Anesth Prog 37:72 1990
Discussion on New Approaces to the Differential Diagnosis of Chronic Orofacial Pain
Ronald Dubner,
DDS, PhD Neurobiology and Anesthesiology Branch, National Institutes of Health, Bethesda, Maryland
promising new approaches and techniques for the diagnosis and measurement of orofacial chronic pain. It is clear, as Dr. Casey pointed out, that we are limited in our differential diagnosis by the lack of sensitivity and reliability of the diagnostic procedures available. However, part of the variability and low resolution of some of the procedures may be due to our lack of understanding of the disease process and our inability to correctly categorize various conditions. Dr. Laskin was correct in pointing out that investigations of temporomandibular disorders are based on heterogeneous populations of patients. We are grouping under the heading of temporomandibular disorders a cluster of conditions that may be unrelated in terms of their etiology and pathophysiology, but appear to have similar signs and symptoms. The heterogeniety of the population may reduce the sensitivity and resolution of our diagnostic tools. When we attempt to identify new and promising diagnostic approaches, we should also identify the appropriate populations in which they can be evaluated and ultimately applied. The same principles should apply when we attempt to identify methodologies that can be applied to the study of psychological, behavioral, and social aspects of the conditions. Similar approaches are appropriate in population-based epidemiologic studies of chronic orofacial pain. We should identify homogenous populations of chronic pain patients and identify diagnostic approaches that provide definitive characteristics of the pain condition. In conclusion, I believe we have an opportunity to broaden the existing approaches to the diagnosis of chronic orofacial conditions and to provide more objective assessment measures. However, we should first examine existing measures and assess their reliability in appropriately defined homogeneous populations before attempting to apply new approaches to the diagnosis of poorly understood, more complex conditions.
Our plenary speakers have identified some of the major problems in our understanding of chronic orofacial pain that have limited the development of appropriate methods and techniques for differential diagnosis. First, the underlying mechanisms and pathophysiology of many conditions are poorly understood. Dr. Casey correctly pointed out that our understanding of the mechanisms of cutaneous acute pain is considerable. This is in contrast to the minimal information we have about muscle and deep pain. Yet, some of the most difficult chronic pain problems to diagnose and treat are those that involve the pathophysiology of muscle. This includes the cluster of orofacial problems referred to as temporomandibular disorders, some forms of headache, and upper and lower back pains. Damage to nerves, referred to as neuropathies, is of matabolic, viral, or traumatic origin, and often results in spontaneous and evoked chronic pain, and represents another cluster of conditions that is not easily treated. Thus, a major objective of this workshop should be to identify those conditions in which more research on the pathophysiology of the condition is needed before one can identify useful diagnostic tools. Another important dimension of chronic pain conditions is the overlying psychopathology that often accompanies the tissue pathology. In fact, in many instances, history and examination reveal minimal tissue pathology in the face of major psychological, behavioral, and social problems. Emphasis needs to be placed on better differential diagnosis of the psychopathology of chronic pain conditions and their importance to appropriate treatment. Another major objective of this workshop is to identify
Address correspondence to Ronald Dubner, DDS, PhD, Neurobiology and Anesthesiology Branch, National Institute of Dental Research, National Institutes of Health, Bethesda, MD 20892.
72
Discussion on New Approaces to the Differential Diagnosis of Chronic Orofacial Pain
Ronald Dubner,
DDS, PhD Neurobiology and Anesthesiology Branch, National Institutes of Health, Bethesda, Maryland
promising new approaches and techniques for the diagnosis and measurement of orofacial chronic pain. It is clear, as Dr. Casey pointed out, that we are limited in our differential diagnosis by the lack of sensitivity and reliability of the diagnostic procedures available. However, part of the variability and low resolution of some of the procedures may be due to our lack of understanding of the disease process and our inability to correctly categorize various conditions. Dr. Laskin was correct in pointing out that investigations of temporomandibular disorders are based on heterogeneous populations of patients. We are grouping under the heading of temporomandibular disorders a cluster of conditions that may be unrelated in terms of their etiology and pathophysiology, but appear to have similar signs and symptoms. The heterogeniety of the population may reduce the sensitivity and resolution of our diagnostic tools. When we attempt to identify new and promising diagnostic approaches, we should also identify the appropriate populations in which they can be evaluated and ultimately applied. The same principles should apply when we attempt to identify methodologies that can be applied to the study of psychological, behavioral, and social aspects of the conditions. Similar approaches are appropriate in population-based epidemiologic studies of chronic orofacial pain. We should identify homogenous populations of chronic pain patients and identify diagnostic approaches that provide definitive characteristics of the pain condition. In conclusion, I believe we have an opportunity to broaden the existing approaches to the diagnosis of chronic orofacial conditions and to provide more objective assessment measures. However, we should first examine existing measures and assess their reliability in appropriately defined homogeneous populations before attempting to apply new approaches to the diagnosis of poorly understood, more complex conditions.
Our plenary speakers have identified some of the major problems in our understanding of chronic orofacial pain that have limited the development of appropriate methods and techniques for differential diagnosis. First, the underlying mechanisms and pathophysiology of many conditions are poorly understood. Dr. Casey correctly pointed out that our understanding of the mechanisms of cutaneous acute pain is considerable. This is in contrast to the minimal information we have about muscle and deep pain. Yet, some of the most difficult chronic pain problems to diagnose and treat are those that involve the pathophysiology of muscle. This includes the cluster of orofacial problems referred to as temporomandibular disorders, some forms of headache, and upper and lower back pains. Damage to nerves, referred to as neuropathies, is of matabolic, viral, or traumatic origin, and often results in spontaneous and evoked chronic pain, and represents another cluster of conditions that is not easily treated. Thus, a major objective of this workshop should be to identify those conditions in which more research on the pathophysiology of the condition is needed before one can identify useful diagnostic tools. Another important dimension of chronic pain conditions is the overlying psychopathology that often accompanies the tissue pathology. In fact, in many instances, history and examination reveal minimal tissue pathology in the face of major psychological, behavioral, and social problems. Emphasis needs to be placed on better differential diagnosis of the psychopathology of chronic pain conditions and their importance to appropriate treatment. Another major objective of this workshop is to identify
Address correspondence to Ronald Dubner, DDS, PhD, Neurobiology and Anesthesiology Branch, National Institute of Dental Research, National Institutes of Health, Bethesda, MD 20892.
72
