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Difference between revisions of "Conclusion of the ‘Normal Science’ section"
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= | {{ArtBy|||autore=Gianni Frisardi|autore2=Giorgio Cruccu|autore3=Luca Fontana|autore4=Cesare Iani|autore5=|autore6=Diego Centonze|autore7=Manuel Luci|autore8=Flavio Frisardi|autore9=}} | ||
'''Abstract:'''This chapter marks the conclusion of the 'Normal Science' phase, addressing key diagnostic issues in the complex field of Orofacial Pain (OP) and Temporomandibular Disorders (TMDs). Through a critical examination of current diagnostic paradigms such as the RDC/TMD, the chapter highlights the challenges of distinguishing TMD from other systemic diseases. A 5-year clinical study forms the basis for a new diagnostic model, the 'Index Ψ,' which integrates classical Bayesian probability with quantum models to address diagnostic uncertainty. | |||
This chapter | |||
The | Bayes' Theorem was applied to the data from the RDC/TMD model, showing a high probability (81%) of diagnosing TMD in symptomatic patients. However, the study's follow-up revealed the presence of serious non-TMD pathologies in many patients, leading to interference that reduced the diagnostic accuracy to 9.56%. This discrepancy was mathematically represented by a quantum interference term, introducing the idea of non-commutative diagnostic variables. The order of diagnostic tests was shown to influence outcomes, suggesting the need for a quantum-inspired approach to complex medical diagnoses. | ||
The study concludes by emphasizing the limits of deterministic diagnostic models and advocating for a flexible, multidisciplinary approach that accounts for the complex interplay between different clinical conditions. Future research should explore the integration of quantum models in medical diagnostics to improve accuracy and patient outcomes in multifactorial conditions like TMDs. | |||
==Introduction== | ==Introduction== | ||
We have reached the conclusion of the 'Normal Science' section, which | We have reached the conclusion of the 'Normal Science' section, which fundamentally equates to phase 2 of 'Kuhn's Paradigms' where the status quo of the paradigm in the field of Orofacial Pain (OP) and Temporomandibular Disorders (TMDs) has been presented. At the same time, a range of diagnostic issues that are not yet classifiable as 'Anomalies' but rather as critical elements to evaluate within the chapter context were highlighted. | ||
Chronic 'OP' conditions can be particularly challenging to diagnose and treat due to their complexity and limited understanding of the mechanisms underlying their etiology and pathogenesis.<ref>[https://www.ncbi.nlm.nih.gov/books/NBK555057/ NASEM Temporomandibular Disorders: Priorities for Research and Care] The National Academies Press, Washington, DC (2020), 10.17226/25652</ref><ref>B.J. Sessle. [https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/34281164/ Chronic orofacial pain: models, mechanisms, and genetic and related environmental influences]. Int J. Mol. Sci., 22 (2021), p. 7112, 10.3390/ijms22137112</ref> A frequent characteristic of 'OP' is the multifactorial nature of the pathology, which further complicates diagnosis. TMDs, for example, referred to variously as Temporo-Mandibular Disorders (TMDs), Cranio Facial Pain (CFP), and Temporo-Mandibular Joint Dysfunction (TMJ dysfunction) in Anglo-Saxon countries, sometimes present diagnostic challenges. The orofacial pain caused by TMDs often overlaps with symptoms and clinical signs similar to other painful disorders, which may be manifestations of other systemic neurological diseases. This clinical scenario can make differential diagnosis difficult, especially in the early stages of the disease.<ref>Sollecito T.P., Richardson R.M., Quinn P.D., Cohen G.S.: Intracranial schwannoma as atypical facial pain. Case report. Oral Surg Oral Med Oral Pathol. 1993;76:153-6</ref><ref>Shankland W.E.: Trigeminal neuralgia: typical or atypical? Cranio. 1993;11:108-12.</ref><ref>Graff-Radford S.B., Solberg W.K.: Is atypical odontalgia a psychological problem? Oral Surg Oral Med Oral Pathol. 1993;75:579-82.</ref><ref>Ruelle A., Datti R., Andrioli G.: Cerebellopontine angle osteoma causing trigeminal neuralgia: case report. Neurosurgery. 1994;35:1135-7.</ref> In a percentage of patients with functional disorders of the stomatognathic apparatus, some peripheral risk factors, i.e., occlusal, have been identified<ref>B.C. Cooper Temporomandibular disorders: a position paper of the International College of Cranio-Mandibular Orthopedics (ICCMO) Cranio, 29 (2011), pp. 237-244, 10.1179/crn.2011.034</ref><ref>M.S. Nguyen, T. Jagomägi, T. Nguyen, M.Saag, Ü. Voog-Oras Occlusal support and temporomandibular disorders among elderly Vietnamese Int J. Prosthodont, 30 (2017), pp. 465-470, 10.11607/ijp.5216</ref><ref>M.S. Nguyen, M. Saag, T. Jagomägi, Q.H.Nguyen, Ü. Voog-Oras The impact of occlusal support on temporomandibular disorders: a literature review Proc. Singap. Healthc., 31 (2021), pp. 1-12, 10.1177/2010105821102</ref><ref>T.R. Walton, D.M. Layton Mediotrusive occlusal contacts: best evidence consensus statement J. Prosthodont, 30 (S1) (2021), pp. 43-51, 10.1111/jopr.13328</ref><ref>A. Kucukguven, M.D. Demiryurek, I.Vargel Temporomandibular joint innervation: anatomical study and clinical implications Ann. Anat., 240 (2022), Article 151882, 10.1016/j.aanat.2021.151882</ref><ref>E. Tervahauta, L. Närhi, P. Pirttiniemi, K.Sipilä, R. Näpänkangas, M. Tolvanen, V.Vuollo, A.S. Silvola Prevalence of sagittal molar and canine relationships, asymmetries and midline shift in relation to temporomandibular disorders (TMD) in a Finnish adult population Acta Odontol. Scand., 80 (2022), pp. 1-11, 10.1080/00016357.2022.2036364</ref> as well as a series of central biopsychosocial risk factors concerning Central Nervous System dysfunctions.<ref>R.B. Fillingim, R. Ohrbach, J.D.Greenspan, C. Knott, R. Dubner, E. Bair, C. Baraian, G.D. Slade, W. Maixner [https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/22074752/ Potential psychosocial risk factors for chronic TMD: descriptive data and empirically identified domains from the OPPERA case-control study] J. Pain., 12 (11 Suppl) (2011), pp. T46-T60, 10.1016/j.jpain.2011.08.007</ref><ref>G.D. Slade, R. Ohrbachm, J.D.Greenspan, R.B. Fillingim, E. Bair, A.E.Sanders, R. Dubner, L. Diatchenko, C.B.Meloto, S. Smith, W. Maixner [https://pubmed.ncbi.nlm.nih.gov/27339423/ Painful temporomandibular disorder: decade of discovery from OPPERA studies] J. Dent. Res, 95 (10) (2016), pp. 1084-1092, 10.1177/0022034516653743</ref><ref>G.D. Slade, R. Ohrbach, J.D. Greenspan, R.B. Fillingim, E. Bair, A.E. Sanders, R.Dubner, L. Diatchenko, C.B. Meloto, S.Smith, W. Maixner [https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/27339423/ Painful temporomandibular disorder: decade of discovery from OPPERA studies] J. Dent. Res, 95 (2016), pp. 1084-1092, 10.1177/0022034516653743</ref> However, these studies have not provided new information on the main causes of TMDs and their implications for managing these patients<ref>P. Svensson, F. Exposto Commentary 2: further evidence for overlaps among chronic pain conditions-but no news about causal relationships J. Oral. Facial Pain. Headache, 34(Suppl) (2020), pp. s6-s8, 10.11607/ofph.2020.suppl.c2</ref> and consequently, a wide variety of mostly conservative treatments have been proposed<ref>C.S. Stohler, G.A. Zarb On the management of temporomandibular disorders: a plea for a low-tech, high-prudence therapeutic approach J. Orofac. Pain., 13 (1999), pp. 255-261</ref><ref>J. Feng, M. Luo, J. Ma, Y. Tian, X. Han, D.Bai [https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/31725647/ The treatment modalities of masticatory muscle pain a network meta-analysis] Med. (Baltim. ), 98 (2019), Article e17934, 10.1097/MD.0000000000017934</ref><ref>Z. Al-Ani Occlusion and temporomandibular disorders: a long-standing controversy in dentistry Prim. Dent. J., 9 (2020), pp. 43-48, 10.1177/2050168420911029</ref><ref>C. Penlington, C. Bowes, G. Taylor, A.A.Otemade, P. Waterhouse, J. Durham, R.Ohrbach [https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/35951347/ Psychological therapies for temporomandibular disorders (TMDs)] Cochrane Database Syst. Rev., Issue 8(2022), Article CD013515, 10.1002/14651858.CD013515.pub2</ref> but the lack of clinical evidence has allowed the role of occlusion in TMDs to be contested<ref>P. Alanen Occlusion and temporomandibular disorders (TMD): still unsolved question? J. Dent. Res, 81 (2002), pp. 518-519, 10.1177/154405910208100803</ref> although there is no scientific evidence contradicting a causal occlusal role in functional disorders.<ref>P. Kirveskari, T. Jamsa, P. Alanen Occlusal adjustment and the incidence of demand for temporomandibular disorder treatment J. Prosthet. Dent., 79 (1998), pp. 433-438, 10.1016/s0022-3913(98)70158-1</ref><ref>T. de Abreu, C. Bahia, T. Foscaldo, P.Senna, H. de Souza, R. Fischer, P.Kirveskari Effect of occlusal equilibration on masticatory muscle activity in females with sleep bruxism: a double-blind randomised controlled trial J. Sleep. Res., 14 (2023), Article e13879, 10.1111/jsr.13879</ref> | |||
In conclusion, a critical obstacle in understanding TMDs and consequently in differential diagnosis with 'OP' has been the loss of standardized diagnostic criteria for defining subtypes of TMDs, and for this reason numerous studies have been conducted to create a standardized diagnostic evaluation method called Research Diagnostic Criteria (RDC) and signed in RDC. For more information on the RDC theme follow the [[Research Diagnostic Criteria (RDC)|specific chapter]]. | |||
The fact is that in previous chapters we have highlighted critical issues not to be underestimated both for the delay in diagnosis and for the danger of diagnostic errors that can compromise the health of patients as well documented in the presentation of clinical cases. The prospective clinical study, which we will present in this chapter, will form the foundation of a new diagnostic paradigm that we will see realized at the end of the editorial writing of Masticationpedia and precisely in the 'Extraordinary Science' section. Given the complexity, delicacy, and criticality of the subject, the prospective clinical study lasted 5 years during which the subjects involved were studied, followed, and re-examined at three different times: at a time '''<math>t_0=</math>''' Preliminary diagnostic phase; a time '''<math>t_n=</math>''' Advanced diagnostic phase and finally a time '''<math>t_{n+1}=</math>''' Definitive diagnostic phase that will close the project from which a protocol called 'Index <math>|\Psi\rangle</math>' will be modeled, read as 'Index ket Psi'. | |||
The | The accuracy of the data derived from the prospective study at various evaluation times has been correlated with the Bayesian model, which is why it is necessary to briefly recall it. | ||
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Bayes' theorem is an important principle of probability theory that allows us to update beliefs or probabilities about an event in light of new evidence or information. In other words, it allows us to recalculate the probability of a hypothesis, given the observation of some data. | Bayes' theorem is an important principle of probability theory that allows us to update beliefs or probabilities about an event in light of new evidence or information. In other words, it allows us to recalculate the probability of a hypothesis, given the observation of some data. | ||
The formula for Bayes' Theorem is: | The formula for Bayes' Theorem is: | ||
<math>P(A|B) = \frac{P(B|A) \cdot P(A)}{P(B)}</math> | <math>P(A|B) = \frac{P(B|A) \cdot P(A)}{P(B)}</math> | ||
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At this point, we can transfer the results of the RDC test into Bayes and quantify the probabilities of clinical positivity and/or negativity. We begin with the data exiting the first analysis of the sample based on the classic RDC model and called Index <math>\Psi</math> at time <math>t_0</math> | At this point, we can transfer the results of the RDC test into Bayes and quantify the probabilities of clinical positivity and/or negativity. We begin with the data exiting the first analysis of the sample based on the classic RDC model and called Index <math>\Psi</math> at time <math>t_0</math> | ||
[[File:Table 1 CNSS.jpg|thumb]] | [[File:Table 1 CNSS.jpg|thumb|'''Table 1:''' representation of the output data from the RDC test in 40 subjects of which 30 asymptomatic and 10 symptomatic. For the RDC model, there are 9 subjects affected by TMDs and 1 symptomatic subject considered healthy but who in the follow up will realize that he was suffering from a serious tumor pathology, so the accuracy data will vary slightly depending on whether the false positive subject is considered or false negative, the conceptual substance does not change in this context. For the model emerging from the 'Group of Experts', however, the subjects affected by TMDs were 2, the subjects affected by other pathologies (noTMDs) were 7 and also for this model the subject n° 40 was considered not ill (healthy )]] | ||
===Index <math>\Psi</math> at time <math>t_0</math>=== | ===Index <math>\Psi</math> at time <math>t_0</math>=== | ||
We begin with an overview of the results obtained from the RDC model applied to a sample of 30 asymptomatic and 10 symptomatic subjects, analyzing the sensitivity and specificity of the test and, consequently, the total probability calculated through Bayes' theorem. This theorem is fundamental for evaluating the probability that a patient with a positive test is actually affected by the disease. | We begin with an overview of the results obtained from the RDC model applied to a sample of 30 asymptomatic and 10 symptomatic subjects, analyzing the sensitivity and specificity of the test and, consequently, the total probability calculated through Bayes' theorem. This theorem is fundamental for evaluating the probability that a patient with a positive test is actually affected by the disease. | ||
The model identified 9 symptomatic subjects affected by TMDs who met the RDC clinical criteria, and one healthy subject among the symptomatic, with a disease prevalence of | The model identified 9 symptomatic subjects affected by TMDs who met the RDC clinical criteria, and one healthy subject among the symptomatic, with a disease prevalence of 9%<ref>?</ref> in the examined population. (Table 1) We proceed to apply Bayes' theorem to the statistical data. | ||
Based on the results of the RDC test for our 40 subjects, of which 9 were considered affected by TMDs and 1 as a false negative, we proceed as follows: | Based on the results of the RDC test for our 40 subjects, of which 9 were considered affected by TMDs and 1 as a false negative, we proceed as follows: | ||
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|<math>P(B = \beta) = \sum_\alpha | |<math>P(B = \beta) = \sum_\alpha | ||