Fibromyalgia: practical considerations for oral health care providers

J Dent Anesth Pain Med. 2020 Oct; 20(5): 263–269.

Published online 2020 Oct 30. doi: 10.17245/jdapm.2020.20.5.263

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Fibromyalgia is a syndrome characterized by chronic pain in the skeletal system accompanied by stiffness, sleep disturbance, fatigue, and psychiatric problems, such as anxiety and depression. Fibromyalgia commonly affects orofacial health, presenting with a variety of oral manifestations, including temporomandibular disorder, xerostomia, glossodynia, and dysgeusia. Therefore, oral healthcare providers need to be aware of this clinical entity to effectively manage oral symptoms and provide proper oral self-care modification and education on the nature of fibromyalgia. This review focuses on the epidemiology, pathophysiology, clinical manifestation, diagnosis, orofacial concerns, and treatment of fibromyalgia.

Keywords: Dysgeusia, Fibromyalgia, Glossodynia, Oral Health, Temporomandibular Joint Disorder, Xerostomia

Fibromyalgia (FM) is a chronic pain syndrome characterized by widespread musculoskeletal pain and specific sites of tenderness, stiffness, and fatigue. In particular, specific tender regions are detected without signs of inflammation in patients with FM. This can severely decrease the quality of life and affect any region in a patient, including the orofacial area [1,2]. Oral care practitioners can detect the early symptoms of FM and assist patients in receiving the proper diagnosis and treatment. The epidemiology, pathophysiology, clinical manifestation, diagnosis, orofacial concerns, and treatment of FM are reviewed here.

FM has been diagnosed in 3–6% of the population, imposing substantial medical costs [3]. It occurs in up to 4% of men and 2.5–10.5% of women with a peak onset of disease in middle age (45–60 years). FM has a familial preponderance with variable manifestations [4,5]. It is prevalent in lower socioeconomic groups, which have members more likely to work in manual occupations, leading to an increase in trauma and pain [6,7].

The etiology of FM is unknown. It is associated with a multifactorial etiology. First-degree relatives with FM are 8.5 times more likely to have this disorder than the general population [5]. However, genetic factors associated with FM are unknown. It has been suggested that serotonin- and dopamine-related genes may play a role in the pathogenesis of FM [8].

Many researchers report that patients with FM have neuroendocrine dysfunctions such as hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis and sympathoadrenal system, and relative hypocortisolism [9,10]. Emotional and physical stress can affect the HPA axis [9,10].

Patients with FM have a three times higher concentration of substance P in the cerebrospinal fluid than healthy controls [11]. Activation of the N-methyld-aspartate receptor (NMDAR) is increased in FM patients. Substance P modulates the responsiveness of the NMDAR to glutamate, which consequently leads to temporary central sensitization and temporal summation in otherwise healthy individuals [12,13]. It has been demonstrated that serotonin levels in the serum are reduced and inversely correlated with pain threshold in FM patients [14,15]. Combined dysfunctional neurotransmitter systems, such as low serotonin and high substance P levels, can produce more pain than either abnormality on their own and be responsible for the onset of FM [16,17].

Dysfunction of the autonomic nervous system is common in FM patients. Positional changes often result in syncope, palpitations, and dizziness [18,19]. Heart rate variability among FM patients is reduced due to an increased nocturnal exaggerated sympathetic modulation of the sinus node [18,19]. Abnormal functioning of the HPA axis leads to dysregulation of diurnal cortisol production, which can result in cortisol deficiency and maladaptation [14]. This abnormal chronobiology is linked to sleep disturbances and fatigue in FM patients [14,19].

Research has demonstrated that FM patients have a lower level of dopamine, which plays a central role in modulating pain perception and natural analgesia within supraspinal regions and the spine in painful conditions [20,21]. It was found that several serum pro-inflammatory cytokines, such as tumor necrosis factor (TNF)-α and interleukin, are involved in the generation of symptoms in FM, including sleep disturbances, fatigue, and myalgia [8,22,23,24]. It has been suggested that oxidative stress may also play a role in the pathophysiology of FM. Several studies have shown that lipid peroxidation is correlated with pain, depression, and quality of life in FM patients [24,25]. The severity of pain was significantly associated with oxidized low-density lipoprotein [24].

Physical trauma, infection, and psychosocial factors are reported to be associated with the onset of FM [26,27]. Environmental triggers, such as acute illness and psychosocial stress, may alter the pain modulatory response in the brain, leading to enhanced pain perception [27].

FM is a complex systemic disorder characterized by generalized musculoskeletal pain and specific sites of tenderness, sleep disturbance, stiffness and fatigue, and psychological problems [1,2]. The diagnosis of fibromyalgia is based predominantly on the patient’s history and physical examination findings. However, it is difficult because patients with FM may have several comorbid conditions, such as a history of headaches, temporomandibular disorder (TMD), irritable bowel syndrome, interstitial cystitis, myofascial pain syndrome, and restless leg syndrome [1,28]. FM is defined as a chronic musculoskeletal pain syndrome of unknown etiology, characterized by widespread pain for more than 3 months and tenderness in at least 11 out of 18 tender point sites by the American College of Rheumatology () [29].

Table 1

Excluded studies with reasons

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Scoring
Widespread pain index: Count the number of regions the patient reports pain within the last week
Score will range from 0 to 19.
Symptom severity scale score*: Indicate how severe each of these three symptoms (fatigue, waking unre-freshed, cognitive symptoms) have been over the past week using the following scale:
0 – No problem
1 – Slight or mild problems
2 – Moderate, often present and/or at a moderate level
3 – Severe, continuous, life-disturbing problems
Considering common other symptoms, note whether the patient has:
0 – No symptoms
1 – Few symptoms
2 – A moderate amount of symptoms
3 – Many symptoms

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^*The symptom severity scale score is the sum of the severity of the three symptoms (fatigue, waking unrefreshed, cognitive symptoms) and the extent of the other symptoms in general. The score ranges between 0 and 12.

Psychiatric conditions, such as depression, panic disorder, anxiety, and post-traumatic stress disorder, are common in FM patients [30]. FM patients are more than three times as likely to have psychiatric disorders than the general population. It was found that the psychiatric disorders associated with FM greatly compromise the quality of life of affected patients [31,32]. Sleep disturbances such as non-restorative sleep, insomnia, and poor quality sleep, are reported to be higher in patients with FM, which is strongly associated with pain and fatigue [1,33].

Many patients with FM have orofacial pain disorders, such as TMD and oral complaints [22,34].

TMD is a term encompassing chronic orofacial pain conditions involving the masticatory muscles, temporomandibular joint, and associated structures. The exact etiology and progression of TMD are poorly understood, while the primary pathology appears to be a degenerative condition, such as osteoarthritis or osteoarthrosis [22,35]. The prevalence of TMD ranges from 42% to 94% in FM patients [35,36]. Therefore, it was suggested that FM may be a predisposing factor for the onset of TMD [37,38]. It has been reported that the masticatory muscles are sensitive and can be tender points in patients with FM [37]. The comorbidity of TMD and FM may lead to or be a consequence of the centrally mediated alteration in pain perception [39,40,41]. Therefore, routine treatments for patients with TMD and FM may not be effective [39]. Occlusal splints were found to be ineffective in relieving myofascial pain in patients with widespread pain [42]. It was reported that full body tactile stimulation using massage was effective to improve the signs and symptoms of TMD in patients who are refractory to conservative TMD treatment [43]. Failure to diagnose underlying FM may not provide appropriate treatment. FM patients with TMD are associated with several comorbidities and psychosocial problems.

FM patients may present with numerous oral complaints, such as xerostomia, glossodynia, and dysgeusia.

Xerostomia, known as dry mouth, is a subjective sensation of dryness in the mouth, which often accompanies salivary gland hypofunction. The incidence of xerostomia with FM varies from 7% to 71% [39,44]. FM patients with various comorbidities are usually managed with xerostomia-inducing medications including antidepressants, sedatives, and muscle relaxants [44,45]. It was demonstrated that about 71% of FM patients have xerostomia, while only 27.5% of FM patients receive xerogenic medications [44]. This suggests a significant prevalence of xerostomia in FM patients independent of the use of xerogenic medications [44]. Xerostomia can increase the rates of caries, periodontal disease, dysphasia, mouth ulcers, and candidiasis. Therefore, it is important to provide appropriate treatment for xerostomia and avoid oral complications [45].

Glossodynia (burning mouth syndrome) is also commonly noted in FM patients. Approximately 33% of patients with FM experience glossodynia [44]. Hormonal disturbance, malnutrition, and depression are also associated with burning mouth syndrome [44,46]. The exact etiology and pathogenesis of burning mouth syndrome remains unclear. Neurological mechanisms, including peripheral neurogenic damage and central hyperexcitability, may induce hyperalgesia and allodynia in FM patients with glossodynia [39,44]. Antidepressants, such as amitriptyline, are reported to be effective in treating FM with glossodynia [39,47]. In addition, the use of saliva substitutes and sialagogues and avoiding consumption of alcohol and caffeine are recommended for FM patients with xerostomia [39,47].

Dysgeusia is a taste disorder that causes foul, rancid, metallic, or salty taste perception. Dysgeusia was reported in 34.2% of FM patients [44]. This can represent a symptom of somatization or side effect of xerogenic medications [44,46].

Headache is reported by 35% to 82% of FM patients [48,49]. Migraine or tension-type headache is common in FM patients. It was demonstrated that chronic headache was endorsed by 76% of treatment-seeking FM patients, with 84% reporting substantial or severe impact from their headaches [40,48]. Therefore, it was suggested that assessment of headache should be a part of the routine evaluation of patients with FM [49].

The clinical presentation of FM varies. Patients should be questioned about a detailed history of orofacial complaints, current medications, and commodities. When the diagnosis of FM is suspected, the patients can be referred to a pain physician or rheumatologist for appropriate diagnostic workup and treatment [46].

A multidisciplinary approach is required for the treatment of patients with FM. Education, pharmacological therapy, and nonpharmacological therapy are the mainstay of treating pain and associated conditions in patients with FM (). [1,2]. Strategies to reduce stress during oral care, build a trusting relationship between the patient and the practitioner, and provide effective pain management are required [39]. One of the most important aspects in the treatment of FM is to recognize the nature of this disease. FM is not an acute but chronic condition [39,46,50]. Therefore, the aim of treatment is to manage symptoms of FM, such as pain, sleep disturbance, and depression. A variety of medications are used to treat the symptoms of FM (). Polypharmacy is usually employed. Pharmacological treatment should be guided toward pain as well as comorbidities. Healthcare providers should be familiar with the side effects of drugs and possible adverse drug reactions associated with multiple medications. For instance, combined treatment with antidepressants and anticonvulsants can increase dry mouth, sedation, dizziness, and constipation, compared with that with each treatment alone [50].

Table 2

Treatments for fibromyalgia

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Pharmacological treatment alone is often ineffective in treating FM [39]. The combination of education, cognitive behavioral therapy, and exercise regimens with pharmacologic treatment are important for managing FM [50]. These therapies are reported to provide long-term beneficial effects with an improvement in symptoms and overall quality of life [46,49,50]. Psychological interventions, including basic body awareness therapy, cognitive-behavioral therapy, and imagery intervention, are often used for FM [39,50]. Other nonpharmacologic therapies such as heat application and dietary modulation are also effective [50].

Due to pain and comorbidities, it is often difficult for patients with FM to perform effective oral health self-care, which can lead to perioral lesions such as ulceration and aphthous stomatitis [36]. Perioral infection exacerbates stress on the body, which consequently worsens the symptoms of FM. Oral health care providers should frequently monitor oral self-care and help prevent oral diseases and infections [39,46].

FM patients commonly have various psychiatric disorders. It is important to reduce emotional stress and anxiety prior to their oral hygiene treatment. In addition, FM patients often complain of heightened pain sensitivity and fatigue [27]. Poor management of pain and stress can lead to adverse patient outcomes. Therefore, pretreatment with anti-anxiety drugs and topical and local anesthetic agents is beneficial for the management of discomfort during oral healthcare [39,50].

FM affects the overall health of patients, and FM patients commonly present with a variety of oral manifestations, including temporomandibular disorder, xerostomia, glossodynia, and dysgeusia. Therefore, oral healthcare providers need to be aware of this disorder to better manage oral symptoms and provide proper oral self-care modification and education about the nature of FM. Additionally, it should be considered to provide a stress-free treatment environment.

Contributed by

AUTHOR CONTRIBUTIONS:

• Younghoon Jeon: Writing, review, & editing.

^NOTENo conflicts of interest or funding.

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Fibromyalgia

Home / Articles / Fibromyalgia

Fibromyalgia is characterized by chronic generalized skeletal muscle pain caused by a non-inflammatory rheumatic soft tissue lesion. It is a fairly common condition and occurs in 0.5-5% of the population.

Clinical manifestations

Symptoms of fibromyalgia vary. As a rule, patients complain of persistent, diffuse, deep throbbing or cutting pain. Very often fibromyalgia is accompanied by:

• anxiety,
• depressed,
• sleep disorders,
• dizzy,
• difficulty in moving in the morning,
• physical fatigue,
• irritable bowel syndrome.

May be combined with other abnormal conditions:

• TMD;
• Chronic headache;
• Chronic low back pain;
• Intolerance to many chemical compounds.

Common psychiatric disorders associated with fibromyalgia:

• Bipolar disorders;
• Severe depression;
• Eating disorders;
• Abuse of drugs, drugs, alcohol.

Etiology

Genetic and environmental factors play an important role in the development of this disease, as evidenced by the high prevalence of fibromyalgia among blood relatives. This disease belongs to a group of functional somatic symptoms that are similar in clinical manifestations, pathogenesis, epidemiological parameters and treatment strategy.

TMJ and facial pain

Temporomandibular disorders (TMJ) are considered the most common chronic anomaly of the maxillofacial region. You need to know that the term “TMJ” includes several pathological conditions that differ in etiology and pathogenesis. Pain in the facial area is one of the main indicators for the treatment of TMJ. TMJ symptoms are quite common. According to statistics, facial pain occurs in 10-20% of adults, most often at the age of 20-40 years.

TMJ and fibromyalgia

A number of studies have noted the prevalence of the combination of TMJ and fibromyalgia. According to some reports, 53-94% of patients with fibromyalgia have symptoms of TMD. Recent studies suggest that 40% of patients with fibromyalgia have myofascial pain, 30% have disc displacement, and 70% have arthralgia, osteoarthritis, or osteoarthritis.

Despite some common characteristics of fibromyalgia and TMJ, there are some differences between them, in particular in terms of disability and patients’ attitudes towards their condition.

Differential diagnosis of these diseases is carried out using a number of clinical parameters. Studies have shown that fibromyalgia is a significantly more severe disease than TMJ due to multiple painful areas, somatic symptoms, and severe pain intensity.

Thus, despite the possibility of a relationship between TMJ and fibromyalgia, it is still not clear.

Clinical aspects

The effectiveness of TMJ treatment, in particular with occlusal caps, varies depending on the presence or absence of diffuse pain. Therefore, it is advisable to conduct an examination aimed at identifying such pain in patients with facial myofascial pain, since the combination of various disorders can affect the outcome of treatment. In clinical practice, it is necessary to separate the TMJ from TMJ symptoms caused by the spread of fibromyalgia.

With the simultaneous presence of TMJ and fibromyalgia, we can talk about a violation of the central mechanism of pain perception, which explains the insufficient effectiveness of conservative treatment of TMJ.

Methods for the treatment of fibromyalgia

They can be divided into pharmacological and non-pharmacological, which include various psychological effects. Often, the treatment of fibromyalgia requires the help of specialists in various fields of medicine – a physiotherapist, rheumatologist, psychologist, therapist.

Based on the presence of similar symptoms, the differential diagnosis of fibromyalgia and TMJ is significantly difficult. If the results of conservative treatment of TMJ are unsatisfactory, an additional examination is necessary to identify concomitant fibromyalgia. If you suspect fibromyalgia, you should consult a rheumatologist or a general practitioner, as well as a physiotherapist.

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Fibromyalgia – treatment, symptoms, causes, diagnosis

Fibromyalgia is a chronic disease characterized by pain, stiffness and soreness of the muscles, tendons, and joints. Fibromyalgia is also characterized by sleep disturbance, chronic fatigue, depression, anxiety, and bowel dysfunction. Fibromyalgia is sometimes called fibromyalgic syndrome or fibrositis.

Although fibromyalgia is one of the most common diseases affecting muscles, the cause is still unknown. Tissues that are a source of pain are not accompanied by inflammation of this tissue. And therefore, pain, which causes a lot of inconvenience for the patient, does not lead to irreversible changes and destruction of tissues. In addition, there is no damage to internal organs. In this regard, fibromyalgia differs from rheumatic diseases such as rheumatoid arthritis, SLE, or polymyositis. In these diseases, inflammation of the tissues occurs – this is the main cause of pain, stiffness, soreness in the joints, tendons and muscles, and, in addition, damage to both tissues and internal organs occurs.

Causes

The cause of fibromyalgia is unknown. Fibromyalgia patients experience pain in response to stimuli that are not normally perceived as painful. Studies have shown that patients with fibromyalgia have elevated levels of a neurotransmitter (called substance P) and nerve growth factor in their cerebrospinal fluid. In addition, patients with fibromyalgia have reduced levels of serotonin in the brain. A study of pain in fibromyalgia suggested hypersensitivity of the central nervous system. Scientists have also noted disturbances in pain perception in patients with fibromyalgia.

In addition, patients with fibromyalgia reported a decrease in slow eye movements during sleep (which partly explains the feeling of fatigue after sleep or frequent awakenings). The debut of fibromyalgia is often associated with a psychological factor, trauma or infection.

Who is prone to fibromyalgia

Fibromyalgia affects mainly women (up to 80% women suffer) aged 35 to 55 years. Much less frequently, fibromyalgia occurs in men, children, and the elderly. The disease may appear on its own or be associated with other diseases such as SLE or rheumatoid arthritis. The prevalence of this disease varies from country to country. For example, in Sweden and Great Britain 1% and in the USA – 4%.

Symptoms

The universal symptom of fibromyalgia is, of course, pain. As mentioned above, fibromyalgia pain is not caused by tissue inflammation. Instead, patients seem to have hypersensitivity to various sensory stimuli and an unusually low pain threshold. Minor sensory stimulations that do not usually cause great distress to other people can be significant and disruptive in patients with fibromyalgia.

Fibromyalgia pain can be in different parts of the body, and on both sides. Most often, pain occurs in the neck, buttocks, shoulders, in the chest, in the upper body. Sensitive zones are limited areas where there is increased sensitivity.

Fatigue occurs in 90% of patients. Fatigue may be associated with pathological disturbances in sleep phases, which is often observed in these patients. Normally, there are several levels of sleep depth. A person needs to be in a deep stage of sleep for a longer time in order to restore the body’s strength. Fibromyalgia patients lack a deep, restorative level of sleep (called the slow eye movement stage). As a result, patients wake up in the morning feeling tired and with heaviness in the muscles and a feeling of lack of sleep (although the number of hours of sleep was sufficient).

Mental or emotional problems occur in more than half of patients with fibromyalgia. These disorders include poor concentration, impaired fixation memory, irritability, and depressed mood. And due to the fact that the diagnosis of fibromyalgia is difficult to verify, such patients are often diagnosed with depression.

Other symptoms of fibromyalgia may include migraine headaches or tension headaches, various sensations of numbness or tingling in various parts of the body. In addition, there may be discomfort in the abdomen (spasmodic bowel) irritated bladder (frequent sometimes painful urination). But the examination does not show signs of inflammation in the intestines or bladder. Each patient with fibromyalgia is unique in their own way, and symptoms can occur in various combinations.

Diagnosis

There are no tests or x-rays to support the diagnosis of fibromyalgia. Tests and examinations are prescribed to rule out other diseases. The diagnosis of fibromyalgia is based on the history of the disease and physical examination findings. In patients with chronic pain, the diagnosis of fibromyalgia can be made based on the detection of tender points (up to 80% of cases), the presence of tissue inflammation and the exclusion of other diseases. Many diseases have symptoms similar to fibromyalgia. For example, these are diseases such as:0003

• Low thyroid hormone levels (hypothyroidism),
• Vitamin D deficiency
• Increased function of the parathyroid glands (causes an increase in the level of calcium in the blood),
• Muscle diseases accompanied by muscle pain (polymyositis),
• Bone disorders, with bone pain (Paget’s disease),
• Increased blood calcium level (hypercalcemia),
• Infectious diseases (hepatitis, Epstein-Bar virus, AIDS),
• Oncological diseases.

Although blood tests do not confirm fibromyalgia, they are essential for the differential diagnosis. Therefore, it is necessary to do blood tests for thyroid hormones, the level of calcium in the blood (to rule out hypercalcemia, hyperparathyroidism, hypothyroidism). Alkaline phosphatase levels are often elevated in patients with Paget’s disease. Creatine phosphokinase is often elevated in patients with polymyositis. A detailed blood test and blood biochemistry allows diagnosing hepatitis.

Fibromyalgia may present on its own or in association with systemic rheumatic diseases. In systemic rheumatological diseases (SLE, rheumatoid arthritis, polymyositis), inflammation and damage to various tissues and organs occur. For the diagnosis of these diseases, such analyzes as ESR plasma protein levels, antinuclear factor, C reactive protein, sialic acid are important. With fibromyalgia, these tests are within the normal range.

Treatment

Because the symptoms of fibromyalgia vary greatly from patient to patient, treatment programs must be personalized for each patient. Fibromyalgia treatment programs are most effective when combined with pharmacological and non-pharmacological treatments.

Stress reduction

It is practically impossible to measure stress levels in different patients. For some people, spilled milk on the table is almost a tragedy. And for others, even if the tank drives into the room, there will be no concern. A good effect for reducing stress is given by biofeedback and relaxation techniques. Sometimes, changes in environmental factors (such as noise, temperature, weather changes) are enough to increase the symptoms of fibromyalgia. And the impact on these factors can have a positive impact. Optimal amount of sleep is very helpful.

Exercise therapy

Low-intensity physical activity such as swimming, cycling, walking Especially beneficial in the morning. The mechanism by which exercise influences fibromyalgia is not known. One factor may be improved sleep (prolongation of REM sleep).

Diet

There is no specific diet for the treatment of fibromyalgia. It is recommended to avoid drinking alcohol and coffee in the evening in order to improve sleep. In the presence of irritable bowel syndrome, it is necessary to avoid products that provoke violations of the gastrointestinal tract.

Drug treatment

Traditionally, tricyclic antidepressants, commonly used to treat depression, have been considered most effective. In the treatment of fibromyalgia, tricyclic antidepressants are used at dosages several times lower than in the treatment of depression. Tricyclic antidepressants relieve fatigue to some extent, reduce muscle pain, and improve sleep. Science believes this is due to a change in the levels of a neurotransmitter called serotonin. A tricyclic antidepressant is, for example, amitriptyline or doxepin. Practice has shown that the combination of drugs such as fluoxetine (Prozac) with a reduced dose of amitriptyline increases the reduction of symptoms, improves sleep and well-being. But these drugs unfortunately have side effects.