Perspectives on next steps in classification of oro-facial pain - part 1: role of ontology

Classification and Diagnosis of Temporomandibular Disorders and Temporomandibular Disorder Pain

Designing classification systems and developing diagnostic criteria for temporomandibular disorders is difficult. An appreciation of the utility and applicability of these entities requires an understanding of the importance of each, the differences between the two, and how they may be optimally operationalized for both clinical and research activities in light of their inherent advantages and limitations. In addition, consideration for adopting newer approaches, such as following ontological and precision-based medicine principles, accounting for genetics/epigenetic and neurobiological factors, and the inclusion of biomarkers will potentially result in more thorough and comprehensive classification systems and diagnostic criteria.

Multimodal pain therapy for persistent idiopathic facial pain - a pilot study

OBJECTIVE

Persistent Idiopathic Facial Pain (PIFP) is a pain syndrome with missing evidence-based therapy recommendations. According to the biopsychosocial pain model, multidisciplinary pain treatment (MPT) offers a promising therapeutic option for chronic pain syndromes. MPT is an interprofessional treatment procedure, consisting of medical, physiotherapeutic and psychotherapeutic treatment units, which has not yet been studied in PIFP.

METHODS

This retrospective study included 25 patients with PIFP, who had been treated with MPT. Pain intensity on the numerical rating scale (NRS), perceived disability, habitual well-being, as well as anxiety/depression and stress scales were recorded. Moreover, the patients evaluated the efficacy of each type of the single therapeutic interventions.

RESULTS

There was a highly significant decrease in the characteristic pain intensity. Also habitual well-being improved significantly, as did anxiety and depression. The perceived disability and stress also improved, but without statistical significance. Physiotherapy was rated as the most effective therapeutic unit. Among the medical measures, consultations took first place (40% of the participants). Nearly three-fourths of the patients (72%) would recommend MPT.

CONCLUSION

The present study shows beneficial outcomes in patients with PIFP following MPT. Patients evaluate physiotherapeutic treatment as particularly efficacious. Therefore, MPT can be considered as a therapeutic option in patients with PIFP.

Consensus agreement to rename burning mouth syndrome and improve International Classification of Diseases-11 disease criteria: an international Delphi study

ABSTRACT

The International Classification of Diseases (ICD-11) proposes revisions in the nomenclature, disease definition, and diagnostic criteria for "burning mouth syndrome" (BMS). This process could benefit from additional systematically collected expert input. Thus, the purpose of this study was to use the Delphi method to (1) determine whether revision in nomenclature and alternative names for "BMS" are warranted and (2) identify areas of consensus among experts for changes to the disease description and proposed diagnostic criteria of "BMS," as described in the ICD-11 (World Health Organization). From 31 international invited experts, 23 who expressed interest were sent the survey. The study used 4 iterative surveys, each with a response rate of ≥82%. Consensus was predefined as 70% of participants in agreement. Data were summarized using both descriptive statistics and qualitative thematic analysis. Consensus indicated that BMS should not be classified as a syndrome and recommended instead renaming to "burning mouth disorder." Consensus included deletion of 2 diagnostic criteria: (1) emotional distress or functional disability and (2) the number of hours symptoms occur per day. Additional items that reached consensus clarified the disease definition and proposed more separate diagnostic criteria, including a list of local and systemic factors to evaluate as potential secondary causes of oral burning. Experts in this study recommended and came to consensus on select revisions to the proposed ICD-11 BMS nomenclature, diagnostic criteria, and disease definition. The revisions recommended have the potential to improve clarity, consistency, and accuracy of diagnosis for this disorder.

A realism-based approach to an ontological representation of symbiotic interactions

Background

The symbiotic interactions that occur between humans and organisms in our environment have a tremendous impact on our health. Recently, there has been a surge in interest in understanding the complex relationships between the microbiome and human health and host immunity against microbial pathogens, among other things. To collect and manage data about these interactions and their complexity, scientists will need ontologies that represent symbiotic interactions as they occur in reality.

Methods

We began with two papers that reviewed the usage of ‘symbiosis’ and related terms in the biology and ecology literature and prominent textbooks. We then analyzed several prominent standard terminologies and ontologies that contain representations of symbiotic interactions, to determine if they appropriately defined ‘symbiosis’ and related terms according to current scientific usage as identified by the review papers. In the process, we identified several subtypes of symbiotic interactions, as well as the characteristics that differentiate them, which we used to propose textual and axiomatic definitions for each subtype of interaction. To both illustrate how to use the ontological representations and definitions we created and provide additional quality assurance on key definitions, we carried out a referent tracking analysis and representation of three scenarios involving symbiotic interactions among organisms.

Results

We found one definition of ‘symbiosis’ in an existing ontology that was consistent with the vast preponderance of scientific usage in biology and ecology. However, that ontology changed its definition during the course of our work, and discussions are ongoing. We present a new definition that we have proposed. We also define 34 subtypes of symbiosis. Our referent tracking analysis showed that it is necessary to define symbiotic interactions at the level of the individual, rather than at the species level, due to the complex nature in which organisms can go from participating in one type of symbiosis with one organism to participating in another type of symbiosis with a different organism.

Conclusion

As a result of our efforts here, we have developed a robust representation of symbiotic interactions using a realism-based approach, which fills a gap in existing biomedical ontologies.

The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises

ABSTRACT

The current International Association for the Study of Pain (IASP) definition of pain as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" was recommended by the Subcommittee on Taxonomy and adopted by the IASP Council in 1979. This definition has become accepted widely by health care professionals and researchers in the pain field and adopted by several professional, governmental, and nongovernmental organizations, including the World Health Organization. In recent years, some in the field have reasoned that advances in our understanding of pain warrant a reevaluation of the definition and have proposed modifications. Therefore, in 2018, the IASP formed a 14-member, multinational Presidential Task Force comprising individuals with broad expertise in clinical and basic science related to pain, to evaluate the current definition and accompanying note and recommend whether they should be retained or changed. This review provides a synopsis of the critical concepts, the analysis of comments from the IASP membership and public, and the committee's final recommendations for revisions to the definition and notes, which were discussed over a 2-year period. The task force ultimately recommended that the definition of pain be revised to "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage," and that the accompanying notes be updated to a bulleted list that included the etymology. The revised definition and notes were unanimously accepted by the IASP Council early this year.

Persistent dentoalveolar pain disorder: A putative intraoral chronic overlapping pain condition

Chronic overlapping pain conditions (COPCs) are conditions that share several clinical characteristics and symptomatology, are usually considered idiopathic in nature, and are frequently comorbid. Currently, there are no established inclusion criteria to determine which conditions should be included under this umbrella term despite different systems proposed. Persistent dentoalveolar pain disorder (PDAP), also referred to as atypical odontalgia and thought to be a component of persistent idiopathic facial pain, is a chronic pain condition that manifests as a persistent tooth pain or pain over a dentoalveolar site formerly occupied by a tooth in the absence of detectable pathology during clinical or radiological examination. PDAP is considered idiopathic in nature, and its pathophysiological mechanisms are not fully understood. Our objective was to investigate whether PDAP fits the conceptual paradigm of COPC given its characteristics and commonalities with other COPC, based on published literature identified through a scoping review. We found that PDAP fits 16 out of 18 common characteristics among COPCs, and based on this finding, we discuss the implications of PDAP being considered a COPC.

AAPT Diagnostic Criteria for Chronic Painful Temporomandibular Disorders

The classification of temporomandibular disorders (TMD) has progressed substantially over the past 25 years owing to the strategic implementation of an initial classification system based on core taxonomic principles. In this article, we describe the development of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) and its translation into the multidimensional Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks-AAPT for chronic pain disorders. The initial scientific classification system (Research Diagnostic Criteria for Temporomandibular Disorders) relied on a boot-strapping process that did not attempt to solve all known clinical problems but, rather, focused on problems that could be solved at that time. The core design principles included using epidemiologic data, operationalized concepts, reliable methods, and the incorporation of the biopsychosocial model into a dual axis system. This system led to sufficient data collection internationally that the system itself could be revised, first by critical evaluation of all aspects, second by review from invited experts, and third by the construction of a revised taxonomy (DC/TMD) that maintained the core design principles of the Research Diagnostic Criteria for Temporomandibular Disorders. The resultant disorders with pain as a dominant feature exhibit substantial sensitivity and specificity, and they have been translated into the AAPT framework. The AAPT TMD criteria are part of an evidence-based classification system providing a systematic structure that includes 5 dimensions: diagnostic criteria, common features, comorbidities, consequences, and putative mechanisms. Future research will attempt to extend this AAPT domain from solely TMDs to include other orofacial pain conditions. PERSPECTIVE: The painful TMDs have well-established sensitivity and specificity, as based on the DC/TMD; their translation to the AAPT framework for chronic pain conditions provides a structure for consistent clinical application within the broader health care settings and for future research on the TMDs.

Assessment of association between muscular diagnosis in temporomandibular disorders with mandibular kinematics

Objective: To study the association between mandibular kinematics and muscular diagnoses in temporomandibular disorders (TMD). Method: Retrospective, descriptive clinical study based on an analysis of 370 clinical records of muscle diagnoses in TMD. Statistical analysis was performed with the SPSS program. Results: Five different muscle diagnoses were considered. Myospasm and centrally mediated myalgia were discarded from the statistical analysis because of their low incidences. The diagnoses included in the analysis were protective co-contraction, myofascial pain, and myalgia. Decreased mandibular kinematics in the frontal and horizontal planes were related to myofascial pain. Mandibular kinematics with deflection in opening values decreased in the frontal plane, but intermediate or increased values in the horizontal plane were related to the protective co-contraction. Muscle pain with normal or increased mandibular kinematics was associated with a diagnosis of myalgia. Conclusion: Values of mandibular kinematics are correlated with the muscular diagnoses in TMD and are useful for diagnosis.

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

BACKGROUND

Medical symptoms independent of body location burden individuals to varying degrees and may require care by more than one expert. Various paper and computer-based tools exist that aim to comprehensively capture data for optimal clinical management and research.

METHODS

A web-based interdisciplinary symptom evaluation (WISE) was newly designed, constructed, and technically implemented. For worldwide applicability and to avoid copyright infringements, open source software tools and free validated questionnaires available in multiple languages were used. Highly secure data storage limits access strictly to those who use the tool for collecting, storing, and evaluating their data. Concept and implementation is illustrated by a WISE sample tailored for the requirements of a single center in Switzerland providing interdisciplinary care to orofacial pain and temporomandibular disorder patients.

RESULTS

By combining a symptom- burden checklist with in-depth questionnaires serving as case-finding instruments, an algorithm was developed that assists in clarifying case complexity and need for targeted expert evaluation. This novel modular approach provides a personalized, response-tailored instrument for the time- and cost-effective collection of symptom-burden focused quantitative data. The tool includes body drawing options and instructional videos. It is applicable for biopsychosocial evaluation in a variety of clinical settings and offers direct feedback by a case report summary.

CONCLUSIONS

In clinical practice, the new instrument assists in clarifying case complexity and referral need, based on symptom burden and response -tailored case finding. It provides single-case summary reports from a biopsychosocial perspective and includes graphical symptom maps. Secure, centrally stored data collection of anonymous data is possible. The tool enables personalized medicine, facilitates interprofessional education and collaboration, and allows for multicenter patient-reported outcomes research.

Chronic orofacial pain

The issues specific to trigeminal pain include the complexity of the region, the problematic impact on daily function and significant psychological impact (J Dent, 43, 2015, 1203). By nature of the geography of the pain (affecting the face, eyes, scalp, nose, mouth), it may interfere with just about every social function we take for granted and enjoy (J Orofac Pain, 25, 2011, 333). The trigeminal nerve is the largest sensory nerve in the body, protecting the essential organs that underpin our very existence (brain, eyes, nose, mouth). It is no wonder that pain within the trigeminal system in the face is often overwhelming and inescapable for the affected individual.

Are Randomized Controlled Trials the (G)old Standard? From Clinical Intelligence to Prescriptive Analytics

Despite the accelerating pace of scientific discovery, the current clinical research enterprise does not sufficiently address pressing clinical questions. Given the constraints on clinical trials, for a majority of clinical questions, the only relevant data available to aid in decision making are based on observation and experience. Our purpose here is 3-fold. First, we describe the classic context of medical research guided by Poppers' scientific epistemology of "falsificationism." Second, we discuss challenges and shortcomings of randomized controlled trials and present the potential of observational studies based on big data. Third, we cover several obstacles related to the use of observational (retrospective) data in clinical studies. We conclude that randomized controlled trials are not at risk for extinction, but innovations in statistics, machine learning, and big data analytics may generate a completely new ecosystem for exploration and validation.

Perspectives on next steps in classification of oro-facial pain - Part 3: biomarkers of chronic oro-facial pain - from research to clinic

The purpose of this study was to review the current status of biomarkers used in oro-facial pain conditions. Specifically, we critically appraise their relative strengths and weaknesses for assessing mechanisms associated with the oro-facial pain conditions and interpret that information in the light of their current value for use in diagnosis. In the third section, we explore biomarkers through the perspective of ontological realism. We discuss ontological problems of biomarkers as currently widely conceptualised and implemented. This leads to recommendations for research practice aimed to a better understanding of the potential contribution that biomarkers might make to oro-facial pain diagnosis and thereby fulfil our goal for an expanded multidimensional framework for oro-facial pain conditions that would include a third axis.

Perspectives on next steps in classification of oro-facial pain - part 2: role of psychosocial factors

This study was initiated by a symposium, in which the present authors contributed, organised by the International RDC/TMD Consortium Network in March 2013. The purpose of the study was to review the status of biobehavioural research - both quantitative and qualitative - related to oro-facial pain (OFP) with respect to the aetiology, pathophysiology, diagnosis and management of OFP conditions, and how this information can optimally be used for developing a structured OFP classification system for research. In particular, we address representation of psychosocial entities in classification systems, use of qualitative research to identify and understand the full scope of psychosocial entities and their interaction, and the usage of classification system for guiding treatment. We then provide recommendations for addressing these problems, including how ontological principles can inform this process.