Publications
APS Bulletin • Volume 15, Number 2, Spring 2005
Past Presidents’ Perspectives
John L. Reeves II, PhD ABPP, Department Editor
An Interview with Ronald Dubner, DDS PhD, APS President, 1987-1988
How did you get into the field of pain, and who has influenced you the most?
The management of pain is of particular concern to the dentist. Pain is a major, if not the major, complaint of patients presenting to the dental office. The two most prevalent diseases of the mouth, caries and periodontal disease, cause pain. Proper treatment involves procedures that can produce postoperative pain. Dentists also are the primary-care practitioners for chronic pain conditions of the face and mouth, including temporomandibular disorders and pains of neurogenic origin. Tension headaches are often related to the mandibular and cervical musculature, so the dentist might be the first medical expert that a patient experiencing a tension headache might see. In light of the above, it is not surprising that my interest in pain began when I was a dental student. I was particularly excited about the early work on temporomandibular pain disorders and their relationship to neural mechanisms of sensory and motor function in the trigeminal region.
My interest in pain was rekindled early on in my research career at the NIH. I initiated a study on temporomandibular disorders and pain and quickly learned that most patients with acute symptoms improved in a few months irrespective of my treatment approaches (e.g., muscle relaxants, placebo medication, topical and regional local anesthesia, muscle exercises, and real and placebo occlusal adjustment). Few treatments were effective in patients who had pain that had persisted for months or years, however.
The field of pain management in the early 1960s was almost nonexistent. Whenever possible, most dentists and physicians avoided treating chronic pain patients. The idea that most of these pains were “in the head” was rampant. My lack of understanding of the etiology of chronic pain was so perplexing that I decided to spend the next few years learning about the physiology of the jaw musculature and the physiological control of this musculature, with the hope that such knowledge would lead to my improved understanding of these chronic orofacial conditions.
My early career in neuroscience led me far afield from pain and its control and into the study of the role of association areas of the cerebral cortex in sensory experience. I returned to the study of nociception, however, during a one-year sabbatical with Patrick Wall in London in 1971. When I returned to the NIH, I focused my research on the study of pain. I decided that a multidisciplinary approach, which included basic and clinical studies, was necessary for success in the area, so I recruited clinical and basic scientists to my laboratory.
In the 1960s and early 1970s, pain emerged as an important field of research, and this was an exciting time. Melzack and Wall had published their gate-control theory in 1965, resulting in the testing of its tenets and a renewed interest in mechanisms of nociception in peripheral tissues, the spinal cord, and the brain. A number of laboratories elucidated the physiology and pharmacology of the brain’s pain-suppressing systems and the role of naturally occurring opioids. The excitement generated by this research and renewed interest in pain problems were spearheaded by the innovative abilities and motivational drive of John Bonica, who organized an interdisciplinary meeting in Issaquah (Seattle) in 1973 that brought together leading scientists and clinicians with an interest in pain. This meeting led to the development of the International Association for the Study of Pain (IASP), which ultimately spawned the American Pain Society (APS) and national chapters throughout the world.
One of the most important outcomes of the proliferation of national and international pain societies is the recognition of the importance of communication among basic and clinical scientists in the field. I have had the opportunity to work with many scientists in our laboratory at the NIH and now in our department of biomedical sciences at the University of Maryland. Many of these scientists went on to develop successful independent research programs of their own. A major characteristic of these research programs is their multidisciplinary nature. The field of pain has taken the lead in demonstrating the success of this approach and is a model for other biomedical fields of study.
What are you doing now?
I have been very fortunate to have the opportunity to develop an outstanding department of biomedical sciences at the University of Maryland during the past 10 years. I left the NIH in 1995 and moved to the dental school at the University of Maryland as the chair of a multidisciplinary department that is a merger of the departments of anatomy, biochemistry, microbiology, physiology, and pharmacology. In addition to pain research, we have major research programs in microbiology, immunology, molecular biology, and cell biology. I have recruited over 15 new faculty members and have been successful in both research and education. Our annual external funding has increased from $1 million to over $11.5 million. We look forward to occupying a new building in 2006 that will contain state-of-the-art research space, which will allow us to expand our basic and clinical research programs. During a career in science research that has spanned over 40 years, I feel that my most important legacy has been the opportunity to train and mentor over 100 young scientists from all over the world.
What do you think has been the most significant contribution to the field of pain?
There are many important outcomes resulting from the last two decades of pain research and treatment. One is the growing acceptance in the medical community that pain is a symptom that cannot be ignored. Another is the spread of pain clinics throughout the United States, where medical and dental experts are now willing to diagnose and treat patients in pain. The patient’s report of pain is believed, respected, and measured with quantitative approaches. The relief of acute pain is now predicated on around-the-clock steady relief rather than on “as-needed” administration of analgesics. There is a growing realization that pain is not merely a passive symptom of disease but that it is an aggressive disease in itself. This belief is based on scientific evidence that pain produces changes in the spinal cord and the brain that may underlie hyperalgesia and exaggerated spontaneous pain. The lack of organic signs commensurate with the patient’s report of pain indicates that the “pain is in the head” idea is slowly disappearing because of this evidence. Pain that persists beyond the warning period can lead to central nervous system changes that are responsible for the presumed exaggerated report of pain by the patient. We have also learned that pain is a complex, multidimensional experience that can alter the quality of one’s life. Therefore, major goals of therapy are to improve the functioning of patients in their daily lives and to reduce their pain.
How do you view current U.S. pain research and treatment?
Pain research is more exciting than ever before. The era of molecular biology and our ability to clone important receptors involved in pain and analgesia have opened the door to new approaches to the treatment of acute and chronic pain. We have taken advantage of advances in brain imaging to study the changes in brain function at forebrain sites associated with persistent pain. We have learned that neuronal activation originating from peripheral and other target sites in the nervous system leads to long-term changes ultimately resulting in amplification and persistence of pain. This so-called neuronal plasticity presents new targets for the development of new agents and approaches to the treatment of chronic pain conditions. It is unfortunate that new treatment approaches have not kept pace with all of these research advances. We still rely on treatments used since the early part of the twentieth century as our mainstays for helping patients (e.g., local anesthetics, aspirin-like drugs, and opiates). Major leaps in treatment efficacy will require that we move toward new treatment paradigms that take advantage of modern technology, research advances in genetics and bioinformatics, and interdisciplinary expertise.
What is your forecast for the future?
The last two decades have been a rewarding period in pain research. We have learned that accepted and well-proven methods of pain relief (e.g., local anesthetics and non-steroidal anti-inflammatory drugs [NSAIDs]) can reduce pain by decreasing the neural barrage that enters the central nervous system following injury. At the basic science level, we are learning about the changes in the chemistry of the brain produced by tissue or nerve injury and evaluating new pharmacological approaches to treat developing pain. Physical therapies and behavioral and cognitive approaches are proving to be useful in the treatment of chronic pain and its debilitating after- effects. If the past two decades are a sign of the rate of progress in our understanding of pain, then the future is very bright.
Ronald Dubner, DDS PhD, is Professor and Chair of the Department of Biomedical Sciences at the University of Maryland Dental School, Baltimore, MD.
Please direct your comments or suggestions about this article or department to John L. Reeves II, Department Editor, at reeves@ucla.edu.