Psychometric properties of the modified Symptom Severity Index (SSI)

Non-Pharmacological Pain Treatment of Patients with Myofascial Pain Syndrome of the Masticatory Muscles-Case Series

Myofascial pain is the most common cause of chronic pain in the masticatory region and can be assessed through clinical analysis and muscle palpation. Generally, it appears with headache and orofacial pain associated with sensitive points (trigger points) due to the excessive contraction of the masticatory muscle fibers. The study aims to evaluate how a correct treatment of myofascial pain can improve the life quality of affected patients. In this case series, 300 patients with myofascial pain were divided into two groups: 150 with intra- and extra-articular disorders and 150 with only extra-articular disorder. Each group included 75 males and 75 females. All the patients were treated with gnathological therapy through passive aligners and biofeedback exercises for four months. They underwent pain assessment (through a visual analogue scale and muscular palpation test) before, during, and after the treatment, as well as nuclear magnetic resonance of the temporomandibular joint before and after the gnathological treatment. The treatment considerably reduced the pain in all patients, without drugs, in four months according to the visual analogue scales and the palpation test. The temporomandibular magnetic resonance in each patient was similar before and after the gnathological treatment. The improvement in pain did not depend on a change in the relationship between the articular condyle and the disc.

Patient-Reported Outcome Measures Used in Temporomandibular Disorders: A Review of the Literature

AIMS

To identify the range of patient-reported outcome measures (PROMs) used in TMD studies, summarize the available evidence for their psychometric properties, and provide guidance for the selection of such measures.

METHODS

A comprehensive search was conducted to retrieve articles published between 2009 and 2018 containing a patient-reported measure of the effects of TMDs. Three databases were searched: MEDLINE, Embase, and Web of Science.

RESULTS

A total of 517 articles containing at least one PROM were included in the review, and 57 additional studies were also located describing the psychometric properties of some tools in a TMD population. A total of 106 PROMs were identified and fell into the following categories: PROMs describing the severity of symptoms; PROMs describing psychologic status; and PROMs describing quality of life and general health. The most commonly used PROM was the visual analog scale. However, a wide range of verbal descriptors was employed. The Oral Health Impact Profile-14 and Beck Depression Inventory were the most commonly used PROMs describing the effect of TMDs on quality of life and psychologic status, respectively. Additionally, the Oral Health Impact Profile (various versions) and the Research Diagnostic Criteria Axis ll questionnaires were the instruments most repeatedly tested in a TMD population, and these instruments have undergone cross-cultural validation in several languages.

CONCLUSION

A wide range of PROMs have been used to describe the impact of TMDs on patients. Such variability may limit the ability of researchers and clinicians to evaluate the efficacy of different treatments and make meaningful comparisons.

Commonalities among dental patient-reported outcomes (dPROs)—A Delphi consensus study

Improvement of patients’ oral health-related quality of life (OHRQoL) is the main goal of oral health care professionals. However, OHRQoL is not a homogenous construct and how to assess it is challenging because of the large number of currently available instruments. Investigating available instruments and what they have in common would be necessary for consolidation and standardization of these instruments into a smaller set of tools. If the OHRQoL dimensions including Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact are the fundamental building blocks of the dental patient’s oral health experience, then these dimensions should be measured by generic multi-item dPROMs. In this study, a panel of 11 international dentists use the Delphi consensus process to determine how well 20 of these instruments measured the four OHRQoL dimensions. All 20 dPROMs questionnaires assessed at least one OHRQoL dimension while all four OHRQoL dimensions were measured by at least one dPROM instrument, i.e., the four OHRQoL dimensions were essential components of the patient’s oral health experience. This shows that the currently available generic multi-item dPROMs have a lot in common, in that they share Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact as targeted dimensions. Based on these commonalities, it is plausible and desirable to move towards a single four-dimensional metric to assess oral health impact in all clinical, community-based, and research settings. This step is necessary to advance evidence-based dentistry and value-based oral health care.

Functional Magnetic Resonance Connectivity in Patients With Temporomadibular Joint Disorders

Myofascial pain in the masticatory region, generally referred to as headache, is a common temporomandibular disorder (TMD) characterized by the hypersensitive regions of the contracted skeletal muscle fibers. A correct clinical treatment of myofascial pain has the potential to modify the functional activation of cerebral networks associated with pain and unconscious teeth clenching, specifically the pain network (PN) and default mode network (DMN). In this study, research is presented as a case series of five patients with myofascial pain: three were diagnosed with intra- and extra-articular disorders, and two were diagnosed with only extra-articular disorders. All five patients received gnathological therapy consisting of passive splints and biofeedback exercises for tongue–palatal vault coordination. Before and after treatment, patients underwent pain assessments (through measures of visual analog scales and muscular palpation tests), nuclear magnetic resonance of the temporomandibular joint, and functional nuclear magnetic resonance of the brain. In each patient, temporomandibular joint nuclear magnetic resonance results were similar before and after the gnathological treatment. However, the treatment resulted in a considerable reduction in pain for all patients, according to the visual analog scales and the palpation test. Furthermore, functional nuclear magnetic resonance of the brain clearly showed a homogeneous modification in cerebral networks associated with pain (i.e., PN and DMN), in all patients. In conclusion, gnathological therapy consisting of passive aligners and biofeedback exercises improved myofascial pain in all five patients. Most importantly, this study showed that all five patients had a homogeneous functional modification of pain and default mode networks. Using passive splints in combination with jaw exercises may be an effective treatment option for patients with TMD. This research could be a starting point for future investigations and for clinicians who want to approach similar situations.

Methodological considerations when measuring oral health-related quality of life

BACKGROUND

Dental patient-reported outcomes (dPROs) and their measures, dPROMs, are fundamental for evidence-based dentistry. However when selecting, applying and evaluating an instrument with a focus on OHRQoL assessment for adults, several methodological considerations are essential to derive valid and meaningful results.

METHODS

In this review article, criteria for selecting the appropriate OHRQoL instrument, aspects of administering the instrument and how to evaluate resulting scores of single and multiple assessments are presented and critically assessed.

RESULTS

Oral disease-generic and dimension-generic instruments capturing the entire construct OHRQoL allow for best comparability of findings across different diseases, settings and populations, with the Oral Health Impact Profile (OHIP) being the most often used and methodologically best investigated one. It is available in several versions with the 5-item version being the one with the lowest burden for the patient. Responses are given on a 5-point ordinal rating scale, the recommended response scale for dPROMs. A 7-day recall period allows for assessment of short-term effects. Clinically relevant effects of item or instrument order or administration method on OHIP scores do not seem to be likely. OHIP summary and dimension scores can be compared to norms from general population or different patient populations. Change scores should be set into context with the minimal important difference of the instrument.

CONCLUSION

OHIP-5 has greatest potential to be used across all settings for assessment and evaluation of OHRQoL in adults. It allows a comprehensive characterising of patients suffering from oral diseases and of this impact using OHRQoL dimensions.

Patient-Reported Outcome Measures for Adult Dental Patients: A Systematic Review

OBJECTIVES

Patient-reported outcomes (PROs) are used beside disease-oriented outcomes (eg, number of teeth, clinical attachment level) to better capture the impact of diseases or interventions. To assess PROs for dental patients (dPROs), dental PRO measures (dPROMs) are applied. The aim of this systematic review was to identify generic dPROMs for adult patients and the dPROs.

METHODS

This systematic review searched the MEDLINE, Embase, and PsycINFO databases along with hand searching, through December 2017, to identify English-language, multi-item dPROMs that are oral health generic, that is, they are applicable to a broad range of adult patients.

RESULTS

We identified 20 questionnaires that contained 36 unique dPROs. They were measured by 53 dPROMs. dPRO names (N = 36) suggested they could be grouped into four dPRO categories: (1) Oral Function (N = 11), Orofacial Pain (N = 7), Orofacial Appearance (N = 3), and Psychosocial Impact (N = 14), as well as an additional dPRO that represented perceived oral health in general. Only eight questionnaires had a specific recall or reference period. dPROM's score dimensionality was only investigated in 13 of the 20 questionnaires.

CONCLUSIONS

The identified 36 dPROs represent the major aspects of an adult dental patient's oral health experience; however, four major dPRO categories, that is, Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact, summarize how patients are impacted. If multi-item, oral health-generic dPROMs are to be used to measure patients' suffering, the 53 dPROMs represent current available tools. Limitations of the majority of these dPROMs include incomplete knowledge about their dimensionality, which affects their validity, and an unspecified recall period, which reduces their clinical applicability.

Examining the Sensitivity and Specificity of 2 Screening Instruments: Odontogenic or Temporomandibular Disorder Pain?

INTRODUCTION

Two groups of patients with orofacial pains that are clinically important to distinguish from each other are patients with odontogenic pain and temporomandibular disorder (TMD) pain. The aim of this study was to determine the sensitivity and specificity of 2 screening instruments in distinguishing between patients with these types of pain.

METHODS

A convenience sample of patients seeking care at an endodontic clinic and an orofacial pain clinic were recruited. The 14-item dental pain questionnaire (DePaQ) was used to screen for odontogenic pain and the 6-item TMD screener was used to screen for TMD pain. Sensitivity and specificity calculations with 95% confidence intervals (CIs) were performed for both instruments, and thresholds/acceptability/performance was assessed using published guidelines.

RESULTS

Thirty-four patients with odontogenic pain and 37 patients with TMD pain were included in this study. The sensitivity of the DePaQ was 0.85 (95% CI, 0.69-0.95), and specificity was 0.11 (95% CI, 0.03-0.25). The sensitivity of the TMD screener was 0.92 (95% CI, 0.78-0.98), and specificity was 0.59 (95% CI, 0.41-0.75). The point estimates, a single value used to estimate the population parameter, for both the DePaQ and TMD screener were "acceptable" in identifying patients who had the pain condition in question (ie, sensitivity), whereas the point estimate for appropriately identifying patients who did not have the pain condition when they did not have it (ie, specificity) was "nonacceptable" for both.

CONCLUSIONS

The DePaQ and the TMD screener lack diagnostic accuracy for differentiating TMD from odontogenic tooth pain without adjunctive (clinical) investigation(s) or examination. However, the TMD screener has high sensitivity for identifying true positives (ie, TMD pain) and would therefore be useful as a screening instrument when one can definitively exclude odontogenic etiology for pain on clinical and radiographic grounds, for instance in endodontic practices. In this study, the negative predictive value was also high in the TMD screener, and, therefore, we can trust a negative result (ie, when the TMD screener is negative, we can be fairly certain the pain diagnosis is not TMD and rule out TMD).

Multilevel Factor Analysis: Reporting Guidelines and a Review of Reporting Practices

We provide reporting guidelines for multilevel factor analysis (MFA) and use these guidelines to systematically review 72 MFA applications in journals across a range of disciplines (e.g., education, health/nursing, management, and psychology) published between 1994 and 2014. Results are organized in terms of the (a) characteristics of the MFA application (e.g., construct measured), (b) purpose (e.g., measurement validation), (c) data source (e.g., number of cases at Level 1 and Level 2), (d) statistical approach (e.g., maximum likelihood), and (e) results reported (e.g., intraclass correlations for indicators and latent variables, standardized factor loadings, fit indices). Results from this review have implications for applied researchers interested in expanding their approaches to psychometric analyses and construct validation within a multilevel framework and for methodologists using Monte Carlo methods to explore technical and methodological issues grounded in realistic research design conditions.

Comparative evaluation of clinical performance of different kind of occlusal splint in management of myofascial pain

Purpose:

To determine the efficacy of hard, liquid, and soft splints in the management of myofascial pain dysfunction syndrome.

Materials and Methods:

In this randomized clinical trial, 45 patients with myofascial pain were diagnosed and were randomly assigned into three groups of 15 patients each. Group 1 - subjects were given hard splint, Group 2 - soft splint, and Group 3 - liquid oral splint for 3 months. Subjective pain analysis using Modified Symptom Severity Index (Mod-SSI) and objective pain analysis muscle palpation was performed at 7 days, 1 month, 2 months, and 3 months after splint insertion. The changes in mean pain value by both methods, in all three groups, were analyzed with Tukey test and Kruskal–Wallis H-test, respectively (P < 0.05).

Results:

Both Mod-SSI and palpation scores showed statistically significant reduction in pain for all three groups at the end of 3 months. However, the hard splints proved to be very effective in a shorter period of time, followed by liquid splints and finally soft splints.

Conclusion:

The result of this study advocates the use of any one of the three types of the occlusal splints in the therapeutic management of myofascial pain due to temporomandibular disorders.

Root canal therapy reduces multiple dimensions of pain: a national dental practice-based research network study

INTRODUCTION

Initial orthograde root canal therapy (RCT) is used to treat dentoalveolar pathosis. The effect RCT has on pain intensity has been frequently reported, but the effect on other dimensions of pain has not. Also, the lack of large prospective studies involving diverse groups of patients and practitioners who are not involved in data collection suggest that there are multiple opportunities for bias to be introduced when these data are systematically aggregated.

METHODS

This prospective observational study assessed pain intensity, duration, and its interference with daily activities among RCT patients. Sixty-two practitioners (46 general dentists and 16 endodontists) in the National Dental Practice-Based Research Network enrolled patients requiring RCT. Patient-reported data were collected before, immediately after, and 1 week after treatment using the Graded Chronic Pain Scale.

RESULTS

The enrollment of 708 patients was completed over 6 months with 655 patients (93%) providing 1-week follow-up data. Before treatment, patients reported a mean (± standard deviation) worst pain intensity of 5.3 ± 3.8 (0-10 scale), 50% had "severe" pain (≥ 7), and mean days in pain and days pain interfered with activities were 3.6 ± 2.7 and 0.5 ± 1.2, respectively. After treatment, patients reported a mean worst pain intensity of 3.0 ± 3.2, 19% had "severe" pain, and mean days in pain and days with pain interference were 2.1 ± 2.4 and 0.4 ± 1.1, respectively. All changes were statistically significant (P < .0001).

CONCLUSIONS

RCT is an effective treatment for patients experiencing pain, significantly reducing pain intensity, duration, and related interference. Further research is needed to reduce the proportion of patients experiencing "severe" postoperative pain.

Evidence for the use of dry needling and physiotherapy in the management of cervicogenic or tension-type headache: A systematic review

Background:

There is good evidence in the literature supporting physiotherapy in the management of some forms of headache. Dry needling of myofascial trigger points is becoming an increasingly common approach despite a paucity of research evidence supporting its use. The purpose of this review was to determine the evidence supporting the use of dry needling in addition to conventional physiotherapy in the management of tension-type and cervicogenic headache.

Methods:

Ten databases were searched for evidence of the effect of dry needling on the severity and frequency of tension and cervicogenic headache based ICHD classifications.

Results:

Three relevant studies were identified and all three showed statistically significant improvements following dry needling, but no significant differences between groups. Only one study reported on headache frequency or intensity, reporting a 45 mm improvement in VAS score following the addition of dry needling to conventional physiotherapy. Two studies showed significant improvements with dry needling over 4–5 weeks of treatment. No adverse events were reported.

Conclusions:

The literature suggests that while there is insufficient evidence to strongly advocate for the use of dry needling, it may be a useful addition to conventional physiotherapy in headache management. Further research with a stronger methodological design is required.

Timing interventions in relation to temporomandibular joint closed lock duration: a systematic review of 'locking duration'

Temporomandibular joint (TMJ) 'closed lock' (CL) is a clinical condition causing TMJ pain and limited mouth opening (painful locking) that is mostly attributed to disc displacement without reduction (DDwoR), or less commonly to anchored disc phenomenon (ADP). Both conditions are described clinically as CL that can be 'acute' or 'chronic' depending on the duration of locking. There is, however, no consensus about the duration of locking that defines the acute state and its effect on the success of interventions. This review paper, therefore, aims to provide: (i) a narrative review of the pathophysiological need for early intervention in DDwoR and the clinical implications of acute/chronic CL stages on the management pathway; (ii) a systematic review investigating the effects of locking duration on the success of interventions for CL management. Electronic and manual searches until mid-August 2013 were conducted for English-language studies of any design investigating the effects of non-surgical and surgical interventions for acute or chronic CL (DDwoR or ADP). A total of 626 records were identified, and 113 studies were included. Data extraction and quality assessment were completed for all included studies. Included studies were, however, heterogeneous and mostly of poor-quality leading to contradictory and inconsistent evidence on the effect of the duration of locking on treatment outcomes. Future high-quality trials investigating the effect of CL duration on treatment outcome are needed. At present, early intervention by 'unlock' mandibular manipulation seems to be the most practical and realistic approach that can be attempted first in every CL patient as an initial diagnostic/therapeutic approach.

Effects of four treatment strategies for temporomandibular joint closed lock

A previous randomized controlled trial (RCT) by Schiffman et al. (2007)(15) compared four treatments strategies for temporomandibular joint (TMJ) disc displacement without reduction with limited mouth opening (closed lock). In this parallel group RCT, 106 patients with magnetic resonance imaging (MRI)-confirmed TMJ closed lock were randomized between medical management, non-surgical rehabilitation, arthroscopic surgery, and arthroplasty. Surgical groups also received rehabilitation post-surgically. The current paper reassesses the effectiveness of these four treatment strategies using outcome measures recommended by the International Association of Oral and Maxillofacial Surgeons (IAOMS). Clinical assessments at baseline and at follow-up (3, 6, 12, 18, 24, and 60 months) included intensity and frequency of TMJ pain, mandibular range of motion, TMJ sounds, and impairment of chewing. TMJ MRIs were performed at baseline and 24 months, and TMJ tomograms at baseline, 24 and 60 months. Most IAOMS recommended outcome measures improved significantly over time (P≤0.0003). There was no difference between treatment strategies relative to any treatment outcome at any follow-up (P≥0.16). Patient self-assessment of treatment success correlated with their ability to eat, with pain-free opening ≥35mm, and with reduced pain intensity. Given no difference between treatment strategies, non-surgical treatment should be employed for TMJ closed lock before considering surgery.

The Relaxation Response Resiliency Enhancement Program in the Management of Chronic Refractory Temporomandibular Joint Disorder: Results from a Pilot Study

OBJECTIVES

This is an open-pilot study to evaluate the feasibility, acceptability and efficacy of a pain-specific version of an established mind-body medicine program, the Relaxation Response [RR] Resiliency Program [R₃P], in patients with chronic temporomandibular disorder [TMD].

METHODS

Male and female with at least a six-month history of pain involving the masticatory muscles were sought in the Orofacial Pain Centers of the Massachusetts General Hospital [MGH] or through an advertisement sent to MGH employees from 2008 to 2010. Eligible participants underwent the R₃P intervention [eight group sessions] after standard medical management. Pre- and post-group patients underwent objective measures of impairment [vertical and lateral range of motion with and without pain, temporomandibular joint and muscle pain palpation, and algometer measures] and completed psychosocial measures [Symptom Severity Index, Perceived Stress Scale, the Symptom Checklist-90-Revised and Short Form 36 Health Survey].

RESULTS

Twenty-four subjects [16 females, 90% from MGH Orofacial Pain Centers,10% from among MGH employees], mean age 38 years, met eligibility criteria and participated in the study. The intervention was highly feasible and accepted by patients, as evidenced by a 92% rate of completion. Paired t-test analyses revealed improvement on self-reported pain measures: pain intensity [p<0.02], pain frequency [p<0.002], pain duration [p<0.027], pain tolerability [p<0.009] and on several objective tests.

CONCLUSIONS

The pain specific R₃P is efficacious in reducing objective and subjective symptoms in patients with chronic refractory TMD. The comprehensive intervention, which combines educational information about pain with RR, cognitive behavioral and resiliency-enhancement skills, is accepted by patients and may be more efficacious than other treatments with fewer elements.