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Chronic pain nothing to ignore: Research unveils better treatments
By Helen Adams | MUSC News Center | August 15, 2014
Dr. Theresa Gonzales helps patients figure out complex chronic pain conditions. Gonzales is director of the Center for Orofacial Pain Diagnosis and Management at MUSC's College of Dental Medicine.
Debbie Talley was desperate. The 62-year-old Greenville woman had seen dentists, driven to Georgia for an appointment with a specialist and even had a tooth pulled to try to relieve her chronic pain.
“The pain in my gums affected my entire body. At night I was so tired I’d just break down in tears because the pain was all over. I told everyone I’m not depressed, but I feel like I’m going to die an early death,” said Talley.
Then, a dentist told her about a specialist at MUSC. Talley ended up in the office of orofacial pain expert Theresa S. Gonzales, DMD and professor in the Department of Stomatology in the College of Dental Medicine.
“She immediately knew what was wrong,” Talley said. “When I left there, it was like a weight had been lifted off my shoulders.”
Gonzales, who was one of the speakers at MUSC’s recent scientific retreat on pain research, examined Talley carefully. She didn’t just focus on her gum pain. She asked Talley about her overall health, seeing the gum discomfort as part of a larger picture.
They spent more than an hour discussing Talley’s pain, which began after she had two dental bridges put in and got worse after a tooth was pulled to try to ease that pain. The discomfort eventually spread to other parts of her body.
Gonzales’s diagnosis involved something Talley had never heard of.
“On top of orofacial pain, I had central sensitization. That played a huge part in this gum area. She informed me about the healing process when you had that. If I ever have an operation I am to immediately let her know,” said Talley.
When she received that diagnosis of central sensitization, it was the first time that Talley felt like someone finally understood the extent of her pain.
Central sensitization is a somewhat mysterious but real nervous system disorder. Gonzales said that the cause is often unknown, but it is probably triggered by changes in the brain in response to repeated pain. Doctors are becoming better at monitoring those changes thanks to the development of new non-invasive neuroimaging and electrophysiological technologies that are revealing how both acute and chronic pain affect signal processing, metabolic activity and even structural changes in the brain.
Gonzales said they have learned that the amount of gray matter in the brain actually shrinks in both volume and density when a person is in chronic pain, leaving the patient less able to cope with that discomfort.
In Talley’s case, the chronic pain that resulted from her dental procedures may have been the trigger that caused her brain to start over-reacting to pain, leading to daily discomfort, interrupted sleep and an overall feeling of discouragement.
Gonzales prescribed the muscle relaxer Baclofen and put Talley on a daily regimen of physical exercises designed to supplement the medication. It includes posture and head movements and even a specific routine designed to help Talley reduce how much she moves while she’s asleep.
Talley’s case helps illustrate a problem that Gonzales said is all too common: People in chronic pain often struggle to find relief. She sees that often in her role as director of orofacial pain management at MUSC.
“Chronic pain is poorly treated in general,” Gonzales said. “Only about half of chronic pain patients say they have any relief from treatments, and about the same number say they feel they have very little control over their pain.”
The majority of health care expenditure, between 560 and 635 billion dollars a year, is spent on chronic pain management, she said.
“So we have this enormous need and that need is growing. By 2030, 20 percent of our population will be in that cohort at increased risk for the development of chronic pain by virtue of their age. So it’s probably okay to spend that much revenue on chronic pain. What’s not okay is to spend that much money and have so little return on the investment from a patient perspective.”
To get a better return on that investment, Gonzales said health care professionals who treat chronic pain need to acknowledge that they can do a better job of easing their patients’ discomfort and make sure they get the full picture.
For example, in her experience, the average oral facial pain patient has seven “co-morbidities,” or medical conditions that happen at the same time but are independent of each other. Gastrointestinal problems, reflux, irritable bowel trouble, headache, fibromyalgia, multiple chemical sensitivities and sleep disorders often come as a group, she said, and doctors need to work together to address those problems.
MUSC is in the process of creating a “chronic pain working group,” with experts in fields including dentistry, gastrointestinal disorders and psychiatry, to more effectively treat people’s pain.
In the meantime, Gonzales makes a point of putting her patients’ chronic pain into a holistic context. For example, if someone comes to her with what he or she believes is temporomandibular joint disorder, Gonzales gets a thorough patient history to learn about the jaw pain as well as to find out if that person has other discomforts as well.
Odds are, the answer is yes.
“Studies show the best treatments are multi-modal. Cognitive behavioral therapy, combined with judicious use of pharmacology, combined with physical self-regulation, how to control your own nervous system to reduce or stop amplifying the pain experience,” she said.
Talley said the way that Gonzales handled her case, looking not only at her gum pain but also at the reason it persisted and affected the rest of her body, was life-altering.
“I’ve told everyone about her,” Talley said. “I have suffered so long. I can’t tell you how she changed my life.”