Developing Effective and Efficient care pathways in chronic Pain: DEEP study protocol

DEEP Study: Modeling Outcomes and Costs of Persistent Orofacial Pain

KNOWLEDGE OF TRANSFER STATEMENT

Despite a substantial number of consultations, individuals experiencing the care pathways in this study continued to have far from perfect health over their life course. The modeling suggests they would only experience 18 y in "perfect health." There is considerable scope to improve current care/outcomes and patient experience.

DEEP Study: Utility of the multidimensional pain inventory in persistent oro-facial pain

BACKGROUND

Persistent oro-facial pain (POFP) is disabling, and patients' treatment outcomes are difficult to predict; psychosocial factors play a role. The West Haven-Yale Multidimensional Pain Inventory (MPI) is a self-report measure, which to our knowledge, has not been studied across primary and secondary care in heterogeneous POFP.

OBJECTIVE

Assess the MPI's ability to predict clinical outcome in POFP patients across primary and secondary care settings receiving usual care.

METHODS

About 146 patients receiving usual care for POFP were recruited from primary and secondary care medical and dental practices in north-east England. Participants completed the MPI (v3) and Graded Chronic Pain Scale (GCPS) at recruitment, and after 6, 12, 18 and 24 months. The Patient Health Questionnaire-4 (PHQ-4) was completed at recruitment, 12, and 24 months. 'Good' and 'poor' outcome status was assigned to participants based on their mode dichotomised GCPS score across timepoints. Logistic regression was used with overall GCPS outcome (good/poor) as the dependent variable and MPI subscale scores, demographic variables, and PHQ-4 scores as predictors.

RESULTS

110 participants had a 'good', and 36 had a 'poor' outcome. In the 'poor' outcome group, age, mean income, and life control scores were lower; deprivation, months in pain, PHQ-4, pain severity, interference, and affective distress scores were higher. In the 'good' group, MPI scores improved over time. Interference was the only consistent predictor of 'poor' outcome in the logistic regression model (OR: 1.14-1.98, p < 0.05).

CONCLUSION

The MPI interference subscale may help to identify patients with POFP who are likely to have consistent pain-related disability over time; it may therefore be useful clinically to identify patients likely to need early intervention.

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.

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.

Oral splints for patients with temporomandibular disorders or bruxism: a systematic review and economic evaluation

BACKGROUND

Splints are a non-invasive, reversible management option for temporomandibular disorders or bruxism. The clinical effectiveness and cost-effectiveness of splints remain uncertain.

OBJECTIVES

The objectives were to evaluate the clinical effectiveness and cost-effectiveness of splints for patients with temporomandibular disorders or bruxism. This evidence synthesis compared (1) all types of splint versus no/minimal treatment/control splints and (2) prefabricated versus custom-made splints, for the primary outcomes, which were pain (temporomandibular disorders) and tooth wear (bruxism).

REVIEW METHODS

Four databases, including MEDLINE and EMBASE, were searched from inception until 1 October 2018 for randomised clinical trials. The searches were conducted on 1 October 2018. Cochrane review methods (including risk of bias) were used for the systematic review. Standardised mean differences were pooled for the primary outcome of pain, using random-effects models in temporomandibular disorder patients. A Markov cohort, state-transition model, populated using current pain and Characteristic Pain Intensity data, was used to estimate the incremental cost-effectiveness ratio for splints compared with no splint, from an NHS perspective over a lifetime horizon. A value-of-information analysis identified future research priorities.

RESULTS

Fifty-two trials were included in the systematic review. The evidence identified was of very low quality with unclear reporting by temporomandibular disorder subtype. When all subtypes were pooled into one global temporomandibular disorder group, there was no evidence that splints reduced pain [standardised mean difference (at up to 3 months) -0.18, 95% confidence interval -0.42 to 0.06; substantial heterogeneity] when compared with no splints or a minimal intervention. There was no evidence that other outcomes, including temporomandibular joint noises, decreased mouth-opening, and quality of life, improved when using splints. Adverse events were generally not reported, but seemed infrequent when reported. The most plausible base-case incremental cost-effectiveness ratio was uncertain and driven by the lack of clinical effectiveness evidence. The cost-effectiveness acceptability curve showed splints becoming more cost-effective at a willingness-to-pay threshold of ≈£6000, but the probability never exceeded 60% at higher levels of willingness to pay. Results were sensitive to longer-term extrapolation assumptions. A value-of-information analysis indicated that further research is required. There were no studies measuring tooth wear in patients with bruxism. One small study looked at pain and found a reduction in the splint group [mean difference (0-10 scale) -2.01, 95% CI -1.40 to -2.62; very low-quality evidence]. As there was no evidence of a difference between splints and no splints, the second objective became irrelevant.

LIMITATIONS

There was a large variation in the diagnostic criteria, splint types and outcome measures used and reported. Sensitivity analyses based on these limitations did not indicate a reduction in pain.

CONCLUSIONS

The very low-quality evidence identified did not demonstrate that splints reduced pain in temporomandibular disorders as a group of conditions. There is insufficient evidence to determine whether or not splints reduce tooth wear in patients with bruxism. There remains substantial uncertainty surrounding the most plausible incremental cost-effectiveness ratio.

FUTURE WORK

There is a need for well-conducted trials to determine the clinical effectiveness and cost-effectiveness of splints in patients with carefully diagnosed and subtyped temporomandibular disorders, and patients with bruxism, using agreed measures of pain and tooth wear.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017068512.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 7. See the NIHR Journals Library website for further project information.

Predicting Persistent Orofacial Pain: The Role of Illness Perceptions, Anxiety, and Depression

INTRODUCTION

Persistent orofacial pain (POFP) can be caused by a range of conditions affecting the mouth and face and is often associated with significant disability. Biopsychosocial factors are known to be important predictors and have not yet been fully explored in this population.

OBJECTIVES

This study aimed to explore whether illness perceptions and psychological distress (anxiety and depression) could predict long-term outcome in a community-based sample of patients receiving routine care for POFP.

METHODS

A longitudinal cohort design study assessed 198 patients recruited from primary or secondary health care settings on 5 separate occasions over a 2-y period. Outcome was measured by the Graded Chronic Pain Scale and dichotomized into good or poor outcome categories. Independent variables included subscale scores of the psychometrically shortened Illness Perception Questionnaire and the Patient Health Questionnaire-4 (PHQ-4, assessing anxiety and depressive symptomatology). Logistic regressions were performed to test whether scores on each subscale would be associated with different outcomes for patients at 12 and 24 mo and overall.

RESULTS

Beliefs about consequences predicted outcome category (good vs. poor) above and beyond other illness perception subscales, anxiety, and depressive symptomatology (z = 3.78; P < 0.000; odds ratio [OR], 3.05; 95% confidence interval [CI], 1.71-5.43). Both depressive symptomatology, measured by the PHQ-2 (P = 0.001; OR, 4.06; 95% CI, 1.74-9.52), and psychological distress (mixed anxiety and depression; P = 0.029; OR, 2.88; 95% CI, 1.12-7.41), measured by the PHQ-4, were also predictive of poor outcome, but these effects were no longer significant once measures of illness perceptions were added.

CONCLUSION

Beliefs about the consequences of POFP are important predictors of outcome independent of other variables and can easily and briefly be included in assessments to inform management decisions.

KNOWLEDGE TRANSFER STATEMENT

The results of this study are relevant because they will allow clinicians to consider the use of brief and easy-to-administer self-report measures to identify POFP patients at higher risk of poor outcome so that management can be planned accordingly.

Selective vs stepwise removal of deep carious lesions in primary molars: 12-Months results of a randomized controlled pilot trial

OBJECTIVES

For deep carious lesions, selective or stepwise carious tissue removal (SE, SW) seem advantageous compared with non-selective removal. For primary molars, there is insufficient evidence comparing SE against SW. This randomized pilot trial compared SE and SW over 12 months.

METHODS

A two-arm superiority trial was conducted comparing SE and SW in primary molars with deep lesions but without pulpal symptoms. We recruited 74 children (one molar/child) aged 3-9 years. In both groups, peripheral carious tissue removal was performed at T1 to hard dentin. In proximity to the pulp, leathery dentin was left followed by an adhesive compomer restoration. Blinded re-examination was performed after six months (T2). Molars allocated to SW were re-entered, removal to firm dentin carried out pulpo-proximally, and again restored. After another 6 months, all molars were re-examined (T3). Our primary outcome was success, defined as no restorative/endodontic complications (including pulp exposure) leading to reinterventions. Secondary outcomes included total treatment and opportunity costs. Patients', dentists' and parents' subjective assessments were recorded. This trial was registered (ClinicalTrials.gov/NCT02232828).

RESULTS

After 12 months a total of 72 children (36 SE, 36 SW) were analyzed. Three failures occurred (2 exposures in SW, 1 pulpal complication leading to extraction in SE) (p > 0.05). The subjective evaluation by patients, parents or dentists did not differ significantly. Combined treatment and opportunity costs were significantly higher in SW (mean;SD: 186;61 Euro) than SE (100;59) (p < 0.001).

CONCLUSIONS

The significantly increased costs for performing SW instead of SE in deep carious lesions in primary molars may not be justified.

CLINICAL SIGNIFICANCE

For primary molars with deep lesions, but vital pulps, SE was less costly at similar efficacy compared with SW. Dentists' decision-making should consider this alongside further clinical aspects.

DEEP Study: Indirect and Out-of-pocket Costs of Persistent Orofacial Pain

Persistent orofacial pain (POFP) is common and caused by a group of conditions affecting the face, head, or mouth. Recent research highlighted a problematic care pathway with high costs to the health care provider, but the financial impact on patients and employers is not understood. This study aimed to describe patient (out-of-pocket) and employer (indirect) costs of POFP and to identify whether the dichotomized Graded Chronic Pain Scale (GCPS) was predictive of costs. A cohort of 198 patients was recruited from primary and secondary care settings in North East England and followed over a 24-mo period. Patients completed the GCPS and Use of Services and Productivity Questionnaire every 6 mo and a Time and Travel Questionnaire at 14 mo. Questionnaires examined the implications of health care utilization on patients’ everyday lives and personal finances. Time and travel costs were calculated and applied to use-of-services data to estimate out-of-pocket costs, while the human capital method and QQ method (quantity and quality of work completed) were used to estimate absenteeism and presenteeism costs, respectively. Per person per 6-mo period (in 2017 pounds sterling), mean out-of-pocket costs were £333 (95% CI, £289 to £377), and indirect costs were £1,242 (95% CI, £1,014 to £1,470). Regression analyses indicated that over 6 mo, the GCPS was predictive of the following: out-of-pocket costs—a difference of £311 between low and high GCPS per person per 6-mo period (95% CI, £280 to £342; P < 0.01, n = 705 observations over 24 mo); indirect costs—a difference of £2,312 between low and high GCPS per person per 6-mo period (95% CI, £1,886 to £2,737; P < 0.01; n = 352 observations over 24 mo). This analysis highlights “hidden” costs of POFP and supports the use of the dichotomized GCPS to identify patients at risk of higher impact and associated costs and thereby stratify care pathways and occupational health support appropriately.

Orofacial pain - an update on diagnosis and management

The diagnosis and management of orofacial pain may be challenging due to complex histories, pathophysiology and associated psychosocial co-morbidities such as depression and anxiety. Neuropathic facial pain conditions such as burning mouth syndrome (BMS), persistent idiopathic facial pain (PIFP), atypical odontalgia (AO) and trigeminal neuralgia (TN) require early recognition by primary care clinicians and referral to secondary care. Acute pain-related temporomandibular disorder (TMD) may be managed in the primary care setting, with identification of those at risk of developing chronic TMD receiving an early referral to secondary care. Adopting a biopsychosocial approach, consisting of physical therapies, pharmacotherapy and psychological support can lead to effective management and may limit the negative impact of facial pain upon quality of life and daily functioning.

Care Pathways in Persistent Orofacial Pain: Qualitative Evidence from the DEEP Study

Persistent orofacial pain is relatively common and known to have an adverse effect on quality of life. Previous studies suggest that the current care pathway may be problematic, but it is not well understood which health services patients access and what their experience is. The aim of this study was to explore care pathways and their impact from the perspective of patients. Qualitative interviews were conducted with a maximum variation sample of patients recruited from primary (community based) and secondary (specialist hospital based) care in the United Kingdom. Questions focused on the stages in their pathway and the impact of the care that they had received. Interviews were digitally recorded and transcribed verbatim, and analysis followed principles of the constant comparative method. NVivo 10 was used to help organize and analyze data. Twenty-two patients were interviewed at baseline, and 18 took part in a second interview at 12 mo. Three main themes emerged from the data: the "fluidity of the care pathway," in which patients described moving among health care providers in attempts to have their pain diagnosed and managed, occurring alongside a "failure to progress," where despite multiple appointments, patients described frustration at delays in obtaining a diagnosis and effective treatment for their pain. Throughout their care pathways, patients described the "effects of unmanaged pain," where the longer the pain went unmanaged, the greater its potential to negatively affect their lives. Findings of this study suggest that the current care pathway is inefficient and fails to meet patient needs. Future work needs to focus on working with stakeholder groups to redesign patient-centered care pathways. Knowledge Transfer Statement: Data from qualitative interviews conducted with patients with persistent orofacial pain suggest significant problems with the existing care pathway, consisting of delays to diagnosis, treatment, and referral. Patients describing their struggle to progress through the current care pathway highlighted the difficulties occurring while living with orofacial pain. This study suggests a need for a revised care pathway, which better meets the needs of people with persistent orofacial pain.

Adults seeking orthodontic treatment: expectations, periodontal and TMD issues

The growth in adult orthodontics presents new challenges to both the general dental practitioner and the orthodontist. Although many of the main objectives of orthodontic treatment are similar for adults, young adults and children, adult patients frequently bring significant challenges in several areas not often seen in the younger patient group. In areas such as planning realistic treatment outcomes, it is paramount that the patient's expectations are identified, respected and managed where appropriate. The adult patient's dental health often dictates deviation from the ideal treatment plan and periodontal problems are a common example. Based on current evidence, this paper presents an overview of some of the difficulties in the management of these issues, as well as highlighting developments with regard to pain conditions and their relevance to orthodontic treatment and its effects on temporomandibular joint disorders (TMD) management.

Healthcare Cost and Impact of Persistent Orofacial Pain: The DEEP Study Cohort

Few data are available on the healthcare costs of those suffering from persistent orofacial pain (POFP). This cohort and cost analysis study examined the direct costs of POFP from the perspective of the healthcare provider (specifically, the UK National Health Service) in 2012 pounds sterling and sought to identify whether dichotomized (high, IIb to IV; low, 0 to IIa) graded chronic pain scale (GCPS) status is predictive of the total cost of healthcare over the last 6 mo. The healthcare utilization data of 198 patients with POFP were collected using a structured interview and a validated "use of services and productivity" questionnaire. Unit costs were used with these utilization data to calculate direct healthcare costs in 3 categories: consultation, medication, and appliances and interventions. Consultation costs were a significant proportion of cumulative healthcare cost (P < 0.001). Dichotomized GCPS status was predictive of increased healthcare cost over the last 6 mo, accounting for an average increase of £366 (95% confidence interval, 135 to 598; P < 0.01) when moving from a low GCPS status to a high GCPS status. Given the predictive capability of dichotomized GCPS status and the success of stratified models of care for other persistent pain conditions, dichotomized GCPS status may offer an opportunity to help determine stratification of care for patients with POFP.

DEEP Study: does EQ-5D-5L measure the impacts of persistent oro-facial pain?

The EQ-5D-5L is a generic quality of life (QOL) measure widely used throughout the world, which has the advantage that it allows health-state preferences to be elicited. The aim of this study was to examine whether: a) variation in the standardised reference period for EQ-5D-5L from 'today' to 'the last month' had a minimal clinically meaningful difference; (b) EQ-5D-5L had convergent validity with a multidimensional pain measure in quantifying the impacts of pain. As part of a larger study into the effectiveness and efficiency of care pathways for persistent orofacial pain (POFP) (http://research.ncl.ac.uk/deepstudy), participants with POFP (n = 100) completed two versions of the EQ-5D-5L at the same time with different reference periods ('today' vs. 'last month'). Participants also completed the first section of the West Haven-Yale Multidimensional Pain Inventory (v3) to assess convergent validity. Two-tailed nonparametric inferential statistics, intra-class correlation coefficients (ICC), and within-subject change scores were used to compare the two EQ-5D-5L versions. Convergent validity was assessed using Spearman's rho correlation coefficients. Health-state valuations were significantly different (P < 0.01), and there was good similarity between the two versions' ICC 0.86 (95% CI 0.79-0.91). The within-subject mean change was 0.03 (95% CI 0.01-0.06). For convergent validity, all relationships were significant (P < 0.05) and in the expected directions. EQ-5D-5L demonstrates sufficient convergent validity to be used with POFP, and a change in the standard reference period may be unnecessary if a multidimensional pain measure is also used.