Summaries of the Padua symposium on myofascial pain, fibromyalgia, and fascial pain disorders, June 2023, Aula Falloppio at the Human Anatomy Institute of the University of Padova, Italy.

The International Symposium on Myofascial Pain, Fibromyalgia, and Fascial Pain Disorders was held at the University of Padua, Padua, Italy in June of 2023. This report presents a summary of the presentations from scientists and clinicians from around the world who presented to the symposium. The purpose of this symposium and resultant paper is improve health professional's recognition and understanding of the clinical characteristics, co-morbidities, mechanisms, and treatment strategies for these common conditions to better understand and manage their pain, dysfunction, and quality life.

Calcitonin Gene-Related Peptide-Mediated Trigeminal Ganglionitis: The Biomolecular Link between Temporomandibular Disorders and Chronic Headaches.

A bidirectional causal relationship has been established between temporomandibular disorders (TMDs) and chronic headaches. Recent advances in the neurobiology of chronic pain offer a framework for understanding the comorbidity between these two conditions that might reside in the shared biomolecular mechanisms of peripheral and central sensitization. The initiation of these processes is inflammatory in nature and is most likely mediated by key molecules, including calcitonin gene-related peptide (CGRP). This scoping review proposes that CGRP-mediated neuroinflammation in the trigeminal ganglion may partly explain the biomolecular bidirectional link between TMDs and chronic headaches. Finally, clinical implications of this neuropathologic process are briefly discussed.

Management of painful temporomandibular disorders: Methods and overview of The National Dental Practice-Based Research Network prospective cohort study.

BACKGROUND: Patients often seek consultation with dentists for temporomandibular disorders (TMDs). The objectives of this article were to describe the methods of a large prospective cohort study of painful TMD management, practitioners' and patients' characteristics, and practitioners' initial treatment recommendations conducted by The National Dental Practice-Based Research Network (the "network"). METHODS: Participating dentists recruited into this study treated patients seeking treatment for painful TMDs. The authors developed self-report instruments based on well-accepted instruments. The authors collected demographics, biopsychosocial characteristics, TMD symptoms, diagnoses, treatments, treatment adherence, and painful TMDs and jaw function outcomes through 6 months. RESULTS: Participating dentists were predominately White (76.8%) and male (62.2%), had a mean age of 52 years, and were general practitioners (73.5%) with 23.8% having completed an orofacial pain residency. Of the 1,901 patients with painful TMDs recruited, the predominant demographics were White (84.3%) and female (83.3%). Patients' mean age was 44 years, 88.8% self-reported good to excellent health, and 85.9% had education beyond high school. Eighty-two percent had pain or stiffness of the jaw on awakening, and 40.3% had low-intensity pain. The most frequent diagnoses were myalgia (72.4%) and headache attributed to TMDs (51.0%). Self-care instruction (89.4%), intraoral appliances (75.4%), and medications (57.6%) were recommended frequently. CONCLUSIONS: The characteristics of this TMD cohort include those typical of US patients with painful TMDs. Network practitioners typically managed TMDs using conservative treatments. PRACTICAL IMPLICATIONS: This study provides credible data regarding painful TMDs and TMD management provided by network practitioners across the United States. Knowledge acquired of treatment recommendations and patient reports may support future research and improve dental school curricula.

Acute and Chronic Temporomandibular Disorder Pain: A critical review of differentiating factors and predictors of acute to chronic pain transition.

AIMS: The aims of this critical review were to: (i) assess the factors that differentiate acute from chronic temporomandibular disorders (TMD) pain; (ii) assess the risk factors associated with the transition from acute to chronic TMD pain; and (iii) summarize and appraise the studies. METHOD: The databases used were MEDLINE, Embase, and Cochrane Database of Systematic Reviews. Eligible studies included articles comparing acute to chronic TMD pain, and cohort studies assessing the risk factors implicated in the transition from acute to chronic TMD pain. RESULTS: Seven articles were selected: one case-control study, three cross-sectional studies, and three cohort studies. These studies found that psychological factors were more common in chronic than acute TMD pain patients; however, these factors did not increase the transition risk in the multivariable model. Myofascial and baseline pain intensity were associated with the transition from acute to chronic TMD pain at a 6-month follow-up. Due to methodological weaknesses in the available literature, more research is required to establish the risk factors implicated in the transition from acute to chronic TMD pain. CONCLUSION: This review found some evidence that myofascial pain is associated with the transition risk from acute to chronic TMD pain at a 6-month follow-up and that pain intensity at baseline is associated with more intense TMD pain 6 months later. There is insufficient evidence to draw conclusions about the role of demographics and psychological disorders as independent risk factors.

Dental Decision Simulation (DDSim): Development of a virtual training environment.

PURPOSE: Case-based simulations are powerful training tools that can enhance learning and drive behavior change. This is an overview of the design/development of Dental Decision Simulation (DDSim), a web-based simulation of an electronic dental record (EDR). The purpose was to use DDSim to train dentists to make evidence-based treatment planning decisions consistent with current evidence. This simulated EDR provides case-based information in support of a set of defined evidence-based learning objectives. METHODS: The development of this complex simulation model required coordinated efforts to create several components: identify behavior changes, case authoring mechanism, create virtual patient visits, require users to make treatment plan decisions related to learning objectives, and a feedback mechanism to help users recognize departures from those learning objectives. This simulation was evaluated in a 2-arm, clinic-randomized, controlled pilot study examining the extent to which DDSim changed dentists' planned treatment to conform to evidence-based treatment guidelines relative to change in dentists not exposed to DDSim. Outcomes were measured by comparing preintervention and postintervention patient EDR treatment data. RESULTS: Changes in behavior over time did not favor intervention or control clinics. CONCLUSION: DDSim provides a standardized learning platform that cannot be achieved through the use of live patients. Both live patients and case-based simulations can be used to transfer knowledge and skill development. DDSim offers the advantage of providing a platform for developing treatment planning skills in a low-risk environment. However, further research examining behavior change is needed.

Myofascial Pain: Mechanisms to Management.

More than 100 million adults in the United States have chronic pain conditions, costing more than $500 billion annually in medical care and lost productivity. They are the most common reason for seeking health care, for disability and addiction, and the highest driver of health care costs. Myofascial pain is the most common condition causing chronic pain and can be diagnosed through identifying clinical characteristics and muscle palpation. Management is focused on integrating patient training in changing lifestyle risk factors with evidence-based treatment. Understanding the cause, diagnosis, and management of myopain conditions will help prevent the impact of chronic pain.

Preventing Chronic Pain: A Human Systems Approach-Results From a Massive Open Online Course.

Chronic pain conditions are the top reason patients seek care, the most common reason for disability and addiction, and the biggest driver of healthcare costs; their treatment costs more than cancer, heart disease, dementia, and diabetes care. The personal impact in terms of suffering, disability, depression, suicide, and other problems is incalculable. There has been much effort to prevent many medical and dental conditions, but little effort has been directed toward preventing chronic pain. To address this deficit, a massive open online course (MOOC) was developed for students and healthcare professionals. "Preventing Chronic Pain: A Human Systems Approach" was offered by the University of Minnesota through the online platform Coursera. The first offering of this free open course was in the spring of 2014 and had 23 650 participants; 53% were patients or consumers interested in pain. This article describes the course concepts in preventing chronic pain, the analytic data from course participants, and postcourse evaluation forms.

Las afecciones de dolor crónico son el principal motivo de búsqueda de asistencia sanitaria, la causa más frecuente de discapacidad y toxicomanía, y el factor generador de costos sanitarios más importante, con un coste mayor al generado por el cáncer, la cardiopatía, la demencia y la diabetes. Las repercusiones en cuanto a sufrimiento, discapacidad, depresión, suicidio y otros problemas son incalculables. Se han consagrado grandes esfuerzos a la prevención de muchas enfermedades médicas y dentales, pero no se han dirigido los suficientes hacia la prevención del dolor crónico. Para hacer frente a este déficit, se ha desarrollado un curso en línea masivo y abierto (massive open online course, MOOC) para estudiantes y profesionales sanitarios. La Universidad de Minnesota ofreció el curso "Prevención del dolor crónico: enfoque de un sistema humanista" a través del sitio www.Coursera.org. La primera oferta de este curso abierto y gratuito se hizo en primavera de 2014 y acogió a 23 650 participantes; de los cuales un 53 % eran pacientes o clientes interesados en el dolor. En este artículo se describen los conceptos del curso en la prevención del dolor crónico, los datos analíticos de los participantes y los formularios de evaluación posteriores al curso.

Temporomandibular disorders: a human systems approach.

The face and associated cranial, oral and dental structures are among the most complicated areas of the body, contributing to an array of common orofacial disorders that include temporomandibular disorders (TMD), orofacial pain disorders and orofacial sleep disorders. This paper presents a broad, inclusive approach to diagnosis and management of TMD that reflects both conceptual models of human systems in understanding chronic illnesses as well as systematic reviews of treatment for successful management.

The feasibility of a clinical trial of pain related to temporomandibular muscle and joint disorders: the results of a survey from the Collaboration on Networked Dental and Oral Research dental practice-based research networks.

BACKGROUND: The authors conducted a survey to characterize the strategies used by general dentists to manage pain related to temporomandibular muscle and joint disorders (TMJDs) and to assess the feasibility of conducting a randomized controlled trial (RCT) to determine the effectiveness of these strategies. METHODS: Dentists from three dental practice-based research networks (PBRNs) (The Dental Practice-Based Research Network, Practitioners Engaged in Applied Research and Learning Network and Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry) agreed to participate in this survey. RESULTS: Of 862 dentists surveyed, 654 were general dentists who treated TMJDs; among these, 80.3 percent stated they would participate in a future RCT. Dentists treated an average of three patients with TMJD-related pain per month. Splints or mouthguards (97.6 percent), self-care (85.9 percent) and over-the-counter or prescribed medications (84.6 percent) were the treatments most frequently used. The treatments dentists preferred to compare in an RCT were splint or mouthguard therapy (35.8 percent), self-care (27.4 percent) and medication (17.0 percent). CONCLUSIONS: Most general dentists treat TMJD-related pain, and initial reversible care typically is provided. It is feasible to conduct an RCT in a dental PBRN to assess the effectiveness of splint or mouthguard therapy, self-care or medication for the initial management of painful TMJD. CLINICAL IMPLICATIONS: There is an opportunity to do an RCT in a dental PBRN, which could lead to the development of evidence-based treatment guidelines for the initial treatment of TMJD-related pain by primary care dentists.

Diagnostic criteria for headache attributed to temporomandibular disorders.

AIMS: We assessed and compared the diagnostic accuracy of two sets of diagnostic criteria for headache secondary to temporomandibular disorders (TMD). METHODS: In 373 headache subjects with TMD, a TMD headache reference standard was defined as: self-reported temple headache, consensus diagnosis of painful TMD and replication of the temple headache using TMD-based provocation tests. Revised diagnostic criteria for Headache attributed to TMD were selected using the RPART (recursive partitioning and regression trees) procedure, and refined in half of the data set. Using the remaining half of the data, the diagnostic accuracy of the revised criteria was compared to that of the International Headache Society's International Classification of Headache Diseases (ICHD)-II criteria A to C for Headache or facial pain attributed to temporomandibular joint (TMJ) disorder. RESULTS: Relative to the TMD headache reference standard, ICHD-II criteria showed sensitivity of 84% and specificity of 33%. The revised criteria for Headache attributed to TMD had sensitivity of 89% with improved specificity of 87% (p < 0.001). These criteria are (1) temple area headache that is changed with jaw movement, function or parafunction and (2) provocation of that headache by temporalis muscle palpation or jaw movement. CONCLUSION: Having significantly better specificity than the ICHD-II criteria A to C, the revised criteria are recommended to diagnose headache secondary to TMD.

The effect of electronic health records on the use of clinical care guidelines for patients with medically complex conditions.

BACKGROUND: The emergence of health information technology provides an opportunity for health care providers to improve the quality and safety of dental care, particularly for patients with medically complex conditions. METHODS: The authors randomized each of 15 dental clinics (HealthPartners, Bloomington, Minn.) to one of three groups to evaluate the impact of two clinical decision support (CDS) approaches during an 18-month study period. In the first approach--provider activation through electronic dental records (EDRs)--a flashing alert was generated at the dental visit to identify patients with medically complex conditions and to direct the dental care provider to Web-based personalized care guidelines. In the second approach--patient activation through personal health records--a secure e-mail was generated or a letter was mailed to patients before dental visits encouraging them to ask their dental care provider to review the care guidelines specific to their medical conditions. RESULTS: The authors evaluated the rate of reviewing care guidelines among 102 providers. Participants in the provider and patient activation groups increased their use of the system during the first six months, which had a generalized effect of increasing use of the guidelines for all patients, even if they were not part of the study (P < .05). The study results showed that provider activation was more effective than was patient activation. However, providers did not sustain their high level of use of the system, and by the end of the study, the rate of use had returned to baseline levels despite participants' continued receipt of electronic alerts. CONCLUSIONS: The study results demonstrated that review of clinical care guidelines for patients with medically complex conditions can be improved with CDS systems that involve the use of electronic health records. CLINICAL IMPLICATIONS: As the U.S. population ages, dentists must be vigilant in adapting care for patients with medically complex conditions to ensure therapeutic safety and effectiveness. Expanded use of CDS via EDRs can help dental care providers achieve this objective.

The effect of catastrophizing and depression on chronic pain--a prospective cohort study of temporomandibular muscle and joint pain disorders.

Although most cases of temporomandibular muscle and joint disorders (TMJD) are mild and self-limiting, about 10% of TMJD patients develop severe disorders associated with chronic pain and disability. It has been suggested that depression and catastrophizing contributes to TMJD chronicity. This article assesses the effects of catastrophizing and depression on clinically significant TMJD pain (Graded Chronic Pain Scale [GCPS] II-IV). Four hundred eighty participants, recruited from the Minneapolis/St. Paul area through media advertisements and local dentists, received examinations and completed the GCPS at baseline and at 18-month follow-up. In a multivariable analysis including gender, age, and worst pain intensity, baseline catastrophizing (ß 3.79, P<0.0001) and pain intensity at baseline (ß 0.39, P<0.0001) were positively associated with characteristic of pain intensity at the 18th month. Disability at the 18-month follow-up was positively related to catastrophizing (ß 0.38, P<0.0001) and depression (ß 0.17, P=0.02). In addition, in the multivariable analysis adjusted by the same covariates previously described, the onset of clinically significant pain (GCPS II-IV) at the 18-month follow-up was associated with catastrophizing (odds ratio [OR] 1.72, P=0.02). Progression of clinically significant pain was related to catastrophizing (OR 2.16, P<0.0001) and widespread pain at baseline (OR 1.78, P=0.048). Results indicate that catastrophizing and depression contribute to the progression of chronic TMJD pain and disability, and therefore should be considered as important factors when evaluating and developing treatment plans for patients with TMJD.

Ask the Experts: Ensuring accurate diagnosis of orofacial pain disorders.

Dr Fricton received his BS and DDS degree from the University of Iowa (IA, USA), and then undertook his postgraduate studies, completing an MS in Oral Biology at UCLA School of Dentistry (University of California, CA, USA) and an Anesthesiology and Pain Management Residency at UCLA Medical Center. After research and clinical training at UCLA, he joined the faculty at the University of Minnesota (MN, USA), where he is currently a Professor in the Department of Diagnostic and Surgical Sciences and Physical Medicine and Rehabilitation. He is also a Senior Research Investigator at HealthPartners Research Foundation (MN, USA). He has over 30 years experience in clinical care, research and teaching in the field of chronic pain, orofacial pain, temporomandibular muscle and joint disorders, muscle pain, and, more recently, health informatics. His sponsored research has focused on epidemiological studies and clinical trials of therapeutic strategies for chronic pain conditions. He has developed a biobehavioral framework for personalized care for chronic pain conditions and has integrated this pain research with studies of health information technology, focusing on the use of electronic health records, personal health records and clinical decision support to improve the outcomes and quality of healthcare. He is Principal Investigator for the NIH NIDCR's temporomandibular joint (TMJ) Implant Registry and Repository, which includes research into the genetic, biomechanical and biobehavioral factors involved in the success or failure of TMJ implants. In addition, he has served on the governing board of the American Pain Society, and was president of both the American Board of Orofacial Pain and the American Academy of Orofacial Pain. He maintains an active private practice for patients with TMJ, orofacial, head and neck pain in Plymouth (MN, USA) and St Paul (MN, USA).