Depression and diffuse physical symptoms in southern Chinese with temporomandibular disorders

Summary  The study investigated the experience of depressive symptoms and the relationship with diffuse physical symptoms reporting in southern Chinese seeking professional care for temporomandibular disorders (TMD) in Hong Kong. Eighty-seven new patients [77 females/10 males; mean age 39·3 years (SD 12·7)] referred to the specialist TMD clinic at the Prince Philip Dental Hospital, Hong Kong participated in this study. The Research Diagnostic Criteria (RDC)/TMD history questionnaire was used to derive Axis II psychological data. Psychological status was assessed through depression and non-specific physical symptoms (NPS) scores (pain items included and excluded) measured with RDC/TMD Axis II instruments; 42·5% of patients experienced moderate/severe depression symptoms; 59·8% and 57·5% had moderate/severe NPS scores when pain items were included and excluded, respectively. Strong, positive and statistically significant correlations were noted between depression scores and the NPS scores that included pain items ( r  = 0·80) and those that did not ( r  = 0·80). The correlations remained consistent and were of similar magnitude when male patients were excluded from the computation and also when the possible effect of patient age was controlled. While taking into account the modest patient sample which was related to a low rate of treatment seeking, depressive symptoms were common and similar to other western and Chinese patient groups. NPS reports were higher than in Singapore Chinese patients. There appeared to be a clear association between depression and diffuse physical symptoms. The findings should be considered in the holistic care of Chinese people with TMD.     

Clinical examination of patients with orofacial pain

Abstract A thorough clinical examination of patients with orofacial pain is of paramount importance. The examination is time-consuming, but is usually fully rewarding in that it may prevent unnecessary or incorrect and often irreversible treatment, and clarify to the clinician and hopefully to the patient the nature of the patient's problem. Only then may proper treatment be rendered. In this context it should be noted that a skillfully performed examination in these patients in itself provides valuable and effective treatment, especially when muscular dysfunction is the primary cause of the pain.     

Diagnostic sub-types, psychological distress and psychosocial dysfunction in southern Chinese people with temporomandibular disorders

Summary  The study aimed to assess the distribution of temporomandibular disorders (TMD) sub-types, psychological distress and psychosocial dysfunction in southern Chinese people seeking treatment for TMD using Research Diagnostic Criteria for TMD (RDC/TMD) and investigate potential cross-cultural differences in sub-type prevalence and psychosocial impact. Eighty-seven consecutive patients (77 females; 10 males) with a mean age of 39·3 years (s.d. 12·8) newly referred to the specialist TMD clinic at the Prince Philip Dental Hospital, Hong Kong over a 20-month period took part in the study. RDC/TMD history questionnaire and clinical assessment data were used to derive Axis I and II findings. Group I muscle disorders were the most common and found in 57·5% of patients. Group II (disc displacement) disorders were found in 42·5% and 47·1% of the right and left temporomandibular joints (TMJ) respectively. Group III disorders (arthralgia/arthrosis/arthritis) were revealed in 19·5% and 23·0% of right and left TMJ's respectively. In the Axis II assessment, 42·5% of patients had moderate/severe depression scores, 59·7% had moderate/severe somatization scores and based on graded chronic pain scores 15·0% had psychosocial dysfunction (grade III and IV). While acknowledging the small sample size, the distribution of RDC/TMD Axis I and II diagnoses was fairly similar in Chinese TMD patients compared with Western and other Asian patient groups. However, in Chinese patients, myofascial pain with limited jaw opening and TMJ disc displacement with reduction were more common and a significant number experienced psychological distress and psychosocial dysfunction. The findings have implications for the management of TMD in Chinese people.     

Socioeconomic and demographic disparities in symptoms of orofacial pain

OBJECTIVES: The purpose of this study was to document the association between socioeconomic status (SES) and the prevalence and impact of orofacial pain by anatomical location. In addition, differential effects of SES on orofacial pain across levels of sex, race, and age were documented. METHODS: The subjects were 724 participants in the Florida Dental Care Study, a study of oral health among dentate adults, aged 45 years and older at baseline. Pain prevalence and subjective ratings were assessed for a range of orofacial pain sites using a standardized telephone interview. RESULTS: Lower SES was associated with reporting pain and pain impact at many, but not all, of the orofacial sites. Some sex, race, and age cohort differences in orofacial pain were found when adjusting for differences in socioeconomic position. The most consistent result, as evidenced by similar findings across orofacial pain sites, was that the effects of SES on orofacial pain appear to have a sex-differentiated effect. CONCLUSION: Consistent with findings for other subjective measures of oral health, persons of lower SES are at increased risk for orofacial pain and pain-related behavioral impact.     

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疼痛治疗分为药物治疗和非药物治疗。药物治疗包括非甾体类抗炎药、阿司匹林和扑热息痛等非阿片类镇痛药、阿片类镇痛药、"辅助"药物如抗抑郁药阿米替林和抗惊厥药卡马西平等。非药物治疗包括神经刺激疗法、神经阻滞疗法、外科手术、物理治疗、心理-行为疗法等。本文介绍我们临床上常见的颞下颌关节骨关节炎、肌筋膜疼痛、神经病理性疼痛(非典型牙痛、治疗后神经痛、三叉神经痛)及复合性局部疼痛综合征的主要临床用药和理论基础,如非甾体类抗炎药特异性COX-2抑制剂、改善骨关节炎症状和关节结构的药物硫酸氨基葡萄糖、阿片类药物曲马多、三环类抗抑郁药阿米替林、新一代抗惊厥药加巴喷丁等。     

Depression levels in chronic orofacial pain patients: a pilot study

The assessment of depressive behaviour in chronic pain patients is especially important, because depression is commonly associated with chronic pain. The aim of this pilot study was to compare depression levels between patients with head and neck cancer pain and temporomandibular disorders (TMD), and to determine whether there is an association between depression levels and chronic pain severity. This study was an observational and sectional study and the sample consisted of 40 patients, uniformly divided into those with chronic orofacial pain related to cancer and those with painful TMD classified with research diagnostic criteria for temporomandibular disorders (RDC/TMD) axis I. Depression levels, pain intensity and severity were assessed with RDC/TMD axis II. The study demonstrated statistically significant differences in depression levels present in the head and neck cancer pain group and the painful TMD group, with the occurrence of a moderate statistically significant correlation between depression levels and chronic pain severity.     

Psychological distress in chronic craniomandibular and cervical spinal pain patients

Recent studies to chronic pain have shown that the number of painful body areas is related to the level of psychological distress. Therefore, the first aim of this study was to analyse differences in level of psychological distress between craniomandibular pain patients with or without cervical spinal pain. In this analysis, the number of painful body areas below the cervical spine was also taken into account. The second aim was to determine psychological differences between subgroups of craniomandibular pain patients. In this study, 103 out of 250 persons with or without craniomandibular pain were included in the final analyses. Patients who suffered from both craniomandibular and cervical spinal pain showed higher levels of psychological distress, as measured with the Symptom Checklist 90 (SCL-90) than patients with local craniomandibular pain and persons without pain. Further, a positive relationship was found between the number of painful body areas below the cervical spine, as measured on a body drawing, and the SCL-90 scores. No psychological differences were found between myogenous and arthrogenous craniomandibular pain patients. In conclusion, chronic craniomandibular pain patients with a coexistent cervical spinal pain showed more psychological distress compared to patients with only a local craniomandibular pain and asymptomatic persons.     

Persistent orofacial pain associated with nasopharyngeal extramedullary plasmacytoma

Orofacial pain (OFP) disorders affect the maxillofacial complex and typically involve other locations in the head and neck. Common etiologies of OFP disorders include odontogenic sources, temporomandibular disorders, neuropathic pain, chemosensory disorders, and headaches. Less commonly, benign and malignant neoplasms can be associated with OFP complaints. Patients with OFP symptoms require a thorough evaluation and are often referred to additional healthcare providers for interprofessional management. In those OFP patients whose symptoms do not respond to conventional treatment(s), whose symptoms change over time, or who report positive responses to review of systems questions that suggest more extensive involvement, further investigation is warranted. To the best of our knowledge, this is the first case report of nasopharyngeal extramedullary plasmacytoma, a localized malignant neoplasm, associated with persistent OFP.     

压力痛阈测试在口腔颌面部疼痛研究的应用

压力痛阈测试（Pain-pressure threshold,PPT）作为定量感觉测试被用于口腔颌面部疼痛的临床研究,其在揭示疾病疼痛的发生机制、预测疾病发展过程、判断不同治疗方法下临床效果的差异等方面作用显著。该文就PPT在口腔颌面部疼痛研究的进展及其局限性作一综述。     

Incompletely fractured teeth associated with diffuse longstanding orofacial pain: diagnosis and treatment outcome

AIM: To evaluate the diagnostic value of different clinical findings, and analyse the symptoms experienced from teeth with incomplete dentinal fractures in patients with diffuse orofacial pain. Secondly, to present the outcome of different treatment modalities in these patients. METHODOLOGY: Thirty-two patients, referred to the teaching clinic at the Faculty of Dentistry, University of Bergen, with poorly localized orofacial pain, were finally diagnosed with 46 incompletely fractured teeth. The distribution and pattern of pain was thoroughly recorded for each patient. The final diagnosis, incompletely fractured tooth, was obtained after removal of fillings and direct inspection of possible fracture lines. RESULTS: Many of the patients had suffered diffuse orofacial pain for more than 1 year, and had earlier consulted dental and medical expertise. Direct inspection of fracture lines, combined with staining solution and transillumination proved to be the best diagnostic tools. The longer the duration of pain before the diagnosis of an incompletely fractured tooth was established, the more diffuse was the distribution of pain. Endodontic or restorative treatment relieved the symptoms in 90% of the patients, whilst persisting symptoms in 10% were considered part of an orofacial pain complex of obscure aetiology. CONCLUSION: This study shows that the diagnosis of the incompletely fractured teeth in patients with longstanding diffuse orofacial pain symptoms are time consuming and represent a diagnostic problem. With appropriate endodontic and/or restorative treatment, symptoms were relieved in the majority of cases.     

The psychosocial impact of orofacial pain in trigeminal neuralgia patients: a systematic review

Trigeminal neuralgia (TN) is characterized by sharp, electric shock-like pain, which can be triggered by trivial stimuli. Although medical and surgical treatments are available for TN, some patients experience refractory pain, which has a significant impact on their quality of life. The aim of this systematic review was to determine the psychosocial impact of orofacial pain in patients with diagnosed TN. A search was initiated in three electronic databases (Embase, MEDLINE, PubMed) to identify potential studies for inclusion in the review. All types of study published in English that reported psychosocial measures using validated psychometric questionnaires were included. A total of 585 articles were retrieved from the search. These were screened thoroughly, leading to the selection of 13 articles for data extraction and final analysis. The results show the chronic overwhelming nature of TN, with pain levels varying from mild to severe. Psychometric scores indicated mild to moderate depression, moderate to severe anxiety, and moderate to severe functional limitation of daily life activities in TN patients. Therefore, psychological support within a multidisciplinary team is recommended for TN patients to help them cope better with their chronic disorder and to improve the efficacy of treatment.     

Persistent orofacial muscle pain: Its synonymous terminology and presentation

Objective: The purpose of the present paper is to describe the presentation of persistent orofacial muscle pain, also commonly referred to as myofascial temporomandibular disorder.

Methods: In this practice survey, the authors reviewed the demographic and clinical features of 34 patients who were evaluated and diagnosed personally.

Results: The majority of the 34 patients were women (82.4%), and their age at consultation averaged 44.6 ± 12.6 (SD) years. The median pain duration was 4.0 years (range: 0.2–34 years). In 97.1% of patients, the pain occurred daily and continuously, and in 51.9% it was unilateral. Chewing or eating made the pain worse in 50% of the patients, and talking in 29.4%. On examination, tightness of the masseter muscle(s) was present in 58.8%, and tenderness in 58.8%.

Conclusions: Persistent orofacial muscle pain mostly affects women, generally occurs daily and continuously, and is equally often unilateral and bilateral. Chewing, eating, and talking are the most common aggravating factors, and tightness or tenderness of the masseter muscle(s) is often found on examination.     

Cannabis and orofacial pain: a systematic review

The naturally occurring cannabis plant has played an established role in pain management throughout recorded history. However, in recent years, both natural and synthetic cannabis-based products for medicinal use (CBPM) have gained increasing worldwide attention due to growing evidence supporting their use in alleviating chronic inflammatory and neuropathic pain associated with an array of conditions. In view of these products’ growing popularity in both the medical and commercial fields, we carried out a systematic review to ascertain the effects of cannabis and its synthetically derived products on orofacial pain and inflammation. The application of topical dermal cannabidiol formulation has shown positive findings such as reducing pain and improving muscle function in patients suffering from myofascial pain. Conversely, two orally-administered synthetic cannabinoid receptor agonists (AZD1940 and GW842166) failed to demonstrate significant analgesic effects following surgical third molar removal. There is a paucity of literature pertaining to the effects of cannabis-based products in the orofacial region; however, there is a wealth of high-quality evidence supporting their use for treating chronic nociceptive and neuropathic pain conditions in other areas. Further research is warranted to explore and substantiate the therapeutic role of CBPMs in the context of orofacial pain and inflammation. As evidence supporting their use expands, healthcare professionals should pay close attention to outcomes and changes to legislation that may impact and potentially benefit their patients.     

Development and validation of the Manchester orofacial pain disability scale

OBJECTIVE: To design and validate a self-administered instrument for assessing orofacial pain related disability in the general population. METHODS: The 32-item questionnaire was developed by open-ended interviews with patients attending dental hospital clinics and was subsequently tested on 171 community subjects with self-reported orofacial pain and 48 dental hospital patients. RESULTS: Construct validity of the instrument was demonstrated in three ways. First, levels of reported disability were greater in dental hospital patients than for community subjects reporting orofacial pain. Secondly, the instrument was able to detect differences in disability levels reported by community subjects who did and did not consult with a healthcare professional and those who had acute and chronic pain. Thirdly, amongst community subjects with pain, disability scores increased with higher pain intensity, pain duration and were greater amongst subjects who had sought a consultation. Results of factor analysis identified two constructs: physical and psychosocial disabilities, associated with orofacial pain. The Cronbach's alpha score was 0.78 and 0.92 for the physical and psychosocial constructs, respectively, and this along with item correlation values between 0.43 and 0.80 confirmed the internal consistency. CONCLUSION: We have therefore designed a valid instrument for assessing the impact of painful orofacial conditions in both community and clinic settings.     

Pain-related worry in patients with chronic orofacial pain

BackgroundPain-related worry is distinct from, but related to, pain catastrophizing (PC) and anxiety. Worry and its relationship with other variables have been studied in people with chronic pain but not in people with chronic orofacial pain. The authors explored the prevalence of trait, general and pain-related worry and the association of worry with higher pain levels and other variables.MethodsThe authors assessed people who had a diagnosis of chronic orofacial pain by using nonpain-related trait worry, state anxiety, trait anxiety, PC and pain measures. The participants’ answers to an open-ended question about what they were most worried about led to the identification of worry domains, including worry about pain.ResultsThe authors found that worrying about pain was related significantly to worst and least pain levels, pain interference and pain duration, as well as moderated trait worry in predicting pain interference. Although trait worry was not correlated directly with pain, when moderated by PC, it made substantial contributions in predicting pain interference.ConclusionsParticipants with chronic orofacial pain reported experiencing substantial levels of trait worry, anxiety, PC and worry about pain that related to pain ratings directly and indirectly.Practical ImplicationsClinicians should assess pain-related worry in patients with chronic orofacial pain to understand the effects of worry on pain and functioning. Clinicians could treat these patients more effectively by helping them reduce their levels of pain-related worry and focusing on improved coping.     

An update of management of insomnia in patients with chronic orofacial pain

In this review, we discuss the management of chronic orofacial pain (COFP) patients with insomnia. Diagnostic work‐up and follow‐up routines of COFP patients should include assessment of sleep problems. Management is based on a multidisciplinary approach, addressing the factors that modulate the pain experience as well as insomnia and including both non‐pharmacological and pharmacological modalities. Parallel to treatment, patients should receive therapy for comorbid medical and psychiatric disorders, and possible substance abuse that may be that may trigger or worsen the COFP and/or their insomnia. Insomnia treatment should begin with non‐pharmacological therapy, to minimize potential side effects, drug interactions, and risk of substance abuse associated with pharmacological therapy. Behavioral therapies for insomnia include the following: sleep hygiene, cognitive behavioral therapy for insomnia, multicomponent behavioral therapy or brief behavioral therapy for insomnia, relaxation strategies, stimulus control, and sleep restriction. Approved U.S. Food and Drug Administration medications to treat insomnia include the following: benzodiazepines (estazolam, flurazepam, temazepam, triazolam, and quazepam), non‐benzodiazepine hypnotics (eszopiclone, zaleplon, zolpidem), the melatonin receptor agonist ramelteon, the antidepressant doxepin, and the orexin receptor antagonist suvorexant. Chronic orofacial pain can greatly improve following treatment of the underlying insomnia, and therefore, re‐evaluation of COFP is advised after 1 month of treatment.