Bill Klaproth (Host): This is an AAOMS On the Go podcast. I'm Bill Klaproth and with me is Dr. John Zuniga, recipient of the 2024 AAOMS Clinical Research Award. The Clinical Research Award recognizes fellows and members engaged in clinical research that fosters innovations and new diagnostic and therapeutic interventions. And that's what we're going to talk about today. Welcome Dr. Zuniga.

John Zuniga, DMD, PhD, MS: Well, thank you, Bill. I appreciate the opportunity.

Host: Yeah, and congratulations on being named recipient of the 2024 AAOMS Clinical Research Award. Pretty darn cool.

John Zuniga, DMD, PhD, MS:  Well, thanks. That's an honor.

Host: Yeah. So congrats again on that. So what initially inspired your interest in clinical research, particularly in the areas of orofacial pain and neurosensory disorders?

John Zuniga, DMD, PhD, MS: Sure, thanks for that question. Well, I received my PhD at the University of Rochester in the neuroendocrine unit, and my primary interest was in the endorphins. And at that time, that was the big thing. And that led me down a path of understanding pain mechanisms mostly central nervous system.

And along the way, I did a lot of small animal surgery. And that required small surgical instrumentations and microscopes. So I learned self-taught and a little bit of microsurgery. And so, with that emphasis on central nervous system and pain mechanisms, I combined that – looked for a clinical match – and the match was in peripheral nerve for me. And so I wanted to improve my microsurgical skills, so I did a sabbatical in the University of Vienna with raw fevers and that was eye opening. So I came back and combined my microsurgical skills, my interest in pain, and I went peripheral trigeminal.

And so that's the beginning of those skills. And then with, at the University of North Carolina, where was previous to where I'm now, my colleague Bill Maxner, who also has a PhD, is interested in chronic pain. We developed the chronic pain clinic there. And it's just been a wonderful experience.

Host: Yeah so, let me ask you this. I'm very curious. What are some of the most surprising findings from your studies on nerve injury and its role in orofacial pain? Share with us.

John Zuniga, DMD, PhD, MS: Yeah. Well, that is the Nobel Prize question. And I'm not ready to get that Nobel Prize yet, but I'm working to it.

Well, I think that the probably the one goal I hope to have in my career and to help add to the understanding of what are the mechanisms, and I'm talking about the actual mechanisms, and neurochemical, neuroanatomic, I'm not sure, neurophysiologic, and where are the sites causing these nerve pain problems?

Because these patients with neuropathic pain are miserable and um, we really don't have a cure. We're fishing around, and I'll use that word because we're in Florida, but uh, we're just looking for the answers, and until we find that, it really remains that we don't have a cure.

Now what we did find as a surgeon, that we found that peripheral nerve surgery, when done immediately following a nerve injury, appears to prevent development of these pain problems and it reduces the incidence of chronic post operative pain from developing. So it appears that the nervous system reacts, which you would expect, like any other system.

And if you can reestablish normality early, you might prevent this horrible problem. So what that says to me that our next targets are early detection for early intervention, and is paramount to our future studies.

Host: Yeah, so that is good information and enlightening to know that. So, how can a practicing OMS put that into practice today? Are we at that point?

John Zuniga, DMD, PhD, MS: I think we are. I think there are segments of our profession that are able to address nerve injury early, effectively, with the clinical skills to repair these intentionally injured nerves. That's going on now in certain centers.

It's not a standard. I'm not saying we need to make that yet, but before we can prove all these things we'll, should it be a standard, but there are individuals and groups that are practicing that. For the outpatient non traumatic problems with the peripheral nerve, then recognizing early detection is imperative.

And that's why we've developed some MRI type of technology to help those individuals. The problem is it's not readily available and it's not because of the institutions as much as the organizations. And so, we need to partner with our radiology colleagues, and if you have that tool with high specificity and sensitivity, it's clinically applicable for patient care.

Host: Yeah, alright. Well, that's good to know. So through your research, what are some of the biggest challenges that you've faced in your clinical research and how have you addressed them?

John Zuniga, DMD, PhD, MS: Well, I think probably, I would speak to the early investigations in the trigeminal nerve problems, pain, and repair.

And the problem, at least in my opinion, was general acceptance of the application of how to perform trigeminal nerve diagnosis using diagnostic modalities, surgical methods, or medical management. And that led to ambivalence by clinicians due in most part to lack of standardizations. And that could be of any medical problem. Not just specific to this, but what our solution is, or my solution is suggesting, is that we need to keep doing high level evidence based clinical research from clinical trials, observational studies, Delphi studies even asking relevant research questions answered by powered investigations with proper controls.

Host: Yeah, so I asked you earlier, how can a surgeon put this in practice today, and you answered that wonderfully. Well, let me ask you a different way. In the future, how do you hope this will impact clinical practice in treating related disorders in the future? What is your hope looking ahead for this?

John Zuniga, DMD, PhD, MS: Yeah, my hope is that we'll have accurate diagnostic modalities that are non-invasive, chair side, not necessarily chair side, but if it can be, great, but available for both the clinician and their patients to make the right diagnosis to, in other words, if you have a nerve injury that's not going to recover, that patient needs early intervention.

But if you have a patient who has symptoms of injury, but is a recoverable injury and you operate, you're going to make that patient worse. So until we have that high-level diagnostic modalities, I don't recommend standardizations but that's the future.

Host: Right. So that's where this is going.

John Zuniga, DMD, PhD, MS: I hope.

Host: Yeah. So speaking of the future, obviously you're involved in many things. Are there any emerging trends or technologies in clinical research that you are particularly excited about?

John Zuniga, DMD, PhD, MS: Yeah, I am. I mentioned the MRI, and that's MR neurography. And what that is, it's a non-radiation, MRI-based imaging modalities to actually identify peripheral nerves down to the millimeters. And what I'm hoping is that the development of higher powered MRI, and we talk about powers, values of Tesla. Right now we use three Tesla. Five, ten years ago we were using one Tesla. Hopefully two or three years from now we're using ten Tesla. And, so the more power, the more you can see.

So, that's one. The other is, expanding this MRN technology across the country and then globally. So, that's the practical part of this equation. We, you have to have the image, you have to, we're there, we have the image. You make it better, but you have to make it available. And that's a task that's going to require a partnership with our radiologists and others.

And the other is, I've been involved uh, one of the founding members of what's called the Global Nerve Foundation. And what we're about is that our mission is to improve the quality of life for patients who have peripheral nerve injuries. Bottom line. That's our mission. To solve that, the Foundation has four arms. Education, and that's education of clinicians and patients. Advocacy, and that would be improve the governmental regulations for recognizing as legitimate problems and treating them and referring them appropriately. Research is the other arm and that's what I'm intimately involved in.

And our goal is to develop funding distributions to qualified research, with an emphasis more on the clinical component rather than basic. But there are plenty of clinicians, not just OMFS, head and neck, orthopedic hand. And you can see neurosurgery. But along with the advocacy group is exposure. We need to expose these problems. In fact, one study, I believe it was two years ago, showed that 91 percent of peripheral nerves injuries are actually missed in the emergency room. And so what that means is that patients who have peripheral nerve injuries and may suffer these chronic pain problems are condemned to delayed management, which we already discussed, increases the risk of not being able to solve it.

Host: Right, and when addressing the issue promptly, certainly helps the situation and can potentially help the patient avoid that nerve pain, as you talked about. So your research has received support from several prestigious organizations, including AAOMS and OMS Foundation.

How has this funding shaped your work and facilitated your research goals? How has this helped you?

John Zuniga, DMD, PhD, MS: Tremendously. I always like to say and it's not my quote, I'm not sure where I got this, but if you don't study it, you don't own it.

And so having OMS support, OMFS support from the Foundation or the professional organization meant I didn't have to go outside for my funding. And so if I did, the evidence that I produce would be resided in those institutions.

Host: It would be somebody else’s.

John Zuniga, DMD, PhD, MS: Right. And they could take credit for supporting this. That's fine. I mean, I'm a researcher. I'm gonna, I need funding. But if I can keep it in OMS, that's where we need to be. So that made all the difference to me.

Host: Yeah, that's really important. So Dr. Zuniga, for someone listening to this saying, I'm interested in research. I want to try to help us make our procedures better in what we do. What would, advice would you give to early career researchers interested in pursuing a career in clinical research?

John Zuniga, DMD, PhD, MS: That's a very important question. In my opinion, that person needs to find a good mentor. You need to find someone who is a successful clinical researcher and listen to them.

If in an academics, understand the promotion tenure requirements of your educational track that fits you and plan five years ahead for each step. Not understanding will result in frustration in most part, due to lack of preparation and thus delaying what criteria need to be reached to move on.

So, don't repeat your career year after year. You need to keep going forward and put goals in front of you.

And finally, once you do have a proven strength, stay with it. Don't do everything and achieve mediocrity. Do one, maybe two things, really, really well, and achieve recognition and success.

Host: So once you find that thing, focus on it instead of spreading yourself too thin with a whole bunch of different things, really pour yourself into that that one.

John Zuniga, DMD, PhD, MS: Correct. Have that passion for that topic, though. If you don't have a passion, you know, and it's, you don't like it, you're gonna hate it after ten years.

Host: Yeah, well and that's exactly what you did.

John Zuniga, DMD, PhD, MS: I tried.

Host: Yeah, so taking your passion and your experience and putting them together, and you came up with this. So as we wrap up Dr. Zuniga, can you reflect or share any thoughts that you have on being recognized with this award?

John Zuniga, DMD, PhD, MS: Well, I don't do my research for awards, but an award means recognition from your peers, and that was important. So, yeah, it does mean, it's an honor, and makes you introspective that we're on the right track, and don't give up.

Host: Well, it says people are noticing. This is something that's worthwhile. So that only helps build the awareness of the great work that you're doing.

John Zuniga, DMD, PhD, MS: Thank you.

Host: Yeah. So thank you for your time. Appreciate it.

John Zuniga, DMD, PhD, MS: Thank you.

Host: And once again, that is Dr. John Zuniga. And for more information, please visit AAOMS.org. And if you enjoyed this podcast, please share it on your social media and make sure you subscribe so you don't miss an episode. Thanks for listening.