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In the Field: Unraveling the complexities of pain

Dr. Richard Ohrbach is a dentist who became so enamored with pain that he made it his career.

In a healthy way.

Ohrbach, a North Carolina native, landed at the University at Buffalo in the mid-1980s after stints as an Air Force dentist in Japan and San Antonio, Texas. While treating patients, he became fixated on what caused jaw pain. He wondered whether these temporomandibular disorders (TMDs) might be a window on chronic pain. His curiosity took him to a pain research fellowship at the University of California, Los Angeles.

“That really turned my life upside-down,” said Ohrbach, an associate professor of oral diagnostic services at the UB School of Dental Medicine. “I was working with psychologists and neurologists and acupuncturists, and learning about the real world of pain. I realized how much I really needed to learn, which is what brought me to Buffalo.”

Ohrbach got a master’s in oral sciences and Ph.D. in clinical psychology at UB, then landed a faculty post. He is director of the school’s Center for Orofacial Pain Research on the South Campus, founded in 2000.

He and his wife, Luisa Ferretti, a pediatric neuropsychologist in Williamsville, have a daughter Maddalena, 15. The family lives in Getzville.

Q. What is it like to practice dentistry in the military?

Like anywhere else except that it’s a fantastic health care system. You don’t worry about costs. You provide the best care. That spoiled me.

Q. Why did you choose UB?

They had the only post-doctorale training program in the country that was basically an introduction to pain research. After being eight years out of school ... it was kind of like starting over again. For the first time, I enjoyed learning more than ever before. Graduate school is different. It’s self-directed. One of my mentors, who was the chair at the time, had this great way of framing things because I didn’t know what I wanted to do next. His question was a simple one: “When you wake up in the morning, what do you want to see yourself doing?” If I think about it that way, rather than the big picture – I want to be a what when I grow up? – it was, “How do I want to spend my day?” I had been tormented for years about when I was going to find true happiness. I kept thinking big picture, not the small one, which is “How do you want to spend your day and who do you want to spend your day with?,” I’ve come to learn, is by far a much more useful way in finding job happiness and life happiness.

Q. What did you think when you first arrived?

I ended up in North Buffalo, the Elmwood Village. I was really charmed by the simplicity of Buffalo. I was living in West Hollywood, Los Angeles. Pretentious. The absence of pretentiousness in Buffalo was refreshing to me. Buffalo is a city where what you see is what you get. I was impressed back then at its simplicity. I didn’t see it as a Rust Belt City, not so much a city that was not prospering but was a place where people were happily living, and that meant a lot.

Q. Talk about your roles at UB.

I have a part-time private pain practice with two colleagues: Yoly Gonzalez and Heidi Crow. I work one day a week in the practice, which is based with the oral surgeons in the dental school. I do some teaching with the dental students and graduate students and it’s all focused on pain. I spend the rest of the time doing research.

Q. What grabbed you when it came to pain?

One, its incredible complexity, meaning it was a challenge. Second was that pain spans everything from neuroreceptors up to philosophy. There was this extraordinarily broad range of people involved in pain. No field owns it.

Q. What sort of pain do you treat in private practice?

The typical patient has had pain five to 10 years that has not responded to prior treatments. Because I’m identified most commonly as a dentist, it’s jaw pain and headaches that cause people to walk in the door. … Pain can be a symptom of a disease. Pain also can be the primary disorder. In the cases I see, pain has become the primary disorder.

Q. How do you tend to treat pain?

Part of it is starting with a good diagnosis. A lot of our research has been foundational in the world of TMD internationally. We’re in the second generation of the diagnostic criteria. We had NIH funding for that. We spent a lot of years doing the research and a lot of years consolidating that into a paper that we published in 2014 that is now the standard for TMDs internationally. I’m part of an international consortium where we have about 20 different groups now translating that whole protocol into other languages for use around the world. I find that international cooperation extremely fulfilling. You can look at what happens in your backyard but when you’re able to see what happens around the world – different cultures, different languages, different health care systems – how things morph, how things have to change, that’s fascinating.

I have a colleague who’s a surgeon and sociologist in England – a very interesting combination – and we work very well together. He takes what we have defined as the orthodox view and he’s had to mold it to adapt to the National Health Care Service in England.

Q. Is there an intersection of psychology and anatomy when it comes to pain?

It’s huge. Pain is bigger than any one kind of process that we think of. Pain occupies the space from the neuron up – for example the primary receptor that detects the presence of heat on the stove – to the culture that we live in, and shapes our expectations about what is normal and what is painful. So it’s not just an intersection of psychology and anatomy. It’s just two ways of thinking about the same fundamental process. We can’t have a thought without our brain doing something. There’s two things going on. There’s the neurons talking to each other at that kind of level and there’s the self-consciousness, this awareness that we have.

Q. How challenging can it be to pinpoint the symptoms that lead to a diagnosis of TMD?

This is me the psychologist talking. I’m a big fan and proponent of the field that has developed called narrative medicine. It’s to say if you really want to understand a person who has a disease, you need to understand their story. In their story is all those elements that go into play of how a life is lived and what a disease can represent. For me, it always comes back to history taking and understanding the person, understanding what behaviors and problems are associated with symptoms and what behaviors are not. A person could be depressed, for example, and the depression could have been a precursor of their pain or a consequence of their pain. How would you know? Well, you take a good history.

Q. How effective is conventional medicine in unraveling this narrative?

Interventional medicine, which is based on medication and surgery? I think poorly. Mindfulness in medicine (he shared a brochure about an upcoming mindfulness conference March 4 at UB – read a Refresh Buffalo Blog story about the conference here) is a tradition that goes back two and a half thousand years but has become a buzzword these days. There are folks who are now working on this seriously. You can use a search engine and go to mindfulness and Harvard and find out about profound, really, really good research that they’re doing there. A lot of it is based on brain imaging and showing how we can literally change our brains by the way we
use our minds. UB is late in the game compared to a lot of universities that have really thought seriously about this stuff. I see this program coming up as somebody really starting to jump-start what they see as … a merger across a lot of different kinds of traditions.

Q. Where do you find pain medication at work in your treatment?

We go back and forth with pain meds. In the last five or 10 years, there’s been increasing scrutiny around the use of opioids for treatment of chronic, non-cancer pain, so much so I think the pendulum is swinging very strongly toward don’t use opioids. I think that probably has error with it as well, because there are a lot of folks with chronic pain who find they can be managed well with opioids. But the most common type of meds for a TMD condition is probably antidepressants – tricyclics, in particular – muscle depressants short-term, and over-the-counter analgesics. By and large, for musculoskeletal pain, more of a rehab approach, retraining, exercise and better use of soft tissues tends to be much more powerful than medications. At this point, it’s been probably two years since I’ve written a script, since the non-pharmacological approach often works. Using ice, for example, judiciously, along with stretching of the painful muscles, just like with any sports injury, tends to be extremely powerful in terms of helping people start to manage their pain.

One of the big pieces – and this comes not so much out of our work as general medicine – is the role of self-management in particular. When people have the power and the confidence to take care of themselves, brains change in response to that. When we feel better about ourselves, we do better with ourselves. When we can do better, we feel better. So self-empowerment, giving people control so that they can better manage their pain, is not only cost-effective in the short term, it’s pivotal in the long term.

Q. Talk about the Orofacial Pain Prospective Evaluation and Risk Assessment (OPPERA) study and your role as one of six principal investigators.

There are four study sites plus a data center and a geneticist. The study is sponsored out of the University of North Carolina. We were funded out of the National Institutes of Health, initially about 10 years ago … OPPERA I was for seven years and we enrolled across the four study sites about three and a half thousand people who had never had TMD. We followed them every three months, looking for when people began to develop symptoms. We identified about 300 people with first lifetime of TMD. It was a unique set of folks. We also enrolled another cohort of about 1,000 people who had chronic TMD. Both of those groups are still with us 10 years later in OPPERA II.

Q. What did you conclude were among the most common risk factors for TMD?

If they have other pain disorders, they are more likely to report TMD. People who engage in various kinds of behaviors with their jaw – clenching the teeth together; pressing their teeth together; playing with their cheek, their tongue; holding the jaw rigid – if they’re done to excess, it’s also one of the strong risk factors that has been speculated upon for decades from dentists around the world but we didn’t have evidence (until now).

The third one is a shift in the state of their oral tissues. So we ask about non-pain symptoms in the facial region – aching or tightness or tingling – but clearly not pain. Those symptoms have a very strong role in who develops TMD.

And of course we found the usual spectrum on the psychology realm. Any kinds of symptoms of distress – depression, anxiety, problems with coping with stress, pain catastrophizing, having thoughts about “If I have this pain, I can’t make it, I can’t do it anymore, I can’t fix it, this pain is the worst” – is also very predictive.

Q. Why does it seem that those with other pain disorders are more at risk for TMD?

It’s a very interesting area that NIH is now actively pursuing. It’s called comorbidities. People don’t have to be restricted to one illness or disorder. If you go into a clinic that specializes in TMD, you’ll find a whole lot of people there who have other disorders. If you go into a back pain clinic, you’ll discover that a whole lot of people have other disorders. If you go to a clinic where Irritable Bowel Syndrome is being treated – such as Erie County Medical Center, for example – you’ll find the IBS population has other disorders. It seems that from looking at data across all the different pain conditions, the comorbity with other conditions with the index condition seems to be pretty much the same regardless of the index condition. There doesn’t seem to be any primacy in terms of one condition or another.

It’s rather, if there is a pain disorder that persists, it changes the person. We believe that it has to do with how the nervous system responds to persistent pain as an aversive experience and how we intentionally or unintentionally begin to adapt and change the way our brain works, the way we behave.

We assume – we don’t have any evidence – but we assume the same holds true for any other musculoskeletal pain. So what we’re doing with the NIH-funded OPPERA study has been really pivotal worldwide. They’re the only studies that have been done with this kind of detailed investigation.

Q. The sooner you address these issues, the better chance you’re going to have in the long run to overcome them?

Yes. Primary prevention would be great but I don’t see that happening anytime soon. Early intervention, however, is very much the key. That relies on early detection. People need to realize they have a disorder and practitioners need to say to themselves, “Let’s not just sit on this. Let’s be much more assertive in providing the right kinds of interventions.” Some studies have been done on this and demonstrate that earlier treatment makes a difference. The challenge is how to make the treatments more widely available, more efficient. Part of our work in the diagnostic realm has been in the development of screening approaches so people can be identified much more quickly in routine practice setting. Practitioners are busy. How do you screen for every possible thing? Blood pressure, for instance, takes a minute and it’s a fantastic screening device for cardiovascular systems. We developed an instrument a couple of years ago as a screener for people who have TMD pain as a way of early identification.

Q. How does it work?

It’s some self-report items that ask about symptoms. Often people won’t complain about symptoms. They won’t talk to their doc about this ache or that ache because what drives us in to health care is a particular kind of complaint. People don’t speculate about the possible presence of hypertension but physician and dental offices intervene with a proper screening test – they take a blood pressure. It’s that idea, but adding efficient screening tools into regular practice is a very difficult kind of thing, partly because people are very busy and don’t get paid for it.

Q. What sort of questions do you ask?

Simple ones: Do you have pain in your jaw area? Is your pain affected by function – chewing, kissing talking, clenching or grinding of the teeth? It gets into the core of what represents musculoskeletal pain. It’s often the case that people will have pain that’s associated with chewing. But life is simple. They set it aside, set it aside, set it aside. This is what I often hear from my patients in private practice. “I had symptoms for years. I was busy raising my kids. I didn’t have time for me.” Or “I thought it would go away,” o
r “I was too busy working and pushed it aside until one day, bang, I couldn’t deal with it any more.”

Q. It also sounds like eating properly, exercising, meditating – doing a lot of things that are good for us generally – would seem to help with pain.

Yes, and it’s interesting you bring up exercising. One of our consultants in the study is a well-known rheumatologist at the University of Florida, Roland Staud. Roland and I were talking in December. He’s originally from Germany and has this different way of thinking about American culture because he didn’t grow up here. He says, “It’s activity. It’s all about activity. I tell my back pain patients, my fibromyalgia patients that they need to exercise more. Do you know how many of them do? No one. They don’t want to.”

I think that’s part of the challenge. Pain is something we can create in the brain or it’s some stimulus to the body. The parallel is that there is another system that modulates all that. When you’re in a feel-good moment, things are going to be less painful to you than if your depressed or feeling anxious, which goes against activating that modulatory system. Regular physical exercise profoundly activates that system. Part of what creates that pain is a disregulation. It’s not an excess of pain signals but rather an insufficiency of the pain modulatory system that keeps it balanced. That’s where mediation also helps. It activates that pain modulatory system and changes our perception about how we respond to what we’re feeling. We think that physical activity will help for fibromyalgia, pain all over the body, or back pain, but physical activity for jaw pain or headache? We’ve got to get out of thinking of it as a regional disorder and thinking of it as rather a representation or manifestation of a more central process. Underlying all pain is exactly the same stuff in the brain.

Q. Your research is ongoing. Where does it stand now and who are you looking for to participate as you continue?

Anybody who has jaw pain in Erie County or southern Niagara County, whether it’s new or long-standing, fits within our geographic frame. We have one of two studies for folks to enter. We also will be starting a clinical trial coming up soon with medication treatment of TMD pain. We’re interested in looking at a gene by medication interaction: Why does the medication work in some people and not others? It’s going to be a beta blocker, propranolol. It’s used in headache and cardiovascular disease and has also been shown to be effective with TMD pain. For more information or to register, call 829-2984.

email: refresh@buffnews.com

Twitter: @BNrefresh; @ScottBScanlon

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