Joseph J. Marbach

Epidemiologic studies of mandibular dysfunction: a critical review.

w hen epidemiologic methods identify a large percentage of the population as “sick” with some disease or disorder, concern may arise about a possible “epidemic.” In the case of mandibular dysfunction, recent epidemiologic studies suggest that as many as three fourths of the population may, to some degree, be affected by this disorder. If these studies are accepted as presented, the dental profession is obliged to attempt identification of the large number of affected individuals and then to either advise or treat them appropriately. There are serious doubts, however, about whether the findings of these studies should be accepted without first raising critical questions regarding their validity. Two major issues must be considered: (1) Have conventional epidemiologic methods been correctly applied to the study of mandibular dysfunction? (2) Have proper inferences been drawn from the findings? The concerns of population medicine, or epidemiology, are different from those of the clinical disciplines. In population medicine, groups replace individuals as the focus of study. The study of the distribution and dynamics of diseases in human populations can provide clinicians and researchers with answers to important questions, such as: (1) Can we identify those persons most likely to become ill? (2) What common features of susceptibility or exposure do these people share? (3) What is the natural history of the disease if not treated? In addition, epidemiologic studies may elucidate the causal relationships of a particular disease, which then establishes the basis for programs of prevention and control. Epidemiology has contributed dramati-

Incidence of phantom tooth pain: An atypical facial neuralgia

The aid of endodontists was sought in an attempt to determine the incidence PTP in an endodontically treated population. A total of 732 questionnaires were mailed to past patients of one endodontist; 463 (63 percent) usable responses were returned. Of 256 female subject, eight (3 percent) manifested persistent chronic pain not explained by physical or radiographic examination but consistent with the signs and symptoms of PTP. Other patients met three of the four criteria of PTP. The incidence of PTP in the population studied is between 3 and 6 percent.

Depression, anhedonia and anxiety in temporomandibular joint and other facial pain syndromes

Abstract Depression, anhedonia, state anxiety (A‐state), trait anxiety (A‐trait), and self‐reported pain estimate were measured in almost 500 facial pain patients. These patients were divided into 3 diagnostic categories: myofascial pain dysfunction syndrome (MPD) [8], arthritis of the temporomandibular joints (TMJ arthritis), and trigeminal neuralgia. Three control groups were measured for comparison. They consisted of a normal, or non‐patient group, a group of arthritis patients, and a group of movement disorder patients attending a neurology clinic. Among the facial pain patients and the normal controls few differences were found with regard to anhedonia and depression. The arthritis and neurology patients produced significantly higher depression and anhedonia scores than did several of the facial pain groups. Pain estimate ranged from 0 for the controls, to a mean of 67.6 ± 31.3 for the trigeminal neuralgia patients with the MPD (Symbol) and the TMJ arthritis patients (Symbol) somewhat lower. Clinical variables such as duration of pain, help seeking behavior and total number of symptoms were correlated with depression but not with anhedonia scores. It is hypothesized that anhedonia is a measure separate from depression and may be more closely linked to suffering behavior than to pain behavior. Psychological variables did not discriminate among facial pain patients and in particular did not distinguish between so‐called functional and organic illness. Symbol. No caption available. Symbol. No caption available.

Candidate risk factors for temporomandibular pain and dysfunction syndrome: Psychosocial, health behavior, physical illness and injury

&NA; The purpose of this paper is to identify potential risk factors for the temporomandibular pain and dysfunction syndrome (TMPDS). The investigation focuses on the relations of TMPDS to personal, social and recent experiential factors, especially health behaviors and physical illnesses and injuries, that contribute to life stress. The data come from a retrospective case‐control study of 151 TMPDS patients and 139 healthy controls. Results show that cases and controls are similar on most measures of personality characteristics although cases are somewhat more external in locus of control expectancy and appear far more distressed than do controls. There are no case/control differences in reports of desirable and undesirable life events that do not involve physical illness and injury. The social situations of cases and controls differ in that cases have fewer sources of emotional support than controls. No differences were found in the proportion of cases and controls who reported that they ever ground or clenched their teeth, although cases were told they do so more frequently by dentists than were controls. Excluding never married women, cases were less likely than controls to have children. This could not be explained on the basis of birth control and may provide a clue to a biologic base for the much higher rates of women than men who are treated for TMPDS. Cases reported more past pain‐related illnesses, more life‐threatening physical problems and more recent events involving injury and non‐pain‐related physical illnesses. There was no difference between cases and controls in reports of physical problems prior to age 13. TMPDS patients appear to be unusually distressed individuals who are beleaguered by physical illnesses and injuries as well as by pain, who tend to attribute their fate to external factors, and who have fewer sources of emotional support.

Is phantom tooth pain a deafferentation (neuropathic) syndrome?: Part I: Evidence derived from pathophysiology and treatment☆

Phantom tooth pain is a syndrome of persistent pain or paresthesia in teeth and other oral tissues that may follow dental or surgical procedures such as pulp extirpation, apicoectomy, tooth extractions, or exenteration of the contents of the maxillary antrum. It can also occur when nerves are injured after trauma to the face or even after routine inferior alveolar nerve blocks if the needle pierces the nerve sheath. In the case of tooth extraction, the pain is found in the edentate area. After periodontal surgery, pain or paresthesia is located in the gingiva. The incidence of phantom tooth pain after extirpation may be as high as 3% of cases. Clinically, phantom tooth pain is similar in many essential characteristics to deafferentation pain syndromes also known as phantom pain syndromes. A limitation to this taxonomy is the lack of definitive information with respect to the pathophysiology of deafferentation pain in the trigeminal nerve. This article amplifies previous clinical descriptions of phantom tooth pain. Current concepts in the pathophysiology of neuropathic pain are reviewed as they pertain to phantom tooth pain. Treatments are described that use three routes of drug administration: oral, nerve blocks by injections, and intranasal applications. Reasons are discussed for the high rates of morbidity after dental and neurosurgery in attempts to treat phantom tooth pain.

Is phantom tooth pain a deafferentation (neuropathic) syndrome

Phantom tooth pain is a syndrome of persistent pain or paresthesia in teeth and other oral tissues that may follow dental or surgical procedures such as pulp extirpation, apicoectomy, tooth extractions, or exenteration of the contents of the maxillary antrum. It can also occur when nerves are injured after trauma to the face or even after routine inferior alveolar nerve blocks if the needle pierces the nerve sheath. In the case of tooth extraction, the pain is found in the edentate area. After periodontal surgery, pain or paresthesia is located in the gingiva. The incidence of phantom tooth pain after extirpation may be as high as 3% of cases. Clinically, phantom tooth pain is similar in many essential characteristics to deafferentation pain syndromes also known as phantom pain syndromes. A limitation to this taxonomy is the lack of definitive information with respect to the pathophysiology of deafferentation pain in the trigeminal nerve. This article amplifies previous clinical descriptions of phantom tooth pain. Current concepts in the pathophysiology of neuropathic pain are reviewed as they pertain to phantom tooth pain. Treatments are described that use three routes of drug administration: oral, nerve blocks by injections, and intranasal applications. Reasons are discussed for the high rates of morbidity after dental and neurosurgery in attempts to treat phantom tooth pain.

Coping and Adaptation to Facial Pain in Contrast to Other Stressful Life Events

This article investigates whether coping with chronic pain influences adaptation to other negative life events using data on Temporomandibular Pain and Dysfunction Syndrome (TMPDS) patients (N = 99) and nonpatient controls (N = 98). It is found that cases cope very differently with pain than with other stressful events and that cases and controls do not differ on coping with nonpain events, with 2 exceptions. Cases view nonfateful events as more outside their control and they have more negative changes in usual activities following negative events. This excess of negative change is associated with greater demoralization and physical exhaustion. It is concluded that coping with repeated pain episodes leaves cases vulnerable to stressful events. Alternative interpretations, especially those involving the role of preexisting personality differences, are discussed.

The examination of myofascial face pain and its relationship to psychological distress among women.

In this study, 110 female myofascial face pain patients were assessed monthly for 10 months on measures of pain, distress, and stressful life events. D. A. Kenny and A. J. Zautras (1995) structural equation model for examining the separate trait, state, and error components of the variables was used to analyze the data. Both pain and distress had sizable trait variance, and the trait components were correlated. The 2 variables also showed sizable state variance, and the states of pain covaried with states of distress. A significant time-lagged relationship between the 2 variables was found: Increases in distress led to elevations in pain 1 month later. Stressful life events arising from major social roles were also associated with greater distress, but not pain. Illness events unrelated to the pain syndrome were associated with both pain and distress.

Illness Behavior, Depression and Anhedonia in Myofascial Face and Back Pain Patients

Levels of depression, anhedonia, and illness behavior, as well as clinical and demographic variables, were measured in two groups of patients with chronic pain, one with facial, the other with back pain. For the total sample, significant correlations (p less than 0.01) were found between illness behavior and pain estimate (r = 0.30), anhedonia and depression (r = 0.33), and pain estimate and pain duration (r = 0.31). Facial pain patients showed illness behavior most strongly related to estimate of pain severity (r = 0.62); back pain patients showed illness behavior significantly related to depression (r = 0.59). Results also show that the physical site of pain relates to illness behavior but not mood of chronic pain patients.

Erythrocyte Catechol-O-Methyltransferase Activity in Facial Pain Patients:

Depressive illness sometimes includes hypochondriacal preoccupations that may lead to an assortment of physical symptoms termed depressive equivalents. Several groups have shown that depression is a typical finding in recalcitrant patients with chronic myofacial pain lysfunction (MPD) . The hypothesis that a relationship exists between depi2ssion and facial pain has been strengthened through clinical investigation into the psychodynamics of the MPD patient (MARBACH and DWORKIN, JADA 90: 827, 1975). Evidence has accumulated that suggests a possible connection between affective disorders (depression), and central nervous system (CNS) norepinephrine metabolism. According to the catecholamine hypothesis, depression is associated with decreased availability of neorepinephrine, and can be effectively treated by drugs that increase the concentrations of this neurotransmitter at the receptor site (SCHILDKRAUT, Am J Psychiatry 122: 509, 1965). Although this hypothesis fails to provide an explanation for some aspects of affective disorders, it has provided a valuable framework for additional investigations. Higher catecholamine concentrations have been reported in the urine of the patients with MPD compared to the urine of the controls (EVASKUS and LASKIN, J Dent Res 51: 1464, 1972) . The principal pathway for the metabolism of extraneuronal catecholamines in the CNS is 0-methylation by catechol-O-methyltransferase (COMT). Dunner and co-workers reported (Arch Gen Psychiatry 25: 348, 1-971) that red blood (RBC) cell COMT activity is lower in manic-depressive women than in normal female controls, or ill, or well males. Human RBC COMT activity may be an index of COMT activity in the brain. Its activity was measured in 31 consecutive patients, 28 females and 3 males, who were at the Temporomandibular Joint