- Email: [email protected]
Screening for psychosocial risk factors
Methods.—The orthodontic wires were immersed in 2.0% acidulated phosphate fluoride solution at 37°C for 60 minutes. Then they were subjected to a tensile test, observation with the SEM, and hydrogen TDA. Results.—The immersed nickel-titanium wire declined in tensile strength from 1380 to 1160 MPa, a reduction of 16.2%. This wire fractured before yielding. Compared with nonimmersed wire, the critical stress for the immersed nickel-titanium wire increased from 430 to 480 MPa. A slight decline in tensile strength (5.6%) was noted for the beta titanium wire after immersion. The reduction in tensile strength of the stainless steel wire was only 2.6%, and that of the immersed cobalt-chromium-nickel wire was 0.9%. SEM results indicated that all wire surfaces became rough as a result of corrosion to a fairly equal degree. The mass of the nickel-titanium wire decreased after immersion, but that of the beta titanium and stainless steel wires increased. The mass change of the cobalt-chromium-nickel wire was barely perceptible. TDA curves revealed the nickel-titanium and beta titanium wires absorbed a large amount of hydrogen during their immersion, but the stainless steel and cobaltchromium-nickel alloy wires had no increase in desorbed hydrogen.
wires made of titanium alloys. This process occurs even with short immersions in fluoride solutions. Clinically, it would be prudent to avoid using wires with titanium protective film in areas that are in contact with prophylactic agents, toothpastes, or dental rinses that contain fluoride.
Clinical Significance.—Be careful substituting titanium alloy wires for stainless steel in patients allergic to nickel. Titanium alloy wires immersed in acid fluoride solutions suffered severe loss of tensile strength, whereas stainless steel and chrome cobalt wires were only slightly affected.
Kaneko K, Yokoyama K, Moriyama K, et al: Degradation in performance of orthodontic wires caused by hydrogen absorption during short-term immersion in 2.0% acidulated phosphate fluoride solution. Angle Orthod 74:487-495, 2004 Reprints available from K Yokoyama, Dept of Dental Engineering, School of Dentistry, The Univ of Tokushima, 3-18-15 Kuramoto-cho, Tokushima, 770-8504, Japan; e-mail: [email protected]
Discussion.—Hydrogen absorption proved to be the cause of the degradation in performance of orthodontic
Pain and Pain Control Screening for psychosocial risk factors Background.—When a patient’s pain is chronic, especially in conjunction with significant disability, dentists should screen for the presence of psychosocial factors that can influence the patient’s pain, function, and treatment response. Research findings dealing with psychosocial factors that proved important in chronic pain, specifically temporomandibular disorder pain, were reviewed. Methods.—The psychosocial risk factors were dubbed “yellow flags” for risk of poor outcomes in patients with
174 Dental Abstracts
chronic orofacial pain syndromes. MEDLINE searches covered the years between 1995 and 2002, with supplemental information drawn from the authors’ personal files. Results.—The yellow flags identified included disability out of proportion to objective findings, symptoms of psychological disorders, and prolonged or excessive use of opiates, benzodiazepines, alcohol, or other drugs. To identify these yellow flags, a questionnaire approach was suggested. This method obtains important sociodemographic
Box.—Valid and Reliable Self-Administered Measures of Psychosocial Risk Factors* Construct Assessed/Questionnaire
Pain Intensity and Pain-Related Activity Limitations GCPS
MPI
Depression and Somatization SCL-90 Depression scale
BDI
CES-D
PHQ-9
SCL-90 Somatization scale
Alcohol and Drug Abuse AUDIT-C
TICS Multiple Psychiatric Disorders PHQ
Comments
Yields characteristic pain intensity and pain-related disability scores, pain grade classification (five groups based on pain and disability level; two highest grades may warrant multidisciplinary treatment); included in RDC/TMD Twelve scales assess pain impact (severity, interference), responses of others and activities; categorizes patients into interpersonally distressed, dysfunctional and adaptive-coper subgroups; interpersonally distressed and dysfunctional patients may need multidisciplinary treatment Validated as a screening tool (not diagnostic); normed for RDC/TMD using population-based data—patients classified as normal, moderate or severe symptom level; patients with moderate or severe levels probably should be referred to a psychologist or psychiatrist; included in RDC/TMD Widely used to assess depressive symptom severity, but not a diagnostic tool; patients who score 2 or 3 on the suicidal ideation question or > 20 on the scale should be referred for depression assessment Widely used to assess depressive symptom severity, but not a diagnostic tool; patients who score ≥ 27 probably should be referred for depression assessment Screens for major depression and assesses depression severity; scores ≥ 10 are sensitive and specific for major depression; 5, 10, 15 and 20 are cutoff points for mild, moderate, moderately severe and severe depression Validated as a screening tool, but not diagnostic; assesses tendency to report nonspecific physical symptoms as troublesome; normed for RDC/TMD using population-based data—patients classified as normal, moderate or severe symptom level; patients with severe levels probably should be referred to a psychiatrist or psychologist; patients with moderate levels may be monitored and re-evaluated within one-year; included in RDC/TMD Three-item screen for heavy drinking and /or alcohol abuse or dependence; a score ≥ 3 or a report of drinking ≥ six drinks on one occasion in the past year indicates a need for more in-depth assessment of drinking problems Two-item screen for alcohol/drug abuse; one or more positive responses indicates a need for more in-depth assessment Screens for major depressive disorder, other depressive disorders, panic disorder, other anxiety disorders, bulimia nervosa, alcohol abuse/dependence, somatoform disorder, binge-eating disorder; patients with a positive screen should be referred for psychiatric or psychological assessment
*The cutoff points in this box should be considered general guidelines only. Actual cutoff points may vary according to the patient population, setting in which the measure is administered, and the purpose of administration. Patient responses on measures should be considered in the context of other information about the patient. However, scores reflecting moderate or greater levels of psychosocial disability indicate the need for monitoring symptom severity and referral if symptoms do not improve. Abbreviations: GCPS, Graded Chronic Pain Scale; RDC/TMD, Research Diagnostic Criteria/Temporomandibular Disorders; MPI, Multidimensional Pain Inventory; SCL-90, Symptom Checklist; BDI, Beck Depression Inventory; CES-D, Center for Epidemiological Studies—Depression Scale; PHQ, Patient Health Questionnaire; AUDIT-C, Alcohol Use Disorders Identification Test—Consumption; TICS, Two-Item Conjoint Screen. (Courtesy of Turner JA, Dworkin SF: Screening for psychosocial risk factors in patients with chronic orofacial pain: Recent advances. J Am Dent Assoc 135:1119-1125, 2004. Copyright 2004 American Dental Association. All rights reserved. Reproduced by permission.)
Volume 50 • Issue 3 • 2005 175
information efficiently and also can be used to administer standardized measures of pain intensity, disability, and psychological symptom severity. Disability measures ask patients to rate their average, worst, and current pain intensity; the mean of these 3 ratings is the pain intensity score. In addition, ratings from 0 to 10 are used to help patients convey how much the pain interferes with their daily activities, work and/or housework activities, and recreational and/or social activities. The mean of these 3 ratings is the pain-related disability score. Review of the patient’s responses to the questionnaire can provide a framework for discussion and clarification of psychosocial problems. Because the goal is to screen for indicators that a referral is warranted, the dentist is not required to make a psychiatric diagnosis. Multiple valid and reliable self-report measures are available (Box). It is estimated that it requires less than 3 minutes to screen for 8 mental disorders. Because depression, somatization, and anxiety are often found in patients who suffer chronic pain, it is advisable to screen all patients who have chronic pain (even in primary care settings) for depression. Depression is common and highly debilitating, but the good news is that it is also highly treatable. Patients who indicate by their answers on the screening questionnaire that they may be depressed should be promptly referred to a mental health professional or psychiatric emergency facility for further assessment.
Discussion.—Dentists perform a valuable service to their patients with chronic pain by screening for the presence of psychosocial risk factors. When psychosocial yellow flags are present, patients are at higher risk for failure of standard treatments. In addition, referring patients who have such psychosocial risk factors to a psychologist or psychiatrist with expertise in assessing and treating such cases is the best way to provide appropriate care for these individuals.
Clinical Significance.—Chronic pain, such as with TMD, often presents with a psychological overlay that must be addressed if treatment is to be effective. Presented is discussion of screening tests available to identify, for example, depression, a frequent accompaniment of chronic pain, and a table listing these tests.
Turner JA, Dworkin SF: Screening for psychosocial risk factors inpatients with chronic orofacial pain: Recent advances. J Am Dent Assoc 135:1119-1125, 2004 Reprints available from JA Turner, Dept of Psychiatry and Behavioral Sciences, and Dept of Rehabilitation Medicine, Univ of Washington, 1959 NE Pacific St, Rm BB1517, Seattle, WA 98195; e-mail: jturner @u.washington.edu
Preoperative NSAIDs decrease postoperative pain Background.—The pain experience is most clearly comprehended from a biopsychosocial aspect that encompasses everything from the activation of a peripheral nociceptor and transmission of the noxious signal through the neuroaxis to the psychological components of pain and suffering. Pain after surgery is a predictable event, and taking steps to minimize the patient’s pain experience is appropriate. Nonsteroidal anti-inflammatory drugs (NSAIDs) offer both a direct analgesic effect and the ability to inhibit prostaglandin formation, making them useful for the con-
176 Dental Abstracts
trol of postoperative pain. Their role as a preoperative analgesic was investigated. Studies.—Patients having third molar surgery were given various NSAIDs perioperatively to determine their effectiveness against postoperative pain (Table 1). When 1000 mg aspirin was given preoperatively in comparison to placebo, bleeding time was significantly increased, platelet aggregation response was significantly reduced, blood loss during and after surgery was significantly increased, the in-
wires made of titanium alloys. This process occurs even with short immersions in fluoride solutions. Clinically, it would be prudent to avoid using wires with titanium protective film in areas that are in contact with prophylactic agents, toothpastes, or dental rinses that contain fluoride.
Clinical Significance.—Be careful substituting titanium alloy wires for stainless steel in patients allergic to nickel. Titanium alloy wires immersed in acid fluoride solutions suffered severe loss of tensile strength, whereas stainless steel and chrome cobalt wires were only slightly affected.
Kaneko K, Yokoyama K, Moriyama K, et al: Degradation in performance of orthodontic wires caused by hydrogen absorption during short-term immersion in 2.0% acidulated phosphate fluoride solution. Angle Orthod 74:487-495, 2004 Reprints available from K Yokoyama, Dept of Dental Engineering, School of Dentistry, The Univ of Tokushima, 3-18-15 Kuramoto-cho, Tokushima, 770-8504, Japan; e-mail: [email protected]
Discussion.—Hydrogen absorption proved to be the cause of the degradation in performance of orthodontic
Pain and Pain Control Screening for psychosocial risk factors Background.—When a patient’s pain is chronic, especially in conjunction with significant disability, dentists should screen for the presence of psychosocial factors that can influence the patient’s pain, function, and treatment response. Research findings dealing with psychosocial factors that proved important in chronic pain, specifically temporomandibular disorder pain, were reviewed. Methods.—The psychosocial risk factors were dubbed “yellow flags” for risk of poor outcomes in patients with
174 Dental Abstracts
chronic orofacial pain syndromes. MEDLINE searches covered the years between 1995 and 2002, with supplemental information drawn from the authors’ personal files. Results.—The yellow flags identified included disability out of proportion to objective findings, symptoms of psychological disorders, and prolonged or excessive use of opiates, benzodiazepines, alcohol, or other drugs. To identify these yellow flags, a questionnaire approach was suggested. This method obtains important sociodemographic
Box.—Valid and Reliable Self-Administered Measures of Psychosocial Risk Factors* Construct Assessed/Questionnaire
Pain Intensity and Pain-Related Activity Limitations GCPS
MPI
Depression and Somatization SCL-90 Depression scale
BDI
CES-D
PHQ-9
SCL-90 Somatization scale
Alcohol and Drug Abuse AUDIT-C
TICS Multiple Psychiatric Disorders PHQ
Comments
Yields characteristic pain intensity and pain-related disability scores, pain grade classification (five groups based on pain and disability level; two highest grades may warrant multidisciplinary treatment); included in RDC/TMD Twelve scales assess pain impact (severity, interference), responses of others and activities; categorizes patients into interpersonally distressed, dysfunctional and adaptive-coper subgroups; interpersonally distressed and dysfunctional patients may need multidisciplinary treatment Validated as a screening tool (not diagnostic); normed for RDC/TMD using population-based data—patients classified as normal, moderate or severe symptom level; patients with moderate or severe levels probably should be referred to a psychologist or psychiatrist; included in RDC/TMD Widely used to assess depressive symptom severity, but not a diagnostic tool; patients who score 2 or 3 on the suicidal ideation question or > 20 on the scale should be referred for depression assessment Widely used to assess depressive symptom severity, but not a diagnostic tool; patients who score ≥ 27 probably should be referred for depression assessment Screens for major depression and assesses depression severity; scores ≥ 10 are sensitive and specific for major depression; 5, 10, 15 and 20 are cutoff points for mild, moderate, moderately severe and severe depression Validated as a screening tool, but not diagnostic; assesses tendency to report nonspecific physical symptoms as troublesome; normed for RDC/TMD using population-based data—patients classified as normal, moderate or severe symptom level; patients with severe levels probably should be referred to a psychiatrist or psychologist; patients with moderate levels may be monitored and re-evaluated within one-year; included in RDC/TMD Three-item screen for heavy drinking and /or alcohol abuse or dependence; a score ≥ 3 or a report of drinking ≥ six drinks on one occasion in the past year indicates a need for more in-depth assessment of drinking problems Two-item screen for alcohol/drug abuse; one or more positive responses indicates a need for more in-depth assessment Screens for major depressive disorder, other depressive disorders, panic disorder, other anxiety disorders, bulimia nervosa, alcohol abuse/dependence, somatoform disorder, binge-eating disorder; patients with a positive screen should be referred for psychiatric or psychological assessment
*The cutoff points in this box should be considered general guidelines only. Actual cutoff points may vary according to the patient population, setting in which the measure is administered, and the purpose of administration. Patient responses on measures should be considered in the context of other information about the patient. However, scores reflecting moderate or greater levels of psychosocial disability indicate the need for monitoring symptom severity and referral if symptoms do not improve. Abbreviations: GCPS, Graded Chronic Pain Scale; RDC/TMD, Research Diagnostic Criteria/Temporomandibular Disorders; MPI, Multidimensional Pain Inventory; SCL-90, Symptom Checklist; BDI, Beck Depression Inventory; CES-D, Center for Epidemiological Studies—Depression Scale; PHQ, Patient Health Questionnaire; AUDIT-C, Alcohol Use Disorders Identification Test—Consumption; TICS, Two-Item Conjoint Screen. (Courtesy of Turner JA, Dworkin SF: Screening for psychosocial risk factors in patients with chronic orofacial pain: Recent advances. J Am Dent Assoc 135:1119-1125, 2004. Copyright 2004 American Dental Association. All rights reserved. Reproduced by permission.)
Volume 50 • Issue 3 • 2005 175
information efficiently and also can be used to administer standardized measures of pain intensity, disability, and psychological symptom severity. Disability measures ask patients to rate their average, worst, and current pain intensity; the mean of these 3 ratings is the pain intensity score. In addition, ratings from 0 to 10 are used to help patients convey how much the pain interferes with their daily activities, work and/or housework activities, and recreational and/or social activities. The mean of these 3 ratings is the pain-related disability score. Review of the patient’s responses to the questionnaire can provide a framework for discussion and clarification of psychosocial problems. Because the goal is to screen for indicators that a referral is warranted, the dentist is not required to make a psychiatric diagnosis. Multiple valid and reliable self-report measures are available (Box). It is estimated that it requires less than 3 minutes to screen for 8 mental disorders. Because depression, somatization, and anxiety are often found in patients who suffer chronic pain, it is advisable to screen all patients who have chronic pain (even in primary care settings) for depression. Depression is common and highly debilitating, but the good news is that it is also highly treatable. Patients who indicate by their answers on the screening questionnaire that they may be depressed should be promptly referred to a mental health professional or psychiatric emergency facility for further assessment.
Discussion.—Dentists perform a valuable service to their patients with chronic pain by screening for the presence of psychosocial risk factors. When psychosocial yellow flags are present, patients are at higher risk for failure of standard treatments. In addition, referring patients who have such psychosocial risk factors to a psychologist or psychiatrist with expertise in assessing and treating such cases is the best way to provide appropriate care for these individuals.
Clinical Significance.—Chronic pain, such as with TMD, often presents with a psychological overlay that must be addressed if treatment is to be effective. Presented is discussion of screening tests available to identify, for example, depression, a frequent accompaniment of chronic pain, and a table listing these tests.
Turner JA, Dworkin SF: Screening for psychosocial risk factors inpatients with chronic orofacial pain: Recent advances. J Am Dent Assoc 135:1119-1125, 2004 Reprints available from JA Turner, Dept of Psychiatry and Behavioral Sciences, and Dept of Rehabilitation Medicine, Univ of Washington, 1959 NE Pacific St, Rm BB1517, Seattle, WA 98195; e-mail: jturner @u.washington.edu
Preoperative NSAIDs decrease postoperative pain Background.—The pain experience is most clearly comprehended from a biopsychosocial aspect that encompasses everything from the activation of a peripheral nociceptor and transmission of the noxious signal through the neuroaxis to the psychological components of pain and suffering. Pain after surgery is a predictable event, and taking steps to minimize the patient’s pain experience is appropriate. Nonsteroidal anti-inflammatory drugs (NSAIDs) offer both a direct analgesic effect and the ability to inhibit prostaglandin formation, making them useful for the con-
176 Dental Abstracts
trol of postoperative pain. Their role as a preoperative analgesic was investigated. Studies.—Patients having third molar surgery were given various NSAIDs perioperatively to determine their effectiveness against postoperative pain (Table 1). When 1000 mg aspirin was given preoperatively in comparison to placebo, bleeding time was significantly increased, platelet aggregation response was significantly reduced, blood loss during and after surgery was significantly increased, the in-