A personal exploration of oral health in Parkinson's disease through the eyes of a multifaceted authority.

BACKGROUND AND OBJECTIVE: Parkinson's disease (PD) poses a range of challenges, including oral health issues, that significantly impact the patient's quality of life. Despite growing awareness of PD, oral health receives limited attention. To shed light on this matter, this personal scoping review explores the perspectives of Professor K.G. Raphael, who is both a professional and a PD patient, on various aspects of oral health in PD. METHODS: Through semi-structured interviews, Prof. Raphael shares her insights on the complexities of oral health as a PD patient to compose an agenda for oral health care, research, and education, for PD patients. RESULTS: She emphasises the importance of interdisciplinary collaboration and education. Additionally, Prof. Raphael identifies crucial research areas, such as exploring the role of the oral microbiome and assessing the impact of exercise on oral health in PD. CONCLUSION: This study resulted in agendas to improve oral health care, research and education, advocating for a holistic approach to enhance PD patients' well-being. Despite its limitations, this study highlights the imperative of integrating oral health into the broader management of PD, emphasising interdisciplinary collaboration and patient empowerment.

Personal scoping review: A novel review type with a personal touch.

BACKGROUND: The importance of incorporating patient and medical professional perspectives in medical research is increasingly recognized. However, formal platforms for these voices are limited. OBJECTIVE: To address this gap, this study proposes a novel manuscript type, the Personal Scoping Review, within the Journal of Oral Rehabilitation. MATERIALS AND METHODS: Personal Scoping Reviews utilize a qualitative design with semi-structured interviews to gather patient and professional perspectives. This approach offers flexibility and depth, allowing authors to explore diverse insights. The reviews focus on care, education and research agendas related to the topic, using the voices of individuals as primary evidence. RESULTS & CONCLUSION: Personal Scoping Reviews highlight concerns in patient care, educational needs and research gaps, offering a comprehensive view. By integrating diverse perspectives, these reviews provide valuable insights for improving medical research and practice. They facilitate the formulation of agendas to address key issues in care, education and research. By amplifying individual perspectives, these reviews aim to enhance the relevance and impact of research, ultimately benefiting patients and healthcare providers alike.

Constructing the brief diagnostic criteria for temporomandibular disorders (bDC/TMD) for field testing.

BACKGROUND: Despite advances in temporomandibular disorders' (TMDs) diagnosis, the diagnostic process continues to be problematic in non-specialist settings. OBJECTIVE: To complete a Delphi process to shorten the Diagnostic Criteria for TMD (DC/TMD) to a brief DC/TMD (bDC/TMD) for expedient clinical diagnosis and initial management. METHODS: An international Delphi panel was created with 23 clinicians representing major specialities, general dentistry and related fields. The process comprised a full day workshop, seven virtual meetings, six rounds of electronic discussion and finally an open consultation at a virtual international symposium. RESULTS: Within the physical axis (Axis 1), the self-report Symptom Questionnaire of the DC/TMD did not require shortening from 14 items for the bDC/TMD. The compulsory use of the TMD pain screener was removed reducing the total number of Axis 1 items by 18%. The DC/TMD Axis 1 10-section examination protocol (25 movements, up to 12 sets of bilateral palpations) was reduced to four sections in the bDC/TMD protocol involving three movements and three sets of palpations. Axis I then resulted in two groups of diagnoses: painful TMD (inclusive of secondary headache), and common joint-related TMD with functional implications. The psychosocial axis (Axis 2) was shortened to an ultra-brief 11 item assessment. CONCLUSION: The bDC/TMD represents a substantially reduced and likely expedited method to establish (grouping) diagnoses in TMDs. This may provide greater utility for settings requiring less granular diagnoses for the implementation of initial treatment, for example non-specialist general dental practice.

Investigating trial design variability in trials of disease-modifying therapies in Parkinson's disease: a scoping review protocol.

INTRODUCTION: Parkinson's disease (PD) is a debilitating neurological disorder for which the identification of disease-modifying interventions represents a major unmet need. Diverse trial designs have attempted to mitigate challenges of population heterogeneity, efficacious symptomatic therapy and lack of outcome measures that are objective and sensitive to change in a disease modification setting. It is not clear whether consensus is emerging regarding trial design choices. Here, we report the protocol of a scoping review that will provide a contemporary update on trial design variability for disease-modifying interventions in PD. METHODS AND ANALYSIS: The Population, Intervention, Comparator, Outcome and Study design (PICOS) framework will be used to structure the review, inform study selection and analysis. The databases MEDLINE, Web of Science, Cochrane and the trial registry ClinicalTrials.gov will be systematically searched to identify published studies and registry entries in English. Two independent reviewers will screen study titles, abstracts and full text for eligibility, with disagreements being resolved through discussion or by a third reviewer where necessary. Data on general study information, eligibility criteria, outcome measures, trial design, retention and statistically significant findings will be extracted into a standardised form. Extracted data will be presented in a descriptive analysis. We will report our findings using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review extension. ETHICS AND DISSEMINATION: This work will provide an overview of variation and emerging trends in trial design choices for disease-modifying trials of PD. Due to the nature of this study, there are no ethical or safety considerations. We plan to publish our findings in a peer-reviewed journal.

An International Multi-Stakeholder Delphi Survey Study on the Design of Disease Modifying Parkinson's Disease Trials.

BACKGROUND: Design of disease modification (DM) trials for Parkinson's disease (PD) is challenging. Successful delivery requires a shared understanding of priorities and practicalities. OBJECTIVE: To seek stakeholder consensus on phase 3 trials' overall goals and structure, inclusion criteria, outcome measures, and trial delivery and understand where perspectives differ. METHODS: An international expert panel comprising people with Parkinson's (PwP), care partners (CP), clinical scientists, representatives from industry, funders and regulators participated in a survey-based Delphi study. Survey items were informed by a scoping review of DM trials and PwP input. Respondents scored item agreement over 3 rounds. Scores and reasoning were summarized by participant group each round until consensus, defined as≥70% of at least 3 participant groups falling within the same 3-point region of a 9-point Likert scale. RESULTS: 92/121 individuals from 13 countries (46/69 PwP, 13/18 CP, 20/20 clinical scientists, representatives from 8/8 companies, 4/5 funders, and 1/1 regulator) completed the study. Consensus was reached on 14/31 survey items: 5/8 overall goals and structure, 1/8 Eligibility criteria, 7/13 outcome measures, and 1/2 trial delivery items. Extent of stakeholder endorsement for 428 reasons for scores was collated across items. CONCLUSIONS: This is the first systematic multi-stakeholder consultation generating a unique repository of perspectives on pivotal aspects of DM trial design including those of PwP and CP. The panel endorsed outcomes that holistically measure PD and the importance of inclusive trials with hybrid delivery models. Areas of disagreement will inform mitigating strategies of researchers to ensure successful delivery of future trials.

Examination of Conditioned Pain Modulation in Myofascial TMD With Consideration of Temporal Summation.

Research on myofascial temporomandibular disorder (mTMD) has often focused on potential dysfunction in endogenous pain modulation. However, studies on the specific inhibitory and facilitatory components of endogenous pain modulation using conditioned pain modulation (CPM) and temporal summation of second pain (TSSP) have shown mixed results. This study aimed to 1) examine whether women with mTMD demonstrated efficient CPM compared to controls; 2) explore the association between independent measures of CPM and TSSP in women with mTMD relative to controls; and 3) determine whether resulting modulatory profiles differentially predicted pain intensity among cases. All participants were recruited from dental clinics. Cases were women who met the research diagnostic criteria for mTMD. Controls did not have facial pain on exam and were selected to be sociodemographically similar to cases. CPM and TSSP were assessed via independent psychophysical protocols. CPM was examined in linear mixed models predicting pain thresholds adjusted for age and stratified by TSSP. Mean CPM was estimated at a 2.2 (SD = 2.8) degree increase in pain thresholds (P ≤ .001), similar in cases and controls (P = .67). CPM was less efficient in cases with enhanced TSSP (P = .031), but not in controls. Although the double-pronociceptive profile of both low CPM and high TSSP trended higher among cases than controls, it did not predict higher levels of pain intensity among cases. This study does not support deficient inhibitory endogenous pain modulation in mTMD, but results suggest that inhibitory and facilitatory pain modulation should be examined concomitantly in the study of endogenous pain modulation. PERSPECTIVE: This manuscript presents a novel examination of inhibitory modulation by the level of facilitatory modulation in mTMD. The findings and approach may prove useful for mechanistic researchers studying endogenous pain modulation and clinical researchers seeking to jointly examine conditioned pain modulation and temporal summation in future research on chronic pain.

The association between sleep bruxism and awake bruxism: Polysomnographic and electromyographic recordings in women with and without myofascial pain.

BACKGROUND: Sleep bruxism (SB) and awake bruxism (AB) are masticatory muscle activities that are rarely assessed in the same individuals and are thought to be associated with different behaviours. OBJECTIVES: To investigate whether individuals engaging in SB also engage in AB, that occurs during rest and during stress-related activity, and to investigate whether SB and AB are associated with different characteristics. METHODS: Females with myofascial pain (N = 122) and non-myofascial pain controls (N = 46) were evaluated for SB events and for AB events at rest and AB during stress-related activity, using electromyographic (EMG) recordings and a standardised scoring of bruxism events. The joint distributions between SB and AB events and EMG activity were evaluated, and the characteristic qualities of SB and AB were assessed. RESULTS: Neither SB event rates nor the EMG activity associated with those events was associated with AB events rates or EMG activity, either at rest or during stress-related activity. On the contrary, event rates and EMG activity when awake and at rest were positively associated with events and activity during stress-related activity. SB was characterised mainly by grinding, while AB was characterised mainly by clenching. CONCLUSION: Sleep bruxism and awake bruxism do not tend to occur in the same individuals.

Temporal Summation and Aftersensations of Second Pain in Women with Myofascial Temporomandibular Disorder Differ by Presence of Temporomandibular Joint Pain.

Purpose: Mechanisms underlying myofascial temporomandibular disorder (mTMD) are poorly understood. One theory is dysfunction in the central mediation of pain, specifically in enhanced facilitatory pain modulation. Because mechanisms leading to central sensitization may differ for joint and muscle pain, this study of mTMD addressed phenotypic heterogeneity by temporomandibular (TM) joint pain in the examination of quantitative sensory testing (QST). Patients and Methods: The stimulus dependent increase in second pain (temporal summation (TS)) and associated aftersensations (AS) were examined across groups of women with mTMD with TM joint pain and without, and a demographically matched control group. Results: TS was slightly more evident in mTMD without joint pain vs with (p = 0.035), but AS were most robustly persistent in the group with joint pain vs without (p < 0.002). Conclusion: While both subgroups demonstrated evidence of central sensitization relative to controls on one of two measures, differences in QST results, if replicated, may point to possible differences in the mechanisms that yield central sensitization. Alternatively, it may represent methodological artifacts that need to be addressed. Therefore, greater consideration should be given to symptom-based phenotypes in studies examining TS and AS.

Stress-evoked muscle activity in women with and without chronic myofascial face pain.

BACKGROUND: Amplified muscle activity in reaction to daily life stressors might explain chronic pain in temporomandibular disorder (TMD). OBJECTIVES: To assess whether patients with myofascial TMD pain (MFP) react to standardised stressors with greater masticatory muscle activity than demographically matched controls. METHODS: A total of 124 female MFP patients and 46 demographically matched and pain-free controls rated distress while performing a series of standardised stress-reactivity tasks (viz., cold pressor test, mental arithmetic test, speech stressor test and reaction time/startle response test) as well as a vanilla baseline control task. Blood pressure was measured before and after each task, and electromyographic (EMG) activity was continuously recorded over the jaw-closing muscles and several non-masticatory muscles during each task. Linear mixed model analyses were used to test the hypothesis that case status, stress-reactivity task and muscle recording site influenced EMG activity. RESULTS: Stress induction was successful, as evidenced by distress ratings and blood pressure measurements that were significantly elevated during performance of the stress tasks. Participants reported that some of the tasks were stressful in a way that resembled stressors experienced in their daily lives. Elevated muscle activity could be confirmed only for the reaction time/startle response task, where mean EMG activity was elevated more in cases than in controls, specifically in the jaw-closing muscles. CONCLUSION: These data could not provide clear support for the theory that psychological stressors produce a differential increase in masticatory muscle activity in MFP patients than pain-free controls.

Effect of multiple injections of botulinum toxin into painful masticatory muscles on bone density in the temporomandibular complex.

BACKGROUND: Adverse effects of masticatory muscle injections of Botulinum Toxin (Btx) have been noted in animal and, less dramatically, human studies. OBJECTIVE: Among women treated in multiple community-based private practices, to compare TMJ bone density and mandibular condylar volume between patients with myofascial TMJD receiving multiple masticatory muscle Btx treatments and similarly diagnosed women not receiving such treatment. METHODS: Cohorts consisted of women whose treatment charts indicated a diagnosis of myofascial TMJD: 35 received at least 2 Btx treatment cycles; 44 received none. Bone density at pre-specified regions of interest (ROI) was defined by grey scale values from Cone Beam CT, adjusting for a fixed density phantom included in each scan. Mean bone density and mandibular condyle volume were compared between groups. Dose-response effects were tested within the Btx-exposed group. RESULTS: The mean density of primary and secondary ROIs was similar between exposure groups, as was condylar volume. Among Btx-exposed women, increasing dose of Btx to the temporalis muscle was inversely proportional to the density of the trabecular area of the mandible body. Many Btx-exposed women received smaller doses of Btx to the masseter muscles than in most TMJD Btx clinical trials. CONCLUSION: Masticatory muscle injections of Btx failed to produce clinically significant TMJ bone-related changes. Should Btx receive regulatory approval for treatment of myofascial TMJD, a phase IV study is recommended to evaluate potential adverse effects of Btx on bone and muscle when administered at higher doses and/or for more treatment cycles.

Absence of joint pain identifies high levels of sleep masticatory muscle activity in myofascial temporomandibular disorder.

Although the development of reliable diagnostic criteria for temporomandibular disorders (TMDs) has operationalised identification of a subgroup with myofascial pain (mTMD), causal mechanisms remain elusive. This study examines masticatory muscle activity (MMA) in more homogenous research subgroups of mTMD. Data from an existing case-control study of women were used to subcategorise mTMD cases based on joint pain with palpation to isolate muscle-only pain (M-pain) vs muscle and joint pain (MJ-pain). Differences in laboratory indicators of MMA, specifically research diagnostic criteria for sleep bruxism (SB) and high background EMG activity, and other clinical and sociodemographic indicators were examined between groups. Compared to controls, the MJ-pain subgroup did not show elevated background EMG or sleep bruxism. In contrast, the M-pain subgroup showed significantly higher background EMG and a trend towards elevated prevalence of sleep bruxism. These results may explain why it has been difficult for studies of SB in mixed TMD and even mTMD samples to find a consistent positive association, since a positive association may be limited to mTMD without joint pain. The subcategorising of mTMD based on joint pain with palpation (ie M-pain, MJ-pain) appears to reveal subgroups with relatively high and low sleep masticatory muscle-specific activity. Findings need replication in a larger study with updated mTMD diagnostic criteria, but may prove useful for understanding mechanism of pain maintenance in mTMD with and without joint pain.

Perceived helpfulness of treatments for myofascial TMD as a function of comorbid widespread pain.

OBJECTIVE: This study examined whether patients with myofascial temporomandibular disorder (mTMD) comorbid with fibromyalgia (FM) receive different treatments or respond differently to these treatments than mTMD-only patients. MATERIALS AND METHODS: A total of 125 mTMD+ women were enrolled (26 FM+ and 98 FM-). mTMD and FM were assessed via clinical research examinations. Treatment histories and self-reported treatment-related improvement were obtained via interview. RESULTS: The top 3 most common treatments reported were oral appliances (59%), physical therapy (54%), and jaw exercises at home (34%). Use of alternative medicine was reported more frequently among FM+ women, but self-reported improvement did not differ by comorbid FM. Physical therapy was as likely reported by FM status but self-reported improvement scores trended higher for FM+ women. CONCLUSIONS: Oral appliances were as likely to be reported by FM comorbid as FM- women. Oral appliances did not outperform self-management treatments on self-reported improvement of facial pain. CLINICAL RELEVANCE: Results support the use of self-management as first-line treatment for mTMD and potential utility of inquiring about widespread pain for treatment planning.

Single-Item, Self-Rated Health is a Useful Indicator of Health in Myofascial Temporomandibular Disorders.

AIMS: To (1) examine differences in self-rated health (SRH) between a group of women with myofascial temporomandibular disorders (mTMD) and controls; (2) determine the extent to which pain, mental health, and physical function mediate these differences; and (3) explore specific mTMD symptoms and impairments explaining SRH among mTMD cases. METHODS: An existing dataset of a sample of women with mTMD (n = 125) and a group of demographically similar controls (n = 49) was used. SRH was measured via a single item with 5 answer options ranging from poor (SRH = 1) to excellent (SRH = 5). Bodily pain, mental health, and physical function were measured with the Short-Form Health Survey. Regression analyses with SRH as the outcome were conducted. RESULTS: mTMD cases reported poorer SRH compared to controls, and bodily pain score fully mediated these lower scores. Physical function partially mediated the association between mTMD and SRH, while mental health did not explain much of the variance in SRH. This pattern held in case-only analyses. The association was not explained by mTMD-specific symptoms or by localized mTMD pain severity, although mTMD disability was independently associated with lower SRH. CONCLUSION: SRH is a simple and useful tool to consider in mTMD research, as it discriminates between cases and controls based on pain and physical function and is associated with mTMD disability.

Mind the Gap: A Systematic Review of Implementation of Screening for Psychological Comorbidity in Dental and Dental Hygiene Education.

The biopsychosocial model is advocated as part of a more comprehensive approach in both medicine and dentistry. However, dentists have not traditionally been taught psychosocial screening as part of their predoctoral education. The aim of this systematic review was to provide an overview of published studies on the implementation of screening for psychological comorbidity in dental and dental hygiene education. The term "psychological comorbidity" refers to the degree of coexisting anxiety, depression, or other mental health problems in a patient presenting with a physical condition. The review followed a protocol registered in PROSPERO (CRD42016054083) and was carried out in accordance with the PRISMA guidelines. The methodological quality of the included studies was assessed using a ten-item tool developed for medical education. The electronic search in PubMed, Scopus, and PsycINFO from the inception of each database until December 31, 2016, together with a hand search, identified 1,777 articles. After abstracts were screened, 52 articles were reviewed in full text applying inclusion and exclusion criteria; four articles remained for the qualitative synthesis. Generally, the reported data on specific methods or instruments used for psychological screening were limited. Only one of the included articles utilized a validated screening tool. The results of this systematic review show that published data on the implementation of psychological patient assessment in dental and dental hygiene education are limited. To address this gap, the authors recommend short screening tools such as the Graded Chronic Pain Scale and the Patient Health Questionnaire for Depression and Anxiety. Educating dental and dental hygiene students about easy-to-use, reliable, and validated screening tools for assessing psychological comorbidity warrants more research attention and greater implementation in educational curricula.

Parkinson Matters.

Recent epidemiological observations have drawn attention to the rapid rise in the burden caused by Parkinson's disease over the past years, emphasizing that Parkinson's disease is a matter of serious concern for our future generations. A recent report by Public Health England corroborates this message, by providing new insight on trends in deaths associated with neurological diseases in England between 2001 to 2014. The report indicates that mortality associated with Parkinson's disease and related disorders increased substantially between 2001 and 2014. This trend is partially explained by increased longevity in the population. However, it is possible that changes in exposure to risk factors, recent improvements in multidisciplinary care (leading to prolonged survival), and improved diagnostic awareness or improved registration also influenced the observed trend. Furthermore, patients with Parkinson's disease and related disorders were found to die at an advanced age, and the majority die in a care home or hospital, despite a preponderant preference for many patients and their families to spend their last days at home. To combat these concerning observations, future efforts should be focused on providing resources for vulnerable elderly Parkinson patients, avoiding unplanned hospital admissions and out-of-home deaths as much as possible. Possible solutions include a community-based network of specifically trained allied health therapists, personal case managers for Parkinson patients, dedicated Parkinson nursing homes, and improved centralised support services from university clinics to regional community hospitals aimed at facilitating optimal wide-scale care delivery.

Benefits of implementing pain-related disability and psychological assessment in dental practice for patients with temporomandibular pain and other oral health conditions.

BACKGROUND: Evidence in the field of dentistry has demonstrated the importance of pain-related disability and psychological assessment in the development of chronic symptoms. The Diagnostic Criteria for Temporomandibular Disorders offer a brief assessment for the diagnostic process in patients with orofacial pain (Axis II). The authors describe relevant outcomes that may guide general oral health care practitioners toward tailored treatment decisions and improved treatment outcomes and provide recommendations for the primary care setting. METHODS: The authors conducted a review of the literature to provide an overview of knowledge about Axis II assessment relevant for the general oral health care practitioner. RESULTS: The authors propose 3 domains of the Axis II assessment to be used in general oral health care: pain location (pain drawing), pain intensity and related disability (Graded Chronic Pain Scale [GCPS]), and psychological distress (Patient Health Questionnaire-4 [PHQ-4]). In the case of localized pain, low GCPS scores (0-II), and low PHQ-4 scores (0-5), patients preferably receive treatment in primary care. In the case of widespread pain, high GCPS scores (III-IV), and high PHQ-4 scores (6-12), the authors recommend referral to a multidisciplinary team, especially for patients with temporomandibular disorder (TMD) pain. CONCLUSIONS: The authors recommend psychological assessment at first intake of a new adult patient or for patients with persistent TMD pain. The authors recommend the pain-related disability screening tools for all TMD pain symptoms and for dental pain symptoms that persist beyond the normal healing period. PRACTICAL IMPLICATIONS: A brief psychological and pain-related disability assessment for patients in primary care may help the general oral health care practitioner make tailored treatment decisions.

Interepisode Sleep Bruxism Intervals and Myofascial Face Pain.

Study Objectives: Sleep bruxism (SB) is considered as a possible etiological factor for temporomandibular disorder (TMD) pain. However, polysomnographic (PSG) studies, which are current "gold standard" diagnostic approach to SB, failed to prove an association between SB and TMD. A possible explanation could be that PSG studies have considered only limited characteristics of SB activity: the number of SB events per hour and, sometimes, the total duration of SB per night. According to the sports sciences literature, lack of adequate rest time between muscle activities leads to muscle overloading and pain. Therefore, the aim of this study was to determine whether the intervals between bruxism events differ between patients with and without TMD pain. Methods: Two groups of female volunteers were recruited: myofascial TMD pain group (n=124) and non-TMD control group (n=46). From these groups, we selected 86 (69%) case participants and 37 (80%) controls who had at least two SB episodes per night based on PSG recordings. A linear mixed model was used to compare case and control groups over the repeated observations of interepisode intervals. Results: The duration of interepisode intervals was statistically similar in the case (mean [standard deviation {SD}] 1137.7 [1975.8] seconds)] and control (mean [SD] 1192.0 [1972.0] seconds) groups. There were also a similar number of SB episodes per hour and a total duration of SB episodes in both groups. Conclusions: The current data fail to support the idea that TMD pain can be explained by increasing number of SB episodes per hour of sleep or decreasing the time between SB events.

Thermal temporal summation and decay of after-sensations in temporomandibular myofascial pain patients with and without comorbid fibromyalgia.

INTRODUCTION: Chronic myofascial temporomandibular disorders (TMD) may have multiple etiological and maintenance factors. One potential factor, central pain sensitization, was quantified here as the response to the temporal summation (TS) paradigm, and that response was compared between case and control groups. OBJECTIVES: As previous research has shown that fibromyalgia (FM) is diagnosed iñ20% of TMD patients, Aim 1 determined whether central sensitization is found preferentially in myofascial TMD cases that have orofacial pain as a regional manifestation of FM. Aim 2 determined if the report of after-sensations (AS) following TS varied depending on whether repeated stimuli were rated as increasingly painful. METHODS: One hundred sixty-eight women, 43 controls, 100 myofascial TMD-only cases, and 25 myofascial TMD + FM cases, were compared on thermal warmth and pain thresholds, thermal TS, and decay of thermal AS. All cases met Research Diagnostic Criteria for TMD; comorbid cases also met the 1990 American College of Rheumatology criteria for FM. RESULTS: Pain thresholds and TS were similar in all groups. When TS was achieved (~60%), significantly higher levels of AS were reported in the first poststimulus interval, and AS decayed more slowly over time, in myofascial TMD cases than controls. By contrast, groups showed similar AS decay patterns following steady state or decreasing responses to repetitive stimulation. CONCLUSION: In this case-control study, all myofascial TMD cases were characterized by a similar delay in the decay of AS. Thus, this indicator of central sensitization failed to suggest different pain maintenance factors in myofascial TMD cases with and without FM.