Journal of Oral & Facial Pain and Headache, 03/2002

The principal aim of the Third Educational Conference to Develop the Curriculum in Temporomandibular Disorders and Orofacial Pain was to enhance the teaching of temporomandibular disorders (TMD) and orofacial pain to predoctoral dental students and to postdoctoral students in this field. Within this context, the conference sought to: (1) provide information regarding the current status of the predoctoral and postdoctoral teaching of TMD and orofacial pain, (2) present ways in which teaching of the basic sciences can be better integrated into the teaching of TMD and orofacial pain in the predoctoral and postdoctoral curriculum, (3) present ways in which the teaching of oral medicine can be better integrated into the teaching of TMD and orofacial pain in the predoctoral and postdoctoral curriculum, and (4) discuss how TMD and orofacial pain should be taught in a manner that is consistent with newly proposed accreditation standards. The papers addressing these specific aspects, as well as a summary paper on the conclusions from the conference, are presented in this issue of the journal. Keywords: orofacial pain, temporomandibular disorders, dental curriculum, educational conference

This paper addresses questions 2 to 6 posed in the charge to the conference to discuss the study of temporomandibular disorders (TMD) and orofacial pain from the perspective of the predoctoral dental curriculum. This paper lends itself to an additional query: how much diagnostic and therapeutic skill relative to TMD and orofacial pain should a new graduate possess and demonstrate to be deemed competent in accordance with the definition of competence of the American Dental Association's Commission on Dental Accreditation? Although much of the content of this and the accompanying articles from the conference pertain to the TMD and orofacial pain curricula of dental schools in North America, most of what is presented here is universal to the teaching of the subject matter; therefore, it could be applied to educational institutions in other parts of the world. Indeed, an international survey relative to the teaching of TMD and orofacial pain would be of interest and value to dental schools worldwide. Keywords: orofacial pain, temporomandibular disorders, dental curriculum, educational conference

This paper outlines several aspects of the integration of basic sciences into the predoctoral dental curriculum. It addresses a number of the points or questions posed by the organizers of the Third Educational Conference to Develop the Curriculum in Temporomandibular Disorders and Orofacial Pain. The importance of the basic sciences for a comprehensive overview of knowledge bearing on temporomandibular disorders and orofacial pain is first emphasized, followed by considerations of what material should be taught and by whom. The paper concludes by considering at what stage of the curriculum this material should be included, how the pertinent basics sciences should be taught, and under what circumstances. Under the term "basic sciences" are included not only relevant biomedical or biologic sciences such as physiology and anatomy, but also the behavioral sciences such as psychology and cognitive science. Keywords: biological sciences, behavioral sciences, curriculum, dentistry, temporomandibular disorders, orofacial pain, continuing education

This paper discusses the role of oral medicine in the teaching of temporomandibular disorders (TMD) and orofacial pain. Education in orofacial pain and TMD has traditionally been managed in academic dental settings as 2 distinct processes separate from the teaching of diagnosis and management as applied to systemic diseases and oral conditions. The rationale for such a segmented approach appears to have been driven by the concept that orofacial pain usually reflects a localized disease rather than arising as a component of more generalized systemic disease or modulated in intensity or morbidity by systemic pathology, generalized neurobiological, or behavioral contributors. Conversely, oral disease and head and neck manifestations of systemic disease often provoke pain as a major symptom. Management of such conditions should include acute and long-term pain management strategies when the underlying condition has no definitive cure and the pain is disabling. An argument is made for integrating the teaching of oral medicine and orofacial pain to enhance a broad-based approach to the assessment and management of primary pain disorders and to assure appropriate management of pain that is associated with mucosal disease and other forms of regional or systemic pathology including behavioral disorders that present as somatic and painful complaints. Keywords: orofacial pain, temporomandibular disorders, dental curriculum, educational conference, oral medicine

This paper discusses the critical issues that surround the development of an orofacial pain program in a dental school and suggests strategies to address them. Since the University of Minnesota has an established orofacial pain program involved in both predoctoral and postdoctoral teaching, clinical and basic research, and interdisciplinary patient care over the past 20 years, this article uses this as a model for development of an orofacial pain program. The proposal includes overall goals, background and rationale, specific aims, and program activities, including teaching, research, patient care, and financial and resource needs. These features may be of assistance to those considering the development of such programs in the United States and elsewhere in the world. Keywords: orofacial pain, temporomandibular disorders, dental curriculum, educational conference

The ability to recognize, evaluate, and manage patients with temporomandibular disorders is an important component of general dental practice. Therefore, information about these disorders should be a basic part of the dental curriculum. Although most dental schools do include this subject in their educational programs, its teaching typically involves the presentation of didactic material in formal lectures or in seminars. This teaching, however valuable, rarely includes the "hands-on" clinical experience of actually caring for this patient population. To address this lack of clinical experience, the Department of Oral Diagnostic Sciences of the School of Dental Medicine at the University at Buffalo has also developed a special elective program to offer dental students in their final undergraduate year the opportunity to obtain such experience. Keywords: temporomandibular disorders, orofacial pain, dental education, patient care, descriptive epidemiology

Aims: To analyze the reliability, validity, and clinical utility of the depression, non-specific physical symptoms, and graded chronic pain scales comprising the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis II. Methods: Data resulting from independent longitudinal and cross-sectional epidemiological studies as well as randomized clinical trials conducted at the University of Washington and the University at Buffalo were submitted to descriptive, correlational, and inferential statistical analyses to evaluate selected psychometric properties of the RDC/TMD Axis II scales. Results: Analyses of available data from both TMD clinical centers revealed good to excellent reliability, validity, and clinical utility for the Axis II measures of depression, somatization, and graded chronic pain. Specifically, data were presented comparing the RDC/TMD depression scale to the Beck Depression Inventory and the Center for Epidemiologic Studies Depression Scale; these data supported concurrent validity of the RDC/TMD measure and its use as a depression screening tool. Its clinical utility lies in its demonstrated usefulness for alerting TMD clinicians to potentially noteworthy depressive symptomatology in TMD patients. Others have shown that elevated somatization, the tendency to report non-specific physical symptoms as noxious or troublesome, is a predictor of poor TMD treatment outcome. The present analyses demonstrated that the RDC/TMD Axis II non-specific physical symptoms scale has acceptable reliability and that severe levels of somatization can potentially confound interpretation of the Axis I clinical examination. The graded chronic pain scale was demonstrated to have clinical utility for tailoring TMD treatment to levels of a patient's psychosocial adaptation. Conclusion: The major RDC/TMD Axis II measures demonstrate psychometric properties suitable for comprehensive assessment and management of TMD patients. Keywords: temporomandibular disorders, depression, somatization, chronic pain, RDC/TMD, reliability, validity

Aims: To explore the relationships between sleep quality, perceived pain, and psychologic distress among patients with temporomandibular disorders (TMD). Methods: A total of 137 consecutive patients who sought care at the University of Kentucky Orofacial Pain Center for the management of TMD participated in this study and completed a battery of standardized, self-report questionnaires at their first clinic visit. The Pittsburgh Sleep Quality Index (PSQI) and the Multidimensional Pain Inventory (MPI) were used to measure patients' sleep quality and multiple dimensions of pain and suffering, respectively. The Revised Symptom Checklist-90 (SCL-90R) was used to evaluate psychologic symptoms. A median cutoff (PSQI total score: 10) divided the patients into 2 groups, ie, 67 poor sleepers and 70 good sleepers. Results: There were no statistically significant differences in gender and age distributions between the 2 groups. Poor sleepers reported significantly higher scores than good sleepers on each of the 14 scales of the SCL-90R (P .003) and on 7 of the 13 scales of the MPI (P .05). Stepwise multiple regression analyses demonstrated that poorer sleep quality was predicted by higher pain severity (P .001), greater psychologic distress (P .05), and less perceived life control (P .05). Conclusion: This study supports the frequent comorbidity of reported sleep disturbance, perceived pain severity, and psychologic distress in patients with TMD. Keywords: temporomandibular disorders, sleep quality, psychological tests

Aims: To specify the regions of the brain stem that are characterized by changes in substance P (SP)-like immunoreactivity following activation of capsaicin-sensitive afferents innervating temporomandibular joint (TMJ) tissues in New Zealand rabbits. Methods: Capsaicin, an activator of small-diameter unmyelinated and thinly myelinated nociceptive afferent fibers, was administered unilaterally to the right TMJ of experimental animals. Another group received vehicle solution and served as controls. The animals were sacrificed 6 hours post-treatment through transcardial perfusion. Their brain stems were removed and sectioned, and SP-like immunoreactivity was assessed in serial horizontal sections. Results: A decrease in brain stem SP-like immunoreactivity occurred ipsilateral to capsaicin application. This reduction was primarily localized in brain stem regions that correspond to the trigeminal main sensory nucleus, as well as subnucleus oralis, interpolaris, and caudalis of the trigeminal spinal tract nucleus. Conclusion: The present study revealed central nervous system changes following TMJ capsaicin treatment in rabbits. Keywords: temporomandibular joint, nociception, substance P, immunocytochemistry, rabbit