Effect of stabilization-type splints on the asymmetry of masseter muscle sites during maximal clenching

Patients with temporomandibular disorders may present with a cluster of joint and muscle disorders characterized primarily by pain, joint sounds and irregular or deviating jaw function. Maxillary stabilization-type splints represent the best standard therapy, so the purpose of this study was to evaluate changes in local maximal clenching-related asymmetry patterns of masseter muscle sites associated with the immediate 'application of splint therapy' using the diagnostic approach of high-resolution gray-scale ultrasonography. The study included 24 patients who had signs and symptoms of temporomandibular disorders. Ultrasonographic investigation was performed with a linear (B-scan) 7.5 Mhz small-part transducer to visualize the antero-superior, antero-inferior, medio-superior, medio-inferior, postero-superior, and postero-inferior sites of the masseter muscle. To assess local maximal clenching-related muscle asymmetry patterns and to evaluate the respective effect of occluding splints, the 'absolute asymmetry index' was used, with the mean maximum muscle diameter of the respective right and left sides calculated from three consecutive measurements before and after splint insertion. Comparing the values assessed before splint insertion with those after splint insertion revealed a significant decrease in local maximal clenching-related muscle asymmetry values for the antero-inferior masseter muscle site (P < 0.05). The results of this study suggest stabilization-type splints to have a site-specific effect in the immediate reduction of local maximal clenching-related muscle asymmetries. Further studies are warranted to evaluate muscle-site specific effects in patient and non-patient groups and to relate these effects to pre-treatment variables like bite force, preferred chewing side, facial morphology and occlusion.     

Laser Doppler flow investigation of fractured permanent maxillary incisors

Laser Doppler flowmetry (LDF) is a non-invasive method to assess pulpal blood-flow (PBF). Dental injury has been associated with losses of pulpal sensibility. The purpose of this study was to assess the outcome of splint therapy on tooth fracture type-related PBF values. In 15 trauma patients, a single maxillary incisor treated by repositioning and splinting was investigated by LDF to assess local PBF values. Perfusion units were taken in four sessions, on the day of splint removel, and 12, 24 and 36 weeks after splint removal. Analysis of the tooth fracture type-related PBF measurements revealed root fractures to be associated with a significant decrease (P < 0.05) and uncomplicated crown fractures to be associated with a significant increase in PBF values (P < 0.05), while complicated crown fractures showed no significant difference between the session-related values (P > 0.05). The main findings of this study suggest splint therapy of root fractures of the central maxillary incisor to be associated with a short- and long-term decrease in PBF values. The LDF may become useful in the detection of transient ischaemic episodes and the identification of teeth at risk for adverse sequelae such as avascular necrosis and tissue loss.     

Temporomandibular joint osteoarthrosis diagnosed with high resolution ultrasonography versus magnetic resonance imaging: how reliable is high resolution ultrasonography?

The purpose of this study was to determine whether 12.5 MHz ultrasonography (US) could be used to assess the presence or absence of temporomandibular joint (TMJ) condylar osteoarthrosis. In 40 consecutive patients with TMJ disorders, 80 TMJs were investigated by US to analyse the condylar morphology. In order to compare the respective findings with those of a diagnostic method offering a high accuracy, coronal and sagittal magnetic resonance imaging was carried out immediately afterwards. With US showing a sensitivity of 87%, and a specificity of 20%, the data revealed US to be sensitive in detecting the presence, but insufficient in detecting the absence of osteoarthrosis. In addition, with a positive predictive value of 88%, and a negative predictive value of 18%, the results indicate that US may be valuable in diagnosing the presence, but insufficient in diagnosing the absence of osteoarthrosis. In view of the fact that the 12.5 MHz US technique proved to be a valuable diagnostic aid for the detection and prediction of abnormal condylar morphology, the results of this study should be of further interest and encourage research in its potential uses and diagnostic capabilities.     

Temporomandibular joint internal derangement: detection with 12.5 MHz ultrasonography

The purpose of this study was to determine whether 12.5 MHz ultrasonography (US) could be used to assess the presence or absence of temporomandibular joint (TMJ) internal derangement (ID). In 48 consecutive patients with TMJ disorders 192 TMJ positions were investigated by US to analyse the functional disc-condyle relationship (DCR). In order to compare the respective findings with those of a diagnostic method offering a high accuracy, coronal and sagittal magnetic resonance imaging was carried out immediately afterwards. With US showing a sensitivity of 0.58 and 0.75, and a specificity of 0.92 and 0.84 for disc displacement with and without reduction, the data revealed US to be marginal in detecting the presence, but sensitive in detecting the absence of the respective types of a TMJ ID. In addition, with a positive predictive value of 0.83 and 0.71, and a negative predictive value of 0.81 and 0.87 for disc displacement with and without reduction, the results indicate that US may be insufficient in establishing a correct diagnosis for the presence or absence of the respective types of TMJ ID. Regarding the diagnosis of absence or presence of TMJ ID, the results demonstrate high-resolution (HR)-US to be sensitive in detecting the absence, and reliable in predicting the presence of TMJ ID. In view of the fact that the 12.5 MHz US technique proved to be a reliable diagnostic aid for the detection of normal, and the prediction of abnormal DCR, the results of this study should be of further interest and encourage research in its potential uses and diagnostic capabilities.     

Bone marrow edema of the mandibular condyle related to internal derangement, osteoarthrosis, and joint effusion.

PURPOSE: The purpose of this prospective study was to evaluate whether common magnetic resonance imaging (MRI) variables such as temporomandibular joint (TMJ) internal derangement, osteoarthrosis, and effusion may predict the diagnostic group of bone marrow edema of the mandibular condyle. MATERIALS AND METHODS: The relationship between bone marrow edema and TMJ disc displacement, osteoarthrosis, and effusion was analyzed in MRIs of 120 TMJs in 73 consecutive patients with TMJ pain and/or a clinical diagnosis of TMJ internal derangement type III (disc displacement without reduction). The diagnostic bone marrow edema group was comprised of 54 TMJs in 40 patients with a unilateral or bilateral MRI diagnosis of bone marrow edema. The control group consisted of 66 non-bone marrow edema TMJs in 33 patients with a bilateral MRI finding of an absence of bone marrow edema. A logistic regression analysis was used to compute the odds ratios for internal derangement, osteoarthrosis, and effusion for non-bone marrow edema TMJs (n = 66) versus TMJs with bone marrow edema (n = 54). RESULTS: Using Chi;(2) analysis for pair-wise comparison, the TMJ-related data showed a significant relationship between the MR imaging findings of TMJ bone marrow edema and those of internal derangement (P = .000), osteoarthrosis (P = .000), and effusion (P = .010). Of the MRI variables considered simultaneously in the multiple logistic regression analysis, osteoarthrosis (P = .107) and effusion (P = .102) dropped out as nonsignificant in the diagnostic bone marrow edema group when compared with the control group. The odds ratio for individuals with an internal derangement showing bone marrow edema was strong (3.6:1) and highly significant (P = .000). Significant increases in risk of bone marrow edema occurred with disc displacement without reduction and osteoarthrosis (9.2:1) (P = .000) and disc displacement without reduction and effusion (6.4:1) (P = .002). CONCLUSIONS: The results suggest that the MR imaging findings for TMJ bone marrow edema are related to those of internal derangement, osteoarthrosis, and effusion. However, the data re-emphasize the aspect that internal derangement, osteoarthrosis, and effusion may not be regarded as the unique and dominant factors in defining TMJ bone marrow edema instances.     

The role of mycophenolate mofetil in kidney transplantation revisited

Since its regulatory approval in 1995, mycophenolate mofetil (MMF) has largely replaced azathioprine (AZA) as the anti-metabolite immunosuppressive of choice in kidney transplantation. While the initial industry-sponsored clinical trials suggested strong reductions in the incidence of acute rejection in the first six months post transplantation, long-term follow-up studies have failed to demonstrate a similar degree of benefit in overall graft and patient survival. In addition, several subsequent studies have raised questions on the potential attenuating effects of calcineurin inhibitor choice on MMF efficacy when compared to AZA. This review will revisit the question of whether the available evidence continues to support the superiority of MMF over AZA in kidney transplantation outcomes while comprehensively reviewing the available evidence from clinical trial data, systematic reviews, and registry studies.     

Erfahrungen von Tumorpatienten mit Durchbruchschmerzen und medikamentösen Behandlungen

Background

Of cancer patients receiving palliative care, 80% suffer from cancer pain, and again 80% of these patients report breakthrough pain. This study explores the patients’ perception of breakthrough pain, their experiences with existing therapeutic regimens and their expectations regarding an ideal breakthrough pain medication.

Method

From November 2008 to February 2010 two German palliative care units recruited 80 in- or outpatient cancer patients who completed a standardized questionnaire on breakthrough pain characteristics, analgesic medication, attitudes towards new treatment approaches for breakthrough pain, and experiences with alternative routes of drug administration as part of the “European Survey of Oncology Patients’ Experience of Breakthrough Pain”.

Results

The study participants suffered from 1–12 episodes of either incident (47.5%) or spontaneous pain (37.5%) per day which were perceived as “severe” in 71% of all cases. These exacerbations highly interfered with the patients’ general activity, mood, walking ability, and normal work. Overall, 64% of the patients reported alleviation from pharmacological (26%) and non-pharmacological (73%) interventions. Subcutaneous (40%) and oral (39%) routes were used frequently; intranasal (1.25%) and intrapulmonary (1.25%) routes were used rarely. Only 64% of all participants stated an overall satisfaction with their breakthrough analgesia.

Conclusion

The diagnosis and treatment of breakthrough pain seems to be conducted in a suboptimal manner, and standard recommendations on breakthrough pain relief are not implemented consistently. Possible causes of pain should be taken into account as well as multi-professional treatment interventions and alternative routes of administration of fast onset, effective drugs should be considered.