Galit Almoznino

Sleep disorders and chronic craniofacial pain: Characteristics and management possibilities

Chronic craniofacial pain involves the head, face and oral cavity and is associated with significant morbidity and high levels of health care utilization. A bidirectional relationship is suggested in the literature for poor sleep and pain, and craniofacial pain and sleep are reciprocally related. We review this relationship and discuss management options. Part I reviews the relationship between pain and sleep disorders in the context of four diagnostic categories of chronic craniofacial pain: 1) primary headaches: migraines, tension-type headache (TTH), trigeminal autonomic cephalalgias (TACs) and hypnic headache, 2) secondary headaches: sleep apnea headache, 3) temporomandibular joint disorders (TMD) and 4) painful cranial neuropathies: trigeminal neuralgia, post-herpetic trigeminal neuropathy, painful post-traumatic trigeminal neuropathy (PTTN) and burning mouth syndrome (BMS). Part II discusses the management of patients with chronic craniofacial pain and sleep disorders addressing the factors that modulate the pain experience as well as sleep disorders and including both non-pharmacological and pharmacological modalities.

Trigeminal neuralgia (part I): Revisiting the clinical phenotype

Aims We conducted a cross-sectional study to re-examine the clinical profile of patients with a clinical diagnosis of classical trigeminal neuralgia (CTN). Methods Inclusion criteria consisted of the International Headache Society’s published classification of CTN. For the specific purposes of the study, features such as autonomic signs, persistent background pain, attack durations of >2 minutes and reports of pain-related awakening were included. The demographic and clinical phenotype of each patient were carefully recorded for analysis. Results The study cohort consisted of 81 patients and based on reported attack duration these were divided into short (≤ 2 minutes, n = 61) and long (> 2 minutes, n = 20) groups for further analysis. The group with short attack duration neatly fit most of the criteria for CTN while the long attack group presents a more challenging diagnosis. There were no significant differences in pain severity, quality and location between the short and long attack groups. The frequency of persistent background pain was significantly higher in the long (70%) compared to the short attack group (29.5%, p = 0.001). There were significantly more reports of pain-related awakenings in the long (55%) than in the short attack groups (29.5%, p = 0.04). There were no significant differences in the frequency of autonomic signs between the short (21.3%) and long attack groups (40%, p = 0.1). In the short attack group, the presence of autonomic signs was significantly associated with longer disease duration, increased pain-related awakenings, and a reduced prognosis. Conclusion There are clear diagnostic criteria for CTN but often patients present with features, such as long pain attacks, that challenge such accepted criteria. In our cohort the clinical phenotype of trigeminal, neuralgiform pain with or without autonomic signs and background pain was observed across both short and long attack groups and the clinical implications of this are discussed.

Oral Health-Related Quality of Life in Patients with Temporomandibular Disorders.

AIMS To measure the oral health-related quality of life (OHRQoL) in patients with temporomandibular disorders (TMD) compared to controls and analyze its association with various demographic and clinical parameters. METHODS The survey included 187 TMD patients and 200 controls. OHRQoL was measured using the validated Hebrew version of the Oral Health Impact Profile-14 (OHIP-14). A self-report questionnaire assessed personal details, smoking habits, history of trauma and orthodontic treatment, comorbid headaches, oral habits, and pain. TMD patients were divided into diagnostic categories according to the newly recommended diagnostic criteria for TMD (DC/TMD) Axis I protocol. Differences between groups were examined with a Pearson chi-square test for categorical variables and analysis of variance (ANOVA) for continuous variables. RESULTS Among TMD patients, the diagnostic categories included: (1) masticatory muscle disorders (MMD; n = 38; 20.32%), (2) isolated disorders of the temporomandibular joint (TMJ; n = 46; 24.59%), (3) patients with both MMD and TMJ (TMP; n = 103; 55.08%). Compared to controls, TMD patients exhibited worse global OHIP-14 scores (12.50 ± 8.14 vs 9.58 ± 10.00; P = .002) and worse scores in the following domains: physical pain (P < .001), psychological discomfort (P = .005), physical disability (P = .004), and psychological disability (P = .013). Among TMD patients, those categorized as TMP exhibited the highest scores in the physical pain (P = .02) domain. Previous orthodontic treatment, comorbid headache and body pain, limitations in mouth opening and lateral movement, pain, and muscle tenderness scores were found to be strongly related to the OHIP-14. CONCLUSION TMD patients suffered from impaired OHRQoL considerably more than controls. OHRQoL in TMD patients is a multidimensional phenomenon influenced by previous orthodontic treatment, comorbid symptoms, pain, functional limitations, and muscle tenderness scores.

Sleep quality in patients with dental anxiety

BACKGROUND Psychological distress is associated with sleep disturbances; however there is little research on sleep quality in dental anxiety (DA) patients. OBJECTIVES To measure the sleep quality in patients with DA compared to patients with an exacerbated gag reflex (GAG) and controls and to analyze its association with various demographic and behavioral parameters. METHODS 67 DA patients, 54 GAG patients and 100 controls with no history of DA or GAG participated in the study. Data regarding: demographic details, smoking habits, the Pittsburgh Sleep Quality Index (PSQI), Numeric Rating Scale (NRS) for pain assessment, Corahs dental anxiety scale (DAS) and Oral Health Impact Profile-14 (OHIP-14), plaque index (PI) and Decay, Missing and Filled Teeth (DMFT) scores were collected. RESULTS 49.3% of the DA group and 38.9% of the GAG group were poor sleepers (mean PSQI score > 5), compared to 29.0% of the controls (PSQI mean scores: 5.8 ± 3.4, DA group; 5.2 ± 3.6 GAG group vs. 4.5 ± 2.7, control group; p = 0.029). Compared to controls, DA and GAG patients exhibited poorer scores in the sleep disturbances PSQI component (p = 0.001). DA patients exhibited poorer scores in the sleep duration PSQI component compared to the control (p = 0.002) and GAG groups (p = 0.033). Female gender (p = 0.039), higher current (p = 0.046) and maximal NRS (p = 0.019), higher DAS (p < 0.001) and OHIP-14 (p < 0.001) scores and more missing teeth (p = 0.003) were positively associated with higher PSQI scores. CONCLUSIONS DA patients suffered more from impaired sleep than controls and GAGs. Impaired sleep in DA patients is multidimensional phenomenon influenced by the specific diagnosis, gender, pain, dental anxiety levels, dental experience and oral health related quality of life.

Trigeminal neuralgia (part II): Factors affecting early pharmacotherapeutic outcome.

Aims We conducted a cohort study to examine demographic and clinical features associated with the pharmacotherapeutic outcome in classical trigeminal neuralgia (CTN) patients. Methods Patients with a clinical profile indicating a diagnosis of CTN, as per the International Headache Society’s published classification, were enrolled prospectively. Demographic and pain-related characteristics were carefully collected. For the purposes of the study, patients with features such as autonomic signs and longer attack duration were included. All patients were then initiated on a standardised and accepted stepped pharmacotherapeutic protocol for the management of CTN. Initial pain scores and prospectively collected pain scores from pain diaries were used to assess the treatment outcome, with a ≥50% reduction considered significant. Results A total of 86 patients were seen, of whom five had an underlying disorder that could account for the pain. The study cohort therefore consisted of 81 patients, and based on attack duration these were divided into short (≤2 minutes, n = 61) and long (>2 minutes, n = 20) groups, for further analysis. The features of these patients and a discussion on the differential diagnosis have been presented in part 1 of this report. Employing an accepted stepped pharmacotherapeutic protocol for the management of CTN, significant improvement was more frequent in the short (74%) than in the long attack group (50%, p = 0.05). In the short attack group there were statistically significant associations between a poor treatment response and longer disease duration, the presence of autonomic signs and atypical pain descriptors for pain quality (p < 0.05). Conclusion This report supports previous findings that prolonged disease duration and autonomic signs are negative prognostic indicators. The present study now adds long attack duration as a further negative prognostic sign.

Elevated serum IgE in recurrent aphthous stomatitis and associations with disease characteristics

OBJECTIVES To characterize demographic, clinical and serological parameters in recurrent aphthous stomatitis (RAS) patients and analyse their association with serum immunoglobulin E (IgE) levels. SUBJECTS AND METHODS Forty-nine patients with RAS responded to a questionnaire that included demographic background, stress status, smoking habits, history and course of RAS episodes. They were also subjected to relevant laboratory tests, including determination of serum IgE levels. RESULTS A familial history of RAS was reported by 47.9% of the patients, stress in the previous year by 51.1% and smoking by 18.4%. Non-Caucasian origin, familial history of RAS, stress and smoking were associated with increased severity of RAS episodes. Haematological deficiencies were observed in 18.7% of RAS patients. Average IgE levels were increased and were significantly associated ‎with younger ‎age, ‎≤12 years of schooling, ‎female gender, ‎RAS ‎episode frequency of every ‎2 weeks‎,‎ early onset of RAS episodes and elevated C reactive protein levels. CONCLUSION Immunoglobulin E levels may be considered as part of the RAS patients work-up. Further research is needed to identify biological mechanisms that account for the observed associations.

Subjective Sleep Quality in Temporomandibular Disorder Patients and Association with Disease Characteristics and Oral Health–Related Quality of Life

AIMS To measure sleep quality in temporomandibular disorder (TMD) patients, to compare it with that of control subjects, and to analyze its association with disease characteristics and oral health-related quality of life (OHRQoL). METHODS The collected data included demographics, tobacco use, the Pittsburgh Sleep Quality Index (PSQI), trauma history, presence of coexisting headaches and/or body pain, parafunctional habits, pain scores, muscle tenderness to palpation scores, and the Oral Health Impact Profile-14 (OHIP-14). Differences between groups were examined with Pearson chi-square test for categorical variables and independent t test and analysis of variance (ANOVA) for numeric variables. Significant differences were then further tested with multivariate backward stepwise linear regression analysis. RESULTS The final analysis was performed on 286 individuals (187 TMD patients and 99 controls). Poor sleep (PSQI global score > 5) was exhibited in 43.3% of the TMD group and in 28.3% of the control group (P = .013) (mean ± standard deviation [SD] PSQI score = 5.53 ± 2.85 for TMD patients and 4.41 ± 2.64 for controls, P = .001). TMD patients had significantly worse scores in the sleep quality component of the PSQI questionnaire (P = .006). Higher PSQI global scores and poor sleep were positively associated with whiplash history (P = .009 and P = .004, respectively), coexisting headaches (P = .005 and P = .002), body pain (P = .001 and P < .001), clenching habit (P = .016 and P = .006), reduced unassisted (P = .014 and P = .042) and assisted (P = .005 and P = .006) mouth opening, higher muscle tenderness scores, higher pain scores, and higher OHIP-14 global and dimension scores. CONCLUSION TMD patients had poorer sleep than controls. Sleep quality was positively associated with TMD disease characteristics, comorbid pain conditions, and poorer OHRQoL. Assessing sleep quality should be a routine part of the diagnostic work-up of TMD patients. A multidisciplinary management approach is needed to address all the factors-including sleep-that modulate pain experience.

Tic, Triggering, and Tearing: From CTN to SUNHA

Classical trigeminal neuralgia (CTN) and the short‐lasting unilateral neuralgiform headache attacks (SUNHA) are clinically similar.

Overlap between dental anxiety, gagging and Blood-Injection-Injury related fears - A spectrum of one multidimensional phenomenon.

BACKGROUND AND OBJECTIVES Dental anxiety (DA) and gagging (GAG) are prevalent problems that severely impact social behavior and quality of life. Furthermore, because dental phobia is considered a Blood-Injection-Injury (B-I-I) phobia, the present study contrasted DA, GAG and control subjects regarding the severity of dental anxiety and investigated the comorbidity of GAG, DA and B-I-I fears. METHODS Demographics, Verbal Pain Scale (VPS), Oral Health Impact Profile-14 (OHIP-14), Decay, Missing and Filled Teeth (DMFT), Dental Anxiety Scale (DAS) and response to phobic stimuli were collected from 53 GAG, 68 DA and 80 control subjects. RESULTS GAGs exhibited results between DA and controls regarding the likelihood to have high-anxiety/phobia (DA group: OR=55.56; GAG group: OR=17.24), self-assessed dental anxiety (OR=29.14; OR=17.48), fear of dental injections (OR=8.51; OR=2.91) and dental drills (OR=12.02; OR=5.82). DA and GAG had similar results regarding: DAS score (p=0.13), fear of blood tests (OR=4.68; OR=4.09) and blood donations (OR=3.13; OR=3.10). Overlap between GAG, DA and a B-I-I fear was observed. GAG and DA patients and worse maximal VPS and OHIP-14 scores retained their significant positive association with the DAS score in the multivariate analysis. CONCLUSIONS The co-occurrence of DA, GAG and B-I-I-related fears suggests these entities are linked. However, different anxiety levels, symptoms and triggers, reflect the broad spectrum of fear of medical/dental situations.

Demographic profile, Oral Health Impact Profile and Dental Anxiety Scale in patients with chronic periodontitis: a case-control study

OBJECTIVES To examine whether dental anxiety (DA) and oral health-related quality of life (OHRQoL) differ between persons with and those without chronic periodontitis. METHODS One-hundred patients with chronic periodontitis and 50 age- and- sex-matched controls were included. Data were collected on the following: demographics; smoking habits; Numerical Rating Scale (NRS) for dental pain assessment; Corahs Dental Anxiety Scale (DAS); Oral Health Impact Profile 14 (OHIP-14); Decayed, Missing and Filled Teeth (DMFT) index; Plaque Index (PI); probing depth (PD); bleeding on probing (BOP); and radiographic bone loss. RESULTS Patients with chronic periodontitis exhibited a significantly higher percentage of high anxiety and phobia compared with subjects in the control group. Furthermore, patients with chronic periodontitis were statistically significantly more likely to consider themselves as suffering from dental anxiety (68.7% vs. 14.3%, P < 0.001) as well as more likely to have fear of receiving dental injections, hearing the dental drill noise and feeling a foreign object in the mouth. Patients with chronic periodontitis exhibited worse OHIP-14 global scores as well as worse scores in the following individual domains: functional limitation (P = 0.005); physical disability (P = 0.003); psychological disability (P = 0.010); social disability (P = 0.011); and handicap (P = 0.012). CONCLUSIONS Compared with controls, patients with chronic periodontitis had higher levels of dental anxiety and worse OHRQoL. It is important to consider dental anxiety and OHRQoL assessment as an integral component of the evaluation of patients with chronic periodontitis. Communication between dental and behavioral health professionals is needed to implement a multidisciplinary team approach involving behavioural and psychological interventions.