Challenges in the clinical implementation of a biopsychosocial model for assessment and management of orofacial pain

Exploring the causal effects of sleep characteristics on TMD-related pain: a two-sample Mendelian randomization study

OBJECTIVES

The study was to explore the causal effects of sleep characteristics on temporomandibular disorder (TMD)-related pain using Mendelian randomization (MR) analysis.

MATERIALS AND METHODS

Five sleep characteristics (short sleep, insomnia, chronotype, snoring, sleep apnea) were designated as exposure factors. Data were obtained from previous publicized genome-wide association studies and single nucleotide polymorphisms (SNPs) strongly associated with them were utilized as instrumental variables (IVs). TMD-related pain was designed as outcome variable and sourced from the FinnGens database. MR analysis was employed to explore the causal effects of the five sleep characteristics on TMD-related pain. The causal effect was analyzed using the inverse variance-weighted (IVW), weighted median, and MR-Egger methods. Subsequently, sensitivity analyses were conducted using Cochran's Q tests, funnel plots, leave-one-out analyses, and MR-Egger intercept tests.

RESULTS

A causal effect of short sleep on TMD-related pain was revealed by IVW (OR: 1.60, 95% CI: 1.06-2.41, P = 0.026). No causal relationship was identified between other sleep characteristics (insomnia, chronotype, snoring, sleep apnea) and TMD-related pain.

CONCLUSIONS

Our study suggests that short sleep may increase the risk of TMD-related pain, while there was no causal relationship between other sleep characteristics and TMD-related pain. Further studies are warranted to deepen and definitively clarify their relationship.

CLINICAL RELEVANCE

These findings reveal that the short sleep may be a risk factor of TMD-related pain and highlight the potential therapeutical effect of extending sleep time on alleviating TMD-related pain.

Constructing the brief diagnostic criteria for temporomandibular disorders (bDC/TMD) for field testing

BACKGROUND

Despite advances in temporomandibular disorders' (TMDs) diagnosis, the diagnostic process continues to be problematic in non-specialist settings.

OBJECTIVE

To complete a Delphi process to shorten the Diagnostic Criteria for TMD (DC/TMD) to a brief DC/TMD (bDC/TMD) for expedient clinical diagnosis and initial management.

METHODS

An international Delphi panel was created with 23 clinicians representing major specialities, general dentistry and related fields. The process comprised a full day workshop, seven virtual meetings, six rounds of electronic discussion and finally an open consultation at a virtual international symposium.

RESULTS

Within the physical axis (Axis 1), the self-report Symptom Questionnaire of the DC/TMD did not require shortening from 14 items for the bDC/TMD. The compulsory use of the TMD pain screener was removed reducing the total number of Axis 1 items by 18%. The DC/TMD Axis 1 10-section examination protocol (25 movements, up to 12 sets of bilateral palpations) was reduced to four sections in the bDC/TMD protocol involving three movements and three sets of palpations. Axis I then resulted in two groups of diagnoses: painful TMD (inclusive of secondary headache), and common joint-related TMD with functional implications. The psychosocial axis (Axis 2) was shortened to an ultra-brief 11 item assessment.

CONCLUSION

The bDC/TMD represents a substantially reduced and likely expedited method to establish (grouping) diagnoses in TMDs. This may provide greater utility for settings requiring less granular diagnoses for the implementation of initial treatment, for example non-specialist general dental practice.

Patient-centeredness and psychometric properties of the Defense and Veterans Pain Rating Scale 2.0 (DVPRS)

OBJECTIVE

This study aims to assess the patient-centeredness and psychometric properties of the Defense and Veterans Pain Rating Scale 2.0 (DVPRS) as a patient-reported outcome measure (PROM) for pain assessment in a military population.

DESIGN

A critical evaluation of the DVPRS was conducted, considering its fit-for-purpose as a PROM and its patient-centeredness using the National Health Council's Rubric to Capture the Patient Voice.

SETTING

The study focused on the use of the DVPRS within the Department of Defense (DoD) and Veterans Health Administration (VA) healthcare settings.

SUBJECTS

The DVPRS was evaluated based on published studies and information provided by measure developers. The assessment included content validity, reliability, construct validity, and ability to detect change. Patient-centeredness and patient engagement were assessed across multiple domains.

METHODS

Two independent reviewers assessed the DVPRS using a tool/checklist/questionnaire, and any rating discrepancies were resolved through consensus. The assessment included an evaluation of psychometric properties and patient-centeredness based on established criteria.

RESULTS

The DVPRS lacked sufficient evidence of content validity, with no patient involvement in its development. Construct validity was not assessed adequately, and confirmatory factor analysis was not performed. Patient-centeredness and patient engagement were also limited, with only a few domains showing meaningful evidence of patient partnership.

CONCLUSIONS

The DVPRS as a PROM for pain assessment in the military population falls short in terms of content validity, construct validity, and patient-centeredness. It requires further development and validation, including meaningful patient engagement, to meet current standards and best practices for PROMs.

Updating The General Practitioner on The Association Between Teeth Loss and Temporomandibular Disorders: A Systematic Review

The belief about a possible association between the absence of one or more teeth and the presence of temporomandibular disorders (TMD), although old, is still present among the dental class. Although evidence points to a lack of association between loss of posterior support and the presence of TMD, we do not have critical studies on the extent, quantity, or location of these losses. In this sense, this systematic review aims to investigate the association between tooth loss and the presence of TMD signs or diagnostic subgroups. Search strategies using a combination of keywords tooth loss and TMDs were performed in six databases (PubMed, Embase, Web of Science, Livivo, Lilacs, and Scopus) and gray literature from August to September 2020. Observational studies that investigated the association between tooth loss in TMD were considered. The risk of bias was assessed using the Joanna Briggs Institute (JBI) Critical Assessment Checklist for cross-sectional analytical studies, case-control, and cohort studies. Finally, the level of certainty measured by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was assessed. Six articles were included in the review according to the eligibility criteria. Of these, five had a high risk of bias and one had a moderate risk. Only one study showed an association between the loss of posterior teeth and the presence of joint sounds and joint pain, the others found no significant association with sign or TMD subgroups diagnostic.There is no scientific evidence to support the association between one or more tooth loss and the presence of TMD signs and symptoms or diagnostic subgroups.

Plastic changes in nociceptive pathways contributing to persistent orofacial pain

BACKGROUND

Pain is a warning signal for the body defense mechanisms and is a critical sensation for supporting life. However, orofacial pain is not a vital sensation, but a disease. However, there are still many unclear points about the pathophysiological mechanism of orofacial pain. This situation makes it difficult for many clinicians to treat orofacial pain hypersensitivity.

HIGHLIGHT

Noxious information on the orofacial region received by trigeminal ganglion neurons is recognized as "orofacial pain" by being transmitted to the somatosensory cortex and limbic system via the spinal trigeminal nucleus and the thalamic sensory nuclei. Orofacial inflammation or trigeminal nerve injury causes neuropathic changes in various nociceptive signaling pathways, resulting in persistent orofacial pain. It is considered that persistent oral facial pain is triggered by plastic changes in nociceptive signaling pathways involving various cells such as satellite glial cells, astrocytes, microglia, and macrophages, as well as nociceptive neurons.

CONCLUSION

Recent studies have shown that hyperexcitability of nociceptive neurons in the nociceptive signaling pathways of the orofacial region caused by a variety of factors causes persistent orofacial pain. This review outlines the pathophysiology of orofacial pain along with the results of our study.

Psychosocial profiles and their correlation with physical diagnosis in temporomandibular disorders, a preliminary report

OBJECTIVE

To assess representative psychosocial features in a group of temporomandibular disorder (TMD) patients from Jordan using Axis II of the Diagnostic Criteria for TMD (DC/TMD) protocol.

METHODS

Ninety-eight TMD patients were examined according to Axis I DC/TMD protocol in addition to assessment of their pain-related disability, psychological distress, and stress reactivity.

RESULTS

Just under half of the patients (49%) had high intensity of characteristic pain (self-reported TMJ-related pain) and one-third (32%) had high levels of pain-related disability. Furthermore, significant proportions of patients expressed moderate-severe degrees of distress and stress reactivity (41% and 39%, respectively). Significant correlations were identified between the Graded Chronic Pain Scale (GCPS) and each of the pain-related TMD subgroups.

CONCLUSION

TMD patients are susceptible to high levels of pain-related psychosocial impairment, and clinicians should be aware of the possible correlations between the physical TMD diagnosis and specific psychosocial features during treatment planning.

Evaluation of the efficacy of platelet rich fibrin (I-PRF) intra-articular injections in the management of internal derangements of temporomandibular joints - a controlled preliminary prospective clinical study

Background

The temporomandibular joint (TMJ) is one of the most complex joints in the body. Temporomandibular disorders (TMD) are among the most troublesome disorders for patients, as they can cause pain, affect oral functions and disturb dentists on the level of diagnosis and treatment. The most common symptoms of temporomandibular joint disorders are articulated sounds (such as clicking or TMJ crepitation), joint pain in comfort and function situations (jaw movements), pain or strain in masseter and jaw muscles and or restricted mandibular movements. One of the most modern biocompatible substances used to treat joint disorders, including the TMJ, is platelet-rich plasma (PRP) and injectable platelet-rich fibrin (I-PRF). This study aims to evaluate the efficacy of platelet-rich fibrin (I-PRF) intra-articular injections in managing internal derangements of temporomandibular.

Methods

Twenty patients suffering from a unilateral click due to temporomandibular disorders were individually injected with 1 mL of (I-PRF) twice 1 week apart into the superior joint space of the TMJ with the internal disorder. Data were recorded and evaluated by the Helkimo index. This evaluation was conducted three times; 1 week after the first injection, 1 week after the second injection, and 6 months after the first injection.

Results

The clicking disappeared entirely in 14 out of 20 patients after 1 week of getting the first injection, and in all patients after 1 week of getting the second injection, and returned to two of them after a six-month since the first injection.

Conclusion

Preliminary results showed the efficacy of the Injectable Platelet-Rich Fibrin (I-PRF) in managing articular clicking in patients with internal disorders of the temporomandibular joint. Injectable Platelet Rich Fibrin has significant clinical efficacy in treating the articular clicking resulting from internal temporomandibular joint disorders.

[Studies on the psychodynamics of Chronic Orofacial Pain Disorder]

Studies on the psychodynamics of Chronic Orofacial Pain Disorder Objectives: Psychodynamic factors play an important role in its emergence and development of Chronic Orofacial Pain Disorder (COP), which is also known as Chronic Primary Orofacial Pain. This factors form the basis for differentiated psychotherapy. Methods: Seven female and two male patients with COP who had visited the Dental School, University Hospital, Ludwig Maximilian University of Munich, and the dental surgery of a practising dentist over the year were included in the study. Following a detailed dental examination, a psychodynamic interview was videotaped, reconstructing the connections between the life history and the development of the illness. Psychosomatic data were assessed by 3 psychotherapists based on a consensus model with regard to symptom trigger mechanisms such as conflicts and pressure, the development of symptoms, and the personality structure. Pathogenetically, we differentiated among conversion, somatization and projection. Results: The patients had a mean age of 57 years (range: 44-67) and an average illness duration of three (1-5) years. The average age where the illness had manifested was 54 (43-64). All patients showed clear psychodynamic factors in the development and course of the illness. The symptoms developed mainly during transitional situations during the life history, predominately in midlife. During this phase, dental treatment undertaken for whatever reason could trigger the chronic symptoms, which could then be further exacerbated by further dental interventions. The mode of symptom development by equal number of patients related to a somatoform disorder, such as a somatization of affect, a conversion with conflict symbolism and a projective-hypochondriac disorder. In the remaining patients, COP was an accompanying symptom of depressive disorder or the consequence of a posttraumatic stress disorder with self-mutilating tendencies. Conclusion: The consideration of psychosomatic connections and pathogenetic differentiation is helpful for the understanding and management of COP. This diagnostic differentiation could serve as a basis for prognosis and for specific therapeutic indications. Despite numerous general researches about chronic pain syndromes, there is a lack of intervention studies which take into account the specific conditions of COP on a larger sample.

Postoperative Pain and Age: A Retrospective Cohort Association Study

BACKGROUND

As the population ages, the number of elderly people undergoing surgery increases. Literature on the incidence and intensity of postoperative pain in the elderly is conflicting. This study examines associations between age and pain-related patient reported outcomes and perioperative pain management in a dataset of surgical patients undergoing four common surgeries: spinal surgery, hip or knee replacement, or laparoscopic cholecystectomy. Based on the authors' clinical experience, they hypothesize that pain scores are lower in older patients.

METHODS

In this retrospective cohort, study data were collected between 2010 and 2018 as part of the international PAIN OUT program. Patients filled out the International Pain Outcomes Questionnaire on postoperative day 1.

RESULTS

A total of 11,510 patients from 26 countries, 59% female, with a mean age of 62 yr, underwent one of the aforementioned types of surgery. Large variation was detected within each age group for worst pain, yet for each surgical procedure, mean scores decreased significantly with age (mean Numeric Rating Scale range, 6.3 to 7.3; β = -0.2 per decade; P ≤ 0.001), representing a decrease of 1.3 Numeric Rating Scale points across a lifespan. The interference of pain with activities in bed, sleep, breathing deeply or coughing, nausea, drowsiness, anxiety, helplessness, opioid administration on the ward, and wish for more pain treatment also decreases with age for two or more of the procedures. Across the procedures, patients reported being in severe pain on postoperative day one 26 to 38% of the time, and pain interfered moderately to severely with movement.

CONCLUSIONS

The authors' findings indicate that postoperative pain decreases with increasing age. The change is, however, small and of questionable clinical significance. Additionally, there are still too many patients, at any age, undergoing common surgeries who suffer from moderate to severe pain, which interferes with function, supporting the need for tailoring care to the individual patient.

EDITOR’S PERSPECTIVE

Oral health-related quality of life of patients with acute and chronic temporomandibular disorder diagnostic subtypes

BACKGROUND

Studies have indicated the negative effects of temporomandibular disorders (TMDs) on oral health-related quality of life (OHRQoL). The authors investigated the OHRQoL of patients with acute and chronic TMD subtypes.

METHODS

The authors recruited a total of 830 patients. They derived TMD diagnoses using the Diagnostic Criteria for TMDs protocol involving symptom history, physical examination, and diagnostic imaging as indicated. The authors categorized patients into acute (≤ 3 months) or chronic (> 3 months) pain-related TMD (PT), nonpainful intra-articular TMD (IT), and combined TMD (CT) groups. They also gathered sociodemographic information and assessed OHRQoL with the Oral Health Impact Profile (OHIP)-TMDs. The authors evaluated data using 2-way analysis of variance and Bonferroni test and multiple regression analysis.

RESULTS

Patients in the chronic PT and CT subgroups had significantly higher mean global OHIP scores than their acute counterparts. The authors observed significant acute-chronic differences in OHIP-TMDs domain scores in 5 and 2 domains for the PT and CT groups, respectively. Patients in the acute IT group had significantly higher functional limitation scores than those in the chronic IT group. The ranking of mean global scores, in descending order was CT, PT, and IT for acute TMDs and PT, CT, and IT for chronic TMDs, with significant differences observed among the 3 TMD subtypes (P < .001).

CONCLUSIONS

Both TMD chronicity and subtypes influenced OHRQoL. Painful TMDs (PT and CT) were associated with significantly poorer OHRQoL than nonpainful TMDs. TMD chronicity appeared to affect OHRQoL only for the painful TMD conditions. Future work on the impact of TMDs on OHRQoL should strive to stratify patients by TMD chronicity and subtypes.

PRACTICAL IMPLICATIONS

TMD chronicity and subtypes influence the impact of TMDs on OHRQoL. Given that chronic painful TMDs impair quality of life, early biopsychosocial intervention of acute TMD pain is important for minimizing chronification and OHRQoL deterioration.

The Correlation between Pain, Stress, and Oral Function in Oral and Maxillofacial Infection and Trauma Patients

Background:

The relationship between stress and acute pain has been documented in previous studies. Yet, very few studies have evaluated the relationship between stress and acute orofacial pain and its impact on jaw functional activities.

Objective:

The objective of the current study was to evaluate the correlation between acute orofacial pain, stress, and the limitation of the jaw and facial activities in oral and maxillofacial infection and oral and maxillofacial trauma patients.

Methods:

The current study recruited 50 (16 male, 34 female) patients from the Emergency Unit of the Ujung Berung Hospital, Bandung Indonesia. Twenty-five patients were those who had oral and maxillofacial trauma, and the rest were those who had an oral and maxillofacial infection. The patient’s stress level was evaluated by measuring their salivary alpha-amylase level, the pain level was measured by using the numeric rating scale (NRS), whilst the limitation of the jaw and facial activities was measured by using the Jaw and Facial Activities Limitation (JFAL) Questionnaire. All data were analysed using the Spearman correlation test.

Results:

Based on the analysis, it was revealed that there was no significant correlation (r = 0.176, p= 0.22) between stress and pain level. When associated with jaw and facial activities limitation, there was a significant positive correlation (r = 0.555, p < 0.01) found between pain level and jaw and facial activity limitation.

Conclusion:

The current study concluded that there was a significant positive correlation found between pain and jaw activity limitation on oral and maxillofacial infection and trauma patients.

Orofacial musculoskeletal pain: An evidence-based bio-psycho-social matrix model

Pain is a multidimensional experience comprising sensory-discriminative, affective-motivational, and cognitive-evaluative dimensions. Clinical and research findings have demonstrated a complex interplay between social burdens, individual coping strategies, mood states, psychological disorders, sleep disturbances, masticatory muscle tone, and orofacial musculoskeletal pain. Accordingly, current classification systems for orofacial pain require psychosocial assessments to be an integral part of the multidimensional diagnostic process. Here, we review evidence on how psychosocial and biological factors may generate and perpetuate musculoskeletal orofacial pain. Specifically, we discuss studies investigating a putative causal relationship between stress, bruxism, and pain in the masticatory system. We present findings that attribute brain structures various roles in modulating pain perception and pain-related behavior. We also examine studies investigating how the nervous and immune system on cellular and molecular levels may account for orofacial nociceptive signaling. Furthermore, we review evidence pointing towards associations between orofacial musculoskeletal pain and neuroendocrine imbalances, sleep disturbances, and alterations of the circadian timing system. We conclude with several proposals that may help to alleviate orofacial pain in the future.

Chairside risk assessment for first-onset temporomandibular disorders: Result from the Orofacial Pain: Prospective Evaluation and Risk Assessment data set

BACKGROUND

Temporomandibular disorders (TMD) risk assessment is difficult in general dentistry owing to the complexity of multifactorial risk contributions and the lack of standardized education. The authors explored a health history-based chairside risk assessment.

METHODS

Secondary data analysis was performed on the Orofacial Pain: Prospective Evaluation and Risk Assessment data set. Potential demographic, systemic, and local risk contributors were conceptualized into 10 risk categories. Multivariate Cox proportional hazards modeling with backward selection was applied. Variables with P values < .05 were kept in each successive model.

RESULTS

The analysis included data from 2,737 participants. The final model indicated that people with any psychological conditions, pain disorders, sleep disorders, or orofacial symptoms were at elevated risks of developing first-onset TMD. Results of post hoc analysis showed the coexistence of conditions from multiple body systems conferred greater risk of developing TMD.

CONCLUSIONS

Coexisting conditions and symptoms from multiple body systems substantially increase the risk of developing TMD pain. Therefore, multisystem risk assessment and interprofessional collaborations are important for the prevention of TMD.

PRACTICAL IMPLICATIONS

Dentists should include psychological conditions, pain disorders, sleep disorders, and orofacial symptoms when assessing patients' risk of developing TMD pain.

New International Classification of Orofacial Pain: What Is in It For Endodontists?

Pain is a common symptom in endodontic conditions, but differential diagnostic procedures are often needed to exclude other pain origins. Thus, general dentists and endodontists need to be aware of alternative painful orofacial conditions and be able to identify them. The new International Classification of Orofacial Pain (ICOP) is the first comprehensive classification that uniquely deals with orofacial pain. The ICOP is a hierarchical classification modeled on the International Classification of Headache Disorders and covers pain in dentoalveolar and anatomically related tissues, muscle pain, temporomandibular joint pain, neuropathic pain affecting cranial nerves, pain resembling primary headaches, and idiopathic pain in the orofacial region. A description of each condition is given, and structured diagnostic criteria for each condition are proposed based on research data when available. This narrative review aims (1) to give an overview and brief explanation of the ICOP system, (2) to describe and give examples of how it can be of use to general dentists and endodontists with special attention to differential diagnosis of tooth pain, and (3) to highlight how endodontic research can contribute to validation and improvement of the classification. A comparison to other classification and diagnostic systems is also included.

Orofacial pain education in dentistry: A path to improving patient care and reducing the population burden of chronic pain

Dentists stand in an optimal position to prevent and manage patients suffering from chronic orofacial pain (OFP) disorders, such as temporomandibular disorders, burning mouth syndrome, trigeminal neuralgia, persistent idiopathic dentoalveolar pain, among others. However, there are consistent reports highlighting a lack of knowledge and confidence in diagnosing and treating OFP among dental students, recent graduates, and trained dentists, which leads to misdiagnosis, unnecessary costs, delay in appropriate care and possible harm to patients. Education in OFP is necessary to improve the quality of general dental care and reduce individual and societal burden of chronic pain through prevention and improved quality of life for OFP patients. Our aims are to emphasize the goals of OFP education, to identify barriers for its implementation, and to suggest possible avenues to improve OFP education in general, postgraduate, and continuing dental education levels, including proposed minimum OFP competencies for all dentists. Moreover, patient perspectives are also incorporated, including a testimony from a person with OFP. General dentists, OFP experts, educators, researchers, patients, and policy makers need to combine efforts in order to successfully address the urgent need for quality OFP education.

Field-testing a psychosocial assessment scoring form for TMD patients - summarizing axis II instruments

Background

The etiology of temporomandibular disorders (TMD) can be explained on the basis of a biopsychosocial model. However, psychosocial assessment is challenging in daily dental practice. The purpose of the current study was to field-test the practicability of a novel psychosocial assessment scoring form regarding the reliability of scoring procedures and the opinion of examiners. The working hypotheses were that the scoring results of inexperienced undergraduate students were similar to the results collected by a gold standard and that the scoring form was easy to use.

Methods

A psychosocial assessment scoring form was developed in accordance with guidelines of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), including results of the Graded Chronic Pain Scale (GCPS), Patient Health Questionnaires (PHQ), and Generalized Anxiety Disorders (GAD). Inexperienced operators (undergraduate students) examined patients with TMD-associated complaints and rated the practicability of the scoring form. The scoring results were recalculated by two experienced operators and a consensus was defined as a gold standard. Reliability coefficients were determined comparing results of the gold standard and the inexperienced operators.

Results

Sixty-five examiners used the scoring form to obtain results for patients with TMD-associated complaints. Of the patients, 78.8% received a diagnosis according to DC/TMD decision trees. Two-thirds of the operators (62.9%) stated that the form was easy to complete, and 83.0% would use it in their dental practice. The reliability coefficients ranged between 0.81–1.00.

Conclusions

Within the limitations of the present study, the psychosocial assessment scoring form seems to be an easy-to-use and practicable tool. The vast majority of the inexperienced examiners recommended the application.

Clinical presentations on a facial pain clinic

Introduction The complex nature of facial pain conditions creates a diagnostic challenge which may necessitate specialist referral.Aim To identify the case mix presenting to a specialist tertiary care facial pain clinic.Methods A retrospective review of 112 patient records was undertaken. Trends in provisional diagnoses from referrers and the correlation to diagnoses made following specialist consultation were reviewed.Results The most common provisional diagnoses recorded in referral letters were painful temporomandibular disorders, trigeminal neuralgia and persistent idiopathic facial pain (PIFP). Over a quarter of referrals did not include a provisional diagnosis. Following assessment, only one case was not given a definitive diagnosis and no patients were diagnosed with PIFP. A causative factor was identified in all the initially queried PIFP cases, and painful post-traumatic trigeminal neuropathic pain was found in multiple patients.Conclusions Painful post-traumatic trigeminal neuropathic pain should be considered if pain onset coincides with dental treatment or other traumatic events. PIFP is a rare facial pain diagnosis and may be over-diagnosed by dental and medical practitioners. It is important to systematically exclude other causes before reaching this diagnosis. This will facilitate effective treatment, manage patient expectations and potentially reduce unnecessary referrals.

Applying a general systems theory framework in mental health treatment pathways: the case of the Hellenic Center of Mental Health and Research

Language, socio-emotional and cognitive development in children and adolescents with mental health issues is getting increased attention over the last years. Establishing communication patterns and addressing behavioural diversities among this population should be of priority, along with a better understanding in a large variety of patient characteristics within the operational framework of mental healthcare centers. Therefore, the relationships between provided services and operational capability should become more evident. As integrated systems’ approaches are still missing to predict the efficiency of treatment services in a macroscopic scale, a General Systems Theory framework is hereby proposed. This framework is applied and tested against the operational framework of the Hellenic Center of Mental Health and Research, in order to identify the need of such an approach and the strong cooperation between medical and population interactions. Using such frameworks as a prerequisite to identify important factors affecting population states can lead to evaluating their impact on the treatment outcome and depict the complexity of pathways potentially related to the children’s development.

Photobiomodulation and Stem Cell Therapy for Temporomandibular Joint Disc Disorders

Background: Temporomandibular disorder (TMD) refers to a group of disorders affecting the temporomandibular joint (TMJ) and its related muscles. The two commonly used treatment modalities for TMD are occlusal splint therapy and relaxation therapy. Neither comprises definitive treatment. Objective: The objective of this review was to report updated information on photobiomodulation and stem cells, as an alternative treatment for the degenerative TMJ disc as a part of TMJ disorders. Materials and methods: With only a few research studies reported till date, this review also proposes the mechanism of laser irradiation on inflammatory mediators to treat TMD. Results: Photobiomodulation of stem cells with and without scaffolds could be used indirectly or directly as modulation of degenerative changes of the TMJ disc. Conclusions: The need for a distinct shift of the research margin in this field of dentistry is evident, specifically regarding the application of photobiomodulation and stem cells for tissue engineering of the TMJ disc.