Comorbidity of depression with chronic facial pain and temporomandibular disorders

OBJECTIVE: The objective of this study was to examine the comorbidity of depressive disorders in patients with chronic facial pain presenting to a multidisciplinary facial pain clinic. STUDY DESIGN: Data were collected from 72 consecutive patients with chronic facial pain who had received a maltidisciplinary evaluation including a psychiatric examination for the presence of depressive disorders. RESULTS: Twenty-eight percent of patients met criteria of the latest Diagnostic and Statistical Manual of Mental Disorders for major depression, and 25% met the criteria for minor depression. A further 22% reported subsyndromal depressive symptoms. Temporomandibular disorders were demonstrable in 71% of these patients, but the remaining 29% had no objective physical findings. There was no statistical difference in comorbidity of depressive disorders in patients with temporomandibular disorders compared with patients without temporomandibular disorders. CONCLUSION: Screening for symptoms of depression should be an integral part of the evaluation of all patients with chronic facial pain, even when masticatory muscle or temporomandibular joint disorders are identified.     

Knowledge and beliefs of dentists regarding temporomandibular disorders and chronic pain

To assess the knowledge and beliefs of practicing dentists regarding temporomandibular disorders and chronic pain, a random sample of dentists in the Kansas City metropolitan area was surveyed. A survey instrument examining knowledge and beliefs in four domains (psychophysiological, psychiatric disorders, chronic pain, and pathophysiology) was used. The responses of the practicing dentists were compared to the responses of panels of experts. Results indicated that dentists generally agreed with experts in the psychophysiological and psychiatric disorders domains but disagreed with the experts in the chronic pain and pathophysiology domains. Specialists and general dentists did not differ from one another in their responses. The findings partially replicate an earlier, similar survey of dentists in the Seattle, Washington, area. The findings suggest that the role of psychiatric disorders and psychophysiologic factors in the etiology of temporomandibular disorders is widely acknowledged by practicing dentists. However, there is considerable discrepancy between practicing dentists and temporomandibular disorder experts on the pathophysiology of temporomandibular disorders and how best to diagnose and treat these chronic conditions.     

The role of pharmacy in the management of patients with temporomandibular disorders and orofacial pain

OBJECTIVE: To provide information regarding the current understanding of the etiology and treatment, both nonpharmacologic and pharmacologic, of orofacial pain conditions including temporomandibular disorders (TMDs). This review briefly discusses the etiology and pathophysiology underlying the development of TMDs, generally accepted nonpharmacologic methods of treatment, and the most common current pharmacologic management approaches. DATA SOURCES: Current medical literature and the authors' clinical experiences. DATA SYNTHESIS: TMDs encompass a number of diagnostic subgroups that involve the masticatory musculature, the temporomandibular joint(s), and associated structures. More than 10 million individuals in the United States are affected by TMDs. Most current pharmacologic management approaches in the treatment of orofacial pain conditions, including TMDs, involve the use of antidepressants, anticonvulsants, muscle relaxants, corticosteroids, and nonsteroidal anti-inflammatory drugs. CONCLUSION: Inclusion of pharmacists who are knowledgeable in the nonpharmacologic and pharmacologic treatment approaches on the TMD management team would improve therapeutic monitoring, follow-up, and outcomes in these patients.     

The chronic pain syndrome: misconceptions and management

The management of chronic pain is a universal and vexing problem for physicians. Literature indicates that health care providers have a poor understanding of basic concepts relating to pain, which leads to frustration for the physician and inadequate relief for the patient. This paper addresses misconceptions about organic versus functional pain, discusses placebos and administration of narcotic analgesics, and outlines therapeutic alternatives. Emphasis is on distinguishing chronic pain of benign origin from that secondary to malignancy as an individual treatment plan is formulated.     

The role of the psychologist on the multidisciplinary pain management team.

Psychologists are being increasingly sought for expertise in the area of pain, yet many do not understand the full scope of practice. The current article describes the unique contributions of the psychologist to the understanding of the multifactorial nature of pain. This includes the assessment of preexisting or secondary psychological factors associated with chronic pain and the evidence-based psychological treatment of pain conditions. By following the recommendations outlined in this article, the pain psychologist can position him- or herself to take a positive leadership role in the comprehensive delivery of care to the pain patient. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Correlates of improvement in multidisciplinary treatment of chronic pain.

Although multidisciplinary pain programs have been demonstrated to be effective, the processes of improvement have yet to be clarified. Cognitive-behavioral models posit that improvement is due, in part, to changes in patient pain beliefs and coping strategies. To test the relationships between treatment outcome and changes in beliefs and coping strategies, 94 chronic pain patients (aged 21–64 yrs) completed measures of physical and psychological functioning, health care utilization, pain beliefs, and use of pain coping strategies at admission and 3 to 6 mo after inpatient pain treatment. Improved functioning and decreased health care use were associated with changes in both beliefs and cognitive coping strategies. However, changes in some coping strategies, such as exercise and use of rest, were not associated with improvement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Repression predicts outcome following multidisciplinary treatment of chronic pain.

This study examined whether repression predicts outcome following multidisciplinary treatment for chronic pain and whether links between anxiety and outcome are obscured by repressors. Ninety-three chronic pain patients completed a 4-week pain program. Lifting capacity, walking endurance, depression, pain severity, and activity were measured at pre- and posttreatment. Low-anxious, repressor, high-anxious, and defensive/high-anxious groups were formed from median splits of Anxiety Content (ACS) and Lie scales of the Minnesota Multiphasic Personality Inventory–2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989). Significant ACS?×?Lie interactions were found for lifting capacity, depression, and pain severity changes. Planned comparisons showed that both repressors and high-anxious patients performed poorly on lifting capacity; repressors alone recovered poorly on depression and pain severity. Results imply that repression may interfere with the process and outcome of pain programs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Leg ulcer management in a nurse-led, hospital-based clinic

This paper describes the clinical outcomes from a nurse-led leg ulcer clinic over a period of three and a half years. Leg ulcers were assessed in a structured way and venous ulcers were treated with four-layer compression bandaging. The study involved retrospective analysis of 159 patients with 180 venous leg ulcers. Overall healing rates were 64.5% at 12 weeks, 84.1% at 24 weeks and 91.4% at 36 weeks. Healing rates were not affected by a history of previous ulceration or by bilateral limb ulceration. However, healing rates varied with previous ulcer duration, ulcer size and patient mobility.     

The concepts prevalence, need for treatment, and prevention of temporomandibular disorders: a suggestion for terminology

To determine the effect of pathogenic oral bacteria on interleukin 6 (IL-6) and soluble IL-6 receptor production, we measured their release by human peripheral blood mononuclear cells in vitro. Unseparated peripheral blood mononuclear cells, peripheral blood lymphocytes (monocyte depleted), pure T cells, or monocytes were cultured with Actinobacillus actinomycetemcomitans, Capnocytophaga gingivalis, Capnocytophaga ochracea, Fusobacterium nucleatum or Porphyromonas gingivalis for 24 h. Supernatants were tested for IL-6 and soluble IL-6 receptor by enzyme-linked immunosorbent assay. Only monocytes and peripheral blood mononuclear cells responded with significant IL-6 release in the presence of all bacteria tested. However, peripheral blood lymphocytes were capable of producing IL-6 when activated by phytohemagglutinin or IL-2 followed by bacteria, though substantially less than cultures containing monocytes. No bacteria tested increased soluble IL-6 receptor release over spontaneous soluble IL-6 receptor release. We conclude that monocytes release IL-6 after contact with oral pathogens; however, soluble IL-6 receptor from T cells and monocytes is constitutively produced and may modulate IL-6 actions.     

Treatment of temporomandibular disorders: arthroscopy, orthodontics, kinesitherapy]

In(1LR)pn2a is a pericentric inversion with a euchromatic breakpoint in the 2E polytene region and a heterochromatic breakpoint in the right arm of the X chromosome. It is associated with position-effect variegation (PEV) of the pn, wapl, Pgd and other vital loci of the 2E region, which are relocated near the bulk of the X heterochromatin. Cytological analysis showed that the rearrangement brings the 1A-2E euchromatic segment directly into contact with a major portion of the h34 block, a heterochromatic region that is positively stained by the N-banding technique and contains the AAGAG satellite sequences. Molecular cloning revealed the presence of a new junction between euchromatin and AAGAG satellite sequences and demonstrated that the euchromatic breakpoint of In(1LR)pn2a lies in the vinculin gene. In the X ray-induced secondary rearrangement In(1LR)r30, consisting of a pericentric inversion superimposed on In(1LR)pn2a, the h34 material remains associated with the 2E region but is separated from the rest of the X heterochromatin. In this case, the pn, wapl and Pgd loci no longer variegate, suggesting that the satellite-containing h34 region is not able per se to induce detectable PEV on the adjacent euchromatic genes.     

The possible role of nitric oxide in the physiopathology of pain associated with temporomandibular joint disorders

Temporomandibular joint disorders (TMD) pose a significant challenge to the practice of oral and maxillofacial surgery. When painful, TMD are generally associated with hyperthermia of the overlying skin. It is hypothesized that this skin hyperthermia, caused by regional vasodilation, is induced by nitric oxide (NO) produced in the extravascular space of the joint. Extravascular NO can be produced by osteoblasts, chondrocytes and macrophages, or by stimulated neurons. It is suggested that this kind of pain is associated with NO-enhanced sensitivity of the peripheral nociceptors. Verification and clinical implications of the proposed mechanism are discussed.     

Evidence-based management of chronic pelvic pain

Diagnosis and management of chronic pelvic pain are greatly facilitated by a multidisciplinary approach integrating medical intervention with identification and management of socioenvironmental problems, cognitive-behavioral pain strategies, and treatment of concurrent psychological morbidity. Available evidence suggests that outcomes, including pain severity, general health and functional status, and disability are more significantly improved after this approach than after isolated medical or surgical interventions. Because of the chronic nature of many of the underlying psychological and social factors predisposing to chronic symptom formation and maintenance, care of the patient with chronic pelvic pain must be continuous and longitudinal if recurrent adverse sequelae, including disability, inappropriate healthcare utilization, and recurrent depression, are to be prevented.     

Biofeedback and relaxation therapy for chronic temporomandibular joint pain: Predicting successful outcomes.

57 patients with chronic temporomandibular joint (TMJ) pain were randomly assigned to receive either relaxation or biofeedback therapy. 27 Ss (mean age 35.6 yrs) listened to tape-recorded relaxation once a week at the therapist's office for 3 sessions and were encouraged to practice daily. 30 Ss (mean age 43 yrs) participated in biofeedback sessions and were instructed to practice relaxation for 20 min/day between sessions. Results show no significant differences in outcomes. However, successful Ss in the 2 conditions differed from each other. Successful relaxation Ss tended to be younger, had TMJ pain for a shorter period of time, and reported problems with other psychophysiologic disorders. Successful biofeedback Ss were older, married, had TMJ pain for a longer period of time, and had not received prior equilibration treatment. Equilibration and presence of other disorders were related to both short- and long-term outcomes, suggesting they may be useful as predictors of outcome. It is also suggested that knowledge of pretherapy factors may allow for optimal assignment to therapy conditions. (30 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Management of temporomandibular disorders in a restorative practice

Various disorders related to the masticatory muscles or to the temporomandibular joints may be encountered in a restorative dental practice. Most of them can be managed by the restorative dentist whose primary interest may not lie in the area of temporomandibular disorders. The term temporomandibular disorders is used in this discussion to denote the group of diseases of the masticatory system that involves primarily the temporomandibular joints, the masticatory muscles, and the occlusion of the teeth. The learning objective of this article is to describe temporomandibular disorders encountered in general practice. Managing these disorders in the general practice of restorative dentistry is not difficult and adds to the comfort of the patient and possibly to the success of the restorations.     

The cerebrovascular manifestations of temporomandibular joint pain dysfunction

Overall 37 patients with painful dysfunction of the temporomandibular joint (TMJ), characterized clinically by headaches and dizziness as well (25 persons) were examined. A study was made of REG. The responsiveness of the sinocarotid node (SCN) was recorded. Diverse changes in the REG readings that attested to the development of cerebral angiodystonia were recorded. Abnormal responsiveness of SCN was discovered. Skillful orthopedic correction of the spatial position of the mandible was associated with noticeable changes in the normalizing and optimizing character of numerous REG readings. These data together with optimization of the responsiveness of the SCN point to the role played by the irritative vascular mechanism in the pathogenesis of headaches and dizziness seen in TMJ dysfunction.     

Craniofacial pain of myofascial origin: temporomandibular pain & tension-type headache

Craniofacial pain of myofascial origin is a common chronic disorder. When the pain is unilateral and located periauricularly, masticatory myalgia is likely. Tension-type headache is usually bilateral and affects the upper part of the head. The possible interrelationship with generalized myofascial disorders are discussed. Practical approaches to history-taking, diagnosis, and treatment are suggested.     

Emergency treatment of acute temporomandibular disorders: Part II

In this, the second part of a presentation on the emergency treatment of an acute temporomandibular disorder, we will address the problems of joint sounds, open and closed locking and psychological considerations. The management of pain and muscle spasm was considered in the previous paper.