from attention from loved ones. They may have some perfectly legitimate amount of pain and disability, and this may fluctuate over time. Cases of malingering in the absence of physical cause are actually quite rare. Somatization, on the other hand, is commonly associated with chronic pain, and the link between somatization and pain-related disability is present in most studies (Burri, et al., 2009). Text Box 3 provides two examples of symptom exaggeration in chronic pain.
are generating symptoms for secondary gain may not be consciously aware of what they are doing, and instead are using pain as a way to express emotional distress or satisfy an unmet need for attention. This unconscious process of converting psychological distress into physical symptoms is referred to as somatization. Although the difference between primary and secondary gain may seem clear and distinct, in practice it is difficult to differentiate between the two. Individuals may be involved in litigation because of their pain, but they may also benefit
Box 3: Two Malingerers To understand the complexities of symptom exaggeration in chronic pain, consider the following two cases.
Jared is a 26-year-old unemployed man who presents to a dental practitioner with complaints of dental pain in tooth #14. The dental practitioner obtains a periapical radiograph of the tooth and finds a periapical lesion at the apex of the tooth in question, but no tenderness to percussion or other sign of acute dental pain. The dental practitioner proposes the following treatment options: a root canal treatment, a pulpectomy, or extraction of the tooth. However, for financial reasons, the patient is unwilling to submit to treatment. During the appointment with the dental practitioner, the patient repeatedly asks for “something to take the edge off” so he can go home and consider the treatment options; he gets upset when the dental practitioner informs him that he will not receive a prescription for the opioid he has specifically requested. The dental practitioner is concerned about Jared’s behavior and checks Jared’s name in a local patient registry. She learns that he has seen three different providers in the past week and has received multiple prescriptions for narcotic medications. When confronted with this information, Jared threatens to sue the dental practitioner for “breaking confidentiality.” Jared is labeled as malingering, offered some ibuprofen for inflammatory pain, and sent home. 1. Mona is a 37-year-old schoolteacher who fell at her job and hit the side and back of her head, and now suffers almost daily from headaches. She states that she is experiencing continued jaw pain that makes it hard for her to talk in the classroom. When she first started having headaches, she had tried working through the pain, but after several months realized that she was unable to concentrate when the headaches were very bad, and came home exhausted from a day’s work. She presented to her healthcare provider, who ordered an MRI of the jaw joints and the brain. The MRI of the brain showed no abnormalities; the MRI of the jaw joints showed a disc displacement with reduction on the side opposite to her painful jaw. The results were otherwise negative. Because Mona is so exhausted from the pain, she lies down on the couch when she gets home from work. Her husband and children cook for her and have taken over most of her household chores. Despite being relieved of her household chores, Mona still experiences excruciating pain, and eventually she is prescribed a preventive medication for her chronic headaches – in this case amitriptyline, a medication that also may improve sleep. The medication seems to help with the pain and fatigue, and Mona seems to be feeling much better at work. However, upon returning home she immediately lies down on the couch because she believes that resuming her daily household routines might aggravate her pain. This behavior is putting a strain on her home life and her marriage. PAIN PREVALENCE AND IMPACT Prevalence and social cost
black patients, people of color and indigenous patients receive inadequate pain management only at (50%) compared to white patients (35%) for metastatic or recurrent cancer (Ghosal, 2020). With regard to racial and ethnic differences the literature varies in reports on the prevalence of temporomandibular joint disorders (TMJD). One report indicated that patients of Chinese ethnicity and to a lesser extent those of African descent had more radiographic features of TMJD than people of other racial groups while those of Indian descent had the least of these features (Obamiyi, et al., 2018). Yet another report indicated that TMJD were higher in whites than non-whites (Fenton, et al., 2018). Age and gender differences It is well documented that the frequency of pain complaints generally increases with age, with most older adults reporting some degree of chronic pain. However temporomandibular disorders are significantly higher between ages 20 and 40 and occur with twice the frequency in women than in men (Ryan et al., 2019; Patton and Glick, 2016; Bueno, et al., 2018). Interestingly, this age pattern may differ by race, notably for women. Hispanic and African American women reported lower rates of temporomandibular disorders, severe headaches, and neck pain than White women at younger ages, but higher rates than White women at later ages (Plesh et al., 2011). In contrast, the age and gender distribution of trigeminal neuropathic pain is not well known, most likely because of the low prevalence of this condition.
Determining accurate estimates of chronic pain prevalence is challenging because there is great variability from study to study. However, recent studies provide a picture of the prevalence of chronic pain. It is estimated that 20.4% of adults in the United States have chronic pain with 8.0% of these patients afflicted with high-impact chronic pain with the latter being persistent pain that causes significant restrictions of the activities of daily life for six months or more (The Good Body, 2021). It is widely acknowledged that chronic pain presents a major social and economic problem in the United States. The annual cost of pain is estimated at $635 billion annually in direct medical costs and costs related to lost productivity (The Good Body, 2021). Chronic pain is the most common reason for people to seek medical care (Centers for Diseases Control and Prevention, 2018). National Center for Complementary and Integrative Health [NCCIH], 2018).. Racial and ethnic differences A growing body of literature has shown differences in the report of pain, and treatment for pain, among racial and ethnic minorities. He data indicates that 16% of black patients and 22% of Hispanic American patients reported access problems to pain specialists compared to 8% of white patients with fewer pharmacies located in unrepresented areas. Indigenous people and Native Americans have indicated their frustration and betrayal by a healthcare system that underserves them (Ghosal and Malini, 2020). Recent research indicates that black patients who are treated for fractures in the emergency room receive less analgesics compared to white patients (57% to 74 %) for the same condition and that
EliteLearning.com/Dental
Page 53
Powered by FlippingBook