Showing papers in "Journal of Orofacial Pain in 2011"

Profiling of patients presenting with posttraumatic neuropathy of the trigeminal nerve

Abstract: Aims: To describe the cause, clinical signs, and symptoms of patients presenting to a tertiary care center with iatrogenic lesions to the mandibular branches of the trigeminal nerve. Methods: Pain history, pain scores using the visual analog scale, and mechanosensory testing results were recorded from 93 patients with iatrogenic lingual nerve injuries (LNI) and 90 patients with iatrogenic inferior alveolar nerve injuries (IANI). Results were analyzed using the SPSS statistical software. Chi-square tests were applied for nonparametric testing of frequencies, where P ≤ .05 indicated statistical significance. Appropriate correlations were also carried out between certain data sets. Results: Significantly more females were referred than males (P < .05). Overall, third molar surgery (TMS) caused 73% of LNI, followed by local anesthesia (LA) (17%). More diverse procedures caused IANI, including TMS (60%), LA (19%), implants (18%), and endodontics (8%). Approximately 70% of patients presented with neuropathic pain coincident with anesthesia and/or paresthesia. Neuropathy was demonstrable in all patients with varying degrees of loss of mechanosensory function, paresthesia, dysesthesia, allodynia, and hyperalgesia. Functionally, IANI and LNI patients mostly had problems with speech and eating, where speech was affected amongst significantly more patients with LNI (P < .001). Sleep, brushing teeth, and drinking were significantly more problematic for IANI patients (P < .05, P < .001, and P < .0001, respectively). Conclusion: Neuropathic pain, as well as anesthesia, frequently occurs following iatrogenic trigeminal nerve injury similar to other posttraumatic sensory nerve injuries. This must be acknowledged by clinicians as a relatively common problem and informed consent appropriately formulated for patients at risk of trigeminal nerve injuries in relation to dentistry requires revision. J Or O fac Pain 2011;25:333–344

Temporomandibular joint and muscle disorder-type pain and comorbid pains in a national US sample.

Abstract: Aims: To compare prevalences of self-reported comorbid headache, neck, back, and joint pains in respondents with temporomandibular joint and muscle disorder (TMJMD)-type pain in the 2000-2005 US National Health Interview Survey (NHIS), and to analyze these self-reported pains by gender and age for Non-Hispanic (NH) Whites (Caucasians), Hispanics, and NH Blacks (African Americans). Methods: Data from the 2000-2005 NHIS included information on gender, age, race, ethnicity, education, different common types of pain (specifically TMJMD-type, severe headache/migraine, neck, and low back pains), changes in health status, and health care utilization. Estimates and test statistics (ie, Pearson correlations, regressions, and logistic models) were conducted using SAS survey analysis and SUDAAN software that take into account the complex sample design. Results: A total of 189,977 people (52% female and 48% males, 73% NH Whites, 12% Hispanic, 11% NH Blacks, and 4% "Other") were included. A total of 4.6% reported TMJMD-type pain, and only 0.77% overall reported it without any comorbid headache/migraine, neck, or low back pains; also 59% of the TMJMD-type pain (n = 8,964) reported >= two comorbid pains. Females reported more comorbid pain than males (odds ratio [OR] = 1.41, P < .001); Hispanic and NH Blacks reported more than NH Whites (OR = 1.56, P <.001; OR= 1.38, P <.001, respectively). In addition, 53% of those with TMJMD-type pain had severe headache/migraines, 54% had neck pain, 64% low back pain, and 62% joint pain. Differences in gender and race by age patterns were detected. For females, headache/migraine pain with TMJMD-type pain peaked around age 40 and decreased thereafter regardless of race/ethnicity. Neck pain continued to increase up to about age 60, with a higher prevalence for Hispanic women at younger ages, and more pronounced in males, being the highest in the non-Whites. Low back pain was higher in Black and Hispanic females across the age span, and higher among non-White males after age 60. Joint pain demonstrated similar patterns by race/ethnicity, with higher rates for Black females, and increased with age regardless of gender. Conclusion: TMJMD-type pain was most often associated with other common pains, and seldom existed alone. Two or more comorbid pains were common. Gender, race, and age patterns for pains with TMJMD-type pain resembled the specific underlying comorbid pain.

Racial/Ethnic and gender prevalences in reported common pains in a national sample.

Abstract: Aims To compare prevalences of self-reported temporomandibular joint and muscle disorders (TMJMD)-type pain, headaches, and neck and back pains in the 2000 to 2005 US National Health Interview Survey (NHIS) by gender and age for non-Hispanic Whites (Whites), Hispanics, and non-Hispanic Blacks (Blacks). Methods Data from the 2000 to 2005 NHIS included information on gender, age, race, ethnicity, and different common types of pain specifically: TMJMD-type pain, severe headaches/migraine, neck, and low back pains. Results A total of 189,992 people were included: 52% female and 48% male, 73% White, 12% Hispanic, 11% Black, and 4% "Other." The overall prevalence of TMJMD-type pain was 4.6%; severe headaches/migraine was 15.4%; neck, 14.9%; and low back, 28.0%. Survey logistic regression models estimating race-specific, age-adjusted curves revealed race by age pain differences. For TMJMD-type pain, White females presented the highest prevalence at younger ages, decreasing after age 40. Prevalences for Hispanic and Black females, although lower at younger ages, increased up to age 60 and remained higher than Whites. Males showed less racial/ethnic and age variation. Severe headaches/migraines presented an age pattern similar to TMJMD-type pain for White females and little overall variation for males, but without racial differences. Neck pain showed some similarities to TMJMD-type pain: higher in Whites at younger ages, lower at older ages, with Hispanics having the highest rates after their 60's. For low back pain, the rates peaked around the sixth decade for all racial/ethnic groups. Conclusion The patterns of TMJMD-type pain varied greatly within and across racial/ethnic groups by gender and across the adult lifespan. Similarities and differences for the other pains were noted.

Effectiveness of low-level laser therapy in temporomandibular disorders: a systematic review and meta-analysis.

Abstract: Aim To assess the scientific evidence on the efficacy of low-level laser therapy (LLLT) in the treatment of temporomandibular disorders (TMD). Methods The databases of PubMed, Science Direct, Cochrane Clinical Trials Register, and PEDro were manually and electronically searched up to February 2010. Two independent reviewers screened, extracted, and assessed the quality of the publications. A meta-analysis- was performed to quantify the pooled effect of LLLT on pain and function in patients with chronic TMD. Results The literature search identified 323 papers without overlap between selected databases, but after the two-phase study selection, only six randomized clinical trials (RCT) were included in the systematic review. The primary outcome of interest was the change in pain from baseline to endpoint. The pooled effect of LLLT on pain, measured through a visual analog scale with a mean difference of 7.77 mm (95% confidence interval [CI]: -2.49 to 18.02), was not statistically significant from placebo. Change from baseline to endpoint of secondary outcomes was 4.04 mm (95% CI 3.06 to 5.02) for mandibular maximum vertical opening; 1.64 mm (95% CI 0.10 to 3.17) for right lateral excursion and 1.90 mm (95% CI: -4.08 to 7.88) for left lateral excursion. Conclusion Currently, there is no evidence to support the effectiveness of LLLT in the treatment of TMD.

Changes in regional gray and white matter volume in patients with myofascial-type temporomandibular disorders: a voxel-based morphometry study.

Abstract: Aims: To use magnetic resonance imaging (MRI) and voxel-based morphometry (VBM) to search for evidence of altered brain morphology in patients with temporomandibular disorders (TMD). Methods: Using VBM, regional gray and white matter volume was investigated in nine TMD patients and nine carefully matched healthy controls. Results: A decrease in gray matter volume occurred in the left anterior cingulate gyrus, in the right posterior cingulate gyrus, the right anterior insular cortex, left inferior frontal gyrus, as well as the superior temporal gyrus bilaterally in the TMD patients. Also, white matter analyses revealed decreases in regional white matter volume in the medial prefrontal cortex bilaterally in TMD patients. Conclusion: These data support previous findings by showing that TMD, like other chronic pain states, is associated with changes in brain morphology in brain regions known to be part of the central pain system. J OROFAC PAIN 2011;25:99–106

Combined topical and systemic clonazepam therapy for the management of burning mouth syndrome: a retrospective pilot study.

Abstract: Aims: To evaluate retrospectively the efficacy of administering an anticonvulsant medication, clonazepam, by dissolving tablets slowly orally before swallowing, for the management of burning mouth syndrome (BMS). Methods: A retrospective clinical records audit was performed of patients diagnosed with BMS between January 2006 and June 2009. Patients were prescribed 0.5 mg clonazepam three times daily, and changes were made to this regimen based on their individual response. Patients were asked to dissolve the tablet orally before swallowing and were reviewed over a 6-month period. Pain was assessed by patients on an 11-point numerical scale (0 to 10). A nonparametric (Spearman) two-tailed correlation matrix and a two-tailed Mann-Whitney test were performed. Results: A total of 36 patients (27 women, 9 men) met the criteria for inclusion. The mean (± SEM) pain score reduction between pretreatment and final appointment was 4.7 ± 0.4 points. A large percentage (80%) of patients obtained more than a 50% reduction in pain over the treatment period. One patient reported no reduction in pain symptoms, and one third of the patients had complete pain resolution. Approximately one third of patients experienced side effects that were transient and mild. Conclusion: This pilot study provides preliminary evidence that the novel protocol of combined topical and systemic clonazepam administration provides an effective BMS management tool.

Head and cervical posture in patients with temporomandibular disorders.

Abstract: Aim To determine whether patients with myogenous or mixed (ie, myogeneous plus arthrogeneous) temporomandibular disorders (TMD) had different head and cervical posture measured through angles commonly used in clinical research settings when compared to healthy individuals. Methods One hundred fifty-four persons participated in this study. Of these, 50 subjects were healthy, 55 subjects had myogenous TMD, and 49 subjects had mixed TMD (ie, arthrogenous plus myogenous TMD). A lateral photograph was taken with the head in the self-balanced position. Four angles were measured in the photographs: (1) Eye-Tragus-Horizontal, (2) Tragus-C7-Horizontal, (3) Pogonion-Tragus-C7, and (4) Tragus-C7-Shoulder. Alcimagen software specially designed to measure angles was used in this study. All of the measurements were performed by a single trained rater, a dental specialist in orthodontics, blinded to each subject's group status. Results The only angle that reached statistical significance among groups was the Eye-Tragus-Horizontal (F = 3.03, P = .040). Pairwise comparisons determined that a mean difference of 3.3 degrees (95% confidence intervals [CI]: 0.15, 6.41) existed when comparing subjects with myogenous TMD and healthy subjects (P = .036). Postural angles were not significantly related to neck disability, jaw disability, or pain intensity. Intrarater and interrater reliability of the measurements were excellent, with intraclass correlation coefficient (ICC) values ranging between 0.996-0.998. Conclusion The only statistically significant difference in craniocervical posture between patients with myogenous TMD and healthy subjects was for the Eye-Tragus-Horizontal angle, indicating a more extended position of the head. However, the difference was very small (3.3 degrees) and was judged not to be clinically significant.

Quantitative sensory testing in the trigeminal region: site and gender differences.

Abstract: Aims: To establish a quantitative sensory testing (QST) profile in the trigeminal (V) area and test for site and gender differences in healthy humans. Methods: A standardized QST protocol was applied on 15 healthy men (age range: 18 to 25 years old) and 15 age-matched women, and the sensitivity was examined bilaterally in facial sites supplied by the infraorbital (V2) and mental (V3) nerves. The cold detection threshold (CDT), cold pain threshold (CPT), warm detection threshold (WDT), heat pain threshold (HPT), thermal sensory limen (TSL), mechanical detection threshold (MDT), mechanical pain sensitivity (MPS), mechanical pain threshold (MPT), dynamic mechanical allodynia (ALL), windup ratio (WUR), pressure pain threshold (PPT), and vibration detection threshold (VDT) were determined. Data were tested with ANOVAs for repeated measures and post-hoc comparisons were calculated using Bonferroni tests. Results: There were significant gender differences with lower threshold (higher sensitivity) in women for CDT (P = .030) and PPT (P = .006). A significantly lower threshold (higher sensitivity) was detected for HPT (P < .001), and significantly higher thresholds (lower sensitivity) for VDT (P < .001) and CDT (P < .001) in V2 compared to V3. There were no significant right-to-left side differences for any of the QST parameters. Conclusion: Application of this standardized QST protocol may allow for a better understanding of the underlying mechanisms from somatosensory phenotypes and provide basic information for the study of sensory dysfunctions in the V area

Chewing in temporomandibular disorder patients: an exploratory study of an association with some psychological variables

Abstract: Aims: To compare kinematic parameters (ie, amplitude, velocity, cycle frequency) of chewing and pain characteristics in a group of female myofascial temporomandibular disorder (TMD) patients with an age-matched control female group, and to study correlations between psychological variables and kinematic variables of chewing. Methods: Twenty-nine female participants were recruited. All participants were categorized according to the Research Diagnostic Criteria for TMD (RDC/TMD) into control (n = 14, mean age 28.9 years, SD 5.0 years) or TMD (n = 15, mean age 31.3 years, SD 10.7) groups. Jaw movements were recorded during free gum chewing and chewing standardized for timing. Patients completed the Depression, Anxiety, and Stress Scales (DASS-42), the Pain Catastrophizing Scale (PCS), the Fear of Pain Questionnaire-III (FPQ-III), and the Pain Self-Efficacy Questionnaire (PSEQ). Statistical analyses involved evaluation for group differences, and correlations between kinematic variables and psychological questionnaire scores (eg, depression, anxiety, stress) and pain intensity ratings. Results: Velocity and amplitude of standardized (but not free) chewing were significantly greater (P < .05) in the TMD group than the control group. There were significant (P < .05) positive correlations between pain intensity ratings and velocity and amplitude of standardized chewing but not free chewing. There were significant (P < .05) positive correlations between depression and jaw amplitude and stress and jaw velocity for standardized but not free chewing. Conclusion: This exploratory study has provided data suggesting that psychological factors, manifesting in depression and stress, play a role in influencing the association between pain and motor activity.

Topical review: orofacial pain in dementia patients. A diagnostic challenge

Abstract: This article presents a comprehensive review of the literature on the diagnosis of pain in the orofacial region of patients suffering from a cognitive impairment or a dementia. This review was based on a literature search yielding 74 papers, most of which dealt with the assessment of pain in general in nonverbal individuals, for which several observational tools were developed. Unfortunately, none of these tools have been designed for the specific assessment of orofacial or dental pain. Thus, none of them can be recommended for use in the dental setting. There is hardly any information available in the literature on how to assess orofacial and/or dental pain in patients with a cognitive impairment or a dementia. Given the expected increase in the incidence of dementia over the upcoming decades, it is of the utmost importance that dentists can use well-tested tools that can help them in the diagnosis of orofacial and dental pain in this vulnerable patient population. Such tools should incorporate specific orofacial/dental pain indicators, such as the patient holding/rubbing the painful orofacial area, limiting his/her mandibular movements, modifying his/her oral behavior, and being uncooperative/resistant to oral care.

Conditioned pain modulation evoked by different intensities of mechanical stimuli applied to the craniofacial region in healthy men and women.

Abstract: Aims: To investigate systematically whether conditioned pain modulation (CPM) evoked by tonic mechanical stimuli applied to the craniofacial region is intensity-, assessment site-, and gender-dependent. Methods: Twenty healthy men and 20 women participated in four sessions. Tonic painful mechanical stimulation was applied to pericranial muscles by a mechanical headband pressure device. The pressures applied to four probes were adjusted via pain feedback from a 0 to 10 electronic visual analog scale (VAS) to generate different pain levels (VAS0, VAS1, VAS3, or VAS5) for 10 minutes. Pressure pain thresholds (PPTs) and pressure pain tolerance thresholds (PPTols) were assessed from right masseter muscle and left forearm by pressure algometry before, during, immediately after, 10 minutes after, and 20 minutes after the conditioning stimulus (CS). Data were analyzed with multilevel ANOVAs. Results: PPT values normalized to baseline recordings were not dependent on gender or assessment site, but dependent on intensity (P < .001) and time (P < .001). The most painful CS (VAS5) was associated with the highest PPT increases (32.6% ± 3.3%, mean value for the two assessment sites and two genders) during CS compared to all other intensities of CS (P < .001). PPTol values normalized to baseline recordings were also not dependent on gender or assessment site, but dependent on intensity (P < .001) and time (P < .001). The most painful CS (VAS5) was associated with higher PPTol increases (11.2% ± 2.8%, mean value for the two assessment sites and two genders) during CS (P < .001). Conclusion: CPM evoked by mechanical stimulation of the craniofacial region is intensity-dependent but not assessment site- or gender-dependent.

Unexplained somatic comorbidities in patients with burning mouth syndrome: a controlled clinical study.

Abstract: Aims: To evaluate the prevalence of unexplained extraoral symptoms in a group of patients with burning mouth syndrome (BMS) and compare the prevalence with that in patients with oral lichen planus (OLP) and age- and gender-matched controls. Methods: The occurrence of extraoral symptoms was analyzed in a group of 124 BMS patients, a group of 112 oral lichen planus (OLP) patients, and a group of 102 healthy patients. Oral symptoms were collected by a specialist in oral medicine and a general dentist, while data concerning unexplained extraoral symptoms were gathered by each specialist ward, ie, ophthalmology, gynecology, otolaryngology, gastroenterology, neurology, cardiology, internal medicine, and dermatology. A Fisher exact test (α = .05) and Kruskal-Wallis test (α = .05) were performed for statistical analysis. Results: In the BMS group, 98 (96.1%) patients reported unexplained extraoral symptoms, while 4 (3.9%) patients reported only oral symptoms. A painful symptomatology in different bodily regions was reported more frequently by BMS patients (83.3%) than by OLP patients (1.8%) and healthy patients (11.7%) (P < .0001). The differences in the overall unexplained extraoral symptoms between BMS (96.1%) and OLP patients (9.3%) (P < .0001) and between BMS (96.1%) and healthy patients (15.7%) (P < .0001) were statistically significant. The unexplained extraoral symptoms in BMS patients consisted of pain perceived in different bodily areas (odds ratio [OR]: 255; 95% confidence interval [CI]: 58.4-1112), ear-nose-throat symptoms (OR: 399.7; 95%CI: 89.2-1790), neurological symptoms (OR: 393; 95% CI: 23.8-6481), ophthalmological symptoms (OR: 232.3; 95% CI: 14.1-3823), gastrointestinal complaints (OR: 111.2; 95% CI: 42.2-293), skin/gland complaints (OR: 63.5; 95% CI: 3.8-1055), urogenital complaints (OR: 35; 95% CI: 12-101), and cardiopulmonary symptoms (OR: 19; 95% CI: 4.5-82). Conclusion: The great majority of BMS patients presented with several additional unexplained extraoral comorbidities, indicating that various medical disciplines should be involved in the BMS diagnostic process. Furthermore, the results suggest that BMS may be classified as a complex somatoform disorder rather than a neuropathic pain entity.

Efficacy of topical 1% lidocaine in the symptomatic treatment of pain associated with oral mucosal trauma or minor oral aphthous ulcer: a randomized, double-blind, placebo-controlled, parallel-group, single-dose study.

Abstract: Aims To determine the efficacy in pain reduction of a topical 1% lidocaine compared to a placebo cream in patients with oral mucosal lesions due to trauma or minor oral aphthous ulcer Methods The design was a double-blind, randomized, placebo-controlled, six-center trial on 59 patients Pain intensity and relief were measured using a 100-mm visual analog scale (VAS) One-tailed Student t test and ANOVA analyses were used for statistical analyses Results Independent of the pain origin (oral mucosal trauma or minor oral aphthous ulcer), the application of the 1% lidocaine cream led to a mean reduction in VAS pain intensity of 294 mm ± 170, which was significantly greater than the decrease obtained with the placebo cream Analysis showed a statistically significant efficacy of the 1% lidocaine cream (P = 0003) Its efficacy was not related to the type of lesion, and no adverse drug reaction, either local or systemic, was reported by any of the patients Conclusion A significant reduction in pain intensity occurred after application of 1% lidocaine cream and was significantly greater than that with the placebo cream Taking into account the study's limitations, this product seems safe to use

A Mandibular Advancement Appliance Reduces Pain and Rhythmic Masticatory Muscle Activity in Patients with Morning Headache

Abstract: Aims: To evaluate the influence of an oral appliance on morning headache and orofacial pain in subjects without reported sleep-disordered breathing (SDB) Methods: Twelve subjects aged 276 ± 21 (mean ± SE) years and suffering from frequent morning headache participated in this study Each subject was individually fitted with a mandibular advancement appliance (MAA) The first two sleep laboratory polygraphic recording (SLPR) nights were for habituation (N1) and baseline (N2) Subjects then slept five nights without the MAA (period 1: P1), followed by eight nights with the MAA in neutral position (P2), ending with SLPR night 3 (N3) Subjects then slept five nights without the MAA (P3), followed by eight nights with the MAA in 50% advanced position (P4), ending with SLPR night 4 (N4) Finally, subjects slept 5 nights without the MAA (P5) Morning headache and orofacial pain intensity were assessed each morning with a 100-mm visual analog scale Repeated measures ANOVAs and Friedman tests were used to evaluate treatment effects Results: Compared to the baseline period (P1), the use of an MAA in both neutral and advanced position was associated with a >= 70% reduction in morning headache and >= 42% reduction in orofacial pain intensity (P <= 001) During the washout periods (P3 and P5), morning headache and orofacial pain intensity returned to close to baseline levels Compared to N2, both MAA positions significantly reduced (P < 05) rhythmic masticatory muscle activity (RMMA) Conclusion: Short-term use of an MAA is associated with a significant reduction in morning headache and orofacial pain intensity Part of this reduction may be linked to the concomitant reduction in RMMA

Risk factors for anterior disc displacement with reduction and intermittent locking in adolescents.

Abstract: AIMS: To test the hypothesis that oral parafunctions and symptomatic temporomandibulair joint (TMJ) hypermobility are risk factors in adolescents for both anterior disc displacement with reduction (ADDR) and intermittent locking. METHODS: Participants were two hundred sixty 12- to 16-year-old adolescents (52.3% female) visiting a university clinic for regular dental care. ADDR and symptomatic TMJ hypermobility were diagnosed using a structured clinical examination. During the anamnesis, reports of intermittent locking and of several parafunctions were noted, eg, nocturnal tooth grinding, diurnal jaw clenching, gum chewing, nail biting, lip and/or cheek biting, and biting on objects. The adolescents' dentitions were examined for opposing matching tooth-wear facets as signs of tooth grinding. Risk factors for ADDR and intermittent locking were first assessed using univariate logistic regression and then entered into a stepwise backward multiple model. RESULTS: While in the multiple model, ADDR was weakly associated only with increasing age (P = .02, explained variance 8.1%), intermittent locking was weakly correlated to diurnal jaw clenching (P = .05, explained variance 27.3%). CONCLUSION: In adolescence, diurnal clenching may be a risk factor for intermittent locking while age may be a risk factor for ADDR. Symptomatic TMJ hypermobility seems to be unrelated to either ADDR or to intermittent locking.

Adolescents with temporomandibular disorder pain-the living with TMD pain phenomenon.

Abstract: Aim: To acquire a deeper understanding of adolescents' experiences of living with temporomandibular disorder (TMD) pain. Methods: twenty-one adolescents with TMD pain, aged 15 to 19, were strategically selected from a group of patients referred to an orofacial pain clinic. The patients were examined and received diagnoses per the Research Diagnostic Criteria for TMD. One-on-one interviews that followed a semistructured protocol focused on the patient's experiences of living with TMD pain. The interviews were recorded and transcribed verbatim, followed by content analysis to obtain a deeper understanding of adolescents' experieces living with TMD pain. Results: Content analysis led to the overall theme "Adolescents with TMD live with recurrent pain; physical problems and daily demands form a vicious circle that causes adolescents to oscillate between hope and despondency." The latent content forming the theme is grounded in three categories that evolved from 13 subcategories. For instance, five subcategories - headache; headache on awakening; jaw and tooth pain; constant thoughts of pain; and popping, cracking, clicking, and locking - formed the category that was labeled TMD pain is recurrent. The latent interpretation, ie, the meaning, of this category was that adolescents with TMD pain constantly thought about the pain, even when it was absent. Conclussion: TMD pain is a substantial problem for affected adolescents and has consequences for all aspects of their lives. In this study, the adolescents were able to talk openly and introduce issues outside of the interview protocol. Qualitative analysis deepens our understanding of the adolescent patient with TMD pain.

Differences in psychosocial functioning and sleep quality between idiopathic continuous orofacial neuropathic pain patients and chronic masticatory muscle pain patients.

Abstract: Aim: To examine differences between idiopathic continuous orofacial neuropathic pain (ICONP) patients and chronic masticatory muscle pain (MMP) patients for psychosocial functioning and sleep quality. Methods: Archival data were used to compare 81 ICONP patients to 81 age- and sex-matched chronic MMP patients on pain severity, life interference, life control, and affective distress measures from the Multidimensional Pain Inventory (MPI), a global severity index of psychological symptoms from the Symptom Checklist-90-R (SCL-90-R), Posttraumatic Stress Disorder Checklist-Civilian (PCL-C), and overall sleep quality from the Pittsburgh Sleep Quality Index (PSQI). MANOVA, MANCOVA, and chi-square analysis were used to investigate differences between the two groups in the psychosocial and sleep variables. Results: The ICONP group reported greater pain severity (P = .013) and more life interference (P = .032) than the MMP group, while the MMP group reported higher levels of global psychological symptoms (P = .005) than the ICONP group. After controlling for pain severity, however, the MMP group demonstrated greater affective distress (P = .014) than the ICONP group, and life interference was no longer significantly different between the groups. ICONP patients were more likely to report a traumatic life event (P = .007). Conclusion: Although ICONP patients are likely to present more intense pain and report that their pain causes more interference in their lives, MMP patients are more likely to present with higher levels of overall psychological symptoms. The greater levels of pain severity reported by ICONP patients appear to be partially responsible for their higher levels of reported life interference.

Nocturnal heart rate variability is lower in temporomandibular disorder patients than in healthy, pain-free individuals.

Abstract: Aims: To determine whether patients with a painful myofascial temporomandibular disorder (TMD) have diminished nocturnal heart rate variability (HRV), a marker of autonomic nervous system (ANS) dysfunction, relative to healthy, pain-free controls. Methods: Participants with myofascial TMD and healthy, pain-free volunteers underwent nocturnal polysomnography studies during which HRV indices were measured. Multiple linear regression analyses were used to determine whether TMD status exerted unique effects on HRV. Results: Ninety-five participants (n = 37 TMD; n = 58 controls) were included in the analyses. The TMD group had a lower standard deviation of R-R intervals (89.81 ± 23.54 ms versus 107.93 ± 34.42 ms, P <= .01), a lower root mean squared successive difference (RMSSD) of R-R intervals (54.78 ± 27.37 ms versus 81.88 ± 46.43 ms, P < .01), and a lower high frequency spectral power (2336.89 ± 1224.64 ms2 versus 2861.78 ± 1319 ms2, P = .05) than the control group. The ratio of the low-frequency (LF) to the high-frequency (HF) spectral power was higher in the TMD group (2.47 ± 2 versus 1.38 ± 0.65, P < .01). The differences in RMSSD (91.21 ms versus 112.03 ms, P = .05) and LF:HF ratio (0.71 versus 0.32, P < .01) remained significant after controlling for age and psychological distress. Conclusion: Myofascial TMD patients revealed lower nocturnal HRV than healthy, pain-free controls. Further research should focus on processes that address this ANS imbalance, which may potentially lead to effective therapeutic interventions.

Orofacial thermal thresholds: time-dependent variability and influence of spatial summation and test site.

Abstract: Aim To investigate time-dependent variability and influence of test site and stimulation area size on intraoral cold detection, warmth detection, and heat pain thresholds. Methods Thirty healthy volunteers (15 women and 15 men) participated. Six extra- and intraoral sites were examined, and cold detection, warmth detection, and heat pain thresholds were measured. Time variability and influence of spatial summation were also studied at one site-the tip of the tongue-three times over a 6-week period. One-way ANOVA for repeated measures and paired sample t test compared mean values and SD within and between sites for all thresholds. Results Several between-site differences were significant (P .05). Conclusion Test site affects orofacial thermal thresholds substantially, whereas time variability and spatial summation on the tongue appear to be modest.

Development and validation of a screening checklist for temporomandibular disorders.

Abstract: Aims: To develop and validate a short screening tool for temporomandibular disorders (TMD) from the comprehensive Research Diagnostic Criteria for TMD (RDC/TMD) assessment. Methods: Complete RDC/TMD assessments of four subject groups (96 TMD; 102 dental pain; 68 headache; 115 no-pain patients) were compared. Classification tree and multiple logistic regression analyses were utilized to develop the tool. To test external validity, a further 54 TMD and 51 non-TMD subjects whose diagnoses had been established by RDC/TMD assessment were reassessed with the new screening tool. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios (LRs) were calculated for the screening tool in the validation set of subjects. Results: A short TMD checklist was developed. This screening instrument had sensitivity of 94.4% (95% confidence intervals [CI], 84.9% to 98.1%), specificity of 94.1% (95% CI, 84.1% to 98%), PPV of 94.4% (95% CI, 84.9% to 98.1%), NPV of 94.1% (95% CI, 84.1% to 98%), and positive and negative LRs of 16.056 (95% CI, 5.346 to 48.219) and 0.059 (95% CI, 0.02 to 0.178) in an independent validation set. Conclusion: A short TMD screening checklist with high validity has been developed. This checklist may have good utility in general practice as a primary screening tool for TMD.

Magnetic Resonance Imaging of the Temporomandibular Joint Disc: Feasibility of Novel Quantitative Magnetic Resonance Evaluation Using Histologic and Biomechanical Reference Standards

Abstract: Aims To use the ultrashort time-to-echo magnetic resonance imaging (UTE MRI) technique to quantify short T2* properties (obtained through gradient echo) of a disc from the human temporomandibular joint (TMJ) and to corroborate regional T2* values with biomechanical properties and histologic appearance of the discal tissues. Methods A cadaveric human TMJ was sliced sagittally and imaged by conventional and UTE MRI techniques. The slices were then subjected to either biomechanical indentation testing or histologic evaluation, and linear regression was used for comparison to T2* maps obtained from UTE MRI data. Feasibility of in vivo UTE MRI was assessed in two human volunteers. Results The UTE MRI technique of the specimens provided images of the TMJ disc with greater signal-to-noise ratio (~3 fold) and contrast against surrounding tissues than conventional techniques. Higher T2* values correlated with lower indentation stiffness (softer) and less collagen organization as indicated by polarized light microscopy. T2* values were also obtained from the volunteers. Conclusion UTE MRI facilitates quantitative characterization of TMJ discs, which may reflect structural and functional properties related to TMJ dysfunction.

Effect of estrogen and altered diet hardness on the expression of estrogen receptor alpha and matrix metalloproteinase-8 in rat condylar cartilage.

Abstract: Aims: To examine the effect of decreased estrogen level and altered diet hardness on condylar cartilage morphology of the rat temporomandibular joint (TMJ) and on the expression of condylar cartilage estrogen receptor alpha (ERα) and matrix metalloproteinase-8 (MMP-8). Methods: A total of 36 female rats was divided into four groups: ovariectomized rats fed a normal diet, non-ovariectomized controls fed a normal diet, ovariectomized rats fed a soft diet, and non-ovariectomized controls fed a soft diet. Ovariectomy was performed at the age of 60 days. Seven days after the operation, the rats were sacrificed. Repeated measures ANOVA and Duncan's multiple comparison tests were used for statistical analysis. Results: The ovariectomized rats had thicker cartilage layers than the controls, both in the normal diet and soft diet groups. The thinnest cartilage layers were found in the control rats fed with the soft diet. The thickness of the chondroblastic layer was significantly higher (P < .001) in the normal-diet rats than in the soft-diet rats in both ovariectomized and non-ovariectomized groups. The thickness of the proliferative layer was significantly higher (P < .001) in the ovariectomized soft-diet rats than in the soft-diet control rats. The proportional amount of ERα was statistically significantly higher (P < .001) in the condylar cartilage of the ovariectomized rats than in the non-ovariectomized control rats both in the normal- and soft-diet groups. The proportional amount of ERα was statistically significantly higher (P < .001) in the ovariectomized normal-diet rats than in the ovariectomized soft-diet rats. The proportional number of MMP-8-positive cells was statistically significantly higher (P < .001) in the condylar cartilage of ovariectomized rats fed the soft diet than in non-ovariectomized control rats fed the soft diet. Control rats fed with the normal diet had a higher proportional amount of MMP-8 positive cells than control rats fed with the soft diet (P < .05). Conclusion: The rat TMJ condylar cartilage is sensitive to changes in estrogen levels and altered diet hardness.

Effect of chewing upon disc reduction in the temporomandibular joint

Abstract: Aims: To test whether an intensive chewing exercise influences the moment of disc reduction in subjects with or without reports of intermittent locking of the jaw. Methods: This experimental study included 15 subjects with a reducing anteriorly displaced disc (ADD) and with symptoms of intermittent locking and 15 subjects with a reducing ADD without such symptoms. The moment of disc reduction (MDR), quantified using mandibular movement recordings, was recorded at baseline, and after maximally 60 minutes of chewing. Thereafter, MDR was recorded again after 20 minutes of rest, and if necessary after 72 hours, in order to document return of MDR to baseline values. Results: In subjects without intermittent locking, the MDR after chewing was not different from baseline (P = .25). However, in the subjects with intermittent locking, the MDR value had increased significantly after chewing (P = .008); two subjects showed a later moment of disc reduction, and four showed a temporary loss of disc reduction. Conclusion: While intensive chewing did not influence disc reduction in subjects without intermittent locking, it caused a delay or even hampered disc reduction in approximately half of the subjects reporting intermittent locking.

Oral pain and eating problems in Spanish adults and elderly in the Spanish National Survey performed in 2005.

Abstract: Aims To analyze and quantify the sociodemographic, behavioral, and clinical factors influencing the oral pain and eating difficulties reported by Spanish 35- to 44-year-old adults and more elderly people in the most recent Spanish National Oral Health Survey. Methods Pain and chewing difficulties were gathered in a Likert-scale format from a representative sample of the Spanish general population between the ages of 35 and 44 years (n = 540) and 65 to 74 years (n = 540). Risk factors were identified using bivariate analysis, after which the crude association between risk factors (sociodemographic, behavioral, and clinical) and outcome variables (pain and eating problems) was assessed by adjusted odds ratios, calculated by means of multivariate logistic regression. Results In the 35- to 44-year-old adults, eating problems were mainly associated with caries and prosthetic treatment needs and oral pain by the number of decayed teeth. In the more elderly individuals, eating problems and oral pain were influenced by prosthetic needs and the number of missing teeth. Female sex was seen to be a risk factor for suffering pain and eating restrictions. Additionally, several independent variables such as social class, place of residence, brushing habits, or periodontal needs became nonsignificant after logistic regression modelling. Conclusion According to this high-specificity regression model, caries and prosthetic treatment needs should be considered key factors in determining the oral well-being of the Spanish population. Missing teeth represent the most relevant influencing factor for the elderly and decayed teeth for younger adults.

Control of jaw-clenching forces in dentate subjects.

Abstract: Aims: To characterize the control of jaw-clenching forces by means of a simple force-matching exercise. Methods: Seventeen healthy subjects, provided with visual feedback of the exerted force, carried out a unilateral force-matching exercise requiring developing and maintaining for 7 seconds a jaw-clenching force at 10%, 30%, 50%, and 70% of the maximum voluntary contraction. The task was repeated three times in each of two sessions. Motor performance was assessed, for both left and right sides, by different indices quantifying mean distance (MD), offset error (OE), and standard deviation (SD). Their dependence on force intensity, side, and time was assessed by ANOVA. Results: All error indices increased with the intensity of contraction in absolute terms. After normalization with respect to force level, the average performance in the second session was characterized by MD of 8.1% ± 2.6, OE 4.8% ± 2.9, and SD 12.7% ± 6.7 (mean ± standard deviation). Assessment of performance exhibited good reliability for all indices (intraclass correlation coefficient ranging from 74% to 88%). The motor performance improved with repetition (P .05) but was highly correlated between left and right side (P < .01). Conclusion: The adopted approach is adequate to provide for an objective assessment of individual force control, although the presence of a learning phase must be taken into account.

Position paper: appropriate use of pharmacotherapeutic agents by the orofacial pain dentist.

Abstract: Orofacial Pain Dentistry is concerned with the prevention, evaluation, diagnosis, treatment, and management of persistent and recurrent orofacial pain disorders. The American Dental Association, through the Commission on Dental Accreditation (CODA), now recognizes Orofacial Pain as an area of advanced education in Dentistry. It is mandated by CODA that postgraduate orofacial pain programs be designed to provide advanced knowledge and skills beyond those of the standard curriculum leading to the DDS or DMD degrees. Postgraduate programs in orofacial pain must include specific curricular content to comply with CODA standards. The intent of CODA standards is to assure that training programs develop specific educational goals and objectives that describe the student/resident’s expected knowledge and skills upon successful completion of the program. A standardized core curriculum, required for accreditation of dental orofacial pain training programs, has now been adopted.Among the various topics mandated in the curriculum are pharmacology and, specifically, pharmacotherapeutics. The American Academy of Orofacial Pain (AAOP) recommends, and the American Board of Orofacial Pain (ABOP) requires, that the minimally competent orofacial pain dentist* be knowledgeable in the management of orofacial pain conditions using medications when indicated. Basic knowledge of the appropriate use of pharmacotherapeutics is essential for the orofacial pain dentist and, therefore, constitutes part of the examination specifications of the ABOP. The minimally competent orofacial pain clinician must demonstrate knowledge, diagnostic skills, and treatment expertise in many areas, such as musculoskeletal, neurovascular, and neuropathic pain syndromes; sleep disorders related to orofacial pain; orofacial dystonias; and intraoral, intracranial, extracranial, and systemic disorders that cause orofacial pain or dysfunction. The orofacial pain dentist has the responsibility to diagnose and treat patients in pain that is often chronic, multifactorial, and complex. Failure to understand pain mechanisms can lead to inaccurate diagnoses and ineffective, delayed, or harmful treatment. It is the responsibility of the orofacial pain dentist to accurately diagnose the cause(s) of the pain and decide if treatment should be dentally, medically, or psychologically oriented, or if optimal management requires a combination of all three treatment approaches. Management may consist of a number of interdisciplinary modalities including, eg, physical medicine, behavioral medicine, and pharmacology or, in rare instances, surgical interventions. Among the essential armamentarium is the knowledge and proper use of pharmacologic agents.

Influence of cross-sectional temporomandibular joint tomography on daignosis and management decisions of patients with temporomandibular joint disorders

Abstract: Aim: To assess whether changes in diagnoses and management of temporomandibular joint disorder (TMJD) patients are influenced by radiographic findings and if there is an association between specific radiologic alterations and management strategy changes. Methods: A total of 204 patients with TMJ symptoms were examined using the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). Diagnoses and management were first decided without the aid of radiographs. Management categories were: pharmacology, physiotherapy, counseling and behavioral treatment, occlusal stabilization, surgery, additional examinations, and referrals, each with subcategories. Sagittal TMJ tomograms were assessed for the presence of flattening, erosion, osteophyte, and sclerosis in the TMJ components. Diagnoses and management were reevaluated after gaining access to the radiographs and radiographic classifications. Logistic regression analyses were performed with changes in management as the dependent variable and age and radiographic findings as the independent variables. Results: Diagnosis was changed for 56 patients, mainly from arthralgia to osteoarthritis. Management was changed for 55 patients. Most changes occurred in pharmacology and physiotherapy followed by counseling and behavioral treatment, occlusal stabilization, referrals, additional examinations, and surgery. Changes were mostly within the categories, and the highest number of changes was seen in pharmacology, physiotherapy, and counseling and behavioral treatment. Radiographic degenerative findings increased the chance of change (any change) (odds ratio [OR] >= 2.03) and the chance of change in pharmacology (OR >= 2.56) and physiotherapy (OR = 2.48) separately. No other significant associations were found. Conclusion: Radiographic degenerative findings increased the chance of changes in management strategy. However, 73% of the TMJD patients had no changes in management after radiographic examination. In cases with changes, these were mainly adjustments within management categories.

Antihyperalgesic effects of clomipramine and tramadol in a model of posttraumatic trigeminal neuropathic pain in mice.

Abstract: Aims To develop a behavioral model in mice that is capable of mimicking some distinctive symptoms of human posttraumatic trigeminal neuropathic pain such as spontaneous pain, cold allodynia, and chemical÷inflammatory hyperalgesia, and to use this model to investigate the antinociceptive effects of clomipramine and tramadol, two drugs used for the treatment of neuropathic pain. Methods A partial tight ligature of the right infraorbital nerve by an intraoral access or a sham procedure was performed. Fourteen days later, mice were subcutaneously injected with saline or drugs and the spontaneous nociceptive behavior, as well as the responses to topical acetone and to formalin or capsaicin injected into the ipsilateral vibrissal pad, were assessed. Data were analyzed by ANOVA. Results Neuropathic mice exhibited an increased spontaneous rubbing÷scratching of the ipsilateral vibrissal pad, together with enhanced responses to cooling (acetone) and the chemical irritants (formalin, capsaicin). Clomipramine and tramadol produced an antihyperalgesic effect on most of these nociceptive responses, but tramadol was ineffective on capsaicin-induced hyperalgesia. Conclusion Nociceptive responses in this neuropathic pain model in mice exhibited a pattern consistent with the pain described by posttraumatic trigeminal neuropathic patients. The selective antihyperalgesic effect obtained with two commonly used drugs for treating neuropathic pain confirms the validity of this preclinical model.

Assessment of pain sensitivity in patients with deep bite and sex- and age-matched controls.

Abstract: Aims: To compare pain sensitivity between deep bite patients and a sex- and age-matched control group with normal occlusion. Methods: Pain sensitivity was assessed by injections of the excitatory amino acid glutamate into the masseter and brachioradialis muscles. Intensity of glutamate-evoked pain was scored by the subjects ( n = 60) on a 0 to 10 cm visual analog scale. Subjects drew the perceived pain area on a face and arm chart and described the quality of pain on the McGill Pain Questionnaire. Thresholds for cold detection, cold pain, cold tolerance, warmth detection, heat pain, and heat tolerance were assessed on the masseter and brachioradialis muscles. Pressure pain threshold and pain tolerance threshold were determined on the temporomandibular joint, masseter, anterior temporalis, and brachioradialis muscles. The differences between groups, age, and gender were tested by two-way ANOVA, and the significant differences were then tested for the effect of the presence of temporomandibular disorder (TMD) by linear regression. Results: Glutamate-evoked pain intensity was significantly different between groups with no gender differences. Quality of pain did not vary between groups, but significant gender-related differences were observed. Significant differences in thermal sensitivity between groups and gender were found, whereas mechanical sensitivity did not vary between groups but between genders. None of the significant differences were due to the effect of TMD. Conclusion: These data provide further evidence of gender-related differences in somatosensory sensitivity and for the first time indicate that subjects with deep bite may be more sensitive to glutamate-evoked pain and thermal stimuli.