Implementing online learning of Diagnostic Criteria for the Temporomandibular Disorders (DC/TMD) protocol in undergraduate dental education.

INTRODUCTION: The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) is part of the undergraduate dental curriculum. Online teaching has nowadays become common also in dentistry. OBJECTIVE: To compare undergraduate students' self-assessed ability and satisfaction with learning DC/TMD Axis I between traditional and online learning and to evaluate the possible gains of online teaching. MATERIAL AND METHODS: Third-year undergraduate dental students in 2018 (traditional learning, Group 1, n = 43/50) and in 2019 (online learning, Group 2, n = 34/50) at the University of Oulu, Finland evaluated their self-assessed ability and satisfaction with learning DC/TMD clinical examination and diagnostics on a 10-point scale. Additionally, those participating in online courses answered to two open-ended questions; Group 2 (n = 50) and another group from the University of Eastern Finland in 2019 and 2020 (n = 75, Group 3). Total of 105/125 students (84%) responded. Content analysis was used to open-ended responses. RESULTS: The online course reported significantly higher self-assessed ability in measurements (p = 0.004), identifying referred pain (p = 0.043) and statement for the diagnostics (p = 0.017) and also higher self-assessed satisfaction in measurements (p = 0.046). According to the content analysis, essential gains of online teaching were efficient learning, videos and exercises, and adjustability to own timetable. CONCLUSION: The online learning course can be considered as a good option for traditional learning of the DC/TMD protocol.

Health-related quality of life in patients with chronic orofacial pain compared with other chronic pain patients.

BACKGROUND: Health-related quality of life (HRQoL) of orofacial pain patients is lower than that of the general population and impaired in multiple dimensions. The aim of the present study was to investigate HRQoL of orofacial pain patients in comparison with patients suffering from other chronic pain disorders. MATERIALS AND METHODS: One hundred and fifty-one tertiary care facial pain patients (mean age, 50 years; standard deviation [SD], 15; 119 females), were compared with 312 other non-cancer chronic pain patients (mean age, 46 years; SD, 13; 204 women), recruited from three multidisciplinary pain clinics in Finland. The groups were compared using the 15D, and pain-related measures such as pain interference, pain acceptance, anxiety, depression, and sleep. Statistical comparisons between groups were done using t test, χ2 test, or analysis of covariance. Multivariate linear regression analysis was used to study whether pain-related aspects influencing HRQoL are similar between the patient groups. RESULTS: The 15D score was significantly higher in facial pain patients (0.823; SD, 0.114) indicating better HRQoL in comparison with other chronic pain patients (0.732; SD, 0.107) (p < .001). The 15D profiles of studied populations resembled each other but orofacial pain patients showed significantly higher scores for most individual 15D dimensions. Dimensions regarding discomfort and symptoms and sleep were most affected in both groups. Orofacial pain patients showed less psychosocial disability and better acceptance of their pain. Pain acceptance was a weaker explanatory factor of HRQoL in orofacial pain patients. CONCLUSION: Compared to other non-cancer chronic pain, chronic pain in the orofacial area causes less impairment in HRQoL. Orofacial pain patients showed less psychosocial disability and better pain acceptance.

Comparison of Axis II psychosocial assessment methods of RDC/TMD and DC/TMD as part of DC/TMD-FIN phase II validation studies in tertiary care Finnish TMD pain patients.

BACKGROUND: The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and Diagnostic Criteria for TMD (DC/TMD) include Axis II instruments for psychosocial assessment. OBJECTIVES: The aims were to compare the Finnish versions of Axis II psychosocial assessment methods of the RDC/TMD and DC/TMD and to study their internal reliability. METHODS: The sample comprised 197 tertiary care referral TMD pain patients. The associations between RDC/TMD [Graded Chronic Pain Scale (GCPS) 1.0, Symptom Check List 90-revised (SCL-90R)] and DC/TMD (GCPS 2.0, Patient Health Questionnaire-9 (PHQ-9), PHQ-15) assessment instruments were evaluated using Spearman correlation coefficients, Wilcoxon Signed Rank s, chi-squared test and gamma statistics. The internal reliability and internal inter-item consistency of SCL-90-R, PHQ-9, PHQ-15 and Generalized Anxiety Disorder-7 (GAD-7) were evaluated using Cronbach's alpha coefficient values. RESULTS: The DC/TMD and RDC/TMD Axis II psychosocial instruments correlated strongly (p < .001). GCPS 1.0 and GCPS 2.0 grades were similarly distributed based on both criteria. The RDC/TMD psychological instruments had a higher tendency to subclassify patients with more severe symptoms of depression and non-specific physical symptoms compared to DC/TMD. The internal reliability and internal inter-item consistency were high for the psychological assessment instruments. CONCLUSION: The Finnish versions of the RDC/TMD and DC/TMD Axis II psychosocial instruments correlated strongly among tertiary care TMD pain patients. Furthermore, the Axis II psychological assessment instruments indicated high validity and internal inter-item consistency and are applicable in Finnish TMD pain patients as part of other comprehensive specialist level assessments, but further psychometric and cut-off evaluations are still needed.

Importance of the Graded Chronic Pain Scale as a Biopsychosocial Screening Instrument in TMD Pain Patient Subtyping.

AIMS: To compare the suitability of Graded Chronic Pain Scale (GCPS) pain intensity and interference assessments (GCPS version 1.0 vs 2.0) for the biopsychosocial screening and subtyping of Finnish tertiary care referral patients with TMD pain. METHODS: Altogether, 197 TMD pain patients participated in this study. All patients received Axis II specialist-level psychosocial questionnaires from the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD-FIN) and Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD-FIN), as well as questionnaires for the assessment of additional pain-related, biopsychosocial, and treatment-related variables. Clinical examinations were performed according to the DC/TMD Axis I protocol. The patients were categorized into TMD subtypes 1, 2, and 3 (GCPS I and II-low; II-high; and III and IV, respectively) based on their biopsychosocial profiles according to GCPS versions 1.0 and 2.0. RESULTS: The distribution of TMD pain patients into TMD subtypes was similar according to the GCPS 1.0 compared to the GCPS 2.0. Over 50% of the patients were moderately (TMD subtype 2) or severely (TMD subtype 3) compromised. Patients in subtype 3 experienced biopsychosocial symptoms and reported previous health care visits significantly more often than patients in subtypes 1 and 2. Patients in subtype 2 reported intermediate biopsychosocial burden compared to subtypes 1 and 3. CONCLUSION: TMD pain patients differ in their biopsychosocial profiles, and, similarly to the GCPS 1.0, the GCPS 2.0 is a suitable instrument for categorizing TMD tertiary care pain patients into three biopsychosocially relevant TMD subtypes. The GCPS 2.0 can be regarded as a suitable initial screening tool for adjunct personalized or comprehensive multidisciplinary assessment.

Symptom severity in burning mouth syndrome associates with psychological factors.

Burning mouth syndrome (BMS) patients are psychologically distressed, but whether this associates with symptom severity is unclear. The aim was to investigate the association of psychological factors with pain intensity and interference in BMS. Fifty-two women (mean age 63.1, SD 10.9) with BMS participated. Pain intensity and interference data were collected using 2-week pain diaries. Psychological factors were evaluated using Depression Scale (DEPS), Pain Anxiety Symptom Scale (PASS) and Pain Vigilance and Awareness Questionnaire (PVAQ). The local ethical committee approved the study. Patients were divided into groups based on pain severity distribution tertiles: low intensity (NRS ≤ 3.7) or interference (NRS ≤ 2.9) (tertiles 1-2, n = 35) and moderate to intense intensity (NRS > 3.7) or interference (>2.9) (tertile 3, n = 17). T test, Wilcoxon's test and Pearson's correlation coefficient were used in the analyses. Patients in the highest intensity and interference tertiles reported more depression (P = .0247 and P = .0169) and pain anxiety symptoms (P = .0359 and P = .0293), and were more preoccupied with pain (P = .0004 and P = .0003) than patients in the low intensity and interference groups. The score of the pain vigilance questionnaire correlated significantly with pain intensity (r = .366, P = .009) and interference (r = .482, P = .009). Depression (r = .399, P = .003) and pain anxiety symptoms (r = .452, P = .001) correlated with pain interference. Symptom severity in BMS associates with symptoms of psychological distress emphasising the need to develop multidimensional diagnostics for the assessment of BMS pain.

Survival of Autotransplanted Teeth With Open Apices: A Retrospective Cohort Study.

PURPOSE: Autotransplantation of teeth is an alternative treatment method in growing patients with hypodontia or impacted teeth. The purpose of the present study was to investigate the occurrence of, and predictors for, the loss of transplanted teeth in children and young adults. PATIENTS AND METHODS: All patients who had undergone tooth transplantation at the Department of Oral and Maxillofacial Surgery, Turku University Hospital, from October 1, 2009 to January 5, 2017, were identified from the hospital's database. The outcome variable was survival of the transplanted tooth. The predictor variables were the transplantation type, donor tooth, maturity of the donor tooth, number of roots of the donor tooth, recipient's jaw, the need for extraoral storage of the donor tooth during surgery, continuation of root development during follow-up, and institution experience. One tooth was randomly selected from each subject. The Kaplan-Meier method for survival analysis, and the Cox proportional hazards regression analysis results were used to assess the association between survival and the risk factors. RESULTS: The sample included 36 subjects with a mean age of 14.3 years; 33.3% were male, 45 teeth were transplanted, and the median follow-up time was 1.3 years. The 1-year survival rate was 87% (95% confidence interval [CI], 75 to 99%). A significant predictor for tooth survival was the continuation of root development (hazard ratio, 21.3; 95% CI, 2.1 to 215.0; P = .009). Although not statistically significantly, more favorable prognoses were found for distant than for transalveolar transplantations, 1-rooted than multirooted teeth, premolars than molars, teeth not stored in an extraoral media, and teeth that had been transplanted later during the study period. CONCLUSIONS: The experience of the professional team, use of open apex premolars, and postoperative continuation of root development of the transplant were the factors associated with favorable outcomes. Transplants could benefit from the use of 3-dimensional models during surgery.

The impact of chronic orofacial pain on health-related quality of life.

Background and aims Health-related quality of life (HRQoL) assessments have been widely used in pain medicine as they are able to reflect the subjective and multidimensional nature of chronic pain. Studies have shown a consistent impairment in HRQoL in different chronic pain conditions. However, it is not known whether HRQoL is impaired in chronic orofacial pain (OFP). The generic 15D HRQoL instrument has been shown to fare as well as or better than other generic HRQoL instruments in the study of chronic pain. The aim was to investigate HRQoL in patients with chronic OFP using the generic 15D HRQoL instrument. The validity of the instrument was tested by studying the association of the 15D data with pain interference. Methods One hundred fifty-one patients (mean age 50 years, SD 15 years, 119 females) were recruited from three tertiary facial pain clinics. HRQoL data of the participants were contrasted with that of an age- and gender- standardized sample of general population by comparing the mean 15D scores and profiles. The data for the general population came from the National Health 2011 Survey representing Finnish population aged 18 years and older. Pain interference was assessed using Brief Pain Inventory. Based on pain interference distribution the participants were divided into tertiles. Statistical comparison between patient and population HRQoL values were performed using Monte-Carlo-type simulations. Statistical significance for the hypothesis of linearity was evaluated by using generalized linear models. Results The mean 15D score of OFP patients (0.824, SD 0.113) was statistically significantly lower than that of the age- and gender-standardized general population (0.929, SD 0.019) (p < 0.001). The difference between the patients and the general population was also clinically important, i.e. over the minimum clinically important difference in the 15D score. All mean 15D dimension values were significantly lower compared with the general population values (p < 0.001 for all dimensions). The largest differences were seen in the dimensions of discomfort and symptoms (0.418, SD 0.222 vs. 0.816, SD 0.027), sleeping (0.693, SD 0.258 vs. 0.838, SD 0.029), and vitality (0.702, SD 0.221 vs. 0.884 SD 0.026). There was a statistically significant linear decrease in the 15D dimension values (p < 0.001) with increasing pain interference. The greatest differences were found on the dimensions of discomfort and symptoms, sleeping and vitality. Conclusions HRQoL is significantly impaired in patients with chronic OFP. A decrease in the 15D dimension values with increasing pain interference indicated convergent validity between 15D and pain interference. Implications The findings suggest that 15D is an appropriate instrument for use in the assessment of HRQoL in OFP patients. By showing the usefulness of the 15D, the present study may encourage further use of generic HRQoL assessments in the study of chronic OFP, and contribute e.g. to the implementation of HRQoL as one of the core outcome measures in future treatment studies on chronic OFP.

Validation of diagnostic methods for traumatic sensory neuropathy and neuropathic pain.

INTRODUCTION: We evaluated diagnostic value of sensory tests during recovery from iatrogenic sensory neuropathy using intraoperatively verified nerve injury with subjective symptoms as gold standard. METHODS: Inferior alveolar nerves were monitored neurophysiologically throughout mandibular osteotomy in 19 patients. Sensory disturbance was registered and sensation tested using clinical and quantitative sensory (QST) and neurophysiologic tests postoperatively at 1, 3, 6, and 12 months. Sensitivity, specificity, and predictive values were calculated for all tests. RESULTS: The sensitivity of clinical tests was at best 37%, with 100% specificity, but they lost diagnostic value at chronic stages. Best diagnostic accuracy (highest combination of sensitivity and specificity) at different time points was achieved by combining neurophysiologic and thermal QST or tactile and thermal QST. The single most accurate test was sensory neurography. CONCLUSIONS: Neurography or combinations of neurophysiologic and quantitative tests enables most reliable early and late diagnosis. Clinical sensory examination is inadequate for accurate diagnosis. Muscle Nerve 59:342-347, 2019.

Pain and pain behavior in burning mouth syndrome: a pain diary study.

AIMS: To characterize pain related to primary burning mouth syndrome (BMS) in terms of intensity, interference, and distress caused by the pain, as well as factors influencing the pain across a period of 2 weeks, and to study the use of coping and management strategies on a daily basis. METHODS: Fifty-two female patients with primary BMS completed a 2-week pain diary. Pain intensity, interference, distress, and mood on a 0 to 10 numeric rating scale (NRS), as well as pain amplifying and alleviating factors, were recorded three times a day. The use of treatments (medication or other means) and coping strategies were recorded at the end of each day. Coefficient of variation, repeated measures analysis of variance, and correlative methods were used to assess the between- and within-subject variation, pain patterns, and associations between various pain scores. RESULTS: The overall mean pain intensity score of the 14 diary days was 3.1 (SD: 1.7); there was considerable variation in pain intensity between patients. Most patients experienced intermittent pain. On average, pain intensity increased from the morning to the evening. Intercorrelations between pain intensity, interference, distress, and mood were high, varying between rs = .75 and rs = .93 (P < .001). Pungent or hot food or beverages, stress, and tiredness were the most frequently mentioned pain-amplifying factors. The corresponding pain-alleviating factors were eating, sucking pastilles, drinking cold beverages, and relaxation. Thirty (58%) patients used pain medication and 35% reported using other means to alleviate their BMS pain. There was large variation in the use of coping strategies -between subjects. CONCLUSION: There were considerable differences in pain, in factors influencing the pain, and in pain behavior across BMS patients. This indicates that patient information and education as well as treatment of BMS pain should be individualized.

Subjective sensory symptoms associated with axonal and demyelinating nerve injuries after mandibular sagittal split osteotomy.

PURPOSE: The effect of the type of nerve injury on subjective sensory disturbances and recovery has not been addressed in orthognathic surgery. Using neurophysiologic monitoring during 19 bilateral sagittal split osteotomy operations, we were able to classify intraoperative inferior alveolar nerve injuries as either axonal or demyelinating. This study aimed to analyze the quality and extent of the subjective sensations experienced by the patients after these 2 injury types at different time points up to 12 months. MATERIALS AND METHODS: Of the 36 injured nerves, 21 showed signs of demyelinating injury and 15 showed signs of axonal damage. The quality of subjective sensory symptoms was asked about at 2 weeks and 1, 3, 6, and 12 months postoperatively and classified into 4 categories: normal, negative, positive (including pain), and mixed sensations. In addition, the extent of the sensory alteration was determined by measuring the affected skin regions from symptom charts. RESULTS: The quantity, quality, and evolution of experienced subjective sensations differed between the injury types during follow-up: Subjective sensations normalized more rapidly after demyelinating-type injuries than after axonal-type injuries. Persistence of mixed sensation patterns at 3 months and appearance instead of disappearance of positive sensory phenomena after 3 months indicated axonal damage. Painful sensations at 1 month or later after surgery indicated axonal damage and predicted poor recovery and more long-term sequelae. CONCLUSIONS: Postoperative pain at 1 month and type of nerve injury are important prognostic factors for the persistence of subjective symptoms and development of neuropathic pain.

[Treatment of dental accidents and associated alveolar fractures]. / Hammasvammojen ja niihin liittyvien alveolimurtumien hoito.

Diagnosis of dental accidents is based on patient history, clinical examination and imaging. A completely avulsed tooth should immediately be reimplanted, and a dislodged tooth urgently repositioned to the original position. Avulsed primary teeth will never be reimplanted, and primary teeth of children under three years are not repositioned. Furthermore, fractures of the alveolar process and various soft tissue injuries but not dental fractures require urgent treatment. All dental accident patients should be referred to dental consultation for further examinations and treatment.

Neurophysiologic and quantitative sensory testing in the diagnosis of trigeminal neuropathy and neuropathic pain.

This study investigated the utility of neurophysiologic examination and thermal quantitative sensory testing (QST) in the diagnosis of trigeminal neuropathy and neuropathic pain. Fifty-eight patients (14 men), 34 with sensory deficit within the inferior alveolar nerve (IAN) and 24 within the lingual nerve (LN) distribution, were included. Twenty-six patients (45%) reported neuropathic pain. Patients underwent blink reflex (BR) test and thermal QST; sensory neurography was done to the IAN patients. Results of clinical sensory testing were available from the charts of 48 patients revealing abnormal findings in 77% of the IAN and in 94% of the LN patients. The BR test was abnormal in 41%, neurography in 96%, and QST in 91% of the IAN patients. In the LN group, BR was abnormal in 33%, and QST in 100% of the patients tested. Neurophysiologic tests and QST verified the subjective sensory alteration in all but 2 IAN patients, both with old injuries, and 4 LN patients who did not undergo QST. When abnormal, thermal QST showed elevation of warm and cold detection thresholds (hypo/anesthesia), hypoalgesia was less marked, and heat allodynia was only occasionally present. Contralateral thermal hypoesthesia after unilateral injury was found in 14 patients. It was associated with the occurrence of neuropathic pain (P=0.016). Axonal Abeta afferent damage was less severe in the IAN patients with pain than in those without pain (P=0.012). Neurophysiologic tests and thermal QST provide sensitive tools for accurate diagnosis of trigeminal neuropathy and study of pathophysiological features characteristic to human neuropathic pain.