“All improvements require change, but not all change is improvement. If we continue to behave as if evidence is bad for patient care we will continue to foster the clinical adage of `if it works well in my hands it must be good'.”
Evidence Based Medicine
Hunt for the “Perfect Treatment”
Evidence Based Medicine
Avicenna or Ibn Sina (980-1037 CE)
Was the foremost physician of his time
Influenced by Greek, Arabic and Indian medicine
His greatest work was “The Canon of Medicine”
He is regarded as the father of early modern medicine due to his extensive work on clinical pharmacology
Pioneer of EBM, clinical trials, etc
The Canon (Quanun) of medicine
Sir Francis Bacon (1561–1626)
Sir Francis Bacon (1561 - 1626)
Baconian methodology for scientific inquiry.
Terminology
The terminology is important because it provides an understanding of the pathophysiology, clue to treatment planning and prognosis
Same applies to definitions, classification by various scientific organizations including Academies
Definition
PAIN:
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” -IASP
OROFACIAL PAIN:
“Pain and associated symptoms arising from a discrete cause, such as postoperative pain or pain associated with a malignancy, or may be syndromes in which pain constitutes the primary problem, such as neuropathic pains or headaches.”
-ABOP
Temporomandibular disorders - A term past its time?
TMD mixes at least two anatomical areas and more than a few mechanism.
Classification of Orofacial Pain
Clinical Features of Orofacial Pain
Pain
Limitation of movement
TM joint sounds
Occlusal changes
Orofacial Pain: What Kind of Problem is it?
Structural alterations were different for the different pain syndromes, but, in terms of functional systems, overlapped to an astounding extent. The most common finding is a decrease of gray matter in the cingulate cortex, the orbitofrontal cortex, the insula and the dorsal pons, suggesting a common basis.
Structural alterations were different for the different pain syndromes, but, in terms of functional systems, overlapped to an astounding extent. The most common finding is a decrease of gray matter in the cingulate cortex, the orbitofrontal cortex, the insula and the dorsal pons, suggesting a common basis.
Overlapping neuronal activations under the equal pain condition. Equal subjective pain intensities result in 7 overlapping or adjacent areas of neuronal activation among the CLBP, HC, and FMS groups (in the contralateral S1, S2, and IPL, anterior cingulate cortex [ACC], insula [not shown], and in ipsilateral S2 and cerebellum).
Overlapping neuronal activations under the equal pain condition. Equal subjective pain intensities result in 7 overlapping or adjacent areas of neuronal activation among the CLBP, HC, and FMS groups (in the contralateral S1, S2, and IPL, anterior cingulate cortex [ACC], insula [not shown], and in ipsilateral S2 and cerebellum).
Genetics
A sustained elevation in catecholamines contributes to
– Painful rheumatoid arthritis
– Non-inflammatory pain
TMD and Fibromyalgia patients exhibit ↑ catecholamines
Psychological disorders and Chronic Pain
Psychological disorders and Chronic Pain – Why?
High prevalence of psychological comorbodities among patients with chronic pain
Presence of chronic pain may cause emotional distress and exacerbate premorbid psychological disorders
Unrecognized and untreated psychological distress may interfere with successful treatment of chronic pain
Psychological Factors
Pre existing stressors
Solicitous vs non-solicitous spouse
Pain and Psychological factors
42 chronic back pain patients
Task: treadmill test
Outcomes: walking time, pain rating, heart rate
Solicitous spouse= more pain, shorter walking time
Sleep
Bruxism
Do you ever grind your teeth?
Is it something abnormal? What is it?
Does it cause orofacial pain?
Bruxism
Sleep disorder: multi factorial in etiology
Rhythmic bilateral activation of jaw closing muscles followed by a period of sustained maximal contraction which frequently occurs in excursive (i.e. lateral) mandibular position (McNeill)
Forces of function versus parafunction: 17,200 lb/sec/day Vs 57,600 lb/sec/day
Function - vertical directional forces, isotonic muscle contraction
Sleep bruxers without painful symptoms have higher EMG activity compared to the sleep bruxers with pain
The aim of this study was to compare two groups of children with bruxism. One group was not submitted to treatment, serving as a control. To the other group, nocturnal bite plate was made. The 4 children of the control group displayed increased wear facets during the study period. On the other hand, of the 5 children that used nocturnal bite plate, showed no increase of wear facets, even after the removal of the device. From this study, we can conclude that the use of nocturnal bite plate is efficient against bruxism in 3- to 5-year-old children.
The aim of this study was to compare two groups of children with bruxism. One group was not submitted to treatment, serving as a control. To the other group, nocturnal bite plate was made. The 4 children of the control group displayed increased wear facets during the study period. On the other hand, of the 5 children that used nocturnal bite plate, showed no increase of wear facets, even after the removal of the device. From this study, we can conclude that the use of nocturnal bite plate is efficient against bruxism in 3- to 5-year-old children.
Muscles: How do they fit in?
Role of Masticatory Muscles
Role of Electromyography
Does increased motor function cause pain ?
Role of Electromyography
Does increased motor function cause pain ?
Role of Electromyography
An initiating factor (morphology, posture, physical/psychologic stress etc) can result in pain that reflexively leads to “functional overload”, which leads to pain and the “Vicious cycle goes on”
Pain adaptation model: pain results in reduced agonist muscle and increased antagonist muscle activity
Integrated Pain Adaptation Model: Pain results in a new, optimized recruitment strategy of motor units that represents the individual's integrated motor response to the sensory-discriminative, motivational-affective, and cognitive-evaluative components of pain. This recruitment strategy aims to minimize pain and maintain homeostasis
These are just hypothesis!!!
Effect of a jig on EMG activity in different orofacial pain conditions.
EMG recordings were obtained from 2 groups of pain patients (myofascial and neuropathic) and from 2 groups of pain-free patients (disc derangement and controls) unaware of the role of dental occlusion treatments.
The decrease of postural EMG activity, especially in the myofascial group, was short lasting and cannot be considered as evidence to support the hypothesis of a long-term muscle relaxation jig effect. However, the results may uphold certain short-term clinical approaches.
What do I think?
Muscle activity is an individual reaction to pain rather than a cause of pain
It could very well be a perpetuating factor!
What do I think?
Muscle activity is an individual reaction to pain rather than a cause of pain
It could very well be a perpetuating factor!
But then, What do I know?
Orthodontics and Orofacial Pain
4 million people are in braces in the US at any one time
40% of population have some type of joint noise, indicating the existence of possible disc problems
“Occlusion is ….. coordinated functional interaction between the various cell populations forming the masticatory system as they differentiate, model, remodel, fail, and repair.”
“Occlusion is ….. coordinated functional interaction between the various cell populations forming the masticatory system as they differentiate, model, remodel, fail, and repair.”
“Morphologic variations are very common and represent the norm.”
Occlusion
A small number of occlusal factors (e.g. anterior open bite, large horizontal overjet, loss of molar support) appear to be weakly associated with TMD.
One of the more robust findings is the association between cross-bite and TMD
Associations Vs Causation
Various malocclusions have been associated with TMD signs or symptoms (e.g. class II and distal molar occlusions; anterior open bites and non-working side contacts; class III; crossbites; deep bites and five or more missing posterior teeth
Causation Vs Association
Management
The seven secrets to successful management of an orofacial pain patient
History
History
History
History
History
History
History
MANAGEMENT OF OROFACIAL PAIN DISORDERS
`The practice of EBD requires the blending of research knowledge with provider experience'.
There is nothing inherent in EBD that is threatening to the wisdom of clinical experience and sound judgment.
Occlusal Orthosis - Mechanisms
Okeson states that occlusal appliances might reduce symptoms by:
Alterating the occlusal condition
Placebo effect,
Regression to the mean
The improvement our patients demonstrate is real.
Current Evidence Providing Clarity in Management of TMDs
Thirty-nine RCT studies involving intraoral splints were reviewed. In general, splints showed modest active therapeutic effects in reducing TMJD pain compared to a placebo control in more severe patients and comparable results to other treatments.
The efficacy of appliance therapy does not only depend on appliance selection but also how well it is adjusted to facilitate patient comfort and compliance.
Fricton’s Meta-analysis
44 RCTs with 2,218 subjects
Hard stabilization appliances, when adjusted properly, have good evidence of modest efficacy in the treatment of TMJD pain
Dao and Lavigne have offered an interesting observation which may tie together much of the discussion of this paper….efficacy is real therapeutic impact while effectiveness is subjective treatment experience. They then recommended that, despite their lack of true efficacy, splints should be employed as a treatment modality for TMD because they are effective treatments..
Dao and Lavigne have offered an interesting observation which may tie together much of the discussion of this paper….efficacy is real therapeutic impact while effectiveness is subjective treatment experience. They then recommended that, despite their lack of true efficacy, splints should be employed as a treatment modality for TMD because they are effective treatments..
They should also recognize that every intervention, whether pharmacological, mechanical, psychological, or surgical, can elicit the expectancy responses described earlier.
Acupuncture, Biofeedback and TENS
None of the seven studies were of high quality. An analysis of the degree of evidence of the results revealed no evidence for the efficacy of biofeedback, acupuncture or transcutaneous electric nerve stimulation in the management of temporomandibular disorders.
The problem with placebo…
Based on findings from brain-imaging analyses, we now know that placebo analgesia is definitely real (ie. Biologically measureable) phenomenon.
Placebo pill Vs placebo surgery
Moseley JB NEJM 2002..A controlled trial of arthroscopic surgery for osteoarthritis of the knee
Past Reviews Regarding Occlusal Orthosis
There is insufficient evidence (20 trials) either for or against the use of stabilization splint therapy over other active interventions for the treatment of temporomandibular myofascial pain. However, it appears that stabilization splint therapy may be beneficial for reducing pain severity at rest and on palpation and depression when compared to no treatment.
Case
24 year old female
Chief complaint of headaches & jaw pain
Headaches: about 3 per week; lasting 1-4 hours; front and sides of the head; no photophobia/phonophobia; varying intensity ranging from dull to throbbing
Jaw pain: mainly on the left side of the face; usually associated with the headaches.
Systems review: unremarkable
Medical history: non-contributory
Physical examination: Severe tenderness in masseters and temporal tendon areas. No referral patterns. Good range of mandibular motion. Overbite of 20% and overjet of about 2 mm. Class I occlusion. Cranial nerves V and VII were grossly normal.
Oral occlusal appliance: full coverage stabilization appliance (full contacts)
Self care
Case…4 years later
Patient reports being almost painfree
She tried not using the appliance multiple times but everytime she had escalation of her pain
No trouble chewing
She has had severe gingival swelling since about 2 months; puffiness and general dentist and PCP suspect it to be an oral manifestation of a systemic disorder.
Case…4 years later
What does this case tells me?
Appliance do work
Occlusal changes are possible
She has a strange occlusal scheme (no intercuspation in posteriors)
When proded about her chewing habits, she is able to eat everything.
Most of these drugs are well absorbed, and food does not substantially change their bioavailability.
Most of the NSAIDs are highly metabolized, some by phase I followed by phase II mechanisms and others by direct glucuronidation (phase II) alone.
NSAID metabolism proceeds, in large part, by way of the CYP3A or CYP2C families of P450 enzymes in the liver.
While renal excretion is the most important route for final elimination, nearly all undergo varying degrees of biliary excretion and reabsorption (enterohepatic circulation).
Although these drugs are skeletal muscle relaxant, they do not directly relax skeletal muscle. Most of the beneficial effects are thought to be due to their sedative properties.
Muscle relaxants may promote healing by facilitating movement
They may reduce the length of acute stage (prevent an acute injury from turning into chronic)
Effective alone or in combination with NSAIDs
Available literature shows skeletal muscle relaxants are better than placebo, but not more effective than NSAIDs in patients with acute back pain. Similar recommendations exist in treating tension headaches.
Available literature shows skeletal muscle relaxants are better than placebo, but not more effective than NSAIDs in patients with acute back pain. Similar recommendations exist in treating tension headaches.
Benzodiazepines
Benzodiazepines
Short acting
Excellent agents for pre-treatment to prevent development of muscle pain (quick acting and short half life)
Risk of dependency
More adverse events relative to muscle relaxants
Antiepileptics
Gabapentin, pregabalin
Anticonvulsants suppresses abnormal neuronal discharges and increasing the threshold for nerve activation.
Different anticonvulsants are effective in different pain contexts,
They tend to be more effective in neuropathic pain states than in acute and chronic nociceptive pain
Psychiatric disorders are common in patients with chronic pain
Sleep disturbance is common in patients with chronic pain, even those who do not meet criteria for psychiatric disorders
Some antidepressants produce pain relief separate from relief of depression or other psychiatric disorders
Opioids
Well not really?
Opioids associated with poor function
Opioids associated with substance use disorders and other psychiatric disorders
Opioids associated with poor outcome
They do work….somewhat…
But generally speaking, if all the drugs of the day ''could be sunk to the bottom of the sea,'' as Oliver Wendell Holmes observed in 1860, ''it would be all the better for mankind -- and all the worse for the fishes.''
But generally speaking, if all the drugs of the day ''could be sunk to the bottom of the sea,'' as Oliver Wendell Holmes observed in 1860, ''it would be all the better for mankind -- and all the worse for the fishes.''
Morphologic variations are very common and represent the norm
The Displaced Disc !!!
Does it need to be treated ? Does it need to be repositioned ? Will it remain repositioned ?
Do we need to even care ?
Drug therapy
Common for patients to have partial response to first-line medication alone
Combinations of 2 first-line medications recommended when there is partial response
Psychological factors may..
Modify the perception of pain
Modulate the pain experience
But they are rarely the sole CAUSE OF PAIN
References
Donoff B. It works in my hands. Evidence based dentistry 2000; 2:1-2
Brandt D. Temporomandibular disorders and their association with morphologic malocclusion in children. In Carlson D S, McNamara J A, Ribbens K A (eds) Developmental aspects of temporomandibular disorders. pp 279–298. Ann Arbor: University of Michigan, 1985 (Craniofacial Growth Series 16).
van der Weele L T, Dibbets J M H. Helkimo index: a scale or just a set of symptoms? J Oral Rehabil 1987; 14: 229–237.
Luther F. Orthodontics and the temporomandibular joint. Where are we now? Part 2: functional occlusion, malocclusion and TMD. Angle Orthod 1998; 68: 305–318.
Diatchenko L, Slade GD, Nackley AG, et al. Genetic basis for individual variations in pain perception and the development of a chronic pain condition. Hum Mol Genet 2005;14:135–143.
Mailis A, Wade J. Profile of Caucasian women with possible genetic predisposition to reflex sympathetic dystrophy: A pilot study. Clin J Pain 1994;10:210–217
Diatchenko L, Anderson AD, Slade GD, et al. Three major haplotypes of the b2 adrenergic receptor define psychological profile, blood pressure, and the risk for development of a common musculoskeletal pain disorder. Am J Med Genet B Neuropsychiatr Genet 2006;141:449–462.
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Lavigne GJ, Rompre´ PH, Montplaisir JY, Lobbezoo F. Motor activity in sleep bruxism with concomitant jaw muscle pain. A retrospective pilot study. Eur J Oral Sci. 1997;105:92–95.
Arima T, Arendt-Nielsen L, Svensson P. Effect of jaw muscle pain and soreness evoked by capsaicin before sleep on orofacial motor activity during sleep. J Orofac Pain. 2001;15:245–256
References
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Diatchenko L. Idiopathic pain disorders “Pathways of vulnerability Pain. 2006: 123(3); 226-231
Pullinger AG, Seligman DA, Gornbein JA. A multiple logistic regression analysis of the risk and relative odds of temporomandibular disorders as a function of common occlusal features. J Dent Res. 1993;72:968–979.
McNamara JA, Jr. Seligman DA, Okeson JP. Occlusion, orthodontic treatment, and temporomandibular disorders: a review. J Orofac Pain. 1995;9:73–90.
Schindler H, Svensson P. Myofascial temporomandibular disorder pain. In: Turp JC, Sommer C, Hugger A, Eds. The Puzzle of Orofacial Pain. Pain and Headache. Basel: Karger,2007:91–123.
Forssell H, Kalso E. Application of principles of evidence based medicine to occlusal treatment for temporomandibular disorders: are there lessons to be learned? J Orofac Pain. 2004;18:9–22.
Sonnesen L, Bakke M, Solow B. Malocclusion traits and symptoms and signs of temporomandibular disorders in children with severe malocclusion. Eur J Orthod. 1998;20: 543–559
Fricton J, Look JO, Wright E, Alencar FG Jr, Chen H, Lang M, Ouyang W, Velly AM. Systematic Review and Meta-analysis of Randomized Controlled Trials Evaluating Intraoral Orthopedic Appliances for Temporomandibular Disorders. J Orofac Pain. 2010 Summer;24(3):237-54.
Jedel E, Carlsson J. Biofeedback, acupuncture and transcutaneous electric nerve stimulation in the management of temperomandibular disorders: a systematic review. Physical Therapy Reviews. 2003; 8(4): 217-223
Greene C.S., Laskin D.M. : Long-term status of TMJ clicking in patients with myofascial pain and dysfunction. JADA, 117:461-465, 1988
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References
Svensson P, Graven-Nielsen T, Matre DA, Arendt-Nielsen L. Experimental muscle pain does not cause long-lasting increases in resting electromyographic activity. Muscle Nerve 1989;21:1382–1389
Travell JG, Rinzler S, Herman M. Pain and disability of the shoulder and arm. Treatment by intramuscular infiltration with procaine hydrochloride. J Amer Med Assoc 1942;120:417–422
Murray GM. Peck CC. Orofacial pain and jaw muscle activity: a new model. Journal of Orofacial Pain. 21(4):263-78
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QUESTIONS?
QUESTIONS?
“The art of medicine consists in amusing the patient while nature cures the disease”
