were recorded. The nature of the tissue change was classified clinically as normal variation, inflammatory, traumatic, dysplastic, or other, and patients were categorized depending on their clinical findings: normal, need follow-up visit, or immediate biopsy. Risk factors related to oral dysplasia also were recorded. The addition of NBI added between one and two minutes to the examination process. Of the 620 examinations, an area with an LOF suggestive of pathology was detected in 69 subjects (11.1%). After a second immediate evaluation, 28 of the 69 subjects were scheduled for follow-up or biopsy. None of the lesions discovered in these 28 subjects had been detected using standard (white light) examination. Adding NBI to the routine clinical examination resulted in detection of changes not seen with white light examination in 11.1% of patients; of these, a small but important number were found to have otherwise undetected persistent changes representing inflammatory lesions or potentially dangerous oral dysplasia. Adding NBI as an adjunctive diagnostic procedure improved the quality and outcome of the examination process.
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Luz , Doenças da Boca/diagnóstico , Mucosa Bucal/anatomia & histologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Consumo de Bebidas Alcoólicas , Biópsia , Complicações do Diabetes , Detecção Precoce de Câncer , Feminino , Fluorescência , Seguimentos , Humanos , Hospedeiro Imunocomprometido , Líquen Plano Bucal/diagnóstico , Medições Luminescentes/instrumentação , Masculino , Pessoa de Meia-Idade , Doenças da Boca/patologia , Mucosa Bucal/lesões , Mucosa Bucal/patologia , Neoplasias Bucais/diagnóstico , Neoplasias Bucais/patologia , Higiene Bucal , Lesões Pré-Cancerosas/diagnóstico , Lesões Pré-Cancerosas/patologia , Fatores de Risco , Fumar , Adulto JovemRESUMO
AIMS: The purpose of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Validation Project was to assess the diagnostic validity of this examination protocol. The aim of this article is to provide an overview of the project's methodology, descriptive statistics, and data for the study participant sample. This article also details the development of reliable methods to establish the reference standards for assessing criterion validity of the Axis I RDC/TMD diagnoses. METHODS: The Axis I reference standards were based on the consensus of two criterion examiners independently performing a comprehensive history, clinical examination, and evaluation of imaging. Intersite reliability was assessed annually for criterion examiners and radiologists. Criterion examination reliability was also assessed within study sites. RESULTS: Study participant demographics were comparable to those of participants in previous studies using the RDC/TMD. Diagnostic agreement of the criterion examiners with each other and with the consensus-based reference standards was excellent with all kappas > or = 0.81, except for osteoarthrosis (moderate agreement, k = 0.53). Intrasite criterion examiner agreement with reference standards was excellent (k > or = 0.95). Intersite reliability of the radiologists for detecting computed tomography-disclosed osteoarthrosis and magnetic resonance imaging-disclosed disc displacement was good to excellent (k = 0.71 and 0.84, respectively). CONCLUSION: The Validation Project study population was appropriate for assessing the reliability and validity of the RDC/TMD Axis I and II. The reference standards used to assess the validity of Axis I TMD were based on reliable and clinically credible methods.
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Transtornos da Articulação Temporomandibular/classificação , Transtornos da Articulação Temporomandibular/diagnóstico , Adolescente , Adulto , Idoso , Consenso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Padrões de Referência , Reprodutibilidade dos Testes , Projetos de Pesquisa , Terminologia como Assunto , Estudos de Validação como Assunto , Adulto JovemRESUMO
The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Validation Project has provided the first comprehensive assessment of reliability and validity of the original Axis I and II. In addition, Axis I of the RDC/TMD was revised with estimates of reliability and validity. These findings are reported in the five preceding articles in this series. The aim of this article is to present further revisions of Axis I and II for consideration by the TMD research and clinical communities. Potential Axis I revisions include addressing concerns with orofacial pain differential diagnosis and changes in nomenclature in an attempt to provide improved consistency with other musculoskeletal diagnostic systems. In addition, expansion of the RDC/TMD to include the less common TMD conditions and disorders would make it more comprehensive and clinically useful. The original standards for diagnostic sensitivity ( < or = 0.70) and specificity (< or = 0.95) should be reconsidered to reflect changes in the field since the RDC/TMD was published in 1992. Pertaining to Axis II, current recommendations for all chronic pain conditions include standardized instruments and expansion of the domains assessed. In addition, there is need for improved clinical efficiency of Axis II instruments and for exploring methods to better integrate Axis I and II in clinical settings.
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Transtornos da Articulação Temporomandibular/classificação , Transtornos da Articulação Temporomandibular/diagnóstico , Algoritmos , Consenso , Dor Facial/diagnóstico , Humanos , Variações Dependentes do Observador , Padrões de Referência , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Terminologia como Assunto , Estudos de Validação como AssuntoRESUMO
AIMS: To evaluate the psychometric properties of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) biobehavioral (Axis II) screening instruments. METHODS: Participants with Axis I TMD diagnoses (n = 626) completed the Axis II instruments (Depression, Nonspecific Physical Symptoms, Graded Chronic Pain) and other instruments assessing psychological distress, pain, and disability at three study sites. Internal consistency, temporal stability, and convergent/discriminant validity of the Axis II measures were assessed. To assess criterion validity of Nonspecific Physical Symptoms and Depression instruments as screeners, 170 participants completed a structured psychiatric diagnostic interview. RESULTS: The Axis II instruments showed very good to excellent internal consistency (Cronbach's alpha coefficients = 0.80 to 0.95). Their convergent (correlation range 0.3 to 0.9) and discriminant (range 0.0 to 0.6) validity were generally supported, although Nonspecific Physical Symptoms was more strongly associated with depressive than with somatic symptoms. Temporal stability was high for characteristic pain intensity (Lin's correlation concordance coefficient [CCC] = 0.91), interference (CCC = 0.89), and chronic pain grade (weighted kappa = 0.87), and fair to good for Depression and Nonspecific Physical Symptoms (CCC = 0.63 to 0.78). The Depression instrument normal versus moderate to severe cutoff point was good at identifying current-year depression and dysthymia diagnoses (sensitivity 87%, specificity 53%). Nonspecific Physical Symptoms did not have high utility for detecting psychiatric disorders (sensitivity 86%, specificity 31%). CONCLUSION: The Axis-II Depression and Graded Chronic Pain instruments have clinically relevant and acceptable psychometric properties for reliability and validity and utility as instruments for identifying TMD patients with high levels of distress, pain, and disability that can interfere with treatment response and course of Axis I disorders.
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Depressão/diagnóstico , Psicometria , Transtornos da Articulação Temporomandibular/classificação , Transtornos da Articulação Temporomandibular/diagnóstico , Adulto , Dor Facial/diagnóstico , Feminino , Humanos , Entrevista Psicológica , Masculino , Variações Dependentes do Observador , Padrões de Referência , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Estudos de Validação como AssuntoRESUMO
AIMS: The primary aim was to determine new estimates for the measurement reliability of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I diagnostic algorithms. A second aim was to present data on the reliability of key clinical measures of the diagnostic algorithms. METHODS: Kappa (k), computed by generalized estimate equation procedures, was selected as the primary estimate of interexaminer reliability. Intersite reliability of six examiners from three study sites was assessed annually over the 5-year period of the RDC/TMD Validation Project. Intrasite reliability was monitored throughout the validation study by comparing RDC/TMD data collections performed on the same day by the test examiner and a criterion examiner. RESULTS: Intersite calibrations included a total of 180 subjects. Intersite reliability of RDC/TMD diagnoses was excellent (k > 0.75) when myofascial pain diagnoses (Ia or Ib) were grouped. Good reliability was observed for discrete myofascial pain diagnoses Ia (k = 0.62) and Ib (k = 0.58), for disc displacement with reduction (k = 0.63), disc displacement without reduction with limited opening (k = 0.62), arthralgia (k = 0.55), and when joint pain (IIIa or IIIb) was grouped (k = 0.59). Reliability of less frequently observed diagnoses such as disc displacements without reduction without limited opening, and osteoarthrosis (IIIb, IIIc), was poor to marginally fair (k = 0.31-0.43). Intrasite monitoring results (n = 705) approximated intersite reliability estimates. The greatest difference in paired estimates was 0.18 (IIc). CONCLUSION: Reliability of the RDC/TMD protocol was good to excellent for myofascial pain, arthralgia, disc displacement with reduction, and disc displacement without reduction with limited opening. Reliability was poor to marginally fair for disc displacement without reduction without limited opening and osteoarthrosis.
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Transtornos da Articulação Temporomandibular/classificação , Transtornos da Articulação Temporomandibular/diagnóstico , Algoritmos , Artralgia/diagnóstico , Dor Facial/diagnóstico , Humanos , Luxações Articulares/diagnóstico , Modelos Estatísticos , Variações Dependentes do Observador , Osteoartrite/diagnóstico , Padrões de Referência , Reprodutibilidade dos Testes , Síndrome da Disfunção da Articulação Temporomandibular/diagnóstico , Estudos de Validação como AssuntoRESUMO
AIMS: To estimate the criterion validity of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I TMD diagnoses. METHODS: A combined total of 614 TMD community and clinic cases and 91 controls were examined at three study sites. RDC/TMD Axis I diagnoses were algorithmically derived from an examination performed by calibrated dental hygienists. Reference standards ("gold standards") were established by means of consensus diagnoses rendered by two TMD experts using all available clinical data, including imaging findings. Validity of the RDC/TMD Axis I TMD diagnoses was estimated relative to the reference-standard diagnoses (gold standard diagnoses). Target sensitivity and specificity were set a priori at greater than or equal to 0.70 and greater than or equal to 0.95, respectively. RESULTS: Target sensitivity and specificity were not observed for any of the eight RDC/TMD diagnoses. The highest validity was achieved for Group Ia myofascial pain (sensitivity 0.65, specificity 0.92) and Group Ib myofascial pain with limited opening (sensitivity 0.79, specificity 0.92). Target sensitivity and specificity were observed only when both Group I diagnoses were combined (0.87 and 0.98, respectively). For Group II (disc displacements) and Group III (arthralgia, arthritis, arthrosis) diagnoses, all estimates for sensitivity were below target (0.03 to 0.53), and specificity ranged from below to on target (0.86 to 0.99). CONCLUSION: The RDC/TMD Axis I TMD diagnoses did not reach the targets set at sensitivity of > or = 0.70 and specificity of > or = 0.95. Target validity was obtained only for myofascial pain without differentiation between normal and limited opening. Revision of the current Axis I TMD diagnostic algorithms is warranted to improve their validity.
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Transtornos da Articulação Temporomandibular/classificação , Transtornos da Articulação Temporomandibular/diagnóstico , Adolescente , Adulto , Idoso , Artralgia/diagnóstico , Dor Facial/diagnóstico , Humanos , Luxações Articulares/diagnóstico , Modelos Logísticos , Pessoa de Meia-Idade , Variações Dependentes do Observador , Padrões de Referência , Reprodutibilidade dos Testes , Projetos de Pesquisa , Sensibilidade e Especificidade , Síndrome da Disfunção da Articulação Temporomandibular/diagnóstico , Estudos de Validação como Assunto , Adulto JovemRESUMO
AIMS: To derive reliable and valid revised Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I diagnostic algorithms for clinical TMD diagnoses. METHODS: The multisite RDC/TMD Validation Project's dataset (614 TMD community and clinic cases, and 91 controls) was used to derive revised algorithms for Axis I TMD diagnoses. Validity of diagnostic algorithms was assessed relative to reference standards, the latter based on consensus diagnoses rendered by two TMD experts using criterion examination data, including temporomandibular joint imaging. Cutoff points for target validity were sensitivity > or = 0.70 and specificity > or = 0.95. Reliability of revised algorithms was assessed in 27 study participants. RESULTS: Revised algorithm sensitivity and specificity exceeded the target levels for myofascial pain (0.82, 0.99, respectively) and myofascial pain with limited opening (0.93, 0.97). Combining diagnoses for any myofascial pain showed sensitivity of 0.91 and specificity of 1.00. For joint pain, target sensitivity and specificity were observed (0.92, 0.96) when arthralgia and osteoarthritis were combined as "any joint pain." Disc displacement without reduction with limited opening demonstrated target sensitivity and specificity (0.80, 0.97). For the other disc displacement diagnoses, osteoarthritis and osteoarthrosis, sensitivity was below target (0.35 to 0.53), and specificity ranged from 0.80 to meeting target. Kappa for revised algorithm diagnostic reliability was > or =0.63. CONCLUSION: Revised RDC/TMD Axis I TMD diagnostic algorithms are recommended for myofascial pain and joint pain as reliable and valid. However, revised clinical criteria alone, without recourse to imaging, are inadequate for valid diagnosis of two of the three disc displacements as well as osteoarthritis and osteoarthrosis.
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Transtornos da Articulação Temporomandibular/classificação , Transtornos da Articulação Temporomandibular/diagnóstico , Algoritmos , Artralgia/diagnóstico , Competência Clínica , Consenso , Dor Facial/diagnóstico , Humanos , Luxações Articulares/diagnóstico , Variações Dependentes do Observador , Osteoartrite/diagnóstico , Padrões de Referência , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Síndrome da Disfunção da Articulação Temporomandibular/diagnóstico , Estudos de Validação como AssuntoRESUMO
OBJECTIVES: The aim of this study was to assess the reliability, frequency, and clinical significance of temporomandibular joint (TMJ) medial and lateral disk positions, observed in the coronal-oblique plane, to determine their importance in clinical diagnosis and for routine imaging. STUDY DESIGN: This cross-sectional study involved secondary data analysis (clinical and imaging) of 401 participants of the TMJ Impact Study. We used the χ2 statistic to evaluate the associations between coronal disk positions with (1) anterior disk displacements with reduction and without reduction; and (2) familiar TMJ pain resulting from excursive movements and palpation, range of motion, and joint sounds. RESULTS: Anterior disk displacements of any type occurred in 67.5% of joints; in contrast, medial and lateral disk positions occurred in 16% and 24% of joints, respectively. Radiologist reliability was as follows: sagittal posterior band position: right κ = 0.68, left κ = 0.60, average 84% agreement; and medial or lateral disk position: right κ = 0.36, left κ = 0.32, average 70% agreement. Medial and lateral disk positions were associated with sagittal displacements (P < .001). However, there were no associations between medial and lateral disk positions and familiar pain, range of motion, and joint sounds. CONCLUSIONS: Coronal disk position does not contribute to clinical symptomatology or findings and currently lacks sufficient evidence to support its inclusion into standard TMJ imaging protocols or into a clinical diagnostic category.
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Luxações Articulares , Transtornos da Articulação Temporomandibular , Estudos Transversais , Humanos , Imageamento por Ressonância Magnética , Reprodutibilidade dos Testes , Articulação TemporomandibularRESUMO
OBJECTIVE: Our previous study of patients with unilateral temporomandibular joint (TMJ) osteoarthritis (OA) showed that the affected joints had greater horizontal condylar angle (HCA) compared with the contralateral unaffected joints. However, it was unclear whether the HCA changes preceded or were the result of OA changes. The aim of this longitudinal study was to investigate the relationship between HCA and OA progression. STUDY DESIGN: In total, 127 patients (with or without TMJ disorders) completed baseline and follow-up examinations (average time to follow-up 7.9 years). Generalized estimating equation models were used to account for correlation of observations within the same patients. RESULTS: (1) HCA was greater in OA-affected joints than in unaffected joints (Pâ¯=â¯.04). (2) Increased HCA at follow-up was associated with change in joint status from no OA to OA. (Pâ¯=â¯.001). (3) Baseline HCA value alone did not predict future OA diagnosis. (4) All OA changes in fossa/articular eminence morphology, and some combinations of condylar changes, were associated with a greater HCA. (5) OA diagnosis was associated with pain during maximum opening (Pâ¯=â¯.005) and pain history (Pâ¯=â¯.002). (6) Aging alone was not correlated with increased HCA. CONCLUSIONS: Clinical progression of OA preceded increases in HCA. HCA alone did not predict OA development.
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Côndilo Mandibular , Osteoartrite , Transtornos da Articulação Temporomandibular , Progressão da Doença , Humanos , Estudos Longitudinais , Côndilo Mandibular/anatomia & histologia , Articulação TemporomandibularRESUMO
Recurrent aphthous stomatitis (RAS) is a common ulcerative condition of the oral mucosa. In this study, minocycline oral rinses were compared to a placebo in patients suffering from frequent episodes of RAS. Thirty-three patients with RAS were randomly allocated to topical therapy with 0.2% minocycline or a placebo aqueous solution mouthwash. Seven patients also participated in a blind crossover study. The intensity of pain was recorded daily using a visual analogue scale. Minocycline mouthwashes resulted in significant reduction in the severity and duration of pain due to RAS. The findings in the subgroup that participated in the crossover were consistent with outcomes in the randomized study. The findings of this study show that minocycline oral rinses reduce pain in patients with RAS and may have implications for the use of minocycline in other non-infectious inflammatory ulcerative oral mucosal diseases.
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Antibacterianos/administração & dosagem , Antibacterianos/uso terapêutico , Minociclina/administração & dosagem , Minociclina/uso terapêutico , Antissépticos Bucais/uso terapêutico , Estomatite Aftosa/tratamento farmacológico , Administração Tópica , Adolescente , Adulto , Idoso , Estudos Cross-Over , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Antissépticos Bucais/administração & dosagem , Medição da Dor , Placebos , Recidiva , Método Simples-Cego , Resultado do TratamentoRESUMO
This study assessed the effectiveness of oral doxepin rinse for mucositis-related pain management in patients following 1 week of repeated dosing. Patients with oral mucositis due to head and neck radiation therapy or hematopoietic stem cell transplant (HSCT) were recruited to participate in a 1-week follow-up study. Subjects who gave informed consent rinsed with doxepin (5 ml) during the initial visit and were then told to use doxepin rinse over the next week as needed, three to six times per day, and return for a follow-up visit. At each visit, mucositis was scored using the Oral Mucositis Assessment Scale and oral pain was assessed using a visual analogue scale before and after rinsing. The use of a systemic analgesic was recorded, and side effects were documented. At the follow-up visit, subjects were also asked to retrospectively report average pain scores they experienced over the past week, 5 and 15 minutes following rinse. Nine subjects were enrolled in the study. Statistically significant reductions in pain scores were reported for 2 hours following doxepin rinse during the initial visit (p < .05). Patients recalled that their pain significantly dropped within 5 minutes of rinsing over the week of repeated dosing (p < .05). At the follow-up visit, subjects reported statistically significant pain reduction 5 minutes after doxepin rinsing (p < .05). These results indicate that doxepin rinsing continues to produce reduced intensity of pain levels over a 1-week span of repeated dosing.
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Antidepressivos Tricíclicos/uso terapêutico , Doxepina/uso terapêutico , Dor Facial/tratamento farmacológico , Neoplasias de Cabeça e Pescoço/tratamento farmacológico , Neoplasias de Cabeça e Pescoço/radioterapia , Mucosite/complicações , Adulto , Irradiação Craniana/efeitos adversos , Feminino , Seguimentos , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Antissépticos Bucais/uso terapêutico , Mucosite/etiologia , Medição da Dor , Estatísticas não Paramétricas , Estomatite/complicações , Estomatite/etiologia , Resultado do TratamentoRESUMO
BACKGROUND: An expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated clinical recommendations to inform primary care clinicians about the potential use of adjuncts as triage tools for the evaluation of lesions, including potentially malignant disorders (PMDs), in the oral cavity. TYPES OF STUDIES REVIEWED: This is an update of the ADA's 2010 recommendations on the early diagnosis of PMDs and oral squamous cell carcinoma. The authors conducted a systematic search of the literature in MEDLINE and Embase via Ovid and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials and diagnostic test accuracy studies. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and to move from the evidence to the decisions. RESULTS: The panel formulated 1 good practice statement and 6 clinical recommendations that concluded that no available adjuncts demonstrated sufficient diagnostic test accuracy to support their routine use as triage tools during the evaluation of lesions in the oral cavity. For patients seeking care for suspicious lesions, immediate performance of a biopsy or referral to a specialist remains the single most important recommendation for clinical practice. In exceptional cases, when patients decline a biopsy or live in rural areas with limited access to care, the panel suggested that cytologic testing may be used to initiate the diagnostic process until a biopsy can be performed (conditional recommendation, low-quality evidence). CONCLUSIONS AND PRACTICAL IMPLICATIONS: The authors urge clinicians to remain alert and take diligent action when they identify a PMD. The authors emphasize the need for counseling because patients may delay diagnosis because of anxiety and denial.
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Neoplasias Bucais/diagnóstico , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/patologia , Odontologia Baseada em Evidências , Humanos , Boca/patologia , Neoplasias Bucais/patologiaRESUMO
BACKGROUND: Oral squamous cell carcinoma is the most common manifestation of malignancy in the oral cavity. Adjuncts are available for clinicians to evaluate lesions that seem potentially malignant. In this systematic review, the authors summarized the available evidence on patient-important outcomes, diagnostic test accuracy (DTA), and patients' values and preferences (PVPs) when using adjuncts for the evaluation of clinically evident lesions in the oral cavity. TYPES OF STUDIES REVIEWED: The authors searched for preexisting systematic reviews and assessed their quality using the Assessing the Methodological Quality of Systematic Reviews tool. The authors updated the selected reviews and searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials and DTA and PVPs studies. Pairs of reviewers independently conducted study selection, data extraction, and assessment of the certainty in the evidence by using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: The authors identified 4 existing reviews. DTA reviews included 37 studies. The authors retrieved 7,534 records, of which 9 DTA and 10 PVPs studies were eligible. Pooled sensitivity and specificity of adjuncts ranged from 0.39 to 0.96 for the evaluation of innocuous lesions and from 0.31 to 0.95 for the evaluation of suspicious lesions. Cytologic testing used in suspicious lesions appears to have the highest accuracy among adjuncts (sensitivity, 0.92; 95% confidence interval, 0.86 to 0.98; specificity, 0.94; 95% confidence interval, 0.88 to 0.99; low-quality evidence). CONCLUSIONS AND PRACTICAL IMPLICATIONS: Cytologic testing appears to be the most accurate adjunct among those included in this review. The main concerns are the high rate of false-positive results and serious issues of risk of bias and indirectness of the evidence. Clinicians should remain skeptical about the potential benefit of any adjunct in clinical practice.
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Carcinoma de Células Escamosas/diagnóstico , Neoplasias Bucais/diagnóstico , American Dental Association , Carcinoma de Células Escamosas/patologia , Testes Diagnósticos de Rotina , Detecção Precoce de Câncer , Humanos , Neoplasias Bucais/patologia , Sensibilidade e Especificidade , Estados UnidosRESUMO
This research expands on our prior study, in which we assessed pain reduction after topical doxepin rinse in patients with oral mucositis resulting from cancer and cancer therapy. We continued to enroll patients with painful oral mucositis attributable solely to cancer therapy and performed further analysis on the duration of pain reduction. Fifty-one patients with oral mucositis were enrolled. Mucositis was scored and oral pain was assessed with a visual analog scale before doxepin oral rinse (5 mg/mL) and at regular intervals up to 4 h after rinsing. Of those who reported pain reduction, 95% did so within 15 min of rinsing with doxepin. In the total sample, the average patient reported a 70% maximum decrease in pain (P < 0.0001). Recurrence of pain was slow and at the conclusion of the study 19 patients (37%) still reported a reduction from baseline pain. With this censored data we used Cox-proportional hazards to determine what variables best explained longer duration of pain reduction. Our final model determined that more severe baseline pain, worse mucosal erythema score, or a larger relative maximum reduction in pain were all associated with a slower rate of pain recurrence after oral rinsing (all P < 0.01).
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Antidepressivos Tricíclicos/administração & dosagem , Doxepina/administração & dosagem , Mucosite/tratamento farmacológico , Neoplasias/terapia , Dor/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Modelos de Riscos Proporcionais , Fatores de TempoRESUMO
AIMS: To describe patients' daily coping with the pain of chronic temporomandibular disorders (TMD), the conservative treatment received, and the self-care strategies used, and to examine the relationships between these strategies and daily pain intensity, activity interference, and jaw use limitations. METHODS: TMD clinic patients (n = 137, 88% women) completed electronic diary measures of pain, interference, jaw use limitations, and use of 20 strategies 3 times daily for 2 weeks. RESULTS: Reliability and validity were demonstrated for 4 scales of related coping items: cognitive coping, relaxation, activity reduction, and emotional support. Average scores were higher on the relaxation and activity reduction scales than on the cognitive coping and emotional support scales. Among the coping items not included in the scales, "did something to try to reduce pain" (direct action) was endorsed most frequently (reported in a median of 74% of interviews). Heat, cold, and seeking spiritual support were used least (< or = 5%). At times of increased pain, patients were more likely to use almost all types of strategies. Pain intensity was associated strongly with concurrent activity interference and jaw use limitations. When the design controlled for pain intensity, activity reduction and seeking emotional support were associated positively within-subjects with interference and jaw use limitations. CONCLUSION: TMD clinic patients use a variety of treatment, self-care, and coping strategies to contend with daily pain. Inquiring about a broad range of strategies might help clinicians better understand how individual patients approach pain management. Research is needed to examine whether decreasing activity reduction and emotional support coping results in improved outcomes.
Assuntos
Adaptação Psicológica , Computadores de Mão , Dor Facial/psicologia , Medição da Dor/métodos , Transtornos da Articulação Temporomandibular/psicologia , Atividades Cotidianas , Adolescente , Adulto , Idoso , Dor Facial/etiologia , Feminino , Humanos , Entrevistas como Assunto , Masculino , Mastigação , Pessoa de Meia-Idade , Clínicas de Dor , Terapia de Relaxamento , Reprodutibilidade dos Testes , Autocuidado , Apoio Social , Transtornos da Articulação Temporomandibular/complicaçõesRESUMO
BACKGROUND: Treatment recommendations for patients with painful temporomandibular disorders (TMDs) range from conservative treatments such as physiotherapy to aggressive and irreversible treatments such as restorative reconstruction and joint surgery. METHODS: The authors randomized 200 subjects diagnosed with TMD into three groups: usual conservative, dentist-prescribed self-care treatment without any intraoral splint appliance (UT); UT plus a conventional flat-plane hard acrylic splint (HS); and UT plus a soft vinyl (a low-cost athletic mouth guard) splint (SS). Subjects completed questionnaires and clinical examinations at three, six and 12 months. RESULTS: The authors observed no significant differences among the groups in TMD-related pain levels or other common signs and symptoms of TMD at baseline (BL) or at any follow-up. The changes from BL were comparable for all three groups. The authors did not note any significant differences at any follow-up for compliance with study protocols or for occurrences of adverse effects from either splint type. For HS versus SS, there were significant differences in rates of splint use, but these differences were not accompanied by differences in either self-reported symptoms or in clinical findings. CONCLUSIONS: All patients improved over time, and traditional splint therapy offered no benefit over the SS splint therapy. Neither splint therapy provided a greater benefit than did self-care treatment without splint therapy. CLINICAL IMPLICATIONS: These findings suggest that clinicians who treat patients with TMD should consider prescribing low-cost nonsplint self-care therapy for most patients.
Assuntos
Transtornos da Articulação Temporomandibular/terapia , Resinas Acrílicas , Adolescente , Adulto , Anti-Inflamatórios não Esteroides/uso terapêutico , Terapia por Exercício , Feminino , Seguimentos , Temperatura Alta/uso terapêutico , Humanos , Masculino , Músculos da Mastigação/fisiopatologia , Pessoa de Meia-Idade , Protetores Bucais , Placas Oclusais , Medição da Dor , Cooperação do Paciente , Satisfação do Paciente , Amplitude de Movimento Articular/fisiologia , Autocuidado/economia , Transtornos da Articulação Temporomandibular/economia , Transtornos da Articulação Temporomandibular/fisiopatologia , Resultado do Tratamento , Compostos de VinilaRESUMO
The VELscope is an important aid in patient assessment, and when added to a well-thought out clinical assessment process that takes into consideration the age of the patient and risk factors that include tobacco, alcohol, and immunologic status, it increases the clinician's ability to detect oral changes that may represent premalignant or malignant cellular transformation. False positive findings are possible in the presence of highly inflamed lesions, and it is possible that use of the scope alone may result in failure to detect regions of dysplasia, but it has been our experience that use of the VELscope improves clinical decision making about the nature of oral lesions and aids in decisions to biopsy regions of concern. Where tissue changes are generalized or cover significant areas of the mouth, use of the scope has allowed us to identify the best region for biopsy. As with all clinical diagnostic activities, no single system or process is enough, and all clinicians are advised to use good clinical practice to assess patients and to recall and biopsy lesions that do not resolve within a predetermined time frame. Lesions that are VELscope-positive and absorb light need to be followed with particular caution, and if they do not resolve within a 2-week period, then further assessment and biopsy are generally advised. It is much better to occasionally sample tissue that turns out to be benign than to fail to diagnose dysplastic or malignant lesions. In our fight to protect patients from cancer, the VELscope improves our odds for early detection, hopefully resulting in fewer deaths from oral cancer.
Assuntos
Neoplasias Bucais/diagnóstico , Lesões Pré-Cancerosas/diagnóstico , Idoso de 80 Anos ou mais , Carcinoma/diagnóstico , Carcinoma in Situ/diagnóstico , Carcinoma de Células Escamosas/diagnóstico , Desenho de Equipamento , Feminino , Filtração/instrumentação , Fluorescência , Seguimentos , Neoplasias Gengivais/diagnóstico , Humanos , Leucoplasia Oral/diagnóstico , Iluminação/instrumentação , Masculino , Programas de Rastreamento/instrumentação , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Mucosa Bucal/patologia , Óptica e Fotônica/instrumentação , Neoplasias da Língua/diagnósticoRESUMO
This article presents an overview of possible mechanisms associated with pain perception, with a specific focus on understanding unusual manifestations of orofacial pain associated with nerve insult. It includes recent evidence concerning neurobiological changes that occur in the periphery at tissue and nerve sites, or within the central nervous system, and that may involve chemical and inflammatory responses, sensitization, or alterations of cellular function. Moreover, the contribution of the autonomic nervous system, changes in emotional reactivity and vigilance, the roles of high brain centers such as the basal ganglia (nigro-striatal) system, and the influence of aging and gender, are briefly described.