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Orofacial pain

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CLINICAL EFFECT OF CAPSAICIN CREAM ON FACIAL PAIN

Sato Abe. Seiji Takahashi, Hideki Furuya*, Dept of Anesthesiology, The Nippon Dental Univ. at Tokyo, 2-3-16, Fujimi, Chiyoda-kli, Tokyo 102-8258, Japan

Aim of Investigation: In this study, we attempted to clinically evaluate the efficacy of 0.075% capsaicin cream in the control of pain on the face.

Methods: The subjects were 14 patients in whom pain on the face was controlled in our Dept, and who gave informed consent after a thorough explanation of the study. The patients were instructed to apply capsaicin cream twice a day to the pain site, without altering any other medical treatments in effect at the time. Pain severity was scored on a 10-point scale by the patients themselves before and one, two and four weeks after topical application. When pain scores decreased by 30% or more after application, the cream was judged as effective.

Results: 10 patients had trigeminal neuralgia and 4 patients had complex regional pain syndrome (CRPS). In the group having trigeminal neuralgia, 6 patients evaluated the cream as effective and the other 4 patients evaluated it as ineffective or could not evaluate it because they had withdrawn it. All 6 patients who responded to the cream had previously shown pain restricted to the infraorbital nerve or the mental nerve. In the group having CRPS, three and one patients evaluated the cream as effective and ineffective, respectively. Pain scores became constant within 2 weeks, and the pain scores no longer continued to reduce.

Conclusion: Topical application of 0.075% capsaicin cream appears to be useful adjunctive therapy for neurogenic pain on the face.

PROSTAGLANDIN E2 AND LEUKOTRIENE B4 IN TEMPOROMANDIBULAR JOINT SYNOVIAL FLUID AND THEIR RELATION TO PAIN IN PATIENTS WITH INFLAMMATORY DISORDERS

Per Alstergren and Sigvard Kopp* (SPON: Michael Ahlqvist). Dept of Clinical Oral Physiology, Karolinska Instt, Box 4064, 141 04 Huddinge, Sweden.

Aim of Investigation: To investigate the influence ofsynovial fluid (SF) levels ofprostaglandin E; (PGE;) and leukotnene 84 (LTB4) on pain of the arthritic temporomandibular joint (TMJ).

Methods: This study comprised 24 patients (30 joints) with TMJ inflammatory disorders and 4 healthy individuals (6 joints). TMJ pain (VAS), tenderness to palpation of the TMJ (TDP), TMJ pressure pain threshold and pain during joint movements (PM) were assessed. PGE; and LTB4 levels were analyzed in TMJ synovial fluid samples (SF-PGE2 and SF-LTB4) and blood plasma. Results: In the 4 healthy individuals, PGE2 was undetectable in the plasma and in the 6 SF samples. In the patients, PGE2 was detectable in 20 out of 30 (67%) SF samples and it was significantly higher than in the healthy individuals. SF-PGE2 was significantly correlated to PM in the patients. LTB4 was undetectable in the two SF samples and in one plasma sample from two healthy individuals. In the patients, LTB4 was detectable in 2 out of 18 (11%) TMJ SF samples and in 5 out of the 17 (29%) plasma samples.

Conclusion: This study shows that the TMJ synovial fluid in patients with TMJ inflammatory disorders contains a level of PGE2 that is higher than in healthy individuals and that it is related to TMJ allodynia.

Acknowledgments: Supported in part by the Swedish Medical Research Council (grant 10416) and the Swedish Dental Association.

PSAICIN INDUCED MUSCLE HYPERALGESIA IN THE EXERCISED AND NON-EXERCISED HUMAN MASSETER

Taro Arima. Peter Svensson, Lars Arendt-Nielsen, Orofacial Pain Laboratory, Center for Sensory-Motor Interaction (SMI), Univ. of Aalborg, DK-9200, Denmark. Dental School, Univ. ofAarhus, DK-8000, Denmark.

Aim: Strong jaw-muscle activity like tooth-grinding is believed to be a predisposing factor in myogenous types of temporomandibular disorders (TMD). This study compared the hyperalgesic effects of intramuscular capsaicin in exercised versus non-exercised masseter muscles.

Methods: Ten healthy men (24.0 2.0 years) without signs or symptoms of TMD participated in 2 sessions separated by 1 week. In one session, 0.1 ml capsaicin (100 ug/ml) was injected into the right masseter immediately after 45 minutes of standardized tooth-grinding. The grinding was performed from the intercuspal position to the right canine-canine position at 0.5 Hz keeping the EMG activity above 50% of the maximal effort. In the other session, the capsaicin was injected into a non-exercised masseter. The perceived intensity of pain evoked by intramuscular capsaicin was scored on a 100-rnm VAS. Pressure pain thresholds (PPT) and maximal bite force were measured before capsaicin injections, 5, 15 and 45 min after, and the following 3 days.

Results: Injections of capsaicin into the non-exercised or exercised masseter did not cause significant differences in peak pain intensity on the VAS (53 6 mm; 57 6 mm; P = 0.64). PPTs in the exercised masseter were significantly decreased up to 45 minutes after the capsaicin injection (P < 0.04), whereas the PPTs in the non-exercised muscle only were decreased after 5 minutes (P = 0.01). The maximal bite force was significantly reduced up to 45 min after capsaicin injection into the exercised masseter (P < 0.04) but only for 5 min in the non-exercised masseter (P = 0.01).

Conclusion: Muscle hyperalgesia was more pronounced after capsaicin stimulation of the exercised masseter muscle. Thus, tooth-grinding activity might render the jaw muscles more susceptible to potential traumatic stimuli.

Acknowledgment: Supported by the Danish National Research Foundation.

PAIN AND OTHER OUTCOMES FOR PATIENTS WITH TMD ASSOCIATED WITH MVA

James Colt. Nancy O. Hester, Julaluk Baramee*, Christopher Centano, Charles Wennogle*, TraumaCare IPA & Univ of CO Denver, CO 80246, USA

Aim of Investigation: The aims of this study were to describe pain and other outcomes for patients with TMD resulting from motor vehicle accidents and to examine relationships and differences among the outcomes and other variables.

Methods: TraumaCare IPA engaged two oral facial practices to collect data from patients using a hand-held computer. Patients completed a questionnaire on each visit. Questions pertained to pain, functional status, satisfaction with care, knowledge of condition, work status, and engagement of an attorney.

Results: Fifty-six (30%) of the patients met the criterion of having data for at least two clinic visits. The patients, mostly female (88%), reported a mean of 2.47 pain sites. Fifty-four percent had pain in three areas; 36%, two areas; and 10% in one area. The most common worst pain areas were the neck (14%), the head (14%), the jaw (12%), and a combination of the head and neck (12%). There was, however, no difference between the pain reports on two occasions even when controlling for the time between the accident and the first measure and the time between the two measures. Functional status was moderately related to the worst and least pain scores. Eighteen patients were not working full time; the primary reason being that they could not physically do the job. Most (82%) of the patients rated their provider care as excellent but they were less satisfied with their overall medical care. Twenty patients had engaged an attorney; the most common reasons were problems with insurance and being worried about the future.

Conclusions: The majority of patients had two or more pain sites and suffered from considerable pain. Pain tended to affect functional status, resulting in some patients being unable to work. Variations in outcomes between the two practices appeared to be minimal.

PERCUTANEOUS RETROGASSERIAN GLYCEROL INJECTION FOR TRIGEMINAL NEURALGIA: LONG-TERM FOLLOW UP RESULTS

H.H. Dash. S. Balachundhar, S.Kathirvel, Dept of Neuroanaesthesiology. All India Inst of Medical Sciences, New Delhi, INDIA.

Aim of Investigation: Percutaneous Retrogasserian Glycerol Injection (PRGR) is an established technique for management oftri-geminal neuralgia. However, long-term outcome after PRGR have not been studied. We carried out a prospective outcome study of 89 patients with classical trigeminal neuralgia after glycerol rhizolysis for 60 months or more to determine the safety and efficacy of PRGR.

Methods: Anhydrous glycerol (0.3ml) was injected into trigeminal cistern by Hartel's approach with aseptic precautions using 22G spinal needle under fluoroscopy in the operating room. All of them were followed up for 48 hours, every 1 month for 6 months and every 6 months thereafter till at least 60 months. The pain relief, recurrence rates, sensory disturbances and complications were recorded.

Results: Fourteen patients were lost to follow up and they were excluded. Out of 75 pts., 64 (85.3%) had good to excellent pain relief with first injection. 10 pts (13.3%) had no effect while 1 (1.3%) could not be injected. 38 pts. (50.6%) were pain free for more than 5 years, 20 pts. (26.6%) were pain free for 24 to 54 months and additional 6 pts. (8%) for 12-24 months. Of the 28 pts. with recurrences, few were controlled with drugs (3), isolated nerve blocks : infraorbital (2), mental (2) and surgery (1). Twenty were reinjected and five had recurrences needing a third injection. Two were injected a fourth time. Complications seen during the procedure were pain (54), headache (28), bleeding and swelling (3) and transient black out (1). Sensory disturbances like mild hypes-thesia (28%), moderate hypesthesia (12%), anesthesia dolorosa (1.33%), dysesthesia (12%), decreased comeal reflex (2.6%), herpes simplex (1.3%), meningitis (1.3%) and atypical pain (1.33%) were seen.

Conclusions: PRGR is a safe and simple method which provides long-term pain relief in majority of patients.

TRIGEMINAL NEURALGIA ASSOCIATED WITH A SMALL CELL LUNG CARCINOMA. A CASE REPORT AND REVIEW

A Garcia Muret*. E Catala, C Pedro*, JM Villar-Landeira*, Dept of oncology and Pain Clinic, Hospital Univ de la Santa Creu i Sant Pau, Barcelona 08025, Spain.

Introduction: Trigeminal neuralgia is associated with malignancies in 10% of cases either by direct invasion or compression of nerves, a remote or paraneoplastic effect or an iatrogenic effect of treatment. When there are no other neurologic deficits, this etiology is rarely suspected, something that can delay its diagnose and an effective treatment.

Case Report: A 43 years old female patient was referred to our Pain Clinic with a right side trigeminal neuralgia (second division) of one year of evolution. She had been treated with benzodi-acepines, dipirone, paracetamol, gabapentin, carbamazepine, dex-tropropoxifeno and dental extractions without effective results. One week before she was accidentally (thorax radiography) diagnosed of a small cell lung carcinoma. Considering the kind of pain and its intensity (VAS over 7) we started with amitriptiline 25 mg/day, dipirone 2mg/8h and slow release oral morphine MST 10 mg/12 h with good results during the first week of treatment. After the first 3 days-session of chemotherapy (CDDP, etoposid and dexametasone) she presented an exacerbation of her facial pain becoming even bilateral. Nevertheless, in the following weeks, after several chemotherapy sessions, lung tumor size was reduced and facial pain disappeared gradually, stopping all pain medications four months later. Actually, ten months after the beginning of chemotherapy, the patient is still pain-free.

Conclusion: This complete resolution suggest a paraneoplastic mechanism, something that, although uncommon, should always be considered in a patient with malignancy and an associated peripheral nerve disorder. Finally, in the initial study of a trigeminal neuralgia, radiographic evaluations should be performed to avoid delays in correct management.

ATYPICAL FACIAL PAIN (AFP): MULTIDSCIPLINARY ASSESSMENT AND TREATMENT

O G Garcia, M Okada, TY Lin. MJ Teixeira, JT Siqueira, CA Pimenta, GF Formigoni, MF Oliveira, Pain Clinic, Univ ofSao Paulo Medical School, Rua Conselheiro Brotero 1539, cj 12, Cep 01232-OlOSao Paulo Brazil.

Aim of Investigation: Evaluation of the clinical, and therapeutic findings of patients with facial pain of uncertain aetiology

Methods: Thirty-three patients (68.7% female) with the diagnosis of AFP were evaluated by a multidisciplinary team (neurologist, dentist, physiatrist, ophthalmologist, ENT specialist, psychologist and nurse). The McGill Pain Questionnaire and the VAS were used for pain evaluation. Image studies of the skull and cervical spine, CSF and blood tests were also performed. The treatment included the prescription ofNSAIDs, psychotropics, and acupuncture. Odontological and physiatric procedures were performed, when necessary.

Results: The final diagnosis was trigeminal neuropathy in 62.5% of the cases, mastigatory, skull and cervical myofascial pain syndromes in 15.6%, and dental or temporo-mandibular dysfunction in 12.5%. Other causes were diagnosed in 6.2%. The median of VAS was 8.2, the median number of MPQ descriptors was 12, and the Pain Index, 30. Pain was constant in 45.1% of the cases and bilateral in 38.4%. The intensity was progressive in 69%. Social life was affected in 53.2% of the cases and daily activities reduced in 63.6%. Isolated facial sensory abnormalities were evident in 36.3% of the cases and hemibody hypoesthesia. in 9%. The multidisciplinary treatment resulted reduction of 50% or more of the initial pain in 38.8% of the patients and improvement of the quality of life in 80%. Trigeminal nucleototomy was performed in 2 patients, resulting in complete alleviation of pain.

Conclusion: The multidisciplinary assessment and treatment is necessary for adequate management of patients presenting AFP. It allowed more precise identification of the aetiologies of pain, which is essential for the selection of the therapeutic program.

A DOUBLE-BLIND RANDOMZED CONTROLLED TRIAL OF DEXTROMETHORPHAN VS. ACTIVE PLACEBO IN CHRONIC OROFACIAL PAIN

lan Gilron, Susan L Booher*, Janet S Rowan*, Gloria Lee*, and Mitchell B Max, Pain and Neurosensory Mechanisms Branch, NIDCR and Dept of Nursing, Clinical Center, NIH, Bethesda, MD

Aim of Investigation Recent studies from our clinic suggest that dextrometh orphan (Dex) relieves pain in diabetic neuropathy': In view of proposed central pain mechanisms in tngeminal neuralgia3 and other oro facial neuropathic pain syndromes, this study evaluates the analgesic efficacy of the centrally acting NMDA glutamate receptor antagonist Dex vs active placebo (lorazepam. Lor) in chronic orofacial pain

Methods To date, 15 patients with definite or probable neuropathic pain have been enrolled in a randomized double blind 2 period crossover trial (part I) Three have anesthesia dolorosa following Gassenon ganglion ablation, 1 had a tngeminal Schwannoma excision, 1 has SUNCT syndrome and 10 have burning or shooting pain and/or allodynia for more than 1 year without an evident cause Each treatment is titrated over a 4 week period to the maximal tolerated dose (MTD), then maintained for 14 days Maximum doses are Dex, 920 mg/day, and Lor, 1 84 mg/day Pain intensity is rated daily using a list of 13 pain intensity descriptors4 The primary outcome is mean pain intensity during the last 14 days of each treatment Global relief is rated at the end of each treatment using a 6-point category scale Patients responding to Dex in part I are enrolled in a confirmatory study with 4 pairs of randomized Dex/Lor crossovers (pan II)

Results To date, 6 patients have completed the part I study The mean MTD was 328 mg/day for Dex, and 1 1 mg/day for Lor Interim analysis shows that 4/6 reported moderate or better global relief with Dex compared to 1/6 with Lor; however, the percent mean pain intensity reduction with Dex compared to Lor was only 4% Side effects (SE's) all appeared during the titration period and were reversible when the doses were lowered. Study patients having at least one moderate or severe SE were Dex, 4/6 and Lor, 5/6 For Dex, these included' ataxia/dizzmess (2 patients), fatigue/ drowsmess (2), and memory loss (2), for Lor, these included fa-tigue/drowsiness (2), and constipation (2).

Conclusions: Dextromethorphan appears to be reasonably well tolerated in this patient group with a side effect profile similar to that described in our previous studies We will defer conclusions regarding efficacy until additional patients have completed the trial

1 Nelson etal. Neurology 48 1212-18, 1997 2 Sang et al , APS Annual Meeting Abstract #661, 1997 3 Dubner et al , Pain 31:22-33, 1987. 4. Gracely etal, Pain 5-5, 1978

MONITORED THERMORHIZOTOMY IN TRIGEMINAL NEURALGIA SECONDARY TO MULTIPLE SCLEROSIS

Alberto Gottlieb. Massimo Luzzani, Massimo Leandn. Centre for Pain Relief, National Cancer Inst & InterUmv Centre for Pain Neurophysiology Largo R Benzi 10, 16146 Geneva Italy

Aim of Investigation. To evaluate the quality of life, changes in neurological symptoms and signs and psychological differences occurred in patients with tngeminal neuralgia secondary to multiple sclerosis who underwent monitored thermorhizotomy and were able to completely interrupt the assumption ofcarbamazepme or other medication for tngeminal neuralgia Methods: 8 patients were assessed according to the Expanded Disability Status Scale (EDSS) and a generic quality of life scale (SF36) before and after monitored thermorhizotomy.as a cure for their tngeminal neuralgia. Pain relief and sensory deficits were also evaluated. The operation of monitored thermorhizotomy was car ried out according to the method described by Leandn and Gottlieb (J Neurosurg 84- 929-939 1996)

Results. Satisfactory pain relief was attained in all patients, which allowed complete withdrawal ofcarbamazepme, previously taken at dosages varying from 400 to 1200mg per day This resulted in a reduction of neurological signs and symptoms, expecially related to gait, balance and coordination The quality of life and the mood of patients improved also These results were confirmed at 6 months follow up

Conclusions The side effects ofcarbamazepme and other antiepi-leptic drugs usually employed in treating tngeminal neuralgia may be particularly pronounced in cases of central nervous system disorders, as in multiple sclerosis Effective treatment of tngeminal neuralgia by operation allows discontinuation of these drugs with sometimes unexpected improvements of neurological conditions and quality of life

Acknowledgments This study has been supported in part by the EEC grant BMH-CT95-0502 "Mechanisms of Tngeminal Pain"

OUTCOME OF TREATMENT OF CHRONIC IDIOPATHIC FACIAL PAIN WITH FLUOXETINE AND COGNITIVE BEHAVIOURAL THERAPY

S Hamson. L Glover, C Femmann, S Pearce and M Harris (Dept ofMaxillofacial Surgery, Eastman Dental Hospital and Univ College London, WC1X 8LD, UK)

Aim of Investigation To compare fluoxetine (20mg daily) and cognitive behavioural therapy (CBT) alone and combined, in the treatment of chronic idiopathic facial pain

Methods A randomised double-blind placebo-controlled trial was undertaken (n=178) Patients were assigned to the following groups 1) placebo 2) drug 3) placebo and CBT 4) drug and CBT The treatment period lasted 3 months Patients were initially assessed clinically and by questionnaire and were reviewed for 1 year An intention to treat analysis was undertaken Pain was assessed using the Multidimensional Pain Inventory (MPI) and the McGill Pain Questionnaire Short-form Results Significant differences were found in MPI severity scores amongst the groups at one year, being reduced in all groups (p<0 01) MPI interference with life scores improved in all groups where patients were initially prescribed fluoxetine (p<0 01) The percentage number of patients who were unable to comply with the protocol were 31%, 35%, 50% and 44% respectively Those patients who received CBT appealed more able to comply with the protocol

Conclusion The study provides some evidence that fluoxetine can be used alone and in conjunction with CBT to reduce pain severity, and interference scores in chronic idiopathic facial pain

Acknowledgments Drugs were provided by Ell Lilly, UK

SELECTION OF TENDERNESS TEST SITES FOR EVALUATING TEMPORO-MANDIBULAR DISORDER PATIENTS

Yasuo Hatano. Crown and Bridge Dept, The Nippon Dental Univ, School of Dentistry at Tokyo, 2-3-16 fujiitii, Chiyoda-ku Tokyo 102-8158 Japan

Aim of Investigation The purpose of this study is to select a combination of tenderness test sites effectively to prognose the after treatment status

Methods The tenderness level difference of 30 sites around head and neck between the right side and the left side were analyzed along with tenderness level of 34 sites at each side Stepwise analysis was used for this purpose. One hundred twenty-five TMD patients visited our Dept, treated with stabilization type splint were used The tenderness level determined by digital palpation before and after treatment were analyzed The tenderness was recorded into 0, 1, 2 and 3 scores according to the response ]

Results 1 The highest correlation for 10 sites at before treatment was, upper pan of the stemocleidomastoid muscle, middle of the superficial masseter, insertion oftemporalis, posterior ramus ofth< mandible, middle oftemporalis, middle part of the stemocleidomastoid muscle, lateral pterygoid, mental foramen, posterior TMJ and occipital area The correlation coefficient between the sum of those 10 sites and total sum of 34 sites was high (r = 0 958) 2 The summation of side differences of tenderness at mental foramen, infra orbitalis, and inferior part oftrapezius minus side differ ences of lateral TMJ, plus a right and left summation of posterior ramus of the mandible and shoulder tips, showed the highest correlation (r = 0 556) with a post-treatment tenderness total summation 3 The summation of side differences of superior masseter origin, posterior digastrics, plus a right and left summation of insertion of superior masseter and shoulder tips, showed the highest correlation (0 485) with a post-treatment tenderness total summation

Conclusion Combination of selected sites tenderness summation gives us some sort of information of tenderness level at after treatment status

PSYCHOLOGICAL FINDINGS IN SUBJECTS WITH TEMPORUMANDIBULAR DISORDER PAIN AND BURNING MOUTH SENSATIONS

Christian Hirsch*. Mike John*, Arco ZwiJnenburg*, (SPON Jens C. Turp, Univ Freiburg), Martin-Luther-Univ Halle and Univ Leip zig, Zentrum fur ZMK, 06097 Halle, Germany

Aim of Investigation To investigate psychological factors in subjects with temporomandibular disorder pain (TMD) and burning mouth sensations (BMS)

Method Prevalence of TMD and BMS using NHIS questionnaire (Lipton et al , 1993) and eight psychological factors using the "Giessen-Test", the "STAI", and the "Beschwerdenliste" (somatiza-tion) were examined in a population based sample of 620 subjects Results- Prevalence of TMD pain was 9 2% (n=57, 74% female), and 3 5% (n=22, 50% female) for BMS Three of eight variables showed significant differences (ANOVA), gender was not a significant factor

Variable Only TMD Only BMS TMD+ BMS Without TMD/BMS P
N 48 13 9 550  
% 7.7 2.1 1.5 88.7  
Social Resonance 45.6 49.7 46.9 48.4 -
Dominance 47.5 54.3 50.5 49.7 -
Control 49.8 55.8 59.8 50.2 ++
Depression 58.2 55.0 57.2 54.2 +
Open-mindedness 49.8 49.2 53.8 50.5 -
Social Potential 52.3 49.0 56.2 50.4 -
Somatization 56.5 55.4 56.6 53.1 +
Anxiety-State 5.3 5.1 5.9 5.2 -

- (non significant,),+(,p<0,05), ++(p<0,01i)

Conclusion TMD and BMS are prevalent in the population Oro-facial pain has a significant influence on psyche TMD has more impact than BMS and occurrence of both conditions increases the effect

Acknowledgments This study was supported by Deutsche Akademie der Naturforscher Leopoldina, Grant LPD96 (BMBF), and by Forschungsverbund Public Health Sachsen, Grant 01EG9532/0.

A PROTOCOL FOR ASSESSING PATIENTS WITH OROFACIAL PAIN

A Just*. Chronic Pain Service, Canberra Hospital, Canberra, ACT 2614 P Hyde*, Westmead Hospital Dental Clinical School, Sydney 2145 I. Taylor*, R Hams, Univ of Sydney Pain Management and Research Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia

Aim of Investigation To evaluate an evidence- based protocol to be used for taking a pain history from patients presenting with temperomandibular dysfunction (TMD) and orofacial pain

Background of Study Orofacial pain is frequently presented to dental, medical and nurse practitioners. TMD is emerging as one of the most frequent bases for orofacial pain, with 60% of complaints providing evidence for this diagnosis (Vickers ER, Cousins MJ, Woodhouse A, 1998) In many patients a diagnosis cannot be ascertained. Chronic orofacial pain patients need a balanced assessment and treatment of both sensory and emotional components for problem resolution Clinicians are challenged by the complexity of many orofacial pain presentations, particularly the way in which psycho-emotional issues cohere in the clinical interview with sensory issues about pain duration, intensity and site

Methods Data were collected using the MCQ and VAS Scores of patients presenting with orofacial pain in three pain clinics Qualitative data from semi-structured interviews revealed significant levels of previously undiagnosed physical and emotional trauma

Conclusions A protocol developed from quantitative and qualitative data facilitates the taking of pain history from patients presenting with orofacial pain It is balanced as to sensory and emotional components and is a useful clinical and teaching tool in multidisciplmary clinics

STUDIES ON THE USE OF LOW INTENSITY LASER THERAPY (LILT) FOR OROFACIAL PAIN

H Karasu*, S Sattayut*, P. Bradley* (SPON GD Baxter) Dept of Oral and Maxillofacial Surgery, St Bartholomew's & The Royal London Hospital Medical & Dental School, Turner St, London El 2AD, UK

Aim of Investigation LILT is increasingly advocated for pain relief plus augmentation of healing in the orofacial region and merits careful assessment

Methods 1) Trial of Pain Relief in Temporomandibular Joint Disorder (TMD) Studied 30 female patients with TMD pain of over 6 months randomly allocated into 3 groups namely conventional energy 820 nm LILT, high energy 820 nm LILT and placebo before and after 3 therapy sessions over a one week penod Evaluation was by symptom seventy indices (SSI/PRI-T), algometry of pressure pain thresholds (PPT) of trigger points, electromyography (EMG) and jaw kmesiology 2) Vascular response trial Four LILT wavelengths (660nm, 820nm, 1060nm, 10,600nm) were evaluated in patients, rabbit ear preparation and human volunteers by ther-mography for surface temperature change, laser doppler for micro-circulatory flux and ultrasound doppler for arterial status

Results 1) The TMD pain study showed that the high energy LILT group had statistically significant increases in PPT and EMG clenching amplitude A significantly greater number of patients recovered from myofascial pain and TMJ arthralgia as assessed clinically in the high energy group, compared with placebo (P value = 0 012 and 0 001, respectively). 2) The vascular study revealed that LILT can produce significant rises in surface temperature and microcirculatory flux related to fluence

Conclusion: LILT at 820nm has a statistically significant beneficial effect on TMD painful disorder in a high-energy regimen It can increase microcirculatory flux which may disperse nociceptive agents

Acknowledgments Royal Hospital Trustees Research Grant Ethical Committee Approval P/96/332 Home Office Project License PPL/70/3815

IS POSTURE CORRECTION IN DAILY LIFE AS PART OF COGNITIVE BEHAVIORAL THERAPY EFFECTIVE IN ALLEVIATING MYOFASCIAL PAIN WITH LIMITED OPENING?

O. Komiyama. M Kawara*, M Aral* and K Kobayashi* Dept of Prosthodontics, Nihon Univ. Sch. of Dent at Matsudo, Chiba 271-8587,Japan

Aim of Investigation. To Investigate the effectiveness of cognitive behavioral (CB) intervention with or without posture correction in daily life to those who suffer from myofascial pain with limited opening

Method: Outcome data come from the sample of 51 patients who completed the entirely study One group received CB intervention (IT-1). Another group received CB intervention with a posture correction in daily life (IT-2) The nonmtervention control group (CT) was only given a generalized instructions The pain-free unassisted mouth opening was measured and their current pain intensity at maximum mouth opening and disturbance in daily life were evaluated by visual analogue scale (VAS) every month, earned out for 12 months

Results. Pain-free unassisted mouth opening significantly increased in IT-2 after 1 month In IT-1, the value gradually increased and after 2 months rose significantly The values in CT increased more gradually over time, with significant difference occurring at 6 months from the baseline value After 2 months in CT and IT-1 and after 1 month in IT-2, there was a significant fall in VAS from the baseline values The three groups displayed similar ratings, with CT being slightly less pronounced

Conclusions It was suggested in this study that CB intervention might be effective in the management of pain in those suffering from myofascial pain with limited opening, and that the addition of posture correction in daily life to the intervention might provide more benefit to the recovery of function

RECRUITMENT UPTAKE AND PROFILE OF PATIENTS REFERRED TO A FACIAL ARTHROMYALGIA PAIN RESEARCH CLINIC

R. Leeson*. P. O'Neilly*, R Ibbetson*, M Harns*, (SPON C Femmann) Eastman Dental Hospital, Univ College London WC1X 8LD, UK.

Aims of investigation To examine recruitment and profile of patients referred to an ongoing randomised, controlled study comparing medical and physical therapy in the management of Facial Arthromyalgia.

Methods 1,730 General dental practitioners were contacted within and around the London area requesting patients suffering from Facial Arthromyalgia. Sociodemographic details, pain and psychometric assessment with standardised questionnaires, history, clinical and radiographic examination were recorded for each new patient.

Results: Over 3? years, 1,007 patients were referred for screening and assessment as potential participants in the study Patients were (22% male, 78% female) mean age 37 years(range 8-88 years) The majority of patients, 60% were employed. 91% of patients had signs and symptoms of pain or discomfort on presentation having experienced pain for a mean duration of 3 years (range 1 wk -32yrs.) 242 patients (24%) met the inclusion criteria for recruitment and consented to participate in the study Indications for exclusion from the study were numerous. The largest group included patients who expressed contentment with reassurance and conservative advice without the need to pursue further treatment ( 23%)

Conclusions. Patients within the clinic population were predominantly female (78%), employed, in the third decade of life having experienced pain for a mean three years 23% of patients with mild symptoms were content with informed reassurance undertaken within the hospital environment

Acknowledgments Medication provided by Ell Lilly, UK

FACTORS ASSOCIATED WITH ANXIETY AND DEPRESSION IN FACIAL ARTHROMYALGIA (TEMPO-ROMANDIBULAR JOINT PAIN, TMD)

Geir Madland2, Charlotte Femmann, Stanton Newman*, Health Psychology Unit, Royal Free & Univ College Medical School, London WIN 8AA, and Eastman Dental Insr, London WC1X 8LD,UK

Aims Facial arthromyalgia (temporomandibular joint pain dysfunction syndrome, TMD) is a chronic pain condition of unknown origin This study examines the extent to which the condition is associated with symptoms of anxiety and depression It also identifies factors which may be associated with raised levels of these two moods and with the presence of clinical anxiety and clinical depression

Method Self-report measures of pain beliefs (Pain Beliefs Questionnaire), pain coping (Coping Strategies Questionnaire), pain intensity (McGill Pain Questionnaire, short form), disability (Oral Health Impact Profile) and mood (Hospital Anxiety and Depression scale) were administered to a sample of 80 facial arthromyalgia patients of differing chronicity, referred from primary care (General Dental Practice)

Results The prevalence rates for possible clinical anxiety and depression in this group were 58% and 23% respectively Factor Analyses followed by Multiple Regression Analyses showed anxious mood to be associated with several factors including passive coping in terms ofcatastrophismg about pain (14% of the variance), speech problems (12%), and beliefs that pain is worsened by negative mood (9%). Depressed mood was associated with catastrophismg (34%) and disability in the form of disturbance m taste and digestion (16%)

Conclusions The associations ofcatastrophising with anxious mood, and of perceived disturbance in taste and digestion with depressed mood, are new findings in facial arthromyalgia patients Cognitive factors, relating to distress and disability, may be considered as potential targets for therapy, rather than the orthodox objective of pain relief

Acknowledgments Geir Madland holds a MRC Clinical Training Fellowship

BURNIG MOUTH - A MULTIDISCIPLINARY ASSESSMENT

C Nasn. MF Oliveira, M Okada, G Formigoni, MJ Teixeira, JTT Siqueira, Orofacial Pain Team, Dentistry Div, and Pain Center, Hosp das Clinicas, Sao Paulo Univ, CP 30657, Brazil

Aim of Investigation Evaluation of the clinical disciplinary and laboratonal aspects of patients presenting burning mouth

Methods. Patients were evaluated accordingly ta the following protocol 1) Multidisciplmary and McGill pain questionnaires, 2) Clinical evaluation, 3) X-rays exams, 4) Laboratory exams (biochemical, microbiologiacal, imunological, hemathological, hormonal, B12 vit, folic acid), 5) Beck and Idate Inventanes

Results. 25 patients (21 female and 4 male) mean age 60,24 (ranging from 37 to 83 years), presents burning sentations in the tongue (64%), palat (32%), gmgiva (20%), lips (20%), oral mucosa (32%), Mean duration of pain complaint was 4 07 years, Xerostomy (60%), gastric disorders (72%); systemics diseases (72%), meno-pause (76%), sleep abnormalities (68%), psychiatric disorders (48%) were adictional aspects precipititing events pos operatory (38 46%), emotional (23 07%), post trauma (15 38%), post radiation (7 6%);RA (7 6%), Endoscopy (7 6%) were founding in 52% of the cases Dental conditions Edentulous (44%), Masseter tenderness to palpation (60%), dental prosthesis (64%), gradual complaint intensity (80%) Laboratory exams without significant alterations

Conclusions: The presenting data showed that high pre\alence of BM in female during menopause is in accordance with the literature The high presence of patients with gastric complaints suggests sleep and emotional disturbances maybe important contributing factors related with the aetiology However neuropathic conditions maybe related with its origin also

NEUROGENIC VASODILATATION IN TRIGEMINAL NEURALGIA

Turo Nurmikko. Carol Haggett, John Miles, Pain Research Inst, The Walton Centre for Neurology and Neurosurgery NHS Trust, Liverpool L9 7LJ, UK

Aim of Investigation It has been previously suggested that shooting pain in trigemmal neuralgia is generated by excessive firing of the cells of the tngeminal ganglion If intense enough, this firing should be expected to lead to cutaneous vasodilatation within the affected dermatome

Methods We studied a 65-year old female patient with a nine-year history ofidiopathic tngeminal neuralgia involving the first division on the left At presentation, she complained of intense tngeminal pain with three distinct components (1) pain shooting from the eye up to the forehead, provoked by talking, eating and touching the face, (2) paroxysms of a "machme-gun-like" pain inside the eye, and (3) constant burning pain around the eye, made worse by heat Laser Doppler analysis of skin blood flow was earned out on both sides of her forehead, prior to and following partial rhi70tomy

Results During pain, the patient was seen to have a red and swollen upper eyelid on the affected side Measurement of cutaneous blood flow showed marked increase on the ipsilateral forehead These abnormalities disappeared after surgery On follow up (up to 12 months) she reported complete relief of all three components of pain The postoperative sensory changes in the first and second divisions normalised over several months

Conclusion- We postulate that the flare reaction and different types of pain in this case resulted from an unusually intense ectopic firing within the tngeminal ganglion and root, leading not only to tic doloureux but to neurogenic inflammation and nociceptor sensiti-sation The latter would explain the burning component of the pain

CHRONIC PAIN IN YOUNG WOMEN: A RACIAL COMPARISON

O Plesh. SA Gansky*, PB Crawford*, ZI Sabry*, School of Dentistry and School of Public Health, Univ of California, San Francisco and Berkeley, CA 94143-0758, USA

Aim of Investigation To assess types of common chronic pains in a community cohort of young black and white women of similar socioeconomic background

Methods 516 young women (48% black, 52% white) currently 19-21 years old were recruited from an established community dwelling cohort in west Contra Costa County, California This study joins the ongoing, 10 year longitudinal US National Heart, Lung and Blood Inst Growth and Health Study Structured telephone interviews administered the "life pain history questionnaire" (von Korffet al, 1988), which included questions on pain lasting at least 1 whole day occumng several times in a year at 5 sites' back, head, abdomen, chest, and face/Jaw

Results Chronic pains were reported with the following overall prevalence' 57% back, 48% head, 34% abdominal, 22% chest, and 17% facial/Jaw There were no significant racial differences in reported back, head or chest pain, but prevalences differed for abdominal and facial pain 29% of white and 39% of black women had abdominal pain (Fisher's exact test p= 020), while 22% of white and 12% of black women had facial/Jaw pain (p= 003) Moreover, white women reported significantly more Jaw pain signs and symptoms than black women' pain on chewing (27% to 14%, p< 001) momingjaw stiff-ness (26% to 15%, p= 002), morning headaches (39% to 31 %, p= 065), and Jaw clenchmg/ grinding (43% to 27%, p< 001)

Conclusion Although there were no significant differences between black and white women in the other types of common pain screened, black women reported significantly more abdominal pains, while white women reported significantly greater amounts of facial/Jaw pain and associated signs and symptoms

Acknowledgments Support NIH/NIDCR DEI 2531 grant

MASTICATORY MUSCLE PAIN IN THE PATIENTS WITH FIBROMYALGIA

JTT Siqueira. LH Chmg, AP Vilela, M Miyazawa, H Kaziyma, TY Lm, Orofacial Pain Team, Dentistry Div, Hosp das Clinicas, Sao Paulo Univ, CP 30657, Brazil

Aim of Investigation Evaluate the incidence oforofacial pain in a sample of patients with Fibromyalgia, and the short and long duration results after aplication of a local therapy

Methods Patients with diagnosis of Fibromyalgia (ACR, 1990) were submitted to the following protocol'1) Orofacial and McGill pain questionnaires, 2) Helkimo Index Basic treatment 1-occlusal splint, 2- physical therapy Evaluation Two groups, A (short follow-up = ninety days and B (longitudinal follow-up = ranging beetwen two and five years), 1- Subjective a) VAS, b) quantitave scale 0-10, c)subjective improvement descriptors - SM, PM, S, 0, SD (no, little, satisfactory, good improvement and no pain, respectively)

Results Group A - ten patients were evaluated with the following results - Complete denture=5, impaired dentures=4, craniofacial pam=7; (pain caused by mandibular function, muscle stiffness after mastication=2) Group B- three females with facial or cervical pain with long duration complaint and treatment for Fibromyalgia that after the local treatment had the segmentar pain absolutely under long duration control (SD,SD and 0) Two of these patients had improvement of the general pain after the control of the facial pain All the patients were female and the age average was 40 years Altrough masseter muscle has not been quoted by the ACR criteria for the classification for Fibromyalgia, tenderness in this muscle was found in 90% of the patients evaluated, 80% has presented objective pain when examined although only 50% had subjective complaint in the facial area The average subjective improvement was 59% (ranging from 45% to 70%) in the period of 15 days after therapy introduction

Conclusions. Patients with Fibromyalgia can also present TMD The association between them remains unclear but when the patient has TMD or when TMD diagnosis is unclear but the patient has a painful facial condition associated with local factors that can con-tnbute to the maintenance of the pain, the elimination of these factors is important to achieve the pain control and the basic treatment is the conventional for this disorder

ARTISTIC EXPRESSIONS OF TRIGEMINAL NEURALGIA

Joanna M Zakrzewska. Oral Medicine Dept, St Bartholomew's and The Royal London School of Medicine and Dentistry, London E12AD, Amanda C de C Williams Pain Input Unit St Thomas Hospital London SE1 7EH UK

Aim of Investigation: To involve patients in the diagnosis and management oftrigeminal neuralgia through patient generated artistic material.

Method: Members of the Pan-American Trigeminal Neuralgia Association support group were asked to generate artistic material for their second national conference.

Results:5 drawings and 8 poems were submitted. The power of these pieces of work is striking and as well as the accuracy with which they reflect the diagnostic criteria proposed by the IASP.

"...Oh the horror of this pain
The ice pick stabs again
The quickness of the pain
Has come and gone again...."

"..Now it is time to eat
Then brush those teeth
Here comes great fear again..."

"..I want to help
but don't know how
Afraid to touch
Your cheek or brow..."

"..Then lo and behold, a support group you found,
With people that all shared your pain
Information was learned, medications tned and the tic you started to tame.
Things improved for a while, you started to smile,
Then back with a vengeance it came..."

Conclusion: These works of art can be used not only for patients to express their feelings but also to help other patients describe their pain and to educate health care professionals as to the nature of this severe form of facial pain.

THE RELATIONSHIP BETWEEN CHRONIC TEMPOROMANDIBULAR JOINT PAIN AND JOINT EFFUSION

Jae-Kap Choi. Sang-Soo Rheu*, Dept of Oral Medicine, Kyung-pook National Univ School of Dentistry, 101 Dongin-Dong, Chung-Ku, Taegu, 700-422, KOREA

Aim of Investigation: To investigate the relationship between chronic temporomandibular joint (TMJ) pain and the amount of joint effusion in patients with TMJ disc displacement.

Methods: Magnetic resonance images ofTMJs were taken for the 223 patients who complained with chronic TMJ symptoms. The disc position was assessed on the Tl-weighted images and was classified into normal position, disc displacement with reduction (DDWR), and disc displacement without reduction (DDWOR). The amount of joint effusion was assessed on the T2-weighted images and was graded as Grade 0,1, II, III according to the size of high signal intensity in the joint. The statistical significance was tested with Mantel-Haenszel Chi-Square test.

Results: No effusion was found in 65.9% of the joints with normal disc position, 25.9% of the joints with DDWR, and 12.8% of the joints with DDWOR, whereas the Grade III effusion was found in 1.5%, 17.5%, and 28.4% respectively. Seventeen point four percent of the joint with no effusion, 19.4% of the joint with Grade I effusion, 26.0% of the joint with Grade II effusion, and 37.0% of the joint with Grade III effusion was related to chronic joint pain.

Conclusions: There was a positive relationship between the degree of TMJ disc displacement and the presence of joint effusion. The TMJ with a higher amount of effusion showed a higher prevalence of joint pain than the joint with no or less effusion.

EFFECTS ON CHINESE MEDICINE FOR INFLUENCE OF PSYCHOSOCIAL FACTORS IN ORAL REGION PAIN

Kazuyoshi Koike. Nobuhito Matsura, Yasuhito Hukatsu, Minoru Gotou, Tosio Matsuno2, Masato Murakami3, Division of Clinical Research, Nihon Univ School of Dentistry, Dept of psychosomatic medicine, Nihon Univ Hospital, First dept of internal medicine, Nihon Univ School of medicine, Tokyo, Japan

Aim: Most pain experienced by patients suffering from oral disorders is associated with psychological factors and is often relieved by the administration ofanxiolytics or antidepressants. Yet in some patients pain is unresponsive to treatment and persists. We have tned Chinese medicine on such intractable pain and achieved satisfactory results. The herb medicine employed in the present study was Kanbakudaisoutou.

Subjects: Subjects consisted of 47 patients (46 females, one male) with intractable pain in the oral cavity, including glossalgia; in all of the patients, some social influence was suspected in the patholo-genesis of the pain. The herb medicine was used independently in eight patients and supplementally in 39 to the ineffective anxiolytic and/or antidepressant agents.

Results: Of the 47 subjects, the herb proved remarkably effective in 21, effective in 13, and ineffective (no change achieved) in 13. Discussion: In our present study of mostly females, the effective rate was estimated at 72.3%.

Conclusions: The use of Chinese medicine should be considered when the patient is under the sustained effect of pain that is refractory to Western medicine.

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p. 302 - 308

   

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