Bruxism and Orofacial Pain

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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

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Sleep Bruxism

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

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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

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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

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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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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

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Biofeedback
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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

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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
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Pharmacology Cellular Level

• Receptors
• agonist
• strong, weak, partial
• antagonist
• competitive (surmountable)
• noncompetitive (insurmountable)
• irreversible
• affinity
• strength

Olson
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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
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Pharmacology Population Level

• Effective concentration 50
• Lethal dose 50
• Therapeutic index
• Margin of safety

Olson
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TMD Pain population (7-10)

• Sleep disorders

Disorders of Initiating and Maintaining Sleep
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Sleep medications

• INITATION
• non-Rx
• Ambien
• Sonota
• Lunesta
• Rozerem

• MAINTANACE
• TCA
• non-TCA
• AEDS

Consider sleep lab referral
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TMD Pain population (7-10)

• Sleep disorders
• Depression

Do not attempt to Dx or Tx depression
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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
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TMD Pain population (7-10)

• Sleep disorders
• Depression
• Anxiety

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Anxiolitics

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

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Pharmacotherapy for Pain

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

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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

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NSAIDs

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

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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

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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

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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

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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

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NSAIDs

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

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Opioid Therapy Drug Selection

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

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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

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Opioid Therapy Side Effects

• Common
• Constipation
• Somnolence, mental clouding
• Less common
• Nausea Sweating
• Myoclonus Amenorrhea
• Itch Sexual dysfunction
• Urinary retention Headache

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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

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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

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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

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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?

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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

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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

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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

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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

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Adjuvant Analgesics

• Multipurpose analgesics
• Neuropathic pain
• Musculoskeletal pain
• Headache

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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

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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

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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

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Multipurpose Adjuvant Analgesics

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

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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

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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

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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

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Saper
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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
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Neurogenic Pain Disorders

• Intermittent
• TGN
• GPN

• Continuous
• CRPS type 1
• CRPS type 2

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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.