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Bruxism and Orofacial Pain

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Title: Bruxism and Orofacial Pain


1
Bruxismand Orofacial Pain
  • Richard R. Riggs, D.D.S.
  • Diplomat American Board of Orofacial Pain
  • Fellow American College of Dentists
  • Fellow International College of Dentists
  • Fellow American Academy of Orofacial Pain

2
Sleep Bruxism
  • Parasomnia Movement Disorder
  • Epileptic related motor event
  • EEG similar to temporal lobe seizures

3
Sleep Bruxism
  • Polysmnographic Studies
  • 7 bruxing bursts/episode (4.6)
  • 36 bursts/hr (6.2)
  • 5.4 episodes/hr (1.7)
  • No difference in sleep parameters
  • Sensitivity 81.3
  • Specifity 83.3

4
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5
Sleep Bruxism
  • Transient arousals gt bruxers
  • Stage 12 N-REM with CAP 20-40 sec intervals
  • Arousals with RMMA
  • Increased breathing gt11X of non-RMMA arousals

6
Sleep Bruxism
  • Associated with RMMA (Rapid Muscle Motor
    Activity)
  • RMMA gt 60 general population
  • RMMA linked to chewing, swallowing and breathing
  • Frequency and amplitude 3X gt in patients
  • RMMA co-contraction opening closing muscles
  • Possibly related to lubrication upper alimentary
    tract increasing airway patency

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14
Behavioral Therapy
  • A habit is a habit, not to be flung out the
  • window by any man, but rather, coaxed
  • downstairs one step at a time.

  • Mark Twain

15
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16
Biofeedback
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18
Pharmacology forOrofacial Pain
  • Richard R. Riggs, D.D.S.
  • Diplomat American Board of Orofacial Pain
  • Fellow American College of Dentists
  • Fellow International College of Dentists
  • Fellow American Academy of Orofacial Pain

19
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20
Classification
  • Action of drug e.g.. narcotic, antihistamine
  • Site of action e.g.. CNS, CV, respiratory
  • Distribution e.g.. membrane permeability, plasma
    protein binding, depot storage
  • Metabolism e.g.. Oxidation/reduction,
    conjugation, prodrug (codeine)
  • Type of patient e.g. opiate responsive or
    non-responsive, high or low hydroxylator

Olson
21
Pharmacology Cellular Level
  • Receptors
  • agonist
  • strong, weak, partial
  • antagonist
  • competitive (surmountable)
  • noncompetitive (insurmountable)
  • irreversible
  • affinity
  • strength

Olson
22
Pharmacology Organism Level
  • Efficacy
  • degree able to produce max effect
  • Potency
  • amt drug to produce 50 max effect
  • Graded dose-response curves
  • dependent on receptor affinity, absorption,
    plasma protein binding, distribution, metabolism,
    and excretion of the individual

Olson
23
Pharmacology Population Level
  • Effective concentration 50
  • Lethal dose 50
  • Therapeutic index
  • Margin of safety

Olson
24
TMD Pain population (7-10)
  • Sleep disorders

Disorders of Initiating and Maintaining Sleep
25
Sleep medications
  • INITATION
  • non-Rx
  • Ambien
  • Sonota
  • Lunesta
  • Rozerem
  • MAINTANACE
  • TCA
  • non-TCA
  • AEDS

Consider sleep lab referral
26
TMD Pain population (7-10)
  • Sleep disorders
  • Depression

Do not attempt to Dx or Tx depression
27
Antidepressants
  • TCA -3º- amitriptyline, imipramine 2º-
    nortriptyline, desipramine
  • non-TCA - trazodone
  • MAOI do not Rx
  • SSRI RCT ? bruxism, sleep
  • SNRI useful neuropathic pain

Sleep, CP450, Seizure
28
TMD Pain population (7-10)
  • Sleep disorders
  • Depression
  • Anxiety

29
Anxiolitics
  • Non-rx
  • Clonazepam
  • Buspirone
  • SSRI
  • SSNRI

30
Pharmacotherapy for Pain
  • Categories of analgesic drugs
  • Nonopioid analgesics
  • Opioid analgesics
  • Adjuvant analgesics
  • Drugs for headache

31
Nonopioid Analgesics
  • Acetaminophen (paracetamol)
  • Minimal anti-inflammatory effects
  • Fewer adverse effects than other nonopioid
    analgesics
  • Adverse effects
  • Renal toxicity
  • Risk for hepatotoxicity at high doses
  • Increased risk with liver disease or chronic
    alcoholism
  • No effect on platelet function

32
NSAIDs
  • Chemical Class Generic Name
  • Nonacidic nabumetone
  • Acidic
  • Salicylates aspirin, diflunisal,
  • choline magnesium
  • trisalicylate, salsalate
  • Proprionic acids ibuprofen, naproxen,
  • fenoprofen, ketoprofen,
  • flurbiprofen, oxaprozin

33
NSAIDs (cont)
  • Chemical Class Generic Name
  • Acidic
  • Acetic acids indomethacin, tolmetin,
    sulindac, diclofenac, ketorolac
  • Oxicams piroxicam
  • Fenamates mefenamic acid, meclofenam
    ic acid
  • Selective COX-2 inhibitors celecoxib

34
NSAIDs
  • Mechanism
  • Inhibit both peripheral and central
    cyclo-oxygenase, reducing prostaglandin formation
  • 2 isoforms of COX
  • COX-1 Constitutive, physiologic
  • COX-2 Inducible, inflammatory
  • Caution with
  • Methotrexate cyclosporin ACE inhibitors
  • lithium anticoagulants diuretics aspirin

35
NSAIDs
  • Properties
  • Nonspecific analgesics, but greater effectiveness
    likely in inflammatory pains
  • Dose-dependent effects, with ceiling dose
  • Marked individual variation in response to
    different drugs
  • Drug-to-drug variation in toxicities partly
    determined by COX-1/COX-2 selectivity

36
NSAIDs
  • Properties
  • Adverse effects GI toxicity, renal toxicity,
    bleeding diathesis
  • GI toxicity reduced by proton pump inhibitors,
    misoprostol, and possibly high-dose H-2 blockers
  • COX-2 selective inhibitors have better GI safety
    profile
  • Use with caution in patients with renal
    insufficiency, congestive heart failure, or
    volume overload

37
NSAIDs
  • Drug selection should be influenced by
    drug-selective toxicities, prior experience,
    convenience, cost

38
Opioid Therapy Drug Selection
  • Immediate-release preparations
  • Combination products
  • Acetaminophen, aspirin, or ibuprofen combined
    with codeine, hydrocodone, dihydrocodeine
  • Single-entity drugs, eg, morphine
  • Tramadol

39
Opioid Therapy Drug Selection
  • Extended-release preparations
  • Preferred because of improved treatment adherence
    and the likelihood of reduced risk in those with
    addictive disease
  • Morphine, oxycodone, fentanyl, hydromorphone,
    codeine, tramadol, buprenorphine
  • Adjust dose q 23 d

40
Opioid Therapy Side Effects
  • Common
  • Constipation
  • Somnolence, mental clouding
  • Less common
  • Nausea Sweating
  • Myoclonus Amenorrhea
  • Itch Sexual dysfunction
  • Urinary retention Headache

41
Opioid Therapy and Chemical Dependency
  • Physical dependence
  • Abstinence syndrome induced by administration of
    an antagonist or by dose reduction
  • Assumed to exist after dosing for a few days but
    actually highly variable
  • Usually unimportant if abstinence avoided
  • Does not independently cause addiction

42
Opioid Therapy and Chemical Dependency
  • Tolerance
  • Diminished drug effect from drug exposure
  • Varied types associative vs pharmacologic
  • Tolerance to side effects is desirable
  • Tolerance to analgesia is seldom a problem in the
    clinical setting
  • Tolerance rarely drives dose escalation
  • Tolerance does not cause addiction

43
Opioid Therapy andChemical Dependency
  • Addiction
  • Disease with pharmacologic, genetic, and
    psychosocial elements
  • Fundamental features
  • Loss of control
  • Compulsive use
  • Use despite harm
  • Diagnosed by observation of aberrant drug-related
    behavior

44
Opioid Therapy and Chemical Dependency
  • Pseudoaddiction
  • Aberrant drug-related behaviors driven by
    desperation over uncontrolled pain
  • Reduced by improved pain control
  • Complexities
  • How aberrant can behavior be before it is
    inconsistent with pseudoaddiction?
  • Can addiction and pseudoaddiction coexist?

45
Opioid Therapy and Chemical Dependency
  • Risk of addiction Evolving view
  • Acute pain Very unlikely
  • Cancer pain Very unlikely
  • Chronic noncancer pain
  • Surveys of patients without abuse or
    psychopathology show rare addiction
  • Surveys that include patients with abuse or
    psychopathology show mixed results

46
Monitoring Drug-Related Behaviors
  • Probably more predictive of addiction
  • Selling prescription drugs
  • Forging prescriptions
  • Stealing or borrowing drugs from another
    person
  • Injecting oral formulation
  • Obtaining prescription drugs from nonmedical
    source
  • Losing prescriptions repeatedly
  • Probably less predictive of addiction
  • Aggressive complaining
  • Drug hoarding when symptoms are milder
  • Requesting specific drugs
  • Acquiring drugs from other medical sources
  • Unsanctioned dose escalation once or twice

47
Monitoring Drug-Related Behaviors (cont.)
  • Probably more predictive of addiction
  • Concurrent abuse of related illicit drugs
  • Multiple dose escalations despite warnings
  • Repeated episodes of gross impairment or
    dishevelment
  • Probably less predictive of addiction
  • Unapproved use of the drug to treat another
    symptom
  • Reporting of psychic effects not intended by
    the clinician
  • Occasional impairment

48
Adjuvant Analgesics
  • Defined as drugs with other indications that may
    be analgesic in specific circumstances
  • Numerous drugs in diverse classes
  • Sequential trials are often needed

49
Adjuvant Analgesics
  • Multipurpose analgesics
  • Neuropathic pain
  • Musculoskeletal pain
  • Headache

50
Multipurpose Adjuvant Analgesics
  • Class Examples
  • Antidepressants amitriptyline,
    desipramine, nortriptyline,
    paroxetine, venlafaxine, citalopram,
  • Alpha-2 adrenergic tizanidine, clonidine
  • agonists
  • Corticosteroids prednisone, dexamethasone
  • AEDS baclofen, klonopin, tizanidine,
    topirimate

51
Multipurpose Adjuvant Analgesics
  • Antidepressants
  • Best evidence 30 amine TCAs (eg, amitriptyline)
  • 20 amine TCAs (desipramine, nortriptyline) better
    tolerated and also analgesic
  • Some evidence for SSRI/SSNRIs/atypical
    antidepressants (eg, paroxetine, venlafaxine,
    maprotiline, bupropion, others) and these are
    better tolerated yet

52
Multipurpose Adjuvant Analgesics
  • Alpha-2 adrenergic agonists
  • Clonidine and tizanidine used for chronic pain of
    any type
  • Tizanidine usually better tolerated
  • Tizanidine starting dose 12 mg/d usual maximum
    dose up to 20 mg/d

53
Multipurpose Adjuvant Analgesics
  • Class Examples
  • NMDA receptor dextromethorphan, ketamine
  • Antagonists amantadine
  • Miscellaneous baclofen, calcitonin
  • Topical lidocaine, lidocaine/prilocaine,
  • capsaicin, NSAIDs

54
Topical Adjuvant Analgesics
  • Used for neuropathic pain
  • Local anesthetics
  • Lidocaine patch (Lidoderm Patch)
  • Cream, eg, lidocaine 5, EMLA
  • Capsaicin
  • Used for musculoskeletal pains
  • Diclofenac 1 (systemic concentration 6 of oral
    form) works on peripherial prostaglandins

55
Adjuvant Analgesics for Musculoskeletal Pain
  • Muscle relaxants
  • Refers to numerous drugs, eg, cyclobenzaprine,
    carisoprodol, orphenadrine, methocarbamol,
    chlorzoxazone, metaxalone
  • Centrally-acting analgesics
  • Do not relax skeletal muscle

56
TMD
  • Analgesics
  • non-opiod
  • Ultram (prodrug)
  • opiod
  • codiene (prodrug)
  • NSAIDS
  • indoles
  • propionic acid
  • COX-2 inhibitors
  • Corticosteroids
  • Anxiolitics
  • benzodiazepines
  • Muscle relaxants
  • Flexeril, Soma, Skelaxin
  • Antidepressants
  • TCA, SRI
  • Anti epileptic drugs (AEDS)
  • Klonopin, Neurontin,
  • Anesthetics
  • TP, Joint, Dx blocks

57
Saper
58
Tension-type
  • Episodic lt 15/mo
  • NSAIDS
  • Mild analgesics
  • Muscle relaxants
  • TCA
  • Chronic gt 15/mo
  • TCA
  • SSNRI
  • Prophylactic migraine meds
  • Local anesthetics

R/O rebound HA on Hx
59
Neurogenic Pain Disorders
  • Intermittent
  • TGN
  • GPN
  • Continuous
  • CRPS type 1
  • CRPS type 2

60
References
  • Clinical Pharmacology Made Ridiculously Simple.
    Olson, James. 8th printing. MedMaster, inc.,
    1997.
  • Drug Therapy Decision Making Guide.
  • McCormack, James (editor). 1st edition. W.B.
    Saunders, 1996.
  • Handbook of Headache Management.
  • Saper, Joel R., et.al. 1st (1993) or 2nd
    edition (1999). Lippincott Williams Wilkins.
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