Alan G. Glaros

Temporomandibular Disorders and Facial Pain: A Psychophysiological Perspective

This article presents a psychophysiological perspective on temporomandibular muscle and joint disorders (TMJD) and facial pain. After a brief introduction to TMJD, the article presents data, largely derived from work carried out in my laboratory, that address four questions: (1) What are the consequences of parafunctional activities? (2) Do TMJD patients engage in parafunctional activities? (3) Why are TMJD patients unaware of these activities? and (4) What are the implications of these findings for treatment? The findings suggest that low-level parafunctions increase pain in otherwise pain-free individuals and can produce symptoms sufficiently severe to meet the diagnostic criteria for TMJD diagnoses of myofascial pain and/or arthralgia. Patients with certain forms of TMJD report very high levels of parafunctional tooth contact. Their lack of awareness of these behaviors may arise from uncertain definitions of the term “clenching”, from proprioceptive deficits, or from the presence of adjunctive behaviors. Preliminary work shows that reduction in tooth contact via habit reversal techniques may be a promising mechanism for reducing pain in these patients.

Tooth Contact in Patients with Temporomandibular Disorders

Abstract Both experimental and retrospective studies suggest a link between parafunctions and pain in temporomandibular disorder (TMD) patients. To investigate the role of parafunctions in TMD, experience sampling methodology was used as a prospective test of the hypothesis that patients with TMD have higher levels of tooth contact and tension than non-TMD controls. Three groups of TMD patients and a group of normal controls carried pagers for one week, were contacted approximately every two hours by an automated calling system, and completed questionnaires assessing tooth contact, tension, and pain at each contact. Results showed that tooth contact was much more frequent among normal controls than is commonly presumed. Patients with myofascial pain with/without arthralgia reported more frequent contact, higher intensity contact, and more tension than patients with disk displacement or normal controls. Increased masticatory muscle activity responsible for tooth contact and tension may be an important mechanism in the etiology and maintenance of the myofascial pain and arthralgia of TMD.

Psychophysiological Definitions of Clenching

Abstract This study tested the hypothesis that individuals show considerable variability in EMG activity produced by the masticatory muscles when they are instructed to clench than when they are instructed to make minimal or maximal contact. Twenty individuals without temporomandibular disorder (TMD) pain participated in a biofeedback-training task to establish a relaxed baseline. They were instructed to clench their teeth according to their personal definition of the term, while EMG data were collected. This process was repeated two more times, followed by similar instructions to make minimal and maximal contact between the teeth. Results showed that individual subjects were very consistent in their behavioral definition of clenching and that the subjects taken as a whole showed markedly greater variability. The precise behavioral meaning of clenching varies across individuals. The failure to account for these individual differences may explain in part reported discrepancies on the role of parafunctions in TMD.

Headache and oral parafunctional behaviors.

AbstractThis study tested the hypotheses that individuals with headaches would show significantly more oral parafunctional behaviors than non-headache controls, be diagnosed with one or more temporomandibular disorders (TMD) significantly more frequently than controls, and would report significantly less pain and other symptoms of headache after participating in a habit reversal treatment to reduce oral parafunctional behaviors, compared to a wait list control. In Phase I, individuals with and without self-reported headaches were examined by a blinded examiner and participated in a week-long experience sampling protocol (ESM) to assess oral parafunctional behaviors, pain, and emotional states. In Phase II, those with headaches were randomly assigned to either a habit reversal treatment or to a wait list control group. In the last, sixth week of the program, participants again completed an ESM protocol. Results showed that headache patients were significantly more likely to report oral parafunctional behaviors than non-headache controls and to receive a Research Diagnostic Criteria/TMD diagnosis. Results from Phase II showed general improvement in both groups on pain and parafunctions. Individuals with headaches engage in significantly higher rates and intensities of oral parafunctional behaviors. Treatment of these behaviors using habit reversal techniques appears to have the same effect on pain as waiting.

The Sinhala version of the pain catastrophizing scale: validation and establishment of the factor structure in pain patients and healthy adults.

OBJECTIVE This study was conducted to translate the Pain Catastrophizing Scale into and adapt it to the Sinhala language and to examine its psychometric properties and factor structure in pain patients and healthy adults in Sri Lanka. SETTING AND DESIGN A cross-sectional study was conducted, recruiting pain patients from multiple clinics and healthy adults from the community as convenience samples. METHODS Cross-cultural adaptation of the Pain Catastrophizing Scale for Sinhala speakers was carried out using recommended methods. The adaptations psychometric properties and factor structure were tested in 149 pain patients and 172 healthy adults. Temporal stability was tested in a sample of 104 young adults. Pain intensity of patients was assessed using a visual analog scale, and personality traits of all participants were assessed with the Eysenck Personality Questionnaire. RESULTS Factor analysis revealed that the three-factor structure of the original version of the Pain Catastrophizing Scale was the best fit to the data from participant samples. Cronbachs alpha values of the three components and total scores for patients and healthy adults ranged from 0.72 to 0.87. Pain catastrophizing exhibited moderate positive correlations with neuroticism in patients and healthy adults and with pain intensities in patients. A high intraclass correlation coefficient of agreement (0.81) revealed an acceptable temporal stability in young adults. CONCLUSIONS The results suggest that the Sinhala version of the Pain Catastrophizing Scale retains the original three-factor structure. It is a stable, valid and sufficiently reliable tool to assess pain catastrophizing in Sinhala-speaking individuals in Sri Lanka.

Assessing Research Competency in a Medical School Environment

The goals of undergraduate medical student research experiences are extremely variable. A uniform tool to assess experiences that link expected competencies to performance is not available. Competencies for students participating in research, aligned with ACGME core competencies, were delineated and an assessment tool was constructed to provide feedback to students. Competencies include Medical Knowledge, Interpersonal and Communication Skills, and Professionalism. An overall assessment rating is derived and longitudinal assessment of students is possible.

Perceived Efficacy, Indications, and Information Sources for Medically Indigent Patients and Their Healthcare Providers Regarding Dietary Supplements

Background: Evidence exists that medically indigent and minority patients use dietary supplements at rates as high or higher than that of the general population. Safety concerns regarding the use of dietary supplements are further exacerbated by a suboptimal level of patient disclosure and provider inquiry. Objective: To determine dietary supplement use, indications, perceived efficacy, and information sources of patients and providers using a pilot study in a clinic for the medically indigent. Methods: Five hundred self-administered patient surveys and 50 healthcare provider surveys were made available to any patient at a free health clinic in Kansas City, MO. Surveys were collected and descriptive analyses were performed. Results: Three hundred eleven patient surveys were returned. Of the 37.3% (116/311) of respondents who had used dietary supplements, 13.8% (n = 16) had 10 comorbid conditions. Ninety-six dietary supplements were used for 8 medical condition categories. The 9 agents most frequently reported used were garlic (n = 32), aloe/green tea (n = 27 each), chamomile/echinacea (n = 24 each), St. Johns wort (n = 22), ginseng (n = 18), and cranberry/Ginkgo biloba (n = 17 each). Patients reported a broad range of indications for taking dietary supplements. Patients reported (mean ± SD) 2.37 ± 4.23 agents as effective and 0.78 ± 1.73 as ineffective or harmful. Provider surveys revealed that 60% (21/35) and 74% (26/35) were currently or had ever used dietary supplements, respectively. Fifty-seven percent (20/35) of providers reported attending educational programs on dietary supplements, and providers perceived patient supplement use to be most influenced by advertisements (40%) and friends (40%). Conclusions: The medically indigent population uses a wide variety of dietary supplements. There is little consistency in perceived indications, which may prevent clinicians from accurately predicting specific herbal use rationale given any individuals or populations set of comorbid conditions. Clinicians are encouraged to accurately determine their individual practice settings use pattern.