Comorbidities between temporomandibular disorders and somatization in young adults: exploring links with personality, emotional, and sleep disturbances

OBJECTIVE

The comorbidities between temporomandibular disorders (TMDs) and somatization and their associations with personality traits, emotional disorders, and sleep disturbances were investigated.

STUDY DESIGN

Adults aged 18 to 24 years completed an electronic survey encompassing TMD symptoms (5Ts), Patient Health Questionnaire-15, Big Five Personality Inventory-10, Depression Anxiety Stress Scales-21, and Pittsburgh Sleep Quality Index. Data were assessed using non-parametric tests/correlation analysis and logistic regression analysis (α = 0.05).

RESULTS

The sample comprised 365 participants, of whom 22.2% and 19.5% were 5Ts-negative without and with somatization, respectively, and 18.1% and 40.3% were 5Ts-positive without and with somatization, respectively. Significant differences in neuroticism, distress, depression, anxiety, stress, and sleep quality were observed between 5Ts-negative participants with somatization and 5Ts-positive participants with somatization compared with 5Ts-negative participants without somatization and 5Ts-positive participants without somatization. Distress, anxiety, stress, and sleep were moderately correlated with somatic but not TMD symptoms (rs = 0.45-0.52).

CONCLUSIONS

Irrespective of whether they had TMDs, participants with somatization exhibited heightened levels of neuroticism and emotional and sleep disturbances.

Occupations associated with treatment seeking and biopsychosocial functioning at a tertiary orofacial pain clinic: A cross-sectional study

BACKGROUND

The aim of this study was to describe whether certain occupations were over- or underrepresented and to compare biopsychosocial functioning by types of occupation and employment status among adults seeking orofacial pain (OFP) treatment.

METHODS

The authors extracted self-reported employment status, occupation, and biopsychosocial functioning from initial appointment records of 444 treatment-seeking adults at a university-affiliated OFP clinic. The authors categorized occupations in major and minor occupational groups according to the 2018 Standard Occupational Classification. The authors compared proportions between their sample and the corresponding state level, using a ratio and 95% CI (1.00 = equal representation in sample vs state, < 1.00 = underrepresentation, > 1.00 = overrepresentation).

RESULTS

Among major occupational categories, health care practitioners and technical occupations were the most common in the study sample (22.4%) and the second most overrepresented (ratio, 3.20; 95% CI, 2.59 to 3.97) after the arts, design, entertainment, sports, and media occupations (ratio, 3.95; 95% CI, 2.15 to 7.26). Among minor occupational categories, teachers and instructors were the most common in the study sample (11.2%) and the most overrepresented (ratio, 90.71; 95% CI, 65.67 to 125.30), followed by managers (ratio, 43.87; 95% CI, 29.61 to 64.99) and photographers (ratio, 40.89; 95% CI, 10.23 to 163.4). No differences were observed in biopsychosocial functioning between major occupational categories. However, those not working due to health reasons or disability had worse biopsychosocial functioning (insomnia, anxiety and depression, life satisfaction, sleep health, pain intensity, pain-related interference; all P < .034) than those who were employed.

CONCLUSIONS

Several occupations are strongly over- and underrepresented among adults seeking OFP treatment. Differences were not explained by biopsychosocial functioning.

PRACTICAL IMPLICATIONS

Future research should attempt to identify and address the underlying mechanisms of association between occupation and seeking care for OFP.

The additional value of e-Health for patients with a temporomandibular disorder: a mixed methods study on the perspectives of orofacial physical therapists and patients

PURPOSE

To assess the experience and perceived added value of an e-Health application during the physical therapy treatment of patients with temporomandibular disorders (TMD).

MATERIALS AND METHODS

A mixed-methods study including semi-structured interviews was performed with orofacial physical therapists (OPTs) and with TMD patients regarding their experience using an e-Health application, Physitrack. The modified telemedicine satisfaction and usefulness questionnaire and pain intensity score before and after treatment were collected from the patients.

RESULTS

Ten OPTs, of which nine actively used Physitrack, described that the e-Health application can help to provide personalised care to patients with TMD, due to the satisfying content, user-friendliness, accessibility, efficiency, and ability to motivate patients. Ten patients, of which nine ended up using Physitrack, felt that shared decision-making was very important. These patients were positive towards the application as it was clear, convenient, and efficient, it helped with reassurance and adherence to the exercises and overall increased self-efficacy. This was mostly built on their experience with exercise videos, as this feature was most used. None of the OPTs or patients used all features of Physitrack. The overall satisfaction of Physitrack based on the telemedicine satisfaction and usefulness questionnaire (TSUQ) was 20.5 ± 4.0 and all patients (100%) showed a clinically relevant reduction of TMD pain (more than 2 points and minimally 30% difference).

CONCLUSION

OPTs and patients with TMD shared the idea that exercise videos are of added value on top of usual physical therapy care for TMD complaints, which could be delivered through e-Health.Implications for RehabilitationPhysical therapists and patients with temporomandibular disorders do not use all features of the e-Health application Physitrack in a clinical setting.Exercise videos were the most often used feature and seen as most valuable by physical therapists and patients.Based on a small number of participants, e-Health applications such as Physitrack may be perceived as a valuable addition to the usual care, though this would need verification by a study designed to evaluate the therapeutic effect (e.g., a randomised clinical trial).

Presentation and primary care management of temporomandibular disorders: A survey of primary care dentists in Santiago and Newcastle

BACKGROUND

Primary care dentists are often the first point of call for people with temporomandibular disorders (TMD) but it is not known how many people present to their dentist with TMD or the forms of first-line management that are routinely offered.

OBJECTIVES

To report rates of presentation of TMD and management offered in primary care by general dental practitioners in two similarly urban areas, Santiago, Chile and North-East England.

METHODS

An online survey was developed and distributed to primary care dentists in both regions. Descriptive data were presented to quantify presentation rates and forms of management offered.

RESULTS

Responses were received from 215 dentists practising in Chile and 46 in Newcastle. The majority reported seeing 1-2 patients weekly with TMD and less than one new presentation each week. Symptoms were most often treated conservatively and with self-management according to international guidelines. The form of self-management varied however and verbal instructions were often not backed up by written information.

CONCLUSIONS

This research provides a useful starting point in understanding the presentation to, and initial treatment of TMD in primary care internationally. Limitations included the method of recruitment and potentially non-representative samples. Further research could build on this work by including more countries and using more structured sampling methods. The work will be useful in understanding and planning early care pathways for people experiencing TMD.

Chronic temporomandibular disorder pain patients with a history of neuropathic pain treatment: a narrative research on their diagnosis and treatment history

The aims of this qualitative research were (1) to gain more insight in the diagnostic and treatment history of patients with chronic temporomandibular disorder (TMD) pain; (2) to get a deeper understanding of possible factors that are involved in the possible delay in setting a TMD-pain diagnosis and receiving appropriate treatment; and (3) to get a deeper understanding of the perspectives and experiences of chronic TMD-pain patients on the possible improvement of various aspects of their diagnostic and treatment journey.MethodsIn this narrative research, semi-structured interviews took place with patients who experienced chronic orofacial pain (OFP) for at least three years before getting diagnosed with, and treated for, TMD pain by an OFP specialist in an interprofessional setting.ResultsIn total, ten patients were interviewed in-depth. Patients experienced their chronic OFP in different ways, but all reported a significant impact of their pain on their quality of life. All patients visited numerous health care professionals before their TMD diagnosis was set. Among others, they underwent anti-neuropathic pain medication therapies and invasive surgeries, which did not significantly reduce their chronic OFP. The interprofessional TMD-pain treatment reduced the suffering of the chronic OFP substantially, also 6 months after the start of therapy, and improved the quality of life for all patients. In most of them, the OFP intensity was also decreased.ConclusionChronic TMD-pain patients with a history of neuropathic pain treatment may experience a long journey until receiving the appropriate diagnosis and treatment. This stresses the need to improve the implementation of chronic TMD-pain guidelines.

THE 3P MODEL AND ORAL HEALTH IMPACT: DEMONSTRATING THE IMPORTANCE OF BEHAVIORAL AND SOCIAL SCIENCES IN THE FUTURE OF EVIDENCE-BASED DENTISTRY

Oral health impact or oral health related quality of life is an increasingly important and well-known metric in dental care and research. There have been recent calls for greater integration of the behavioral and social sciences into oral health research and practice, including the need for frameworks and theories to guide this work. One such framework for understanding the role of predisposing, precipitating, and perpetuating biopsychosocial mechanisms in health and disease is the "3P" model. Here, the 3P model is described and applied to case examples to help understand the development and maintenance of oral health impact. Additionally, this paper outlines how this conceptualization using the 3P model and oral health impact makes way for greater integration of behavioral interventions to prevent, mitigate, or treat the negative impact that oral, craniofacial, or dental disease may have on individuals. Doing this allows for a broadening of what evidence-based dentistry means for the future and provides a roadmap going forward.

Assessment of awake bruxism by a novel bruxism screener and ecological momentary assessment among patients with masticatory muscle myalgia and healthy controls

BACKGROUND

Bruxism is a masticatory muscle activity occurring during sleep or wakefulness, involving grinding and clenching of teeth and/or jaw bracing. As yet, the aetiology, epidemiology and consequences of awake bruxism (AB) are largely unknown.

OBJECTIVES

The aims of the study were to AB behaviours using a novel bruxism screener (BruxScreen) questionnaire part and Ecological Momentary Assessment (EMA; BruxApp©) on AB behaviours, and to investigate AB's prevalence among masticatory muscle myalgia patients and non-patients.

METHODS

Altogether, 115 participants (masticatory myalgia patients referred to a specialist clinic (n = 67) and non-patients (n = 46)) filled in a bruxism screener questionnaire to report bruxism behaviours and jaw symptoms. A selection of both groups did a week-long EMA (patients n = 12, non-patients n = 11) to report AB behaviours. The chi-squared test was used to determine group differences in categorical variables. A logistic regression model was fitted to study the probability of AB.

RESULTS

According to BruxScreen, bruxism behaviours and jaw symptoms were more frequent in patients than in non-patients (p < .001). Based on EMA, 14.6% of the behaviour in patients was tooth clenching; for non-patients, this was 0.5% (p < .000). Relaxed muscles were reported by patients and non-patients at 20.6% and 56.4%, respectively (p < .021). Logistic regression, adjusted by age and sex, revealed that patients reported AB 5 times more often than non-patients (OR 4.8, 95% CI 2.1-11.2).

CONCLUSION

Awake bruxism behaviours are significantly more frequent in masticatory muscle myalgia patients than non-patients and associate with frequent bruxism-related symptoms. Self-reported teeth clenching seems to be the most significant sign of AB behaviour.

The Web-Based Pain-at-Work Toolkit With Telephone Support for Employees With Chronic or Persistent Pain: Protocol for a Cluster Randomized Feasibility Trial

BACKGROUND

Chronic or persistent pain affects one's ability to work or be productive at work, generating high societal and economic burden. However, the provision of work-related advice and support for people with chronic pain is variable or lacking. The Pain-at-Work (PAW) Toolkit was cocreated with people who live with pain, health care professionals, and employers. It aims to increase knowledge about employee rights and how to access support for managing a painful chronic condition in the workplace and provides advice on lifestyle behaviors that facilitate the management of chronic pain.

OBJECTIVE

We aimed to establish the feasibility of conducting a definitive cluster randomized controlled trial comparing access to the PAW Toolkit and telephone support calls from an occupational therapist (PAW) with treatment as usual (ie, standard support from their employer). Our primary outcomes are establishing parameters of feasibility, acceptability, usability, and safety of this digital workplace health intervention. We will assess the candidate primary and secondary outcomes' feasibility and test research processes for a definitive trial.

METHODS

This is an open-label, parallel 2-arm pragmatic feasibility cluster randomized controlled trial with exploratory health economics analysis and a nested qualitative interview study. We aim to recruit 120 participants from at least 8 workplace clusters (any type, >10 employees) in England. The recruitment of workplaces occurs via personal approach, and the recruitment of individual participants is web based. Eligible participants are vocationally active adults aged ≥18 years with internet access and self-reporting chronic pain interfering with their ability to undertake or enjoy productive work. A restricted 1:1 cluster-level randomization is used to allocate employment settings to PAW or treatment as usual; participants are unblinded to group allocation. Following site- and individual-level consent, participants complete a web-based baseline survey (time 0), including measures of work capacity, health and well-being, and health care resource use. Follow-up is performed at 3 months (time 1) and 6 months (time 2). Feasibility outcomes relate to recruitment; intervention fidelity (eg, delivery, reach, uptake, and engagement); retention; and follow-up. Qualitative evaluation (time 2) is mapped to the Capability, Opportunity, Motivation-Behavior model and will explore intervention acceptability to employees and employers, along with individual and contextual factors influencing the delivery and uptake of the intervention.

RESULTS

Ethics approval was obtained in March 2023. Trial recruitment began in June 2023.

CONCLUSIONS

The PAW Toolkit is the first evidence-based digital health intervention aimed at supporting the self-management of chronic or persistent pain at work. This study will inform the design of a definitive trial, including sample size estimation, approaches to cluster site identification, primary and secondary outcomes' selection, and the final health economic model. Findings will inform approaches for the future delivery of this digital health intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05838677; https://clinicaltrials.gov/study/NCT05838677.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51474.

Pharmacological Management of Orofacial Pain

Orofacial pain is a category of complex disorders, including musculoskeletal, neuropathic and neurovascular disorders, that greatly affect the quality of life of the patient. These disorders are within the fields of dentistry and medicine and management can be challenging, requiring a referral to an orofacial pain specialist, essential for adequate evaluation, diagnosis, and care. Management is specific to the diagnosis and a treatment plan is developed with diverse pharmacological and non-pharmacological modalities. The pharmacological management of orofacial pain encompasses a vast array of medication classes and approaches. This includes anti-inflammatory drugs, muscle relaxants, anticonvulsants, antidepressants, and anesthetics. In addition, as adjunct therapy, different injections can be integrated into the management plan depending on the diagnosis and needs. These include trigger point injections, temporomandibular joint (TMJ) injections, and neurotoxin injections with botulinum toxin and nerve blocks. Multidisciplinary management is key for optimal care. New and safer therapeutic targets exclusively for the management of orofacial pain disorders are needed to offer better care for this patient population.

Management protocols of chronic Orofacial Pain: A Systematic Review

Objective

Chronic orofacial pain (CP) is a persistent and debilitating condition that affects the face, mouth, and jaw and can have a significant impact on an individual's quality of life by posing problems to eat, speak, and perform everyday activities. By the means of this narrative review, we aim to assess different types of management modalities that exist to combat chronic orofacial pain.

Design

Various databases were explored with MeSH keywords of chronic orofacial pain, orofacial pain, and interventions and treatment protocols for eligible articles. After an extensive literature search, it was ascertained that this review identified four major categories of treatment modalities for the management of chronic orofacial pain, namely pharmacological management, psychological management, lifestyle interventions-based management, and current stimulation-based management.

Results

Of the four categories discussed, although pharmacological intervention offered the most immediate relief-especially from orofacial pain that was of a sudden, stab-like in nature-psychological management demonstrated a remarkable ability to reduce/alleviate the more serious aspect of chronic orofacial pain and was deemed better in comparison to the rest. Lifestyle-based techniques and current stimulation-based management were of limited use since they tended to focus more on the causal and not the symptomatic aspect of orofacial pain.

Conclusions

Many patients with persistent orofacial discomfort can experience notable improvements in their symptoms and general well-being by all the treatment modalities evaluated.

Temporomandibular disorders-review of evidence-based management and a proposed multidisciplinary care pathway

Temporomandibular disorders (TMDs) are a prevalent but complex group of conditions that cause orofacial pain. Temporomandibular disorders are recognized as one of the most common chronic pain conditions, alongside back pain and headache disorders. Given the competing theories surrounding what causes TMDs and limited high-equality evidence on optimally treating TMDs, clinicians often encounter challenges in developing an effective management plan for patients. Furthermore, patients will often seek advice from multiple health care providers from varying specialties, seeking curative management, often resulting in inappropriate treatments and no improvement in pain symptoms. Throughout this review, we explore the existing evidence base surrounding the pathophysiology, diagnosis, and management of TMDs. An existing United Kingdom-based multidisciplinary care pathway for the management of TMDs is described herein, highlighting the benefits of a multidisciplinary approach to patient care for TMDs.

Experience-based design: Empowering individuals while they wait for interprofessional chronic pain care

OBJECTIVES

Chronic pain is highly prevalent and a leading cause of disability. Long wait times for interprofessional care provide an opportunity to introduce web-based interventions that improve psychosocial function and patients' readiness and ability to manage their condition. Here we describe the process of partnering with people with lived experience (PWLE) to develop an online self-management program enhanced by motivational interviewing. We also report the multiphase usability testing of the program.

METHODS

PWLE were included in all aspects of this project from program inception to content creation, module development, usability testing, and knowledge dissemination. Phase 1 included the development of the interactive, web-based modules. This process involved weekly meetings and asynchronous content creation with a core team of interprofessional pain experts, researchers, and PWLE. Phase 2 included usability testing by our PWLE and clinical expert advisory. Phase 3 included survey-based usability testing with a sample of 10 PWLE.

RESULTS

We created a chronic pain & motivational empowerment program includes a series of eight interactive educational web-based modules. Topics included: setting expectations, chronic pain explained, biopsychosocial factors, empowered management, self-awareness & compassion & acceptance, values, goal setting, and communication. The program is accompanied by a reflection journal and can be enhanced by one-on-one coaching sessions using a motivational interviewing approach. Phase two usability testing resulted in numerous content changes and the addition of accessibility features. Phase 3 usability testing with PWLE found the program highly accessible and easy to use.

CONCLUSIONS

The engagement of our PWLE team member and advisors made the online program more relevant, sensitive and helpful to the needs of people with pain.

PRACTICAL VALUE

This PWLE-centric project sets the foundation for future work to examine the feasibility and effectiveness of the program for supporting individuals with chronic pain self-manage.

Evidence Mapping Based on Systematic Reviews of Cognitive Behavioral Therapy for Neuropathic Pain

Objective

This evidence mapping is aimed at identifying, summarizing, and analyzing the available evidence on cognitive behavioral therapy (CBT) for neuropathic pain (NP).

Methods

This study was conducted following the methodology of Global Evidence Mapping (GEM). Searches were conducted in PubMed, Embase, the Cochrane Library, and PsycINFO to identify systematic reviews (SRs) with or without meta-analysis published before February 15, 2022. The authors independently assessed eligibility, extracted data, and evaluated the methodological quality of the included SRs using AMSTAR-2. The results were presented in the tables and a bubble plot based on the identified population-intervention-comparison-outcome (PICO) questions.

Results

A total of 34 SRs met the eligibility criteria. According to the AMSTAR-2, 2 SRs were rated "high," 2 SRs were rated "moderate," 6 SRs were rated "low," and 24 SRs were rated "critically low." The most common study design utilized to evaluate the efficacy of CBT for NP was the randomized controlled trial. In total, 24 PICOs were identified. Migraine was the most studied population. CBT for NP usually reaches the "potentially better" result at follow-up.

Conclusions

Evidence mapping is a useful way to present existing evidence. Currently, the existing evidence on CBT for NP is limited. Overall, the methodological quality of the included SRs was low. Further improvements in the methodological quality of SRs and more research on the most efficient CBT formats for NP are recommended in the future.

Depression, somatization, and sleep disorders as risk factors for temporomandibular disorders development

The objective of this study was to determine the association between temporomandibular disorders (TMD) with depression, somatization and sleep disorders in the city of Maringá, Brazil. A total of 1,643 participants were selected from the Brazilian Unified Health System (SUS). Of these, the test group consisted of 84 participants who had moderate or severe limitations due to TMD pain and the control group consisted of 1,048 participants with no pain. There was a highly statistically significant difference (p<0.001) between cases and controls regarding depression (82.1 versus 37.4%), somatization (84.5 versus 31.4%), and sleep disorders (84.6 versus 36.4%), in moderate to severe levels. The levels of moderate to severe depression, somatization and sleep disorders were significantly higher in TMD subjects with high TMD pain disability. The risk of developing TMD increased 4 to 5 times when the individual has moderate to severe levels of depression, somatization, and sleep disorders. 

A commentary on Temporomandibular disorders: priorities for research and care - bridging from the US to the UK

In January 2019, the United States National Academy of Medicine initiated a comprehensive study of the status of current knowledge and clinical practices associated with temporomandibular disorders (TMDs). The National Academy of Sciences, which includes the National Academy of Medicine, was chartered by the US Government in the late 1800s as a non-profit institution working outside of government in order to provide unbiased, objective opinions on matters including healthcare. In this brief paper, we will discuss the open access 2020 report Temporomandibular disorders: priorities for research and care, available online. While the main focus of this report was the situation of TMDs in the US, the evidence base, authorship, expertise and literature scope was international and the findings therefore are at least in part generalisable to and important for the UK.

The authors of this commentary were directly involved in the National Academy process, with RO a panel member, JD a consultant and CG one of 15 reviewers of the draft report. There was a wide variety of clinical and research fields involved in gathering the evidence and constructing the report. In addition, there was extensive involvement from affected patients with TMDs and their families, which is critical because their perspective is typically omitted in textbooks and professional consensus meetings.

The report on TMDs from the US National Academy of Medicine is a seminal book describing the problems that individuals with TMDs confront for diagnosis and treatment.

The situation in the UK, according to UK colleagues, is similar with regards to challenges.

The UK has implemented a number of initiatives to provide better diagnosis and treatment; identifying these excellent efforts in relation to the disease challenges is valuable.

Theory-Based Self-Management Interventions for Community-Dwelling Stroke Survivors: A Systematic Review and Meta-Analysis

IMPORTANCE

Self-management is a critical component of stroke rehabilitation. A better understanding of the use of theory and behavior change techniques (BCTs) informs the development of more effective stroke self-management interventions.

OBJECTIVE

To examine what theories and BCTs have been applied in stroke self-management interventions; investigate the extent to which these interventions encourage implementation of behavior changes; and appraise their effectiveness to enhance self-efficacy, quality of life, and functional independence.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, CINAHL, Cochrane Library, and ClinicalTrials.gov were searched from inception to May 26, 2020.

STUDY SELECTION AND DATA COLLECTION

Randomized controlled trials (RCTs) in six databases were reviewed for inclusion and analysis. We included trials that involved community-dwelling adult stroke survivors, assessed the effectiveness of self-management interventions, and explicitly mentioned the use of theory in the development of the intervention. We assessed use of theory and BCTs using the Theory Coding Scheme and BCT taxonomy v1, respectively.

FINDINGS

A total of 3,049 studies were screened, and 13 RCTs were included. The predominant theory and BCT categories were Social Cognitive Theory (7 studies) and goals and planning (12 studies), respectively. Significant and small effect sizes were found for self-efficacy (0.27) and functional independence (0.19).

CONCLUSIONS AND RELEVANCE

Theory-based self-management interventions have the potential to enhance stroke outcomes. Systematic reporting on the use of theory and BCTs is recommended to enhance clarity and facilitate evaluations of future interventions. What This Article Adds: This review supports and guides occupational therapy practitioners to use theory-based self-management intervention as a routine part of stroke rehabilitation to improve stroke survivors' experience in the community.

Myrtenol Reduces Orofacial Nociception and Inflammation in Mice Through p38-MAPK and Cytokine Inhibition

Orofacial pain is one of the commonest and most complex complaints in dentistry, greatly impairing life quality. Preclinical studies using monoterpenes have shown pharmacological potential to treat painful conditions, but the reports of the effects of myrtenol on orofacial pain and inflammation are scarce. The aim of this study was to evaluate the effect of myrtenol in experimental models of orofacial pain and inflammation. Orofacial nociceptive behavior and the immunoreactivity of the phosphorylated p38 (P-p38)-MAPK in trigeminal ganglia (TG) and spinal trigeminal subnucleus caudalis (STSC) were determined after the injection of formalin in the upper lip of male Swiss mice pretreated with myrtenol (12.5 and 25 mg/kg, i.p.) or vehicle. Orofacial inflammation was induced by the injection of carrageenan (CGN) in the masseter muscle of mice pretreated with myrtenol (25 and 50 mg/kg, i.p.) or its vehicle (0.02% Tween 80 in saline). Myeloperoxidase (MPO) activity and histopathological changes in the masseter muscle and interleukin (IL)-1β levels in the TG and STSC were measured. The increase in face-rubbing behavior time induced by formalin and P-p38-MAPK immunostaining in trigeminal ganglia were significantly reduced by myrtenol treatment (12.5 and 25 mg/kg). Likewise, increased MPO activity and inflammatory histological scores in masseter muscle, as well as augmented levels of IL-1β in the TG AND STSC, observed after CGN injection, were significantly decreased by myrtenol (25 and 50 mg/kg). Myrtenol has potential to treat orofacial inflammation and pain, which is partially related to IL-1β levels in the trigeminal pathway and p38-MAPK modulation in trigeminal ganglia.

Management of temporomandibular disorders: a rapid review of systematic reviews and guidelines

Temporomandibular disorders (TMD) impact a significant proportion of the population. Given the range of management strategies, contemporary care should be evidence-informed for different TMD types. A knowledge-to-action rapid review of systematic reviews published in the past 5 years and guidelines published in the past 10 years concerning the management of TMD was conducted. The Cochrane, Embase, MEDLINE, PEDro, and PubMed databases were searched. A qualitative data analysis was undertaken, with quality assessment completed using the AMSTAR 2 checklist. In total, 62 systematic reviews and nine guidelines considering a range of treatment modalities were included. In concordance with current guidelines, moderate evidence supports a multi-modal conservative approach towards initial management. Contrary to existing guidelines, occlusal splint therapy is not recommended due to a lack of supporting evidence. The evidence surrounding oral and topical pharmacotherapeutics for chronic TMD is low, whilst the evidence supporting injected pharmacotherapeutics is low to moderate. In concordance with current guidelines, moderate quality evidence supports the use of arthrocentesis or arthroscopy for arthrogenous TMD insufficiently managed by conservative measures, and open joint surgery for severe arthrogenous disease. Based on this, a management pathway showing escalation of treatment from conservative to invasive is proposed.

Comparative evaluation of occlusal splint therapy and muscle energy technique in the management of temporomandibular disorders: A randomized controlled clinical trial

Background:

Contradicting evidence regarding the effects of occlusal splint therapy in the management of Temporomandibular disorder (TMD) and promising results shown by muscle energy technique.

Aim:

To determine and compare the effects of occlusal splint therapy, muscle energy technique, and combined treatment with education for self-management and counseling in the management of TMD.

Study Design and Settings:

Randomized clinical trial.

Methodology:

A total of 160 participants diagnosed with TMD according to Diagnostic Criteria/TMD axis I were randomly allocated into four treatment groups with equal allocation ratio using random numbers table. The main inclusion criteria were the presence of pain in the preauricular area, TMJ and/or muscles of mastication and maximum mouth opening <40 mm. Group A participants received muscle energy technique, Group B participants received occlusal splint therapy, Group C participants received combined treatment, and Group D participants received education for self-management and counseling (control). Control group treatment was provided to all the trial participants.

Statistical Analysis:

Intragroup comparison was made using Friedman test and Wilcoxon test while intergroup comparison was done using Kruskal–Wallis test and Mann–Whitney U test.

Results:

Intensity of pain on a visual analog scale and maximum mouth opening were measured at baseline, at 1 week, at 2 weeks, at 1 month, and after 3 months.

Conclusion:

Muscle energy technique, occlusal splint therapy and combined treatment significantly reduce pain compared to controls and muscle energy and combined treatment are superior to other groups for mouth opening improvements in patients with TMD.

Telehealth Increases Access to Brief Behavioral Interventions in Orofacial Pain Clinic during COVID-19 Pandemic: A Retrospective Study

Objective

Aim of the study was to test if orofacial pain patients were more likely to start and complete a brief psychological intervention for managing certain chronic orofacial pain conditions (physical self-regulation, PSR) via telehealth (during the COVID-19 pandemic) vs. in-person (prior to the COVID-19 pandemic). Exploratory aim was to describe demographic factors that may influence the patients to start and complete PSR.

Methods

Retrospective medical charts of all patients seen at a university-affiliated tertiary orofacial pain clinic between July–December 2019 (in person, pre-pandemic) and July–December 2020 (telehealth, during pandemic) were reviewed. Charts were examined for demographic information and to compare the number of patients who started and completed PSR during each study period (chi-squared test).

Results

Of 248 new patients seen in the clinic during 2019 period, 25 started PSR in-person (10.08%). Of 252 new patients seen during 2020 period, 53 started PSR via telehealth (21.03%). Patients were more likely to start PSR (OR = 6.21, p<.001, CI = 2.499 to 15.435) and more likely to complete all three sessions of PSR (OR = 5.69, p<.001, CI = 2.352 to 13.794) when it was offered via telehealth than in-person. Among those who started PSR via telehealth, patients from metropolitan areas were more likely to start the intervention than those from non-metropolitan areas (p=.045).

Conclusions

Offering brief psychological pain interventions via telehealth in tertiary orofacial pain clinics has demonstrated feasibility and may improve willingness to participate in psychological treatments. Results need to be replicated with prospective data as modality was confounded with pandemic in the current study.

Interventions for Depressive Symptoms in People Living with Chronic Pain: A Systematic Review of Meta-Analyses

OBJECTIVE

This review investigated the effectiveness of clinical interventions on depressive symptoms in people with all types of chronic pain.

METHODS

We searched seven electronic databases and reference lists on September 15, 2020, and included English-language, systematic reviews and meta-analyses of trials that examined the effects of clinical interventions on depressive outcomes in chronic pain. Two independent reviewers screened, extracted, and assessed the risk of bias. PROSPERO registration: CRD42019131871.

RESULTS

Eighty-three reviews were selected and included 182 meta-analyses. Data were summarized visually and narratively using standardized mean differences with 95% confidence intervals as the primary outcome of interest. A large proportion of meta-analyses investigated fibromyalgia or mixed chronic pain, and psychological interventions were most commonly evaluated. Acceptance and commitment therapy for general chronic pain, and fluoxetine and web-based psychotherapy for fibromyalgia showed the most robust effects and can be prioritized for implementation in clinical practice. Exercise for arthritis, pharmacotherapy for neuropathic pain, self-regulatory psychotherapy for axial pain, and music therapy for general chronic pain showed large, significant effects, but estimates were derived from low- or critically low-quality reviews.

CONCLUSIONS

No single intervention type demonstrated substantial superiority across multiple pain populations. Other dimensions beyond efficacy, such as accessibility, safety, cost, patient preference, and efficacy for non-depressive outcomes should also be weighed when considering treatment options. Further effectiveness research is required for common pain types such as arthritis and axial pain, and common interventions such as opioids, anti-inflammatories and acupuncture.

Implementation of biopsychosocial supported self-management for chronic primary oro-facial pain including temporomandibular disorders: A theory, person and evidence-based approach

BACKGROUND

Aims of the study were to: Implement supported self-management for chronic primary oro-facial pain in a clinical setting. Evaluate its impact on consultation rates, pain severity, interference with life and patient experience.

METHODS

Sixty-six patients with chronic primary oro-facial pain received the intervention at a facial pain clinic at Leeds Dental Institute, UK. Brief Pain Inventory (BPI) scores measured pain severity and interference with life before and after the intervention. Process mining outlined patient care pathways. Monthly consultation rates measured 12 months before and after the intervention were used to evaluate burden on healthcare services and economic impact. Patient feedback was assessed via Patient and Public involvement discussion groups.

RESULTS

Mean BPI scores significantly improved after intervention-from 5.70 (SD 1.89) to 3.78 (SD 2.34) (p < .001); mean pain interference score reduced from 19.95 (SD 9.41) to 12.05 (SD 9.64) (p < .001). Average monthly consultations significantly (p = .001) reduced from 0.42/month before the intervention to 0.16/month after the intervention. Economic assessment showed cost savings of £293 per patient per year. Process mining showed high rates of service usage with 31 patients also attending 51 other specialist services between them. Patient and Public Involvement discussion groups with 5 patients identified that the intervention was a 'constant companion' and should be implemented at the outset in the care pathway.

CONCLUSION

Supported self-management for chronic primary oro-facial pain has a positive impact on health outcomes (physical functioning, pain intensity and patient experience), as well as service usage and healthcare costs when implemented in a secondary care clinical setting. Reconfiguring current care pathways to upscale early implementation of such interventions should be a priority for future testing.

Physical therapist guided active intervention of chronic temporomandibular disorder presenting as ear pain: A case report

This case report describes the successful physical therapy management of a 40-year-old female who presented with left ear pain referred from the temporomandibular joint. Diagnosis was primarily based on clinical examination findings and ruling out of red flags. Guidance was given on active self-care approaches consisting of pain neuroscience education designed with individualized pain curriculum, exercise therapy, manual therapy, and breathing exercises for a period of  sixweeks. Clinically meaningful improvements were obtained in the outcome measures of Numeric Pain Rating Scale (NPRS), Patient-Specific Functional Scale (PSFS), and Global Rating of Change (GROC) scale and progress in Pain-Self Efficacy Questionnaire (PSEQ) and Tampa Scale for Kinesiophobia (TSK) scores. Positive changes were achieved with functional activities (chewing, eating, yawing, brushing teeth and physical intimacy), and the patient was pain-free on discharge, which was maintained at a six-month follow-up.

Temporomandibular disorders: a review of current concepts in aetiology, diagnosis and management

Temporomandibular disorders (TMD) is a collective term for a group of musculoskeletal conditions involving pain and/or dysfunction in the masticatory muscles, temporomandibular joints (TMJ) and associated structures. It is the most common type of non-odontogenic orofacial pain and patients can present with pain affecting the face/head, TMJ and or teeth, limitations in jaw movement, and sounds in the TMJ during jaw movements. Comorbid painful and non-painful conditions are also common among individuals with TMD. The diagnosis of TMD have significantly improved over time with the recent Diagnostic Criteria for TMD (DC/TMD) being reliable and valid for most common diagnoses, and an efficient way to communicate in multidisciplinary settings. This classification covers 12 most common TMD, including painful (myalgia, arthralgia and headache attributed to TMD) as well as the non-painful (disc displacements, degenerative joint disease and subluxation) TMD diagnoses. Recent studies have demonstrated that the pathophysiology of common painful TMD is biopsychosocial and multifactorial, where no one factor is responsible for its development. Importantly, research has suggested different predisposing, initiating and perpetuating factors, including both peripheral and central mechanisms. This is an active field of investigation and future studies will not only seek to clarify specific causal pathways but translate this knowledge into mechanism-directed diagnosis and treatment. In accordance with this complex aetiology, current evidence supports primarily conservative multidisciplinary treatment including self-management strategies, behavioural therapy, physical therapy and pharmacotherapy. The aim of this review is to present an overview of most recent developments in aetiology, pathophysiology, diagnosis and management of TMD.

Internet-Based Multimodal Pain Program With Telephone Support for Adults With Chronic Temporomandibular Disorder Pain: Randomized Controlled Pilot Trial

BACKGROUND

Chronic pain from temporomandibular disorders remains an undertreated condition with debate regarding the most effective treatment modalities.

OBJECTIVE

The aim of the study was to investigate the treatment effect of an internet-based multimodal pain program on chronic temporomandibular disorder pain and evaluate the feasibility of a larger randomized controlled trial.

METHODS

An unblinded randomized controlled pilot trial was conducted with 43 participants (34 females, 9 males; median age 27, IQR 23-37 years) with chronic temporomandibular pain. Participants were recruited within the Public Dental Health Service and randomized to intervention (n=20) or active control (n=23). The intervention comprised a dentist-assisted internet-based multimodal pain program with 7 modules based on cognitive behavior therapy and self-management principles. The control group received conventional occlusal splint therapy. Primary outcomes included characteristic pain intensity, pain-related disability, and jaw functional limitation. Secondary outcomes were depression, anxiety, catastrophizing, and stress. Outcomes were self-assessed through questionnaires sent by mail at 3 and 6 months after treatment start. Feasibility evaluation included testing the study protocol and estimation of recruitment and attrition rates in the current research setting.

RESULTS

Only 49% of participants (21/43) provided data at the 6-month follow-up (internet-based multimodal pain program: n=7; control: n=14). Of the 20 participants randomized to the internet-based multimodal pain program, 14 started treatment and 8 completed all 7 modules of the program. Between-group analysis showed no significant difference for any outcome measure at 3- or 6-month follow-up-characteristic pain intensity (3 months: P=.58; 6 months: P=.41), pain-related disability (3 months: P=.51; 6 months: P=.12), jaw functional limitation (3 months: P=.45; 6 months: P=.90), degree of depression (3 months: P=.64; 6 months: P=.65), anxiety (3 months: P=.93; 6 months: P=.31), stress (3 months: P=.66; 6 months: P=.74), or catastrophizing (3 months: P=.86; 6 months: P=.85). Within-group analysis in the internet-based multimodal pain program group showed a significant reduction in jaw functional limitation score at the 6-month follow-up compared to baseline (Friedman: χ2=10.2, P=.04; Wilcoxon: z=-2.3, P=.02). In the occlusal splint group, jaw function limitation was also reduced at the 6-month follow-up (Friedman: χ2=20.0, P=.045; Wilcoxon: z=-2.3, P=.02), and there was a reduction in characteristic pain intensity at the 3- and 6-month follow-up (Friedman: χ2=25.1, P=.01; Wilcoxon 3 months: z=-3.0, P=.003; Wilcoxon 6 months: z=-3.3, P=.001).

CONCLUSIONS

This study was not able to demonstrate a difference in treatment outcome between an internet-based multimodal pain program and occlusal splint therapy in patients with chronic temporomandibular pain. However, the findings suggested that the internet-based multimodal pain program improves jaw function. The results also confirmed the treatment effect of occlusal splint therapy for chronic temporomandibular pain. Furthermore, because of the high attrition rate, this pilot study showed that a randomized controlled trial with this design is not feasible.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04363762; https://clinicaltrials.gov/show/NCT04363762.

1H-NMR-Based salivary metabolomics from females with temporomandibular disorders - A pilot study

Although temporomandibular disorder (TMD) is the second most common musculoskeletal disorder in the general population, the disease is multifactorial and presents symptoms common to other conditions which misdiagnosis can lead to treatment failure. In this case-control study, we performed, for the first time, a high-resolution ¹H-nuclear magnetic resonance spectroscopy metabolomic analysis of the saliva of 26 women with TMD of muscular origin (experimental group [EG]) at the beginning (EG-pre) and at the end (EG-post) of a conservative treatment, and of 27 normal women (control group [CG]) to identify a metabolic signature for TMD. One-way analysis of variance showed changes in the concentration of phenylacetate, dimethylamine, maltose, acetoin, and isovalerate. Partial least-square discriminant analysis showed that metabolite signals did not overlap in CG X EG-pre and EG-pre X EG-post, but overlapped in CG X EG-post. The area under the receiver operating characteristic curve was 1 in CG X EG-pre (95% CI, 1.000-1.000; p < 0.002), 0.993 in EG-pre X EG-post (95% CI, 0.963-1.000), and 0.832 in CG X EG-post (95% CI, 0.699-0.961). These results suggest that the metabolomic profiles of women with and without TMD differ, while after treatment there is a lower distinction and slight tendency towards overlapping between CG and EG-post compared to pre treatment. We also found that phenylacetate, dimethylamine, maltose, acetoin, and isovalerate are potential biomarkers for TMD of muscular origin.

Adhesive dentistry sensory stimulus technique as a neuromechanism for the treatment of orofacial pain associated to temporomandibular disorders: Case study

Purpose

The authors intend, by presenting a case study, emphasize the neuromodulation process of orofacial pain induced by the stimulation of the sensory and motor stimulation of the trigeminal nerve, which can play an important role on pain modulation.

Materials and methods

A 25 year-old woman presenting orofacial pain was referred to the stomatology service at the Centro Hospitalar do Porto. After collecting the patient's anamnesis, the thermographic camera FLIR i7 was used to record the thermal status of the orofacial structures, before the adhesive dentistry sensory stimulus protocol, after 45 minutes, and after one week.

Results

This study suggests the relation of adhesive dentistry sensory stimulus technique in the neuromodulation of orofacial pain and its association with the temporomandibular disorders . As the tongue senses the stimulus of the resin composite placed on the palatal surface of the 1^st premolar, 2^nd premolar and 1^st molar of the maxilla, this can promote and induce an effect regarding a peripheral nerve neuromodulation resulting in a blockage of the nociceptive trigeminal pathway from temporomandibular disorders.

Conclusion

Orofacial pain is a common complaint among the patients that come to a dentistry appointment, which may have different diagnosis and treatments. A positive effect on the patient's symptomatology was confirmed clinically on subsequent dental appointments and monitored by infrared thermography.

The efficacy of transcranial direct current stimulation and transcranial magnetic stimulation for chronic orofacial pain: A systematic review

BACKGROUND

Transcranial Direct Current Stimulation (tDCS) and Transcranial Magnetic Stimulation (TMS) have been described as promising alternatives to treat different pain syndromes. This study evaluated the effects of TMS and tDCS in the treatment of chronic orofacial pain, through a systematic review.

METHODS

An electronic search was performed in major databases: MEDLINE, Scopus, Web of Science, Cochrane, Embase, LILACS, BBO, Open Gray and CINAHL. The eligibility criteria comprised randomized clinical trials (RCTs) that applied TMS or tDCS to treat chronic orofacial pain. The variables analyzed were pain, functional limitation, quality of life, tolerance to treatment, somatosensory changes, and adverse effects. The risk of bias was assessed through the Cochrane Collaboration tool, and the certainty of evidence was evaluated through GRADE. The protocol was registered in the PROSPERO database (CRD42018090774).

RESULTS

The electronic search resulted in 636 studies. Thereafter, the eligibility criteria were applied and the duplicates removed, resulting in eight RCTs (four TMS and four tDCS). The findings of these studies suggest that rTMS applied to the Motor cortex (M1), the dorsolateral prefrontal cortex (DLPFC) and the secondary somatosensory cortex (S2) provide adequate orofacial pain relief. Two studies reported significant pain improvement with tDCS applied over M1 while the other two failed to demonstrate significant effects compared to placebo.

CONCLUSIONS

rTMS, applied to M1, DLPFC or S2, is a promising approach for the treatment of chronic orofacial pain. Moreover, tDCS targeting M1 seems to be also effective in chronic orofacial pain treatment. The included studies used a wide variety of therapeutic protocols. In addition, most of them used small sample sizes, with a high risk of biases in their methodologies, thus producing a low quality of evidence. The results indicate that further research should be carried out with caution and with better-standardized therapeutic protocols.