New Approaches to Differential Diagnosis of - NCBI

Anesth Prog 37:53 1990

New Approaches to Differential Diagnosis of Chronic Orofacial Pain Proceedings of a research workshop on chronic facial pain sponsored by the National Institute of Dental Research, April 3-4, 1989, Bethesda, Maryland. Guest Editors: James A. Lipton, D.D.S., Ph.D. and Patricia S. Bryant, Ph.D.

This volume presents a majority of the papers presented at the research conference "New Approaches to the Differential Diagnosis of Chronic Orofacial Pain," sponsored by the National Institute of Dental Research and held April 3-4, 1989. This issue also includes summaries of recommendations from four discussion groups during which the participants, all experts in pain research and related fields, discussed and identified special research needs and opportunities. The meeting had the following overall aims:

Discussion group leaders were responsible over the following several months for organizing and summarizing materials developed in the working groups into more concise statements, which appear in this volume. While acknowledging the controversies surrounding complex pain conditions, such as the temporomandibular disorders, this multidisciplinary group of clinical and basic scientists succeeded, in a relatively short period of time, in exchanging a great deal of information and establishing remarkable consensus about research needs. The conference organizers appreciatively recognize the contributions made by each of the presenters, discussants, discussion group leaders, and participants. Specific recommendations from this important conference have already played a major role in shaping the development of current NIDR initiatives to expand its role in research on chronic orofacial pain conditions. Though space constraints have required reducing the length of many of the conference papers, and omifting some of the more lengthy contributions, we hope that this volume will help stimulate further discussion and progress. Improved understanding of the wide array of factors and methods pertinent to differential diagnosis will be essential to improving the understanding, and ultimately management, of many chronic orofacial pain conditions. Patricia S. Bryant, Ph.D. Health Scientist Administrator Craniofacial Anomalies, Pain Control and Behavioral Research Branch Extramural Program National Institute of Dental Research James A. Lipton, D.D.S., Ph.D. Chief, Planning and Evaluation National Institute of Dental Research

* to identify and discuss promising new approaches and techniques for the diagnosis and measurement of chronic pain in the jaw and face. * to identify methods used in the diagnosis of other conditions that may show potential applicability to the diagnosis of chronic orofacial pain conditions. * to identify which of these, and other proposed methodologies, could be applied to population-based epidemiological studies of chronic orofacial pain conditions. * to identify significant unresolved issues, as well as the resources and research needed to resolve these issues.

Each of four discussion groups (Basic Science Issues, Clinical Practice Issues, Issues Bridging Basic Science and Clinical Practice, and Epidemiological Issues) addressed three questions: 1. Which orofacial pain conditions currently present the most diagnostically confusing or frustrating picture? 2. Which newer approaches and techniques have the greatest potential usefulness for the differential diagnosis of chronic orofacial pain conditions? 3. What unresolved research issues and training needs remain to be addressed before effective differential diagnosis can occur?

© 1990 by the American Dental Society of Anesthesiology

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"New Approaches to tie Differential Diagnosis of Chronic Orofacial Pain" Participants PLENARY SPEAKERS

Kenneth L. Casey, M.D. Chief Neurology Service Veterans Administration Medical Center Ann Arbor, Michigan 48105 (313) 769-7100 Ronald Dubner, D.D.S., Ph.D. Director Neurobiology and Anesthesiology Branch National Institute of Dental Research National Institutes of Health Building 30, Room B18 Bethesda, Maryland 20892 (301) 496-6804 Daniel M. Laskin, D.D.S., M.D. Professor and Chairman Oral and Maxillofacial Surgery Medical College of Virginia MCV Station, Box 566 Richmond, Virginia 23298 (804) 786-0602

SESSION SPEAKERS Introduction and Summary Patricia Bryant, Ph.D. Health Scientist Administrator Craniofacial Anomalies Pain Control and Behavioral Research Branch National Institute of Dental Research National Institutes of Health Westwood Building, Room 506 5333 Westbard Avenue Bethesda, Maryland 20892 (301) 496-7807

Joan Wilentz, M.A. Office of Planning, Evaluation, and Communications National Institute of Dental Research National Institutes of Health Building 31, Room 2C36 Bethesda, Maryland 20892 (301) 496-6705 Behavioral Aspects Richard Gracely, Ph.D. Neurobiology and Anesthesiology Branch National Institutes of Dental Research National Institutes of Health Building 10, Room 6S-248 Bethesda, Maryland 20892 (301) 496-5238

Francis Keefe, Ph.D. Associate Professor Department of Medical Psychology Duke University Medical Center Box 3926 Durham, North Carolina 27710 (919) 684-6212 James Lipton, D.D.S., Ph.D. Chief Planning and Evaluation Section Office of Planning, Evaluation, and Communications National Institute of Dental Research National Institutes of Health Building 31, Room 2C-36 Bethesda, Maryland 20892 (301) 496-6705 Thomas Rudy, Ph.D., M.A. Center for Pain Evaluation and Treatment University of Pittsburgh Suite 600 3600 Forbes Avenue Pittsburgh, Pennsylvania 15213 (412) 647-2096

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Anesth Prog 37:55 1990 Neurochemical and Immunological Aspects Anthony J. Bouckoms, M.B., Ch.B. Department of Psychiatry Somatic Therapies Warren 6 Massachusetts General Hospital Fruit Street Boston, Massachusetts 02114 (617) 726-2990 Donna Hammond, Ph.D. G.D. Searle and Company Research and Development Division 4901 Searle Parkway Skokie, Illinois 60077 (312) 982-7767 Kenneth Hargreaves, D.D.S., Ph.D. Neurobiology and Anesthesiology Branch National Institute of Dental Research National Institutes of Health Building 10, Room 1A09 Bethesda, Maryland 20892 (301) 496-8896 Seven Schleifer, M.D.

Department of Psychiatry University of Medicine and Dentistry of New Jersey MSB-501 185 South Orange Avenue Newark, New Jersey 07103 (201) 456-6423

Imaging Aspects Richard W. Katzberg, M.D. Director Magnetic Resonance Imaging Center Department of Radiology University of Rochester Rochester, New York 14642 (716) 275-2445 Alan Reiskin, D.D.S., Ph.D.

Director Department of Radiology University of Connecticut School of Dental Medicine 263 Farmington, Connecticut 06032 (203) 679-2200

David Roberts, D.D.S. University of Pennsylvania School of Dental Medicine 4001 Spruce Street Philadelphia, Pennsylvania 19104 (215) 898-4195 Bernard Sadzot, D.D.S. Visiting Scientist Division of Nuclear Medicine Johns Hopkins Medical School B1130 Tower 600 North Wolfe Street Baltimore, Maryland 21205 (301) 955-8449

Clinical Aspects James Friction, D.D.S., M.S. TMJ and Craniofacial Clinic Department of Oral and Maxillofacial Surgery University of Minnesota HS7174 Moos Tower Minneapolis, Minnesota 55455 (612) 624-2411 Jon Levine, M.D., Ph.D. Rheumatology Section, U426 University of California at San Francisco Box 0724 San Francisco, California 94143-0724 (415) 476-5108

Raymond Maciewicz, M.D., Ph.D. Assistant Professor Neurology Service Massachusetts General Hospital Building 149 13th Street Charlestown, Massachusetts 02129 (617) 726-3817 Mitchell Max, M.D. Clinical Coordinator Pain Research Facility National Institute of Dental Research National Institutes of Health Building 10, Room 3C403 Bethesda, Maryland 20892 (301) 496-5483


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Epidemiology Alexia Antczak-Bouckams, D.M.D., D.Sc. Department of Health Policy and Management Harvard University School of Public Health Room L7A 677 Huntington Avenue Boston, Massachusetts 02115 (617) 732-0890

Thomas Drury, Ph.D. Deputy Director Epidemiology and Oral Disease Prevention Program National Institute of Dental Research National Institutes of Health Westwood Building, Room 532 5333 Westbard Avenue Bethesda, Maryland 20892 (301) 496-7239 Samuel Dworkin, D.D.S., Ph.D. Professor of Oral Medicine University of Washington School of Dentistry, SC63 1911 Northeast Pacific Avenue Seattle, Washington 98195 (206) 543-3266 Dennis Turk, Ph.D. Center for Pain Evaluation and Treatment University of Pittsburgh School of Medicine Suite 600 3600 Forbes Avenue Pittsburgh, Pennsylvania 15213 (412) 647-2096

Group Leaders Marc Heft, D.M.D., Ph.D. Department of Oral and Maxillofacial Surgery University of Florida Box J416, JHMHC Gainesville, Florida 32610 (904) 392-4116

Ralph Katz, D.D.S., Ph.D. Department of Restorative Dentistry University of Connecticut School of Dental Medicine 263 Farmington Avenue Farmington, Connecticut 06032 (203) 679-2200 William Maixner, D.D.S., Ph.D. University of North Carolina School of Dentistry Building 210H, Room 01 Chapel Hill, North Carolina 27514 (919) 966-5218 Barry Sessle, Ph.D., M.D.S. Faculty of Dentistry University of Toronto 124 Edward Street Toronto, Ontario M5G 1G6 CANADA (416) 797-4444

Rapporteurs Gary Bennett, Ph.D. Neurobiology and Anesthesiology National Institute of Dental Research National Institutes of Health Building 30, Room B20 Bethesda, Maryland 20892 (301) 496-6804 Glenn Clark, D.D.S., M.S. University of California at Los Angeles School of Dentistry Los Angeles, California 90024 (213) 825-6406 John Rugh, Ph.D. Department of Oral and Maxillofacial Surgery University of Texas Health Science Center at San Antonio San Antonio, Texas 78284 (512) 567-3461 Michael Von Korff, Sc.D. Center for Health Studies Group Health Administration Conference Center 521 Wall Street Seattle, Washington 98121 (206) 448-2874


AGENDA

New Approaches to te Chronic Orofacial Pain

Diferential Diagnosis of

MONDAY, APRIL 3, 1989

8:15 AM

A) Opening Remarks Welcome General Introduction to Workshop

H. L6e P. Bryant

B) Plenary Session R. Dubner

Chairperson 8:30 AM

K. Casey 1. On the Differential Diagnosis of Chronic Pain Conditions 2. Diagnostic Methodologies in Temporomandibular Disorder Pain: What Have We D. Laskin Learned in Two Decades Discussion

9:30 AM

10:30 AM 10:45 AM

11:45 PM 12:45 PM

1:45 PM

C) Current and Potential Diagnostic Methods and Approaches for Chronic Pain Conditions 1. Behavioral Aspects Chairperson Behavioral Assessment Psychophysiological Assessment Measuring Pain in the Clinic Discussion Coffee Break 2. Neurochemical and Immunological Aspects Chairperson * Psychiatric and Neurochemical Profiles Associated With Chronic Facial Pain Conditions * Psychoneuroimmunology * Neuroendocrine Markers of Stress * Discussion Lunch 3. Imaging Aspects Chairperson Neuroimaging and Pain MRI, CT, Arthrography (non-CNS) MRI and Muscle Spectroscopy of the Temporomandibular Joint Discussion 4. Clinical Aspects Chairperson Neurology/Neurophysiology .

Inflammatory Pain Musculoskeletal Measures Discussion C 1990 by the American Dental Society of Anesthesiology

J. Lipton F. Keefe T. Rudy R. Gracely

D. Hammond A. Bouckoms

S. Schleifer K. Hargreaves

A. B. R. D.

Reiskin Sadzot Katzberg Roberts

M. Max R. Maciewicz J. Levine J. Friction

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2:45 PM 3:00 PM

COFFEE BREAK 5. Epidemiological Aspects Chairperson * Diagnostic Techniques for Population-Based Studies * Comparing a Priori and Empirically Derived Chronic Pain Classification Systems * Diagnostic Decisionmaking

T. Drury S. Dworkin D. Turk A. AntczakBouckoms

* Discussion

TUESDAY, APRIL 4, 1989 10:15 AM

12:00 noon

1:00 PM

2:40 PM

E) Subgroup Reports and Discussion

Presenter P. Bryant

Each report will be 30 minutes, followed by general discussion lasting 20 minutes. The report will include recommendations for future research and clinical applications. Group 1: Basic Science Issues Chair: B. Sessle Rapporteur: G. Bennett Group 2: Clinical Practice Issues Chair: M. Heft Rapporteur: J. Rugh Lunch

E) Subgroup Reports and Discussion (continued) Group 3: Issues Bridging Basic Science and Clinical Practice Chair: W. Maixner Rapporteur: G. Clark Group 4: Epidemiology Issues Chair: R. Katz Rapporteur: M. Von Korff Coffee Break F) Summary and Wrap-up

3:00 PM 3:15 PM 3:30 PM 4:00 PM

Recommendations for Future Research and Clinical Applications Discussion Adjournment

J. Wilentz

D) Small Group Discussion

Attendees will be divided into four groups. Each will discuss the question "What are the major research issues that need to be addressed for improving differential diagnosis of the chronic orofacial pain conditions?" This question will be approached from the following four perspectives: * Basic science issues * Clinical practice issues * Issues bridging basic science and clinical practice * Epidemiology issues Specific topics that can be used in the group discussions include: * Which conditions currently present the most diagnostically confusing or frustrating picture?


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* Which newer approaches and techniques that were presented (or not presented) at this workshop have the greatest potential usefulness for the differential diagnosis of chronic facial pain conditions? Can the approaches discussed at the workshop be intergrated to form a diagnostic test battery of desired sensitivity and specificity? Can/should this battery be used to develop a new or revised nosology for chronic facial pain conditions? If so, how can this be accomplished most efficiently? * What unresolved research issues and training needs remain in order to apply the technique discussed? * Which of the presented approaches could be applied to population-based epidemiological investigations of chronic facial pain? Which could be tested in multi-site clinical studies?

TUESDAY, APRIL 4, 1989 8:30 AM 10:00 AM

D) Small Group Discussion (continued) Coffee break