Yaron Haviv

Painful Traumatic Trigeminal Neuropathy: An Open Study on the Pharmacotherapeutic Response to Stepped Treatment

AIMS To evaluate pharmacotherapeutic success in patients with painful traumatic trigeminal neuropathy (PTTN) and to identify patient or pain characteristics that may predict treatment outcome. METHODS Pharmacotherapy was instituted for PTTN patients and was based on widely accepted protocols for neuropathic pain and conducted in an open fashion. Outcome was assessed by employing prospective diaries recording pain intensity measured with an 11-point (0 to 10) verbal pain score (VPS). Individual characteristics in the patients and their influence on outcome were analyzed. Treatment results in the PTTN patients were compared with those in classical trigeminal neuralgia (CTN) patients, who were used as a comparative cohort. Data were analyzed with a Pearson chi-square test for nominal variables and with an independent samples t test or analysis of variance for continuous variables. RESULTS A total of 145 patients were included: 91 with PTTN and 54 with CTN. In PTTN patients, 11% had a ≥ 50% reduction in pain intensity. Higher VPS scores in the PTTN patients were associated with a significantly reduced response to therapy (P = .03). No other pain-related or demographic parameters were associated with treatment outcome in the PTTN patients. Also the response rate of PTTN patients was significantly inferior to that of CTN patients, 74.1% of whom attained a significant reduction in pain intensity (P < .001). CONCLUSION This study underpins the poor pharmacotherapeutic prognosis of PTTN. The results support findings on neuropathic pain in other sites and point to the need for further research and reexamination of current PTTN treatment protocols.

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.

Myofascial pain: an open study on the pharmacotherapeutic response to stepped treatment with tricyclic antidepressants and gabapentin.

AIMS To evaluate, in an open trial, the pharmacotherapeutic efficacy of tricyclic antidepressant (TCA) drugs and gabapentin in patients with persistent myofascial pain and to identify patient and pain characteristics that may predict treatment outcome. METHODS A stepped pharmacotherapeutic protocol was employed. All 42 patients having persistent facial pain with tenderness of regional muscles were first prescribed amitriptyline, but those with side effects were subsequently transferred to nortriptyline. In patients where no response to TCAs was observed, gabapentin was initiated. Outcome was assessed by employing prospective diaries recording pain intensity measured with an 11-point (0-10) verbal pain scale (VPS). Individual characteristics in these patients and their influence on drug response and outcome were analyzed; specifically, patients treated with TCAs were compared with those subsequently treated with gabapentin. Chi-square and t tests were used to analyze the data. RESULTS A total of 23 patients responded to TCAs and continued on this regimen, while 19 were resistant to TCAs and were subsequently treated with gabapentin. Their mean (± SD) VPS score at baseline was 6.5 ± 1.9 on an 11-point scale. In TCA-treated patients, 43% showed ≥ 50% reduction in pain intensity. This was achieved with a mean amitriptyline dose of 16 ± 1.1 mg/d and a mean nortriptyline dose of 25 ± 2.1 mg/d. Patients who did not respond to TCAs were characterized by a significantly higher age, more comorbid medical illness, and evidence of more regional pain spread (P < .05). In spite of not responding to TCAs, 36.8% of this group showed ≥ 50% reduction in pain intensity following gabapentin therapy at a mean daily dose of 973.7 ± 68.8 mg. Overall, a stepped approach employing TCAs and gabapentin resulted in 54.8% of all treated patients reporting improvements of ≥ 50% in VPS scores. CONCLUSION This study has demonstrated the good pharmacotherapeutic response of persistent myofascial pain, even in more severe cases. Not being a randomized controlled trial, the results may be biased and should be interpreted with caution. Patients who do not respond to TCAs may be a distinct subgroup and this needs further investigation. The results also suggest that gabapentin, at a lower dose than previously reported, is a good alternative in TCA-resistant patients.

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.

On the edge between medicine and dentistry: review of the dentist's role in the diagnosis and treatment of snoring and sleep apnea.

OBJECTIVES Snoring and obstructive sleep apnea syndrome (OSA) can affect both esthetics and health. In this review article, we describe the role of the dentist in evaluation and treatment of snoring and OSA in children and adults, with an emphasis on oral appliances as a means to treat the adult population. DATA SOURCES A comprehensive literature search of publications from 1934 to 2013 in the PubMed/Medline/Science Direct databases was performed to collect information about snoring, OSA, and oral or dental appliances using these terms as key words. The search was limited to peer-reviewed articles written in English, with a few exceptions in other languages. The literature search was endorsed by manual searching through peer-reviewed journals and reference lists of the selected articles. CONCLUSION The dentists role in the diagnosis of OSA in children and in diagnosis and treatment in the adult population with the help of oral appliances is vital. Diagnosis and treatment by the aware dentist can reduce major health risk outcomes.

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.