Occlusal conditions just after the relief of temporomandibular joint and masticatory muscle pain

When the signs and symptoms of temporomandibular joint disorders (TMD) are present, it is possible that occlusal conditions and mandibular movements are changed. Accordingly, the presence of occlusal interferences may be misjudged. It is therefore reasonable to consider that occlusal conditions should be examined just after the relief of symptoms. The comparison of occlusal conditions in 52 temparomandibular joint (TMJ) pain patients and 27 muscle pain patients with that in 60 asymptomatic controls was made. Occlusal examination in the patients was administered just after the relief of pain by bite plane therapy alone. The only occlusal factor which was associated with pain symptoms was no canine contact on the working side on laterotrusion. It is suggested therefore that further studies as regards this type of interference should be performed.     

(i) The principles of foot and ankle arthrodesis

Successful arthrodesis of a diseased joint for pain relief and stability in the appropriate patient is achieved by thorough pre-operative planning and attention to risk factors for non-union, meticulous surgical technique including respect for soft tissues, adequate joint surface preparation and co-aptation of joint surfaces with stable fixation in the position of most useful function. Here we outline how these principles are applied in the foot and ankle.     

A short-term evaluation of the effectiveness of stabilization-type occlusal splint therapy for specific symptoms of temporomandibular joint dysfunction syndrome

To clarify the short-term effectiveness of stabilization-type occlusal splint therapy, a specific symptom approach was used toward 30 temporomandibular joint dysfunction patients with more than two major symptoms (temporomandibular joint and/or masticatory muscle pain, temporomandibular joint sounds, and limitation of mandibular movement). Eighty-seven percent of the patients with pain responded with this therapy and more than 50% had complete relief of pain 4 weeks after insertion of the splint. Temporomandibular joint sounds and limitation of mandibular movement responded more slowly than pain. These results suggest that the stabilization-type occlusal splint should be selected as a first choice among several therapies and that temporomandibular joint pain is particularly susceptible to this therapy.     

Evaluation of iontophoretically applied dexamethasone for painful pathologic temporomandibular joints

The effects of iontophoretically applied dexamethasone in a lidocaine vehicle were compared with those of saline placebo in 53 patients with one of three diagnoses of painful temporomandibular joint pathologic conditions: disk displacement with reduction, disk displacement without reduction, and osteoarthritis. Both dexamethasone and the saline placebo produced a significant reduction in pain scores from baseline levels after the first two of three treatments. There were no observed differences, however, in pain report or mandibular range of motion between the dexamethasone and placebo groups. A trend for pain relief was noted in the subgroup that received dexamethasone with a diagnosis of osteoarthritis. Results may reflect varying degrees of inflammation or central nervous system hyperexcitability, or both, in this heterogeneous study sample. Potential confounding variables were lack of knowledge of actual drug penetration, the effects of electric current transmitted by the iontophoresor, and pain reduction caused by cyclic fluctuations in symptoms. These data suggest that iontophoretically applied dexamethasone is no more effective than saline placebo in providing pain relief in patients with temporomandibular joint pain.     

Cryoanalgesia in the management of intractable pain in the temporomandibular joint: a five-year retrospective review

Cryoanalgesia is a controversial adjunct to the management of chronic pain, but we know of no studies that have investigated its effect in the management of temporomandibular joint (TMJ) pain. In this five-year retrospective study we treated 17 patients who had severe pain that had failed to respond to all forms of conventional conservative treatment and were not appropriate for simple open operation. None had a clear indication for open operation on the joint or had too severe disease to warrant a simple procedure. Preliminary diagnostic injections of bupivacaine to the TMJ relieved the pain. We applied the cryoprobe in the region of the auriculotemporal nerve and TMJ capsule. There was a small but insignificant improvement in mean mouth opening together with a significant (p = 0.000) improvement in visual analogue pain scores (VAS) from 6.8 (range 4–10) to 2.0 (range 0–7). Two patients had no change in their pain scores, and 2 had complete resolution of their pain. The mean number of pain-free months after treatment was 7 (IQR 3–15). Three patients had long-term pain relief, and 12 temporary relief; 6 of these subsequently had successful relief after total replacement of the TMJ. One patient had further cryoanalgesia, one was referred for specialist pain management, and one controlled the pain with nortriptyline. Of the 17 cases studied, 2 had temporary complications after cryoanalgesia. Cryoanalgesia is a useful adjunct to the management of intractable pain in the TMJ. Short-term pain relief can be achieved, and long-term relief is possible in some, deferring more complex and costly treatments.     

Change of site of intra-articular injection of hypertonic dextrose resulted in different effects of treatment

Most minimally invasive treatments for dysfunction of the temporomandibular joint (TMJ) are empirical, and aimed at the painful trigger points with the purpose of preventing muscular spasm and restoring normal function. In this prospective study I investigated whether the choice of site of injection of hypertonic dextrose affected the benefits of treatment of internal derangement and pain. I studied 72 patients with pain and clicking as a result of dysfunction of the TMJ. Patients were divided into four groups with four separate sites for intra-articular injection. Dextrose was injected into the superior joint space, inferior joint space, retrodiscal tissue, and anterior capsule injection. Results showed that the retrodiscal site was the most effective for reducing clicking and subsequently improving derangement, while the inferior joint space was the best site for the relief of pain, and the extracapsular site should be used in cases of hypermobility. In conclusion, the injection site should be selected according to the symptoms being treated, and could be used as an adjunct to other sites to improve outcome.     

Cryoneurotomy for intractable temporomandibular joint pain

A review of cryoneurotomy to the temporomandibular joint capsule and/or the great auricular nerve for six consecutive patients with intractable neurogenic pain in the preauricular region is presented. All the patients had severe pain complicated by failed previous treatment, analgesic abuse or psychiatric problems. All the patients had excellent pain relief for 1 year following cryoneurotomy but with recurrence in four patients. Repeated cryoneurotomy can be performed but with decreasing effectiveness.     

The analgesic efficacy and safety of intra-articular morphine and mepivicaine following temporomandibular joint arthroplasty.

PURPOSE: This study was designed to evaluate the efficacy and safety of intra-articular morphine, mepivacaine, or a combination of both in the management of temporomandibular joint (TMJ) pain in a 24-hour period after arthroplasty. PATIENTS AND METHODS: This was a randomized, double-blind, prospective, parallel, placebo-controlled, single-injection study of 35 patients who underwent TMJ arthroplasty. Patients were randomized into 4 groups. Group M (morphine) received 1 mg of morphine sulfate in 1 mL of saline; group MEP (mepivicaine) received 30 mg of mepivacaine hydrochloride in 1 mL of saline; group M/MEP received 30 mg of mepivacaine hydrochloride and 1 mg of morphine in 1 mL of saline; and group C (saline control) received 1 mL of saline. Patients received a single dose of study medication when their postoperative pain reached a moderate or severe intensity and was 50 mm or greater on a 100-mm pain scale. Analgesic efficacy measures included the time to meaningful pain relief measured using a stop watch and time to rescue medication. Pain relief and pain intensity ratings were recorded at the time to relief and time to rescue medication. A global evaluation for the effectiveness of the medications was recorded within 24 hours after dosing. Adverse events were recorded and categorized by system effect. RESULTS: MEP and M/MEP were significantly more effective than placebo for all the analgesic measures. Morphine alone provided only mild analgesia and did not differ from placebo in the primary efficacy measures. The average overall pain relief was substantially better for MEP than M and M/MEP (P = .03). In patients receiving MEP, the mean time to pain relief was 2.9 minutes and the mean analgesic duration was 9.7 hours (586 minutes); 3 patients required no rescue medication in the 24 hour postdosing period. In patients receiving M/MEP, the mean time to analgesia was 7.6 minutes and the duration of analgesia was 2.7 hours (175 minutes). The average time to onset and duration of analgesia in the MEP and M/MEP groups was statistically significantly better (P < .001) then in the M alone group (17.7 minutes, 0.43 hours, respectively) and the placebo C group (16.1 minutes, 0.17 hours, respectively). At the end of the study, 80% of the patients given MEP rated the medication as a very good or excellent pain reliever, whereas only 40% of patients given M/MEP, 10% of patients given M, and no patients given placebo gave these same ratings. No serious adverse events occurred in this study. Gastrointestinal adverse events were the most common side effect noted in the MEP and M/MEP groups but were mild in intensity and reversed without treatment. CONCLUSION: All intra-articular TMJ injections of active substances provided better analgesia than placebo. Morphine alone provided only mild and short-acting analgesia. The local anesthetic, mepivacaine, given alone was safe, provided the quickest, longest acting and most effective analgesia. This proof of concept study suggests that local anesthetics are superior analgesics when given intra-articularly for postoperative TMJ surgery pain and should be investigated for dose response and multiple or continuous infusion effectiveness.     

糖皮质激素对关节腔灌洗治疗关节盘不可复性前移位疗效的影响

目的探讨关节腔灌洗后加糖皮质激素注射对治疗关节盘不可复性前移位的短期、长期疗效以及髁突骨质影像改变的影响。方法按照随机原则将90例颞下颌关节盘不可复性前移位患者分为对照组（44例）和试验组（46例）,对照组在关节腔灌洗后只注入生理盐水,试验组在关节腔灌洗后注入生理盐水与醋酸曲安奈德的混合液。治疗后3~4周（短期）和6个月（长期）复查,采用疼痛自评视觉模拟尺和Fricton颞下颌关节指数评价临床疗效,影像学评价髁突骨质的改变。对有疼痛主诉的患者同时记录治疗后1周每天睡前疼痛分值。结果1）治疗后1周,试验组疼痛减轻更显著（P<0.05）。2）2组患者治疗前后的临床体征和疼痛均有统计学差异（P<0.001）,2种治疗方法均能有效改善症状和体征,但2组之间各项指标的比较均无统计学差异。3）治疗后大多数患者的髁突骨质没有明显的变化。结论除炎症疼痛明显者外,关节腔灌洗治疗关节盘不可复性前移位不必再加激素注射。     

Comparison of preoperative pain and medication use in emergency patients presenting with irreversible pulpitis or teeth with necrotic pulps

OBJECTIVE: This retrospective study compared differences in preoperative pain and medication use in patients with moderate to severe pain who sought emergency endodontic care for teeth with irreversible pulpitis and for symptomatic teeth with necrotic pulps. STUDY DESIGN: A total of 323 patients seeking emergency endodontic treatment completed questionnaires regarding their biographical information, pain, pain history, and medications. Teeth were tested for vitality, mobility, percussion, and palpation pain. Lymphadenopathy was also evaluated. RESULTS: Patients with irreversible pulpitis waited significantly (P <.05) longer before seeking emergency care (9 days vs 4 days) than patients with symptomatic teeth with necrotic pulps. No differences (P >.05) were found between the groups in terms of analgesic or antibiotic use and pain relief from preoperative narcotic medications. Nonnarcotic analgesics were reported to significantly reduce pain more often in patients with symptomatic teeth with necrotic pulps. There were sex differences in the group of patients with irreversible pulpitis: More women than men were taking analgesic medications and, in the group having symptomatic teeth with necrotic pulps, more men than women reported pain relief from their analgesic medications. CONCLUSION: Patients with irreversible pulpitis wait longer to seek emergency treatment. A majority (81%-83%) of emergency patients with moderate to severe pain will have taken some type of medication(s) to help control their pain, and more women than men with irreversible pulpitis will take an analgesic. By taking their preoperative medication(s), this group of patients will get relief 62% to 65% of the time; furthermore, more men than women with symptomatic teeth with necrotic pulps will experience pain relief.     

Clinical implications of the innervation of the temporomandibular joint

The successful management of temporomandibular joint (TMJ) pain remains elusive. Often, the initial relief of pain is complicated by recurrence of the symptoms. This time frame suggests that the pain may be related to neuromas of the nerves that innervate the TMJ. The current study attempted to define the innervation pattern of the TMJ as identified in 16 embalmed and 8 fresh-frozen specimens. In each specimen, the auriculotemporal nerve, a branch of the mandibular portion (V3) of the trigeminal nerve, was found to innervate the lateral capsule of the TMJ. In 75% of the specimens, the masseteric nerve, a branch of the maxillary portion (V2) of the trigeminal nerve, was found to innervate the anteromedial capsule of the TMJ. In 33% of the specimens, there was a branch coming through the mandibular notch to innervate the anteromedial capsule that was not from the masseteric nerve; this nerve is believed to have passed through the lateral pterygoid muscle after leaving V2. These consistent patterns of innervation of the TMJ suggest that diagnostic nerve blocks can be done to determine the pain pathway in these patients. It is suggested that if the nerve blocks are successful, TMJ denervation may be a future method of pain relief in patients with recalcitrant or recurrent TMJ pain.     

Endoscope-assisted conservative condylectomy in the treatment of condylar osteochondroma through an intraoral approach

Mandibular condylar osteochondroma (OC) can result in morphological and functional disturbances, including facial asymmetry and temporomandibular joint (TMJ) dysfunction. The aim of this study was to explore the feasibility of endoscope-assisted tumour resection and conservative condylectomy via an intraoral approach. Seven patients with condylar OC were enrolled in this study. Endoscope-assisted tumour resection and conservative condylectomy were achieved intraorally, and no conventional extraoral incision was needed. Direct vision of the magnified and illuminated operative field was realized with the assistance of an endoscope. No facial nerve injury or salivary fistula occurred in any patient. Stable occlusion was realized through postoperative orthodontic treatment. The patients showed no signs of tumour recurrence or TMJ ankylosis during follow-up (range 18–43 months). Endoscope-assisted condylar OC resection and conservative condylectomy via intraoral approach offers great advantages with no significant complications compared with conventional extraoral incisions. The endoscope provides us with a valuable treatment option for this potentially complicated procedure     

The efficacy of pain control following nonsurgical root canal treatment using ibuprofen or a combination of ibuprofen and acetaminophen in a randomized, double-blind, placebo-controlled study

AIM: To compare ibuprofen, to an ibuprofen/acetaminophen combination in managing postoperative pain following root canal treatment. It is hypothesized that the drug combination will provide more postoperative pain relief than the placebo or ibuprofen alone. METHODOLOGY: Patients presenting at the Texas A&M Baylor College of Dentistry's graduate endodontic clinic, experiencing moderate to severe pain, were considered potential candidates. Fifty-seven patients were included based on established criteria. Following administration of local anaesthesia, a pulpectomy was performed. The patients were administered a single dose of either: (i) placebo; (ii) 600 mg ibuprofen; or (iii) 600 mg ibuprofen and 1000 mg of acetaminophen. Patients recorded pain intensity following treatment on a visual analogue scale and a baseline four-point category pain scale as well as pain relief every hour for the first 4 h then every 2 h thereafter for a total of 8 h. A general linear model (GLM) analysis was used to analyse the outcome. RESULTS: Based upon the GLM analysis, there was a significant difference between the ibuprofen and the combination drug group, and between placebo and combination drug groups. There was no significant difference between the placebo and the ibuprofen. CONCLUSION: The results demonstrate that the combination of ibuprofen with acetaminophen may be more effective than ibuprofen alone for the management of postoperative endodontic pain.     

颅底—颞下颌关节区骨巨细胞病变的切除及修复

目的：探讨发生于颅底—颞下颌关节区的骨巨细胞病变的手术切除特点及修复原则。方法：1994年3月～2007年7月共手术治疗颅底—颞下颌关节区骨巨细胞病变18例,12例行颅颌联合手术。15例病变全部切除,3例近全切除,仅1例切除部分硬脑膜并修补。对于术后缺损,17例用邻近带蒂组织瓣如颞肌系统瓣、胸锁乳突肌瓣修复,1例用游离背阔肌肌皮瓣修复;4例用钛板重建颧弓,6例用钛网重建颅底,2例分别用人工关节和游离髂骨重建颞下颌关节。3例近全切除者加用术后放疗。结果：除1例术后第3天发生脑脊液漏,经保守治疗康复,其余无并发症。所有18例术后外形基本对称,术前各种症状明显改善。16例在随访期间（6个月～10a）未出现复发,2例失访。结论：对发生于颅底-颞下颌关节区的骨巨细胞病变,应力求根治性切除,硬脑膜缺损应予修补。用邻近的带蒂组织瓣修复软组织缺损,钛板或钛网修复骨组织缺损,可获得满意的外形,较大的缺损可用游离组织瓣修复。     

Effect of occlusal relief on endodontic pain

It has been suggested that removal of occlusion contacts will prevent or reduce postoperative endodontic pain during treatment. However, this theory has not been tested in clinical experiments. In this study, after endodontic instrumentation, the treated posterior tooth randomly received occlusal relief or mock-occlusal relief. Mean pain levels and the incidence of pain to occlusal pressure at various time intervals were recorded on questionnaire postcards by all patients, as was the duration of discomfort. Comparison of pain experienced by the occlusal treatment groups through statistical analysis gave the following conclusions: Spontaneous pain levels in the mock-occlusal relief and occlusal relief groups were not significantly different; Spontaneous pain levels in the mock-occlusal relief and occlusal relief groups did significantly relate to preoperative pain; Pain incidence from occlusal pressure in the mock-occlusal relief and occlusal relief groups did not significantly differ; Pain from occlusal pressure in both occlusal treatment groups did not significantly relate to preoperative pain; Duration of discomfort was not related to the occlusal treatment provided. The theory may be invalid that prophylactic removal of occlusal contacts is a pain preventive measure.     

A comparison of ibuprofen and dihydrocodeine in relieving pain following wisdom teeth removal

Although dihydrocodeine (DF118) is widely prescribed by general dental practitioners, there is little evidence that it is successful in controlling post-operative dental pain. Ibuprofen is known to be effective in this situation. A single dose, double-blind study was carried out in 148 patients to compare 400 mg ibuprofen with 30 mg dihydrocodeine and placebo for treating moderate to severe pain following the removal of unilateral, impacted mandibular third molar teeth under local anaesthesia. An additional dose of either ibuprofen or dihydrocodeine was available after 2 hours. The post-operative ibuprofen reduced pain and produced more pain relief than dihydrocodeine or placebo. Furthermore, fewer patients receiving ibuprofen took additional analgesic at 2 hours. Patients who received ibuprofen as supplementary medication also experienced less pain and had greater pain relief than those receiving dihydrocodeine as supplementary medication, even when their post-operative treatment had been placebo. More patients reported the medication as having been effective if they took ibuprofen either post-operatively or as supplementary analgesia. Ibuprofen is an appropriate analgesic for treating post-operative dental pain.     

Evaluation of prolotherapy in comparison with occlusal splints in treating internal derangement of the temporomandibular joint – A randomized controlled trial

PurposeThe aim of this study was to compare the efficacy of dextrose prolotherapy with that of occlusal splints in treating internal derangement of the temporomandibular joint.Patients and methodsA total of 34 patients with temporomandibular joint internal derangement classed as Wilkes stages II or III were recruited for the study, and were randomly divided into study and control groups with 17 patients each. The patients in these control and study groups were treated with splints and prolotherapy, respectively. Outcome parameters, such as pain, mouth opening, clicking and deviation, were assessed using the Helkimo clinical dysfunction index for a review period of 1 year.ResultsNine patients in the study group had complete absence of pain, compared with only one patient in the control group. The results showed that patients who received prolotherapy demonstrated improvement in pain (p < 0.001), mouth opening (p = 0.032), and clicking (p < 0.001), but no significant difference in deviation was observed between the groups after 1 year (p = 0.862).ConclusionProlotherapy was found to be superior in providing long-term clinical relief, with reduction in pain and clicking along with improved mouth opening.     

A case of pigmented villonodular synovitis, with few clinical symptoms, arising from the temporomandibular joint

Pigmented villonodular synovitis is a relatively rare disease that usually affects the knee, hip, hand, wrist, foot, ankle, or shoulder joints. Pigmented villonodular synovitis arising from the temporomandibular joint is extremely rare. The common clinical symptoms of pigmented villonodular synovitis are swelling and pain of the joint region. When patients perceive their symptoms and present at a hospital, the lesion has often developed and extensively destroyed its adjacent tissue. In this article, we report a case of pigmented villonodular synovitis, with few clinical symptoms, arising from the temporomandibular joint.     

Ibuprofen and Acetaminophen Versus Intranasal Ketorolac (Sprix) in an Untreated Endodontic Pain Model: A Randomized,Double-blind Investigation

Introduction

Previously, ketorolac was available for primary use only via intravenous and intramuscular routes. Its availability in intranasal form offers an alternative route of administration that patients can self-administer. The purpose of this study was to compare the efficacy of intranasal ketorolac (Sprix; Egalet US Inc, Wayne, PA) with a combination of ibuprofen/acetaminophen in an acute pain model of untreated endodontic patients experiencing moderate to severe pain and symptomatic apical periodontitis.

Psychosocial profiles of diagnostic subgroups of temporomandibular disorder patients

The purpose of the study was to examine whether patients' psychosocial profiles differ depending on if the location of pain is in the masticatory muscles, the temporomandibular joint, or both. Eligible participants were 491 consecutive patients examined according to the research diagnostic criteria for temporomandibular disorders (RDC/TMD). Among these a total of 225 adult TMD patients had at least one pain-related TMD diagnosis and were therefore included in this study and completed the multidimensional pain inventory (MPI). Patients diagnosed with myogenous pain only ( n  = 103), patients with joint pain only ( n  = 56), and patients with both ( n  = 66) were compared with respect to depression, somatization, jaw disability, pain intensity and chronicity, and MPI scores and profiles. The MPI profiles were analyzed using a multivariate analysis of variance and Hotelling's T² test. Although patients with joint pain were significantly more impaired in jaw function, no significant differences in depression, in somatization or in the 11 scales of the MPI were observed. The location of pain in TMD patients is not a major factor for the prediction of psychosocial profiles. Therefore, clinical TMD diagnoses alone form an insufficient basis for tailored behavioural or psychological management.