needed research to improve care for people with trigeminal neuropathic pains donald nixdorf, dds ms...
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Needed Research to Needed Research to Improve Care for Improve Care for
People with Trigeminal People with Trigeminal Neuropathic PainsNeuropathic Pains
Donald Nixdorf, DDS MSAssistant Professor
University of Minnesota
What do YOU think?
• Education– More Awareness in Primary Care (DDS &
MD)
• Better medications & treatments– More effective– Less side-effects
• Improved Diagnostic Criteria– Based on WHAT?
Knowledge of the Knowledge of the MechanismsMechanisms
H.M.S. Salisbury James Lind (1716-1794)
“The number of seaman in time of war who died of shipwreck, capture, famine, fire or sword, are but of inconsiderable in respect of such as are destroyed by the ship diseases, and by the usual maladies of intemperate climates.” – Dr. Lind, 1753
Symptoms of Scurvy
• lethargy
• irritability
• weight loss
• aching of the joints
• bleeding under the skin and nails
• swollen and bleeding gums
• spontaneous bruising
• wounds slow to heal
Scurvy: Timeline 1601 - James Lancaster (sea captain) records lemon juice
as protective against scurvy
1744 - British Admiral George Anson completes trip around the world in the Centurion . Over half of the 2,000 sailors die from scurvy
1747 - Lind’s experiment on the HMS Salisbury
1754 - Lind publishes “A Treatise of the Scurvy”
1775 - Captain James Cook completes historic voyagesSailors remained free from scurvy
1795 - British Navy supplies daily ration of lime or lemon juice
1932 - Waugh and King (U of Pittsburgh) and Szent Gyorgyi (Hungary) isolate and synthesize vitamin C
DiseaseDiscoverer of
preventive measure
Year of discovery of preventive measure
Year of discovery of causal agent
Agent
Scurvy J. Lind 1753 1932 Ascorbic acid
Scrotal cancer P. Pott 1775 1933 Benzo(a)pyrene
Smallpox E. Jenner 1798 1958 Orthopoxvirus
Puerperal fever I. Semmelweis 1847 1879 Streptococcus
Cholera J. Snow 1849 1893 Vibrio cholerae
Bladder cancer L. Rehn 1895 1938 2-Naththylamine
Yellow fever W. Reed et al 1901 1928 Flavivirus
Oral cancer R. Abbe 1915 1974 N-
nitrosonomicotine
Wynder EL. Am J Epidemiol 1994; 547-549
What we are looking for…
Care Provider
Scientist
Epidemiologist
What am I going to do…
• Functional Magnetic Resonance Imaging
ffMRIMRI
Acquisition parameters:TR/TE = 50/3.5 ms, readout bandwidth 20 kHz, FOV 20 x 11.2 x 2.5 mm, matrix 384 x 216 x 16, 16 averages,Acquisition time 2:53 min/scan, total time 46:08 min. The image was reconstructed 2x zero-filling, producing a reconstructed resolution of 26 x 26 x 78 mm.
High Resolution (post-MION) acquisition
Bolan, Yacoub, Garwood, Ugurbil, Harel NeuroImage 2006
Vessel Classification 3D Vessel Reconstruction
blue = veinred = artery
Bolan, Yacoub, Garwood, Ugurbil, Harel NeuroImage 2006
Maximum Intensity Projections (MIP)
MIP of the 3D subtraction (Pre/Post MION)
Bolan, Yacoub, Garwood, Ugurbil, Harel NeuroImage 2006
First human images at 9.4 Tesla
Vaughan et al., MRM 2006
Definitions
Neuropathic Pain needs to fulfill the following criteria:
1) Pain presents in a neuranatomically defined area
2) History of a relevant disease or lesion in the nervous system (dental procedures)
3) Partial or complete sensory loss in all or part of the painful area
4) Confirmation of the lesion or disease by a specific test (i.e. surgical evidence, imaging, neurophys., biopsy)
1. Does persistent pain arise from surgery?
2. What are the factors that would put some patients at higher risk for developing persistent pain than others ?
3. What are the human neuroanatomical & functional mechanisms involved in this type of pain?
…multiple other research questions & steps… What are viable interventions and when
should they best be applied ? (pre-op, intra-op & post-op)
Procedures performed within U.S. (in 100,000/yr)
15,838
40,036
55,874
45,023
0 15,000 30,000 45,000 60,000
All General Surgeries
Nose/Mouth/Pharynx
All Dental Surgeries
Tooth Extractions
Root Canal Therapies
Data from the CDC (2004) & American Dental Association (1999)
309
Take Home • 30% get persistent pain
• 10% are severely affected
Kehlet et al, 2006
in Lancet
Type of Procedure
# Studies in Literature
Post-op nerve
damage
Persistent pain at 12 months
#’s seen in tertiary
pain clinics
BSSO 4 ~75%
(60-88%)
~4%
(0-6%)
some
3rd Molar Extraction
6 ~5%
(0.5-8%)
<1%
(0-0.9%)
few
Root Canal Therapy
4 unknown ~5%
(3-13%)
several
SUMMARYDental Procedures
Procedures performed within U.S. (in 100,000/yr)
792 (5%)
400 (1%)
1,676 (3%)
0 15,000 30,000 45,000 60,000
All General Surgeries
Nose/Mouth/Pharynx
All Dental Surgeries
Tooth Extractions
Root Canal Therapies
Data from the CDC (2004) & American Dental Association (1999)
93 (30%)
13,406 (30%)
Pain & OralPain & OralHealth Quality of Life:Health Quality of Life:
Measuring Success of Root Measuring Success of Root Canal TherapyCanal Therapy
Prospective cohort evaluating non-surgical root canal therapy 1 year after treatment
Aims:1) Determine incidence of persistent pain at 1 year
2) Assess the burden on the individual
3) Evaluate the risk factors associated with developing this type of pain
Laboratory Clinical Practice-based Community- research trials research based
in academic research settings
Why participate in practice-based research networks?
1. Generalizability
2. Sample size