Journal of Oral & Facial Pain and Headache, 04/2021

Aims: (1) To deepen knowledge on how specialized health care professionals (HCPs) reflect on encounters with children diagnosed with juvenile idiopathic arthritis (JIA) and (2) to outline a theory for orofacial care. Methods: Grounded theory was used to discover the psychosocial processes involved in communication between HCPs, children, and parents, and this information was used to develop a theory about these processes. Using classic grounded theory, a total of 20 interviews with HCPs were analyzed. Results: One main concern, “secure health and biopsychosocial development,” permeated all care. A core category was identified as “create a responsive interaction with the child and family.” The data that supported this core category helped to explain how the HCP responded to a patient to promote orofacial health. Based on the dentist’s responses to the child, eight subcategories were identified: (1) secure confidential relationships; (2) convey disease-specific knowledge; (3) communicate healthy findings and form mutual insights at examination; (4) encourage health-promoting behaviors; (5) ensure follow-up; (6) share perspectives; (7) guide parenting; and (8) improve knowledge and networks. Conclusion: How the dentist shall best understand the needs of a child diagnosed with JIA requires further evaluation. To promote oral health, the child must feel safe, confirmed, and supported with knowledge. Also, further studies are needed on the dentist’s collaboration with the pediatrician and the physiotherapist for contributing to overall health. Keywords: interdisciplinary network, juvenile idiopathic arthritis, oral health, professional care, qualitative

Aims: To determine the effects of botulinum toxin type A (BoNT-A) on the psychosocial features of patients with masticatory myofascial pain (MFP). Methods: A total of 100 female subjects diagnosed with MFP were randomly assigned into five groups (n = 20 each): oral appliance (OA); saline solution (SS); and three groups with different doses of BoNT-A. Chronic pain-related disability and depressive and somatic symptoms were evaluated with the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis II instruments at baseline and after 6 months of treatment. Differences in treatment effects within and between groups were compared using chi-square test, and Characteristic Pain Intensity (CPI) was compared using two-way ANOVA. A 5% probability level was considered significant in all tests. Results: Most patients presented low pain-related disability (58%), and 6% presented severely limiting, high pain-related disability. Severe depressive and somatic symptoms were found in 61% and 65% of patients, respectively. In the within-group comparison, BoNT-A and OA significantly improved (P < .001) scores of pain-related disability and depressive and somatic symptoms after 6 months. Only the scores for painrelated disability changed significantly over time in the SS group. In the betweengroup comparison, BoNT-A and OA significantly improved (P < .05) scores of all variables at the final follow-up when compared to the SS group. No significant difference was found between the BoNT-A and OA groups (P > .05) for all assessed variables over time. Conclusion: BoNT-A was at least as effective as OA in improving pain-related disability and depressive and somatic symptoms in patients with masticatory MFP. Keywords: botulinum toxin, depression, myofascial pain, psychosocial impairment, temporomandibular disorders

Aims: To evaluate the efficacy of intravenous preemptive analgesia on postoperative pain in children undergoing dental rehabilitation under general anesthesia. Methods: In this prospective randomized clinical trial, 70 children aged 3 to 7 years were scheduled for dental treatment and randomized into two groups: the control group or the preemptive group. Patients received 15 mg/kg of intravenous paracetamol either before the start of treatment (preemptive group, n = 35) or at the end of treatment (control group, n = 35). Postoperative pain scores were recorded at 1, 2, 4, 6, 8, 12, and 24 hours using the Wong-Baker FACES Pain Rating Scale (WBFS). Additionally, the need for rescue analgesic and the total opioid consumption of the patients were recorded during the first 24 hours postoperative. Results: The pain scores in the preemptive group were significantly lower than those in the control group at the postanesthesia care unit and at 2, 4, and 8 hours postoperative (P < .05). However, there were no statistically significant differences in pain scores between groups at 12 and 24 hours postoperative. Need for rescue analgesics and total intravenous fentanyl consumption were significantly higher in the control group than in the preemptive group (P < .05). The percentage of children who received medication for pain relief at home was higher in the control group than in the preemptive group, but the difference was not statistically significant (P > .05). Conclusion: Preemptive use of intravenous paracetamol reduces postoperative pain scores and postoperative opioid consumption. However, there is a need to evaluate pain levels in children who receive comprehensive dental treatment under general anesthesia after hospital discharge for effective postoperative pain control. Keywords: children, dental treatment, general anesthesia, opioid, postoperative pain

Aims: To compare the suitability of Graded Chronic Pain Scale (GCPS) pain intensity and interference assessments (GCPS version 1.0 vs 2.0) for the biopsychosocial screening and subtyping of Finnish tertiary care referral patients with TMD pain. Methods: Altogether, 197 TMD pain patients participated in this study. All patients received Axis II specialist-level psychosocial questionnaires from the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD-FIN) and Research Diagnostic Criteria for Temporomandibular Disorders (RDC/ TMD-FIN), as well as questionnaires for the assessment of additional painrelated, biopsychosocial, and treatment-related variables. Clinical examinations were performed according to the DC/TMD Axis I protocol. The patients were categorized into TMD subtypes 1, 2, and 3 (GCPS I and II-low; II-high; and III and IV, respectively) based on their biopsychosocial profiles according to GCPS versions 1.0 and 2.0. Results: The distribution of TMD pain patients into TMD subtypes was similar according to the GCPS 1.0 compared to the GCPS 2.0. Over 50% of the patients were moderately (TMD subtype 2) or severely (TMD subtype 3) compromised. Patients in subtype 3 experienced biopsychosocial symptoms and reported previous health care visits significantly more often than patients in subtypes 1 and 2. Patients in subtype 2 reported intermediate biopsychosocial burden compared to subtypes 1 and 3. Conclusion: TMD pain patients differ in their biopsychosocial profiles, and, similarly to the GCPS 1.0, the GCPS 2.0 is a suitable instrument for categorizing TMD tertiary care pain patients into three biopsychosocially relevant TMD subtypes. The GCPS 2.0 can be regarded as a suitable initial screening tool for adjunct personalized or comprehensive multidisciplinary assessment. Keywords: DC/TMD, GCPS, psychosocial, RDC/TMD, temporomandibular disorders

Aims: To highlight and discuss the term “refractory” when used to describe pain conditions and its application to orofacial pain, as well as to highlight the factors that must be considered in a refractory patient. Methods: A scoping review of recent publications (2010 to 2021) applying the term “refractory” to orofacial pain was conducted, and this paper presents their limitations and definitions. Results: The term “refractory” is often used to describe pain instead of “persistent” or “nonresponsive.” There are clear definitions in the use of refractory for migraine, cluster headaches, and other nonheadache disorders. Currently, the term is applied to pain conditions in order to alter the patient pathway of treatment, sometimes to escalate a patient from one care sector to another and sometimes to escalate treatment to more costly surgical interventional techniques. Conclusion: There is a need for a clear definition for use of the term “refractory” in orofacial pain conditions, excluding migraine and cluster headaches. In addition, there is a requirement for a consensus on the implications of the use of refractory when assessing and managing patients. Keywords: nonresponsive, orofacial, pain, persistent, refractory

Aims: To investigate the effectiveness of the auriculotemporal nerve block (ATNB) technique in conjunction with noninvasive therapies for the treatment of disc displacement with reduction (DDWR) or without reduction (DDWOR) in addition to arthralgia of the temporomandibular joint (TMJ). Methods: The data of 22 patients diagnosed with DDWR and DDWOR whose clinical conditions did not improve despite noninvasive treatments were analyzed. ATNB was applied to each patient during the first visit and readministered at 1- and 4-week follow-up visits. Pain intensity values (0 to 10 visual analog scale [VAS] scores) were evaluated pre- ATNB and at the 6-month follow-up visit, and the maximal mouth opening values were measured pre-ATNB and at the 1-week, 4-week, and 6-month follow-up visits. Results: Noninvasive therapies did not make a significant difference in the outcomes between the initial visit and first administration of ATNB (VAS P = .913, MMO P = .151). However, there were significant differences in outcomes between pre-ATNB and the 1-week (MMO P = .000), 4-week (MMO P = .000), and 6-month (VAS P = .027, MMO P = .000) follow-ups. Conclusion: ATNB may be considered as a supportive treatment approach in noninvasive TMJ disorder therapies. Keywords: anesthesia, auriculotemporal nerve block, local, physiotherapy, temporomandibular disorders

Aims: To evaluate the association between clinical signs/symptoms and bone changes on CBCT images in patients with degenerative joint disease (DJD) of the temporomandibular joint (TMJ). Methods: An electronic literature search of the MEDLINE, PubMed, EMBASE, Scopus, and Web of Science databases, as well as Google Scholar for gray literature, was conducted to identify relevant articles on February 26, 2021. Risk of bias was evaluated using the Joanna Briggs Institute critical appraisal tools. The GRADEpro (Recommendation, Assessment, Development, and Evaluation) system instrument was applied to assess the level of evidence across studies. Results: Nine papers assessing clinical signs/symptoms and CBCT findings were included. TMJ pain (arthralgia) and TMJ noises carried the strongest associations with various CBCT findings, each of which were supported by four studies with significant associations. Only one study found significant associations between masticatory myalgia (muscle pain) and CBCT findings. Range of motion carried no significant associations with CBCT findings in the included studies. Based on the GRADEpro system, the certainty of evidence is low for said associations. Conclusion: The results suggest that TMD patients with TMJ arthralgia and joint noises may benefit from CBCT imaging. There would be less benefit in TMD patients exhibiting primarily myalgia or limited range of motion, and therefore these patients should not be prescribed routine CBCT radiographs unless indicated by other clinical findings. The heterogeneity of reporting in the included studies suggests that embracing universal clinical (DC/TMD) and radiographic diagnostic criteria for TMJ-DJD would benefit both research and clinical outcomes.