Orofacial Pain--Part II: Assessment and management of vascular, neurovascular, idiopathic, secondary, and psychogenic causes

Chronic orofacial pain is a common health complaint faced by health practitioners today and constitutes a challenging diagnostic problem that often requires a multidisciplinary approach to diagnosis and treatment. The previous article by the same authors in this issue discussed the major clinical characteristics and the treatment of various musculoskeletal and neuropathic orofacial pain conditions. This second article presents aspects of vascular, neurovascular, and idiopathic orofacial pain, as well as orofacial pain due to various local, distant, or systemic diseases and psychogenic orofacial pain. The emphasis in this article is on the general differential diagnosis and various therapeutic regimens of each of these conditions. An accurate diagnosis is the key to successful treatment of chronic orofacial pain. Given that for many of the entities discussed in this article no curative treatment is available, current standards of management are emphasized. A comprehensive reference section has been included for those who wish to gain further information on a particular entity.     

The determinants of serum vitamin D levels in participants in a melanoma case?Ccontrol study living in a temperate climate

Background

We report the determinants of serum levels of vitamin D in a UK melanoma case?Ccontrol study benefitting from detailed exposure and genotyping data.

Methods

Sun exposure, supplemental vitamin D, and SNPs reported to be associated with serum levels were assessed as predictors of a single serum 25-hydroxyvitamin D₃ measurement adjusted for season, age, sex, and body mass index.

Results

Adjusted analyses showed that vitamin D levels were sub-optimal especially in the sun-sensitive individuals (?2.61?nmol/L, p?=?0.03) and for inheritance of a genetic variant in the GC gene coding for the vitamin D-binding protein (?5.79 for heterozygotes versus wild type, p?=?<0.0001). Higher levels were associated with sun exposure at the weekend in summer (+4.71?nmol/L per tertile, p?=?<0.0001), and on hot holidays (+4.17?nmol/L per tertile, p?=?<0.0001). In smoothed scatter plots, vitamin D levels of 60?nmol/L in the non-sun-sensitive individuals were achieved after an average 6?h/day summer weekend sun exposure but not in the sun-sensitive individuals. Users of supplements had levels on average 11.0?nmol/L higher, p?=?<0.0001, and achieved optimal levels irrespective of sun exposure.

Conclusions

Sun exposure was associated with increased vitamin D levels, but levels more than 60?nmol/L were reached on average only in individuals reporting lengthy exposure (??12?h/weekend). The sun-sensitive individuals did not achieve optimal levels without supplementation, which therefore should be considered for the majority of populations living in a temperate climate and melanoma patients in particular. Inherited variation in genes such as GC is a strong factor, and carriers of variant alleles may therefore require higher levels of supplementation.     

The psychosocial factors at work related to depression among female white-collar workers in Vilnius (Lithuania)

Objectives  

The aim of this study is to establish which psychosocial factors at work are related to depression among female white-collar workers in Vilnius.     

Physiological comparison between non-athletes,endurance, power and team athletes

European Journal of Applied Physiology - We hypothesized that endurance athletes have lower muscle power than power athletes due to a combination of weaker and slower muscles, while their higher...     

Referring patients for stress-related disorders

Stress and psychological disorders can have a profound effect on the etiology, duration, and outcome of nearly all physical conditions. They also can interfere with the dentist's diagnosis and treatment of patients, particularly those who suffer from chronic pain. Dentists should be able to identify the possibility of the presence of stress and psychological disorders in patients and to make an appropriate referral when it is indicated.     

The Role of Echocardiography in the Differential Diagnosis Between Training Induced Myocardial Hypertrophy Versus Cardiomyopathy

Increased myocardial mass due to regular high-volume intense exercise training (so-called athlete’s heart) is not uncommon. Although directly correlated with the extent of training loads, myocardial hypertrophy is not present exclusively in well-trained or elite athletes. Athlete’s heart is considered a physiological phenomenon with no known harmful consequences. However, extreme forms of myocardial hypertrophy due to endurance training resemble a structural heart disease such as hypertrophic cardiomyopathy, a condition associated with substantially increased risk of cardiac event. Endurance sports such as rowing and road cycling, rather than strength/power training, are most commonly associated with left ventricular (LV) wall thickness compatible with hypertrophic cardiomyopathy. The differentiation between physiological and maladaptive cardiac hypertrophy in athletes is undoubtedly important, since untreated cardiac abnormality often possesses a real threat of premature death due to heart failure during intense physical exertion. Luckily, the distinction from pathological hypertrophy is usually straightforward using transthoracic echocardiography, as endurance athletes, in addition to moderately and proportionally thickened LV walls with normal acoustic density, tend to possess increased LV diameter. In more uncertain cases, a detailed evaluation of myocardial function using (tissue) Doppler and contrast echocardiography is effective. When a doubt still remains, knowledge of an athlete’s working capacity may be useful in evaluating whether the insidious cardiac pathology is absent. In such cases cardiopulmonary exercise testing typically resolves the dilemma: indices of aerobic capacity are markedly higher in healthy endurance athletes compared to patients. Other characteristics such as a decrease of LV mass due to training cessation are also discussed in the article.

Key points

• Transthoracic echocardiography is still the most common relevant differentiation technique applied to distinguish athlete’s heart from the cardiomyopathy.
• Conventional echocardiographic criteria such as left ventricular chamber size and diastolic function parameters are to be regarded first when making differential diagnosis between substantially increased wall thickness in athlete’s heart (i.e. physiological adaptation) versus a disease (usually hypertrophic cardiomyopathy).
• When conventional echocardiographic parameters fail to diagnose the nature of myocardial hypertrophy, other differentiation criteria such as aerobic fitness, cardiac performance in response to physical exertion, and changes in echocardiographic parameters due to detraining, must be taken into consideration.
• Tissue Doppler, contrast and three-dimensional imaging are state-of-the-art echocardiographic techniques which have recently appeared in the differential diagnostics.

Key words: Left ventricle, physical exercises, physiological adaptation