Journal of Oral & Facial Pain and Headache, 03/2019

Aims: To assess the validity of the resting and chewing components of the recently developed observational diagnostic tool, the Orofacial Pain Scale for Non-Verbal Individuals (OPS-NVI). Methods: This cross-sectional observational study was carried out in two UK hospitals. A total of 56 participants with dementia who were admitted to the acute hospital were observed for 3 minutes during rest and during chewing, and the OPS-NVI was used to identify orofacial pain. Afterwards, the participants were asked about the presence of orofacial pain using self-report pain scales. The sensitivity, specificity, and area under the receiver operating curve (AUROC) of the OPS-NVI were calculated for each activity. Spearman coefficient was calculated to assess the correlation between the number of positively scored behavior items of the OPS-NVI and the presence of orofacial pain according to self-report. Results: According to the OPS-NVI, orofacial pain was present in 5.4% of participants during rest and in 9.1% during chewing. According to self-report, the prevalence of orofacial pain was 5.4% during rest and 10.7% during chewing. The specificity of the OPS-NVI was 98.1% to 100%, the sensitivity was 66.7% to 83.3%, and the AUROC was 0.824 to 0.917. The predictive validity showed a strong correlation (0.633 to 0.930, P < .001) between the number of positive behavior items and the self-reported presence of orofacial pain. Conclusion: The resting and chewing components of the OPS-NVI showed promising concurrent and predictive validity. Nevertheless, further validation is required and highly recommended. Keywords: dementia, facial pain, hospital, observation, OPS-NVI, toothache, validation

Aims: To investigate the occurrence, associations, and impacts of self-reported nocturnal parafunction, daytime parafunction, temporomandibular joint (TMJ) pain, and TMJ clicking in a New Zealand birth cohort of 38-year-old individuals. Methods: A cross-sectional analysis of data from a longstanding prospective observational study of a Dunedin, New Zealand birth cohort was undertaken. A questionnaire was used to measure self-reported nocturnal parafunction, daytime parafunction, TMJ pain, and TMJ clicking, and the short-form Oral Health Impact Profile (OHIP-14) tool was used to measure the impacts of these factors while controlling for personality traits. Results: Of the 912 participants (49.7% female) who were dentally assessed and had completed questionnaire data, 31.6% reported nocturnal parafunction and 48.3% reported daytime parafunction. TMJ pain was reported by 29.4% and TMJ clicking by 34.8%. The prevalence of daytime grinding was significantly greater among women (54.2%) than men (42.5%), as was the prevalence of TMJ pain (34.5% and 24.1%, respectively). Those with parafunction or TMJ symptoms had higher mean OHIP-14 scores, and this difference remained significant after controlling for sex, socioeconomic status, xerostomia, untreated dental caries, missing teeth, and personality traits. Conclusion: People with parafunction or TMJ symptoms have poorer oral health-related quality of life than those without these symptoms. Keywords: adults, epidemiology, orofacial pain, quality of life, temporomandibular dysfunction

Aims: To (1) examine differences in self-rated health (SRH) between a group of women with myofascial temporomandibular disorders (mTMD) and controls; (2) determine the extent to which pain, mental health, and physical function mediate these differences; and (3) explore specific mTMD symptoms and impairments explaining SRH among mTMD cases. Methods: An existing dataset of a sample of women with mTMD (n = 125) and a group of demographically similar controls (n = 49) was used. SRH was measured via a single item with 5 answer options ranging from poor (SRH = 1) to excellent (SRH = 5). Bodily pain, mental health, and physical function were measured with the Short-Form Health Survey. Regression analyses with SRH as the outcome were conducted. Results: mTMD cases reported poorer SRH compared to controls, and bodily pain score fully mediated these lower scores. Physical function partially mediated the association between mTMD and SRH, while mental health did not explain much of the variance in SRH. This pattern held in case-only analyses. The association was not explained by mTMD-specific symptoms or by localized mTMD pain severity, although mTMD disability was independently associated with lower SRH. Conclusion: SRH is a simple and useful tool to consider in mTMD research, as it discriminates between cases and controls based on pain and physical function and is associated with mTMD disability. Keywords: general health, pain, self-perceived health, self-rated health, TMD

Aims: To determine the prevalence of sleep bruxism (SB) in adult obstructive sleep apnea (OSA) patients, to assess the association between SB and OSA in terms of sleep macrostructure and respiratory parameters, and to determine possible OSA risk factors for SB. Methods: Type I polysomnographic data of 147 adult OSA patients (mean age 44.6 ± 12.8 years) were evaluated for SB. SB episodes were scored when masseter rhythmic masticatory muscle activity (RMMA) was twice the background electromyography amplitude, and SB was established when patients had more than four SB episodes per hour of sleep. Demographic characteristics, sleep macrostructure, and respiratory parameters, including respiratory-related arousal index (RAI), spontaneous arousal index (SAI), oxygen desaturation index (ODI), and Apnea-Hypopnea Index (AHI), were analyzed for differences between patients with and without SB using independent samples t test and Mann-Whitney U test. Multivariate logistic regression analysis was performed to determine the odds of OSA risk factors for SB. Results: Approximately one-third (33.3%) of the adult OSA patients had concomitant SB. Most of the RMMA observed in OSA-SB patients was phasic in nature. OSA patients with SB demonstrated significantly greater RAI (P = .001) and ODI (P = .005). RAI (odds ratio =1.05, 95% confidence interval = 1.00 to 1.10) and SAI (odds ratio = 0.89, 95% confidence interval = 0.80 to 0.96) demonstrated marginal effects on the odds of experiencing SB. Conclusion: About one-third of adult OSA patients had SB, and these patients demonstrated significantly more respiratory-related arousals and oxygen desaturations. These findings suggest that a phenotypic subtype of OSA patients with predominantly phasic SB exists and allude to a possible protective role of RMMA in respiratory-related arousals. Keywords: association, bruxism, obstructive sleep apnea

Aims: To compare somatosensory function profiles and psychologic factors in patients with primary burning mouth syndrome (BMS) and healthy controls and to evaluate correlations of subjective pain ratings with somatosensory and psychologic parameters. Methods: A quantitative sensory testing (QST) protocol-including cold detection threshold (CDT), warmth detection threshold (WDT), thermal sensory limen (TSL), paradoxical heat sensation (PHS), cold pain threshold (CPT), heat pain threshold (HPT), mechanical pain threshold (MPT), wind-up ratio (WUR), and pressure pain threshold (PPT)-was performed at the oral mucosa of the tongue, buccal, and palatal sites in 30 Chinese patients (25 women and 5 men, mean age 50.9 ± 9.2 years) with primary BMS and in 18 age- and gender-matched healthy controls (15 women and 3 men, mean age 53.2 ± 7.0 years). For each BMS patient, z scores and loss/gain scores were computed. Psychologic status was evaluated in both groups using the Self-Rating Anxiety Scale and Self-Rating Depression Scale. Correlations of BMS patients' subjective pain ratings with somatosensory and psychologic profiles were assessed with the use of Pearson or Spearman correlations and multiple linear regression. Results: In BMS patients, 53.3% had somatosensory abnormalities according to z scores vs 22.2% of healthy controls (P = .033). The abnormalities in BMS patients were somatosensory loss to thermal nonnoxious stimuli (TSL = 20.0%, CDT = 13.3%, WDT = 13.3%), mechanical pressure stimuli (PPT = 16.7%), pinprick stimuli (MPT = 6.7%), and thermal pain stimuli (CPT = 3.3%), and somatosensory gain to repetitive pinprick stimuli (WUR = 6.7%), pressure stimuli (PPT = 6.7%), and thermal pain stimuli (HPT = 3.3%). The most frequent loss/gain score was 13.3% for loss of thermal somatosensory function with no somatosensory gain; 13.3% for loss of thermal and mechanical somatosensory function with no somatosensory gain; and 13.3% for gain of mechanical somatosensory function with no somatosensory loss. Mild elevations in anxiety scores were seen in 30% of the BMS patients, and 50% and 36.7% had mild and moderate elevations, respectively, in depression scores. No anxiety or depression was detected in the control group. QST results, but not psychologic scores, were significantly correlated with patients' subjective pain ratings (PHS, Spearman coefficient -0.384, P = .029; CPT, Pearson coefficient -0.370, P = .034; MPT, Pearson coefficient -0.376, P = .032; PPT, Pearson coefficient 0.363, P = .037). Conclusion: The present findings documented distinct differences in somatosensory function in patients with primary BMS compared to controls, indicating a complex pathophysiology and interaction between impairments in nociceptive processing and psychologic functioning. Keywords: burning mouth syndrome, psychological changes, quantitative sensory testing, somatosensory profiles

Aims: To assess the presence of dental pain in child abuse victims and to compare the findings to children in the same age group with no history of abuse in a Southern Brazilian city. Methods: This cross-sectional comparative study was carried out in a convenience sample of 68 child abuse victims from a center for psychologic support and in a comparative group of 204 students from public and private schools, all aged between 8 and 12 years. Data for socioeconomic and demographic variables were collected, and information regarding dental pain in the last 6 months was obtained via interviews with the children. World Health Organization criteria were used to assess the presence of decayed, missing, or filled teeth in primary and permanent dentition. Dental trauma was measured using the O'Brien Index, and gingival bleeding was assessed. Crude and adjusted logistic regression analyses were performed to assess the association between dental pain and history of abuse. Results: Reporting of dental pain was higher among child abuse victims (54.41%) than in the comparative group (36.14%) (P < .01). After adjustment for clinical variables in the logistic regression analyses, the child abuse victims group had an odds ratio of 2.03 (95% confidence interval 1.13 to 3.64) for dental pain (P = .01). Conclusion: Child abuse victims presented a higher prevalence of dental pain than children with no history of maltreatment, regardless of oral health status. Keywords: child, child abuse, oral health, pain, toothache

Aims: To describe headache characteristics among celiac disease (CD) patients and to analyze the relationship between CD and headache. Methods: An online survey analyzing the characteristics of headache and its response to the glutenfree diet (GFD) in celiac patients was published on Argentinean Celiac social networks, open to the public to complete. The results were analyzed using chisquare test or Mann-Whitney test accordingly. Results: A total of 1,517 subjects completed the survey, and 866 (55.2%) met the inclusion criteria (headache and CD confirmed with positive biopsy). The subjects were predominantly female (94.5%) and had a median age of 39 ± 11.27 years. Tension-type headache was the most prevalent headache type (52%), followed by migraine without (32.5%) and with aura (15.4%), respectively. Of the included participants, 24% reported headache as the main symptom that resulted in the diagnosis of CD. Following initiation of GFD, headache frequency and intensity improved significantly more in participants with migraine than tension-type headache (P = .02 and P = .013, respectively). Compliance to GFD was higher among subjects with severe manifestations (77% vs 66%, P = .05), and compliant individuals showed a 48% improvement in headache frequency (P = .049). An association between food transgressions and headache was better recognized by migraineurs (P = .02). Conclusion: These results suggest that strict compliance to the GFD could improve headache in celiac patients with headache, even in those without gastrointestinal symptoms. This observation could provide an additional factor when convincing patients to follow a GFD, thus reducing the morbidity related to CD. Keywords: celiac disease, gluten, gluten-free diet, headache, migraine, migraine with aura

Aims: To quantify the pain experienced by orthodontic patients during the first 10 days of appliance placement, to determine whether chewing gum reduces orthodontic pain compared to placebo, and to examine patients' overall perceptions of the impact of orthodontic pain. Methods: Patients bonded with fixed appliances were randomly assigned to one of two groups (gum group [GG] or placebo group [PG]) and then followed for 10 days. The main outcome was a visual analog scale (VAS) pain score, and the secondary outcomes included patients' subjective assessments of overall pain level, the impact of pain on hygiene habits and treatment decision, and the frequency of analgesics consumption. Eighty kits (40 for GG and 40 for PG) were pre-randomized and concealed before patient enrollment using a computer-generated random sequence. Operators and patients were blinded. Data were analyzed using generalized linear models and Mann-Whitney U, chi-square, and Fisher exact tests. Results: A total of 75 patients were allocated to intervention groups; 37 participated and completed diaries (20 in GG and 17 in PG). No statistically significant differences were detected between the GG and PG groups in any tested variable. Pain negatively affected some patients' oral hygiene practices. A mismatch existed between patient expectations and actual pain experiences. Female patients used analgesics more frequently than male patients (P = .046). Conclusion: Chewing gum three times per day does not seem to significantly reduce orthodontic pain compared to placebo. Orthodontists should manage their patients' pain expectations. Keywords: chewing gum, fixed appliance, orthodontic pain, placebo, randomized controlled trial, visual analog scale

Aims: To investigate whether temporomandibular disorders treatment can positively influence tinnitus complaints. Methods: Four online databases (PubMed, Web of Science, Scopus, and the Cochrane Library) were searched up to August 2018 for relevant studies. Two independent reviewers extracted the data and performed a risk of bias assessment. Results: A total of 11 studies were included. These studies showed an overall positive effect of the combination of splint therapy and exercise treatment on tinnitus severity and intensity (as measured on a visual analog or numeric rating scale), as well as on global perceived effect. One study specified that the treatment effect was only present in patients with severe to very severe tinnitus, while the others found an effect in the overall study group. The risk of bias in the included studies was high, mainly due to lack of statistical analyses between groups and before vs after treatment, incomplete presentation of the data, and selective reporting. Additionally, most included studies showed a lack of information concerning blinding of the subjects, therapists, and investigators. The heterogeneity of the inclusion criteria, outcome measurements, and treatments made data pooling and meta-analysis impossible. Conclusion: There is low-quality evidence for a positive effect of conservative temporomandibular disorders treatment on tinnitus complaints. The combination of splint therapy and exercise treatment is currently the best investigated treatment approach, showing a decrease in tinnitus severity and intensity. Despite the low level of evidence and the methodologic issues in the included studies, it is noteworthy that all included studies show positive treatment effects. Keywords: occlusal splints, physical therapy modalities, somatic, somatosensory, temporomandibular joint disorders

Aims: To investigate the region-specific effects of painful trigeminal capsaicin stimulation in healthy participants. Methods: Twenty healthy participants (10 men and 10 women) participated in four sessions in which they received application of 0.05 mL Vaseline (placebo) or capsaicin cream (0.1%) to a different area innervated by the three branches of the trigeminal nerve: the supraorbital area (V1), the nasal mucosa (V1/V2), and the maxillary (V2) and mandibular (V3) oral mucosa. The participants rated their perceived sensations on a 0-50-100 numeric rating scale (NRS). Thermal (5°C, 23°C, and 50°C) and mechanical (32 mN and 256 mN) sensitivities were assessed. The Schirmer tearing test was used to monitor the lacrimation level as a local measure of autonomic activity, and the Task Force Monitor was used to record systemic autonomic activity. Data were analyzed using repeated measures analysis of variance. Results: Capsaicin application evoked significantly higher overall NRS scores (P < .001) and induced significantly higher ratings to the heat stimuli (P < .009) in all sessions compared to control. For lacrimation level, capsaicin stimulation resulted in a significant increase compared to control (P < .0002) only in the nasal mucosa session. Conclusion: Topical application of capsaicin cream to the different branches of the trigeminal nerve caused higher NRS scores along with an altered somatosensory sensitivity. Furthermore, in the nasal mucosa session, a robust local and generalized parasympathetic activation appeared following capsaicin application. Keywords: autonomic nervous system, capsaicin, experimental pain model, trigeminal nociception, trigeminal parasympathetic reflex

Aims: To evaluate prescription of prophylactic treatment before and after consultation in a neurology headache clinic and to determine predictors for prophylactic treatment and clinical improvement. Methods: Clinical records of consecutive patients assessed in a neurologic headache clinic in Portugal and diagnosed with acute or chronic migraine and/or tension-type headache were assessed. Prescription of prophylaxis before and after the first visit to the clinic were compared. Logistic regression was used to evaluate predictors of the need for therapeutic intervention and clinical improvement. Results: Among 409 patients (86.8% women; mean age 41.6 years), 315 (77%) had indication for prophylaxis, and 70 (22%) of these patients were already on prophylactic treatment. Among the 265 patients with information for follow-up, prophylactic treatment was added in 178 (67.2%), and there was a significant change in the number of treated patients between the first and second visits. Ongoing treatment was switched or the dose increased in 21 patients. Multivariate logistic regression revealed that women (odds ratio [OR] = 2.09, 95% confidence interval [CI] 1.1 to 3.97] and patients with medication overuse headache (MOH) (OR = 6.97, 95% CI 1.60 to 30.39) were more likely to need therapeutic intervention, whereas patients referred from the emergency room were less likely to need it (OR = 0.44, 95% CI 0.22 to 0.89). Of the 265 patients, 185 (69.8%) had improved at a follow-up. Having prophylactic treatment at the time of the second visit was associated with improvement (OR = 2.39, 95% CI 1.23 to 4.63; P = .01). Conclusion: Women and medication overuse headache patients were more likely to need therapeutic intervention. However, only a minority of patients with treatment indication were treated before their first visit to the headache clinic. Prophylaxis prescription was associated with clinical improvement at follow-up. Keywords: chronic headache, headache, migraine, outpatient clinic, prophylaxis, referrals

Aims: To assess the utility of corneal confocal microscopy in identifying small fiber damage in patients with burning mouth syndrome (BMS). Methods: A prospective cross-sectional cohort study was conducted at two United Kingdom dental hospitals between 2014 and 2017. A total of 17 consecutive patients with idiopathic BMS aged between 18 and 85 years and 14 healthy age-matched control subjects were enrolled in this study. Corneal subbasal nerve plexus measures were quantified in images acquired using a laser-scanning in vivo corneal confocal microscope. The main outcome measures were corneal nerve fiber density, nerve branch density, nerve fiber length, and Langerhans cell density. Results: Of the 17 patients with BMS, 15 (88%) were women, and the mean (standard deviation) age of the sample was 61.7 (6.5) years. Of the healthy controls, 7 (50%) were women, and the mean (standard deviation) age was 59.3 (8.68) years. Corneal nerve fiber density (no./mm2) (BMS: 29.27 ± 6.22 vs controls: 36.19 ± 5.9; median difference = 6.71; 95% CI: 1.56 to 11.56; P = .007) and corneal nerve fiber length (mm/mm2) (BMS: 21.06 ± 4.77 vs controls: 25.39 ± 3.91; median difference = 4.5; 95% CI: 1.22 to 6.81; P = .007) were significantly lower in BMS patients compared to controls, and Langerhans cell density (no./mm2) (BMS: 74.04 ± 83.37 vs controls: 29.17 ± 45.14; median difference = -21.27; 95% CI: -65.35 to -2.91; P = .02) was significantly higher. Conclusion: Using a rapid noninvasive ophthalmic imaging technique, this study provides further evidence for small fiber damage in BMS and has potential utility for monitoring disease progression and/or response. Furthermore, this technique shows a hitherto undocumented increased density of immune cells in this group of patients. Keywords: burning mouth syndrome, corneal confocal microscopy

Erythermalgia is a rare cutaneous disease characterized by episodic attacks of burning pain, erythema, and increased temperature. It primarily involves the extremities, with possible extensions to the ears, face, neck, and scrotum; in rare instances, it may afflict the ears, face, or the scrotum alone. Although various medications alone or in different combinations have been tried with significant variations in response, no recommended therapeutics have been established until very recently. This report presents two case histories of a 20-year-old and a 46-year-old woman, respectively, who displayed intermittent facial erythema associated with warmth and pain during the episodes and who presented normal between episodes. Both had good response to combinative treatments of systemic medication and topical lidocaine compounds. The younger was diseasefree after more than 4 years of follow-up, and the older had recurrence after stopping the treatment. Conclusion: Erythermalgia may involve the face alone, and combinative approaches may be of choice for its treatment. Topical lidocaine compounds are considered to be a good option for palliative treatment. Keywords: erythermalgia, erythromelalgia, face, pain, treatment

Aims: To describe a technique of minimally invasive trigeminal nerve ablation of the long buccal nerve that was performed at a tertiary care academic medical center. Methods: This case describes a 44-year-old woman with refractory left long buccal nerve neuropathy following a dental procedure. After failing medical management, she was taken for nerve exploration, which revealed no nerve discontinuity or neuroma formation. She was therefore counseled regarding the risks and possible benefits of a novel minimally invasive trigeminal nerve thermoablation of the long buccal nerve technique. Results: Postoperatively, the patient experienced mild anesthesia along the long buccal nerve division and no longer experiences any allodynia or hypersensitivity. Additionally, she no longer requires any additional medical therapy or interventions. Conclusion: Minimally invasive trigeminal nerve ablation of the long buccal nerve may be effective surgical intervention in treating refractory neuropathic pain in cases of no structural nerve defects. However, long-term well-designed studies are required to fully define its role. Keywords: long buccal nerve, minimally invasive, posttraumatic trigeminal neuropathy, thermoablation