Transcript EBM Perspectives New - Dr. Barry Glassman Seminars

Orofacial Pain:
Evidence Based Perspectives
Brijesh Chandwani, B.D.S., D.M.D., F.O.P.
Clinical Associate Professor
Craniofacial Pain Center,
Tufts University School of Dental Medicine
Orofacial Pain:
Evidence Based Perspectives
Brijesh Chandwani, B.D.S., D.M.D., F.O.P.
Clinical Associate Professor
Craniofacial Pain Center,
Tufts University School of Dental Medicine
•
•
•
•
So what did the injections do?
What is the mechanism?
Is it the anesthetic?
Is it an acupuncture effect?
Evidence Based Medicine
Evidence based medicine is the conscientious,
explicit, and judicious use of current best
evidence in making decisions about the care of
individual patients.1
It uses techniques and methods from science,
math, statistics to calculate and predict the
possibility of positive outcome when a specific
treatment is used.
Guyatt et al introduced the term “evidence based
medicine” to the literature in 1992.2
1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: What it is and
what it isn’t. BMJ. 1996 Jan 13;312(7023):71-2.
2.Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to teaching the practice of
medicine. JAMA. 1992 Nov 4;268(17):2420-5.
“IT WORKS WELL IN MY
HANDS….”
“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'.”
B. Donoff (2000)
Evidence Based Medicine
• Hunt for the “Perfect Treatment”
Abu ‘Ali al-Husayn ibn Sina
“Avicenna”
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
Rules for the efficacy of a medication:
•“The drug must be free from any extraneous
accidental quality.”
•“The time of action must be observed, so
that essence and accident are not confused.”
•“The effect of the drug must be seen to
occur constantly or in many cases, for if this
did not happen, it was an accidental effect.”
•“The experimentation must be done with the
human body, for testing a drug on a lion or a
horse might not prove anything about its
effect on man.”
Sir Francis
Bacon
(1561–1626)
Sir Francis Bacon (1561 - 1626)
"Men have sought to make a world from
their own conception and to draw from their
own minds all the material which they
employed, but if, instead of doing so, they
had consulted experience and observation,
they would have
the facts and not opinions to reason about,
and might have ultimately arrived at the
knowledge of the laws which govern the
material world."
Baconian methodology for
scientific inquiry.
• “Knowledge is power.”
• Instead of actual philosophy he
introduced the concept of developing
philosophy. He wrote that philosophers
should use observation and scientific
methods to reach the truth and explain
natural phenomena.
• Fact - Axiom - Law
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.
DM Laskin JADA
Classification of Orofacial Pain
-American Academy of Orofacial Pain
Temporomandibular
Disorders
Masticatory muscle,
temporomandibular joint
Primary Headaches
Migraine, tension type and other
primary HA
Neurogenic Pain Disorders Neuralgias (TN, PHN, GN),
Persistent idiopathic facial pain,
Burning mouth syndrome
Intracranial Pain Disorders Neoplasm, aneurysm, abscess,
hemorrage, hematoma
Intra Oral Pain Disorders
Dental pathology
Others
Associated structures
Clinical Features of Orofacial Pain
•
•
•
•
Pain
Limitation of movement
TM joint sounds
Occlusal changes
What do these symptoms mean??
• Impaired range of movement. This condition may
originate within the joints as well as within many other
regions, e.g. an oversized coronoid process
• Impaired TMJ function. Sounds probably do originate in
the joints; but the mechanism for locking may be
completely different from the mechanism for luxation.
• Muscle pain. It has yet to be demonstrated that muscle
pain on palpation is directly related to the TMJ.
• Jaw pain. This item relates directly to structures of the
joint.
• Pain on movement of the mandible. May relate to the
entire masticatory system as well as to the joint.
Orofacial Pain: What Kind of
Problem is it?
Nociception
Disability/
Suffering
Pain
Other physical
Physical impairments
Neuropathic Psychological
Social isolation
mechanisms processes
Family distress
Role disruption
Other co-morbidities
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.
MAY A. Neuroscientist April 2011
Regions of greater gray matter volume in the brains of individuals with
chronic myofascial temporomandibular pain contrasted with controls
Regions of greater gray matter volume (orange)
are displayed on an MNI-normalized average of
all student participant’s brain images (N = 29). All
slices are axial; anterior is at top. Significant
areas include (left pane, anterior to posterior) the
right inferior frontal gyrus, right anterior insula,
right globus pallidus, right thalamus, left
thalamus, and (right pane) right posterior
putamen
Younger et al.Pain.
GIESECKE ET AL (2004)
ARTHRITIS & RHEUMATISM
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
Torpy et al., Arthrit Rheum 2000;
Evaskus & Laskin, J Dent Res 1972
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
• Emotional problems may increase perceived
pain intensity, disability and perpetuate
dysfunction
• Unrecognized and untreated psychological
distress may interfere with successful treatment
of chronic pain
Adapted from Turk. D
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
Lousberg 1992
Sleep
•
•
•
•
Sleep Disturbance and Chronic
Pain
Sleep disturbance is common in patients with
chronic pain, even those who do not meet
criteria for psychiatric disorders
50%-80% of patients with chronic pain have
sleep disturbances
Experimental disruption of slow-wave sleep has
been shown to increase pain sensitivity
Clinical studies have shown a reciprocal
relationship between sleep disturbances and
pain
Smith NT2004.
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
• Parafunction – tangential forces, isometric
contraction
Bruxism
• Prevalence: 6-88% in children; 5-20% in
adults
• Sleep bruxers without painful symptoms
have higher EMG activity compared to the
sleep bruxers with pain
Lavigne GJ 1997
Arima T
2001
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.
J Clin Pediatr Dent. 24(1):9-15, 1999
Muscles: How do they fit in?
Role of Masticatory Muscles
Muscles of Mastication
A
B
C
D
E
F
G
H
I
J
K
Temporalis
Lateral Pterygoid
Medial Pterygoid
Anterior belly of Digastric
Mylohyoid
Posterior belly of Digastric
Masseter
Hyoid bone
Sternohyoid
Omohyoid
Thyrohyoid
Role of Electromyography
Does increased motor function cause pain ?
Role of Electromyography
Does increased motor function cause pain ?
Role of Electromyography
1. 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”
2. Pain adaptation model: pain results in reduced
agonist muscle and increased antagonist
muscle activity
Travell 1942; Mense 1993
Svensson P, 1998
3. 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
Murray GM 200
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
• 24% have some head, neck and/or face
pain
• 12% report pain when opening
• Although a stable occlusion is a reasonable
orthodontic goal, not achieving an ideal gnathological
occlusion does not result in signs or symptoms of
TMD
• There is little evidence that orthodontic treatment
prevents TMD
“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.”
McNeill C. 2000
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
Pullinger AG 1993; McNamara 1995; Schindler
2007; Forssell 2004; Sonnesen 1998
Temporomandibular Joint
Sounds
Clicking is generally benign and does not
progress to more serious clinical
dysfunction or disease, even in subjects
that previously had symptoms.
Furthermore, subjects with symptomatic
clicking can be successfully treated without
addressing the position of the disc.
Greene CS 1988
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
•Brandt 1985
•van der Weele 1987
•Luther 1998
Causation Vs Association
Management
• The seven secrets to successful
management of an orofacial pain patient
1.History
“Occasional, constant, infrequent headaches.”
2.History
“My pain is a 20 on a 0-10 pain scale”
3.History
“
4.History
5.History
6.History
7.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:
1. Alterating the occlusal condition
2. Placebo effect,
3. 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 J. The Journal of Evidence based Dental Practice. 6(1):48-52, 2006 Mar.
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..
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.
Jedel, E; Carlsson, J: Physical Therapy Reviews, 2003
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.
Ziad Al-Ani, J Dent Educ. 69(11): 1242-1250 2005
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.
Case..contd
• Clinical impressions: Masticatory myalgia
and tension type headaches
• Management plan:
– 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.
Drug Therapy in Management of
Orofacial Pain
Drug Therapy in Management of
Orofacial Pain
Pharmacologic Targets:
A Mechanistic Approach
Perception: opioids,
α2-agonists, TCAs,
SSRIs, SNRIs
Pain
Ascending input
Descending modulation
Dorsal
horn
Modulation: TCAs,
SSRIs, SNRIs
Transmission: LAs,
opioids, α2-agonists
Dorsal root ganglion
Spinothalamic
tract
Peripheral
nerve
Trauma
Peripheral nociceptors
Transmission: LAs, opioids
Transduction: LAs, capsaicin,
anticonvulsants, NSAIDs,
ASA, acetaminophen, nitrate
TCAs=tricyclic antidepressants; SSRIs=selective serotonin reuptake inhibitors; SNRIs=serotonin-norepinephrine reuptake
inhibitors; LAs=local anesthetics; NSAIDs=nonsteroidal anti-inflammatory drugs; ASA=aspirin.
Adapted with permission from Kehlet H, Dahl JB. Anesth Analg. 1993;77:1048-1056.
NSAIDs
• Diclofenac, naproxen, celecoxib, etodolac, ampiroxicam,
meclefenamate
• 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).
Muscle relaxants
Muscle Relaxants
• Tizanidine, cyclobenzaprine, carisoprodol,
methocarbamol
• 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.
•Chou R, et al., Ann Intern Med. 2008
National Headache Foundation. National Headache Foundation standards
of care for headache diagnosis and treatment. Chicago, Ill.:
•National Headache Foundation; 2007. http://www.headaches.org/
consumer/press%20releases/51507/FINAL_NHF%20Treatment.pdf.
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
Anti depressants
• Amitriptyline, nortiptyline, duloxetine,
venlafaxine
• 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.''
Guidelines for drug therapy in
TMD?
Management strategies
• Physical medicine/rehabilitation
– Occlusal appliance therapy
– Avoiding inactivity
– Non-pharmacologic treatment (trigger point injections,
Stretching, strengthening, work rehab)
• Mental health professional
– Psychopharmacology
– Counseling
– Behavioral therapy
• Pharmacotherapy
– Amitriptyline/Nortriptyline, Diazepam, Diclofenac,
Cyclobenzaprine, Neurontin
Patients perspectives
Awareness & interpretation of symptoms
DEMOLARIZED
Help/treatment seeking
Diagnostic uncertainty
Physician
frustration
PATIENT FRUSTRATION
Significant other
frustration
Doctor shopping
Diagnostics – cost, time
Suggestion of psychological causation or malingering
Increased symptom reporting, pain behaviors, help seeking
Increased emotional distress
Conclusions
• Occlusion
– 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 firstline 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.
Devor M, Raber P. Heritability of symptoms in an experimental model of neuropathic pain. Pain
1990;42:51–67.
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
•
•
•
•
•
•
•
•
•
•
•
McNeill C. Occlusion: what it is and what it is not. J Calif Dent Assoc. 2000 Oct;28(10):748-58.
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
. Smith NT, Haythornthwaite JA: How do sleep disturbances and chronic pain interrelate? Sllep
Med Rev. 8:119-132, 2004.
References
• Svensson P, Graven-Nielsen T, Matre DA, ArendtNielsen 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
• Lousberg R, Schmidt AJ, Groenman N. The relationship
between spouse solicitousness and pain behavior:
searching for more experimental evidence. Pain
1992:51:75-79
QUESTIONS?
“The art of medicine consists in amusing the
patient while nature cures the disease”
- Voltaire