The changing focus of chronic temporomandibular disorders: management within a hospital-based, multidisciplinary pain centre.

Despite evidence to the contrary, many dentists still cling to outdated beliefs and practices regarding the aetiology and management of chronic temporomandibular disorders (TMDs). Chronic pain disorders require a multidisciplinary approach with a strong focus on psychological factors. Treatment failures and relapse are likely if such factors are not considered. Most chronic temporomandibular pain problems are extracapsular and of myofascial origin. Mechanistic or invasive treatments in such cases may be inappropriate and can cause harm. Conservative measures used for other types of chronic muscular pain are generally recommended. All health practitioners who deal with acute and chronic pain should be aware of recent major advances in the understanding of pain mechanisms. Along with psychosocial considerations, these must be emphasised in undergraduate and continuing education programmes.

Preemptive analgesia: the prevention of neurogenous orofacial pain.

Chronic neurogenous pain is often an extremely difficult condition to manage. In the orofacial region, trauma from injury or dental procedures may lead to the development of severe neuralgic pains and major distress to the patient. Clinical and experimental evidence suggests that the use of adequate preemptive regional anesthesia, systemic analgesia, and the avoidance of repeated, painful stimuli may reduce the incidence of this problem.

Temporomandibular disorders.

1. Temporomandibular disorders represent predominantly a group of psycho-physiological problems. 2. The temporomandibular joint is no different from other joints, and the role of the dentition in the induction of TMDs is relatively unimportant. 3. The majority of patients get better with time. Only a small proportion require surgical intervention. 4. A therapeutic history is an important part of the overall management, and must exclude other pathology. 5. Treatment protocols should be conservative, non-invasive, and reversible.

An evaluation of the diagnosis, treatment, and outcome of patients with chronic orofacial pain.

A review of the records and follow-up of 106 patients who had been referred to pain management clinics in Auckland between January 1990 and October 1992 because of chronic, protracted, orofacial pain, showed that more than half gained lasting benefit. This is consistent with the experience of other interdisciplinary pain clinics dealing with various chronic pain disorders, where previous and often multiple treatments have proved unsuccessful. The patients who made good progress tended to be those motivated to take charge of, and responsibility for, their own rehabilitation. Those patients still seeking a "cure", or who felt it was not up to them to take an active part in the management of their pain problem, tended to make poor or no progress. Of concern was the number of instances of misdiagnosis seen, resulting in inappropriate and, on occasion, harmful treatments. On average, the patients had consulted three general or specialist dental or medical practitioners before referral. Chronic pain problems usually require considerable time and a multidisciplinary environment for accurate diagnoses, and a carefully planned management programme. Often, neither are readily available to the busy general practitioner, whose training and experience is directed toward the treatment of acute pain. As a result, patients with chronic pain often end up treated with methods more appropriate for acute pain, which may entrench and compound the pain problem and lead to permanent disability. Recognition and referral of the patient with chronic pain at an early stage can improve the chances of successful management, and avoid frustration and disillusionment of both the practitioner and the patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Practical patient management: the integrated approach.

Pharmacologic agents have been traditionally used in dentistry for the management of patient fears. Results have been mixed, depending on the drugs and techniques used, the skill and training of the operator, and the degree of anxiety of the patient. Pharmacology alone may be unsuitable and even hazardous for some patients. All forms of sedation and anesthesia should be administered in an environment of trust, empathy, and competence in both the behavioral and clinical sciences. Such an integrated approach will result in reduced drug dosages, decreased need for multiple drug techniques, improved patient safety, and better control of anxiety. For optimum benefits, the teaching of behavioral sciences, including interpersonal and communication skills, should be integrated with the teaching of pharmacologic methods of anxiety and pain control at both undergraduate and continuing education levels.