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Pacifico A, Iorizzo M, Pasch M, Kridin K, Del Fabbro M, Mercuri SR, Peluso L, Damiani G. Telemedicine in Nail Psoriasis: Validation of a New Tool to Monitor (In-Person, In-Picture, and In-Video) Nail Psoriasis Severity in Patients with Concurrent Onychophagia and Onychotillomania. Dermatol Ther (Heidelb) 2024; 14:1161-1172. [PMID: 38700647 PMCID: PMC11116310 DOI: 10.1007/s13555-024-01160-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 04/04/2024] [Indexed: 05/24/2024] Open
Abstract
INTRODUCTION Since during the COVID-19 pandemic nail psoriasis was evaluated exclusively with teledermatology, dermatologists started to face the difficulty in rating it concurrent with other onycopathies (i.e., onychotillomania and onychophagy). Thus, we aimed to improve the existing severity scores and verify the value in different clinical settings (i.e., in person vs. teledermatology (video or picture)). METHODS This multicenter prospective observational study evaluated patients with nail psoriasis and screened them for onychophagy or onychotillomania in telemedicine from May 2020 to January 2021. For therapeutic purposes patients with nail psoriasis were followed and rated with the Nijmegen-Nail psoriasis Activity Index tooL (N-NAIL) for 9 months; at the same time, N-NAIL and a new dedicated index that monitor also the changes in nail dimension (Galeazzi-(G) N-NAIL) were tested for accuracy. We assessed inter- and intraobserver agreement for the three different settings (in person, video, and pictures). RESULTS In our cohort of 382 patients with nail psoriasis after a clinical and dermatoscopic assessment we found 20 (5.24%) patients with onychophagy and 17 (4.45%) patients with onychotillomania. Analysis of the impact of nail psoriasis on patients revealed that onycholysis and crumbing, followed by subungual hyperkeratosis, were the clinical signs that prevalently bothered patients. N-NAIL score displayed moderate intra- and interobserver agreement. Over the 9 months follow-up, N-NAIL vs. GN-NAIL displayed a solid correlation at all the examined time points, i.e., baseline and after 3, 6, and 9 months. CONCLUSION We created a new tool, the GN-NAIL capable of efficiently scoring nail psoriasis severity in complex cases, such as patients with onychotillomania and onychophagy, and monitor response to treatment during the COVID-19 pandemic.
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Affiliation(s)
- Alessia Pacifico
- Clinical Dermatology Department, IRCCS S. Gallicano Dermatological Institute, 00144, Rome, Italy
| | | | - Marcel Pasch
- Department of Dermatology, Radboud University Medical Center, 6525, Nijmegen, The Netherlands
| | - Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, 23538, Lübeck, Germany
| | - Massimo Del Fabbro
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122, Milan, Italy
| | - Santo R Mercuri
- Unit of Dermatology, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1050, Brussels, Belgium
| | - Giovanni Damiani
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122, Milan, Italy.
- Clinical Dermatology, IRCCS Ospedale Galeazzi-Sant'Ambrogio, 20161, Milan, Italy.
- Italian Center of Precision Medicine and Chronic Inflammation, Via Della Commenda 10, 20122, Milan, Italy.
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Update on Diagnosis and Management of Onychophagia and Onychotillomania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063392. [PMID: 35329078 PMCID: PMC8953487 DOI: 10.3390/ijerph19063392] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/07/2022] [Accepted: 03/11/2022] [Indexed: 12/16/2022]
Abstract
Onychophagia (nail biting) and onychotillomania (nail picking) are chronic nail conditions categorized as body-focused repetitive behavior (BFRB) disorders. Due to a limited awareness of their clinical presentations, embarrassment on the part of patients, and/or comorbid psychiatric conditions, these conditions are frequently underrecognized and misdiagnosed. This article reviews the prevalence, etiology, diagnostic criteria, historical and physical exam findings, and treatment options for these conditions. The PubMed/MEDLINE database was searched for relevant articles. Onychophagia and onychotillomania are complex disorders necessitating a detailed patient history and physical examination and a multidisciplinary treatment approach for successful diagnosis and management. Due to the dearth of clinical trials for treatment of nail biting and nail picking, large clinical trials are necessary to establish standardized therapies.
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Mosca M, Martin K, Hadeler E, Hong J, Brownstone N, Koo J. Review of the diagnosis and management of pediatric psychodermatologic conditions: Part I. Pediatr Dermatol 2022; 39:17-21. [PMID: 34929757 DOI: 10.1111/pde.14888] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/29/2021] [Accepted: 11/21/2021] [Indexed: 12/01/2022]
Abstract
Pediatric psychodermatologic conditions encompass both primary dermatologic conditions with psychiatric comorbidities and primary psychiatric conditions with self-induced dermatologic manifestations. Detection, diagnosis, and management of primary psychiatric conditions with dermatologic manifestations are challenging due to patient-perceived stigma and lack of educational opportunities for dermatology providers. This two-part series highlights the most up-to-date evidence-based data and management techniques of some of the more common dermatoses of primary psychiatric conditions in children. Part I includes trichotillomania, skin-picking disorder, and onychophagia, and part II covers dermatitis artefacta, body dysmorphic disorder, and delusions of parasitosis by proxy, with special considerations for family dynamics.
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Affiliation(s)
- Megan Mosca
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, San Francisco, California, USA
| | - Kari Martin
- Department of Dermatology, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Edward Hadeler
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, San Francisco, California, USA
| | - Julie Hong
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, San Francisco, California, USA
| | - Nicholas Brownstone
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, San Francisco, California, USA
| | - John Koo
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, San Francisco, California, USA
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Lesinskiene S, Pociute K, Dervinyte-Bongarzoni A, Kinciniene O. Onychophagia as a clinical symptom: A pilot study of physicians and literature review. Sci Prog 2021; 104:368504211050288. [PMID: 34874802 PMCID: PMC10373863 DOI: 10.1177/00368504211050288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although onychophagia is a medical condition and is associated with poorer health, there are no guidelines for assessment or treatment. The purpose of this study was to investigate the clinical aspects of nail biting from doctors' points of view, to estimate the prevalence of onychophagia among physicians, and to review the literature on and treatment methods for onychophagia. Twenty-four percent of doctors reported nail-biting periods during their lifetimes, and 2% of them remained active nail biters. A total of 64.4% of doctors see nail biting in their practices, and 60.6% never or only on request ask patients about nail biting and examine their nails. Family doctors and pediatricians ask their patients about nail biting most often. Attitudes and opinions on the treatment of nail biting are undefined and vary. Doctors reported usually treating nail-biting patients by referring them to another specialist or offering special nail polish. There is a need to improve physicians' knowledge of nail-biting treatment methods, but a lack of studies evaluating the clinical aspects of onychophagia and its relation to mental health and emotion dysregulation. Further research is needed. Clinical attitudes toward nail biting could be more precise in training and medical practice.
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Affiliation(s)
- Sigita Lesinskiene
- Clinic of Psychiatry, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kamile Pociute
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Asta Dervinyte-Bongarzoni
- Clinic of Psychiatry, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Odeta Kinciniene
- Clinic of Children's Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Shin JO, Roh D, Son JH, Shin K, Kim HS, Ko HC, Kim BS, Kim MB. Onychophagia: detailed clinical characteristics. Int J Dermatol 2021; 61:331-336. [PMID: 34416026 DOI: 10.1111/ijd.15861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/14/2021] [Accepted: 07/30/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Onychophagia is a common disorder affecting 20% to 30% of the general population. It is defined as habitual nail biting and can cause various changes in the nail units. However, to date, there has been a paucity of data focusing on nail deformities related to onychophagia. This study was performed to investigate the clinical characteristics of onychophagia in Korea. METHODS This study included 53 patients with onychophagia who visited the Pusan National University Hospital (Busan and Yangsan) over a 10-year period (2011-2020). We retrospectively reviewed medical records and clinical and dermoscopic photographs. RESULTS All 10 fingernails were affected in 37.7% of the patients. The left thumbnail was the most predominantly affected site (81.1%). Clinical findings showed that short nails with ragged distal borders were the most common presentation (100.0%), followed by generalized or patchy rough areas (50.9%), linear and pinpoint hemorrhage (32.1%), longitudinal melanonychia (30.2%), transverse groove (28.3%), brittleness (28.3%), macrolunula (24.5%), washboard nail (13.2%), and pterygium (3.8%). Of the patients, 88.7% had periungual complications, such as periungual exfoliation (77.4%), absent or ragged cuticle (52.8%), hyponychial hyperkeratosis (37.7%), and paronychia (15.1%). CONCLUSIONS Although onychophagia is a common disorder, its clinical characteristics have not been reported in the literature. The results of this study may be helpful in managing patients with onychophagia.
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Affiliation(s)
- Jun-Oh Shin
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea.,Department of Dermatology, Pusan National University, Yangsan Hospital, Yangsan, Korea
| | - Dongyoung Roh
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea.,Department of Dermatology, Pusan National University, Yangsan Hospital, Yangsan, Korea
| | - Jin-Hwa Son
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea.,Department of Dermatology, Pusan National University, Yangsan Hospital, Yangsan, Korea
| | - Kihyuk Shin
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea.,Department of Dermatology, Pusan National University, Yangsan Hospital, Yangsan, Korea
| | - Hoon-Soo Kim
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea
| | - Hyun-Chang Ko
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea.,Department of Dermatology, Pusan National University, Yangsan Hospital, Yangsan, Korea
| | - Byung-Soo Kim
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Moon-Bum Kim
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Erdogan HK, Arslantas D, Atay E, Eyuboglu D, Unsal A, Dagtekin G, Kilinc A. Prevalence of onychophagia and its relation to stress and quality of life. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2021. [DOI: 10.15570/actaapa.2021.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Wu AG, Lin K, Cooley V, Lipner SR. A cross-sectional study of onychotillomania and onychophagia in graduate students. Dermatol Ther 2020; 34:e14639. [PMID: 33314596 DOI: 10.1111/dth.14639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/25/2020] [Accepted: 12/01/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Albert G Wu
- New York Medical College, Valhalla, New York, USA
| | - Krysta Lin
- Paul L. Foster School of Medicine, El Paso, Texas, USA
| | - Victoria Cooley
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
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Siegel M, Adlmann EM, Gittler G, Pietschnig J. Bite the Stress Away? Nail Biting and Smoking Predict Maladaptive Stress Coping Strategies. JOURNAL OF INDIVIDUAL DIFFERENCES 2020. [DOI: 10.1027/1614-0001/a000303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Abstract. Psychological correlates of adult nail biting have received little empirical attention so far, despite its high prevalence and negative associations with physical and mental health. One possible correlate of nail biting is arousal modulation, which has also been linked to smoking (i.e., another oral behavior). Here, we link nail biting to an adaptive (i.e., Task-oriented) and two maladaptive stress-coping strategies (i.e., Emotion-oriented, Avoidance-oriented) as well as smoking while controlling for personality traits and socio-demographic characteristics. In all, 838 German-speaking adults ( Mage = 32.02, SD = 13.48; 431 women) completed measures of stress coping (CISS-SF), the Big Five personality traits (Mini-IPIP), and indicated nail biting and smoking behavior. In three theory-guided, hierarchical linear regressions we predicted each stress coping strategy by nail biting and smoking while controlling for personality and socio-demographic characteristics. Oral behaviors had differential effects on maladaptive stress coping strategies: The interaction between nail biting and smoking predicted Emotion-oriented coping, while smoking predicted Avoidance-oriented coping. Both behaviors were unrelated to adaptive, Task-oriented coping. In sum, our results show that nail biting and smoking are important predictors of maladaptive but not adaptive coping strategies, even when controlling for confounders.
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Affiliation(s)
- Magdalena Siegel
- Department of Applied Psychology: Health, Development, Enhancement and Intervention, Faculty of Psychology, University of Vienna, Austria
| | - Eva-Maria Adlmann
- Department of Applied Psychology: Health, Development, Enhancement and Intervention, Faculty of Psychology, University of Vienna, Austria
| | - Georg Gittler
- Department of Applied Psychology: Health, Development, Enhancement and Intervention, Faculty of Psychology, University of Vienna, Austria
| | - Jakob Pietschnig
- Department of Applied Psychology: Health, Development, Enhancement and Intervention, Faculty of Psychology, University of Vienna, Austria
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Silva LCD, Vedovello SAS, Vedovello Filho M, Meneghin MDC, Ambrosano Bovi GM, Degan VV. Anxiety and oral habits as factors associated with malocclusion. Cranio 2019; 39:249-253. [PMID: 31232226 DOI: 10.1080/08869634.2019.1633492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: The aim of this study was to associate the presence of oral habits with anxiety and malocclusion.Methods: Cross-sectional observational study with 199 schoolchildren 6-14 years old. Malocclusion was evaluated by using the Index of Orthodontic Treatment Need (IOTN). Oral Habits Questionnaire and Hospital Anxiety and Depression Scale (HADS) were used to assess oral habits and anxiety. The schoolchildren were divided into two groups: mixed and permanent dentition. The associations between the outcome variable (oral habits) and the independent variables (anxiety and malocclusion) were evaluated using the Exact Fischer test and the Chi square test.Results: Of the individuals with malocclusion in permanent dentition, 77.4% reported some deleterious oral habit, and 55% of those with no malocclusion at this stage had deleterious habits.Discussion: Oral habits may be associated with the presence of malocclusion in different stages of occlusal development (mixed and permanent dentition) and may be influenced by anxiety.
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Affiliation(s)
- Luan César da Silva
- Department of Orthodontics, University Center of Herminio Ometto Foundation-FHO, São Paulo, Araras, Brazil
| | | | - Mario Vedovello Filho
- Department of Orthodontics, University Center of Herminio Ometto Foundation-FHO, São Paulo, Araras, Brazil
| | - Marcelo de Castro Meneghin
- Department of Community Dentristry, Piracicaba Dental School, University of Campinas, Piracicaba, São Paulo, Brazil
| | - Glaucia Maria Ambrosano Bovi
- Department of Community Dentristry, Piracicaba Dental School, University of Campinas, Piracicaba, São Paulo, Brazil
| | - Viviane Veroni Degan
- Department of Orthodontics, University Center of Herminio Ometto Foundation-FHO, São Paulo, Araras, Brazil
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Gür K, Erol S, İncir N. The effectiveness of a nail-biting prevention program among primary school students. J SPEC PEDIATR NURS 2018; 23:e12219. [PMID: 29797491 DOI: 10.1111/jspn.12219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 04/09/2018] [Accepted: 04/27/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE This study aimed to demonstrate the effect of a program called "Do Not Bite Your Nails, Cut Your Nails," which is based on a health promotion model to change the nail-biting habit among primary school students. DESIGN AND METHODS This quasi-experimental study was conducted using the pre- and post-test and interrupted time series design. The study sample included 299 students. Nurse observation form and nail follow-up chart were used to evaluate behavioral outcomes. This program was conducted under the guidance of school nurses and lasted 6 weeks. The data were analyzed using McNemar and Cochran Q tests. RESULTS The number of those who selected "yes" for "I cut my nails this weekend" and "I didn't bite my nails today" increased. However, the number of the students that selected "yes" for "I pulled out my nails," "I pulled out and ate," "I pulled out my nail skin," "My cuticle bled today," and "My nails hurt today" decreased significantly and statistically compared with pretest, first and second observation, and post-test (P < 0.001). The rate of the students with minimum one abnormal finger was 83.9% according to observations, and 6% following the intervention (P < 0.001). New insights were provided into the program to diminish nail-biting habit. PRACTICE IMPLICATIONS The program significantly reduced the nail-biting rate among primary school students. The nurse that implement this program will be able to do a comprehensive evaluation of students' nail-biting habits, perform solution-focused interventions, and prevent advanced complications that might develop in connection to nail-biting. Thus, the effectiveness of nursing implementations will improve in the prevention of nail-biting habit, early diagnosis, and changing students' habits. "Do Not Bite Your Nails, Cut Your Nails" program can be applied again in different schools.
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Affiliation(s)
- Kamer Gür
- Assistant Professor, Public Health Nursing Section, Faculty of Health Sciences, Department of Nursing, Marmara University, Maltepe, Istanbul, Turkey
| | - Saime Erol
- Associate Professor, Public Health Nursing Section, Faculty of Health Sciences, Department of Nursing, Marmara University, Maltepe, Istanbul, Turkey
| | - Nursultan İncir
- Nurse, Istanbul University Topkapı Mahallesi, Turgut Özal caddesi No: 118, 34093, Fatih, Istanbul, Turkey
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Abstract
A notable number of people struggle to control the desire to bite their nails, resulting in impairment and distress. Understanding this behavior and the inability to control it has received little research attention. One possible mechanism to understand nail biting is through the use of neurocognitive assessments. Neurocognitive assessments of pathological nail biting, however, are lacking. This analysis assesses the clinical presentation and neurocognitive profile of adults with nail biting relative to participants without nail biting. A total of 87 participants (aged 18-29 years) were recruited for a study on nail biting in young adults. Participants completed diagnostic, self-report, and neurocognitive measures which assessed two cognitive domains - motor impulsivity and cognitive flexibility. In the sample, 34 participants reported current nail biting. The nail biting group showed no significant differences in impulsivity or cognitive flexibility compared to the healthy controls. The lack of association between nail biting and cognitive deficits suggests that perhaps identifying meaningful subtypes of nail biting that reflect distinct pathology from normal grooming behavior may be important.
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12
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Halteh P, Scher RK, Lipner SR. Onychophagia: A nail-biting conundrum for physicians. J DERMATOL TREAT 2016; 28:166-172. [DOI: 10.1080/09546634.2016.1200711] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Cioffi I, Michelotti A, Perrotta S, Chiodini P, Ohrbach R. Effect of somatosensory amplification and trait anxiety on experimentally induced orthodontic pain. Eur J Oral Sci 2016; 124:127-34. [PMID: 26918812 DOI: 10.1111/eos.12258] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2016] [Indexed: 01/21/2023]
Abstract
The perception of pain varies considerably across individuals and is affected by psychological traits. This study aimed to investigate the combined effects of somatosensory amplification and trait anxiety on orthodontic pain. Five-hundred and five adults completed the State Trait Anxiety Inventory (STAI) and the Somatosensory Amplification Scale (SSAS). Individuals with combined STAI and SSAS scores below the 20th percentile (LASA group: five men and 12 women; mean age ± SD = 22.4 ± 1.3 yr) or above the 80th percentile (HASA group: 13 men and seven women; mean age ± SD = 23.7 ± 1.0 yr) were selected and filled in the Oral Behaviors Checklist (OBC). Orthodontic separators were placed for 5 d in order to induce experimental pain. Visual analog scales (VAS) were administered to collect ratings for occlusal discomfort, pain, and perceived stress. Pressure pain thresholds (PPT) were measured. A mixed regression model was used to evaluate pain and discomfort ratings over the 5-d duration of the study. At baseline, the LASA group had statistically significantly higher PPT values for the masseter muscle than did the HASA group. During the experimental procedure, the HASA group had statistically significantly higher discomfort and pain. A significant difference in pain ratings during the 5 d of the study was found for subjects in the HASA group. Higher OBC values were statistically significantly positively associated with pain. Somatosensory amplification and trait anxiety substantially affect experimentally induced orthodontic pain.
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Affiliation(s)
- Iacopo Cioffi
- Department of Orthodontics, Faculty of Dentistry, University of Toronto, and University of Toronto Center for the Study of Pain, Toronto, ON, Canada.,Department of Neuroscience, Reproductive and Oral Sciences, Section of Orthodontics, University of Naples Federico II, Naples, Italy
| | - Ambrosina Michelotti
- Department of Neuroscience, Reproductive and Oral Sciences, Section of Orthodontics, University of Naples Federico II, Naples, Italy
| | - Stefania Perrotta
- Department of Neuroscience, Reproductive and Oral Sciences, Section of Orthodontics, University of Naples Federico II, Naples, Italy
| | - Paolo Chiodini
- Medical Statistics Unit, Seconda Università degli Studi di Napoli, Naples, Italy
| | - Richard Ohrbach
- Department of Oral Diagnostic Sciences, Center for Orofacial Pain Research, University at Buffalo, Buffalo, NY, USA
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