The Official Patient's Sourcebook on Temporomandibular Joint Syndrome

THE OFFICIAL PATIENT’S SOURCEBOOK

on

TEMPOROMANDIBULAR JOINT SYNDROME

J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D., E DITORS

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ICON Health Publications ICON Group International, Inc. 4370 La Jolla Village Drive, 4th Floor San Diego, CA 92122 USA Copyright Ó2002 by ICON Group International, Inc. Copyright Ó2002 by ICON Group International, Inc. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher. Printed in the United States of America. Last digit indicates print number: 10 9 8 7 6 4 5 3 2 1

Publisher, Health Care: Tiffany LaRochelle Editor(s): James Parker, M.D., Philip Parker, Ph.D. Publisher's note: The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consultation with your dentist or oral surgeon. All matters regarding your health require medical supervision. As new medical or scientific information becomes available from academic and clinical research, recommended treatments and drug therapies may undergo changes. The authors, editors, and publisher have attempted to make the information in this book up to date and accurate in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of this book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation, in close consultation with a qualified dentist or oral surgeon. The reader is advised to always check product information (package inserts) for changes and new information regarding dose and contraindications before taking any drug or pharmacological product. Caution is especially urged when using new or infrequently ordered drugs, herbal remedies, vitamins and supplements, alternative therapies, complementary therapies and medicines, and integrative medical treatments. Cataloging-in-Publication Data Parker, James N., 1961Parker, Philip M., 1960The Official Patient’s Sourcebook on Temporomandibular Joint Syndrome: Revised and Updated for the Internet Age/James N. Parker and Philip M. Parker, editors p. cm. Includes bibliographical references, glossary and index. ISBN: 0-597-83148-3 1. Temporomandibular Joint Syndrome-Popular works. I. Title.

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Disclaimer This publication is not intended to be used for the diagnosis or treatment of a health problem or as a substitute for consultation with licensed medical professionals. It is sold with the understanding that the publisher, editors, and authors are not engaging in the rendering of medical, psychological, financial, legal, or other professional services. References to any entity, product, service, or source of information that may be contained in this publication should not be considered an endorsement, either direct or implied, by the publisher, editors or authors. ICON Group International, Inc., the editors, or the authors are not responsible for the content of any Web pages nor publications referenced in this publication.

Copyright Notice If a dentist or oral surgeon wishes to copy limited passages from this sourcebook for patient use, this right is automatically granted without written permission from ICON Group International, Inc. (ICON Group). However, all of ICON Group publications are copyrighted. With exception to the above, copying our publications in whole or in part, for whatever reason, is a violation of copyright laws and can lead to penalties and fines. Should you want to copy tables, graphs or other materials, please contact us to request permission (e-mail: [email protected]). ICON Group often grants permission for very limited reproduction of our publications for internal use, press releases, and academic research. Such reproduction requires confirmed permission from ICON Group International Inc. The disclaimer above must accompany all reproductions, in whole or in part, of this sourcebook.

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Dedication To the healthcare professionals dedicating their time and efforts to the study of temporomandibular joint syndrome.

Acknowledgements The collective knowledge generated from academic and applied research summarized in various references has been critical in the creation of this sourcebook which is best viewed as a comprehensive compilation and collection of information prepared by various official agencies which directly or indirectly are dedicated to temporomandibular joint syndrome. All of the Official Patient’s Sourcebooks draw from various agencies and institutions associated with the United States Department of Health and Human Services, and in particular, the Office of the Secretary of Health and Human Services (OS), the Administration for Children and Families (ACF), the Administration on Aging (AOA), the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Substances and Disease Registry (ATSDR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Healthcare Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), the institutions of the National Institutes of Health (NIH), the Program Support Center (PSC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition to these sources, information gathered from the National Library of Medicine, the United States Patent Office, the European Union, and their related organizations has been invaluable in the creation of this sourcebook. Some of the work represented was financially supported by the Research and Development Committee at INSEAD. This support is gratefully acknowledged. Finally, special thanks are owed to Tiffany LaRochelle for her excellent editorial support.

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About the Editors James N. Parker, M.D. Dr. James N. Parker received his Bachelor of Science degree in Psychobiology from the University of California, Riverside and his M.D. from the University of California, San Diego. In addition to authoring numerous research publications, he has lectured at various academic institutions. Dr. Parker is the medical editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

Philip M. Parker, Ph.D. Philip M. Parker is the Eli Lilly Chair Professor of Innovation, Business and Society at INSEAD (Fontainebleau, France and Singapore). Dr. Parker has also been Professor at the University of California, San Diego and has taught courses at Harvard University, the Hong Kong University of Science and Technology, the Massachusetts Institute of Technology, Stanford University, and UCLA. Dr. Parker is the associate editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

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About ICON Health Publications In addition to temporomandibular joint syndrome, Official Patient’s Sourcebooks are available for the following related topics: ·

The Official Patient's Sourcebook on Diabetes-related Periodontal Disease

·

The Official Patient's Sourcebook on Dry Mouth

·

The Official Patient's Sourcebook on Gingivitis

·

The Official Patient's Sourcebook on Oral Cancer

·

The Official Patient's Sourcebook on Periodontitis

·

The Official Patient's Sourcebook on Tooth Decay

To discover more about ICON Health Publications, simply check with your preferred online booksellers, including Barnes & Noble.com and Amazon.com which currently carry all of our titles. Or, feel free to contact us directly for bulk purchases or institutional discounts: ICON Group International, Inc. 4370 La Jolla Village Drive, Fourth Floor San Diego, CA 92122 USA Fax: 858-546-4341 Web site: www.icongrouponline.com/health

Contents vii

Table of Contents INTRODUCTION ................................................................................................................. 1 Overview .................................................................................................................................... 1 Organization ............................................................................................................................. 3 Scope ............................................................................................................................................ 3 Moving Forward ...................................................................................................................... 4

PART I: THE ESSENTIALS ..................................................................... 7 CHAPTER 1. THE ESSENTIALS ON TEMPOROMANDIBULAR JOINT SYNDROME: GUIDELINES ........................................................................ 9 Overview .................................................................................................................................... 9 What Is Temporomandibular Joint Syndrome? ............................................................ 10 What Is the Temporomandibular Joint?.......................................................................... 11 What Are Temporomandibular Disorders? ................................................................... 12 What Causes TMD? ............................................................................................................. 12 TMD Signs and Symptoms ................................................................................................ 13 Diagnosis .................................................................................................................................. 14 Treatment ................................................................................................................................. 14 If You Think You Have TMD... ........................................................................................ 16 Research .................................................................................................................................... 16 More Guideline Sources....................................................................................................... 17 Vocabulary Builder ............................................................................................................... 20

CHAPTER 2. SEEKING GUIDANCE ................................................................. 22 Overview .................................................................................................................................. 22 Associations and Temporomandibular Joint Syndrome ............................................. 22 Finding Dentists .................................................................................................................... 25 Selecting Your Dentist......................................................................................................... 26 Working with Your Dentist ............................................................................................... 26 Broader Health-Related Resources.................................................................................... 28

CHAPTER 3. CLINICAL TRIALS AND TEMPOROMANDIBULAR JOINT SYNDROME .......................................................................................................... 29 Overview .................................................................................................................................. 29 Recent Trials on Temporomandibular Joint Syndrome .............................................. 32 Benefits and Risks .................................................................................................................. 38 Keeping Current on Clinical Trials .................................................................................. 41 General References................................................................................................................. 42

PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL ....................................................................... 44

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CHAPTER 4. STUDIES ON TEMPOROMANDIBULAR JOINT SYNDROME .......................................................................................................................... 45 Overview .................................................................................................................................. 45 Federally-Funded Research on Temporomandibular Joint Syndrome ................... 45 The National Library of Medicine: PubMed.................................................................. 59 Vocabulary Builder ............................................................................................................... 61

CHAPTER 5. BOOKS ON TEMPOROMANDIBULAR JOINT SYNDROME .......................................................................................................................... 67 Overview .................................................................................................................................. 67 Book Summaries: Federal Agencies .................................................................................. 67 Book Summaries: Online Booksellers............................................................................... 68 Chapters on Temporomandibular Joint Syndrome ...................................................... 68 General Home References .................................................................................................... 69 Vocabulary Builder ............................................................................................................... 70

CHAPTER 6. MULTIMEDIA ON TEMPOROMANDIBULAR JOINT SYNDROME .......................................................................................................... 73 Overview .................................................................................................................................. 73 Bibliography: Multimedia on Temporomandibular Joint Syndrome...................... 73 Vocabulary Builder ............................................................................................................... 76

CHAPTER 7. PERIODICALS AND NEWS ON TEMPOROMANDIBULAR JOINT SYNDROME ......................................... 77 Overview .................................................................................................................................. 77 News Services & Press Releases ........................................................................................ 77 Academic Periodicals covering Temporomandibular Joint Syndrome ................... 79 Vocabulary Builder ............................................................................................................... 80

CHAPTER 8. PHYSICIAN GUIDELINES AND DATABASES ......... 81 Overview .................................................................................................................................. 81 NIH Guidelines ...................................................................................................................... 81 NIH Databases ....................................................................................................................... 82 Other Commercial Databases ............................................................................................. 86 The Genome Project and Temporomandibular Joint Syndrome .............................. 86 Specialized References .......................................................................................................... 91 Vocabulary Builder ............................................................................................................... 92

CHAPTER 9. DISSERTATIONS ON TEMPOROMANDIBULAR JOINT SYNDROME .......................................................................................................... 93 Overview .................................................................................................................................. 93 Dissertations on Temporomandibular Joint Syndrome .............................................. 93 Keeping Current..................................................................................................................... 94 Vocabulary Builder ............................................................................................................... 94

PART III. APPENDICES ............................................................................ 95

Contents

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APPENDIX A. RESEARCHING YOUR MEDICATIONS .................... 97 Overview .................................................................................................................................. 97 Your Medications: The Basics............................................................................................ 98 Learning More about Your Medications ........................................................................ 99 Commercial Databases ....................................................................................................... 100 Contraindications and Interactions (Hidden Dangers) ........................................... 101 A Final Warning.................................................................................................................. 102 General References............................................................................................................... 103

APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE ........ 105 Overview ................................................................................................................................ 105 What Is CAM? ..................................................................................................................... 105 What Are the Domains of Alternative Medicine? ..................................................... 106 Can Alternatives Affect My Treatment?...................................................................... 109 Finding CAM References on Temporomandibular Joint Syndrome .................... 110 Additional Web Resources ................................................................................................ 114 General References............................................................................................................... 115 Vocabulary Builder ............................................................................................................. 116

APPENDIX C. RESEARCHING NUTRITION ........................................... 119 Overview ................................................................................................................................ 119 Food and Nutrition: General Principles ....................................................................... 119 Finding Studies on Temporomandibular Joint Syndrome....................................... 124 Federal Resources on Nutrition ....................................................................................... 126 Additional Web Resources ................................................................................................ 127 Vocabulary Builder ............................................................................................................. 128

APPENDIX D. FINDING MEDICAL LIBRARIES ................................... 131 Overview ................................................................................................................................ 131 Preparation ............................................................................................................................ 131 Finding a Local Medical Library ..................................................................................... 132 Medical Libraries Open to the Public ............................................................................ 132

APPENDIX E. YOUR RIGHTS AND INSURANCE ............................... 139 Overview ................................................................................................................................ 139 Your Rights as a Patient.................................................................................................... 139 Patient Responsibilities ...................................................................................................... 143 Choosing an Insurance Plan............................................................................................. 144 Medicare and Medicaid ...................................................................................................... 147 NORD’s Medication Assistance Programs ................................................................. 150 Additional Resources .......................................................................................................... 150

APPENDIX F. MORE ON PAIN .......................................................................... 153 Overview ................................................................................................................................ 153 A Brief History of Pain ...................................................................................................... 153 The Two Faces of Pain: Acute and Chronic ................................................................. 154 The A to Z of Pain ............................................................................................................... 155

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How Is Pain Diagnosed? ................................................................................................... 159 How Is Pain Treated? ......................................................................................................... 160 What Is the Role of Age and Gender in Pain? ............................................................ 166 A Pain Primer: What Do We Know about Pain? ...................................................... 168 What Is the Future of Pain Research? ........................................................................... 172 Hope for the Future ............................................................................................................. 174 Spine Basics: The Vertebrae, Discs, and Spinal Cord ............................................... 175 The Nervous Systems ......................................................................................................... 176 Information Resources........................................................................................................ 179

ONLINE GLOSSARIES............................................................................. 183 Online Dictionary Directories ......................................................................................... 185

TEMPOROMANDIBULAR JOINT SYNDROME GLOSSARY .................................................................................................................. 187 General Dictionaries and Glossaries .............................................................................. 196

INDEX ................................................................................................................................... 198

Introduction

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INTRODUCTION Overview Dr. C. Everett Koop, former U.S. Surgeon General, once said, “The best prescription is knowledge.”1 The Agency for Healthcare Research and Quality (AHRQ) of the National Institutes of Health (NIH) echoes this view and recommends that every patient incorporate education into the treatment process. According to the AHRQ: Finding out more about your condition is a good place to start. By contacting groups that support your condition, visiting your local library, and searching on the Internet, you can find good information to help guide your treatment decisions. Some information may be hard to find—especially if you don't know where to look.2 As the AHRQ mentions, finding the right information is not an obvious task. Though many healthcare providers and public officials had thought that the emergence of the Internet would do much to assist patients in obtaining reliable information, in March 2001 the National Institutes of Health issued the following warning: The number of Web sites offering health-related resources grows every day. Many sites provide valuable information, while others may have information that is unreliable or misleading.3

Quotation from http://www.drkoop.com. The Agency for Healthcare Research and Quality (AHRQ): http://www.ahcpr.gov/consumer/diaginfo.htm. 3 From the NIH, National Cancer Institute (NCI): http://cancertrials.nci.nih.gov/beyond/evaluating.html. 1 2

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Temporomandibular Joint Syndrome

Since the late 1990s, healthcare providers have seen a general increase in patient Internet usage rates. Patients frequently enter their dentists’ offices with printed Web pages of home remedies in the guise of latest medical research. This scenario is so common that dentists often spend more time dispelling misleading information than guiding patients through sound therapies. The Official Patient’s Sourcebook on Temporomandibular Joint Syndrome has been created for patients who have decided to make education and research an integral part of the treatment process. The pages that follow will tell you where and how to look for information covering virtually all topics related to temporomandibular joint syndrome, from the essentials to the most advanced areas of research. The title of this book includes the word “official.” This reflects the fact that the sourcebook draws from public, academic, government, and peerreviewed research. Selected readings from various agencies are reproduced to give you some of the latest official information available to date on temporomandibular joint syndrome. Given patients’ increasing sophistication in using the Internet, abundant references to reliable Internet-based resources are provided throughout this sourcebook. Where possible, guidance is provided on how to obtain free-ofcharge, primary research results as well as more detailed information via the Internet. E-book and electronic versions of this sourcebook are fully interactive with each of the Internet sites mentioned (clicking on a hyperlink automatically opens your browser to the site indicated). Hard copy users of this sourcebook can type cited Web addresses directly into their browsers to obtain access to the corresponding sites. Since we are working with ICON Health Publications, hard copy Sourcebooks are frequently updated and printed on demand to ensure that the information provided is current. In addition to extensive references accessible via the Internet, every chapter presents a “Vocabulary Builder.” Many health guides offer glossaries of technical or uncommon terms in an appendix. In editing this sourcebook, we have decided to place a smaller glossary within each chapter that covers terms used in that chapter. Given the technical nature of some chapters, you may need to revisit many sections. Building one’s vocabulary of medical terms in such a gradual manner has been shown to improve the learning process. We must emphasize that no sourcebook on temporomandibular joint syndrome should affirm that a specific diagnostic procedure or treatment discussed in a research study, patent, or doctoral dissertation is “correct” or your best option. This sourcebook is no exception. Each patient is unique.

Introduction

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Deciding on appropriate options is always up to the patient in consultation with their dentist and other healthcare providers.

Organization This sourcebook is organized into three parts. Part I explores basic techniques to researching temporomandibular joint syndrome (e.g. finding guidelines on diagnosis, treatments, and prognosis), followed by a number of topics, including information on how to get in touch with organizations, associations, or other patient networks dedicated to temporomandibular joint syndrome. It also gives you sources of information that can help you find a dentist or oral surgeon in your local area specializing in treating temporomandibular joint syndrome. Collectively, the material presented in Part I is a complete primer on basic research topics for patients with temporomandibular joint syndrome. Part II moves on to advanced research dedicated to temporomandibular joint syndrome. Part II is intended for those willing to invest many hours of hard work and study. It is here that we direct you to the latest scientific and applied research on temporomandibular joint syndrome. When possible, contact names, links via the Internet, and summaries are provided. It is in Part II where the vocabulary process becomes important as authors publishing advanced research frequently use highly specialized language. In general, every attempt is made to recommend “free-to-use” options. Part III provides appendices of useful background reading for all patients with temporomandibular joint syndrome or related disorders. The appendices are dedicated to more pragmatic issues faced by many patients with temporomandibular joint syndrome. Accessing materials via medical libraries may be the only option for some readers, so a guide is provided for finding local medical libraries which are open to the public. Part III, therefore, focuses on advice that goes beyond the biological and scientific issues facing patients with temporomandibular joint syndrome.

Scope While this sourcebook covers temporomandibular joint syndrome, your dentist, research publications, and specialists may refer to your condition using a variety of terms. Therefore, you should understand that temporomandibular joint syndrome is often considered a synonym or a condition closely related to the following:

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Temporomandibular Joint Syndrome

·

Costes Syndrome

·

Impostor Disease

·

Myofacial Pain Dysfunction Syndrome

·

Pain-dysfunction Syndrome

·

Temporomandibular Joint Syndrome

·

TMJ Syndrome

In addition to synonyms and related conditions, healthcare providers may refer to temporomandibular joint syndrome using certain coding systems. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is the most commonly used system of classification for the world's illnesses. Your dentist may use this coding system as an administrative or tracking tool. The following classification is commonly used for temporomandibular joint syndrome:4 ·

524.6 temporomandibular joint disorders

·

524.60 temporomandibular joint disorders, unspecified

·

524.61 adhesions and ankylosis (bony or fibrous)

·

524.62 arthralgia of temporomandibular joint

·

524.63 articular disc disorder (reducing or nonreducing)

·

524.69 other specified temporomandibular joint disorders

For the purposes of this sourcebook, we have attempted to be as inclusive as possible, looking for official information for all of the synonyms relevant to temporomandibular joint syndrome. You may find it useful to refer to synonyms when accessing databases or interacting with healthcare professionals and medical librarians.

Moving Forward Since the 1980s, the world has seen a proliferation of healthcare guides covering most illnesses. Some are written by patients or their family members. These generally take a layperson's approach to understanding and 4 This list is based on the official version of the World Health Organization's 9th Revision, International Classification of Diseases (ICD-9). According to the National Technical Information Service, “ICD-9CM extensions, interpretations, modifications, addenda, or errata other than those approved by the U.S. Public Health Service and the Health Care Financing Administration are not to be considered official and should not be utilized. Continuous maintenance of the ICD-9-CM is the responsibility of the federal government.”

Introduction

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coping with an illness or disorder. They can be uplifting, encouraging, and highly supportive. Other guides are authored by dentists or other healthcare providers who have a more clinical outlook. Each of these two styles of guide has its purpose and can be quite useful. As editors, we have chosen a third route. We have chosen to expose you to as many sources of official and peer-reviewed information as practical, for the purpose of educating you about basic and advanced knowledge as recognized by medical science today. You can think of this sourcebook as your personal Internet age reference librarian. Why “Internet age”? All too often, patients diagnosed with temporomandibular joint syndrome will log on to the Internet, type words into a search engine, and receive several Web site listings which are mostly irrelevant or redundant. These patients are left to wonder where the relevant information is, and how to obtain it. Since only the smallest fraction of information dealing with temporomandibular joint syndrome is even indexed in search engines, a non-systematic approach often leads to frustration and disappointment. With this sourcebook, we hope to direct you to the information you need that you would not likely find using popular Web directories. Beyond Web listings, in many cases we will reproduce brief summaries or abstracts of available reference materials. These abstracts often contain distilled information on topics of discussion. While we focus on the more scientific aspects of temporomandibular joint syndrome, there is, of course, the emotional side to consider. Later in the sourcebook, we provide a chapter dedicated to helping you find peer groups and associations that can provide additional support beyond research produced by medical science. We hope that the choices we have made give you the most options available in moving forward. In this way, we wish you the best in your efforts to incorporate this educational approach into your treatment plan. The Editors

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PART I: THE ESSENTIALS

ABOUT PART I Part I has been edited to give you access to what we feel are “the essentials” on temporomandibular joint syndrome. The essentials of a disease typically include the definition or description of the disease, a discussion of who it affects, the signs or symptoms associated with the disease, tests or diagnostic procedures that might be specific to the disease, and treatments for the disease. Your dentist or oral surgeon may have already explained the essentials of temporomandibular joint syndrome to you or even given you a pamphlet or brochure describing temporomandibular joint syndrome. Now you are searching for more in-depth information. As editors, we have decided, nevertheless, to include a discussion on where to find essential information that can complement what your dentist or oral surgeon has already told you. In this section we recommend a process, not a particular Web site or reference book. The process ensures that, as you search the Web, you gain background information in such a way as to maximize your understanding.

Guidelines

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CHAPTER 1. THE ESSENTIALS ON TEMPOROMANDIBULAR JOINT SYNDROME: GUIDELINES Overview Official agencies, as well as federally-funded institutions supported by national grants, frequently publish a variety of guidelines on temporomandibular joint syndrome. These are typically called “Fact Sheets” or “Guidelines.” They can take the form of a brochure, information kit, pamphlet, or flyer. Often they are only a few pages in length. The great advantage of guidelines over other sources is that they are often written with the patient in mind. Since new guidelines on temporomandibular joint syndrome can appear at any moment and be published by a number of sources, the best approach to finding guidelines is to systematically scan the Internet-based services that post them.

The National Institutes of Health (NIH)5 The National Institutes of Health (NIH) is the first place to search for relatively current patient guidelines and fact sheets on temporomandibular joint syndrome. Originally founded in 1887, the NIH is one of the world's foremost medical research centers and the federal focal point for medical research in the United States. At any given time, the NIH supports some 35,000 research grants at universities, medical schools, and other research and training institutions, both nationally and internationally. The rosters of those who have conducted research or who have received NIH support over the years include the world's most illustrious scientists and physicians.

5

Adapted from the NIH: http://www.nih.gov/about/NIHoverview.html.

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Among them are 97 scientists who have won the Nobel Prize for achievement in medicine. There is no guarantee that any one Institute will have a guideline on a specific disease, though the National Institutes of Health collectively publish over 600 guidelines for both common and rare diseases. The best way to access NIH guidelines is via the Internet. Although the NIH is organized into many different Institutes and Offices, the following is a list of key Web sites where you are most likely to find NIH clinical guidelines and publications dealing with temporomandibular joint syndrome and associated conditions: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

·

National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc. ) with guidelines available at http://www.nlm.nih.gov/medlineplus/healthtopics.html

·

National Institute of Dental and Craniofacial Research (NIDCR); guidelines available at http://www.nidr.nih.gov/health/

Among these, the National Institute of Dental and Craniofacial Research (NIDCR) is particularly noteworthy.6 Its mission is to promote the general health of the American people by improving their oral, dental, and craniofacial health. Through nurturing fundamental research and the development of researchers, the NIDCR aims to promote health, to prevent diseases and conditions, and to develop new diagnostics and therapeutics. Knowledge acquisition through science and effective and efficient science transfer are the means used to contribute to improved quality of health. The following is NIDCR’s patient guideline on temporomandibular joint syndrome.

What Is Temporomandibular Joint Syndrome?7 You may have read articles in newspapers and magazines about “TMD” -temporomandibular (jaw) disorders, also called “TMJ syndrome.” Perhaps you have even felt pain sometimes in your jaw area, or maybe your dentist or physician has told you that you have TMD.

6 Adapted from the NIDCR: http://www.nidr.nih.gov/about/mission.asp. For the remainder of the book, “adapted” indicates reproduction with attribution, with minor editorial adjustments, as needed. 7 Adapted from the National Institute of Dental and Craniofacial Research (NIDCR): http://www.nidr.nih.gov/health/pubs/tmd/menu.htm.

Guidelines 11

If you have questions about TMD, you are not alone. Researchers, too, are looking for answers to what causes TMD, what are the best treatments, and how can we prevent these disorders. The National Institute of Dental and Craniofacial Research has written this pamphlet to share with you what we have learned about TMD. TMD is not just one disorder, but a group of conditions, often painful, that affect the jaw joint (temporomandibular joint, or TMJ) and the muscles that control chewing. Although we don't know how many people actually have TMD, the disorders appear to affect about twice as many women as men. The good news is that for most people, pain in the area of the jaw joint or muscles is not a signal that a serious problem is developing. Generally, discomfort from TMD is occasional and temporary, often occurring in cycles. The pain eventually goes away with little or no treatment. Only a small percentage of people with TMD pain develop significant, long-term symptoms.

What Is the Temporomandibular Joint?

The temporomandibular joint connects the lower jaw, called the mandible, to the temporal bone at the side of the head. If you place your fingers just in front of your ears and open your mouth, you can feel the joint on each side of your head. Because these joints are flexible, the jaw can move smoothly up and down and side to side, enabling us to talk, chew and yawn. Muscles attached to and surrounding the jaw joint control its position and movement.

12 Temporomandibular Joint Syndrome

When we open our mouths, the rounded ends of the lower jaw, called condyles, glide along the joint socket of the temporal bone. The condyles slide back to their original position when we close our mouths. To keep this motion smooth, a soft disc lies between the condyle and the temporal bone. This disc absorbs shocks to the TMJ from chewing and other movements.

What Are Temporomandibular Disorders? Today, researchers generally agree that temporomandibular disorders fall into three main categories (A person may have one or more of these conditions at the same time.): ·

Myofascial pain, the most common form of TMD, which is discomfort or pain in the muscles that control jaw function and the neck and shoulder muscles;

·

Internal derangement of the joint, meaning a dislocated jaw or displaced disc, or injury to the condyle;

·

Degenerative joint disease, such as osteoarthritis or rheumatoid arthritis in the jaw joint.

What Causes TMD? We know that severe injury to the jaw or temporomandibular joint can cause TMD. A heavy blow, for example, can fracture the bones of the joint or damage the disc, disrupting the smooth motion of the jaw and causing pain or locking. Arthritis in the jaw joint may also result from injury. Other causes of TMD are less clear. Some suggest, for example, that a bad bite (malocclusion) can trigger TMD, but recent research disputes that view. Orthodontic treatment, such as braces and the use of headgear, has also been blamed for some forms of TMD, but studies now show that this is unlikely.

Guidelines 13

And there is no scientific proof that gum chewing causes clicking sounds in the jaw joint, or that jaw clicking leads to serious TMJ problems. In fact, jaw clicking is fairly common in the general population. If there are no other symptoms, such as pain or locking, jaw clicking usually does not need treatment. Researchers believe that most people with clicking or popping in the jaw joint likely have a displaced disc -- the soft, shock-absorbing disc is not in a normal position. As long as the displaced disc causes no pain or problems with jaw movement, no treatment is needed. Some experts suggest that stress, either mental or physical, may cause or aggravate TMD. People with TMD often clench or grind their teeth at night, which can tire the jaw muscles and lead to pain. It is not clear, however, whether stress is the cause of the clenching/grinding and subsequent jaw pain, or the result of dealing with chronic jaw pain or dysfunction. Scientists are exploring how behavioral, psychological and physical factors may combine to cause TMD.

TMD Signs and Symptoms A variety of symptoms may be linked to TMD. Pain, particularly in the chewing muscles and/or jaw joint, is the most common symptom. Other likely symptoms include: ·

Limited movement or locking of the jaw,

·

Radiating pain in the face, neck or shoulders,

·

Painful clicking, popping or grating sounds in the jaw joint when opening or closing the mouth.

·

A sudden, major change in the way the upper and lower teeth fit together.

Symptoms such as headaches, earaches, dizziness and hearing problems may sometimes be related to TMD. It is important to keep in mind, however, that occasional discomfort in the jaw joint or chewing muscles is quite common and is generally not a cause for concern. Researchers are working to clarify TMD symptoms, with the goal of developing easier and better methods of diagnosis and improved treatment.

14 Temporomandibular Joint Syndrome

Diagnosis Because the exact causes and symptoms of TMD are not clear, diagnosing these disorders can be confusing. At present, there is no widely accepted, standard test to correctly identify TMD. In about 90 percent of cases, however, the patient's description of symptoms, combined with a simple physical examination of the face and jaw, provides information useful for diagnosing these disorders. The examination includes feeling the jaw joints and chewing muscles for pain or tenderness; listening for clicking, popping or grating sounds during jaw movement; and examining for limited motion or locking of the jaw while opening or closing the mouth. Checking the patient's dental and medical history is very important. In most cases, this evaluation provides enough information to locate the pain or jaw problem, to make a diagnosis, and to start treatment to relieve pain or jaw locking. Regular dental X-rays and TMJ x-rays (transcranial radiographs) are not generally useful in diagnosing TMD. Other x-ray techniques, such as arthrography (joint x-rays using dye); magnetic resonance imaging (MRI), which pictures the soft tissues; and tomography (a special type of x-ray), are usually needed only when the practitioner strongly suspects a condition such as arthritis or when significant pain persists over time and symptoms do not improve with treatment. Before undergoing any expensive diagnostic test, it is always wise to get another independent opinion. One of the most important areas of TMD research is developing clear guidelines for diagnosing these disorders. Once scientists agree on what these guidelines should be, it will be easier for practitioners to correctly identify temporomandibular disorders and to decide what treatment, if any, is needed.

Treatment The key words to keep in mind about TMD treatment are “conservative” and “reversible.” Conservative treatments are as simple as possible and are used most often because most patients do not have severe, degenerative TMD. Conservative treatments do not invade the tissues of the face, jaw or joint. Reversible treatments do not cause permanent, or irreversible, changes in the structure or position of the jaw or teeth.

Guidelines 15

Because most TMD problems are temporary and do not get worse, simple treatment is all that is usually needed to relieve discomfort. Self-care practices, for example, eating soft foods, applying heat or ice packs, and avoiding extreme jaw movements (such as wide yawning, loud singing and gum chewing) are useful in easing TMD symptoms. Learning special techniques for relaxing and reducing stress may also help patients deal with pain that often comes with TMD problems. Other conservative, reversible treatments include physical therapy you can do at home, which focuses on gentle muscle stretching and relaxing exercises, and short-term use of muscle-relaxing and anti-inflammatory drugs. The health care provider may recommend an oral appliance, also called a splint or bite plate, which is a plastic guard that fits over the upper or lower teeth. The splint can help reduce clenching or grinding, which eases muscle tension. An oral splint should be used only for a short time and should not cause permanent changes in the bite. If a splint causes or increases pain, stop using it and see your practitioner. The conservative, reversible treatments described are useful for temporary relief of pain and muscle spasm -- they are not “cures” for TMD. If symptoms continue over time or come back often, check with your doctor. There are other types of TMD treatment, such as surgery or injections, that invade the tissues. Some involve injecting pain relieving medications into painful muscle sites, often called “trigger points.” Researchers are studying this type of treatment to see if these injections are helpful over time.

Surgical Treatments Surgical treatments are often irreversible and should be avoided where possible. When such treatment is necessary, be sure to have the doctor explain to you, in words you can understand, the reason for the treatment, the risks involved, and other types of treatment that may be available. Scientists have learned that certain irreversible treatments, such as surgical replacement of jaw joints with artificial implants, may cause severe pain and permanent jaw damage. Some of these devices may fail to function properly or may break apart in the jaw over time. Before undergoing any surgery on the jaw joint, it is very important to get other independent opinions.

16 Temporomandibular Joint Syndrome

The Food and Drug Administration has recalled artificial jaw joint implants made by Vitek, Inc., which may break down and damage surrounding bone. If you have these implants, see your oral surgeon or dentist. If there are problems with your implants, the devices may need to be removed.

Other Irreversible Treatments Other irreversible treatments that are of little value -- and may make the problem worse -- include orthodontics to change the bite; restorative dentistry, which uses crown and bridge work to balance the bite; and occlusal adjustment, grinding down teeth to bring the bite into balance. Although more studies are needed on the safety and effectiveness of most TMD treatments, scientists strongly recommend using the most conservative, reversible treatments possible before considering invasive treatments. Even when the TMD problem has become chronic, most patients still do not need aggressive types of treatment.

If You Think You Have TMD... Keep in mind that for most people, discomfort from TMD will eventually go away whether treated or not. Simple self-care practices are often effective in easing TMD symptoms. If more treatment is needed, it should be conservative and reversible. Avoid, if at all possible, treatments that cause permanent changes in the bite or jaw. If irreversible treatments are recommended, be sure to get a reliable second opinion. Many practitioners, especially dentists, are familiar with the conservative treatment of TMD. Because TMD is usually painful, pain clinics in hospitals and universities are also a good source of advice and second opinions for these disorders. Specially trained facial pain experts can often be helpful in diagnosing and treating TMD.

Research The National Institute of Dental Research supports an active research program on TMD. Developing reliable guidelines for diagnosing these disorders is a top priority. Studies are also under way on the causes, treatments, and prevention of TMD. Through continued research, pieces of the TMD puzzle are falling slowly but steadily into place.

Guidelines 17

A Technology Assessment Conference on Management of Temporomandibular Disorders was held at the National Institutes of Health in Spring 1996. Free copies of the summary statement from the TMD conference are available from: NIH Consensus Program Information Center P.O. Box 2577 Kensington, MD 20891 Toll free: 1-888-644-2667 http://consensus.nih.gov

More Guideline Sources The guideline above on temporomandibular joint syndrome is only one example of the kind of material that you can find online and free of charge. The remainder of this chapter will direct you to other sources which either publish or can help you find additional guidelines on topics related to temporomandibular joint syndrome. Many of the guidelines listed below address topics that may be of particular relevance to your specific situation or of special interest to only some patients with temporomandibular joint syndrome. Due to space limitations these sources are listed in a concise manner. Do not hesitate to consult the following sources by either using the Internet hyperlink provided, or, in cases where the contact information is provided, contacting the publisher or author directly.

Topic Pages: MEDLINEplus For patients wishing to go beyond guidelines published by specific Institutes of the NIH, the National Library of Medicine has created a vast and patientoriented healthcare information portal called MEDLINEplus. Within this Internet-based system are “health topic pages.” You can think of a health topic page as a guide to patient guides. To access this system, log on to http://www.nlm.nih.gov/medlineplus/healthtopics.html. From there you can either search using the alphabetical index or browse by broad topic areas. If you do not find topics of interest when browsing health topic pages, then you can choose to use the advanced search utility of MEDLINEplus at the following: http://www.nlm.nih.gov/medlineplus/advancedsearch.html. This utility is similar to the NIH Search Utility, with the exception that it

18 Temporomandibular Joint Syndrome

only includes material linked within the MEDLINEplus system (mostly patient-oriented information). It also has the disadvantage of generating unstructured results. We recommend, therefore, that you use this method only if you have a very targeted search. The National Guideline Clearinghouse™ The National Guideline Clearinghouse™ offers hundreds of evidence-based clinical practice guidelines published in the United States and other countries. You can search their site located at http://www.guideline.gov by using the keyword “temporomandibular joint syndrome” or synonyms. The following was recently posted: ·

Management of temporomandibular disorders. Source: National Institutes of Health (NIH) Consensus Development Panel on Management of Temporomandibular Disorders.; 1997 November; 24 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 0516&sSearch_string=temporomandibular+joint+syndrome Healthfinder™

Healthfinder™ is an additional source sponsored by the U.S. Department of Health and Human Services which offers links to hundreds of other sites that contain healthcare information. This Web site is located at http://www.healthfinder.gov. Again, keyword searches can be used to find guidelines.

The NIH Search Utility After browsing the references listed at the beginning of this chapter, you may want to explore the NIH Search Utility. This allows you to search for documents on over 100 selected Web sites that comprise the NIH-WEBSPACE. Each of these servers is “crawled” and indexed on an ongoing basis. Your search will produce a list of various documents, all of which will relate in some way to temporomandibular joint syndrome. The drawbacks of this approach are that the information is not organized by theme and that the references are often a mix of information for professionals and patients. Nevertheless, a large number of the listed Web sites provide useful background information. We can only recommend this route, therefore, for

Guidelines 19

relatively rare or specific disorders, or when using highly targeted searches. To use the NIH search utility, visit the following Web page: http://search.nih.gov/index.html. NORD (The National Organization of Rare Disorders, Inc.) NORD provides an invaluable service to the public by publishing, for a nominal fee, short yet comprehensive guidelines on over 1,000 diseases. NORD primarily focuses on rare diseases that might not be covered by the previously listed sources. NORD’s Web address is www.rarediseases.org. To see if a recent fact sheet has been published on temporomandibular joint syndrome, simply go to the following hyperlink: http://www.rarediseases.org/cgi-bin/nord/alphalist. A complete guide on temporomandibular joint syndrome can be purchased from NORD for a nominal fee. Additional Web Sources A number of Web sites that often link to government sites are available to the public. These can also point you in the direction of essential information. The following is a representative sample: ·

AOL: http://search.aol.com/cat.adp?id=168&layer=&from=subcats

·

drkoop.comÒ: http://www.drkoop.com/conditions/ency/index.html

·

Family Village: http://www.familyvillage.wisc.edu/specific.htm

·

Google: http://directory.google.com/Top/Health/Conditions_and_Diseases/

·

Med Help International: http://www.medhelp.org/HealthTopics/A.html

·

Open Directory Project: http://dmoz.org/Health/Conditions_and_Diseases/

·

Yahoo.com: http://dir.yahoo.com/Health/Diseases_and_Conditions/

·

WebMDÒHealth: http://my.webmd.com/health_topics

20 Temporomandibular Joint Syndrome

Vocabulary Builder The material in this chapter may have contained a number of unfamiliar words. The following Vocabulary Builder introduces you to terms used in this chapter that have not been covered in the previous chapter: American Heart Association: A voluntary organization concerned with the prevention and treatment of heart and vascular diseases. [NIH] Arthrography: Roentgenography of a joint, usually after injection of either positive or negative contrast medium. [NIH] Bloom Syndrome: An autosomal recessive disorder characterized by telangiectatic erythema of the face, photosensitivity, dwarfism, and other abnormalities. [NIH] Cardiopulmonary: Pertaining to the heart and lungs. [EU] Chronic: Persisting over a long period of time. [EU] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Dizziness: An imprecise term which may refer to a sense of spatial disorientation, motion of the environment, or lightheadedness. [NIH] Invasive: 1. having the quality of invasiveness. 2. involving puncture or incision of the skin or insertion of an instrument or foreign material into the body; said of diagnostic techniques. [EU] Mandible: The largest and strongest bone of the face constituting the lower jaw. It supports the lower teeth. [NIH] Oral: Pertaining to the mouth, taken through or applied in the mouth, as an oral medication or an oral thermometer. [EU] Orthopaedic: Pertaining to the correction of deformities of the musculoskeletal system; pertaining to orthopaedics. [EU] Osteoarthritis: Noninflammatory degenerative joint disease occurring chiefly in older persons, characterized by degeneration of the articular cartilage, hypertrophy of bone at the margins, and changes in the synovial membrane. It is accompanied by pain and stiffness, particularly after prolonged activity. [EU] Panic: A state of extreme acute, intense anxiety and unreasoning fear accompanied by disorganization of personality function. [NIH] Phobia: A persistent, irrational, intense fear of a specific object, activity, or situation (the phobic stimulus), fear that is recognized as being excessive or unreasonable by the individual himself. When a phobia is a significant

Guidelines 21

source of distress or interferes with social functioning, it is considered a mental disorder; phobic disorder (or neurosis). In DSM III phobic disorders are subclassified as agoraphobia, social phobias, and simple phobias. Used as a word termination denoting irrational fear of or aversion to the subject indicated by the stem to which it is affixed. [EU] Prevalence: The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. [NIH] Resuscitation: The restoration to life or consciousness of one apparently dead; it includes such measures as artificial respiration and cardiac massage. [EU]

Rheumatoid: Resembling rheumatism. [EU] Spondylitis: Inflammation of the vertebrae. [EU] Surgical: Of, pertaining to, or correctable by surgery. [EU] Tomography: The recording of internal body images at a predetermined plane by means of the tomograph; called also body section roentgenography. [EU]

22 Temporomandibular Joint Syndrome

CHAPTER 2. SEEKING GUIDANCE Overview Some patients are comforted by the knowledge that a number of organizations dedicate their resources to helping people with temporomandibular joint syndrome. These associations can become invaluable sources of information and advice. Many associations offer aftercare support, financial assistance, and other important services. Furthermore, healthcare research has shown that support groups often help people to better cope with their conditions.8 In addition to support groups, your dentist can be a valuable source of guidance and support. Therefore, finding a dentist that can work with your unique situation is a very important aspect of your care. In this chapter, we direct you to resources that can help you find patient organizations and medical specialists. We begin by describing how to find associations and peer groups that can help you better understand and cope with temporomandibular joint syndrome. The chapter ends with a discussion on how to find a dentist or oral surgeon that is right for you.

Associations and Temporomandibular Joint Syndrome As mentioned by the Agency for Healthcare Research and Quality, sometimes the emotional side of an illness can be as taxing as the physical side.9 You may have fears or feel overwhelmed by your situation. Everyone has different ways of dealing with disease or physical injury. Your attitude, Churches, synagogues, and other houses of worship might also have groups that can offer you the social support you need. 9 This section has been adapted from http://www.ahcpr.gov/consumer/diaginf5.htm. 8

Clinical Trials 23

your expectations, and how well you cope with your condition can all influence your well-being. This is true for both minor conditions and serious illnesses. For example, a study on female breast cancer survivors revealed that women who participated in support groups lived longer and experienced better quality of life when compared with women who did not participate. In the support group, women learned coping skills and had the opportunity to share their feelings with other women in the same situation. There are a number of directories that list additional medical associations that you may find useful. While not all of these directories will provide different information, by consulting all of them, you will have nearly exhausted all sources for patient associations. The National Health Information Center (NHIC) The National Health Information Center (NHIC) offers a free referral service to help people find organizations that provide information about temporomandibular joint syndrome. For more information, see the NHIC’s Web site at http://www.health.gov/NHIC/ or contact an information specialist by calling 1-800-336-4797.

DIRLINE A comprehensive source of information on associations is the DIRLINE database maintained by the National Library of Medicine. The database comprises some 10,000 records of organizations, research centers, and government institutes and associations which primarily focus on health and biomedicine. DIRLINE is available via the Internet at the following Web site: http://dirline.nlm.nih.gov/. Simply type in “temporomandibular joint syndrome” (or a synonym) or the name of a topic, and the site will list information contained in the database on all relevant organizations.

The Combined Health Information Database Another comprehensive source of information on healthcare associations is the Combined Health Information Database. Using the “Detailed Search” option, you will need to limit your search to “Organizations” and “temporomandibular joint syndrome”. Type the following hyperlink into your Web browser: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For publication date, select “All Years.” Then,

24 Temporomandibular Joint Syndrome

select your preferred language and the format option “Organization Resource Sheet.” By making these selections and typing in “temporomandibular joint syndrome” (or synonyms) into the “For these words:” box, you will only receive results on organizations dealing with temporomandibular joint syndrome. You should check back periodically with this database since it is updated every 3 months. The National Organization for Rare Disorders, Inc. The National Organization for Rare Disorders, Inc. has prepared a Web site that provides, at no charge, lists of associations organized by specific diseases. You can access this database at the following Web site: http://www.rarediseases.org/cgi-bin/nord/searchpage. Select the option called “Organizational Database (ODB)” and type “temporomandibular joint syndrome” (or a synonym) in the search box. Online Support Groups In addition to support groups, commercial Internet service providers offer forums and chat rooms for people with different illnesses and conditions. WebMDÒ, for example, offers such a service at their Web site: http://boards.webmd.com/roundtable. These online self-help communities can help you connect with a network of people whose concerns are similar to yours. Online support groups are places where people can talk informally. If you read about a novel approach, consult with your dentist or other healthcare providers, as the treatments or discoveries you hear about may not be scientifically proven to be safe and effective. The following Internet links may be of particular interest: ·

TMJ Association Web Site: http://www.tmjassociation.com/patienttalk.asp

·

1st TMJ Dentist Web Site: http://www.1sttmjdentist.com/forum/default.asp

·

Jaw Joints & Allied Musculo-Skeletal Disorders Foundation, Inc. Web Site: http://www.tmjoints.org/

Clinical Trials 25

Finding Dentists One of the most important aspects of your treatment will be the relationship between you and your dentist or specialist. All patients with temporomandibular joint syndrome must go through the process of selecting a dentist. While this process will vary from person to person, the Agency for Healthcare Research and Quality makes a number of suggestions, including the following:10 ·

If you are in a managed care plan, check the plan's list of dentists first.

·

Ask dentists or other health professionals who work with dentists, such as dental assistants and oral surgeons, for referrals.

·

Call a dentist referral service, but keep in mind that these services refer you to dentists who pay to be members. The services do not have information on the quality of care that these dentists provide.

·

Some local dental societies offer lists of member dentists. Again, these lists do not have information on the quality of care that these dentists provide.

Additional steps you can take to locate dentists include the following: ·

Check with the associations listed earlier in this chapter.

·

You can log on to the American Dental Association’s “Find a Dentist” Web site at http://www.ada.org/public/disclaimer.html.

·

Contact the dental organization in your State. Information on how to find the dental organization in your State is available on the ADA’s Web site: http://www.ada.org/ada/resources/societies/searchconst.asp.

If the previous sources did not meet your needs, you may want to log on to the Web site of the National Organization for Rare Disorders (NORD) at http://www.rarediseases.org/. NORD maintains a database of physicians with expertise in various rare diseases. The Metabolic Information Network (MIN), 800-945-2188, also maintains a database of physicians with expertise in various metabolic diseases.

10

This section is adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

26 Temporomandibular Joint Syndrome

Selecting Your Dentist11 When you have compiled a list of prospective dentists, call each of their offices. First, ask if the dentist accepts your health insurance plan and if he or she is taking new patients. If the dentist is not covered by your plan, ask yourself if you are prepared to pay the extra costs. The next step is to schedule a visit with your chosen dentist. During the first visit you will have the opportunity to evaluate your dentist and to find out if you feel comfortable with him or her. Ask yourself, did the dentist: ·

Give me a chance to ask questions about temporomandibular joint syndrome?

·

Really listen to my questions?

·

Answer in terms I understood?

·

Show respect for me?

·

Ask me questions?

·

Make me feel comfortable?

·

Address the health problem(s) I came with?

·

Ask me my preferences about different kinds of treatments for temporomandibular joint syndrome?

·

Spend enough time with me?

Trust your instincts when deciding if the dentist is right for you. But remember, it might take time for the relationship to develop. It takes more than one visit for you and your dentist to get to know each other.

Working with Your Dentist12 Research has shown that patients who have good relationships with their dentists tend to be more satisfied with their care and have better results. Here are some tips to help you and your dentist become partners: ·

You know important things about your symptoms and your health history. Tell your dentist what you think he or she needs to know.

11 This

section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm. 12 This section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

Clinical Trials 27

·

It is important to tell your dentist personal information, even if it makes you feel embarrassed or uncomfortable.

·

Bring a “health history” list with you (and keep it up to date).

·

Always bring any medications you are currently taking with you to the appointment, or you can bring a list of your medications including dosage and frequency information. Talk about any allergies or reactions you have had to your medications.

·

Tell your dentist about any natural or alternative medicines you are taking.

·

Bring other medical information, such as x-ray films, test results, and medical records.

·

Ask questions. If you don't, your dentist will assume that you understood everything that was said.

·

Write down your questions before your visit. List the most important ones first to make sure that they are addressed.

·

Consider bringing a friend with you to the appointment to help you ask questions. This person can also help you understand and/or remember the answers.

·

Ask your dentist to draw pictures if you think that this would help you understand.

·

Take notes. Some dentists do not mind if you bring a tape recorder to help you remember things, but always ask first.

·

Let your dentist know if you need more time. If there is not time that day, perhaps you can speak to a nurse or dental assistant on staff or schedule a telephone appointment.

·

Take information home. Ask for written instructions. Your dentist may also have brochures and audio and videotapes that can help you.

·

After leaving the dentist's office, take responsibility for your care. If you have questions, call. If your symptoms get worse or if you have problems with your medication, call. If you had tests and do not hear from your dentist, call for your test results. If your dentist recommended that you have certain tests, schedule an appointment to get them done. If your dentist said you should see an additional specialist, make an appointment.

By following these steps, you will enhance the relationship you will have with your dentist.

28 Temporomandibular Joint Syndrome

Broader Health-Related Resources In addition to the references above, the NIH has set up guidance Web sites that can help patients find healthcare professionals. These include:13 ·

Caregivers: http://www.nlm.nih.gov/medlineplus/caregivers.html

·

Choosing a Oral Surgeon or Healthcare Service: http://www.nlm.nih.gov/medlineplus/choosingadoctororhealthcareserv ice.html

·

Hospitals and Health Facilities: http://www.nlm.nih.gov/medlineplus/healthfacilities.html

You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html.

13

Clinical Trials 29

CHAPTER 3. CLINICAL TRIALS TEMPOROMANDIBULAR JOINT SYNDROME

AND

Overview Very few medical conditions have a single treatment. The basic treatment guidelines that your healthcare provider has discussed with you, or those that you have found using the techniques discussed in Chapter 1, may provide you with all that you will require. For some patients, current treatments can be enhanced with new or innovative techniques currently under investigation. In this chapter, we will describe how clinical trials work and show you how to keep informed of trials concerning temporomandibular joint syndrome.

What Is a Clinical Trial?14 Clinical trials involve the participation of people in medical research. Most medical research begins with studies in test tubes and on animals. Treatments that show promise in these early studies may then be tried with people. The only sure way to find out whether a new treatment is safe, effective, and better than other treatments for temporomandibular joint syndrome is to try it on patients in a clinical trial.

The discussion in this chapter has been adapted from the NIH and the NEI: www.nei.nih.gov/netrials/ctivr.htm.

14

30 Temporomandibular Joint Syndrome

What Kinds of Clinical Trials Are There? Clinical trials are carried out in three phases: ·

Phase I. Researchers first conduct Phase I trials with small numbers of patients and healthy volunteers. If the new treatment is a medication, researchers also try to determine how much of it can be given safely.

·

Phase II. Researchers conduct Phase II trials in small numbers of patients to find out the effect of a new treatment on temporomandibular joint syndrome.

·

Phase III. Finally, researchers conduct Phase III trials to find out how new treatments for temporomandibular joint syndrome compare with standard treatments already being used. Phase III trials also help to determine if new treatments have any side effects. These trials--which may involve hundreds, perhaps thousands, of people--can also compare new treatments with no treatment.

How Is a Clinical Trial Conducted? Various organizations support clinical trials at medical centers, hospitals, universities, and oral surgeons' offices across the United States. The “principal investigator” is the researcher in charge of the study at each facility participating in the clinical trial. Most clinical trial researchers are medical doctors, academic researchers, and specialists. The “clinic coordinator” knows all about how the study works and makes all the arrangements for your visits. All oral surgeons and researchers who take part in the study on temporomandibular joint syndrome carefully follow a detailed treatment plan called a protocol. This plan fully explains how the healthcare providers will treat you in the study. The “protocol” ensures that all patients are treated in the same way, no matter where they receive care. Clinical trials are controlled. This means that researchers compare the effects of the new treatment with those of the standard treatment. In some cases, when no standard treatment exists, the new treatment is compared with no treatment. Patients who receive the new treatment are in the treatment group. Patients who receive a standard treatment or no treatment are in the “control” group. In some clinical trials, patients in the treatment group get a new medication while those in the control group get a placebo. A placebo is a harmless substance, a “dummy” pill, that has no effect on temporomandibular joint syndrome. In other clinical trials, where a new

Clinical Trials 31

surgery or device (not a medicine) is being tested, patients in the control group may receive a “sham treatment.” This treatment, like a placebo, has no effect on temporomandibular joint syndrome and does not harm patients. Researchers assign patients “randomly” to the treatment or control group. This is like flipping a coin to decide which patients are in each group. If you choose to participate in a clinical trial, you will not know which group you will be appointed to. The chance of any patient getting the new treatment is about 50 percent. You cannot request to receive the new treatment instead of the placebo or sham treatment. Often, you will not know until the study is over whether you have been in the treatment group or the control group. This is called a “masked” study. In some trials, neither researchers nor patients know who is getting which treatment. This is called a “double masked” study. These types of trials help to ensure that the perceptions of the patients or researchers will not affect the study results. Natural History Studies Unlike clinical trials in which patient volunteers may receive new treatments, natural history studies provide important information to researchers on how temporomandibular joint syndrome develops over time. A natural history study follows patient volunteers to see how factors such as age, sex, race, or family history might make some people more or less at risk for temporomandibular joint syndrome. A natural history study may also tell researchers if diet, lifestyle, or occupation affects how a disease or disorder develops and progresses. Results from these studies provide information that helps answer questions such as: How fast will a disease or disorder usually progress? How bad will the condition become? Will treatment be needed? What Is Expected of Patients in a Clinical Trial? Not everyone can take part in a clinical trial for a specific disease or disorder. Each study enrolls patients with certain features or eligibility criteria. These criteria may include the type and stage of disease or disorder, as well as, the age and previous treatment history of the patient. You or your dentist can contact the sponsoring organization to find out more about specific clinical trials and their eligibility criteria. If you are interested in joining a clinical trial, your dentist must contact one of the trial's investigators and provide details about your diagnosis and medical history.

32 Temporomandibular Joint Syndrome

If you participate in a clinical trial, you may be required to have a number of medical tests. You may also need to take medications and/or undergo surgery. Depending upon the treatment and the examination procedure, you may be required to receive inpatient hospital care. Or, you may have to return to the medical facility for follow-up examinations. These exams help find out how well the treatment is working. Follow-up studies can take months or years. However, the success of the clinical trial often depends on learning what happens to patients over a long period of time. Only patients who continue to return for follow-up examinations can provide this important long-term information.

Recent Trials on Temporomandibular Joint Syndrome The National Institutes of Health and other organizations sponsor trials on various diseases and disorders. Because funding for research goes to the medical areas that show promising research opportunities, it is not possible for the NIH or others to sponsor clinical trials for every disease and disorder at all times. The following lists recent trials dedicated to temporomandibular joint syndrome.15 If the trial listed by the NIH is still recruiting, you may be eligible. If it is no longer recruiting or has been completed, then you can contact the sponsors to learn more about the study and, if published, the results. Further information on the trial is available at the Web site indicated. Please note that some trials may no longer be recruiting patients or are otherwise closed. Before contacting sponsors of a clinical trial, consult with your dentist who can help you determine if you might benefit from participation. ·

Study of Etanercept and Celecoxib to Treat Temporomandibular Disorders (Painful Joint Conditions) Condition(s): Temporomandibular Joint Disorder Study Status: This study is currently recruiting patients. Sponsor(s): National Institute of Dental and Craniofacial Research (NIDCR) Purpose - This 2-part study will evaluate the effectiveness and side effects of two anti-inflammatory drugs for relieving pain and improving jaw function in patients with temporomandibular disorder (TMD). Part 1 will evaluate celecoxib (Celebrex); Part 2 will evaluate etanercept (Enbrel). The Food and Drug Administration has approved both of these drugs for treating certain forms of arthritis. Patients between the ages of 18 and 65

15

These are listed at www.ClinicalTrials.gov.

Clinical Trials 33

years with painful jaw joint conditions may be eligible for this study. Candidates will complete several written questionnaires about their jaw condition and will undergo a medical history, complete TMD evaluation, blood and urine tests, and imaging studies of the temporomandibular joint, such as X-rays and magnetic resonance imaging. Patients will rate the quality and intensity of their pain before beginning treatment. At certain periods during the study, they will also keep a pain diary, twice a day recording the intensity and magnitude of their pain. Part 1 Celecoxib: Patients will be randomly assigned to receive either 1) celecoxib twice a day by mouth; 2) naproxen (a non-steroidal antiinflammatory drug) twice a day by mouth; or 3) a placebo (inactive pill) twice a day by mouth. Part 2 - Etanercept: Patients will be randomly assigned to receive either 1) etanercept injected under the skin or 2) saline (an inactive placebo) injected under the skin. Patients in this group will also undergo two aspirations of fluid from the jaw joint - once before treatment begins and again 6 weeks later. For this procedure, the joint is numbed with an anesthetic and then a needle is inserted into the jaw space to withdraw fluid, which will be analyzed for inflammatory processes in the joint. All patients will have a final evaluation 6 weeks after beginning treatment, including a TMD physical examination, laboratory and X-ray tests as required. The pain diary and questionnaires will be collected at this visit. Phase(s): Phase II Study Type: Interventional Contact(s): Maryland; National Institute of Dental And Craniofacial Research (NIDCR), 9000 Rockville Pike Bethesda, Maryland, 20892, United States; Recruiting; Patient Recruitment and Public Liaison Office 1-800-411-1222 [email protected]; TTY 1-866-411-1010 Web Site: http://www.clinicaltrials.gov/ct/gui/c/w2r/show/NCT00001955 ·

Complementary Medicine Approaches to TMD Pain Management Temporomandibular Joint Disorders Study Status: This study is currently recruiting patients. Sponsor(s): National Center for Complementary and Alternative Medicine (NCCAM) Purpose - Temporomandibular disorders are characterized by pain and tenderness in the muscles of mastication and/or the temporomandibular joint (TMJ), limitations of jaw opening often accompanied by deviations

34 Temporomandibular Joint Syndrome

in mandibular path, and clicking, popping or grating TMJ sounds. This Phase II clinical trial will evaluate whether selected complementary approaches to TMD pain management-acupuncture (n=100), chiropractic therapy (n=50), and bodywork therapy (n=50)-delivered by complementary practitioners is as effective as usual TMD care (n=50) provided by clinicians in the KPNW TMD clinic. Subjects will be 18-70 years of age and psychologically functional TMD patients. Functional TMD patients are defined as minimally impacted by their TMD condition, reporting low-moderate pain that is not associated with activity limitation, undue reliance on health care, or psychological disturbance. Subjects will be evaluated at baseline, and six and 12 months post-intervention. Clinical examinations, saliva samples to assess salivary cortisol levels, and a series of questionnaires to assess pain and grade of dysfunctional pain, psychological functioning, and other physical symptoms will be used to assess outcomes. The investigators will passively monitor health care utilization within KPNW using clinical, research, and administrative databases. If these complementary interventions are shown to be effective, the goal is to design and implement a Phase III clinical trial to further evaluate the health consequences and cost of these therapies. Phase(s): Phase II Study Type: Interventional Contact(s): Alex White 1-503-335-6765 [email protected]; Oregon; Center for Health Research, Portland, Oregon, 97227-1110, United States; Recruiting Web Site: http://www.clinicaltrials.gov/ct/gui/c/w2r/show/NCT00010621 ·

Alternative Medicine Approaches Temporomandibular Disorders

for

Women

with

Condition(s): Temporomandibular Joint Disorders Study Status: This study is currently recruiting patients. Sponsor(s): National Center for Complementary and Alternative Medicine (NCCAM) Purpose - Temporomandibular disorders (TMD) are characterized by pain and tenderness in the muscles of mastication and/or the temporomandibular joint (TMJ), limitations of jaw opening often accompanied by deviations in mandibular path, and clicking, popping or grating TMJ sounds.

Clinical Trials 35

TMD is often found in association with other problems: depression, anxiety, sleep disturbances, gastrointestinal symptoms, frequent infections, etc. This project proposes to holistically address patient symptoms through three different approaches, Naturopathic Medicine (NM), Traditional Chinese Medicine (TCM), and usual care at KPNW. We will conduct a pilot test and Phase II trial to evaluate the two alternative healing approaches, TCM (n=50) and NM (n=50) delivered by TCM and NM practitioners, are as effective as usual TMD care (n=50) provided by dental clinicians in the KPNW TMD Clinic. Subjects will be females 25-55 years of age with multiple health problems (defined as patients who have had at least 4 organ system-grouped diagnoses in the past year, not including TMD). Subjects will be evaluated at baseline, 6 and 12 months after start of treatment. The primary endpoint is change from baseline in the Axis II Pain Related Disability and Psychological Status Scale. Clinical examinations, saliva samples to assess salivary cortisol levels, and responses to a series of questionnaires to assess pain, chronic pain, psychosocial functioning, and other physical symptoms will be used to assess outcomes. We will passively monitor health care utilization within KPNW using clinical, research, and administrative databases to determine whether the interventions have an impact on overall health care utilization. If either of these alternative interventions is shown to merit Phase III trial, our goal is to design and implement such a clinical trial to further evaluate the health consequences and costs of these alternative healing paradigms. Phase(s): Phase II Study Type: Interventional Contact(s): Cheryl Ritenbaugh 1-503-335-6668 [email protected] ; Oregon; Center for Health Research, Kaiser Foundation Hospitals, Portland, Oregon, 97227-1110, United States; Recruiting Web Site: http://www.clinicaltrials.gov/ct/gui/c/w2r/show/NCT00009594 ·

Evaluation and Treatment of Oral Soft Tissue Diseases Condition(s): Aphthous Stomatitis, Burning Mouth Syndrome, Lichen Planus, Mouth Disease, Temporomandibular Joint Disorder Study Status: This study is currently recruiting patients.

36 Temporomandibular Joint Syndrome

Sponsor(s): National Institute of Dental and Craniofacial Research (NIDCR) Purpose - This study offers evaluation and treatment of patients with diseases of the mouth or systemic diseases that involve the mouth. The protocol is not designed to test new treatments; rather, patients will receive current standard of care treatments. The purposes of the study are: 1) to allow NIDCR's Gene Therapy and Therapeutics Branch staff to gain more knowledge about oral soft tissue diseases and possibly identify new avenues of research in this area; and 2) to establish a pool of patients who may be eligible for new studies as they are developed. (Participants in this protocol will not be required to join a new study; the decision will be voluntary.) Patients of any age with oral diseases or systemic diseases involving the mouth may be eligible for this study. Women of childbearing potential and women who are pregnant or breastfeeding will only have tests and procedures and receive medications that pose no greater than a minimal risk to the fetus. Participants will have a comprehensive dental and medical examination, including a physical examination of the head and neck. Additional tests and procedures that may be required for diagnosis and to guide treatment include the following: - Blood and urine tests - for routine laboratory studies, assessment of kidney and liver function, and detection of viruses, fungi, bacteria or parasites - Electrocardiogram - to record the electrical activity of the heart - Biopsies - to examine tissue under the microscope. The method and number of biopsies depends on the individual's specific condition and the tissue to be removed. For all biopsies a local anesthetic (lidocaine with or without epinephrine) is injected at the biopsy site. A punch biopsy uses a small sharp cookie-cutter instrument to remove a small (about 1/10- to 1/5-inch) piece of skin. An excisional biopsy uses a small surgical knife or scalpel to remove a piece of tissue, usually requiring some stitches to close the wound. - Diagnostic imaging - X-rays, photographs, or other tests as needed for diagnosis Treatments include tablets, injections and topically applied medications. All preparations are approved by the Food and Drug Administration and are commercially available. Patient follow-up may vary from one visit to intermittent visits over a number of years, depending on the patient's condition. Study Type: Interventional Contact(s): Maryland; National Institute of Dental And Craniofacial Research (NIDCR), 9000 Rockville Pike Bethesda, Maryland, 20892, United States; Recruiting; Patient Recruitment and Public Liaison Office 1-800-411-1222; [email protected] ; TTY 1-866-411-1010 Web Site:http://www.clinicaltrials.gov/ct/gui/c/w2r/show/NCT00001601

Clinical Trials 37

·

Diagnosis and Evaluation of Patients Needing Third Molar (Wisdom Tooth) Extraction and Patients with Chronic Facial Pain Condition(s): Facial Pain, Temporomandibular Joint Disorder Study Status: This study is currently recruiting patients. Sponsor(s): National Institute of Dental and Craniofacial Research (NIDCR) Purpose - This study provides a mechanism for evaluating patients for possible participation in NIDCR clinical research studies. NIDCR studies involve three major areas-pain, neurosensory mechanisms, and pain-relieving drugs-all of which have specific requirements and patient characteristics. No treatment is offered under this protocol; it is intended to facilitate patient recruitment into NIDCR studies. Patients with unusual or unknown conditions that have or have not been diagnosed may be eligible for this screening study. Specific medical criteria for enrollment vary with the particular protocol for which the individual is being screened. Medical and dental histories will be obtained and participants will have a dental examination. Diagnostic procedures will be done in accord with standard medical and dental practice and may include X-rays, blood tests, and routine urinalysis, as appropriate. Participants found eligible for an active study may enroll in that study. Those who are not eligible for a current study may be reevaluated for future studies within a year if they wish. After 1 year, participants for whom no appropriate studies are identified will be referred back to their primary doctor or referring physician or dentist. Study Type: Observational Contact(s): Maryland; National Institute of Dental And Craniofacial Research (NIDCR), 9000 Rockville Pike Bethesda, Maryland, 20892, United States; Recruiting; Patient Recruitment and Public Liaison Office 1-800-411-1222 [email protected] TTY 1-866-411-1010 Web Site:http://www.clinicaltrials.gov/ct/gui/c/w2r/show/NCT00001600

38 Temporomandibular Joint Syndrome

Benefits and Risks16 What Are the Benefits of Participating in a Clinical Trial? If you are interested in a clinical trial, it is important to realize that your participation can bring many benefits to you and society at large: ·

A new treatment could be more effective than the current treatment for temporomandibular joint syndrome. Although only half of the participants in a clinical trial receive the experimental treatment, if the new treatment is proved to be more effective and safer than the current treatment, then those patients who did not receive the new treatment during the clinical trial may be among the first to benefit from it when the study is over.

·

If the treatment is effective, then it may improve health or prevent diseases or disorders.

·

Clinical trial patients receive the highest quality of medical care. Experts watch them closely during the study and may continue to follow them after the study is over.

·

People who take part in trials contribute to scientific discoveries that may help other people with temporomandibular joint syndrome. In cases where certain diseases or disorders run in families, your participation may lead to better care or prevention for your family members. The Informed Consent

Once you agree to take part in a clinical trial, you will be asked to sign an “informed consent.” This document explains a clinical trial's risks and benefits, the researcher’s expectations of you, and your rights as a patient.

What Are the Risks? Clinical trials may involve risks as well as benefits. Whether or not a new treatment will work cannot be known ahead of time. There is always a chance that a new treatment may not work better than a standard treatment. There is also the possibility that it may be harmful. The treatment you

This section has been adapted from ClinicalTrials.gov, a service of the National Institutes of Health: http://www.clinicaltrials.gov/ct/gui/c/a1r/info/whatis?JServSessionIdzone_ct=9jmun6f291. 16

Clinical Trials 39

receive may cause side effects that are serious enough to require medical attention.

How Is Patient Safety Protected? Clinical trials can raise fears of the unknown. Understanding the safeguards that protect patients can ease some of these fears. Before a clinical trial begins, researchers must get approval from their hospital's Institutional Review Board (IRB), an advisory group that makes sure a clinical trial is designed to protect patient safety. During a clinical trial, researchers will closely watch you to see if the treatment is working and if you are experiencing any side effects. All the results are carefully recorded and reviewed. In many cases, experts from the Data and Safety Monitoring Committee carefully monitor each clinical trial and can recommend that a study be stopped at any time. You will only be asked to take part in a clinical trial as a volunteer giving informed consent. What Are a Patient's Rights in a Clinical Trial? If you are eligible for a clinical trial, you will be given information to help you decide whether or not you want to participate. As a patient, you have the right to: ·

Information on all known risks and benefits of the treatments in the study.

·

Know how the researchers plan to carry out the study, for how long, and where.

·

Know what is expected of you.

·

Know any costs involved for you or your insurance provider.

·

Know before any of your medical or personal information is shared with other researchers involved in the clinical trial.

·

Talk openly with healthcare providers and ask any questions.

After you join a clinical trial, you have the right to: ·

Leave the study at any time. Participation is strictly voluntary. However, you should not enroll if you do not plan to complete the study.

·

Receive any new information about the new treatment.

·

Continue to ask questions and get answers.

40 Temporomandibular Joint Syndrome

·

Maintain your privacy. Your name will not appear in any reports based on the study.

·

Know whether you participated in the treatment group or the control group (once the study has been completed).

What about Costs? In some clinical trials, the research facility pays for treatment costs and other associated expenses. You or your insurance provider may have to pay for costs that are considered standard care. These things may include inpatient hospital care, laboratory and other tests, and medical procedures. You also may need to pay for travel between your home and the clinic. You should find out about costs before committing to participation in the trial. If you have health insurance, find out exactly what it will cover. If you don't have health insurance, or if your insurance company will not cover your costs, talk to the clinic staff about other options for covering the cost of your care. What Questions Should You Ask before Deciding to Join a Clinical Trial? Questions you should ask when thinking about joining a clinical trial include the following: ·

What is the purpose of the clinical trial?

·

What are the standard treatments for temporomandibular joint syndrome? Why do researchers think the new treatment may be better? What is likely to happen to me with or without the new treatment?

·

What tests and treatments will I need? Will I need surgery? Medication? Hospitalization?

·

How long will the treatment last? How often will I have to come back for follow-up exams?

·

What are the treatment's possible benefits to my condition? What are the short- and long-term risks? What are the possible side effects?

·

Will the treatment be uncomfortable? Will it make me feel sick? If so, for how long?

·

How will my health be monitored?

·

Where will I need to go for the clinical trial? How will I get there?

Clinical Trials 41

·

How much will it cost to be in the study? What costs are covered by the study? How much will my health insurance cover?

·

Will I be able to see my own dentist? Who will be in charge of my care?

·

Will taking part in the study affect my daily life? Do I have time to participate?

·

How do I feel about taking part in a clinical trial? Are there family members or friends who may benefit from my contributions to new medical knowledge?

Keeping Current on Clinical Trials Various government agencies maintain databases on trials. The U.S. National Institutes of Health, through the National Library of Medicine, has developed ClinicalTrials.gov to provide patients, family members, and healthcare providers with current information about clinical research across the broadest number of diseases and conditions. The site was launched in February 2000 and currently contains approximately 5,700 clinical studies in over 59,000 locations worldwide, with most studies being conducted in the United States. ClinicalTrials.gov receives about 2 million hits per month and hosts approximately 5,400 visitors daily. To access this database, simply go to their Web site (www.clinicaltrials.gov) and search by “temporomandibular joint syndrome” (or synonyms). While ClinicalTrials.gov is the most comprehensive listing of NIH-supported clinical trials available, not all trials are in the database. The database is updated regularly, so clinical trials are continually being added. The following is a list of specialty databases affiliated with the National Institutes of Health that offer additional information on trials: ·

For clinical studies at the Warren Grant Magnuson Clinical Center located in Bethesda, Maryland, visit their Web site: http://clinicalstudies.info.nih.gov/

·

For clinical studies conducted at the Bayview Campus in Baltimore, Maryland, visit their Web site: http://www.jhbmc.jhu.edu/studies/index.html

42 Temporomandibular Joint Syndrome

General References The following references describe clinical trials and experimental medical research. They have been selected to ensure that they are likely to be available from your local or online bookseller or university medical library. These references are usually written for healthcare professionals, so you may consider consulting with a librarian or bookseller who might recommend a particular reference. The following includes some of the most readily available references (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

A Guide to Patient Recruitment : Today's Best Practices & Proven Strategies by Diana L. Anderson; Paperback - 350 pages (2001), CenterWatch, Inc.; ISBN: 1930624115; http://www.amazon.com/exec/obidos/ASIN/1930624115/icongroupinter na

·

A Step-By-Step Guide to Clinical Trials by Marilyn Mulay, R.N., M.S., OCN; Spiral-bound - 143 pages Spiral edition (2001), Jones & Bartlett Pub; ISBN: 0763715697; http://www.amazon.com/exec/obidos/ASIN/0763715697/icongroupinter na

·

The CenterWatch Directory of Drugs in Clinical Trials by CenterWatch; Paperback - 656 pages (2000), CenterWatch, Inc.; ISBN: 0967302935; http://www.amazon.com/exec/obidos/ASIN/0967302935/icongroupinter na

·

The Complete Guide to Informed Consent in Clinical Trials by Terry Hartnett (Editor); Paperback - 164 pages (2000), PharmSource Information Services, Inc.; ISBN: 0970153309; http://www.amazon.com/exec/obidos/ASIN/0970153309/icongroupinter na

·

Dictionary for Clinical Trials by Simon Day; Paperback - 228 pages (1999), John Wiley & Sons; ISBN: 0471985961; http://www.amazon.com/exec/obidos/ASIN/0471985961/icongroupinter na

·

Extending Medicare Reimbursement in Clinical Trials by Institute of Medicine Staff (Editor), et al; Paperback 1st edition (2000), National Academy Press; ISBN: 0309068886; http://www.amazon.com/exec/obidos/ASIN/0309068886/icongroupinter na

·

Handbook of Clinical Trials by Marcus Flather (Editor); Paperback (2001), Remedica Pub Ltd; ISBN: 1901346293;

Clinical Trials 43

http://www.amazon.com/exec/obidos/ASIN/1901346293/icongroupinter na

44 Temporomandibular Joint Syndrome

PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL

ABOUT PART II In Part II, we introduce you to additional resources and advanced research on temporomandibular joint syndrome. All too often, patients who conduct their own research are overwhelmed by the difficulty in finding and organizing information. The purpose of the following chapters is to provide you an organized and structured format to help you find additional information resources on temporomandibular joint syndrome. In Part II, as in Part I, our objective is not to interpret the latest advances on temporomandibular joint syndrome or render an opinion. Rather, our goal is to give you access to original research and to increase your awareness of sources you may not have already considered. In this way, you will come across the advanced materials often referred to in pamphlets, books, or other general works. Once again, some of this material is technical in nature, so consultation with a professional familiar with temporomandibular joint syndrome is suggested.

Studies 45

CHAPTER 4. STUDIES ON TEMPOROMANDIBULAR JOINT SYNDROME Overview Every year, academic studies are published on temporomandibular joint syndrome or related conditions. Broadly speaking, there are two types of studies. The first are peer reviewed. Generally, the content of these studies has been reviewed by scientists or healthcare providers. Peer-reviewed studies are typically published in scientific journals and are usually available at medical libraries. The second type of studies is non-peer reviewed. These works include summary articles that do not use or report scientific results. These often appear in the popular press, newsletters, or similar periodicals. In this chapter, we will show you how to locate peer-reviewed references and studies on temporomandibular joint syndrome. We will begin by discussing research that has been summarized and is free to view by the public via the Internet. We then show you how to generate a bibliography on temporomandibular joint syndrome and teach you how to keep current on new studies as they are published or undertaken by the scientific community.

Federally-Funded Research on Temporomandibular Syndrome

Joint

The U.S. Government supports a variety of research studies relating to temporomandibular joint syndrome and associated conditions. These studies are tracked by the Office of Extramural Research at the National Institutes of

46 Temporomandibular Joint Syndrome

Health.17 CRISP (Computerized Retrieval of Information on Scientific Projects) is a searchable database of federally-funded biomedical research projects conducted at universities, hospitals, and other institutions. Visit the CRISP Web site: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket. You can perform targeted searches by various criteria including geography, date, as well as topics related to temporomandibular joint syndrome and related conditions. For most of the studies, the agencies reporting into CRISP provide summaries or abstracts. As opposed to clinical trial research using patients, many federally-funded studies use animals or simulated models to explore temporomandibular joint syndrome and related conditions. In some cases, therefore, it may be difficult to understand how some basic or fundamental research could eventually translate into medical practice. The following sample is typical of the type of information found when searching the CRISP database for temporomandibular joint syndrome: ·

Project Title: AN ANIMAL INFLAMMATION IN RATS

MODEL

FOR

STUDYING

TMJ

Principal Investigator & Institution: Bellinger, Larry L.; Professor; Biomedical Sciences; Texas A&M Baylor College of Dentistry 3302 Gaston Ave Dallas, Tx 75246 Timing: Fiscal Year 2000; Project End 1-AUG-2002 Summary: (Adapted from Abstract) The primary objective of this proposal is to develop a biobehavioral animal model that will allow for better design of experiments investigating TMJ inflammation. The working hypothesis is that animal feeding patterns will change and will be directly correlated with biological markers during complete Freud's adjuvant (CFA) induced TMJ inflammation. Feeding behavior will be determined via a sophisticated and highly sensitive method of computer operated meal pattern analyses (MPA). In the first experiment, a generalized model will be further developed that uses MPA to determine behavioral changes during early (+2 days after CFA) and late (+42 days after CFA) stage TMJ inflammation. Meal patterns will be correlated to changes in inflammatory markers including histology, TMJ calcitonin gene related peptide and interleukin-1b, trigeminal ganglia substance P, and plasma stress hormones corticosterone, b-endorphin and oxytocin. A Healthcare projects are funded by the National Institutes of Health (NIH), Substance Abuse and Mental Health Services (SAMHSA), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDCP), Agency for Healthcare Research and Quality (AHRQ), and Office of Assistant Secretary of Health (OASH).

17

Studies 47

second experiment will repeat these procedures with and without antiinflammatory treatment. These experiments are intended to provide the clinician with a non- invasive behavioral marker for TMJ inflammation and stress, and a more objective basis for patient diagnosis, treatment and outcomes assessment. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: ANIMAL MODELS FUNCTIONAL 3-D LOADING

FOR

TMJ

RESEARCH:

Principal Investigator & Institution: Rafferty, Katherine L.; Orthodontics; University of Washington 3935 University Way Ne Seattle, Wa 98195 Timing: Fiscal Year 2002; Project Start 1-JAN-2002; Project End 1-DEC2003 Summary: (provided by applicant) Large animals are necessary models to test TMJ protheses, to test the use of cartilage and disc grafts, and in studies on experimentally induced osteoarthritis. Pigs and sheep are now the animals of choice, both for practical reasons (cost and ease of use) and because their TMJ components are similar in size to those of humans. Indeed, a consideration of muscle and occlusal anatomy suggests that TMJ mechanics of pigs and sheep have very little in common. Many of the TMJ studies on pigs and sheep are affected by joint mechanics, yet there is little information or appreciation of the differences and similarities to the human condition. In the proposed study we will explore these differences and similarities by measuring threedimensional loads on the mandible during masticatory function in pigs and sheep. Specifically we will assess torsion and bending of the condyle and mandibular corpus (S.A. 1) by measuring patterns of strain from their medial and lateral surfaces. We expect a three-dimensional analysis of strain will reveal complex patterns of mandibular deformation in both species. Because pigs have balancing side occlusal contacts and a fused symphysis and sheep have working-side only occlusal contact and an open symphysis, we expect dramatic species differences in the relative magnitudes of balancing versus working side condylar and corporal strain. We will also measure the magnitudes and orientations of occlusal forces using a miniature three-component force transducer implanted under the crown of a molar tooth (S.A. 2). Because of the technically challenging nature of this part of the proposed research, we will begin by using it on high-crowned sheep molars. Although sheep show a large medial translation of their mandible during the chew cycle, we expect that their flat-occlusal surface will provide little resistance in this direction. We will simultaneously record condylar and corporal strain and EMG activity, allowing us to explore how strain patterns and

48 Temporomandibular Joint Syndrome

occlusal forces change in relation to each other and in relation to muscle activation during the course of the power stroke. The data we generate will be used in comparison with finite element predictions of mandibular deformations. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: BIOBEHAVIORAL TEMPOROMANDIBULAR

ETIOLOGY

OF

CHRONIC

Principal Investigator & Institution: Fricton, James R.; Professor; Diagnostic/Surgical Scis; University of Minnesota Twin Cities Twin Cities Minneapolis, Mn 55455 Timing: Fiscal Year 2000; Project Start 1-SEP-1997; Project End 0-JUN2002 Summary: This research proposal is designed to determine which central and peripheral factors are involved in the etiology of chronic dysfunctional TMS. This study is a prospective observational cohort study in which baseline jaw dysfunction, oral habits, depression, and fibromyalgia are the primary risk factors to be evaluated for their prognostic importance in the development of chronic dysfunctional pain in temporomandibular disorders. The study design is a 3-year cohort study of 500 non-chronic TMD pain patients who will be followed at 18 and 36 months to determine which subjects develop chronic pain and the influence that these factors have in predicting development. These patients will meet Research Diagnostic Criteria (RDC) axis II Chronic Pain Grading system I or II and have a physical diagnosis of myofacial pain and/or temporomandibular joint (TMJ) disc displacement. Examination data will include the standardized exam of the RDC/TMD axis I, Craniomandibular Index, an occlusal index, and a tender point exam to screen for possible fibromyalgia. Questionnaires will include RDC/TMD axis I and II, coping strategies questionnaire, a self report fibromyalgia screening form, and IMPATH. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: EARLY DETECTION CHRONIC PAIN DISABILIT

AND

PREVENTION

OF

Principal Investigator & Institution: Gatchel, Robert J.; Professor of Psychiatry; Psychiatry; University of Texas Sw Med Ctr/Dallas Southwestern Medical Ctr/Dallas Dallas, Tx 75390 Timing: Fiscal Year 2000; Project Start 1-AUG-1993; Project End 1-AUG2004

Studies 49

Summary: This is a request for a competitive renewal of an NIMH Independent Scientist Award (K02). It will provide important continuity of my research program developed during an original K02 award (199398). The proposal presents 3 separate research projects that evaluate an early prediction-intervention approach to 2 costly chronic pain syndromes-low back pain (LBP) and temporomandibular disorder (TMD). Early detection to prevent such chronic disorders is now recognized as a high priority research area in the PHS Report of "Healthy People 2000." The goal of the first project is the assessment of a large cohort of acute LBP patients in order to screen out those patients who are at "high risk" for developing chronic disability. This screening will be accomplished by using a statistical algorithm developed in an earlier RO1 project that successfully identified such "high risk" patients. These "high risk" patients will then be randomly assigned to an early intervention or a nonintervention group. One-year follow-up evaluations will assess important socioeconomic outcomes such as return to work and healthcare utilization rates. The second project parallels the earlier conducted study that successfully identified "high risk" acute LBP patients. This project will develop a specific algorithm for predicting the development of chronic TMD. Those acute patients who subsequently develop chronic problems will then participate in a second phase which evaluates the relative efficacy of 4 techniques, 3 of which are biobehovioral approaches. Finally, the third project will also assess an early assessment intervention model with TMD. It will parallel the methodology used in the first project. "High risk" patients, screened on the basis of a statistical algorithm, will be randomly assigned to either early intervention or nonintervention. Long term follow-up of these patients will assess important diagnostic, self-report and functional changes. Finally, interwoven within all 3 projects will be the evaluation of a potentially heuristic theory of the interaction between pain and stress. We are now at a point to identify early signs of chronicity, and then provide early intervention in order to prevent costly problems from developing. These 3 research projects will explore the efficacy of early identification of "high risk" acute patients in order to provide biobehavioral treatment intervention, while simultaneously evaluating cost-effectiveness. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: INDIVIDUAL PREDOCTORAL DENTAL SCIENTIST FELLOWSHIP Principal Investigator & Institution: Flake, Natasha M.; Oral & Craniofacial Biol Scis; University of Maryland Balt Prof School Professional Schools Baltimore, Md 21201

50 Temporomandibular Joint Syndrome

Timing: Fiscal Year 2001; Project Start 1-SEP-2001 Summary: Temporomandibular disorders (TMD) are associated with chronic and debilitating pain. These far too common disorders, affecting up 15% of American adults, are often resistant to traditional therapies effective for pain treatment in other areas of the body, possibly reflecting unique properties of primary afferent neurons innervating the temporomandibular joint (TMJ). Furthermore, there is an increased prevalence and severity of TMD pain in women versus men. Epidemiological, clinical, and animal experimental evidence suggests that estrogen may contribute to the pathophysiology of TMD pain. Therefore, we propose to test the hypothesis that estrogen increases the excitability of trigeminal primary afferent neurons innervating the TMJ Pain associated with TMD may also reflect TMJ inflammation. In the presence of inflammation, primary afferent neurons become sensitized, displaying spontaneous activity and/or a leftward shift in the stimulusresponse function. Therefore, we also propose to test the hypothesis that estrogen exacerbates the inflammation-induced sensitization of primary afferent neurons innervating the TMJ. To test these hypotheses, we will perform experiments described under the following Specific Aims. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: INTERNAT. CONSORTIUM FOR RESEARCH ON TMJ DISORDERS Principal Investigator & Institution: Dworkin, Samuel F.; Professor; Oral Medicine; University of Washington 3935 University Way Ne Seattle, Wa 98195 Timing: Fiscal Year 2000; Project Start 1-JUL-2000; Project End 0-JUN2002 Summary: This is an application in response to RFA DE-99-002International Collaborative Oral Health Research Planning Grant. It is a two-year planning project which has its long term goal the conduct of multi-national research into the etiology, prevention, and management of temporomandibular disorders. An international consortium for this purpose is proposed, housed at the University of Washington, which has been the center for developing standardized examination and diagnostic approaches, including the Research Diagnostic Criteria for TMD (RDC/TMD), all of which will be available to the consortium and which will constitute a central component of the proposed planning effort. The specific aims of this two-year planning grant are the following: 1) to establish and leave in place at the end of the planning process a working consortium of multi-national clinical centers having the capability to conduct programmatic, interdisciplinary research on an international

Studies 51

level into the etiology, prevention, and management of TMD; 2) to establish, prior to the end of the planning phase, reliable RDC/TMD examiners at each clinical center of the consortium, and by consensus of the consortium make modifications to the RDC/TMD; 3) use available electronic and networking technology to establish electronic data collection and transmission capabilities at consortium sites for communicating and for management of scientific data and literature databases; and 4) to submit for funding at least two multi-national, interdisciplinary research proposals by the end of the planning phase. A pilot electronic network, serving as prototypical for proposed electronic communications and networking aims, allowed consortium members to be surveyed, provide feedback, receive and return appropriate forms, etc., in timely fashion for preparation of this grant application. The participating individuals and institutions: 1) include some of the most pre-eminent workers in the field; 2) use the RDC/TMD in their respective native languages; 3) are eager to form such a consortium that includes orofacial pain and TMD clinic directors at the Universities of Sydney, Australia; Helsinki, Finland; Halle-Leipsig, Germany; Tel Aviv, Israel; Singapore, Singapore; Oral Rehabilitation Center, Link'ping, Sweden; and in the United States, the consortium participants include the universities of SUNY at Buffalo, Michigan, Minnesota, and Washington. A future goal will be to extend the consortium's domain to include all acute and chronic dental and orofacial pain conditions of significance to dentistry. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: JOINT AND MUSCLE TEMPOROMANDIBULAR JOINT

DYSFUNCTION

OF

Principal Investigator & Institution: Cowley, Allen W.; ; Tmj Association 2433 N Mayfair Rd Milwaukee, Wi 53226 Timing: Fiscal Year 2002; Project Start 1-APR-2002; Project End 1-MAR2003 Summary: (provided by applicant) The TMJ Association Conference on "Joint and Muscle Dysfunction of the Temporomandibular Joint," is scheduled for May 6-8, 2002 in Bethesda, Maryland. Based on a 1989 national survey conducted by the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health, it is estimated that over ten million people in the United States have signs of temporomandibular disorders with as many as 80 percent of patients treated for these disorders being women. Since little research had explored these problems, in May of 2000 a national patient advocacy group, The TMJ Association, organized a meeting to assess the current state of the science and provide directions for future research. The TMJ

52 Temporomandibular Joint Syndrome

Association and several agencies of the NIH, Office of Research on Women's Health, co-sponsored this meeting. It brought together an interdisciplinary team of experts in arthritis, TMJ pathology, bone, joint, muscle physiology, neuroscience, pain, genetics, endocrinology, immunology, bone angiogenesis, and tissue repair/engineering. The state of research was summarized and recommendations were made for future directions in research. The second proposed. TMJ Association Conference will focus on the molecular, cellular, tissue and mechanical features of the temporomandibular joint and masticatory muscle of which there is very limited understanding. Emerging work related to bone/joint angiogenesis will be presented. The fundamental goal of this conference is to enrich the pool of investigators directed to TMJ research by attracting experts from other fields and by stimulating the interest of young investigators in this emerging field of research. The Specific Aims of the conferences are: 1) To convene an internationally recognized interdisciplinary group of basic and clinical investigators in rheumatology and musculoskeletal diseases to address the biochemical, molecular vascular and biomechanical aspects of structure and functions that may lead to diseases/dysfunctions of the TM joint; 2) To promote the participation of young scientists through a travel award program; and 3) to interest new investigators and students in pursuing research on temporomandibular diseases and disorders. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: MECHANICAL ENVIRONMENT IN MANDIBULAR DISTRACTION Principal Investigator & Institution: Herring, Susan W.; Professor & Acting Chair; Orthodontics; University of Washington 3935 University Way Ne Seattle, Wa 98195 Timing: Fiscal Year 2002; Project Start 1-JAN-2002; Project End 1-DEC2006 Summary: (provided by applicant): Distraction osteogenesis (DO) is a means to elongate bone by placing tensile loads on a healing osteotomy. Although DO has been used on the mandible for only a decade, the technique is already supplanting more traditional orthognathic procedures, especially for children. Despite the fact that DO uses mechanics to accomplish its goals, the actual mechanical environment is unknown. Functions such as mastication must place intermittent compressive or shearing strains on the distraction site. These strains, as well as the tensile strains produced by the distraction appliance, are of critical biological significance for the osteogenic process, but have never been measured. Using a well-established model for mandibular DO, the

Studies 53

pig, we propose (Aim 1) to clarify the mechanical environment of the distraction site at the time of osteotomy, during distraction, and during consolidation by making direct measurements of strain using strain gages, digital ultrasonics and differential variable reluctance transducers. These studies will investigate the influence of appliance size, stability, and placement as well as the action of specific muscles and occlusal loads. Further, we will address a major concern of treating growing children by mandibular DO, whether the procedure adversely affects growth at the mandibular condylar by overloading the TMJ. Thus, we propose (Aim 2) to ascertain the impact of DO on TMJ mechanics and growth by performing strain gage measurements on the condylar neck and relating the findings to growth, as measured by mineral apposition rate and periosteal deformation. The mechanical environment of DO, particularly the stability of the distraction site, may affect the course of healing and the final result by influencing which cells are recruited, the rapidity with which they proliferate, and their eventual fate. Therefore, we propose (Aim 3) to relate the mechanical history of DO to the repair process by assessing the contributions of the periosteum, muscle connective tissue, and vascular system to the regenerate. This will be accomplished by pulse labeling of replicating cells during distraction, combined with an investigation of protein expression at the time of sacrifice. The most important contributions of this proposal will be the characterization of strain at the DO site under natural conditions, and the application of that information to understanding of how DO works on a cellular level and how it affects mandibular growth. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: NEURAL CONTROL OF THE JAW UNDER PAIN Principal Investigator & Institution: Capra, Norman F.; Associate Professor; Oral Medicine; University of Maryland Balt Prof School Professional Schools Baltimore, Md 21201 Timing: Fiscal Year 2000; Project Start 1-SEP-1997; Project End 1-AUG2002 Summary: (Adapted from the investigator's Abstract): The goal of the proposal is to understand how muscle pain associated with temporomandibular disorders (TMD) affects neuromotor performance in primates. Current evidence suggests that at least some myogenous jaw pain in humans causes a protective adaptation response, in which there is decreased activity in agonist muscles, and increased activity in antagonist muscles, resulting in restricted ranges of jaw motion. Currently, a hypothetical brainstem model has been proposed to explain this, but it is equally possible that higher levels of motor control are involved, such as

54 Temporomandibular Joint Syndrome

the motor cortex, in addition to, or instead of, the brainstem. Though conscious responses to pain, and control of jaw muscle contraction both involve the sensorimotor cortex, the region's potential contribution to the protective adaptation response has not been studied. Since the applicants have developed a suitable animal model for producing transient jaw muscle pain in the awake monkey (Macaca mulatta) and for observing its effects on voluntary jaw motion and jaw position, the first aim therefore is to carry out a parametric analysis of normal jaw motion and muscle activity during stereotyped motor tasks and automatic chewing, and to repeat the experiment in the presence of induced muscle pain. The second aim is to define relationships between the types and locations of corticomotoneuronal activity, and the same peripheral variables associated with these acts in normal animals. The third aim is to repeat this study of the motor cortex in the presence of induced muscle pain. The applicant hypothesizes that cortical neurons provide signals correlated with the initiation and execution of jaw movements and the maintenance of jaw positions, and that the signals change during the conscious pain experience in such a way as alter muscle contraction patterns, and subsequent jaw motion. They consider that their preliminary data support this proposition. The alternative hypothesis proposed is that this change in cortical signalling does not occur, in which case the applicant will conclude that the pain-adaptation response is due primarily to brainstem mechanisms. The applicant believes the study is significant because it can provide a better understanding of cortical influences in the control of jaw movement generally, and in particular, define the cortex's role in human motor responses to jaw muscle pain. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: PAIN MANAGEMENT IN TEMPOROMANDIBULAR JOINT DISORDERS Principal Investigator & Institution: Haythornthwaite, Jennifer A.; Associate Professor; Psychiatry and Behavioral Scis; Johns Hopkins University 3400 N Charles St Baltimore, Md 21218 Timing: Fiscal Year 2001; Project Start 5-SEP-2001; Project End 1-AUG2006 Summary: The primary goal of the proposed project is to test the efficacy of psychological interventions, a pharmacological intervention, and the combination of these interventions in reducing pain and improving function in persons with temporomandibular disorders (TMD). Since psychological interventions are costly and require expertise that is frequently unavailable in primary care settings, the proposed project will

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also examine the efficacy of a minimal contact/self help psychological intervention based on cognitive-behavioral therapy for pain management. In addition to examining the separate and combined effects of psychological and pharmacological interventions for TMD pain, the proposed study will examine whether the minimal contact cognitivebehavioral intervention can accomplish comparable reductions in pain and improvements in function relative to the therapist-administered treatment. Since patients with TMD pain show high utilization of health care services, this study will examine the cost-effectiveness of psychological and pharmacological treatments. The study will also examine whether individual patient characteristics, such as depression, predict response to treatment and whether treatment gains are maintained at 6-month follow-up. Persons with persistent facial pain due to TMD for 3 months or longer will be enrolled in this randomized controlled study which incorporates a 2 group (nortriptyline vs. active placebo - benztropine) by 3 group (cognitive-behavioral vs. minimal contact CBT vs. education and usual care) design. Following completion of the 8-week active phase of treatment, patients will enter a 6-month maintenance and follow-up period. Outcome measures will assess pain and physical and psychological functioning. Findings derived from this project will lead to further studies that determine which treatments, or combinations of treatments are effective for which subgroups of patients with TMD. Evaluation of a treatment approach combining commonly used psychological and pharmacological approaches promises to promote the development of truly effective pain management programs, contribute to the management of these individuals, and improve the quality of their lives. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: PARAFUNCTIONAL TEMPOROMANDIBULAR DISORDERS

ACTIVITY

AND

Principal Investigator & Institution: Glaros, Alan G.; Professor; Behavioral Science; University of Missouri Kansas City 5100 Rockhill Rd Kansas City, Mo 64110 Timing: Fiscal Year 2000; Project Start 5-SEP-2000; Project End 0-JUN2003 Summary: (adapted from the investigator's abstract): Temporomandibular disorders (TMD) are a heterogeneous collection of disorders characterized by orofacial pain and/or masticatory dysfunction. Parafunctional behaviors, especially clenching and grinding, are presumed to be important initiating and perpetuating factors in TMD (Glaros & Glass, 1993). Recent studies have showed that low-level

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parafunctional activity in otherwise normal individuals increases pain and can produce the same symptoms of TMD reported by clinic patients. However, there is very little direct evidence that TMD patients engage in more parafunctional activities than others or that the parafunctional activities that they may engage in are related to pain. The specific aims of this project are therefore to test the hypotheses that (1) TMD patients engage in higher rates of parafunctional activities than a comparable nonTMD sample, and (2) parafunctional activities produce and/or increase pain. Both in vivo and laboratory-based studies will be conducted to test the hypotheses. One of the proposed studies will utilize a methodologically sophisticated, ecologically valid self-report technique known as ecological momentary assessment (EMA). EMA data are a sample of the participant's behavior, emotional state, or physiological states in the real world, and these data can be examined for co-variation among the variables in time. The long-term objectives of this research are: (1) to better describe and characterize some basic, essential differences among TMD and non-TMD subjects; (2) to develop an etiological theory of TMD which adequately accounts for the observed differences; and (3) to develop effective treatment programs for TMD derived from our improved understanding of this disorder. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: SEX-RELATED MECHANISMS IN TMD PAIN

OPIATE

AND

AUTONOMIC

Principal Investigator & Institution: Bereiter, David A.; Professor; Rhode Island Hospital (Providence, Ri) 593 Eddy St Providence, Ri 02902 Timing: Fiscal Year 2000; Project Start 1-SEP-1998; Project End 0-JUN2002 Summary: Temporomandibular disorders (TMD) to a family of conditions that cause pain of the temporomandibular joint (TMJ) region and surrounding deep craniofacial muscles. Although the etiology of TMD's may vary, this facial pain condition is commonly accompanied by long-term changes in sensory, motor reflex and autonomic function suggesting a central dysfunction. TMD is notable for its higher prevalence in women than in men and for its recurrent nature. Despite evidence for an underlying central neural dysfunction, little is known of the brain mechanisms necessary for TMD pain. The central hypothesis of this proposal is that sex-related differences in TMD pain reside, at least in part, at the level of second-order neurons within the spinal trigeminal nucleus and upper cervical dorsal horn. Since the neurons that supply the tissues of the TMJ region terminate in the trigeminal brainstem complex and upper cervical spinal cord, the activity of second-order neurons

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within these regions must assume a critical importance in determining the various aspects of nociception (e.g., sensory-discrimination, autonomic reflexes, recruitment of descending controls). The proposed studies use an animal model to selectively activate small diameter afferent nerves and converging methodologies (c-fos) immunocytochemistry, in vivo microdialysis, single neuron electrophysiology) to examine the properties of second-order neurons that receive noxious sensory input from the TMJ region in anesthetized male and female rats. The Specific Aims examine the effects of the wellknown activators of endogenous pain control systems, morphine and vagal afferent nerve activity, to assess the properties of TMJ-responsive neurons in male and female rats. The long-term goal of this research is to better understand the influences of brain-endocrine-autonomic interactions in orofacial pain processing. The shorter term goal is to define the involvement of opiate and vagal afferent nerve mechanisms at the level of the trigeminal brainstem complex that may have analgesic effects after inflammation of the TMJ region. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: STRESS-INDUCED ANTI-INFLAMMATORY SIGNALS IN TMJ Principal Investigator & Institution: Agarwal, Sudha; Associate Professor; Orthopedics and Rehabilitation; University of Pittsburgh at Pittsburgh 4200 5Th Ave Pittsburgh, Pa 15260 Timing: Fiscal Year 2000; Project Start 1-SEP-2000; Project End 1-AUG2002 Summary: (Adapted from the Investigator's Abstract): Diseases of the temporomandibular joint (TMJ) are of complex etiopathology associated with progressive inflammation and cartilage destruction. Physical therapies such as continuous passive motion yield beneficial effects on inflamed TMJs by an as-yet-unknown mechanism, but one that is likely to involve mechanical activation of chondrocytes. Since inflammatory cytokines like IL-1beta play a major role in cartilage destruction, it is our hypothesis that the beneficial effects of mechanical strain are antiinflammatory in nature. Furthermore mechanical strain exerts its effects by suppressing IL-lbeta-induced activation of transcription factors. This in turn positively or negatively affects IL-1-induced transcriptional regulation. This is based on the Principal Investigator's recent observations that, in vitro, cyclic tensile strain (CTS) suppresses IL-1dependent mRNA transcription of multiple proteins that induce cartilage destruction such as, inducible nitric oxide synthase, cyclooxygenase-II and collagenase. In addition CTS abrogates IL-lbeta-induced suppression

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of tissue inhibitor of metalloprotease-II synthesis and thereby limits cartilage matrix destruction. These observations suggest that CTS acts on the signal transduction cascade of IL-beta upstream of mRNA transcription. Furthermore, these findings are of clinical relevance in that the effects of CTS on TMJ chondrocytes are observed at concentrations of IL-1beta similar to those present in synovial fluids from inflamed TMJs. Although mechanical strain is known to exert definitive signals on cellular metabolism, how these signals are transduced in cells is largely unknown. In this application studies are proposed to characterize specific mechanisms by which mechanical strain suppresses the destructive effects of inflammatory mediators in TMJ diseases. IL-1-activated chondrocytes are the first cells that provide defined CTS responses, which can be evaluated at the transcriptional level and related to gene activation. These cells are thus ideally suited for systematic examination of mechanisms of CTS mediated signal transduction, specifically those that suppress the inflammatory actions of IL-1beta. Utilizing this system the Principal Investigator proposes to: (1) examine the effects of CTS on receptor activation by assessing activation of IL-lR-associated kinase; (2) identify CTS-mediated signals that may inhibit IL-1beta-induced activation of NF-kB by assessing the activation of MAP kinases upstream of I-kB (inhibitor of NF-kB), including I-kB kinases, IKKalpha and IKKbeta; (3) identify CTS mediated signals that may inhibit the IL-1beta induced nuclear translocation of NF-kB, and the subunit structure of NFkB involved in the anti-inflammatory responses of CTS. The results of these investigations will be critical in unveiling novel pathways used during anti-inflammatory actions of CTS that can be exploited for the development of therapeutic interventions to limit or reverse the catabolic effects of inflammatory cytokines in TMJ diseases. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: VIBRATORY ANALGESIA IN NORMALS AND PERSONS WITH TEMPOROMANDIBULAR DISORDERS Principal Investigator & Institution: Hollins, m; ; University of North Carolina Chapel Hill Chapel Hill, Nc 27514 Timing: Fiscal Year 2000; Project Start 1-JUL-1986; Project End 0-NOV2002 Summary: The purpose of the proposed research is to achieve a more complete understanding of vibratory analgesia, a sensory phenomenon-repeatedly documented in laboratory and clinic, but never subjected to comprehensive psychophysical study--in which pain reduction is achieved by vibrotactile cutaneous stimulation. In the proposed investigations it will be measured under a variety of experimental

Studies 59

conditions, both in normally pain-free individuals, and in persons with temporomandibular disorders. Recently developed psychophysical scaling procedures will be employed to determine the dependence of vibratory analgesia on the frequency, amplitude, and location on the vibratory stimulus, and on the nature of the pain (whether clinical or experimental, and if the latter, whether tonic or phasic). Other experiments will answer questions about the characteristics of the painreduction process itself: whether it can block temporal summation of pain, whether it affects the discriminability and unpleasantness, as well as the perceived intensity of the pain, and whether it is enhanced when attention is focused on the vibratory stimulus. The results of the research will shed additional light on the fundamental nature of submodality interaction in somesthesis, and will also have implications regarding the optimization of vibratory analgesia as a clinical procedure. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

The National Library of Medicine: PubMed One of the quickest and most comprehensive ways to find academic studies in both English and other languages is to use PubMed, maintained by the National Library of Medicine. The advantage of PubMed over previously mentioned sources is that it covers a greater number of domestic and foreign references. It is also free to the public.18 If the publisher has a Web site that offers full text of its journals, PubMed will provide links to that site, as well as to sites offering other related data. User registration, a subscription fee, or some other type of fee may be required to access the full text of articles in some journals. To generate your own bibliography of studies dealing with temporomandibular joint syndrome, simply go to the PubMed Web site at www.ncbi.nlm.nih.gov/pubmed. Type “temporomandibular joint syndrome” (or synonyms) into the search box, and click “Go.” The following is the type of output you can expect from PubMed for “temporomandibular joint syndrome” (hyperlinks lead to article summaries): ·

Otologic complaints in temporomandibular joint syndrome.

PubMed was developed by the National Center for Biotechnology Information (NCBI) at the National Library of Medicine (NLM) at the National Institutes of Health (NIH). The PubMed database was developed in conjunction with publishers of biomedical literature as a search tool for accessing literature citations and linking to full-text journal articles at Web sites of participating publishers. Publishers that participate in PubMed supply NLM with their citations electronically prior to or at the time of publication.

18

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·

Author(s): Henderson DH, Cooper JC Jr, Bryan GW, Van Sickels JE. Source: Archives of Otolaryngology--Head & Neck Surgery. 1992 November; 118(11): 1208-13. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1418900&dopt=Abstract

·

Temporomandibular review.

·

Author(s): Ficarra BJ, Nassif NJ. Source: J Med. 1991; 22(2): 97-121. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1895018&dopt=Abstract

·

Tumors and tumorous masses presenting as temporomandibular joint syndrome.

·

Author(s): Mostafapour SP, Futran ND. Source: Otolaryngology--Head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 2000 October; 123(4): 459-64. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11020186&dopt=Abstract

·

Disocclusion time-reduction therapy with immediate complete anterior guidance development to treat chronic myofascial pain-dysfunction syndrome.

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Author(s): Kerstein RB. Source: Quintessence Int. 1992 November; 23(11): 735-47. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1305288&dopt=Abstract

·

Electromyographic and computer analyses of patients suffering from chronic myofascial pain-dysfunction syndrome: before and after treatment with immediate complete anterior guidance development.

·

Author(s): Kerstein RB, Wright NR. Source: The Journal of Prosthetic Dentistry. 1991 November; 66(5): 677-86. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1805009&dopt=Abstract

·

Role of depressive illness in the outcome of temporomandibular joint pain-dysfunction syndrome.

joint

syndrome:

diagnostician's

dilemma--a

treatment

of

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·

Author(s): Tversky J, Reade PC, Gerschman JA, Holwill BJ, Wright J. Source: Oral Surg Oral Med Oral Pathol. 1991 June; 71(6): 696-9. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=2062523&dopt=Abstract

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Temporomandibular joint pain-dysfunction syndrome and bruxism: etiopathogenesis and treatment from a psychosomatic integrative viewpoint.

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Author(s): Biondi M, Picardi A. Source: Psychotherapy and Psychosomatics. 1993; 59(2): 84-98. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8332706&dopt=Abstract

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TMJ syndrome: is it compensable?

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Author(s): Doerrer A, Figart F. Source: Rehabil Nurs. 1991 January-February; 16(1): 23-6. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1824879&dopt=Abstract

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Treatment of myofascial pain-dysfunction syndrome with occlusal equilibration.

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Author(s): Kerstein RB, Farrell S. Source: The Journal of Prosthetic Dentistry. 1990 June; 63(6): 695-700. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=2102663&dopt=Abstract

Vocabulary Builder Abdominal: Pertaining to the abdomen. [EU] Adverse: Harmful. [EU] Antigen: Any substance which is capable, under appropriate conditions, of inducing a specific immune response and of reacting with the products of that response, that is, with specific antibody or specifically sensitized Tlymphocytes, or both. Antigens may be soluble substances, such as toxins and foreign proteins, or particulate, such as bacteria and tissue cells; however, only the portion of the protein or polysaccharide molecule known as the antigenic determinant (q.v.) combines with antibody or a specific receptor on a lymphocyte. Abbreviated Ag. [EU] Antigens: Substances that are recognized by the immune system and induce

62 Temporomandibular Joint Syndrome

an immune reaction. [NIH] Assay: Determination of the amount of a particular constituent of a mixture, or of the biological or pharmacological potency of a drug. [EU] Asymptomatic: Showing or causing no symptoms. [EU] Atypical: Irregular; not conformable to the type; in microbiology, applied specifically to strains of unusual type. [EU] Bile: An emulsifying agent produced in the liver and secreted into the duodenum. Its composition includes bile acids and salts, cholesterol, and electrolytes. It aids digestion of fats in the duodenum. [NIH] Bilirubin: A bile pigment that is a degradation product of heme. [NIH] Biochemical: Relating to biochemistry; characterized by, produced by, or involving chemical reactions in living organisms. [EU] Bruxism: A disorder characterized by grinding and clenching of the teeth. [NIH]

Cardiac: Pertaining to the heart. [EU] Cardiovascular: Pertaining to the heart and blood vessels. [EU] Chimera: An individual that contains cell populations derived from different zygotes. [NIH] Chondrocytes: Polymorphic cells that form cartilage. [NIH] Cognition: Intellectual or mental process whereby an organism becomes aware of or obtains knowledge. [NIH] Collagen: The protein substance of the white fibres (collagenous fibres) of skin, tendon, bone, cartilage, and all other connective tissue; composed of molecules of tropocollagen (q.v.), it is converted into gelatin by boiling. collagenous pertaining to collagen; forming or producing collagen. [EU] Dimerization: The process by which two molecules of the same chemical composition form a condensation product or polymer. [NIH] Drosophila: A genus of small, two-winged flies containing approximately 900 described species. These organisms are the most extensively studied of all genera from the standpoint of genetics and cytology. [NIH] Ectopic: Pertaining to or characterized by ectopia. [EU] Enzyme: A protein molecule that catalyses chemical reactions of other substances without itself being destroyed or altered upon completion of the reactions. Enzymes are classified according to the recommendations of the Nomenclature Committee of the International Union of Biochemistry. Each enzyme is assigned a recommended name and an Enzyme Commission (EC) number. They are divided into six main groups; oxidoreductases, transferases, hydrolases, lyases, isomerases, and ligases. [EU]

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Ethanol: A clear, colorless liquid rapidly absorbed from the gastrointestinal tract and distributed throughout the body. It has bactericidal activity and is used often as a topical disinfectant. It is widely used as a solvent and preservative in pharmaceutical preparations as well as serving as the primary ingredient in alcoholic beverages. [NIH] Exons: Coding regions of messenger RNA included in the genetic transcript which survive the processing of RNA in cell nuclei to become part of a spliced messenger of structural RNA in the cytoplasm. They include joining and diversity exons of immunoglobulin genes. [NIH] Femoral: Pertaining to the femur, or to the thigh. [EU] Gait: Manner or style of walking. [NIH] Genotype: The genetic constitution of the individual; the characterization of the genes. [NIH] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Glucuronides: Glycosides of glucuronic acid formed by the reaction of uridine diphosphate glucuronic acid with certain endogenous and exogenous substances. Their formation is important for the detoxification of drugs, steroid excretion and bilirubin metabolism to a more water-soluble compound that can be eliminated in the urine and bile. [NIH] Hepatic: Pertaining to the liver. [EU] Homologous: Corresponding in structure, position, origin, etc., as (a) the feathers of a bird and the scales of a fish, (b) antigen and its specific antibody, (c) allelic chromosomes. [EU] Hybridization: The genetic process of crossbreeding to produce a hybrid. Hybrid nucleic acids can be formed by nucleic acid hybridization of DNA and RNA molecules. Protein Hybridization allows for hybrid proteins to be formed from polypeptide chains. [NIH] Hyperbilirubinemia: Pathologic process consisting of an abnormal increase in the amount of bilirubin in the circulating blood, which may result in jaundice. [NIH] Infertility: The diminished or absent ability to conceive or produce an offspring while sterility is the complete inability to conceive or produce an offspring. [NIH]

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Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Intramuscular: Within the substance of a muscle. [EU] Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Ligament: A band of fibrous tissue that connects bones or cartilages, serving to support and strengthen joints. [EU] Lipodystrophy: 1. any disturbance of fat metabolism. 2. a group of conditions due to defective metabolism of fat, resulting in the absence of subcutaneous fat, which may be congenital or acquired and partial or total. Called also lipoatrophy and lipodystrophia. [EU] Lumbar: Pertaining to the loins, the part of the back between the thorax and the pelvis. [EU] Malformation: A morphologic defect resulting from an intrinsically abnormal developmental process. [EU] Manifest: Being the part or aspect of a phenomenon that is directly observable : concretely expressed in behaviour. [EU] Mechanoreceptors: Cells specialized to transduce mechanical stimuli and relay that information centrally in the nervous system. Mechanoreceptors include hair cells, which mediate hearing and balance, and the various somatosensory receptors, often with non-neural accessory structures. [NIH] Membrane: A thin layer of tissue which covers a surface, lines a cavity or divides a space or organ. [EU] Mesoderm: The middle germ layer of the embryo. [NIH] Mobility: Capability of movement, of being moved, or of flowing freely. [EU] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Monosomy: The condition in which one chromosome of a pair is missing. In a normally diploid cell it is represented symbolically as 2N-1. [NIH] Mutagenesis: Process of generating genetic mutations. It may occur spontaneously or be induced by mutagens. [NIH] Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Neuronal: Pertaining to a neuron or neurons (= conducting cells of the nervous system). [EU]

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Neurophysiology: The scientific discipline concerned with the physiology of the nervous system. [NIH] Ophthalmologic: Pertaining to ophthalmology (= the branch of medicine dealing with the eye). [EU] Otolaryngology: A surgical specialty concerned with the study and treatment of disorders of the ear, nose, and throat. [NIH] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Posterior: Situated in back of, or in the back part of, or affecting the back or dorsal surface of the body. In lower animals, it refers to the caudal end of the body. [EU] Preclinical: Before a disease becomes clinically recognizable. [EU] Protease: Proteinase (= any enzyme that catalyses the splitting of interior peptide bonds in a protein). [EU] Proteins: Polymers of amino acids linked by peptide bonds. The specific sequence of amino acids determines the shape and function of the protein. [NIH]

Proximal: Nearest; closer to any point of reference; opposed to distal. [EU] Psychosomatic: Pertaining to the mind-body relationship; having bodily symptoms of psychic, emotional, or mental origin; called also psychophysiologic. [EU] Psychotherapy: A generic term for the treatment of mental illness or emotional disturbances primarily by verbal or nonverbal communication. [NIH]

Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Somatic: 1. pertaining to or characteristic of the soma or body. 2. pertaining to the body wall in contrast to the viscera. [EU] Species: A taxonomic category subordinate to a genus (or subgenus) and superior to a subspecies or variety, composed of individuals possessing common characters distinguishing them from other categories of individuals of the same taxonomic level. In taxonomic nomenclature, species are designated by the genus name followed by a Latin or Latinized adjective or noun. [EU] Spectrum: A charted band of wavelengths of electromagnetic vibrations obtained by refraction and diffraction. By extension, a measurable range of activity, such as the range of bacteria affected by an antibiotic (antibacterial s.) or the complete range of manifestations of a disease. [EU]

66 Temporomandibular Joint Syndrome

Steroid: A group name for lipids that contain a hydrogenated cyclopentanoperhydrophenanthrene ring system. Some of the substances included in this group are progesterone, adrenocortical hormones, the gonadal hormones, cardiac aglycones, bile acids, sterols (such as cholesterol), toad poisons, saponins, and some of the carcinogenic hydrocarbons. [EU] Transplantation: The grafting of tissues taken from the patient's own body or from another. [EU] Visceral: , from viscus a viscus) pertaining to a viscus. [EU]

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CHAPTER 5. BOOKS ON TEMPOROMANDIBULAR JOINT SYNDROME Overview This chapter provides bibliographic book references relating to temporomandibular joint syndrome. You have many options to locate books on temporomandibular joint syndrome. The simplest method is to go to your local bookseller and inquire about titles that they have in stock or can special order for you. Some patients, however, feel uncomfortable approaching their local booksellers and prefer online sources (e.g. www.amazon.com and www.bn.com). In addition to online booksellers, excellent sources for book titles on temporomandibular joint syndrome include the Combined Health Information Database and the National Library of Medicine. Once you have found a title that interests you, visit your local public or medical library to see if it is available for loan.

Book Summaries: Federal Agencies The Combined Health Information Database collects various book abstracts from a variety of healthcare institutions and federal agencies. To access these summaries, go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. You will need to use the “Detailed Search” option. To find book summaries, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer. For the format option, select “Monograph/Book.” Now type “temporomandibular joint syndrome” (or synonyms) into the “For these words:” box. You will only receive results on books. You should check back periodically with this database which is updated every 3 months. The

68 Temporomandibular Joint Syndrome

following is a typical result temporomandibular joint syndrome: ·

when

searching

for

books

on

Instructions for Patients. 5th ed Source: Orlando, FL: W.B. Saunders Company. 1994. 598 p. Contact: Available from W.B. Saunders Company. Order Fulfillment, 6277 Sea Harbor Drive, Orlando, FL 32887-4430. (800) 545-2522 (individuals) or (800) 782-4479 (schools); Fax (800) 874-6418 or (407) 3523445; http://www.wbsaunders.com. PRICE: $52.00 (English); $49.95 (Spanish); plus shipping and handling. ISBN: 0721649300 (English); 0721669972 (Spanish). Summary: This book is a compilation of instructions for patients, published in paperback format. The fact sheets each provide information in three sections: basic information, including a description of the condition, frequent signs and symptoms, causes, risk factors, preventive measures, expected outcome, and possible complications; treatment, including general measures, medication, activity guidelines, and diet; and when to contact one's health care provider. Fact sheets are available on oral health topics including: herpangina, leukoplakia, lichen planus, salivary gland infection, benign mouth or tongue tumors, oral cancer, periodontitis, salivary gland tumors, Sjogren's syndrome, stomatitis, teething, temporomandibular joint syndrome (TMJ), oral candidiasis (thrush), thumbsucking, glossitis (tongue inflammation), bruxism (tooth grinding), necrotizing ulcerative gingivitis (trench mouth), and trigeminal neuralgia (tic douloureux). The fact sheets are designed to be photocopied and distributed to patients as a reinforcement of oral instructions and as a teaching tool.

Book Summaries: Online Booksellers Commercial Internet-based booksellers, such as Amazon.com and Barnes & Noble.com, offer summaries which have been supplied by each title’s publisher. Some summaries also include customer reviews. Your local bookseller may have access to in-house and commercial databases that index all published books (e.g. Books in PrintÒ).

Chapters on Temporomandibular Joint Syndrome Frequently, temporomandibular joint syndrome will be discussed within a book, perhaps within a specific chapter. In order to find chapters that are

Books 69

specifically dealing with temporomandibular joint syndrome, an excellent source of abstracts is the Combined Health Information Database. You will need to limit your search to book chapters and temporomandibular joint syndrome using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find book chapters, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the format option “Book Chapter.” By making these selections and typing in “temporomandibular joint syndrome” (or synonyms) into the “For these words:” box, you will only receive results on chapters in books.

General Home References In addition to references for temporomandibular joint syndrome, you may want a general home medical guide that spans all aspects of home healthcare. The following list is a recent sample of such guides (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): ·

Dental Terminology by Charline M. Dofka, et al; Paperback - 312 pages, 1st edition (July 12, 1999), Delmar Publishers; ISBN: 0827390688; http://www.amazon.com/exec/obidos/ASIN/0827390688/icongroupinter na

·

Oral Medicine Secrets by Sonis; Paperback (August 15, 2002), Hanley & Belfus; ISBN: 1560534192; http://www.amazon.com/exec/obidos/ASIN/1560534192/icongroupinter na

·

The Perfect Smile: A Consumer's Guide to Dental Health and Cosmetic Dentistry by James Doundoulakis, Warren Strugatch; Paperback - 160 pages (May 2002), Hatherleigh Press; ISBN: 1578260957; http://www.amazon.com/exec/obidos/ASIN/1578260957/icongroupinter na

·

Prentice Hall Health: Complete Review of Dental Hygiene by Jacqueline N. Brian, Mary Danusis Cooper; Paperback - 612 pages, 1st edition (July 10, 2001), Prentice Hall; ISBN: 0130833282; http://www.amazon.com/exec/obidos/ASIN/0130833282/icongroupinter na

70 Temporomandibular Joint Syndrome

Vocabulary Builder Arteriovenous: Both arterial and venous; pertaining to or affecting an artery and a vein. [EU] Audiology: The study of hearing and hearing impairment. [NIH] Benign: Not malignant; not recurrent; favourable for recovery. [EU] Candidiasis: Infection with a fungus of the genus Candida. It is usually a superficial infection of the moist cutaneous areas of the body, and is generally caused by C. albicans; it most commonly involves the skin (dermatocandidiasis), oral mucous membranes (thrush, def. 1), respiratory tract (bronchocandidiasis), and vagina (vaginitis). Rarely there is a systemic infection or endocarditis. Called also moniliasis, candidosis, oidiomycosis, and formerly blastodendriosis. [EU] Gingivitis: Inflammation of the gingivae. Gingivitis associated with bony changes is referred to as periodontitis. Called also oulitis and ulitis. [EU] Glossitis: Inflammation of the tongue. [EU] Hypertension: Persistently high arterial blood pressure. Various criteria for its threshold have been suggested, ranging from 140 mm. Hg systolic and 90 mm. Hg diastolic to as high as 200 mm. Hg systolic and 110 mm. Hg diastolic. Hypertension may have no known cause (essential or idiopathic h.) or be associated with other primary diseases (secondary h.). [EU] Inflammation: A pathological process characterized by injury or destruction of tissues caused by a variety of cytologic and chemical reactions. It is usually manifested by typical signs of pain, heat, redness, swelling, and loss of function. [NIH] Neoplasms: New abnormal growth of tissue. Malignant neoplasms show a greater degree of anaplasia and have the properties of invasion and metastasis, compared to benign neoplasms. [NIH] Neuralgia: Paroxysmal pain which extends along the course of one or more nerves. Many varieties of neuralgia are distinguished according to the part affected or to the cause, as brachial, facial, occipital, supraorbital, etc., or anaemic, diabetic, gouty, malarial, syphilitic, etc. [EU] Otitis: Inflammation of the ear, which may be marked by pain, fever, abnormalities of hearing, hearing loss, tinnitus, and vertigo. [EU] Skull: The skeleton of the head including the bones of the face and the bones enclosing the brain. [NIH] Stomatitis: Inflammation of the oral mucosa, due to local or systemic factors which may involve the buccal and labial mucosa, palate, tongue, floor of the mouth, and the gingivae. [EU]

Books 71

Systemic: Pertaining to or affecting the body as a whole. [EU] Tinnitus: A noise in the ears, as ringing, buzzing, roaring, clicking, etc. Such sounds may at times be heard by others than the patient. [EU] Withdrawal: 1. a pathological retreat from interpersonal contact and social involvement, as may occur in schizophrenia, depression, or schizoid avoidant and schizotypal personality disorders. 2. (DSM III-R) a substancespecific organic brain syndrome that follows the cessation of use or reduction in intake of a psychoactive substance that had been regularly used to induce a state of intoxication. [EU]

Multimedia 73

CHAPTER 6. MULTIMEDIA ON TEMPOROMANDIBULAR JOINT SYNDROME Overview Information on temporomandibular joint syndrome can come in a variety of formats. Among multimedia sources, video productions, slides, audiotapes, and computer databases are often available. In this chapter, we show you how to keep current on multimedia sources of information on temporomandibular joint syndrome. We start with sources that have been summarized by federal agencies, and then show you how to find bibliographic information catalogued by the National Library of Medicine. If you see an interesting item, visit your local medical library to check on the availability of the title.

Bibliography: Syndrome

Multimedia

on

Temporomandibular

Joint

The National Library of Medicine is a rich source of information on healthcare-related multimedia productions including slides, computer software, and databases. To access the multimedia database, go to the following Web site: http://locatorplus.gov/. Select “Search LOCATORplus.” Once in the search area, simply type in temporomandibular joint syndrome (or synonyms). Then, in the option box provided below the search box, select “Audiovisuals and Computer Files.” From there, you can choose to sort results by publication date, author, or relevance. The following multimedia has been indexed on temporomandibular joint syndrome. For more information, follow the hyperlink indicated:

74 Temporomandibular Joint Syndrome

·

Complications and their management : postoperative TMJ. Source: condylar complications / AAOMS, San Antonio 1992; produced by InfoMedix; Year: 1992; Format: Videorecording; [United States]: American Association of Oral and Maxillofacial Surgeons, c1992

·

Failed temporomandibular joint surgery ; Medical management of the failed temporomandibular joint patient. Source: Nineteenth Annual Scientific Meeting on Orofacial Pain and Temporomandibular Disorders; produced on location by Teach'em; Year: 1994; Format: Videorecording; [Chicago, IL: Teach'em, 1994?] Infratemporal fossa and temporo-mandibular joint. Source: Memorial University of Newfoundland, AVS, Medical Audiovisual Services; Year: 1988; Format: Videorecording; [St. John's, Nfld.]: The Services, [1988]

·

·

· ·

·

·

·

Internal derangement of the TMJ with loss of condylar mass. Source: [presented by] AAOMS; Year: 1994; Format: Videorecording; [United States]: American Association of Oral and Maxillofacial Surgeons, c1994 Managing craniofacial pain patients. Source: Chicago Dental Society; Year: 1994; Format: Sound recording; [Chicago, Ill.]: The Society, [1994] Mechanisms of tension type headache, myofascial pain, migraine ; Is there such a thing as TMJ headache. Source: Nineteenth Annual Scientific Meeting on Orofacial Pain and Temporomandibular Disorders; produced on location by Teach'em; Year: 1994; Format: Videorecording; [Chicago, IL: Teach'em, 1994] Mini-symposium on TMJ (group B) : staging of patients with combined orthognathic and TMJ disorders. Source: AAOMS; Year: 1993; Format: Videorecording; Rosemont, Ill.: American Association of Oral and Maxillofacial Surgeons, c1993 Mini-symposium, TMJ (group A). Source: American Association of Oral and Maxillofacial Surgeons, in conjunction with the German Society of Oral and Maxillofacial Surgeons; Year: 1993; Format: Videorecording; [Rosemont, Ill.]: AAOMS, [1993] MRI of the TMJ. Source: MRI Education Foundation, Inc; Year: 1989; Format: Videorecording; [Cincinnati, Ohio: The Foundation, 1989]

·

Neurosurgical procedures for management of orofacial pain ; Panel discussion. Source: Nineteenth Annual Scientific Meeting on Orofacial Pain and Temporomandibular Disorders; produced on location by Teach'em; Year: 1994; Format: Videorecording; [Chicago, IL: Teach'em, 1994]

·

Occlusion and TMJ : multicausal relationships. Source: Chicago Dental Society; Year: 1994; Format: Sound recording; [Chicago, Ill.]: The Society, [1994]

·

Psychometrics : why? when? how?; Clinical pain psychology. Source: Nineteenth Annual Scientific Meeting on Orofacial Pain and

Multimedia 75

·

Temporomandibular Disorders; produced on location by Teach'em; Year: 1994; Format: Videorecording; [Chicago, IL: Teach'em, 1994?] Radiography of the temporomandibular joints. Source: produced by the Veterans Administration Dental Training Center; Year: 1973; Format: Motion picture; [Washington, D.C.: The Center, 1973]

·

Reconstruction of the temporomandibular joint using the fossaeminence and condylar prostheses. Source: [presented by] the Rocky Mountain TMJ Surgical Conference; Year: 1991; Format: Videorecording; [Golden, Colo.]: TMJ Implants, c1991

·

Reconstructive grafting challenges. Source: [presented by] AAOMS; Year: 1994; Format: Videorecording; [United States]: American Association of Oral and Maxillofacial Surgeons, c1994

·

Screening for TM disorders and the fabrication of a chair-side occlusal appliance. Source: edited by Robert M. Wood for Hinman Dental Society of Atlanta and Great Plains National, a service agency of the University of Nebraska; Year: 1993; Format: Videorecording; [Atlanta, Ga.?]: The Society, c1993

·

Severe condylar modeling changes : panel discussion. Source: [presented by] AAOMS; Year: 1994; Format: Videorecording; [United States]: American Association of Oral and Maxillofacial Surgeons, c1994 Surgical treatment of TMJ disorders. Source: AAOMS; Year: 1993; Format: Videorecording; [Rosemont, Ill.]: American Association of Oral and Maxillofacial Surgeons, [1993] Symposium on TMD issues. Source: American Association of Oral and Maxillofacial Surgeons 78th Annual Meeting, Scientific Sessions & Exhibition, September 18-22, 1996, Miami Beach, Florida; Year: 1996; Format: Videorecording; Chicago, Ill.: Teach'em, [1996]

·

·

· ·

·

· ·

Symposium, TMJ disorders . Year: 1993; Format: Videorecording; Rosemont, Ill.: American Association of Oral and Maxillofacial Surgeons, c1993 Symposium, TMJ disorders. Source: American Association of Oral and Maxillofacial Surgeons, in conjunction with the German Society of Oral and Maxillofacial Surgeons; Year: 1993; Format: Videorecording; Rosemont, Ill.: The Association, c1993 Temporomandibular disorders. Source: AAOMS Midwinter Conference, February 7-9, 1997, Chicago, Illinois; Year: 1997; Format: Videorecording; Chicago, Ill.: Teach'em, [1997] Temporomandibular joint and its associated structures . Year: 1998; Format: Videorecording; Chicago: Quintessence Pub. Co., c1998 TMD. Source: dental rehabilitation : the team approach / CDS; Year: 1994; Format: Sound recording; [Chicago]: Chicago Dental Society, [1994]

76 Temporomandibular Joint Syndrome

·

· ·

·

TMJ injury and dental malpractice. Source: [presented by] Medi/Legal Institute; a VME production; Year: 1990; Format: Videorecording; [Sherman Oaks, Calif.]: The Institute, c1990 TMJ stress. Source: pain management / Linda N. Cameron; Year: 1990; Format: Sound recording; [Dallas, Tex.]: Mandala Productions, p1990 Treatment techniques for TMJ and their validity. Source: [presented by] Medi-Legal Institute; a VME production; Year: 1990; Format: Videorecording; [Sherman Oaks, Calif.]: The Institute, c1990 Ultimate orthognathic operation : costo-chondral T.M.J. reconstruction, Le Fort I and mandibular sagittal osteotomies, simultaneous correction of temporomandibular ankylosis and facial asymmetry. Source: author, Ian R. Munro; produced and direc; Year: 1985; Format: Videorecording; Danbury, Conn.: American Cyanamid, c1985

Vocabulary Builder Ankylosis: Fixation and immobility of a joint. [NIH] Orofacial: Of or relating to the mouth and face. [EU] Postoperative: Occurring after a surgical operation. [EU] Psychology: The science dealing with the study of mental processes and behavior in man and animals. [NIH]

Periodicals and News 77

CHAPTER 7. PERIODICALS AND TEMPOROMANDIBULAR JOINT SYNDROME

NEWS

ON

Overview Keeping up on the news relating to temporomandibular joint syndrome can be challenging. Subscribing to targeted periodicals can be an effective way to stay abreast of recent developments on temporomandibular joint syndrome. Periodicals include newsletters, magazines, and academic journals. In this chapter, we suggest a number of news sources and present various periodicals that cover temporomandibular joint syndrome beyond and including those which are published by patient associations mentioned earlier. We will first focus on news services, and then on periodicals. News services, press releases, and newsletters generally use more accessible language, so if you do chose to subscribe to one of the more technical periodicals, make sure that it uses language you can easily follow.

News Services & Press Releases Well before articles show up in newsletters or the popular press, they may appear in the form of a press release or a public relations announcement. One of the simplest ways of tracking press releases on temporomandibular joint syndrome is to search the news wires. News wires are used by professional journalists, and have existed since the invention of the telegraph. Today, there are several major “wires” that are used by companies, universities, and other organizations to announce new medical breakthroughs. In the following sample of sources, we will briefly describe how to access each service. These services only post recent news intended for public viewing.

78 Temporomandibular Joint Syndrome

PR Newswire Perhaps the broadest of the wires is PR Newswire Association, Inc. To access this archive, simply go to http://www.prnewswire.com. Below the search box, select the option “The last 30 days.” In the search box, type “temporomandibular joint syndrome” or synonyms. The search results are shown by order of relevance. When reading these press releases, do not forget that the sponsor of the release may be a company or organization that is trying to sell a particular product or therapy. Their views, therefore, may be biased.

Reuters The Reuters' Medical News database can be very useful in exploring news archives relating to temporomandibular joint syndrome. While some of the listed articles are free to view, others can be purchased for a nominal fee. To access this archive, go to http://www.reutershealth.com/frame2/arch.html and search by “temporomandibular joint syndrome” (or synonyms).

The NIH Within MEDLINEplus, the NIH has made an agreement with the New York Times Syndicate, the AP News Service, and Reuters to deliver news that can be browsed by the public. Search news releases at http://www.nlm.nih.gov/medlineplus/alphanews_a.html. MEDLINEplus allows you to browse across an alphabetical index. Or you can search by date at the following: http://www.nlm.nih.gov/medlineplus/newsbydate.html. Often, news items are indexed by MEDLINEplus within their search engine.

Business Wire Business Wire is similar to PR Newswire. To access this archive, simply go to http://www.businesswire.com. You can scan the news by industry category or company name.

Periodicals and News 79

Internet Wire Internet Wire is more focused on technology than the other wires. To access this site, go to http://www.internetwire.com and use the “Search Archive” option. Type in “temporomandibular joint syndrome” (or synonyms). As this service is oriented to technology, you may wish to search for press releases covering diagnostic procedures or tests that you may have read about.

Search Engines Free-to-view news can also be found in the news section of your favorite search engines (see the health news page at Yahoo: http://dir.yahoo.com/Health/News_and_Media/, or use this Web site’s general news search page http://news.yahoo.com/. Type in “temporomandibular joint syndrome” (or synonyms). If you know the name of a company that is relevant to temporomandibular joint syndrome, you can go to any stock trading Web site (such as www.etrade.com) and search for the company name there. News items across various news sources are reported on indicated hyperlinks.

BBC Covering news from a more European perspective, the British Broadcasting Corporation (BBC) allows the public free access to their news archive located at http://www.bbc.co.uk/. Search by “temporomandibular joint syndrome” (or synonyms).

Academic Periodicals covering Temporomandibular Joint Syndrome Academic periodicals can be a highly technical yet valuable source of information on temporomandibular joint syndrome. We have compiled the following list of periodicals known to publish articles relating to temporomandibular joint syndrome and which are currently indexed within the National Library of Medicine's PubMed database (follow hyperlinks to view more information, summaries, etc., for each). In addition to these sources, to keep current on articles written on temporomandibular joint syndrome published by any of the periodicals listed below, you can simply follow the hyperlink indicated or go to the following Web site:

80 Temporomandibular Joint Syndrome

www.ncbi.nlm.nih.gov/pubmed. Type the periodical's name into the search box to find the latest studies published. If you want complete details about the historical contents of a periodical, you can also visit: http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi. Here, type in the name of the journal or its abbreviation, and you will receive an index of published articles. At http://locatorplus.gov/ you can retrieve more indexing information on medical periodicals (e.g. the name of the publisher). Select the button “Search LOCATORplus.” Then type in the name of the journal and select the advanced search option “Journal Title Search.” The following is a sample of periodicals which publish articles on temporomandibular joint syndrome: ·

Archives of Otolaryngology--Head & Neck Surgery. (Arch Otolaryngol Head Neck Surg) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Ar chives+of+Otolaryngology-Head+&+Neck+Surgery&dispmax=20&dispstart=0

·

Otolaryngology--Head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. (Otolaryngol Head Neck Surg) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Ot olaryngology-Head+and+Neck+Surgery+:+Official+Journal+of+American+Academy+ of+Otolaryngology-Head+and+Neck+Surgery&dispmax=20&dispstart=0

·

The Journal of Prosthetic Dentistry. (J Prosthet Dent) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Th e+Journal+of+Prosthetic+Dentistry&dispmax=20&dispstart=0

Vocabulary Builder Expiration: The act of breathing out, or expelling air from the lungs. [EU]

Physician Guidelines and Databases 81

CHAPTER 8. PHYSICIAN GUIDELINES AND DATABASES Overview Healthcare providers and medical researchers rely on a number of information sources to help patients with their conditions. Many will subscribe to journals or newsletters published by their professional associations or refer to specialized textbooks or clinical guides published for the medical profession. In this chapter, we focus on databases and Internetbased guidelines created or written for this professional audience.

NIH Guidelines For the more common diseases, The National Institutes of Health publish guidelines that are frequently consulted by healthcare providers. Publications are typically written by one or more of the various NIH Institutes. For physician guidelines, commonly referred to as “clinical” or “professional” guidelines, you can visit the following Institutes: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

·

National Institute of General Medical Sciences (NIGMS); fact sheets available at http://www.nigms.nih.gov/news/facts/

·

National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines: http://www.nlm.nih.gov/medlineplus/healthtopics.html

·

National Institute of Dental and Craniofacial Research (NIDCR); guidelines available at http://www.nidr.nih.gov/health/

82 Temporomandibular Joint Syndrome

NIH Databases In addition to the various Institutes of Health that publish professional guidelines, the NIH has designed a number of databases for professionals.19 Physician-oriented resources provide a wide variety of information related to the biomedical and health sciences, both past and present. The format of these resources varies. Searchable databases, bibliographic citations, full text articles (when available), archival collections, and images are all available. The following are referenced by the National Library of Medicine:20 ·

Bioethics: Access to published literature on the ethical, legal and public policy issues surrounding healthcare and biomedical research. This information is provided in conjunction with the Kennedy Institute of Ethics located at Georgetown University, Washington, D.C.: http://www.nlm.nih.gov/databases/databases_bioethics.html

·

HIV/AIDS Resources: Describes various links and databases dedicated to HIV/AIDS research: http://www.nlm.nih.gov/pubs/factsheets/aidsinfs.html

·

NLM Online Exhibitions: Describes “Exhibitions in the History of Medicine”: http://www.nlm.nih.gov/exhibition/exhibition.html. Additional resources for historical scholarship in medicine: http://www.nlm.nih.gov/hmd/hmd.html

·

Biotechnology Information: Access to public databases. The National Center for Biotechnology Information conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information for the better understanding of molecular processes affecting human health and disease: http://www.ncbi.nlm.nih.gov/

·

Population Information: The National Library of Medicine provides access to worldwide coverage of population, family planning, and related health issues, including family planning technology and programs, fertility, and population law and policy: http://www.nlm.nih.gov/databases/databases_population.html

·

Cancer Information: Access to caner-oriented databases: http://www.nlm.nih.gov/databases/databases_cancer.html

Remember, for the general public, the National Library of Medicine recommends the databases referenced in MEDLINEplus (http://medlineplus.gov/ or http://www.nlm.nih.gov/medlineplus/databases.html). 20 See http://www.nlm.nih.gov/databases/databases.html. 19

Physician Guidelines and Databases 83

·

Profiles in Science: Offering the archival collections of prominent twentieth-century biomedical scientists to the public through modern digital technology: http://www.profiles.nlm.nih.gov/

·

Chemical Information: Provides links to various chemical databases and references: http://sis.nlm.nih.gov/Chem/ChemMain.html

·

Clinical Alerts: Reports the release of findings from the NIH-funded clinical trials where such release could significantly affect morbidity and mortality: http://www.nlm.nih.gov/databases/alerts/clinical_alerts.html

·

Space Life Sciences: Provides links and information to space-based research (including NASA): http://www.nlm.nih.gov/databases/databases_space.html

·

MEDLINE: Bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the healthcare system, and the pre-clinical sciences: http://www.nlm.nih.gov/databases/databases_medline.html

·

Toxicology and Environmental Health Information (TOXNET): Databases covering toxicology and environmental health: http://sis.nlm.nih.gov/Tox/ToxMain.html

·

Visible Human Interface: Anatomically detailed, three-dimensional representations of normal male and female human bodies: http://www.nlm.nih.gov/research/visible/visible_human.html

While all of the above references may be of interest to healthcare providers who study and treat temporomandibular joint syndrome, the following are particularly noteworthy.

The Combined Health Information Database A comprehensive source of information on clinical guidelines written for professionals is the Combined Health Information Database. You will need to limit your search to “Brochure/Pamphlet,” “Fact Sheet,” or “Information Package” and temporomandibular joint syndrome using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For the publication date, select “All Years,” select your preferred language, and the format option “Fact Sheet.” By making these selections and typing “temporomandibular joint syndrome” (or synonyms) into the

84 Temporomandibular Joint Syndrome

“For these words:” box above, you will only receive results on fact sheets dealing with temporomandibular joint syndrome.

The NLM Gateway21 The NLM (National Library of Medicine) Gateway is a Web-based system that lets users search simultaneously in multiple retrieval systems at the U.S. National Library of Medicine (NLM). It allows users of NLM services to initiate searches from one Web interface, providing “one-stop searching” for many of NLM's information resources or databases.22 One target audience for the Gateway is the Internet user who is new to NLM's online resources and does not know what information is available or how best to search for it. This audience may include dentists and other healthcare providers, researchers, librarians, students, and, increasingly, patients, their families, and the public.23 To use the NLM Gateway, simply go to the search site at http://gateway.nlm.nih.gov/gw/Cmd. Type “temporomandibular joint syndrome” (or synonyms) into the search box and click “Search.” The results will be presented in a tabular form, indicating the number of references in each database category. Results Summary Items Found Category Journal Articles 4295 Books / Periodicals / Audio Visual 70 Consumer Health 0 Meeting Abstracts 0 Other Collections 4 Total 4369

Adapted from NLM: http://gateway.nlm.nih.gov/gw/Cmd?Overview.x. The NLM Gateway is currently being developed by the Lister Hill National Center for Biomedical Communications (LHNCBC) at the National Library of Medicine (NLM) of the National Institutes of Health (NIH). 23 Other users may find the Gateway useful for an overall search of NLM's information resources. Some searchers may locate what they need immediately, while others will utilize the Gateway as an adjunct tool to other NLM search services such as PubMed® and MEDLINEplus®. The Gateway connects users with multiple NLM retrieval systems while also providing a search interface for its own collections. These collections include various types of information that do not logically belong in PubMed, LOCATORplus, or other established NLM retrieval systems (e.g., meeting announcements and pre-1966 journal citations). The Gateway will provide access to the information found in an increasing number of NLM retrieval systems in several phases. 21 22

Physician Guidelines and Databases 85

HSTAT24 HSTAT is a free, Web-based resource that provides access to full-text documents used in healthcare decision-making.25 HSTAT's audience includes healthcare providers, health service researchers, policy makers, insurance companies, consumers, and the information professionals who serve these groups. HSTAT provides access to a wide variety of publications, including clinical practice guidelines, quick-reference guides for clinicians, consumer health brochures, evidence reports and technology assessments from the Agency for Healthcare Research and Quality (AHRQ), as well as AHRQ's Put Prevention Into Practice.26 Simply search by “temporomandibular joint syndrome” (or synonyms) at the following Web site: http://text.nlm.nih.gov.

Coffee Break: Tutorials for Biologists27 Some patients may wish to have access to a general healthcare site that takes a scientific view of the news and covers recent breakthroughs in biology that may one day assist healthcare providers in developing treatments. To this end, we recommend “Coffee Break,” a collection of short reports on recent biological discoveries. Each report incorporates interactive tutorials that demonstrate how bioinformatics tools are used as a part of the research process. Currently, all Coffee Breaks are written by NCBI staff.28 Each report is about 400 words and is usually based on a discovery reported in one or more articles from recently published, peer-reviewed literature.29 This site Adapted from HSTAT: http://www.nlm.nih.gov/pubs/factsheets/hstat.html. The HSTAT URL is http://hstat.nlm.nih.gov/. 26 Other important documents in HSTAT include: the National Institutes of Health (NIH) Consensus Conference Reports and Technology Assessment Reports; the HIV/AIDS Treatment Information Service (ATIS) resource documents; the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (SAMHSA/CSAT) Treatment Improvement Protocols (TIP) and Center for Substance Abuse Prevention (SAMHSA/CSAP) Prevention Enhancement Protocols System (PEPS); the Public Health Service (PHS) Preventive Services Task Force's Guide to Clinical Preventive Services; the independent, nonfederal Task Force on Community Services Guide to Community Preventive Services; and the Health Technology Advisory Committee (HTAC) of the Minnesota Health Care Commission (MHCC) health technology evaluations. 27 Adapted from http://www.ncbi.nlm.nih.gov/Coffeebreak/Archive/FAQ.html. 28 The figure that accompanies each article is frequently supplied by an expert external to NCBI, in which case the source of the figure is cited. The result is an interactive tutorial that tells a biological story. 29 After a brief introduction that sets the work described into a broader context, the report focuses on how a molecular understanding can provide explanations of observed biology and lead to therapies for diseases. Each vignette is accompanied by a figure and hypertext links that lead to a series of pages that interactively show how NCBI tools and resources are used in the research process. 24 25

86 Temporomandibular Joint Syndrome

has new articles every few weeks, so it can be considered an online magazine of sorts, and intended for general background information. You can access the Coffee Break Web site at the following hyperlink: http://www.ncbi.nlm.nih.gov/Coffeebreak/.

Other Commercial Databases In addition to resources maintained by official agencies, other databases exist that are commercial ventures addressing medical professionals. Here are a few examples that may interest you: ·

CliniWeb International: Index and table of contents to selected clinical information on the Internet; see http://www.ohsu.edu/cliniweb/.

·

Image Engine: Multimedia electronic medical record system that integrates a wide range of digitized clinical images with textual data stored in the University of Pittsburgh Medical Center's MARS electronic medical record system; see the following Web site: http://www.cml.upmc.edu/cml/imageengine/imageEngine.html.

·

Medical World Search: Searches full text from thousands of selected medical sites on the Internet; see http://www.mwsearch.com/.

·

MedWeaver: Prototype system that allows users to search differential diagnoses for any list of signs and symptoms, to search medical literature, and to explore relevant Web sites; see http://www.med.virginia.edu/~wmd4n/medweaver.html.

·

Metaphrase: Middleware component intended for use by both caregivers and medical records personnel. It converts the informal language generally used by caregivers into terms from formal, controlled vocabularies; see the following Web site: http://www.lexical.com/Metaphrase.html.

The Genome Project and Temporomandibular Joint Syndrome With all the discussion in the press about the Human Genome Project, it is only natural that healthcare providers, researchers, and patients want to know about how human genes relate to temporomandibular joint syndrome. In the following section, we will discuss databases and references used by healthcare providers and scientists who work in this area.

Physician Guidelines and Databases 87

Online Mendelian Inheritance in Man (OMIM) The Online Mendelian Inheritance in Man (OMIM) database is a catalog of human genes and genetic disorders authored and edited by Dr. Victor A. McKusick and his colleagues at Johns Hopkins and elsewhere. OMIM was developed for the World Wide Web by the National Center for Biotechnology Information (NCBI).30 The database contains textual information, pictures, and reference information. It also contains copious links to NCBI's Entrez database of MEDLINE articles and sequence information. To search the database, go to http://www.ncbi.nlm.nih.gov/Omim/searchomim.html. Type “temporomandibular joint syndrome” (or synonyms) in the search box, and click “Submit Search.” If too many results appear, you can narrow the search by adding the word “clinical.” Each report will have additional links to related research and databases. By following these links, especially the link titled “Database Links,” you will be exposed to numerous specialized databases that are largely used by the scientific community. These databases are overly technical and seldom used by the general public, but offer an abundance of information. The following is an example of the results you can obtain from the OMIM for temporomandibular joint syndrome: ·

Chondrodysplasia, Grebe Type Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?200700

·

Ears, Prominent and Constricted Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?602483

·

Ehlers-danlos Syndrome, Type Viii Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?130080

·

Tight Skin Contracture Syndrome, Lethal Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?275210

30 Adapted from http://www.ncbi.nlm.nih.gov/. Established in 1988 as a national resource for molecular biology information, NCBI creates public databases, conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information--all for the better understanding of molecular processes affecting human health and disease.

88 Temporomandibular Joint Syndrome

Genes and Disease (NCBI - Map) The Genes and Disease database is produced by the National Center for Biotechnology Information of the National Library of Medicine at the National Institutes of Health. This Web site categorizes each disorder by the system of the body associated with it. Go to http://www.ncbi.nlm.nih.gov/disease/, and browse the system pages to have a full view of important conditions linked to human genes. Since this site is regularly updated, you may wish to re-visit it from time to time. The following systems and associated disorders are addressed: ·

Cancer: Uncontrolled cell division. Examples: Breast And Ovarian Cancer, Burkitt lymphoma, chronic myeloid leukemia, colon cancer, lung cancer, malignant melanoma, multiple endocrine neoplasia, neurofibromatosis, p53 tumor suppressor, pancreatic cancer, prostate cancer, Ras oncogene, RB: retinoblastoma, von Hippel-Lindau syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Cancer.html

·

Muscle and Bone: Movement and growth. Examples: Duchenne muscular dystrophy, Ellis-van Creveld syndrome, Marfan syndrome, myotonic dystrophy, spinal muscular atrophy. Web site: http://www.ncbi.nlm.nih.gov/disease/Muscle.html

·

Nervous System: Mind and body. Examples: Alzheimer disease, Amyotrophic lateral sclerosis, Angelman syndrome, Charcot-Marie-Tooth disease, epilepsy, essential tremor, Fragile X syndrome, Friedreich's ataxia, Huntington disease, NiemannPick disease, Parkinson disease, Prader-Willi syndrome, Rett syndrome, Spinocerebellar atrophy, Williams syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Brain.html

·

Signals: Cellular messages. Examples: Ataxia telangiectasia, Baldness, Cockayne syndrome, Glaucoma, SRY: sex determination, Tuberous sclerosis, Waardenburg syndrome, Werner syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Signals.html

·

Transporters: Pumps and channels. Examples: Cystic Fibrosis, deafness, diastrophic dysplasia, Hemophilia A, long-QT syndrome, Menkes syndrome, Pendred syndrome, polycystic kidney disease, sickle cell anemia, Wilson's disease, Zellweger syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Transporters.html

Physician Guidelines and Databases 89

Entrez Entrez is a search and retrieval system that integrates several linked databases at the National Center for Biotechnology Information (NCBI). These databases include nucleotide sequences, protein sequences, macromolecular structures, whole genomes, and MEDLINE through PubMed. Entrez provides access to the following databases: ·

PubMed: Biomedical literature (PubMed), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed

·

Nucleotide Sequence Database (Genbank): Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Nucleotide

·

Protein Sequence Database: Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Protein

·

Structure: Three-dimensional macromolecular structures, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Structure

·

Genome: Complete genome assemblies, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Genome

·

PopSet: Population study data sets, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Popset

·

OMIM: Online Mendelian Inheritance in Man, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM

·

Taxonomy: Organisms in GenBank, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Taxonomy

·

Books: Online books, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=books

·

ProbeSet: Gene Expression Omnibus (GEO), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

·

3D Domains: Domains from Entrez Structure, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

·

NCBI's Protein Sequence Information Survey Results: Web site: http://www.ncbi.nlm.nih.gov/About/proteinsurvey/

To access the Entrez system at the National Center for Biotechnology Information, go to http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=genom e, and then select the database that you would like to search. The databases

90 Temporomandibular Joint Syndrome

available are listed in the drop box next to “Search.” In the box next to “for,” enter “temporomandibular joint syndrome” (or synonyms) and click “Go.”

Jablonski's Multiple Congenital Anomaly/Mental Retardation (MCA/MR) Syndromes Database31 This online resource can be quite useful. It has been developed to facilitate the identification and differentiation of syndromic entities. Special attention is given to the type of information that is usually limited or completely omitted in existing reference sources due to space limitations of the printed form. At the following Web site you can also search across syndromes using an index: http://www.nlm.nih.gov/mesh/jablonski/syndrome_toc/toc_a.html. You can search by keywords at this Web site: http://www.nlm.nih.gov/mesh/jablonski/syndrome_db.html. The Genome Database32 Established at Johns Hopkins University in Baltimore, Maryland in 1990, the Genome Database (GDB) is the official central repository for genomic mapping data resulting from the Human Genome Initiative. In the spring of 1999, the Bioinformatics Supercomputing Centre (BiSC) at the Hospital for Sick Children in Toronto, Ontario assumed the management of GDB. The Human Genome Initiative is a worldwide research effort focusing on structural analysis of human DNA to determine the location and sequence of the estimated 100,000 human genes. In support of this project, GDB stores and curates data generated by researchers worldwide who are engaged in the mapping effort of the Human Genome Project (HGP). GDB's mission is to provide scientists with an encyclopedia of the human genome which is continually revised and updated to reflect the current state of scientific knowledge. Although GDB has historically focused on gene mapping, its focus will broaden as the Genome Project moves from mapping to sequence, and finally, to functional analysis. To access the GDB, simply go to the following hyperlink: http://www.gdb.org/. Search “All Biological Data” by “Keyword.” Type Adapted from the National Library of Medicine: http://www.nlm.nih.gov/mesh/jablonski/about_syndrome.html. 32 Adapted from the Genome Database: http://gdbwww.gdb.org/gdb/aboutGDB.html#mission. 31

Physician Guidelines and Databases 91

“temporomandibular joint syndrome” (or synonyms) into the search box, and review the results. If more than one word is used in the search box, then separate each one with the word “and” or “or” (using “or” might be useful when using synonyms). This database is extremely technical as it was created for specialists. The articles are the results which are the most accessible to non-professionals and often listed under the heading “Citations.” The contact names are also accessible to non-professionals.

Specialized References The following books are specialized references written for professionals interested in temporomandibular joint syndrome (sorted alphabetically by title, hyperlinks provide rankings, information, and reviews at Amazon.com): ·

Advances in Operative Dentistry: Volume 1: Contemporary Clinical Practice by Jean-Francois Roulet (Editor), et al; Hardcover - 263 pages, 1st edition (August 15, 2001), Quintessence Publishing Co.; ISBN: 0867154020; http://www.amazon.com/exec/obidos/ASIN/0867154020/icongroupinter na

·

Behavioural Sciences for Dentistry by Gerry Humphris, Margaret S. Ling; Paperback - 149 pages, 1st edition (October 1, 2005), Churchill Livingstone; ISBN: 0443051909; http://www.amazon.com/exec/obidos/ASIN/0443051909/icongroupinter na

·

Burket's Oral Medicine: Diagnosis and Treatment by Martin S. Greenberg, Michael Glick; Hardcover, 10th edition (July 2002), Decker Periodicals; ISBN: 0781725372; http://www.amazon.com/exec/obidos/ASIN/0781725372/icongroupinter na

·

Churchill's Pocketbook of Clinical Dentistry by I. G. Chestnutt (Editor), J. Gibson (Editor); Hardcover 2nd edition (April 2002), Churchill Livingstone; ISBN: 0443070849; http://www.amazon.com/exec/obidos/ASIN/0443070849/icongroupinter na

·

A Color Atlas and Text of Oral Anatomy, Histology and Embryology by Berkovitz; Hardcover, 3rd edition (July 26, 2002), Mosby-Year Book; ISBN: 0723431817; http://www.amazon.com/exec/obidos/ASIN/0723431817/icongroupinter na

92 Temporomandibular Joint Syndrome

·

Essential Microbiology for Dentistry by L. P. Samaranayake; Paperback - 293 pages, 2nd edition (January 15, 2002), W B Saunders Co; ISBN: 044306461X; http://www.amazon.com/exec/obidos/ASIN/044306461X/icongroupinter na

·

Essentials of Oral Medicine by Sol Silverman, Jr., et al; Paperback, Book & Cd-Rom edition (October 2001), B C Decker; ISBN: 1550091468; http://www.amazon.com/exec/obidos/ASIN/1550091468/icongroupinter na

·

Fundamentals of Oral Medicine: A Practical Guide by Crispian Scully, M.D., Ph.D.; Paperback (September 2001), Butterworth-Heinemann Medical; ISBN: 0723610746; http://www.amazon.com/exec/obidos/ASIN/0723610746/icongroupinter na

·

Medical Emergencies in Dentistry by Jeffrey D. Bennett, Morton B. Rosenberg; Paperback - 556 pages, 1st edition (January 15, 2002), W B Saunders Co; ISBN: 0721684815; http://www.amazon.com/exec/obidos/ASIN/0721684815/icongroupinter na

·

Oral Development and Histology by James K. Avery, D.D.S., Ph.D. (Editor), Hardcover, 3rd edition (October 2001), Thieme Medical Pub; ISBN: 1588900282; http://www.amazon.com/exec/obidos/ASIN/1588900282/icongroupinter na

·

Year Book of Dentistry 2001 by Lawrence H. Meskin; Hardcover (January 2002), Mosby-Year Book; ISBN: 0323015433; http://www.amazon.com/exec/obidos/ASIN/0323015433/icongroupinter na

Vocabulary Builder Contracture: A condition of fixed high resistance to passive stretch of a muscle, resulting from fibrosis of the tissues supporting the muscles or the joints, or from disorders of the muscle fibres. [EU] Lethal: Deadly, fatal. [EU] Microbiology: The study of microorganisms such as fungi, bacteria, algae, archaea, and viruses. [NIH]

Dissertations 93

CHAPTER 9. DISSERTATIONS ON TEMPOROMANDIBULAR JOINT SYNDROME Overview University researchers are active in studying almost all known diseases. The result of research is often published in the form of Doctoral or Master's dissertations. You should understand, therefore, that applied diagnostic procedures and/or therapies can take many years to develop after the thesis that proposed the new technique or approach was written. In this chapter, we will give you a bibliography on recent dissertations relating to temporomandibular joint syndrome. You can read about these in more detail using the Internet or your local medical library. We will also provide you with information on how to use the Internet to stay current on dissertations.

Dissertations on Temporomandibular Joint Syndrome ProQuest Digital Dissertations is the largest archive of academic dissertations available. From this archive, we have compiled the following list covering dissertations devoted to temporomandibular joint syndrome. You will see that the information provided includes the dissertation’s title, its author, and the author’s institution. To read more about the following, simply use the Internet address indicated. The following covers recent dissertations dealing with temporomandibular joint syndrome: ·

A Comparison of Three Conservative Treatments on the Myofascial Component of College-aged Temporomandibular Joint Syndrome

94 Temporomandibular Joint Syndrome

Patients by Davidson, Nedward Thomas, Phd from Texas A&m University, 1988, 127 pages http://wwwlib.umi.com/dissertations/fullcit/8815858 ·

An Exploratory Study of the Personality Styles of Temporomandibular Joint Syndrome Patients and Their Successful or Unsuccessful Response to Treatment (pain, Stress, Secondary Gains, Adjective Checklist, Minnesota Multiphasic Personality Inventory(mmpi)) by Kovacs, Paul George, Phd from The Union for Experimenting Colleges and Universities, 1985, 59 pages http://wwwlib.umi.com/dissertations/fullcit/8528757

Keeping Current As previously mentioned, an effective way to stay current on dissertations dedicated to temporomandibular joint syndrome is to use the database called ProQuest Digital Dissertations via the Internet, located at the following Web address: http://wwwlib.umi.com/dissertations. The site allows you to freely access the last two years of citations and abstracts. Ask your medical librarian if the library has full and unlimited access to this database. From the library, you should be able to do more complete searches than with the limited 2-year access available to the general public.

Vocabulary Builder MMPI: A personality inventory consisting of statements to be asserted or denied by the individual. The patterns of response are characteristic of certain personality attributes. [NIH]

95

PART III. APPENDICES

ABOUT PART III Part III is a collection of appendices on general medical topics which may be of interest to patients with temporomandibular joint syndrome and related conditions.

Researching Your Medications 97

APPENDIX A. RESEARCHING YOUR MEDICATIONS Overview There are a number of sources available on new or existing medications which could be prescribed to patients with temporomandibular joint syndrome. While a number of hard copy or CD-Rom resources are available to patients and dentists for research purposes, a more flexible method is to use Internet-based databases. In this chapter, we will begin with a general overview of medications. We will then proceed to outline official recommendations on how you should view your medications. You may also want to research medications that you are currently taking for other conditions as they may interact with medications for temporomandibular joint syndrome. Research can give you information on the side effects, interactions, and limitations of prescription drugs used in the treatment of temporomandibular joint syndrome. Broadly speaking, there are two sources of information on approved medications: public sources and private sources. We will emphasize free-to-use public sources.

98 Temporomandibular Joint Syndrome

Your Medications: The Basics33 The Agency for Health Care Research and Quality has published extremely useful guidelines on how you can best participate in the medication aspects of temporomandibular joint syndrome. Taking medicines is not always as simple as swallowing a pill. It can involve many steps and decisions each day. The AHCRQ recommends that patients with temporomandibular joint syndrome take part in treatment decisions. Do not be afraid to ask questions and talk about your concerns. By taking a moment to ask questions early, you may avoid problems later. Here are some points to cover each time a new medicine is prescribed: ·

Ask about all parts of your treatment, including diet changes, exercise, and medicines.

·

Ask about the risks and benefits of each medicine or other treatment you might receive.

·

Ask how often you or your healthcare provider will check for side effects from a given medication.

Do not hesitate to ask what is important to you about your medicines. You may want a medicine with the fewest side effects, or the fewest doses to take each day. You may care most about cost, or how the medicine might affect how you live or work. Or, you may want the medicine your dentist believes will work the best. Do not be afraid to “bother” your dentist or oral surgeon with your concerns and questions about medications for temporomandibular joint syndrome. You can also talk to a nurse or a pharmacist. They can help you better understand your treatment plan. Feel free to bring a friend or family member with you when you visit your dentist. Talking over your options with someone you trust can help you make better choices, especially if you are not feeling well. Specifically, ask your dentist the following: ·

The name of the medicine and what it is supposed to do.

·

How and when to take the medicine, how much to take, and for how long.

·

What food, drinks, other medicines, or activities you should avoid while taking the medicine.

·

What side effects the medicine may have, and what to do if they occur.

·

If you can get a refill, and how often.

33

This section is adapted from AHCRQ: http://www.ahcpr.gov/consumer/ncpiebro.htm.

Researching Your Medications 99

·

About any terms or directions you do not understand.

·

What to do if you miss a dose.

·

If there is written information you can take home (most pharmacies have information sheets on your prescription medicines; some even offer large-print or Spanish versions).

Do not forget to tell your dentist about all the medicines you are currently taking (not just those for temporomandibular joint syndrome). This includes prescription medicines and the medicines that you buy over the counter. Then your dentist can avoid giving you a new medicine that may not work well with the medications you take now. When talking to your dentist, you may wish to prepare a list of medicines you currently take, the reason you take them, and how you take them. Be sure to include the following information for each: ·

Name of medicine

·

Reason taken

·

Dosage

·

Time(s) of day

Also include any over-the-counter medicines, such as: ·

Laxatives

·

Diet pills

·

Vitamins

·

Cold medicine

·

Aspirin or other pain, headache, or fever medicine

·

Cough medicine

·

Allergy relief medicine

·

Antacids

·

Sleeping pills

·

Others (include names)

Learning More about Your Medications Because of historical investments by various organizations and the emergence of the Internet, it has become rather simple to learn about the

100 Temporomandibular Joint Syndrome

medications your dentist has recommended for temporomandibular joint syndrome. One such source is the United States Pharmacopeia. In 1820, eleven physicians met in Washington, D.C. to establish the first compendium of standard drugs for the United States. They called this compendium the “U.S. Pharmacopeia (USP).” Today, the USP is a non-profit organization consisting of 800 volunteer scientists, eleven elected officials, and 400 representatives of state associations and colleges of medicine and pharmacy. The USP is located in Rockville, Maryland, and its home page is located at www.usp.org. The USP currently provides standards for over 3,700 medications. The resulting USP DIÒ Advice for the PatientÒ can be accessed through the National Library of Medicine of the National Institutes of Health. The database is partially derived from lists of federally approved medications in the Food and Drug Administration's (FDA) Drug Approvals database.34 While the FDA database is rather large and difficult to navigate, the Phamacopeia is both user-friendly and free to use. It covers more than 9,000 prescription and over-the-counter medications. To access this database, simply type the following hyperlink into your Web browser: http://www.nlm.nih.gov/medlineplus/druginformation.html. To view examples of a given medication (brand names, category, description, preparation, proper use, precautions, side effects, etc.), simply follow the hyperlinks indicated within the United States Pharmacopoeia (USP). It is important to read the disclaimer by the USP (http://www.nlm.nih.gov/medlineplus/drugdisclaimer.html) before using the information provided.

Commercial Databases In addition to the medications listed in the USP above, a number of commercial sites are available by subscription to dentists and their institutions. You may be able to access these sources from your local medical library or your dentist's office. Reuters Health Drug Database The Reuters Health Drug Database can be searched by keyword at the hyperlink: http://www.reutershealth.com/frame2/drug.html. Though cumbersome, the FDA database can be freely browsed at the following site: www.fda.gov/cder/da/da.htm.

34

Researching Your Medications 101

Mosby's GenRx Mosby's GenRx database (also available on CD-Rom and book format) covers 45,000 drug products including generics and international brands. It provides prescribing information, drug interactions, and patient information. Information can be obtained at the following hyperlink: http://www.genrx.com/Mosby/PhyGenRx/group.html.

Physicians Desk Reference The Physicians Desk Reference database (also available in CD-Rom and book format) is a full-text drug database. The database is searchable by brand name, generic name or by indication. It features multiple drug interactions reports. Information can be obtained at the following hyperlink: http://physician.pdr.net/physician/templates/en/acl/psuser_t.htm.

Other Web Sites A number of additional Web sites discuss drug information. As an example, you may like to look at www.drugs.com which reproduces the information in the Pharmacopeia as well as commercial information. You may also want to consider the Web site of the Medical Letter, Inc. which allows users to download articles on various drugs and therapeutics for a nominal fee: http://www.medletter.com/.

Contraindications and Interactions (Hidden Dangers) Some of the medications mentioned in the previous discussions can be problematic for patients with temporomandibular joint syndrome--not because they are used in the treatment process, but because of contraindications, or side effects. Medications with contraindications are those that could react with drugs used to treat temporomandibular joint syndrome or potentially create deleterious side effects in patients with temporomandibular joint syndrome. You should ask your dentist about any contraindications, especially as these might apply to other medications that you may be taking for common ailments. Drug-drug interactions occur when two or more drugs react with each other. This drug-drug interaction may cause you to experience an unexpected side

102 Temporomandibular Joint Syndrome

effect. Drug interactions may make your medications less effective, cause unexpected side effects, or increase the action of a particular drug. Some drug interactions can even be harmful to you. Be sure to read the label every time you use a nonprescription or prescription drug, and take the time to learn about drug interactions. These precautions may be critical to your health. You can reduce the risk of potentially harmful drug interactions and side effects with a little bit of knowledge and common sense. Drug labels contain important information about ingredients, uses, warnings, and directions which you should take the time to read and understand. Labels also include warnings about possible drug interactions. Further, drug labels may change as new information becomes available. This is why it's especially important to read the label every time you use a medication. When your dentist prescribes a new drug, discuss all over-thecounter and prescription medications, dietary supplements, vitamins, botanicals, minerals and herbals you take as well as the foods you eat. Ask your pharmacist for the package insert for each prescription drug you take. The package insert provides more information about potential drug interactions.

A Final Warning At some point, you may hear of alternative medications from friends, relatives, or in the news media. Advertisements may suggest that certain alternative drugs can produce positive results for patients with temporomandibular joint syndrome. Exercise caution--some of these drugs may have fraudulent claims, and others may actually hurt you. The Food and Drug Administration (FDA) is the official U.S. agency charged with discovering which medications are likely to improve the health of patients with temporomandibular joint syndrome. The FDA warns patients to watch out for35: ·

Secret formulas (real scientists share what they know)

·

Amazing breakthroughs or miracle cures (real breakthroughs don't happen very often; when they do, real scientists do not call them amazing or miracles)

·

Quick, painless, or guaranteed cures

35

This section has been adapted from http://www.fda.gov/opacom/lowlit/medfraud.html.

Researching Your Medications 103

·

If it sounds too good to be true, it probably isn't true.

If you have any questions about any kind of medical treatment, the FDA may have an office near you. Look for their number in the blue pages of the phone book. You can also contact the FDA through its toll-free number, 1888-INFO-FDA (1-888-463-6332), or on the World Wide Web at www.fda.gov.

General References In addition to the resources provided earlier in this chapter, the following general references describe medications (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

Drug Dictionary for Dentistry by J. G. Meechan, R. A. Seymour; Hardcover (March 2002), Oxford University Press; ISBN: 0192632744; http://www.amazon.com/exec/obidos/ASIN/0192632744/icongroupinter na

·

Drug Information Handbook for Dentistry, 2001-2002 by Richard L. Wynn, et al; Paperback - 1500 pages, 7th edition (August 15, 2001), Lexi Comp; ISBN: 1930598718; http://www.amazon.com/exec/obidos/ASIN/1930598718/icongroupinter na

·

Handbook of Commonly Prescribed Drugs by G. John Digregorio, Edward J. Barbieri; Paperback 16th edition (2001), Medical Surveillance; ISBN: 0942447417; http://www.amazon.com/exec/obidos/ASIN/0942447417/icongroupinter na

·

Johns Hopkins Complete Home Encyclopedia of Drugs 2nd ed. by Simeon Margolis (Ed.), Johns Hopkins; Hardcover - 835 pages (2000), Rebus; ISBN: 0929661583; http://www.amazon.com/exec/obidos/ASIN/0929661583/icongroupinter na

·

Mosby's Dental Drug Reference by Tommy W. Gage, Frieda Atherton Pickett; Paperback - 815 pages, 5th edition (October 2001), Mosby-Year Book; ISBN: 032301710X; http://www.amazon.com/exec/obidos/ASIN/032301710X/icongroupinter na

Researching Alternative Medicine 105

APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE Overview Complementary and alternative medicine (CAM) is one of the most contentious aspects of modern medical practice. You may have heard of these treatments on the radio or on television. Maybe you have seen articles written about these treatments in magazines, newspapers, or books. Perhaps your friends or healthcare providers have mentioned alternatives. In this chapter, we will begin by giving you a broad perspective on complementary and alternative therapies. Next, we will introduce you to official information sources on CAM relating to temporomandibular joint syndrome. Finally, at the conclusion of this chapter, we will provide a list of readings on temporomandibular joint syndrome from various authors. We will begin, however, with the National Center for Complementary and Alternative Medicine's (NCCAM) overview of complementary and alternative medicine.

What Is CAM?36 Complementary and alternative medicine (CAM) covers a broad range of healing philosophies, approaches, and therapies. Generally, it is defined as those treatments and healthcare practices which are not taught in medical schools, used in hospitals, or reimbursed by medical insurance companies. Many CAM therapies are termed “holistic,” which generally means that the healthcare practitioner considers the whole person, including physical, mental, emotional, and spiritual health. Some of these therapies are also 36

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/faq/index.html#what-is.

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known as “preventive,” which means that the practitioner educates and treats the person to prevent health problems from arising, rather than treating symptoms after problems have occurred. People use CAM treatments and therapies in a variety of ways. Therapies are used alone (often referred to as alternative), in combination with other alternative therapies, or in addition to conventional treatment (sometimes referred to as complementary). Complementary and alternative medicine, or “integrative medicine,” includes a broad range of healing philosophies, approaches, and therapies. Some approaches are consistent with physiological principles of Western medicine, while others constitute healing systems with non-Western origins. While some therapies are far outside the realm of accepted Western medical theory and practice, others are becoming established in mainstream medicine. Complementary and alternative therapies are used in an effort to prevent illness, reduce stress, prevent or reduce side effects and symptoms, or control or cure disease. Some commonly used methods of complementary or alternative therapy include mind/body control interventions such as visualization and relaxation, manual healing including acupressure and massage, homeopathy, vitamins or herbal products, and acupuncture.

What Are the Domains of Alternative Medicine?37 The list of CAM practices changes continually. The reason being is that these new practices and therapies are often proved to be safe and effective, and therefore become generally accepted as “mainstream” healthcare practices. Today, CAM practices may be grouped within five major domains: (1) alternative medical systems, (2) mind-body interventions, (3) biologicallybased treatments, (4) manipulative and body-based methods, and (5) energy therapies. The individual systems and treatments comprising these categories are too numerous to list in this sourcebook. Thus, only limited examples are provided within each.

Alternative Medical Systems Alternative medical systems involve complete systems of theory and practice that have evolved independent of, and often prior to, conventional biomedical approaches. Many are traditional systems of medicine that are 37

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/classify/index.html.

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practiced by individual cultures throughout the world, including a number of venerable Asian approaches. Traditional oriental medicine emphasizes the balance or disturbances of qi (pronounced chi) or vital energy in health and disease, respectively. Traditional oriental medicine consists of a group of techniques and methods including acupuncture, herbal medicine, oriental massage, and qi gong (a form of energy therapy). Acupuncture involves stimulating specific anatomic points in the body for therapeutic purposes, usually by puncturing the skin with a thin needle. Ayurveda is India's traditional system of medicine. Ayurvedic medicine (meaning “science of life”) is a comprehensive system of medicine that places equal emphasis on body, mind, and spirit. Ayurveda strives to restore the innate harmony of the individual. Some of the primary Ayurvedic treatments include diet, exercise, meditation, herbs, massage, exposure to sunlight, and controlled breathing. Other traditional healing systems have been developed by the world’s indigenous populations. These populations include Native American, Aboriginal, African, Middle Eastern, Tibetan, and Central and South American cultures. Homeopathy and naturopathy are also examples of complete alternative medicine systems. Homeopathic medicine is an unconventional Western system that is based on the principle that “like cures like,” i.e., that the same substance that in large doses produces the symptoms of an illness, in very minute doses cures it. Homeopathic health practitioners believe that the more dilute the remedy, the greater its potency. Therefore, they use small doses of specially prepared plant extracts and minerals to stimulate the body's defense mechanisms and healing processes in order to treat illness. Naturopathic medicine is based on the theory that disease is a manifestation of alterations in the processes by which the body naturally heals itself and emphasizes health restoration rather than disease treatment. Naturopathic physicians employ an array of healing practices, including the following: diet and clinical nutrition, homeopathy, acupuncture, herbal medicine, hydrotherapy (the use of water in a range of temperatures and methods of applications), spinal and soft-tissue manipulation, physical therapies (such as those involving electrical currents, ultrasound, and light), therapeutic counseling, and pharmacology.

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Mind-Body Interventions Mind-body interventions employ a variety of techniques designed to facilitate the mind's capacity to affect bodily function and symptoms. Only a select group of mind-body interventions having well-documented theoretical foundations are considered CAM. For example, patient education and cognitive-behavioral approaches are now considered “mainstream.” On the other hand, complementary and alternative medicine includes meditation, certain uses of hypnosis, dance, music, and art therapy, as well as prayer and mental healing.

Biological-Based Therapies This category of CAM includes natural and biological-based practices, interventions, and products, many of which overlap with conventional medicine's use of dietary supplements. This category includes herbal, special dietary, orthomolecular, and individual biological therapies. Herbal therapy employs an individual herb or a mixture of herbs for healing purposes. An herb is a plant or plant part that produces and contains chemical substances that act upon the body. Special diet therapies, such as those proposed by Drs. Atkins, Ornish, Pritikin, and Weil, are believed to prevent and/or control illness as well as promote health. Orthomolecular therapies aim to treat disease with varying concentrations of chemicals such as magnesium, melatonin, and mega-doses of vitamins. Biological therapies include, for example, the use of laetrile and shark cartilage to treat cancer and the use of bee pollen to treat autoimmune and inflammatory diseases.

Manipulative and Body-Based Methods This category includes methods that are based on manipulation and/or movement of the body. For example, chiropractors focus on the relationship between structure and function, primarily pertaining to the spine, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool. In contrast, osteopaths place particular emphasis on the musculoskeletal system and practice osteopathic manipulation. Osteopaths believe that all of the body's systems work together and that disturbances in one system may have an impact upon function elsewhere in the body. Massage therapists manipulate the soft tissues of the body to normalize those tissues.

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Energy Therapies Energy therapies focus on energy fields originating within the body (biofields) or those from other sources (electromagnetic fields). Biofield therapies are intended to affect energy fields (the existence of which is not yet experimentally proven) that surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in or through these fields. Examples include Qi gong, Reiki and Therapeutic Touch. Qi gong is a component of traditional oriental medicine that combines movement, meditation, and regulation of breathing to enhance the flow of vital energy (qi) in the body, improve blood circulation, and enhance immune function. Reiki, the Japanese word representing Universal Life Energy, is based on the belief that, by channeling spiritual energy through the practitioner, the spirit is healed and, in turn, heals the physical body. Therapeutic Touch is derived from the ancient technique of “laying-on of hands.” It is based on the premises that the therapist’s healing force affects the patient's recovery and that healing is promoted when the body's energies are in balance. By passing their hands over the patient, these healers identify energy imbalances. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields to treat illnesses or manage pain. These therapies are often used to treat asthma, cancer, and migraine headaches. Types of electromagnetic fields which are manipulated in these therapies include pulsed fields, magnetic fields, and alternating current or direct current fields.

Can Alternatives Affect My Treatment? A critical issue in pursuing complementary alternatives mentioned thus far is the risk that these might have undesirable interactions with your medical treatment. It becomes all the more important to speak with your healthcare provider who can offer advice on the use of alternatives. Official sources confirm this view. Though written for women, we find that the National Women’s Health Information Center’s advice on pursuing alternative medicine is appropriate for patients of both genders and all ages.38

38

Adapted from http://www.4woman.gov/faq/alternative.htm.

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Is It Okay to Want Both Traditional and Alternative or Complementary Medicine? Should you wish to explore non-traditional types of treatment, be sure to discuss all issues concerning treatments and therapies with your healthcare provider, whether a dentist or practitioner of complementary and alternative medicine. Competent healthcare management requires knowledge of both conventional and alternative therapies you are taking for the practitioner to have a complete picture of your treatment plan. The decision to use complementary and alternative treatments is an important one. Consider before selecting an alternative therapy, the safety and effectiveness of the therapy or treatment, the expertise and qualifications of the healthcare practitioner, and the quality of delivery. These topics should be considered when selecting any practitioner or therapy.

Finding CAM Syndrome

References

on

Temporomandibular

Joint

Having read the previous discussion, you may be wondering which complementary or alternative treatments might be appropriate for temporomandibular joint syndrome. For the remainder of this chapter, we will direct you to a number of official sources which can assist you in researching studies and publications. Some of these articles are rather technical, so some patience may be required.

The Combined Health Information Database For a targeted search, The Combined Health Information Database is a bibliographic database produced by health-related agencies of the Federal Government (mostly from the National Institutes of Health). This database is updated four times a year at the end of January, April, July, and October. Check the titles, summaries, and availability of CAM-related information by using the “Simple Search” option at the following Web site: http://chid.nih.gov/simple/simple.html. In the drop box at the top, select “Complementary and Alternative Medicine.” Then type “temporomandibular joint syndrome” (or synonyms) in the second search box. We recommend that you select 100 “documents per page” and to check the “whole records” options. The following was extracted using this technique:

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·

Fibromyalgia and Chronic Myofascial Pain Syndrome: A Survival Manual Source: Oakland, CA: New Harbinger Publications, Inc. 2001. 401 p. Contact: Available from New Harbinger Publications, Inc. 5674 Shattuck Avenue, Oakland, CA 94609. (800) 748-6273; (510) 652-0215. PRICE: $19.95. ISBN: 1572240466. Summary: This book is a manual for patients with fibromyalgia syndrome (FMS) or myofascial pain syndrome (MPS), two conditions that the authors say are infrequently recognized by conventional physicians. Part 1 defines FMS, the myofascia, myofascial trigger points, and chronic MPS. It describes possible coexisting conditions: carpaltunnel syndrome, cerebral palsy, chronic fatigue syndrome, depression, HIV infection, hypoglycemia, hypometabolism, hypermobility syndrome, lupus, mitral valve prolapse, multiple chemical sensitivities, multiple sclerosis, osteoarthritis, Parkinson's Disease, Post-Polio Syndrome, Raynaud's Phenomenon, Reflex Sympathetic Dystrophy Syndrome, rhematoid arthritis, Temporomandibular Joint Syndrome, and yeast infections. The authors list perpetuating factors that are categorized as behavioral (smoking, muscle abuse, and psychological); biochemical (vitamin inadequacy, impaired muscle metabolism, hypoglycemia, low thyroid, and allergic conditions); and mechanical (body asymmetry, hypermobility, traveling, immobility, computer or typewriter use, and illfitting furniture and shoes, and similar conditions). Part 2 covers common questions and answers about symptoms; chronic pain and other states, such as sleep and pregnancy; and mind-control techniques for counteracting physical symptoms; and provides information about healing tools including medications, nutrition, and bodywork. A section on pain management and survival strategies offers tips on coping with family and work situations, getting support, and dealing with the health care system. The book includes a preface; an introduction; illustrations; worksheets; a bibliography; subject and name indexes; and appendices listing resources, additional reading, and health-care item suppliers.

National Center for Complementary and Alternative Medicine The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (http://nccam.nih.gov) has created a link to the National Library of Medicine's databases to allow patients to search for articles that specifically relate to temporomandibular joint syndrome and complementary medicine. To search the database, go to the following Web site: www.nlm.nih.gov/nccam/camonpubmed.html.

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Select “CAM on PubMed.” Enter “temporomandibular joint syndrome” (or synonyms) into the search box. Click “Go.” The following references provide information on particular aspects of complementary and alternative medicine (CAM) that are related to temporomandibular joint syndrome: ·

"Headache/orofacial pain diagnostic dilemma". Author(s): Hasegawa TK Jr, Matthews M Jr, Harper R. Source: Tex Dent J. 1996 June; 113(6): 71-4. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9518849&dopt=Abstract

·

Disocclusion time-reduction therapy with immediate complete anterior guidance development to treat chronic myofascial pain-dysfunction syndrome. Author(s): Kerstein RB. Source: Quintessence Int. 1992 November; 23(11): 735-47. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1305288&dopt=Abstract

·

Electromyographic and computer analyses of patients suffering from chronic myofascial pain-dysfunction syndrome: before and after treatment with immediate complete anterior guidance development. Author(s): Kerstein RB, Wright NR. Source: The Journal of Prosthetic Dentistry. 1991 November; 66(5): 677-86. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1805009&dopt=Abstract

·

Otologic complaints in temporomandibular joint syndrome. Author(s): Henderson DH, Cooper JC Jr, Bryan GW, Van Sickels JE. Source: Archives of Otolaryngology--Head & Neck Surgery. 1992 November; 118(11): 1208-13. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1418900&dopt=Abstract

·

Role of depressive illness in the outcome of treatment of temporomandibular joint pain-dysfunction syndrome. Author(s): Tversky J, Reade PC, Gerschman JA, Holwill BJ, Wright J. Source: Oral Surg Oral Med Oral Pathol. 1991 June; 71(6): 696-9. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=2062523&dopt=Abstract

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·

Temporomandibular joint pain-dysfunction syndrome and bruxism: etiopathogenesis and treatment from a psychosomatic integrative viewpoint. Author(s): Biondi M, Picardi A. Source: Psychotherapy and Psychosomatics. 1993; 59(2): 84-98. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8332706&dopt=Abstract

·

Temporomandibular joint syndrome: diagnostician's dilemma--a review. Author(s): Ficarra BJ, Nassif NJ. Source: J Med. 1991; 22(2): 97-121. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1895018&dopt=Abstract

·

TMJ syndrome: is it compensable? Author(s): Doerrer A, Figart F. Source: Rehabil Nurs. 1991 January-February; 16(1): 23-6. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1824879&dopt=Abstract

·

Treatment of myofascial pain-dysfunction syndrome with occlusal equilibration. Author(s): Kerstein RB, Farrell S. Source: The Journal of Prosthetic Dentistry. 1990 June; 63(6): 695-700. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=2102663&dopt=Abstract

·

Tumors and tumorous masses presenting as temporomandibular joint syndrome. Author(s): Mostafapour SP, Futran ND. Source: Otolaryngology--Head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 2000 October; 123(4): 459-64. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11020186&dopt=Abstract

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Additional Web Resources A number of additional Web sites offer encyclopedic information covering CAM and related topics. The following is a representative sample: ·

Alternative Medicine Foundation, Inc.: http://www.herbmed.org/

·

AOL: http://search.aol.com/cat.adp?id=169&layer=&from=subcats

·

Chinese Medicine: http://www.newcenturynutrition.com/

·

drkoop.comÒ: http://www.drkoop.com/InteractiveMedicine/IndexC.html

·

Family Village: http://www.familyvillage.wisc.edu/med_altn.htm

·

Google: http://directory.google.com/Top/Health/Alternative/

·

Healthnotes: http://www.thedacare.org/healthnotes/

·

Open Directory Project: http://dmoz.org/Health/Alternative/

·

TPN.com: http://www.tnp.com/

·

Yahoo.com: http://dir.yahoo.com/Health/Alternative_Medicine/

·

WebMDÒHealth: http://my.webmd.com/drugs_and_herbs

·

WellNet: http://www.wellnet.ca/herbsa-c.htm

·

WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html

The following is a specific Web list relating to temporomandibular joint syndrome; please note that any particular subject below may indicate either a therapeutic use, or a contraindication (potential danger), and does not reflect an official recommendation: ·

Alternative Therapy Myotherapy Source: WholeHealthMD.com, LLC.; www.wholehealthmd.com Hyperlink: http://www.wholehealthmd.com/refshelf/substances_view/0,1525,931, 00.html

·

Related Conditions Vertigo

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Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Vertigo.htm

General References A good place to find general background information on CAM is the National Library of Medicine. It has prepared within the MEDLINEplus system an information topic page dedicated to complementary and alternative medicine. To access this page, go to the MEDLINEplus site at: www.nlm.nih.gov/medlineplus/alternativemedicine.html. This Web site provides a general overview of various topics and can lead to a number of general sources. The following additional references describe, in broad terms, alternative and complementary medicine (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): ·

Complementary Therapies in Dental Practice by Peter Varley (Editor); Paperback, 1st edition (January 15, 1998), Butterworth-Heinemann Medical; ISBN: 0723610339; http://www.amazon.com/exec/obidos/ASIN/0723610339/icongroupinter na

·

Alternative Medicine for Dummies by James Dillard (Author); Audio Cassette, Abridged edition (1998), Harper Audio; ISBN: 0694520659; http://www.amazon.com/exec/obidos/ASIN/0694520659/icongroupinter na

·

Complementary and Alternative Medicine Secrets by W. Kohatsu (Editor); Hardcover (2001), Hanley & Belfus; ISBN: 1560534400; http://www.amazon.com/exec/obidos/ASIN/1560534400/icongroupinter na

·

Dictionary of Alternative Medicine by J. C. Segen; Paperback-2nd edition (2001), Appleton & Lange; ISBN: 0838516211; http://www.amazon.com/exec/obidos/ASIN/0838516211/icongroupinter na

·

Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating by Walter C. Willett, MD, et al; Hardcover - 352 pages (2001), Simon & Schuster; ISBN: 0684863375; http://www.amazon.com/exec/obidos/ASIN/0684863375/icongroupinter na

·

Encyclopedia of Natural Medicine, Revised 2nd Edition by Michael T. Murray, Joseph E. Pizzorno; Paperback - 960 pages, 2nd Rev edition

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(1997), Prima Publishing; ISBN: 0761511571; http://www.amazon.com/exec/obidos/ASIN/0761511571/icongroupinter na ·

Integrative Medicine: An Introduction to the Art & Science of Healing by Andrew Weil (Author); Audio Cassette, Unabridged edition (2001), Sounds True; ISBN: 1564558541; http://www.amazon.com/exec/obidos/ASIN/1564558541/icongroupinter na

·

New Encyclopedia of Herbs & Their Uses by Deni Bown; Hardcover 448 pages, Revised edition (2001), DK Publishing; ISBN: 078948031X; http://www.amazon.com/exec/obidos/ASIN/078948031X/icongroupinter na

·

Textbook of Complementary and Alternative Medicine by Wayne B. Jonas; Hardcover (2003), Lippincott, Williams & Wilkins; ISBN: 0683044370; http://www.amazon.com/exec/obidos/ASIN/0683044370/icongroupinter na

For additional information on complementary and alternative medicine, ask your healthcare provider or write to: National Institutes of Health National Center for Complementary and Alternative Medicine Clearinghouse P. O. Box 8218 Silver Spring, MD 20907-8218

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Cerebral: Of or pertaining of the cerebrum or the brain. [EU] Enema: A clyster or injection; a liquid injected or to be injected into the rectum. [EU] Fatigue: The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. [NIH] Fungus: A general term used to denote a group of eukaryotic protists, including mushrooms, yeasts, rusts, moulds, smuts, etc., which are characterized by the absence of chlorophyll and by the presence of a rigid

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cell wall composed of chitin, mannans, and sometimes cellulose. They are usually of simple morphological form or show some reversible cellular specialization, such as the formation of pseudoparenchymatous tissue in the fruiting body of a mushroom. The dimorphic fungi grow, according to environmental conditions, as moulds or yeasts. [EU] Lupus: A form of cutaneous tuberculosis. It is seen predominantly in women and typically involves the nasal, buccal, and conjunctival mucosa. [NIH]

Prolapse: 1. the falling down, or sinking, of a part or viscus; procidentia. 2. to undergo such displacement. [EU] Sympathetic: 1. pertaining to, caused by, or exhibiting sympathy. 2. a sympathetic nerve or the sympathetic nervous system. [EU] Toxicity: The quality of being poisonous, especially the degree of virulence of a toxic microbe or of a poison. [EU]

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APPENDIX C. RESEARCHING NUTRITION Overview Since the time of Hippocrates, healthcare providers have understood the importance of diet and nutrition to patients’ health and well-being. Since then, they have accumulated an impressive archive of studies and knowledge dedicated to this subject. Based on their experience, dentists and healthcare providers may recommend particular dietary supplements to patients with temporomandibular joint syndrome. Any dietary recommendation is based on a patient's age, body mass, gender, lifestyle, eating habits, food preferences, and health condition. It is therefore likely that different patients with temporomandibular joint syndrome may be given different recommendations. Some recommendations may be directly related to temporomandibular joint syndrome, while others may be more related to the patient's general health. These recommendations, themselves, may differ from what official sources recommend for the average person. In this chapter we will begin by briefly reviewing the essentials of diet and nutrition that will broadly frame more detailed discussions of temporomandibular joint syndrome. We will then show you how to find studies dedicated specifically to nutrition and temporomandibular joint syndrome.

Food and Nutrition: General Principles What Are Essential Foods? Food is generally viewed by official sources as consisting of six basic elements: (1) fluids, (2) carbohydrates, (3) protein, (4) fats, (5) vitamins, and

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(6) minerals. Consuming a combination of these elements is considered to be a healthy diet: ·

Fluids are essential to human life as 80-percent of the body is composed of water. Water is lost via urination, sweating, diarrhea, vomiting, diuretics (drugs that increase urination), caffeine, and physical exertion.

·

Carbohydrates are the main source for human energy (thermoregulation) and the bulk of typical diets. They are mostly classified as being either simple or complex. Simple carbohydrates include sugars which are often consumed in the form of cookies, candies, or cakes. Complex carbohydrates consist of starches and dietary fibers. Starches are consumed in the form of pastas, breads, potatoes, rice, and other foods. Soluble fibers can be eaten in the form of certain vegetables, fruits, oats, and legumes. Insoluble fibers include brown rice, whole grains, certain fruits, wheat bran and legumes.

·

Proteins are eaten to build and repair human tissues. Some foods that are high in protein are also high in fat and calories. Food sources for protein include nuts, meat, fish, cheese, and other dairy products.

·

Fats are consumed for both energy and the absorption of certain vitamins. There are many types of fats, with many general publications recommending the intake of unsaturated fats or those low in cholesterol.

Vitamins and minerals are fundamental to human health, growth, and, in some cases, disease prevention. Most are consumed in your diet (exceptions being vitamins K and D which are produced by intestinal bacteria and sunlight on the skin, respectively). Each vitamin and mineral plays a different role in health. The following outlines essential vitamins: ·

Vitamin A is important to the health of your eyes, hair, bones, and skin; sources of vitamin A include foods such as eggs, carrots, and cantaloupe.

·

Vitamin B1, also known as thiamine, is important for your nervous system and energy production; food sources for thiamine include meat, peas, fortified cereals, bread, and whole grains.

·

Vitamin B2, also known as riboflavin, is important for your nervous system and muscles, but is also involved in the release of proteins from nutrients; food sources for riboflavin include dairy products, leafy vegetables, meat, and eggs.

·

Vitamin B3, also known as niacin, is important for healthy skin and helps the body use energy; food sources for niacin include peas, peanuts, fish, and whole grains

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·

Vitamin B6, also known as pyridoxine, is important for the regulation of cells in the nervous system and is vital for blood formation; food sources for pyridoxine include bananas, whole grains, meat, and fish.

·

Vitamin B12 is vital for a healthy nervous system and for the growth of red blood cells in bone marrow; food sources for vitamin B12 include yeast, milk, fish, eggs, and meat.

·

Vitamin C allows the body's immune system to fight various diseases, strengthens body tissue, and improves the body's use of iron; food sources for vitamin C include a wide variety of fruits and vegetables.

·

Vitamin D helps the body absorb calcium which strengthens bones and teeth; food sources for vitamin D include oily fish and dairy products.

·

Vitamin E can help protect certain organs and tissues from various degenerative diseases; food sources for vitamin E include margarine, vegetables, eggs, and fish.

·

Vitamin K is essential for bone formation and blood clotting; common food sources for vitamin K include leafy green vegetables.

·

Folic Acid maintains healthy cells and blood and, when taken by a pregnant woman, can prevent her fetus from developing neural tube defects; food sources for folic acid include nuts, fortified breads, leafy green vegetables, and whole grains.

It should be noted that one can overdose on certain vitamins which become toxic if consumed in excess (e.g. vitamin A, D, E and K). Like vitamins, minerals are chemicals that are required by the body to remain in good health. Because the human body does not manufacture these chemicals internally, we obtain them from food and other dietary sources. The more important minerals include: ·

Calcium is needed for healthy bones, teeth, and muscles, but also helps the nervous system function; food sources for calcium include dry beans, peas, eggs, and dairy products.

·

Chromium is helpful in regulating sugar levels in blood; food sources for chromium include egg yolks, raw sugar, cheese, nuts, beets, whole grains, and meat.

·

Fluoride is used by the body to help prevent tooth decay and to reinforce bone strength; sources of fluoride include drinking water and certain brands of toothpaste.

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·

Iodine helps regulate the body's use of energy by synthesizing into the hormone thyroxine; food sources include leafy green vegetables, nuts, egg yolks, and red meat.

·

Iron helps maintain muscles and the formation of red blood cells and certain proteins; food sources for iron include meat, dairy products, eggs, and leafy green vegetables.

·

Magnesium is important for the production of DNA, as well as for healthy teeth, bones, muscles, and nerves; food sources for magnesium include dried fruit, dark green vegetables, nuts, and seafood.

·

Phosphorous is used by the body to work with calcium to form bones and teeth; food sources for phosphorous include eggs, meat, cereals, and dairy products.

·

Selenium primarily helps maintain normal heart and liver functions; food sources for selenium include wholegrain cereals, fish, meat, and dairy products.

·

Zinc helps wounds heal, the formation of sperm, and encourage rapid growth and energy; food sources include dried beans, shellfish, eggs, and nuts.

The United States government periodically publishes recommended diets and consumption levels of the various elements of food. Again, your healthcare provider may encourage deviations from the average official recommendation based on your specific condition. To learn more about basic dietary guidelines, visit the Web site: http://www.health.gov/dietaryguidelines/. Based on these guidelines, many foods are required to list the nutrition levels on the food’s packaging. Labeling Requirements are listed at the following site maintained by the Food and Drug Administration: http://www.cfsan.fda.gov/~dms/labcons.html. When interpreting these requirements, the government recommends that consumers become familiar with the following abbreviations before reading FDA literature:39 ·

DVs (Daily Values): A new dietary reference term that will appear on the food label. It is made up of two sets of references, DRVs and RDIs.

·

DRVs (Daily Reference Values): A set of dietary references that applies to fat, saturated fat, cholesterol, carbohydrate, protein, fiber, sodium, and potassium.

·

RDIs (Reference Daily Intakes): A set of dietary references based on the Recommended Dietary Allowances for essential vitamins and minerals

39

Adapted from the FDA: http://www.fda.gov/fdac/special/foodlabel/dvs.html.

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and, in selected groups, protein. The name “RDI” replaces the term “U.S. RDA.” ·

RDAs (Recommended Dietary Allowances): A set of estimated nutrient allowances established by the National Academy of Sciences. It is updated periodically to reflect current scientific knowledge. What Are Dietary Supplements?40

Dietary supplements are widely available through many commercial sources, including health food stores, grocery stores, pharmacies, and by mail. Dietary supplements are provided in many forms including tablets, capsules, powders, gel-tabs, extracts, and liquids. Historically in the United States, the most prevalent type of dietary supplement was a multivitamin/mineral tablet or capsule that was available in pharmacies, either by prescription or “over the counter.” Supplements containing strictly herbal preparations were less widely available. Currently in the United States, a wide array of supplement products are available, including vitamin, mineral, other nutrients, and botanical supplements as well as ingredients and extracts of animal and plant origin. The Office of Dietary Supplements (ODS) of the National Institutes of Health is the official agency of the United States which has the expressed goal of acquiring “new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold.”41 According to the ODS, dietary supplements can have an important impact on the prevention and management of disease and on the maintenance of health.42 The ODS notes that considerable research on the effects of dietary supplements has been conducted in Asia and Europe where the use of plant products, in particular, has a long tradition. However, the overwhelming majority of supplements have not been studied scientifically. This discussion has been adapted from the NIH: http://ods.od.nih.gov/whatare/whatare.html. 41 Contact: The Office of Dietary Supplements, National Institutes of Health, Building 31, Room 1B29, 31 Center Drive, MSC 2086, Bethesda, Maryland 20892-2086, Tel: (301) 435-2920, Fax: (301) 480-1845, E-mail: [email protected]. 42 Adapted from http://ods.od.nih.gov/about/about.html. The Dietary Supplement Health and Education Act defines dietary supplements as “a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin, mineral, amino acid, herb or other botanical; or a dietary substance for use to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of any ingredient described above; and intended for ingestion in the form of a capsule, powder, softgel, or gelcap, and not represented as a conventional food or as a sole item of a meal or the diet.” 40

124 Temporomandibular Joint Syndrome

To explore the role of dietary supplements in the improvement of health care, the ODS plans, organizes, and supports conferences, workshops, and symposia on scientific topics related to dietary supplements. The ODS often works in conjunction with other NIH Institutes and Centers, other government agencies, professional organizations, and public advocacy groups. To learn more about official information on dietary supplements, visit the ODS site at http://ods.od.nih.gov/whatare/whatare.html. Or contact: The Office of Dietary Supplements National Institutes of Health Building 31, Room 1B29 31 Center Drive, MSC 2086 Bethesda, Maryland 20892-2086 Tel: (301) 435-2920 Fax: (301) 480-1845 E-mail: [email protected]

Finding Studies on Temporomandibular Joint Syndrome The NIH maintains an office dedicated to patient nutrition and diet. The National Institutes of Health’s Office of Dietary Supplements (ODS) offers a searchable bibliographic database called the IBIDS (International Bibliographic Information on Dietary Supplements). The IBIDS contains over 460,000 scientific citations and summaries about dietary supplements and nutrition as well as references to published international, scientific literature on dietary supplements such as vitamins, minerals, and botanicals.43 IBIDS is available to the public free of charge through the ODS Internet page: http://ods.od.nih.gov/databases/ibids.html. After entering the search area, you have three choices: (1) IBIDS Consumer Database, (2) Full IBIDS Database, or (3) Peer Reviewed Citations Only. We recommend that you start with the Consumer Database. While you may not find references for the topics that are of most interest to you, check back periodically as this database is frequently updated. More studies can be found by searching the Full IBIDS Database. Healthcare professionals and Adapted from http://ods.od.nih.gov. IBIDS is produced by the Office of Dietary Supplements (ODS) at the National Institutes of Health to assist the public, healthcare providers, educators, and researchers in locating credible, scientific information on dietary supplements. IBIDS was developed and will be maintained through an interagency partnership with the Food and Nutrition Information Center of the National Agricultural Library, U.S. Department of Agriculture. 43

Researching Nutrition 125

researchers generally use the third option, which lists peer-reviewed citations. In all cases, we suggest that you take advantage of the “Advanced Search” option that allows you to retrieve up to 100 fully explained references in a comprehensive format. Type “temporomandibular joint syndrome” (or synonyms) into the search box. To narrow the search, you can also select the “Title” field. The following information is typical of that found when using the “Full IBIDS Database” when searching using “temporomandibular joint syndrome” (or a synonym): ·

A parotid fistula and sialocele complicating temporomandibular joint surgery. Author(s): Joint Department of Oral and Maxillofacial Surgery, Eastman Dental Hospital, London. Source: Hutchison, I L Ryan, D Br-J-Oral-Maxillofac-Surg. 1989 June; 27(3): 203-8 0266-4356

·

A report of 22 cases of temporomandibular joint dysfunction syndrome treated with acupuncture and laser radiation. Author(s): Department of Acu-physiotherapy, Jiangshan People's Hospital, Zhejiang, China. Source: Wang, K J-Tradit-Chin-Med. 1992 June; 12(2): 116-8 0254-6272

·

An 8-year-old girl with unilateral facial and ear pain and isolated frontal headaches. Author(s): Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, USA. Source: Gay, C T Semin-Pediatr-Neurol. 1999 September; 6(3): 182-8; discussion 189 1071-9091

·

Clinical results of therapeutic temporomandibular joint arthroscopy: a prospective study of 34 arthroscopies with prediscal section and retrodiscal coagulation. Author(s): Department of Oral and Maxillofacial Surgery, Centre Hospitalier et Universitaire Timone, Marseille, France. Source: Chossegros, C Cheynet, F Gola, R Pauzie, F Arnaud, R Blanc, J L Br-J-Oral-Maxillofac-Surg. 1996 December; 34(6): 504-7 0266-4356

·

Conservative treatment for temporomandibular joint pain dysfunction. Source: Bradley, P F Br-J-Oral-Maxillofac-Surg. 1987 April; 25(2): 125-37 0266-4356

·

Does temporomandibular disorder pain dysfunction syndrome affect dietary intake? Author(s): Liverpool John Moores University, School of Education and Community Studies.

126 Temporomandibular Joint Syndrome

Source: Irving, J Wood, G D Hackett, A F Dent-Update. 1999 November; 26(9): 405-7 0305-5000 ·

Ernest syndrome as a consequence of stylomandibular ligament injury: a report of 68 patients. Source: Shankland, W E 2nd J-Prosthet-Dent. 1987 April; 57(4): 501-6 0022-3913

·

Facial pain, distress, and immune function. Author(s): Division of Sociomedical Sciences, School of Public Health, Columbia University, New York, New York 10032. Source: Marbach, J J Schleifer, S J Keller, S E Brain-Behav-Immun. 1990 September; 4(3): 243-54 0889-1591

·

Synovial fluid glycosaminoglycan (acid mucopolysaccharide) analysis in assessment of temporomandibular joint dysfunction. A pilot study. Author(s): Department of Oral Pathology, University of Birmingham, Dental School, St Chad's Queensway. Source: Smith, A J Basu, M K Speculand, B Kassem, M A Lloyd, J M Br-JOral-Maxillofac-Surg. 1989 October; 27(5): 853-61 0266-4356

·

The painful ear. Author(s): Department of Community Medicine, Box Hill Hospital, Monash University, Melbourne. Source: Murtagh, J Aust-Fam-Physician. 1991 December; 20(12): 1779-83 0300-8495

·

The role of physicians in dental quackery. Author(s): Woodhaven Dental Associates, NY 11421. Source: Dodes, J E Schissel, M J N-Y-State-J-Med. 1993 February; 93(2): 116-7 0028-7628

·

Treatment of 60 cases of dysfunction of temporomandibular joint by puncturing zusanli (St 36) acupoint. Author(s): Tangshan Hospital of TCM, Hebei Province. Source: Cui, Y J-Tradit-Chin-Med. 1993 September; 13(3): 191 0254-6272

Federal Resources on Nutrition In addition to the IBIDS, the United States Department of Health and Human Services (HHS) and the United States Department of Agriculture (USDA) provide many sources of information on general nutrition and health. Recommended resources include: ·

healthfinder®, HHS's gateway to health information, including diet and nutrition:

Researching Nutrition 127

http://www.healthfinder.gov/scripts/SearchContext.asp?topic=238&pag e=0 ·

The United States Department of Agriculture's Web site dedicated to nutrition information: www.nutrition.gov

·

The Food and Drug Administration's Web site for federal food safety information: www.foodsafety.gov

·

The National Action Plan on Overweight and Obesity sponsored by the United States Surgeon General: http://www.surgeongeneral.gov/topics/obesity/

·

The Center for Food Safety and Applied Nutrition has an Internet site sponsored by the Food and Drug Administration and the Department of Health and Human Services: http://vm.cfsan.fda.gov/

·

Center for Nutrition Policy and Promotion sponsored by the United States Department of Agriculture: http://www.usda.gov/cnpp/

·

Food and Nutrition Information Center, National Agricultural Library sponsored by the United States Department of Agriculture: http://www.nal.usda.gov/fnic/

·

Food and Nutrition Service sponsored by the United States Department of Agriculture: http://www.fns.usda.gov/fns/

Additional Web Resources A number of additional Web sites offer encyclopedic information covering food and nutrition. The following is a representative sample: ·

AOL: http://search.aol.com/cat.adp?id=174&layer=&from=subcats

·

Family Village: http://www.familyvillage.wisc.edu/med_nutrition.html

·

Google: http://directory.google.com/Top/Health/Nutrition/

·

Healthnotes: http://www.thedacare.org/healthnotes/

·

Open Directory Project: http://dmoz.org/Health/Nutrition/

·

Yahoo.com: http://dir.yahoo.com/Health/Nutrition/

·

WebMDÒHealth: http://my.webmd.com/nutrition

·

WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html

128 Temporomandibular Joint Syndrome

Vocabulary Builder The following vocabulary builder defines words used in the references in this chapter that have not been defined in previous chapters: Bacteria: Unicellular prokaryotic microorganisms which generally possess rigid cell walls, multiply by cell division, and exhibit three principal forms: round or coccal, rodlike or bacillary, and spiral or spirochetal. [NIH] Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Coagulation: 1. the process of clot formation. 2. in colloid chemistry, the solidification of a sol into a gelatinous mass; an alteration of a disperse phase or of a dissolved solid which causes the separation of the system into a liquid phase and an insoluble mass called the clot or curd. Coagulation is usually irreversible. 3. in surgery, the disruption of tissue by physical means to form an amorphous residuum, as in electrocoagulation and photocoagulation. [EU] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Diuretic: An agent that promotes the excretion of urine. [EU] Diuretics: Agents that promote the excretion of urine through their effects on kidney function. [NIH] Intestinal: Pertaining to the intestine. [EU] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Neurology: A medical specialty concerned with the study of the structures, functions, and diseases of the nervous system. [NIH] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH]

Researching Nutrition 129

Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Quackery: The fraudulent misrepresentation of the diagnosis and treatment of disease. [NIH] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Synovial: Of pertaining to, or secreting synovia. [EU] Thermoregulation: Heat regulation. [EU] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH]

Finding Medical Libraries 131

APPENDIX D. FINDING MEDICAL LIBRARIES Overview At a medical library you can find medical texts and reference books, consumer health publications, specialty newspapers and magazines, as well as medical journals. In this Appendix, we show you how to quickly find a medical library in your area.

Preparation Before going to the library, highlight the references mentioned in this sourcebook that you find interesting. Focus on those items that are not available via the Internet, and ask the reference librarian for help with your search. He or she may know of additional resources that could be helpful to you. Most importantly, your local public library and medical libraries have Interlibrary Loan programs with the National Library of Medicine (NLM), one of the largest medical collections in the world. According to the NLM, most of the literature in the general and historical collections of the National Library of Medicine is available on interlibrary loan to any library. NLM's interlibrary loan services are only available to libraries. If you would like to access NLM medical literature, then visit a library in your area that can request the publications for you.44

44

Adapted from the NLM: http://www.nlm.nih.gov/psd/cas/interlibrary.html.

132 Temporomandibular Joint Syndrome

Finding a Local Medical Library The quickest method to locate medical libraries is to use the Internet-based directory published by the National Network of Libraries of Medicine (NN/LM). This network includes 4626 members and affiliates that provide many services to librarians, health professionals, and the public. To find a library in your area, simply visit http://nnlm.gov/members/adv.html or call 1-800-338-7657.

Medical Libraries Open to the Public In addition to the NN/LM, the National Library of Medicine (NLM) lists a number of libraries that are generally open to the public and have reference facilities. The following is the NLM’s list plus hyperlinks to each library Web site. These Web pages can provide information on hours of operation and other restrictions. The list below is a small sample of libraries recommended by the National Library of Medicine (sorted alphabetically by name of the U.S. state or Canadian province where the library is located):45 ·

Alabama: Health InfoNet of Jefferson County (Jefferson County Library Cooperative, Lister Hill Library of the Health Sciences), http://www.uab.edu/infonet/

·

Alabama: Richard M. Scrushy Library (American Sports Medicine Institute), http://www.asmi.org/LIBRARY.HTM

·

Arizona: Samaritan Regional Medical Center: The Learning Center (Samaritan Health System, Phoenix, Arizona), http://www.samaritan.edu/library/bannerlibs.htm

·

California: Kris Kelly Health Information Center (St. Joseph Health System), http://www.humboldt1.com/~kkhic/index.html

·

California: Community Health Library of Los Gatos (Community Health Library of Los Gatos), http://www.healthlib.org/orgresources.html

·

California: Consumer Health Program and Services (CHIPS) (County of Los Angeles Public Library, Los Angeles County Harbor-UCLA Medical Center Library) - Carson, CA, http://www.colapublib.org/services/chips.html

·

California: Gateway Health Library (Sutter Gould Medical Foundation)

·

California: Health Library (Stanford University Medical Center), http://www-med.stanford.edu/healthlibrary/

45

Abstracted from http://www.nlm.nih.gov/medlineplus/libraries.html.

Finding Medical Libraries 133

·

California: Patient Education Resource Center - Health Information and Resources (University of California, San Francisco), http://sfghdean.ucsf.edu/barnett/PERC/default.asp

·

California: Redwood Health Library (Petaluma Health Care District), http://www.phcd.org/rdwdlib.html

·

California: San José PlaneTree Health Library, http://planetreesanjose.org/

·

California: Sutter Resource Library (Sutter Hospitals Foundation), http://go.sutterhealth.org/comm/resc-library/sac-resources.html

·

California: University of California, Davis. Health Sciences Libraries

·

California: ValleyCare Health Library & Ryan Comer Cancer Resource Center (ValleyCare Health System), http://www.valleycare.com/library.html

·

California: Washington Community Health Resource Library (Washington Community Health Resource Library), http://www.healthlibrary.org/

·

Colorado: William V. Gervasini Memorial Library (Exempla Healthcare), http://www.exempla.org/conslib.htm

·

Connecticut: Hartford Hospital Health Science Libraries (Hartford Hospital), http://www.harthosp.org/library/

·

Connecticut: Healthnet: Connecticut Consumer Health Information Center (University of Connecticut Health Center, Lyman Maynard Stowe Library), http://library.uchc.edu/departm/hnet/

·

Connecticut: Waterbury Hospital Health Center Library (Waterbury Hospital), http://www.waterburyhospital.com/library/consumer.shtml

·

Delaware: Consumer Health Library (Christiana Care Health System, Eugene du Pont Preventive Medicine & Rehabilitation Institute), http://www.christianacare.org/health_guide/health_guide_pmri_health _info.cfm

·

Delaware: Lewis B. Flinn Library (Delaware Academy of Medicine), http://www.delamed.org/chls.html

·

Georgia: Family Resource Library (Medical College of Georgia), http://cmc.mcg.edu/kids_families/fam_resources/fam_res_lib/frl.htm

·

Georgia: Health Resource Center (Medical Center of Central Georgia), http://www.mccg.org/hrc/hrchome.asp

·

Hawaii: Hawaii Medical Library: Consumer Health Information Service (Hawaii Medical Library), http://hml.org/CHIS/

134 Temporomandibular Joint Syndrome

·

Idaho: DeArmond Consumer Health Library (Kootenai Medical Center), http://www.nicon.org/DeArmond/index.htm

·

Illinois: Health Learning Center of Northwestern Memorial Hospital (Northwestern Memorial Hospital, Health Learning Center), http://www.nmh.org/health_info/hlc.html

·

Illinois: Medical Library (OSF Saint Francis Medical Center), http://www.osfsaintfrancis.org/general/library/

·

Kentucky: Medical Library - Services for Patients, Families, Students & the Public (Central Baptist Hospital), http://www.centralbap.com/education/community/library.htm

·

Kentucky: University of Kentucky - Health Information Library (University of Kentucky, Chandler Medical Center, Health Information Library), http://www.mc.uky.edu/PatientEd/

·

Louisiana: Alton Ochsner Medical Foundation Library (Alton Ochsner Medical Foundation), http://www.ochsner.org/library/

·

Louisiana: Louisiana State University Health Sciences Center Medical Library-Shreveport, http://lib-sh.lsuhsc.edu/

·

Maine: Franklin Memorial Hospital Medical Library (Franklin Memorial Hospital), http://www.fchn.org/fmh/lib.htm

·

Maine: Gerrish-True Health Sciences Library (Central Maine Medical Center), http://www.cmmc.org/library/library.html

·

Maine: Hadley Parrot Health Science Library (Eastern Maine Healthcare), http://www.emh.org/hll/hpl/guide.htm

·

Maine: Maine Medical Center Library (Maine Medical Center), http://www.mmc.org/library/

·

Maine: Parkview Hospital, http://www.parkviewhospital.org/communit.htm#Library

·

Maine: Southern Maine Medical Center Health Sciences Library (Southern Maine Medical Center), http://www.smmc.org/services/service.php3?choice=10

·

Maine: Stephens Memorial Hospital Health Information Library (Western Maine Health), http://www.wmhcc.com/hil_frame.html

·

Manitoba, Canada: Consumer & Patient Health Information Service (University of Manitoba Libraries), http://www.umanitoba.ca/libraries/units/health/reference/chis.html

·

Manitoba, Canada: J.W. Crane Memorial Library (Deer Lodge Centre), http://www.deerlodge.mb.ca/library/libraryservices.shtml

Finding Medical Libraries 135

·

Maryland: Health Information Center at the Wheaton Regional Library (Montgomery County, Md., Dept. of Public Libraries, Wheaton Regional Library), http://www.mont.lib.md.us/healthinfo/hic.asp

·

Massachusetts: Baystate Medical Center Library (Baystate Health System), http://www.baystatehealth.com/1024/

·

Massachusetts: Boston University Medical Center Alumni Medical Library (Boston University Medical Center), http://medlibwww.bu.edu/library/lib.html

·

Massachusetts: Lowell General Hospital Health Sciences Library (Lowell General Hospital), http://www.lowellgeneral.org/library/HomePageLinks/WWW.htm

·

Massachusetts: Paul E. Woodard Health Sciences Library (New England Baptist Hospital), http://www.nebh.org/health_lib.asp

·

Massachusetts: St. Luke's Hospital Health Sciences Library (St. Luke's Hospital), http://www.southcoast.org/library/

·

Massachusetts: Treadwell Library Consumer Health Reference Center (Massachusetts General Hospital), http://www.mgh.harvard.edu/library/chrcindex.html

·

Massachusetts: UMass HealthNet (University of Massachusetts Medical School), http://healthnet.umassmed.edu/

·

Michigan: Botsford General Hospital Library - Consumer Health (Botsford General Hospital, Library & Internet Services), http://www.botsfordlibrary.org/consumer.htm

·

Michigan: Helen DeRoy Medical Library (Providence Hospital and Medical Centers), http://www.providence-hospital.org/library/

·

Michigan: Marquette General Hospital - Consumer Health Library (Marquette General Hospital, Health Information Center), http://www.mgh.org/center.html

·

Michigan: Patient Education Resouce Center - University of Michigan Cancer Center (University of Michigan Comprehensive Cancer Center), http://www.cancer.med.umich.edu/learn/leares.htm

·

Michigan: Sladen Library & Center for Health Information Resources Consumer Health Information, http://www.sladen.hfhs.org/library/consumer/index.html

·

Montana: Center for Health Information (St. Patrick Hospital and Health Sciences Center), http://www.saintpatrick.org/chi/librarydetail.php3?ID=41

136 Temporomandibular Joint Syndrome

·

National: Consumer Health Library Directory (Medical Library Association, Consumer and Patient Health Information Section), http://caphis.mlanet.org/directory/index.html

·

National: National Network of Libraries of Medicine (National Library of Medicine) - provides library services for health professionals in the United States who do not have access to a medical library, http://nnlm.gov/

·

National: NN/LM List of Libraries Serving the Public (National Network of Libraries of Medicine), http://nnlm.gov/members/

·

Nevada: Health Science Library, West Charleston Library (Las Vegas Clark County Library District), http://www.lvccld.org/special_collections/medical/index.htm

·

New Hampshire: Dartmouth Biomedical Libraries (Dartmouth College Library), http://www.dartmouth.edu/~biomed/resources.htmld/conshealth.htmld /

·

New Jersey: Consumer Health Library (Rahway Hospital), http://www.rahwayhospital.com/library.htm

·

New Jersey: Dr. Walter Phillips Health Sciences Library (Englewood Hospital and Medical Center), http://www.englewoodhospital.com/links/index.htm

·

New Jersey: Meland Foundation (Englewood Hospital and Medical Center), http://www.geocities.com/ResearchTriangle/9360/

·

New York: Choices in Health Information (New York Public Library) NLM Consumer Pilot Project participant, http://www.nypl.org/branch/health/links.html

·

New York: Health Information Center (Upstate Medical University, State University of New York), http://www.upstate.edu/library/hic/

·

New York: Health Sciences Library (Long Island Jewish Medical Center), http://www.lij.edu/library/library.html

·

New York: ViaHealth Medical Library (Rochester General Hospital), http://www.nyam.org/library/

·

Ohio: Consumer Health Library (Akron General Medical Center, Medical & Consumer Health Library), http://www.akrongeneral.org/hwlibrary.htm

·

Oklahoma: Saint Francis Health System Patient/Family Resource Center (Saint Francis Health System), http://www.sfhtulsa.com/patientfamilycenter/default.asp

Finding Medical Libraries 137

·

Oregon: Planetree Health Resource Center (Mid-Columbia Medical Center), http://www.mcmc.net/phrc/

·

Pennsylvania: Community Health Information Library (Milton S. Hershey Medical Center), http://www.hmc.psu.edu/commhealth/

·

Pennsylvania: Community Health Resource Library (Geisinger Medical Center), http://www.geisinger.edu/education/commlib.shtml

·

Pennsylvania: HealthInfo Library (Moses Taylor Hospital), http://www.mth.org/healthwellness.html

·

Pennsylvania: Hopwood Library (University of Pittsburgh, Health Sciences Library System), http://www.hsls.pitt.edu/chi/hhrcinfo.html

·

Pennsylvania: Koop Community Health Information Center (College of Physicians of Philadelphia), http://www.collphyphil.org/kooppg1.shtml

·

Pennsylvania: Learning Resources Center - Medical Library (Susquehanna Health System), http://www.shscares.org/services/lrc/index.asp

·

Pennsylvania: Medical Library (UPMC Health System), http://www.upmc.edu/passavant/library.htm

·

Quebec, Canada: Medical Library (Montreal General Hospital), http://ww2.mcgill.ca/mghlib/

·

South Dakota: Rapid City Regional Hospital - Health Information Center (Rapid City Regional Hospital, Health Information Center), http://www.rcrh.org/education/LibraryResourcesConsumers.htm

·

Texas: Houston HealthWays (Houston Academy of Medicine-Texas Medical Center Library), http://hhw.library.tmc.edu/

·

Texas: Matustik Family Resource Center (Cook Children's Health Care System), http://www.cookchildrens.com/Matustik_Library.html

·

Washington: Community Health Library (Kittitas Valley Community Hospital), http://www.kvch.com/

·

Washington: Southwest Washington Medical Center Library (Southwest Washington Medical Center), http://www.swmedctr.com/Home/

Your Rights and Insurance 139

APPENDIX E. YOUR RIGHTS AND INSURANCE Overview Any patient with temporomandibular joint syndrome faces a series of issues related more to the healthcare industry than to the medical condition itself. This appendix covers two important topics in this regard: your rights and responsibilities as a patient, and how to get the most out of your medical insurance plan.

Your Rights as a Patient The President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry has created the following summary of your rights as a patient.46

Information Disclosure Consumers have the right to receive accurate, easily understood information. Some consumers require assistance in making informed decisions about health plans, health professionals, and healthcare facilities. Such information includes: ·

Health plans. Covered benefits, cost-sharing, and procedures for resolving complaints, licensure, certification, and accreditation status, comparable measures of quality and consumer satisfaction, provider

46Adapted

from Consumer Bill of Rights and Responsibilities: http://www.hcqualitycommission.gov/press/cbor.html#head1.

140 Temporomandibular Joint Syndrome

network composition, the procedures that govern access to specialists and emergency services, and care management information. ·

Health professionals. Education, board certification, and recertification, years of practice, experience performing certain procedures, and comparable measures of quality and consumer satisfaction.

·

Healthcare facilities. Experience in performing certain procedures and services, accreditation status, comparable measures of quality, worker, and consumer satisfaction, and procedures for resolving complaints.

·

Consumer assistance programs. Programs must be carefully structured to promote consumer confidence and to work cooperatively with health plans, providers, payers, and regulators. Desirable characteristics of such programs are sponsorship that ensures accountability to the interests of consumers and stable, adequate funding. Choice of Providers and Plans

Consumers have the right to a choice of healthcare providers that is sufficient to ensure access to appropriate high-quality healthcare. To ensure such choice, the Commission recommends the following: ·

Provider network adequacy. All health plan networks should provide access to sufficient numbers and types of providers to assure that all covered services will be accessible without unreasonable delay -including access to emergency services 24 hours a day and 7 days a week. If a health plan has an insufficient number or type of providers to provide a covered benefit with the appropriate degree of specialization, the plan should ensure that the consumer obtains the benefit outside the network at no greater cost than if the benefit were obtained from participating providers.

·

Women's health services. Women should be able to choose a qualified provider offered by a plan -- such as gynecologists, certified nurse midwives, and other qualified healthcare providers -- for the provision of covered care necessary to provide routine and preventative women's healthcare services.

·

Access to specialists. Consumers with complex or serious medical conditions who require frequent specialty care should have direct access to a qualified specialist of their choice within a plan's network of providers. Authorizations, when required, should be for an adequate number of direct access visits under an approved treatment plan.

Your Rights and Insurance 141

·

Transitional care. Consumers who are undergoing a course of treatment for a chronic or disabling condition (or who are in the second or third trimester of a pregnancy) at the time they involuntarily change health plans or at a time when a provider is terminated by a plan for other than cause should be able to continue seeing their current specialty providers for up to 90 days (or through completion of postpartum care) to allow for transition of care.

·

Choice of health plans. Public and private group purchasers should, wherever feasible, offer consumers a choice of high-quality health insurance plans.

Access to Emergency Services Consumers have the right to access emergency healthcare services when and where the need arises. Health plans should provide payment when a consumer presents to an emergency department with acute symptoms of sufficient severity--including severe pain--such that a “prudent layperson” could reasonably expect the absence of medical attention to result in placing that consumer's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Participation in Treatment Decisions Consumers have the right and responsibility to fully participate in all decisions related to their healthcare. Consumers who are unable to fully participate in treatment decisions have the right to be represented by parents, guardians, family members, or other conservators. Dentists and other health professionals should: ·

Provide patients with sufficient information and opportunity to decide among treatment options consistent with the informed consent process.

·

Discuss all treatment options with a patient in a culturally competent manner, including the option of no treatment at all.

·

Ensure that persons with disabilities have effective communications with members of the health system in making such decisions.

·

Discuss all current treatments a consumer may be undergoing.

·

Discuss all risks, nontreatment.

benefits,

and

consequences

to

treatment

or

142 Temporomandibular Joint Syndrome

·

Give patients the opportunity to refuse treatment and to express preferences about future treatment decisions.

·

Discuss the use of advance directives -- both living wills and durable powers of attorney for healthcare -- with patients and their designated family members.

·

Abide by the decisions made by their patients and/or their designated representatives consistent with the informed consent process.

Health plans, health providers, and healthcare facilities should: ·

Disclose to consumers factors -- such as methods of compensation, ownership of or interest in healthcare facilities, or matters of conscience -that could influence advice or treatment decisions.

·

Assure that provider contracts do not contain any so-called “gag clauses” or other contractual mechanisms that restrict healthcare providers' ability to communicate with and advise patients about medically necessary treatment options.

·

Be prohibited from penalizing or seeking retribution against healthcare professionals or other health workers for advocating on behalf of their patients.

Respect and Nondiscrimination Consumers have the right to considerate, respectful care from all members of the healthcare industry at all times and under all circumstances. An environment of mutual respect is essential to maintain a quality healthcare system. To assure that right, the Commission recommends the following: ·

Consumers must not be discriminated against in the delivery of healthcare services consistent with the benefits covered in their policy, or as required by law, based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.

·

Consumers eligible for coverage under the terms and conditions of a health plan or program, or as required by law, must not be discriminated against in marketing and enrollment practices based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.

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Confidentiality of Health Information Consumers have the right to communicate with healthcare providers in confidence and to have the confidentiality of their individually identifiable healthcare information protected. Consumers also have the right to review and copy their own medical records and request amendments to their records.

Complaints and Appeals Consumers have the right to a fair and efficient process for resolving differences with their health plans, healthcare providers, and the institutions that serve them, including a rigorous system of internal review and an independent system of external review. A free copy of the Patient's Bill of Rights is available from the American Hospital Association.47

Patient Responsibilities Treatment is a two-way street between you and your healthcare providers. To underscore the importance of finance in modern healthcare as well as your responsibility for the financial aspects of your care, the President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry has proposed that patients understand the following “Consumer Responsibilities.”48 In a healthcare system that protects consumers' rights, it is reasonable to expect and encourage consumers to assume certain responsibilities. Greater individual involvement by the consumer in his or her care increases the likelihood of achieving the best outcome and helps support a quality-oriented, cost-conscious environment. Such responsibilities include: ·

Take responsibility for maximizing healthy habits such as exercising, not smoking, and eating a healthy diet.

·

Work collaboratively with healthcare providers in developing and carrying out agreed-upon treatment plans.

·

Disclose relevant information and clearly communicate wants and needs.

47 To order your free copy of the Patient's Bill of Rights, telephone 312-422-3000 or visit the American Hospital Association’s Web site: http://www.aha.org. Click on “Resource Center,” go to “Search” at bottom of page, and then type in “Patient's Bill of Rights.” The Patient’s Bill of Rights is also available from Fax on Demand, at 312-422-2020, document number 471124. 48 Adapted from http://www.hcqualitycommission.gov/press/cbor.html#head1.

144 Temporomandibular Joint Syndrome

·

Use your health insurance plan's internal complaint and appeal processes to address your concerns.

·

Avoid knowingly spreading disease.

·

Recognize the reality of risks, the limits of the medical science, and the human fallibility of the healthcare professional.

·

Be aware of a healthcare provider's obligation to be reasonably efficient and equitable in providing care to other patients and the community.

·

Become knowledgeable about your health plan’s coverage and options (when available) including all covered benefits, limitations, and exclusions, rules regarding use of network providers, coverage and referral rules, appropriate processes to secure additional information, and the process to appeal coverage decisions.

·

Show respect for other patients and health workers.

·

Make a good-faith effort to meet financial obligations.

·

Abide by administrative and operational procedures of health plans, healthcare providers, and Government health benefit programs.

Choosing an Insurance Plan There are a number of official government agencies that help consumers understand their healthcare insurance choices.49 The U.S. Department of Labor, in particular, recommends ten ways to make your health benefits choices work best for you.50 1. Your options are important. There are many different types of health benefit plans. Find out which one your employer offers, then check out the plan, or plans, offered. Your employer's human resource office, the health plan administrator, or your union can provide information to help you match your needs and preferences with the available plans. The more information you have, the better your healthcare decisions will be. 2. Reviewing the benefits available. Do the plans offered cover preventive care, well-baby care, vision or dental care? Are there deductibles? Answers to these questions can help determine the out-of-pocket expenses you may More information about quality across programs is provided at the following AHRQ Web site: http://www.ahrq.gov/consumer/qntascii/qnthplan.htm. 50 Adapted from the Department of Labor: http://www.dol.gov/dol/pwba/public/pubs/health/top10-text.html. 49

Your Rights and Insurance 145

face. Matching your needs and those of your family members will result in the best possible benefits. Cheapest may not always be best. Your goal is high quality health benefits. 3. Look for quality. The quality of healthcare services varies, but quality can be measured. You should consider the quality of healthcare in deciding among the healthcare plans or options available to you. Not all health plans, dentists, hospitals and other providers give the highest quality care. Fortunately, there is quality information you can use right now to help you compare your healthcare choices. Find out how you can measure quality. Consult the U.S. Department of Health and Human Services publication “Your Guide to Choosing Quality Health Care” on the Internet at www.ahcpr.gov/consumer. 4. Your plan's summary plan description (SPD) provides a wealth of information. Your health plan administrator can provide you with a copy of your plan’s SPD. It outlines your benefits and your legal rights under the Employee Retirement Income Security Act (ERISA), the federal law that protects your health benefits. It should contain information about the coverage of dependents, what services will require a co-pay, and the circumstances under which your employer can change or terminate a health benefits plan. Save the SPD and all other health plan brochures and documents, along with memos or correspondence from your employer relating to health benefits. 5. Assess your benefit coverage as your family status changes. Marriage, divorce, childbirth or adoption, and the death of a spouse are all life events that may signal a need to change your health benefits. You, your spouse and dependent children may be eligible for a special enrollment period under provisions of the Health Insurance Portability and Accountability Act (HIPAA). Even without life-changing events, the information provided by your employer should tell you how you can change benefits or switch plans, if more than one plan is offered. If your spouse's employer also offers a health benefits package, consider coordinating both plans for maximum coverage. 6. Changing jobs and other life events can affect your health benefits. Under the Consolidated Omnibus Budget Reconciliation Act (COBRA), you, your covered spouse, and your dependent children may be eligible to purchase extended health coverage under your employer's plan if you lose your job, change employers, get divorced, or upon occurrence of certain other events. Coverage can range from 18 to 36 months depending on your situation. COBRA applies to most employers with 20 or more workers and

146 Temporomandibular Joint Syndrome

requires your plan to notify you of your rights. Most plans require eligible individuals to make their COBRA election within 60 days of the plan's notice. Be sure to follow up with your plan sponsor if you don't receive notice, and make sure you respond within the allotted time. 7. HIPAA can also help if you are changing jobs, particularly if you have a medical condition. HIPAA generally limits pre-existing condition exclusions to a maximum of 12 months (18 months for late enrollees). HIPAA also requires this maximum period to be reduced by the length of time you had prior “creditable coverage.” You should receive a certificate documenting your prior creditable coverage from your old plan when coverage ends. 8. Plan for retirement. Before you retire, find out what health benefits, if any, extend to you and your spouse during your retirement years. Consult with your employer's human resources office, your union, the plan administrator, and check your SPD. Make sure there is no conflicting information among these sources about the benefits you will receive or the circumstances under which they can change or be eliminated. With this information in hand, you can make other important choices, like finding out if you are eligible for Medicare and Medigap insurance coverage. 9. Know how to file an appeal if your health benefits claim is denied. Understand how your plan handles grievances and where to make appeals of the plan's decisions. Keep records and copies of correspondence. Check your health benefits package and your SPD to determine who is responsible for handling problems with benefit claims. Contact PWBA for customer service assistance if you are unable to obtain a response to your complaint. 10. You can take steps to improve the quality of the healthcare and the health benefits you receive. Look for and use things like Quality Reports and Accreditation Reports whenever you can. Quality reports may contain consumer ratings -- how satisfied consumers are with the dentists in their plan, for instance-- and clinical performance measures -- how well a healthcare organization prevents and treats illness. Accreditation reports provide information on how accredited organizations meet national standards, and often include clinical performance measures. Look for these quality measures whenever possible. Consult “Your Guide to Choosing Quality Health Care” on the Internet at www.ahcpr.gov/consumer.

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Medicare and Medicaid Illness strikes both rich and poor families. For low-income families, Medicaid is available to defer the costs of treatment. The Health Care Financing Administration (HCFA) administers Medicare, the nation's largest health insurance program, which covers 39 million Americans. In the following pages, you will learn the basics about Medicare insurance as well as useful contact information on how to find more in-depth information about Medicaid.51 Who is Eligible for Medicare? Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. You might also qualify for coverage if you are under age 65 but have a disability or EndStage Renal disease (permanent kidney failure requiring dialysis or transplant). Here are some simple guidelines: You can get Part A at age 65 without having to pay premiums if: ·

You are already receiving retirement benefits from Social Security or the Railroad Retirement Board.

·

You are eligible to receive Social Security or Railroad benefits but have not yet filed for them.

·

You or your spouse had Medicare-covered government employment.

If you are under 65, you can get Part A without having to pay premiums if: ·

You have received Social Security or Railroad Retirement Board disability benefit for 24 months.

·

You are a kidney dialysis or kidney transplant patient.

Medicare has two parts: ·

Part A (Hospital Insurance). Most people do not have to pay for Part A.

·

Part B (Medical Insurance). Most people pay monthly for Part B.

This section has been adapted from the Official U.S. Site for Medicare Information: http://www.medicare.gov/Basics/Overview.asp.

51

148 Temporomandibular Joint Syndrome

Part A (Hospital Insurance) Helps Pay For: Inpatient hospital care, care in critical access hospitals (small facilities that give limited outpatient and inpatient services to people in rural areas) and skilled nursing facilities, hospice care, and some home healthcare. Cost: Most people get Part A automatically when they turn age 65. You do not have to pay a monthly payment called a premium for Part A because you or a spouse paid Medicare taxes while you were working. If you (or your spouse) did not pay Medicare taxes while you were working and you are age 65 or older, you still may be able to buy Part A. If you are not sure you have Part A, look on your red, white, and blue Medicare card. It will show “Hospital Part A” on the lower left corner of the card. You can also call the Social Security Administration toll free at 1-800-772-1213 or call your local Social Security office for more information about buying Part A. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772. For more information, call your Fiscal Intermediary about Part A bills and services. The phone number for the Fiscal Intermediary office in your area can be obtained from the following Web site: http://www.medicare.gov/Contacts/home.asp. Part B (Medical Insurance) Helps Pay For: Healthcare providers, services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home healthcare. Part B helps pay for covered services and supplies when they are medically necessary. Cost: As of 2001, you pay the Medicare Part B premium of $50.00 per month. In some cases this amount may be higher if you did not choose Part B when you first became eligible at age 65. The cost of Part B may go up 10% for each 12-month period that you were eligible for Part B but declined coverage, except in special cases. You will have to pay the extra 10% cost for the rest of your life. Enrolling in Part B is your choice. You can sign up for Part B anytime during a 7-month period that begins 3 months before you turn 65. Visit your local Social Security office, or call the Social Security Administration at 1-800-7721213 to sign up. If you choose to enroll in Part B, the premium is usually

Your Rights and Insurance 149

taken out of your monthly Social Security, Railroad Retirement, or Civil Service Retirement payment. If you do not receive any of the above payments, Medicare sends you a bill for your part B premium every 3 months. You should receive your Medicare premium bill in the mail by the 10th of the month. If you do not, call the Social Security Administration at 1800-772-1213, or your local Social Security office. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772. For more information, call your Medicare carrier about bills and services. The phone number for the Medicare carrier in your area can be found at the following Web site: http://www.medicare.gov/Contacts/home.asp. You may have choices in how you get your healthcare including the Original Medicare Plan, Medicare Managed Care Plans (like HMOs), and Medicare Private Fee-for-Service Plans.

Medicaid Medicaid is a joint federal and state program that helps pay medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state. People on Medicaid may also get coverage for nursing home care and outpatient prescription drugs which are not covered by Medicare. You can find more information about Medicaid on the HCFA.gov Web site at http://www.hcfa.gov/medicaid/medicaid.htm. States also have programs that pay some or all of Medicare's premiums and may also pay Medicare deductibles and coinsurance for certain people who have Medicare and a low income. To qualify, you must have: ·

Part A (Hospital Insurance),

·

Assets, such as bank accounts, stocks, and bonds that are not more than $4,000 for a single person, or $6,000 for a couple, and

·

A monthly income that is below certain limits.

For more information on these programs, look at the Medicare Savings Programs brochure, http://www.medicare.gov/Library/PDFNavigation/PDFInterim.asp?Langua ge=English&Type=Pub&PubID=10126. There are also Prescription Drug Assistance Programs available. Find information on these programs which offer discounts or free medications to individuals in need at http://www.medicare.gov/Prescription/Home.asp.

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NORD’s Medication Assistance Programs Finally, the National Organization for Rare Disorders, Inc. (NORD) administers medication programs sponsored by humanitarian-minded pharmaceutical and biotechnology companies to help uninsured or underinsured individuals secure life-saving or life-sustaining drugs.52 NORD programs ensure that certain vital drugs are available “to those individuals whose income is too high to qualify for Medicaid but too low to pay for their prescribed medications.” The program has standards for fairness, equity, and unbiased eligibility. It currently covers some 14 programs for nine pharmaceutical companies. NORD also offers early access programs for investigational new drugs (IND) under the approved “Treatment INDs” programs of the Food and Drug Administration (FDA). In these programs, a limited number of individuals can receive investigational drugs that have yet to be approved by the FDA. These programs are generally designed for rare diseases or disorders. For more information, visit www.rarediseases.org.

Additional Resources In addition to the references already listed in this chapter, you may need more information on health insurance, hospitals, or the healthcare system in general. The NIH has set up an excellent guidance Web site that addresses these and other issues. Topics include:53 ·

Health Insurance: http://www.nlm.nih.gov/medlineplus/healthinsurance.html

·

Health Statistics: http://www.nlm.nih.gov/medlineplus/healthstatistics.html

·

HMO and Managed Care: http://www.nlm.nih.gov/medlineplus/managedcare.html

·

Hospice Care: http://www.nlm.nih.gov/medlineplus/hospicecare.html

·

Medicaid: http://www.nlm.nih.gov/medlineplus/medicaid.html

·

Medicare: http://www.nlm.nih.gov/medlineplus/medicare.html

·

Nursing Homes and Long-term Care: http://www.nlm.nih.gov/medlineplus/nursinghomes.html

Adapted from NORD: http://www.rarediseases.org/cgibin/nord/progserv#patient?id=rPIzL9oD&mv_pc=30. 53 You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html. 52

Your Rights and Insurance 151

·

Patient's Rights, Confidentiality, Informed Consent, Ombudsman Programs, Privacy and Patient Issues: http://www.nlm.nih.gov/medlineplus/patientissues.html

·

Veteran's Health, Persian Gulf War, Gulf War Syndrome, Agent Orange: http://www.nlm.nih.gov/medlineplus/veteranshealth.html

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APPENDIX F. MORE ON PAIN Overview

54

You know it at once. It may be the fiery sensation of a burn moments after your finger touches the stove. Or it’s a dull ache above your brow after a day of stress and tension. Or you may recognize it as a sharp pierce in your back after you lift something heavy. It is pain. In its most benign form, it warns us that something isn’t quite right, that we should take medicine or see a doctor. At its worst, however, pain robs us of our productivity, our well-being, and, for many of us suffering from extended illness, our very lives. Pain is a complex perception that differs enormously among individual patients, even those who appear to have identical injuries or illnesses. In 1931, the French medical missionary Dr. Albert Schweitzer wrote, “Pain is a more terrible lord of mankind than even death itself.” Today, pain has become the universal disorder, a serious and costly public health issue, and a challenge for family, friends, and health care providers who must give support to the individual suffering from the physical as well as the emotional consequences of pain.

A Brief History of Pain Ancient civilizations recorded on stone tablets accounts of pain and the treatments used: pressure, heat, water, and sun. Early humans related pain Adapted from The National Institute of Neurological Disorders and Stroke (NINDS): http://www.ninds.nih.gov/health_and_medical/pubs/pain.htm.

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to evil, magic, and demons. Relief of pain was the responsibility of sorcerers, shamans, priests, and priestesses, who used herbs, rites, and ceremonies as their treatments. The Greeks and Romans were the first to advance a theory of sensation, the idea that the brain and nervous system have a role in producing the perception of pain. But it was not until the Middle Ages and well into the Renaissance-the 1400s and 1500s-that evidence began to accumulate in support of these theories. Leonardo da Vinci and his contemporaries came to believe that the brain was the central organ responsible for sensation. Da Vinci also developed the idea that the spinal cord transmits sensations to the brain. In the 17th and 18th centuries, the study of the body-and the sensescontinued to be a source of wonder for the world’s philosophers. In 1664, the French philosopher René Descartes described what to this day is still called a “pain pathway.” Descartes illustrated how particles of fire, in contact with the foot, travel to the brain and he compared pain sensation to the ringing of a bell. In the 19th century, pain came to dwell under a new domain-science-paving the way for advances in pain therapy. Physician-scientists discovered that opium, morphine, codeine, and cocaine could be used to treat pain. These drugs led to the development of aspirin, to this day the most commonly used pain reliever. Before long, anesthesia-both general and regional-was refined and applied during surgery. “It has no future but itself,” wrote the 19th century American poet Emily Dickinson, speaking about pain. As the 21st century unfolds, however, advances in pain research are creating a less grim future than that portrayed in Dickinson’s verse, a future that includes a better understanding of pain, along with greatly improved treatments to keep it in check.

The Two Faces of Pain: Acute and Chronic What is pain? The International Association for the Study of Pain defines it as: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. It is useful to distinguish between two basic types of pain acute and chronic and they differ greatly:

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·

Acute pain, for the most part, results from disease, inflammation, or injury to tissues. This type of pain generally comes on suddenly, for example, after trauma or surgery, and may be accompanied by anxiety or emotional distress. The cause of acute pain can usually be diagnosed and treated, and the pain is self-limiting, that is, it is confined to a given period of time and severity. In some rare instances, it can become chronic.

·

Chronic pain is widely believed to represent disease itself. It can be made much worse by environmental and psychological factors. Chronic pain persists over a longer period of time than acute pain and is resistant to most medical treatments. It can—and often does—cause severe problems for patients.

The A to Z of Pain Hundreds of pain syndromes or disorders make up the spectrum of pain. There are the most benign, fleeting sensations of pain, such as a pin prick. There is the pain of childbirth, the pain of a heart attack, and the pain that sometimes follows amputation of a limb. There is also pain accompanying cancer and the pain that follows severe trauma, such as that associated with head and spinal cord injuries. A sampling of common pain syndromes follows, listed alphabetically. Arachnoiditis is a condition in which one of the three membranes covering the brain and spinal cord, called the arachnoid membrane, becomes inflamed. A number of causes, including infection or trauma, can result in inflammation of this membrane. Arachnoiditis can produce disabling, progressive, and even permanent pain. Arthritis. Millions of Americans suffer from arthritic conditions such as osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and gout. These disorders are characterized by joint pain in the extremities. Many other inflammatory diseases affect the body’s soft tissues, including tendonitis and bursitis. Back pain has become the high price paid by our modern lifestyle and is a startlingly common cause of disability for many Americans, including both active and inactive people. Back pain that spreads to the leg is called sciatica and is a very common condition (see below). Another common type of back pain is associated with the discs of the spine, the soft, spongy padding between the vertebrae (bones) that form the spine. Discs protect the spine by absorbing shock, but they tend to degenerate over time and may sometimes

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rupture. Spondylolisthesis is a back condition that occurs when one vertebra extends over another, causing pressure on nerves and therefore pain. Also, damage to nerve roots (see Spine Basics in the Appendix) is a serious condition, called radiculopathy, that can be extremely painful. Treatment for a damaged disc includes drugs such as painkillers, muscle relaxants, and steroids; exercise or rest, depending on the patient’s condition; adequate support, such as a brace or better mattress and physical therapy. In some cases, surgery may be required to remove the damaged portion of the disc and return it to its previous condition, especially when it is pressing a nerve root. Surgical procedures include discectomy, laminectomy, or spinal fusion (see section on surgery in How is Pain Treated? for more information on these treatments). Burn pain can be profound and poses an extreme challenge to the medical community. First-degree burns are the least severe; with third-degree burns, the skin is lost. Depending on the injury, pain accompanying burns can be excruciating, and even after the wound has healed patients may have chronic pain at the burn site. Cancer pain can accompany the growth of a tumor, the treatment of cancer, or chronic problems related to cancer’s permanent effects on the body. Fortunately, most cancer pain can be treated to help minimize discomfort and stress to the patient. Headaches affect millions of Americans. The three most common types of chronic headache are migraines, cluster headaches, and tension headaches. Each comes with its own telltale brand of pain. ·

Migraines are characterized by throbbing pain and sometimes by other symptoms, such as nausea and visual disturbances. Migraines are more frequent in women than men. Stress can trigger a migraine headache, and migraines can also put the sufferer at risk for stroke.

·

Cluster headaches are characterized by excruciating, piercing pain on one side of the head; they occur more frequently in men than women.

·

Tension headaches are often described as a tight band around the head.

Head and facial pain can be agonizing, whether it results from dental problems or from disorders such as cranial neuralgia, in which one of the nerves in the face, head, or neck is inflamed. Another condition, trigeminal neuralgia (also called tic douloureux), affects the largest of the cranial nerves and is characterized by a stabbing, shooting pain.

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Muscle pain can range from an aching muscle, spasm, or strain, to the severe spasticity that accompanies paralysis. Another disabling syndrome is fibromyalgia, a disorder characterized by fatigue, stiffness, joint tenderness, and widespread muscle pain. Polymyositis, dermatomyositis, and inclusion body myositis are painful disorders characterized by muscle inflammation. They may be caused by infection or autoimmune dysfunction and are sometimes associated with connective tissue disorders, such as lupus and rheumatoid arthritis. Myofascial pain syndromes affect sensitive areas known as trigger points, located within the body’s muscles. Myofascial pain syndromes are sometimes misdiagnosed and can be debilitating. Fibromyalgia is a type of myofascial pain syndrome. Neuropathic pain is a type of pain that can result from injury to nerves, either in the peripheral or central nervous system (see The Nervous Systems in the Appendix). Neuropathic pain can occur in any part of the body and is frequently described as a hot, burning sensation, which can be devastating to the affected individual. It can result from diseases that affect nerves (such as diabetes) or from trauma, or, because chemotherapy drugs can affect nerves, it can be a consequence of cancer treatment. Among the many neuropathic pain conditions are diabetic neuropathy (which results from nerve damage secondary to vascular problems that occur with diabetes); reflex sympathetic dystrophy syndrome (see below), which can follow injury; phantom limb and post-amputation pain (see Phantom Pain in the Appendix), which can result from the surgical removal of a limb; postherpetic neuralgia, which can occur after an outbreak of shingles; and central pain syndrome, which can result from trauma to the brain or spinal cord. Reflex sympathetic dystrophy syndrome, or RSDS, is accompanied by burning pain and hypersensitivity to temperature. Often triggered by trauma or nerve damage, RSDS causes the skin of the affected area to become characteristically shiny. In recent years, RSDS has come to be called complex regional pain syndrome (CRPS); in the past it was often called causalgia. Repetitive stress injuries are muscular conditions that result from repeated motions performed in the course of normal work or other daily activities. They include: ·

Writer’s cramp, which affects musicians and writers and others

·

Compression or entrapment neuropathies, including carpal tunnel syndrome, caused by chronic overextension of the wrist

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Tendonitis or tenosynovitis, affecting one or more tendons.

Sciatica is a painful condition caused by pressure on the sciatic nerve, the main nerve that branches off the spinal cord and continues down into the thighs, legs, ankles, and feet. Sciatica is characterized by pain in the buttocks and can be caused by a number of factors. Exertion, obesity, and poor posture can all cause pressure on the sciatic nerve. One common cause of sciatica is a herniated disc. Shingles and other painful disorders affect the skin. Pain is a common symptom of many skin disorders, even the most common rashes. One of the most vexing neurological disorders is shingles or herpes zoster, an infection that often causes agonizing pain resistant to treatment. Prompt treatment with antiviral agents is important to arrest the infection, which if prolonged can result in an associated condition known as postherpetic neuralgia. Other painful disorders affecting the skin include: ·

Vasculitis, or inflammation of blood vessels

·

Other infections, including herpes simplex

·

Skin tumors and cysts

·

Tumors associated with neurofibromatosis, a neurogenetic disorder

Sports injuries are common. Sprains, strains, bruises, dislocations, and fractures are all well-known words in the language of sports. Pain is another. In extreme cases, sports injuries can take the form of costly and painful spinal cord and head injuries, which cause severe suffering and disability. Spinal stenosis refers to a narrowing of the canal surrounding the spinal cord. The condition occurs naturally with aging. Spinal stenosis causes weakness in the legs and leg pain usually felt while the person is standing up and often relieved by sitting down. Surgical pain may require regional or general anesthesia during the procedure and medications to control discomfort following the operation. Control of pain associated with surgery includes presurgical preparation and careful monitoring of the patient during and after the procedure. Temporomandibular disorders are conditions in which the temporomandibular joint (the jaw) is damaged and/or the muscles used for chewing and talking become stressed, causing pain. The condition may be the result of a number of factors, such as an injury to the jaw or joint misalignment, and may give rise to a variety of symptoms, most commonly

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pain in the jaw, face, and/or neck muscles. Physicians reach a diagnosis by listening to the patient’s description of the symptoms and by performing a simple examination of the facial muscles and the temporomandibular joint. Trauma can occur after injuries in the home, at the workplace, during sports activities, or on the road. Any of these injuries can result in severe disability and pain. Some patients who have had an injury to the spinal cord experience intense pain ranging from tingling to burning and, commonly, both. Such patients are sensitive to hot and cold temperatures and touch. For these individuals, a touch can be perceived as intense burning, indicating abnormal signals relayed to and from the brain. This condition is called central pain syndrome or, if the damage is in the thalamus (the brain’s center for processing bodily sensations), thalamic pain syndrome. It affects as many as 100,000 Americans with multiple sclerosis, Parkinson’s disease, amputated limbs, spinal cord injuries, and stroke. Their pain is severe and is extremely difficult to treat effectively. A variety of medications, including analgesics, antidepressants, anticonvulsants, and electrical stimulation, are options available to central pain patients. Vascular disease or injury-such as vasculitis or inflammation of blood vessels, coronary artery disease, and circulatory problems-all have the potential to cause pain. Vascular pain affects millions of Americans and occurs when communication between blood vessels and nerves is interrupted. Ruptures, spasms, constriction, or obstruction of blood vessels, as well as a condition called ischemia in which blood supply to organs, tissues, or limbs is cut off, can also result in pain.

How Is Pain Diagnosed? There is no way to tell how much pain a person has. No test can measure the intensity of pain, no imaging device can show pain, and no instrument can locate pain precisely. Sometimes, as in the case of headaches, physicians find that the best aid to diagnosis is the patient’s own description of the type, duration, and location of pain. Defining pain as sharp or dull, constant or intermittent, burning or aching may give the best clues to the cause of pain. These descriptions are part of what is called the pain history, taken by the physician during the preliminary examination of a patient with pain. Physicians, however, do have a number of technologies they use to find the cause of pain. Primarily these include:

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Electrodiagnostic procedures include electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies. Information from EMG can help physicians tell precisely which muscles or nerves are affected by weakness or pain. Thin needles are inserted in muscles and a physician can see or listen to electrical signals displayed on an EMG machine. With nerve conduction studies the doctor uses two sets of electrodes (similar to those used during an electrocardiogram) that are placed on the skin over the muscles. The first set gives the patient a mild shock that stimulates the nerve that runs to that muscle. The second set of electrodes is used to make a recording of the nerve’s electrical signals, and from this information the doctor can determine if there is nerve damage. EP tests also involve two sets of electrodes-one set for stimulating a nerve (these electrodes are attached to a limb) and another set on the scalp for recording the speed of nerve signal transmission to the brain.

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Imaging, especially magnetic resonance imaging or MRI, provides physicians with pictures of the body’s structures and tissues. MRI uses magnetic fields and radio waves to differentiate between healthy and diseased tissue.

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A neurological examination in which the physician tests movement, reflexes, sensation, balance, and coordination.

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X-rays produce pictures of the body’s structures, such as bones and joints.

How Is Pain Treated? The goal of pain management is to improve function, enabling individuals to work, attend school, or participate in other day-to-day activities. Patients and their physicians have a number of options for the treatment of pain; some are more effective than others. Sometimes, relaxation and the use of imagery as a distraction provide relief. These methods can be powerful and effective, according to those who advocate their use. Whatever the treatment regime, it is important to remember that pain is treatable. The following treatments are among the most common. Acetaminophen is the basic ingredient found in Tylenol® and its many generic equivalents. It is sold over the counter, in a prescription-strength preparation, and in combination with codeine (also by prescription).

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Acupuncture dates back 2,500 years and involves the application of needles to precise points on the body. It is part of a general category of healing called traditional Chinese or Oriental medicine. Acupuncture remains controversial but is quite popular and may one day prove to be useful for a variety of conditions as it continues to be explored by practitioners, patients, and investigators. Analgesic refers to the class of drugs that includes most painkillers, such as aspirin, acetaminophen, and ibuprofen. The word analgesic is derived from ancient Greek and means to reduce or stop pain. Nonprescription or overthe-counter pain relievers are generally used for mild to moderate pain. Prescription pain relievers, sold through a pharmacy under the direction of a physician, are used for more moderate to severe pain. Anticonvulsants are used for the treatment of seizure disorders but are also sometimes prescribed for the treatment of pain. Carbamazepine in particular is used to treat a number of painful conditions, including trigeminal neuralgia. Another antiepileptic drug, gabapentin, is being studied for its pain-relieving properties, especially as a treatment for neuropathic pain. Antidepressants are sometimes used for the treatment of pain and, along with neuroleptics and lithium, belong to a category of drugs called psychotropic drugs. In addition, anti-anxiety drugs called benzodiazepines also act as muscle relaxants and are sometimes used as pain relievers. Physicians usually try to treat the condition with analgesics before prescribing these drugs. Antimigraine drugs include the triptans- sumatriptan (Imitrex®), naratriptan (Amerge®), and zolmitriptan (Zomig®)-and are used specifically for migraine headaches. They can have serious side effects in some people and therefore, as with all prescription medicines, should be used only under a doctor’s care. Aspirin may be the most widely used pain-relief agent and has been sold over the counter since 1905 as a treatment for fever, headache, and muscle soreness. Biofeedback is used for the treatment of many common pain problems, most notably headache and back pain. Using a special electronic machine, the patient is trained to become aware of, to follow, and to gain control over certain bodily functions, including muscle tension, heart rate, and skin temperature. The individual can then learn to effect a change in his or her responses to pain, for example, by using relaxation techniques. Biofeedback

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is often used in combination with other treatment methods, generally without side effects. Similarly, the use of relaxation techniques in the treatment of pain can increase the patient’s feeling of well-being. Capsaicin is a chemical found in chili peppers that is also a primary ingredient in pain-relieving creams (see Chili Peppers, Capsaicin, and Pain in the Appendix). Chemonucleolysis is a treatment in which an enzyme, chymopapain, is injected directly into a herniated lumbar disc (see Spine Basics in the Appendix) in an effort to dissolve material around the disc, thus reducing pressure and pain. The procedure’s use is extremely limited, in part because some patients may have a life-threatening allergic reaction to chymopapain. Chiropractic refers to hand manipulation of the spine, usually for relief of back pain, and is a treatment option that continues to grow in popularity among many people who simply seek relief from back disorders. It has never been without controversy, however. Chiropractic’s usefulness as a treatment for back pain is, for the most part, restricted to a select group of individuals with uncomplicated acute low back pain who may derive relief from the massage component of the therapy. Cognitive-behavioral therapy involves a wide variety of coping skills and relaxation methods to help prepare for and cope with pain. It is used for postoperative pain, cancer pain, and the pain of childbirth. Counseling can give a patient suffering from pain much needed support, whether it is derived from family, group, or individual counseling. Support groups can provide an important adjunct to drug or surgical treatment. Psychological treatment can also help patients learn about the physiological changes produced by pain. COX-2 inhibitors (“superaspirins”) may be particularly effective for individuals with arthritis. For many years scientists have wanted to develop the ultimate drug-a drug that works as well as morphine but without its negative side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) work by blocking two enzymes, cyclooxygenase-1 and cyclooxygenase-2, both of which promote production of hormones called prostaglandins, which in turn cause inflammation, fever, and pain. Newer drugs, called COX-2 inhibitors, primarily block cyclooxygenase-2 and are less likely to have the gastrointestinal side effects sometimes produced by NSAIDs. On 1999, the Food and Drug Administration approved two COX-2 inhibitors-rofecoxib (Vioxx®) and celecoxib (Celebrex®). Although the long-term effects of COX-

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2 inhibitors are still being evaluated, they appear to be safe. In addition, patients may be able to take COX-2 inhibitors in larger doses than aspirin and other drugs that have irritating side effects, earning them the nickname “superaspirins.” Electrical stimulation, including transcutaneous electrical stimulation (TENS), implanted electric nerve stimulation, and deep brain or spinal cord stimulation, is the modern-day extension of age-old practices in which the nerves of muscles are subjected to a variety of stimuli, including heat or massage. Electrical stimulation, no matter what form, involves a major surgical procedure and is not for everyone, nor is it 100 percent effective. The following techniques each require specialized equipment and personnel trained in the specific procedure being used: ·

TENS uses tiny electrical pulses, delivered through the skin to nerve fibers, to cause changes in muscles, such as numbness or contractions. This in turn produces temporary pain relief. There is also evidence that TENS can activate subsets of peripheral nerve fibers that can block pain transmission at the spinal cord level, in much the same way that shaking your hand can reduce pain.

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Peripheral nerve stimulation uses electrodes placed surgically on a carefully selected area of the body. The patient is then able to deliver an electrical current as needed to the affected area, using an antenna and transmitter.

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Spinal cord stimulation uses electrodes surgically inserted within the epidural space of the spinal cord. The patient is able to deliver a pulse of electricity to the spinal cord using a small box-like receiver and an antenna taped to the skin.

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Deep brain or intracerebral stimulation is considered an extreme treatment and involves surgical stimulation of the brain, usually the thalamus. It is used for a limited number of conditions, including severe pain, central pain syndrome, cancer pain, phantom limb pain, and other neuropathic pains.

Exercise has come to be a prescribed part of some doctors’ treatment regimes for patients with pain. Because there is a known link between many types of chronic pain and tense, weak muscles, exercise-even light to moderate exercise such as walking or swimming-can contribute to an overall sense of well-being by improving blood and oxygen flow to muscles. Just as we know that stress contributes to pain, we also know that exercise, sleep, and relaxation can all help reduce stress, thereby helping to alleviate pain. Exercise has been proven to help many people with low back pain. It is

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important, however, that patients carefully follow the routine laid out by their physicians. Hypnosis, first approved for medical use by the American Medical Association in 1958, continues to grow in popularity, especially as an adjunct to pain medication. In general, hypnosis is used to control physical function or response, that is, the amount of pain an individual can withstand. How hypnosis works is not fully understood. Some believe that hypnosis delivers the patient into a trance-like state, while others feel that the individual is simply better able to concentrate and relax or is more responsive to suggestion. Hypnosis may result in relief of pain by acting on chemicals in the nervous system, slowing impulses. Whether and how hypnosis works involves greater insight-and research-into the mechanisms underlying human consciousness. Ibuprofen is a member of the aspirin family of analgesics, the so-called nonsteroidal anti-inflammatory drugs (see below). It is sold over the counter and also comes in prescription-strength preparations. Low-power lasers have been used occasionally by some physical therapists as a treatment for pain, but like many other treatments, this method is not without controversy. Magnets are increasingly popular with athletes who swear by their effectiveness for the control of sports-related pain and other painful conditions. Usually worn as a collar or wristwatch, the use of magnets as a treatment dates back to the ancient Egyptians and Greeks. While it is often dismissed as quackery and pseudoscience by skeptics, proponents offer the theory that magnets may effect changes in cells or body chemistry, thus producing pain relief. Nerve blocks employ the use of drugs, chemical agents, or surgical techniques to interrupt the relay of pain messages between specific areas of the body and the brain. There are many different names for the procedure, depending on the technique or agent used. Types of surgical nerve blocks include neurectomy; spinal dorsal, cranial, and trigeminal rhizotomy; and sympathectomy, also called sympathetic blockade (see Nerve Blocks in the Appendix). Nonsteroidal anti-inflammatory drugs (NSAIDs) (including aspirin and ibuprofen) are widely prescribed and sometimes called non-narcotic or nonopioid analgesics. They work by reducing inflammatory responses in tissues. Many of these drugs irritate the stomach and for that reason are usually

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taken with food. Although acetaminophen may have some antiinflammatory effects, it is generally distinguished from the traditional NSAIDs. Opioids are derived from the poppy plant and are among the oldest drugs known to humankind. They include codeine and perhaps the most wellknown narcotic of all, morphine. Morphine can be administered in a variety of forms, including a pump for patient self-administration. Opioids have a narcotic effect, that is, they induce sedation as well as pain relief, and some patients may become physically dependent upon them. For these reasons, patients given opioids should be monitored carefully; in some cases stimulants may be prescribed to counteract the sedative side effects. In addition to drowsiness, other common side effects include constipation, nausea, and vomiting. Physical therapy and rehabilitation date back to the ancient practice of using physical techniques and methods, such as heat, cold, exercise, massage, and manipulation, in the treatment of certain conditions. These may be applied to increase function, control pain, and speed the patient toward full recovery. Placebos offer some individuals pain relief although whether and how they have an effect is mysterious and somewhat controversial. Placebos are inactive substances, such as sugar pills, or harmless procedures, such as saline injections or sham surgeries, generally used in clinical studies as control factors to help determine the efficacy of active treatments. Although placebos have no direct effect on the underlying causes of pain, evidence from clinical studies suggests that many pain conditions such as migraine headache, back pain, post-surgical pain, rheumatoid arthritis, angina, and depression sometimes respond well to them. This positive response is known as the placebo effect, which is defined as the observable or measurable change that can occur in patients after administration of a placebo. Some experts believe the effect is psychological and that placebos work because the patients believe or expect them to work. Others say placebos relieve pain by stimulating the brain’s own analgesics and setting the body’s self-healing forces in motion. A third theory suggests that the act of taking placebos relieves stress and anxiety-which are known to aggravate some painful conditions-and, thus, cause the patients to feel better. Still, placebos are considered controversial because by definition they are inactive and have no actual curative value. R.I.C.E.-Rest, Ice, Compression, and Elevation-are four components prescribed by many orthopedists, coaches, trainers, nurses, and other professionals for temporary muscle or joint conditions, such as sprains or

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strains. While many common orthopedic problems can be controlled with these four simple steps, especially when combined with over-the-counter pain relievers, more serious conditions may require surgery or physical therapy, including exercise, joint movement or manipulation, and stimulation of muscles. Surgery, although not always an option, may be required to relieve pain, especially pain caused by back problems or serious musculoskeletal injuries. Surgery may take the form of a nerve block (see Nerve Blocks in the Appendix) or it may involve an operation to relieve pain from a ruptured disc. Surgical procedures for back problems include discectomy or, when microsurgical techniques are used, microdiscectomy, in which the entire disc is removed; laminectomy, a procedure in which a surgeon removes only a disc fragment, gaining access by entering through the arched portion of a vertebra; and spinal fusion, a procedure where the entire disc is removed and replaced with a bone graft. In a spinal fusion, the two vertebrae are then fused together. Although the operation can cause the spine to stiffen, resulting in lost flexibility, the procedure serves one critical purpose: protection of the spinal cord. Other operations for pain include rhizotomy, in which a nerve close to the spinal cord is cut, and cordotomy, where bundles of nerves within the spinal cord are severed. Cordotomy is generally used only for the pain of terminal cancer that does not respond to other therapies. Another operation for pain is the dorsal root entry zone operation, or DREZ, in which spinal neurons corresponding to the patient’s pain are destroyed surgically. Because surgery can result in scar tissue formation that may cause additional problems, patients are well advised to seek a second opinion before proceeding. Occasionally, surgery is carried out with electrodes that selectively damage neurons in a targeted area of the brain. These procedures rarely result in long-term pain relief, but both physician and patient may decide that the surgical procedure will be effective enough that it justifies the expense and risk. In some cases, the results of an operation are remarkable. For example, many individuals suffering from trigeminal neuralgia who are not responsive to drug treatment have had great success with a procedure called microvascular decompression, in which tiny blood vessels are surgically separated from surrounding nerves.

What Is the Role of Age and Gender in Pain? Gender and Pain It is now widely believed that pain affects men and women differently. While the sex hormones estrogen and testosterone certainly play a role in

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this phenomenon, psychology and culture, too, may account at least in part for differences in how men and women receive pain signals. For example, young children may learn to respond to pain based on how they are treated when they experience pain. Some children may be cuddled and comforted, while others may be encouraged to tough it out and to dismiss their pain. Many investigators are turning their attention to the study of gender differences and pain. Women, many experts now agree, recover more quickly from pain, seek help more quickly for their pain, and are less likely to allow pain to control their lives. They also are more likely to marshal a variety of resources-coping skills, support, and distraction-with which to deal with their pain. Research in this area is yielding fascinating results. For example, male experimental animals injected with estrogen, a female sex hormone, appear to have a lower tolerance for pain-that is, the addition of estrogen appears to lower the pain threshold. Similarly, the presence of testosterone, a male hormone, appears to elevate tolerance for pain in female mice: the animals are simply able to withstand pain better. Female mice deprived of estrogen during experiments react to stress similarly to male animals. Estrogen, therefore, may act as a sort of pain switch, turning on the ability to recognize pain. Investigators know that males and females both have strong natural painkilling systems, but these systems operate differently. For example, a class of painkillers called kappa-opioids is named after one of several opioid receptors to which they bind, the kappa-opioid receptor, and they include the compounds nalbuphine (Nubain®) and butorphanol (Stadol®). Research suggests that kappa-opioids provide better pain relief in women. Though not prescribed widely, kappa-opioids are currently used for relief of labor pain and in general work best for short-term pain. Investigators are not certain why kappa-opioids work better in women than men. Is it because a woman’s estrogen makes them work, or because a man’s testosterone prevents them from working? Or is there another explanation, such as differences between men and women in their perception of pain? Continued research may result in a better understanding of how pain affects women differently from men, enabling new and better pain medications to be designed with gender in mind.

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Pain in Aging and Pediatric Populations: Special Needs and Concerns Pain is the number one complaint of older Americans, and one in five older Americans takes a painkiller regularly. In 1998, the American Geriatrics Society (AGS) issued guidelines for the management of pain in older people. The AGS panel addressed the incorporation of several non-drug approaches in patients’ treatment plans, including exercise.55 AGS panel members recommend that, whenever possible, patients use alternatives to aspirin, ibuprofen, and other NSAIDs because of the drugs’ side effects, including stomach irritation and gastrointestinal bleeding. For older adults, acetaminophen is the first-line treatment for mild-to-moderate pain, according to the guidelines. More serious chronic pain conditions may require opioid drugs (narcotics), including codeine or morphine, for relief of pain. Pain in younger patients also requires special attention, particularly because young children are not always able to describe the degree of pain they are experiencing. Although treating pain in pediatric patients poses a special challenge to physicians and parents alike, pediatric patients should never be undertreated. Recently, special tools for measuring pain in children have been developed that, when combined with cues used by parents, help physicians select the most effective treatments. Nonsteroidal agents, and especially acetaminophen, are most often prescribed for control of pain in children. In the case of severe pain or pain following surgery, acetaminophen may be combined with codeine.

A Pain Primer: What Do We Know about Pain? We may experience pain as a prick, tingle, sting, burn, or ache. Receptors on the skin trigger a series of events, beginning with an electrical impulse that travels from the skin to the spinal cord. The spinal cord acts as a sort of relay center where the pain signal can be blocked, enhanced, or otherwise modified before it is relayed to the brain. One area of the spinal cord in particular, called the dorsal horn (see section on Spine Basics in the Appendix), is important in the reception of pain signals. The most common destination in the brain for pain signals is the thalamus and from there to the cortex, the headquarters for complex thoughts. The 55

Journal of the American Geriatrics Society (1998; 46:635-651).

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thalamus also serves as the brain’s storage area for images of the body and plays a key role in relaying messages between the brain and various parts of the body. In people who undergo an amputation, the representation of the amputated limb is stored in the thalamus. (For a discussion of the thalamus and its role in this phenomenon, called phantom pain, see section on Phantom Pain in the Appendix.) Pain is a complicated process that involves an intricate interplay between a number of important chemicals found naturally in the brain and spinal cord. In general, these chemicals, called neurotransmitters, transmit nerve impulses from one cell to another. There are many different neurotransmitters in the human body; some play a role in human disease and, in the case of pain, act in various combinations to produce painful sensations in the body. Some chemicals govern mild pain sensations; others control intense or severe pain. The body’s chemicals act in the transmission of pain messages by stimulating neurotransmitter receptors found on the surface of cells; each receptor has a corresponding neurotransmitter. Receptors function much like gates or ports and enable pain messages to pass through and on to neighboring cells. One brain chemical of special interest to neuroscientists is glutamate. During experiments, mice with blocked glutamate receptors show a reduction in their responses to pain. Other important receptors in pain transmission are opiate-like receptors. Morphine and other opioid drugs work by locking on to these opioid receptors, switching on pain-inhibiting pathways or circuits, and thereby blocking pain. Another type of receptor that responds to painful stimuli is called a nociceptor. Nociceptors are thin nerve fibers in the skin, muscle, and other body tissues, that, when stimulated, carry pain signals to the spinal cord and brain. Normally, nociceptors only respond to strong stimuli such as a pinch. However, when tissues become injured or inflamed, as with a sunburn or infection, they release chemicals that make nociceptors much more sensitive and cause them to transmit pain signals in response to even gentle stimuli such as breeze or a caress. This condition is called allodynia -a state in which pain is produced by innocuous stimuli. The body’s natural painkillers may yet prove to be the most promising pain relievers, pointing to one of the most important new avenues in drug development. The brain may signal the release of painkillers found in the spinal cord, including serotonin, norepinephrine, and opioid-like chemicals.

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Many pharmaceutical companies are working to synthesize these substances in laboratories as future medications. Endorphins and enkephalins are other natural painkillers. Endorphins may be responsible for the “feel good” effects experienced by many people after rigorous exercise; they are also implicated in the pleasurable effects of smoking. Similarly, peptides, compounds that make up proteins in the body, play a role in pain responses. Mice bred experimentally to lack a gene for two peptides called tachykinins-neurokinin A and substance P-have a reduced response to severe pain. When exposed to mild pain, these mice react in the same way as mice that carry the missing gene. But when exposed to more severe pain, the mice exhibit a reduced pain response. This suggests that the two peptides are involved in the production of pain sensations, especially moderate-to-severe pain. Continued research on tachykinins, conducted with support from the NINDS, may pave the way for drugs tailored to treat different severities of pain. Scientists are working to develop potent pain-killing drugs that act on receptors for the chemical acetylcholine. For example, a type of frog native to Ecuador has been found to have a chemical in its skin called epibatidine, derived from the frog’s scientific name, Epipedobates tricolor. Although highly toxic, epibatidine is a potent analgesic and, surprisingly, resembles the chemical nicotine found in cigarettes. Also under development are other less toxic compounds that act on acetylcholine receptors and may prove to be more potent than morphine but without its addictive properties. The idea of using receptors as gateways for pain drugs is a novel idea, supported by experiments involving substance P. Investigators have been able to isolate a tiny population of neurons, located in the spinal cord, that together form a major portion of the pathway responsible for carrying persistent pain signals to the brain. When animals were given injections of a lethal cocktail containing substance P linked to the chemical saporin, this group of cells, whose sole function is to communicate pain, were killed. Receptors for substance P served as a portal or point of entry for the compound. Within days of the injections, the targeted neurons, located in the outer layer of the spinal cord along its entire length, absorbed the compound and were neutralized. The animals’ behavior was completely normal; they no longer exhibited signs of pain following injury or had an exaggerated pain response. Importantly, the animals still responded to acute, that is, normal, pain. This is a critical finding as it is important to retain the body’s ability to detect potentially injurious stimuli. The protective, early warning

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signal that pain provides is essential for normal functioning. If this work can be translated clinically, humans might be able to benefit from similar compounds introduced, for example, through lumbar (spinal) puncture. Another promising area of research using the body’s natural pain-killing abilities is the transplantation of chromaffin cells into the spinal cords of animals bred experimentally to develop arthritis. Chromaffin cells produce several of the body’s pain-killing substances and are part of the adrenal medulla, which sits on top of the kidney. Within a week or so, rats receiving these transplants cease to exhibit telltale signs of pain. Scientists, working with support from the NINDS, believe the transplants help the animals recover from pain-related cellular damage. Extensive animal studies will be required to learn if this technique might be of value to humans with severe pain. One way to control pain outside of the brain, that is, peripherally, is by inhibiting hormones called prostaglandins. Prostaglandins stimulate nerves at the site of injury and cause inflammation and fever. Certain drugs, including NSAIDs, act against such hormones by blocking the enzyme that is required for their synthesis. Blood vessel walls stretch or dilate during a migraine attack and it is thought that serotonin plays a complicated role in this process. For example, before a migraine headache, serotonin levels fall. Drugs for migraine include the triptans: sumatriptan (Imitrix®), naratriptan (Amerge®), and zolmitriptan (Zomig®). They are called serotonin agonists because they mimic the action of endogenous (natural) serotonin and bind to specific subtypes of serotonin receptors. Ongoing pain research, much of it supported by the NINDS, continues to reveal at an unprecedented pace fascinating insights into how genetics, the immune system, and the skin contribute to pain responses. The explosion of knowledge about human genetics is helping scientists who work in the field of drug development. We know, for example, that the painkilling properties of codeine rely heavily on a liver enzyme, CYP2D6, which helps convert codeine into morphine. A small number of people genetically lack the enzyme CYP2D6; when given codeine, these individuals do not get pain relief. CYP2D6 also helps break down certain other drugs. People who genetically lack CYP2D6 may not be able to cleanse their systems of these drugs and may be vulnerable to drug toxicity. CYP2D6 is currently under investigation for its role in pain.

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In his research, the late John C. Liebeskind, a renowned pain expert and a professor of psychology at UCLA, found that pain can kill by delaying healing and causing cancer to spread. In his pioneering research on the immune system and pain, Dr. Liebeskind studied the effects of stress-such as surgery-on the immune system and in particular on cells called natural killer or NK cells. These cells are thought to help protect the body against tumors. In one study conducted with rats, Dr. Liebeskind found that, following experimental surgery, NK cell activity was suppressed, causing the cancer to spread more rapidly. When the animals were treated with morphine, however, they were able to avoid this reaction to stress. The link between the nervous and immune systems is an important one. Cytokines, a type of protein found in the nervous system, are also part of the body’s immune system, the body’s shield for fighting off disease. Cytokines can trigger pain by promoting inflammation, even in the absence of injury or damage. Certain types of cytokines have been linked to nervous system injury. After trauma, cytokine levels rise in the brain and spinal cord and at the site in the peripheral nervous system where the injury occurred. Improvements in our understanding of the precise role of cytokines in producing pain, especially pain resulting from injury, may lead to new classes of drugs that can block the action of these substances.

What Is the Future of Pain Research? In the forefront of pain research are scientists supported by the National Institutes of Health (NIH), including the NINDS. Other institutes at NIH that support pain research include the National Institute of Dental and Craniofacial Research, the National Cancer Institute, the National Institute of Nursing Research, the National Institute on Drug Abuse, and the National Institute of Mental Health. Developing better pain treatments is the primary goal of all pain research being conducted by these institutes. Some pain medications dull the patient’s perception of pain. Morphine is one such drug. It works through the body’s natural pain-killing machinery, preventing pain messages from reaching the brain. Scientists are working toward the development of a morphine-like drug that will have the paindeadening qualities of morphine but without the drug’s negative side effects, such as sedation and the potential for addiction. Patients receiving morphine also face the problem of morphine tolerance, meaning that over time they require higher doses of the drug to achieve the same pain relief. Studies have identified factors that contribute to the development of tolerance; continued

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progress in this line of research should eventually allow patients to take lower doses of morphine. One objective of investigators working to develop the future generation of pain medications is to take full advantage of the body’s pain “switching center” by formulating compounds that will prevent pain signals from being amplified or stop them altogether. Blocking or interrupting pain signals, especially when there is no injury or trauma to tissue, is an important goal in the development of pain medications. An increased understanding of the basic mechanisms of pain will have profound implications for the development of future medicines. The following areas of research are bringing us closer to an ideal pain drug. ·

Systems and Imaging: The idea of mapping cognitive functions to precise areas of the brain dates back to phrenology, the now archaic practice of studying bumps on the head. Positron emission tomography (PET), functional magnetic resonance imaging (fMRI), and other imaging technologies offer a vivid picture of what is happening in the brain as it processes pain. Using imaging, investigators can now see that pain activates at least three or four key areas of the brain’s cortex-the layer of tissue that covers the brain. Interestingly, when patients undergo hypnosis so that the unpleasantness of a painful stimulus is not experienced, activity in some, but not all, brain areas is reduced. This emphasizes that the experience of pain involves a strong emotional component as well as the sensory experience, namely the intensity of the stimulus.

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Channels: The frontier in the search for new drug targets is represented by channels. Channels are gate-like passages found along the membranes of cells that allow electrically charged chemical particles called ions to pass into the cells. Ion channels are important for transmitting signals through the nerve’s membrane. The possibility now exists for developing new classes of drugs, including pain cocktails that would act at the site of channel activity.

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Trophic Factors: A class of “rescuer” or “restorer” drugs may emerge from our growing knowledge of trophic factors, natural chemical substances found in the human body that affect the survival and function of cells. Trophic factors also promote cell death, but little is known about how something beneficial can become harmful. Investigators have observed that an over-accumulation of certain trophic factors in the nerve cells of animals results in heightened pain sensitivity, and that some receptors found on cells respond to trophic factors and interact with each other. These receptors may provide targets for new pain therapies.

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Molecular Genetics: Certain genetic mutations can change pain sensitivity and behavioral responses to pain. People born genetically insensate to pain-that is, individuals who cannot feel pain-have a mutation in part of a gene that plays a role in cell survival. Using “knockout” animal models-animals genetically engineered to lack a certain gene-scientists are able to visualize how mutations in genes cause animals to become anxious, make noise, rear, freeze, or become hypervigilant. These genetic mutations cause a disruption or alteration in the processing of pain information as it leaves the spinal cord and travels to the brain. Knockout animals can be used to complement efforts aimed at developing new drugs.

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Plasticity: Following injury, the nervous system undergoes a tremendous reorganization. This phenomenon is known as plasticity. For example, the spinal cord is “rewired” following trauma as nerve cell axons make new contacts, a phenomenon known as “sprouting.” This in turn disrupts the cells’ supply of trophic factors. Scientists can now identify and study the changes that occur during the processing of pain. For example, using a technique called polymerase chain reaction, abbreviated PCR, scientists can study the genes that are induced by injury and persistent pain. There is evidence that the proteins that are ultimately synthesized by these genes may be targets for new therapies. The dramatic changes that occur with injury and persistent pain underscore that chronic pain should be considered a disease of the nervous system, not just prolonged acute pain or a symptom of an injury. Thus, scientists hope that therapies directed at preventing the long-term changes that occur in the nervous system will prevent the development of chronic pain conditions.

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Neurotransmitters: Just as mutations in genes may affect behavior, they may also affect a number of neurotransmitters involved in the control of pain. Using sophisticated imaging technologies, investigators can now visualize what is happening chemically in the spinal cord. From this work, new therapies may emerge, therapies that can help reduce or obliterate severe or chronic pain.

Hope for the Future Thousands of years ago, ancient peoples attributed pain to spirits and treated it with mysticism and incantations. Over the centuries, science has provided us with a remarkable ability to understand and control pain with medications, surgery, and other treatments. Today, scientists understand a great deal about the causes and mechanisms of pain, and research has produced dramatic improvements in the diagnosis and treatment of a

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number of painful disorders. For people who fight every day against the limitations imposed by pain, the work of NINDS-supported scientists holds the promise of an even greater understanding of pain in the coming years. Their research offers a powerful weapon in the battle to prolong and improve the lives of people with pain: hope.

Spine Basics: The Vertebrae, Discs, and Spinal Cord Stacked on top of one another in the spine are more than 30 bones, the vertebrae, which together form the spine. They are divided into four regions: ·

7 cervical or neck vertebrae (labeled C1-C7),

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12 thoracic or upper back vertebrae (labeled T1-T12),

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5 lumbar vertebrae (labeled L1-L5), which we know as the lower back, and

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Sacrum and coccyx, a group of bones fused together at the base of the spine.

The vertebrae are linked by ligaments, tendons, and muscles. Back pain can occur when, for example, someone lifts something too heavy, causing a sprain, pull, strain, or spasm in one of these muscles or ligaments in the back. Between the vertebrae are round, spongy pads of cartilage called discs that act much like shock absorbers. In many cases, degeneration or pressure from overexertion can cause a disc to shift or protrude and bulge, causing pressure on a nerve and resultant pain. When this happens, the condition is called a slipped, bulging, herniated, or ruptured disc, and it sometimes results in permanent nerve damage. The column-like spinal cord is divided into segments similar to the corresponding vertebrae: cervical, thoracic, lumbar, sacral, and coccygeal. The cord also has nerve roots and rootlets which form branch-like appendages leading from its ventral side (that is, the front of the body) and from its dorsal side (that is, the back of the body). Along the dorsal root are the cells of the dorsal root ganglia, which are critical in the transmission of “pain” messages from the cord to the brain. It is here where injury, damage, and trauma become pain.

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The Nervous Systems The central nervous system (CNS) refers to the brain and spinal cord together. The peripheral nervous system refers to the cervical, thoracic, lumbar, and sacral nerve trunks leading away from the spine to the limbs. Messages related to function (such as movement) or dysfunction (such as pain) travel from the brain to the spinal cord and from there to other regions in the body and back to the brain again. The autonomic nervous system controls involuntary functions in the body, like perspiration, blood pressure, heart rate, or heart beat. It is divided into the sympathetic and parasympathetic nervous systems. The sympathetic and parasympathetic nervous systems have links to important organs and systems in the body; for example, the sympathetic nervous system controls the heart, blood vessels, and respiratory system, while the parasympathetic nervous system controls our ability to sleep, eat, and digest food. The peripheral nervous system also includes 12 pairs of cranial nerves located on the underside of the brain. Most relay messages of a sensory nature. They include the olfactory (I), optic (II), oculomotor (III), trochlear (IV), trigeminal (V), abducens (VI), facial (VII), vestibulocochlear (VIII), glossopharyngeal (IX), vagus (X), accessory (XI), and hypoglossal (XII) nerves. Neuralgia, as in trigeminal neuralgia, is a term that refers to pain that arises from abnormal activity of a nerve trunk or its branches. The type and severity of pain associated with neuralgia vary widely. Phantom Pain: How Does the Brain Feel? Sometimes, when a limb is removed during an amputation, an individual will continue to have an internal sense of the lost limb. This phenomenon is known as phantom limb and accounts describing it date back to the 1800s. Similarly, many amputees are frequently aware of severe pain in the absent limb. Their pain is real and is often accompanied by other health problems, such as depression. What causes this phenomenon? Scientists believe that following amputation, nerve cells “rewire” themselves and continue to receive messages, resulting in a remapping of the brain’s circuitry. The brain’s ability to restructure itself, to change and adapt following injury, is called plasticity (see section on Plasticity). Our understanding of phantom pain has improved tremendously in recent years. Investigators previously believed that brain cells affected by

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amputation simply died off. They attributed sensations of pain at the site of the amputation to irritation of nerves located near the limb stump. Now, using imaging techniques such as positron emission tomography (PET) and magnetic resonance imaging (MRI), scientists can actually visualize increased activity in the brain’s cortex when an individual feels phantom pain. When study participants move the stump of an amputated limb, neurons in the brain remain dynamic and excitable. Surprisingly, the brain’s cells can be stimulated by other body parts, often those located closest to the missing limb. Treatments for phantom pain may include analgesics, anticonvulsants, and other types of drugs; nerve blocks; electrical stimulation; psychological counseling, biofeedback, hypnosis, and acupuncture; and, in rare instances, surgery.

Chili Peppers, Capsaicin, and Pain The hot feeling, red face, and watery eyes you experience when you bite into a red chili pepper may make you reach for a cold drink, but that reaction has also given scientists important information about pain. The chemical found in chili peppers that causes those feelings is capsaicin (pronounced cap-SAYsin), and it works its unique magic by grabbing onto receptors scattered along the surface of sensitive nerve cells in the mouth. In 1997, scientists at the University of California at San Francisco discovered a gene for a capsaicin receptor, called the vanilloid receptor. Once in contact with capsaicin, vanilloid receptors open and pain signals are sent from the peripheral nociceptor and through central nervous system circuits to the brain. Investigators have also learned that this receptor plays a role in the burning type of pain commonly associated with heat, such as the kind you experience when you touch your finger to a hot stove. The vanilloid receptor functions as a sort of “ouch gateway,” enabling us to detect burning hot pain, whether it originates from a 3-alarm habanera chili or from a stove burner. Capsaicin is currently available as a prescription or over-the-counter cream for the treatment of a number of pain conditions, such as shingles. It works by reducing the amount of substance P found in nerve endings and interferes with the transmission of pain signals to the brain. Individuals can become desensitized to the compound, however, perhaps because of longterm damage to nerve tissue. Some individuals find the burning sensation they experience when using capsaicin cream to be intolerable, especially

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when they are already suffering from a painful condition, such as postherpetic neuralgia. Soon, however, better treatments that relieve pain by blocking vanilloid receptors may arrive in drugstores. Marijuana As a painkiller, marijuana or, by its Latin name, cannabis, continues to remain highly controversial. In the eyes of many individuals campaigning on its behalf, marijuana rightfully belongs with other pain remedies. In fact, for many years, it was sold under highly controlled conditions in cigarette form by the Federal government for just that purpose. In 1997, the National Institutes of Health held a workshop to discuss research on the possible therapeutic uses for smoked marijuana. Panel members from a number of fields reviewed published research and heard presentations from pain experts. The panel members concluded that, because there are too few scientific studies to prove marijuana’s therapeutic utility for certain conditions, additional research is needed. There is evidence, however, that receptors to which marijuana binds are found in many brain regions that process information that can produce pain. Nerve Blocks Nerve blocks may involve local anesthesia, regional anesthesia or analgesia, or surgery; dentists routinely use them for traditional dental procedures. Nerve blocks can also be used to prevent or even diagnose pain. In the case of a local nerve block, any one of a number of local anesthetics may be used; the names of these compounds, such as lidocaine or novocaine, usually have an aine ending. Regional blocks affect a larger area of the body. Nerve blocks may also take the form of what is commonly called an epidural, in which a drug is administered into the space between the spine’s protective covering (the dura) and the spinal column. This procedure is most well known for its use during childbirth. Morphine and methadone are opioid narcotics (such drugs end in ine or one) that are sometimes used for regional analgesia and are administered as an injection. Neurolytic blocks employ injection of chemical agents such as alcohol, phenol, or glycerol to block pain messages and are most often used to treat cancer pain or to block pain in the cranial nerves (see The Nervous Systems).

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In some cases, a drug called guanethidine is administered intravenously in order to accomplish the block. Surgical blocks are performed on cranial, peripheral, or sympathetic nerves. They are most often done to relieve the pain of cancer and extreme facial pain, such as that experienced with trigeminal neuralgia. There are several different types of surgical nerve blocks and they are not without problems and complications. Nerve blocks can cause muscle paralysis and, in many cases, result in at least partial numbness. For that reason, the procedure should be reserved for a select group of patients and should only be performed by skilled surgeons. Types of surgical nerve blocks include: ·

Neurectomy (including peripheral neurectomy) in which a damaged peripheral nerve is destroyed.

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Spinal dorsal rhizotomy in which the surgeon cuts the root or rootlets of one or more of the nerves radiating from the spine. Other rhizotomy procedures include cranial rhizotomy and trigeminal rhizotomy, performed as a treatment for extreme facial pain or for the pain of cancer.

·

Sympathectomy, also called sympathetic blockade, in which a drug or an agent such as guanethidine is used to eliminate pain in a specific area (a limb, for example). The procedure is also done for cardiac pain, vascular disease pain, the pain of reflex sympathetic dystrophy syndrome, and other conditions. The term takes its name from the sympathetic nervous system (see The Nervous Systems) and may involve, for example, cutting a nerve that controls contraction of one or more arteries.

Information Resources The National Institute of Neurological Disorders and Stroke, a component of the National Institutes of Health, is the leading federal supporter of research on brain and nervous system disorders. The Institute also sponsors an active public information program that offers information about diagnosis, treatment, and research on painful neurological disorders. For information on pain research supported by the Institute, or information on other neurological disorders, write to the Institute’s Brain Resources and Information Network (BRAIN) at:

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BRAIN P.O. Box 5801 Bethesda, MD 20824 301-496-5751 800-352-9424 http://www.ninds.nih.gov Additional information about pain research supported by the NIH may be obtained from: Public Information and Liaison Branch National Institute of Dental and Craniofacial Research National Institutes of Health Building 45, Room 4AS19 Bethesda, MD 20892-6400 301-496-4261 http://www.nidcr.nih.gov A number of private organizations offer a variety of services and information that can help those affected by pain. They include: American Chronic Pain Association P.O. Box 850 Rocklin, CA 95677-0850 916-632-0922 http://www.theacpa.org Self-help organization that offers educational materials and peer support groups. They emphasize positive approaches to coping with chronic pain. They will be launching a national pain awareness campaign in 2002. American Pain Foundation 201 North Charles Street, Suite 710 Baltimore, MD 21201 410-783-7292 888-615-PAIN (7246) http://www.painfoundation.org Independent non-profit information, education and advocacy organization serving people with pain. Raises public awareness, provides practical information, promotes research, and works to remove barriers and increase access to effective pain management.

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Arthritis Foundation 1330 West Peachtree Street P.O. Box 7669 Atlanta, GA 30309 404-965-7100 800-283-7800 http://www.arthritis.org Volunteer-driven organization that works to improve lives through leadership in the prevention, control, and cure of arthritis and related diseases. Offers free brochures on various types of arthritis, treatment options, and management of daily activities when affected. National Chronic Pain Outreach Association P.O. Box 274 Millboro, VA 24460 540-862-9437 [email protected] Non-profit organization which serves as a clearinghouse of information about chronic pain for pain sufferers, their physicians, other health care professionals, and the public. National Foundation for the Treatment of Pain 1330 Skyline Drive, Suite #21 Monterey, CA 93940 831-655-8812 http://www.paincare.org Not-for-profit organization dedicated to providing support for patients who are suffering from intractable pain, their families, friends, and the physicians who treat them. Offers a patient forum, advocacy programs, information, support resources, and direct medical intervention.

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ONLINE GLOSSARIES The Internet provides access to a number of free-to-use medical dictionaries and glossaries. The National Library of Medicine has compiled the following list of online dictionaries: ·

ADAM Medical Encyclopedia (A.D.A.M., Inc.), comprehensive medical reference: http://www.nlm.nih.gov/medlineplus/encyclopedia.html

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MedicineNet.com Medical Dictionary (MedicineNet, Inc.): http://www.medterms.com/Script/Main/hp.asp

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Merriam-Webster Medical Dictionary (Inteli-Health, Inc.): http://www.intelihealth.com/IH/

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Multilingual Glossary of Technical and Popular Medical Terms in Eight European Languages (European Commission) - Danish, Dutch, English, French, German, Italian, Portuguese, and Spanish: http://allserv.rug.ac.be/~rvdstich/eugloss/welcome.html

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On-line Medical Dictionary (CancerWEB): http://www.graylab.ac.uk/omd/

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Technology Glossary (National Library of Medicine) - Health Care Technology: http://www.nlm.nih.gov/nichsr/ta101/ta10108.htm

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Terms and Definitions (Office of Rare Diseases): http://rarediseases.info.nih.gov/ord/glossary_a-e.html

Beyond these, MEDLINEplus contains a very user-friendly encyclopedia covering every aspect of medicine (licensed from A.D.A.M., Inc.). The ADAM Medical Encyclopedia Web site address is http://www.nlm.nih.gov/medlineplus/encyclopedia.html. ADAM is also available on commercial Web sites such as drkoop.com (http://www.drkoop.com/) and Web MD (http://my.webmd.com/adam/asset/adam_disease_articles/a_to_z/a). Topics of interest can be researched by using keywords before continuing elsewhere, as these basic definitions and concepts will be useful in more advanced areas of research. You may choose to print various pages specifically relating to temporomandibular joint syndrome and keep them on file. The NIH, in particular, suggests that patients with temporomandibular joint syndrome visit the following Web sites in the ADAM Medical Encyclopedia: ·

Basic Guidelines for Temporomandibular Joint Syndrome

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TMJ Web site: http://www.nlm.nih.gov/medlineplus/ency/article/001227.htm ·

Signs & Symptoms for Temporomandibular Joint Syndrome Dizziness Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003093.htm Headache Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003024.htm Limited range of motion Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003173.htm Otalgia Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003046.htm Tinnitus Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003043.htm

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Diagnostics and Tests for Temporomandibular Joint Syndrome CT Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003330.htm MRI Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003335.htm X-ray Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003337.htm

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Background Topics for Temporomandibular Joint Syndrome

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Etiology Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002356.htm

Online Dictionary Directories The following are additional online directories compiled by the National Library of Medicine, including a number of specialized medical dictionaries and glossaries: ·

Medical Dictionaries: Medical & Biological (World Health Organization): http://www.who.int/hlt/virtuallibrary/English/diction.htm#Medical

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MEL-Michigan Electronic Library List of Online Health and Medical Dictionaries (Michigan Electronic Library): http://mel.lib.mi.us/health/health-dictionaries.html

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Patient Education: Glossaries (DMOZ Open Directory Project): http://dmoz.org/Health/Education/Patient_Education/Glossaries/

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Web of Online Dictionaries (Bucknell University): http://www.yourdictionary.com/diction5.html#medicine

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TEMPOROMANDIBULAR JOINT SYNDROME GLOSSARY The following is a complete glossary of terms used in this sourcebook. The definitions are derived from official public sources including the National Institutes of Health [NIH] and the European Union [EU]. After this glossary, we list a number of additional hardbound and electronic glossaries and dictionaries that you may wish to consult. Abdominal: Pertaining to the abdomen. [EU] Adverse: Harmful. [EU] American Heart Association: A voluntary organization concerned with the prevention and treatment of heart and vascular diseases. [NIH] Ankylosis: Fixation and immobility of a joint. [NIH] Antigen: Any substance which is capable, under appropriate conditions, of inducing a specific immune response and of reacting with the products of that response, that is, with specific antibody or specifically sensitized Tlymphocytes, or both. Antigens may be soluble substances, such as toxins and foreign proteins, or particulate, such as bacteria and tissue cells; however, only the portion of the protein or polysaccharide molecule known as the antigenic determinant (q.v.) combines with antibody or a specific receptor on a lymphocyte. Abbreviated Ag. [EU] Arteriovenous: Both arterial and venous; pertaining to or affecting an artery and a vein. [EU] Arthrography: Roentgenography of a joint, usually after injection of either positive or negative contrast medium. [NIH] Assay: Determination of the amount of a particular constituent of a mixture, or of the biological or pharmacological potency of a drug. [EU] Asymptomatic: Showing or causing no symptoms. [EU] Atypical: Irregular; not conformable to the type; in microbiology, applied specifically to strains of unusual type. [EU] Audiology: The study of hearing and hearing impairment. [NIH] Bacteria: Unicellular prokaryotic microorganisms which generally possess rigid cell walls, multiply by cell division, and exhibit three principal forms: round or coccal, rodlike or bacillary, and spiral or spirochetal. [NIH] Benign: Not malignant; not recurrent; favourable for recovery. [EU] Bile: An emulsifying agent produced in the LIVER and secreted into the

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duodenum. Its composition includes bile acids and salts, cholesterol, and electrolytes. It aids digestion of fats in the duodenum. [NIH] Bilirubin: A bile pigment that is a degradation product of HEME. [NIH] Biochemical: Relating to biochemistry; characterized by, produced by, or involving chemical reactions in living organisms. [EU] Bloom Syndrome: An autosomal recessive disorder characterized by telangiectatic erythema of the face, photosensitivity, dwarfism, and other abnormalities. [NIH] Bruxism: A disorder characterized by grinding and clenching of the teeth. [NIH]

Candidiasis: Infection with a fungus of the genus Candida. It is usually a superficial infection of the moist cutaneous areas of the body, and is generally caused by C. albicans; it most commonly involves the skin (dermatocandidiasis), oral mucous membranes (thrush, def. 1), respiratory tract (bronchocandidiasis), and vagina (vaginitis). Rarely there is a systemic infection or endocarditis. Called also moniliasis, candidosis, oidiomycosis, and formerly blastodendriosis. [EU] Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Cardiac: Pertaining to the heart. [EU] Cardiopulmonary: Pertaining to the heart and lungs. [EU] Cardiovascular: Pertaining to the heart and blood vessels. [EU] Cerebral: Of or pertaining of the cerebrum or the brain. [EU] Chimera: An individual that contains cell populations derived from different zygotes. [NIH] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Chondrocytes: Polymorphic cells that form cartilage. [NIH] Chronic: Persisting over a long period of time. [EU] Coagulation: 1. the process of clot formation. 2. in colloid chemistry, the solidification of a sol into a gelatinous mass; an alteration of a disperse phase or of a dissolved solid which causes the separation of the system into a liquid phase and an insoluble mass called the clot or curd. Coagulation is usually

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irreversible. 3. in surgery, the disruption of tissue by physical means to form an amorphous residuum, as in electrocoagulation and photocoagulation. [EU] Cognition: Intellectual or mental process whereby an organism becomes aware of or obtains knowledge. [NIH] Collagen: The protein substance of the white fibres (collagenous fibres) of skin, tendon, bone, cartilage, and all other connective tissue; composed of molecules of tropocollagen (q.v.), it is converted into gelatin by boiling. collagenous pertaining to collagen; forming or producing collagen. [EU] Contracture: A condition of fixed high resistance to passive stretch of a muscle, resulting from fibrosis of the tissues supporting the muscles or the joints, or from disorders of the muscle fibres. [EU] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Dimerization: The process by which two molecules of the same chemical composition form a condensation product or polymer. [NIH] Diuretic: An agent that promotes the excretion of urine. [EU] Drosophila: A genus of small, two-winged flies containing approximately 900 described species. These organisms are the most extensively studied of all genera from the standpoint of genetics and cytology. [NIH] Ectopic: Pertaining to or characterized by ectopia. [EU] Enema: A clyster or injection; a liquid injected or to be injected into the rectum. [EU] Enzyme: A protein molecule that catalyses chemical reactions of other substances without itself being destroyed or altered upon completion of the reactions. Enzymes are classified according to the recommendations of the Nomenclature Committee of the International Union of Biochemistry. Each enzyme is assigned a recommended name and an Enzyme Commission (EC) number. They are divided into six main groups; oxidoreductases, transferases, hydrolases, lyases, isomerases, and ligases. [EU] Ethanol: A clear, colorless liquid rapidly absorbed from the gastrointestinal tract and distributed throughout the body. It has bactericidal activity and is used often as a topical disinfectant. It is widely used as a solvent and preservative in pharmaceutical preparations as well as serving as the primary ingredient in alcoholic beverages. [NIH] Exons: Coding regions of messenger RNA included in the genetic transcript which survive the processing of RNA in cell nuclei to become part of a spliced messenger of structural RNA in the cytoplasm. They include joining

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and diversity exons of immunoglobulin genes. [NIH] Expiration: The act of breathing out, or expelling air from the lungs. [EU] Fatigue: The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. [NIH] Femoral: Pertaining to the femur, or to the thigh. [EU] Fungus: A general term used to denote a group of eukaryotic protists, including mushrooms, yeasts, rusts, moulds, smuts, etc., which are characterized by the absence of chlorophyll and by the presence of a rigid cell wall composed of chitin, mannans, and sometimes cellulose. They are usually of simple morphological form or show some reversible cellular specialization, such as the formation of pseudoparenchymatous tissue in the fruiting body of a mushroom. The dimorphic fungi grow, according to environmental conditions, as moulds or yeasts. [EU] Gait: Manner or style of walking. [NIH] Genotype: The genetic constitution of the individual; the characterization of the genes. [NIH] Gingivitis: Inflammation of the gingivae. Gingivitis associated with bony changes is referred to as periodontitis. Called also oulitis and ulitis. [EU] Glossitis: Inflammation of the tongue. [EU] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Glucuronides: Glycosides of glucuronic acid formed by the reaction of uridine diphosphate glucuronic acid with certain endogenous and exogenous substances. Their formation is important for the detoxification of drugs, steroid excretion and bilirubin metabolism to a more water-soluble compound that can be eliminated in the urine and bile. [NIH] Hepatic: Pertaining to the liver. [EU] Homologous: Corresponding in structure, position, origin, etc., as (a) the feathers of a bird and the scales of a fish, (b) antigen and its specific antibody, (c) allelic chromosomes. [EU] Hybridization: The genetic process of crossbreeding to produce a hybrid. Hybrid nucleic acids can be formed by nucleic acid hybridization of DNA

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and RNA molecules. Protein hybridization allows for hybrid proteins to be formed from polypeptide chains. [NIH] Hyperbilirubinemia: Pathologic process consisting of an abnormal increase in the amount of bilirubin in the circulating blood, which may result in jaundice. [NIH] Hypertension: Persistently high arterial blood pressure. Various criteria for its threshold have been suggested, ranging from 140 mm. Hg systolic and 90 mm. Hg diastolic to as high as 200 mm. Hg systolic and 110 mm. Hg diastolic. Hypertension may have no known cause (essential or idiopathic h.) or be associated with other primary diseases (secondary h.). [EU] Infertility: The diminished or absent ability to conceive or produce an offspring while sterility is the complete inability to conceive or produce an offspring. [NIH] Inflammation: A pathological process characterized by injury or destruction of tissues caused by a variety of cytologic and chemical reactions. It is usually manifested by typical signs of pain, heat, redness, swelling, and loss of function. [NIH] Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Intestinal: Pertaining to the intestine. [EU] Intramuscular: Within the substance of a muscle. [EU] Invasive: 1. having the quality of invasiveness. 2. involving puncture or incision of the skin or insertion of an instrument or foreign material into the body; said of diagnostic techniques. [EU] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Lethal: Deadly, fatal. [EU] Ligament: A band of fibrous tissue that connects bones or cartilages, serving to support and strengthen joints. [EU] Lipodystrophy: 1. any disturbance of fat metabolism. 2. a group of conditions due to defective metabolism of fat, resulting in the absence of subcutaneous fat, which may be congenital or acquired and partial or total.

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Called also lipoatrophy and lipodystrophia. [EU] Lumbar: Pertaining to the loins, the part of the back between the thorax and the pelvis. [EU] Lupus: A form of cutaneous tuberculosis. It is seen predominantly in women and typically involves the nasal, buccal, and conjunctival mucosa. [NIH]

Malformation: A morphologic defect resulting from an intrinsically abnormal developmental process. [EU] Mandible: The largest and strongest bone of the face constituting the lower jaw. It supports the lower teeth. [NIH] Manifest: Being the part or aspect of a phenomenon that is directly observable : concretely expressed in behaviour. [EU] Mechanoreceptors: Cells specialized to transduce mechanical stimuli and relay that information centrally in the nervous system. Mechanoreceptors include hair cells, which mediate hearing and balance, and the various somatosensory receptors, often with non-neural accessory structures. [NIH] Membrane: A thin layer of tissue which covers a surface, lines a cavity or divides a space or organ. [EU] Mesoderm: The middle germ layer of the embryo. [NIH] Microbiology: The study of microorganisms such as fungi, bacteria, algae, archaea, and viruses. [NIH] MMPI: A personality inventory consisting of statements to be asserted or denied by the individual. The patterns of response are characteristic of certain personality attributes. [NIH] Mobility: Capability of movement, of being moved, or of flowing freely. [EU] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Monosomy: The condition in which one chromosome of a pair is missing. In a normally diploid cell it is represented symbolically as 2N-1. [NIH] Mutagenesis: Process of generating genetic mutations. It may occur spontaneously or be induced by mutagens. [NIH] Neoplasms: New abnormal growth of tissue. Malignant neoplasms show a greater degree of anaplasia and have the properties of invasion and metastasis, compared to benign neoplasms. [NIH] Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Neuralgia: Paroxysmal pain which extends along the course of one or more nerves. Many varieties of neuralgia are distinguished according to the part affected or to the cause, as brachial, facial, occipital, supraorbital, etc., or

Glossary 193

anaemic, diabetic, gouty, malarial, syphilitic, etc. [EU] Neurology: A medical specialty concerned with the study of the structures, functions, and diseases of the nervous system. [NIH] Neuronal: Pertaining to a neuron or neurons (= conducting cells of the nervous system). [EU] Neurophysiology: The scientific discipline concerned with the physiology of the nervous system. [NIH] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Ophthalmologic: Pertaining to ophthalmology (= the branch of medicine dealing with the eye). [EU] Oral: Pertaining to the mouth, taken through or applied in the mouth, as an oral medication or an oral thermometer. [EU] Orofacial: Of or relating to the mouth and face. [EU] Orthopaedic: Pertaining to the correction of deformities of the musculoskeletal system; pertaining to orthopaedics. [EU] Osteoarthritis: Noninflammatory degenerative joint disease occurring chiefly in older persons, characterized by degeneration of the articular cartilage, hypertrophy of bone at the margins, and changes in the synovial membrane. It is accompanied by pain and stiffness, particularly after prolonged activity. [EU] Otitis: Inflammation of the ear, which may be marked by pain, fever, abnormalities of hearing, hearing loss, tinnitus, and vertigo. [EU] Otolaryngology: A surgical specialty concerned with the study and treatment of disorders of the ear, nose, and throat. [NIH] Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Panic: A state of extreme acute, intense anxiety and unreasoning fear accompanied by disorganization of personality function. [NIH] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Phobia: A persistent, irrational, intense fear of a specific object, activity, or situation (the phobic stimulus), fear that is recognized as being excessive or unreasonable by the individual himself. When a phobia is a significant source of distress or interferes with social functioning, it is considered a mental disorder; phobic disorder (or neurosis). In DSM III phobic disorders are subclassified as agoraphobia, social phobias, and simple phobias. Used as a word termination denoting irrational fear of or aversion to the subject

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indicated by the stem to which it is affixed. [EU] Posterior: Situated in back of, or in the back part of, or affecting the back or dorsal surface of the body. In lower animals, it refers to the caudal end of the body. [EU] Postoperative: Occurring after a surgical operation. [EU] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Preclinical: Before a disease becomes clinically recognizable. [EU] Prevalence: The total number of cases of a given disease in a specified population at a designated time. It is differentiated from INCIDENCE, which refers to the number of new cases in the population at a given time. [NIH] Prolapse: 1. the falling down, or sinking, of a part or viscus; procidentia. 2. to undergo such displacement. [EU] Protease: Proteinase (= any enzyme that catalyses the splitting of interior peptide bonds in a protein). [EU] Proteins: Polymers of amino acids linked by peptide bonds. The specific sequence of amino acids determines the shape and function of the protein. [NIH]

Proximal: Nearest; closer to any point of reference; opposed to distal. [EU] Psychology: The science dealing with the study of mental processes and behavior in man and animals. [NIH] Psychosomatic: Pertaining to the mind-body relationship; having bodily symptoms of psychic, emotional, or mental origin; called also psychophysiologic. [EU] Psychotherapy: A generic term for the treatment of mental illness or emotional disturbances primarily by verbal or nonverbal communication. [NIH]

Quackery: The fraudulent misrepresentation of the diagnosis and treatment of disease. [NIH] Resuscitation: The restoration to life or consciousness of one apparently dead; it includes such measures as artificial respiration and cardiac massage. [EU]

Rheumatoid: Resembling rheumatism. [EU] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH]

Glossary 195

Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Skull: The skeleton of the head including the bones of the face and the bones enclosing the brain. [NIH] Somatic: 1. pertaining to or characteristic of the soma or body. 2. pertaining to the body wall in contrast to the viscera. [EU] Species: A taxonomic category subordinate to a genus (or subgenus) and superior to a subspecies or variety, composed of individuals possessing common characters distinguishing them from other categories of individuals of the same taxonomic level. In taxonomic nomenclature, species are designated by the genus name followed by a Latin or Latinized adjective or noun. [EU] Spectrum: A charted band of wavelengths of electromagnetic vibrations obtained by refraction and diffraction. By extension, a measurable range of activity, such as the range of bacteria affected by an antibiotic (antibacterial s.) or the complete range of manifestations of a disease. [EU] Spondylitis: Inflammation of the vertebrae. [EU] Steroid: A group name for lipids that contain a hydrogenated cyclopentanoperhydrophenanthrene ring system. Some of the substances included in this group are progesterone, adrenocortical hormones, the gonadal hormones, cardiac aglycones, bile acids, sterols (such as cholesterol), toad poisons, saponins, and some of the carcinogenic hydrocarbons. [EU] Stomatitis: Inflammation of the oral mucosa, due to local or systemic factors which may involve the buccal and labial mucosa, palate, tongue, floor of the mouth, and the gingivae. [EU] Surgical: Of, pertaining to, or correctable by surgery. [EU] Sympathetic: 1. pertaining to, caused by, or exhibiting sympathy. 2. a sympathetic nerve or the sympathetic nervous system. [EU] Synovial: Of pertaining to, or secreting synovia. [EU] Systemic: Pertaining to or affecting the body as a whole. [EU] Thermoregulation: Heat regulation. [EU] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH] Tinnitus: A noise in the ears, as ringing, buzzing, roaring, clicking, etc. Such sounds may at times be heard by others than the patient. [EU] Tomography: The recording of internal body images at a predetermined plane by means of the tomograph; called also body section roentgenography.

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[EU]

Toxicity: The quality of being poisonous, especially the degree of virulence of a toxic microbe or of a poison. [EU] Transplantation: The grafting of tissues taken from the patient's own body or from another. [EU] Visceral: , from viscus a viscus) pertaining to a viscus. [EU] Withdrawal: 1. a pathological retreat from interpersonal contact and social involvement, as may occur in schizophrenia, depression, or schizoid avoidant and schizotypal personality disorders. 2. (DSM III-R) a substancespecific organic brain syndrome that follows the cessation of use or reduction in intake of a psychoactive substance that had been regularly used to induce a state of intoxication. [EU]

General Dictionaries and Glossaries While the above glossary is essentially complete, the dictionaries listed here cover virtually all aspects of medicine, from basic words and phrases to more advanced terms (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

Dictionary of Medical Acronymns & Abbreviations by Stanley Jablonski (Editor), Paperback, 4th edition (2001), Lippincott Williams & Wilkins Publishers, ISBN: 1560534605, http://www.amazon.com/exec/obidos/ASIN/1560534605/icongroupinter na

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Dictionary of Medical Terms : For the Nonmedical Person (Dictionary of Medical Terms for the Nonmedical Person, Ed 4) by Mikel A. Rothenberg, M.D, et al, Paperback - 544 pages, 4th edition (2000), Barrons Educational Series, ISBN: 0764112015, http://www.amazon.com/exec/obidos/ASIN/0764112015/icongroupinter na

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A Dictionary of the History of Medicine by A. Sebastian, CD-Rom edition (2001), CRC Press-Parthenon Publishers, ISBN: 185070368X, http://www.amazon.com/exec/obidos/ASIN/185070368X/icongroupinter na

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Dorland's Illustrated Medical Dictionary (Standard Version) by Dorland, et al, Hardcover - 2088 pages, 29th edition (2000), W B Saunders Co, ISBN: 0721662544, http://www.amazon.com/exec/obidos/ASIN/0721662544/icongroupinter na

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Dorland's Electronic Medical Dictionary by Dorland, et al, Software, 29th Book & CD-Rom edition (2000), Harcourt Health Sciences, ISBN: 0721694934, http://www.amazon.com/exec/obidos/ASIN/0721694934/icongroupinter na

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Dorland's Pocket Medical Dictionary (Dorland's Pocket Medical Dictionary, 26th Ed) Hardcover - 912 pages, 26th edition (2001), W B Saunders Co, ISBN: 0721682812, http://www.amazon.com/exec/obidos/ASIN/0721682812/icongroupinter na/103-4193558-7304618

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Melloni's Illustrated Medical Dictionary (Melloni's Illustrated Medical Dictionary, 4th Ed) by Melloni, Hardcover, 4th edition (2001), CRC Press-Parthenon Publishers, ISBN: 85070094X, http://www.amazon.com/exec/obidos/ASIN/85070094X/icongroupintern a

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Stedman's Electronic Medical Dictionary Version 5.0 (CD-ROM for Windows and Macintosh, Individual) by Stedmans, CD-ROM edition (2000), Lippincott Williams & Wilkins Publishers, ISBN: 0781726328, http://www.amazon.com/exec/obidos/ASIN/0781726328/icongroupinter na

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Stedman's Medical Dictionary by Thomas Lathrop Stedman, Hardcover - 2098 pages, 27th edition (2000), Lippincott, Williams & Wilkins, ISBN: 068340007X, http://www.amazon.com/exec/obidos/ASIN/068340007X/icongroupinter na

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Tabers Cyclopedic Medical Dictionary (Thumb Index) by Donald Venes (Editor), et al, Hardcover - 2439 pages, 19th edition (2001), F A Davis Co, ISBN: 0803606540, http://www.amazon.com/exec/obidos/ASIN/0803606540/icongroupinter na

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INDEX A Ankylosis ...........................................4, 76 Antigen ..........................................63, 190 Arthrography..........................................14 B Bacteria .....61, 65, 92, 120, 187, 192, 195 Benign .....................................68, 70, 192 Bile...................................62, 66, 188, 195 Biochemical .........................................111 Bruxism..........................................68, 113 C Candidiasis ............................................68 Capsules..............................................123 Carbohydrate.........................63, 122, 190 Cardiac ............................21, 66, 194, 195 Cerebral...............................................111 Cholesterol ....................66, 120, 122, 195 Chronic ..............13, 16, 88, 111, 112, 141 Coagulation .........................................125 Collagen ........................................62, 189 D Degenerative ...................14, 20, 121, 193 Dentists...2, 5, 16, 25, 26, 27, 84, 97, 100, 119, 145, 146 Diarrhea...............................................120 E Enzyme............................62, 65, 189, 194 Exons.............................................63, 190 F Fatigue.................................................111 Fungus...........................................70, 188 G Gingivitis ................................................68 Glossitis .................................................68 Glucose ...........................63, 64, 190, 191 I Inflammation ..........................................68 Insulin ..............................63, 64, 190, 191 Intestinal ..............................................120 Invasive .................................................16 L Ligament..............................................126 Lupus ...................................................111 M Mandible ................................................11

Membrane..................................... 20, 193 Microbiology.................................. 62, 187 MMPI..................................................... 94 Molecular .................................. 82, 85, 87 N Neoplasms .................................... 70, 192 Neural ................................... 64, 121, 192 Neuralgia................................. 68, 70, 192 Niacin .................................................. 120 O Oral ...ii, iii, 3, 7, 10, 15, 16, 20, 22, 25, 30, 68, 70, 98, 128, 188, 193, 195 Orofacial........................................ 74, 112 Osteoarthritis ................................ 12, 111 Overdose ............................................ 121 P Phobia........................................... 20, 193 Postoperative ........................................ 74 Potassium ........................................... 122 Prolapse.............................................. 111 Proteins........... 61, 63, 120, 122, 187, 191 Psychology............................................ 74 Q Quackery............................................. 126 R Rheumatoid........................................... 12 Riboflavin ............................................ 120 S Selenium ............................................. 122 Serum ........................................... 65, 195 Species ........................... 62, 65, 189, 195 Steroid........................................... 63, 190 Stomatitis .............................................. 68 Surgical ..................... 15, 65, 76, 193, 194 Sympathetic ................................ 117, 195 Synovial ........................................ 20, 193 Systemic ............................... 70, 188, 195 T Thermoregulation................................ 120 Thyroxine ............................................ 122 Tinnitus ......................................... 70, 193 Tomography.......................................... 14 Y Yawning ................................................ 15

Index 199

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Index 201

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