Smile prevails over other facial components of male facial esthetics

Background

The aim of this study was to assess whether scores assigned to the eyes, nose, mouth, and chin regions work as predictors of full smiling face scores.

The trigeminal nerve. Part III: The maxillary division

The maxillary nerve gives sensory innervation to all structures in and around the maxillary bone and the midfacial region including the skin of the midfacial regions, the lower eyelid, side of nose, and upper lip; the mucous membrane of the nasopharynx, maxillary sinus, soft palate, palatine tonsil, roof of the mouth, the maxillary gingivae, and maxillary teeth. This vast and complex division of the trigeminal nerve is intimately associated with many sources of orofacial pain, often mimicking maxillary sinus and/or temporomandibular joint involvement. For those who choose to treat patients suffering with orofacial pain and temporomandibular disorders, knowledge of this nerve must be second nature. Just providing the difficult services of a general dental practice should be stimulus enough to understand this trigeminal division, but if one hopes to correctly diagnose and treat orofacial pain disorders, dedication to understanding this nerve cannot be overstated. In this, the third of a four part series of articles concerning the trigeminal nerve, the second or maxillary division will be described and discussed in detail.     

Somesthetic,gustatory, olfactory function and salivary flow in patients with neuropathic trigeminal pain

Oral Diseases (2010) 16 , 482–487 Objectives: To determine somesthetic, olfactory, gustative and salivary abnormalities in patients with burning mouth syndrome (BMS), idiopathic trigeminal neuralgia (ITN) and trigeminal postherpetic neuralgia (PHN). Subjects and Methods: Twenty patients from each group (BMS, ITN, PHN) and 60 healthy controls were evaluated with a systematized quantitative approach of thermal (cold and warm), mechanical, pain, gustation, olfaction and salivary flow; data were analyzed with ANOVA, Tukey, Kruskal–Wallis and Dunn tests with a level of significance of 5%. Results: There were no salivary differences among the groups with matched ages; the cold perception was abnormal only at the mandibular branch of PHN (P = 0.001) and warm was abnormal in all trigeminal branches of PHN and BMS; mechanical sensitivity was altered at the mandibular branch of PHN and in all trigeminal branches of BMS. The salty, sweet and olfactory thresholds were higher in all studied groups; the sour threshold was lower and there were no differences of bitter. Conclusion: All groups showed abnormal thresholds of gustation and olfaction; somesthetic findings were discrete in ITN and more common in PHN and BMS; central mechanisms of balance of sensorial inputs might be underlying these observations.     

The trigeminal nerve. Part II: the ophthalmic division

The ophthalmic, or first division (V1) of the trigeminal nerve, is the smallest of the three divisions and is purely sensory or afferent in function. It supplies sensory branches to the ciliary body, the cornea, and the iris; to the lacrimal gland and conjunctiva; to portions of the mucous membrane of the nasal cavity, sphenoidal sinus, and frontal sinus; to the skin of the eyebrow, eyelids, forehead, and nose; and to the tentorium cerebelli, dura mater, and the posterior area of the falx cerebri. At first glance, one might not expect one interested in the diagnosis and treatment of orofacial pain and temporomandibular joint disorders to have a need to be concerned with the ophthalmic division. Although much of this division's influence is dedicated to structures within the orbit, nose, and cranium, still, the ophthalmic division may be afflicted with a lesion or structural disorder which can cause all sorts of orofacial pain. Ignorance of this or any portion of the trigeminal nerve will lead to diagnostic and therapeutic failures. In this, the second of four (4) articles concerning the trigeminal nerve, the first division of this vast cranial nerve will be described in detail.     

Does adolescent self-reported TMD pain persist into early adulthood? A longitudinal study

Abstract

Objective: To follow up 2209 individuals in a longitudinal study and assess self-reported TMD pain, painful and non-painful comorbid conditions, and pain-related disability.

Material and methods: During 2012–2014, questionnaires were sent to 2209 eligible individuals who had been screened for TMD pain each year during 2000–2003. The two screening questions were (1) Do you have pain in the temple, face, jaw joint, or jaws once a week or more often? and (2) Do you have pain when you open your mouth wide or chew once a week or more often? If the patient answered ‘yes’ to one or both of the questions, TMD pain was recorded. Non-respondents received reminders; telephone interviews were offered a randomised group. The questionnaire queried TMD pain, and painful and non-painful comorbid conditions.

Results: The overall response rate was 36.5%. Individuals were placed into one of four pain groups defined by their pain experience at baseline and at the follow-up: no TMD pain (69.0%), new TMD pain (13.0%), previous TMD pain (9.9%), and persistent TMD pain (8.1%). Based on the self-report surveys, significantly more responders with TMD pain at follow-up had had pain as adolescents than not. Of adolescents with TMD pain, 45.1% had pain at follow-up as young adults, while 15.8% had pain at follow-up without a previous history of TMD pain. Individuals with persistent TMD pain had high frequencies of comorbid pains (p?<?.001), 45.2% reported moderate-severe depression scores (p?<?.001), and 13.0% had moderate pain-related disability (GCPS).

Conclusions: Based on self-report surveys, TMD pain in adolescence appears to triple the risk of TMD pain in young adulthood, and persistent pain increased comorbid pain and psychosocial distress.     

Clinical diagnosis of temporomandibular joint arthritis

Evidence‐based clinical diagnostic criteria for temporomandibular joint (TMJ) arthritis are not available. To establish (i) criteria for clinical diagnosis of TMJ arthritis and (ii) clinical variables useful to determine inflammatory activity in TMJ arthritis using synovial fluid levels of inflammatory mediators as the reference standard. A calibrated examiner assessed TMJ pain, function, noise and occlusal changes in 219 TMJs (141 patients, 15 healthy individuals). TMJ synovial fluid samples were obtained with a push–pull technique using the hydroxycobalamin method and analysed for TNF, TNFsRII, IL‐1β, IL‐1ra, IL‐1sRII, IL‐6 and serotonin. If any inflammatory mediator concentration exceeded normal, the TMJ was considered as arthritic. In the patient group, 71% of the joints were arthritic. Of those, 93% were painful. About 66% of the non‐arthritic TMJs were painful to some degree. Intensity of TMJ resting pain and TMJ maximum opening pain, number of jaw movements causing TMJ pain and laterotrusive movement to the contralateral side significantly explained presence of arthritis (AUC 0.72, P < .001). Based on these findings, criteria for possible, probable and definite TMJ arthritis were determined. Arthritic TMJs with high inflammatory activity showed higher pain intensity on maximum mouth opening (P < .001) and higher number of painful mandibular movements (P = .004) than TMJs with low inflammatory activity. The combination TMJ pain on maximum mouth opening and Contralateral laterotrusion <8 mm appears to have diagnostic value for TMJ arthritis. Among arthritic TMJs, higher TMJ pain intensity on maximum mouth opening and number of mandibular movements causing TMJ pain indicates higher inflammatory activity.     

Toothache Caused by Trigeminal Neuralgia Secondary to Vestibular Schwannoma: A Case Report

Introduction

Vestibular schwannoma, also called acoustic neuroma, is a tumor composed of Schwann cells that most commonly involves the vestibular division of the 8th cranial nerve. A thorough medical and dental history and properly conducted diagnostic testing and radiographic evaluation are essential in differentiating odontogenic tooth pain from tooth pain of a nonodontogenic origin.

Methods

This report discusses a case of acoustic neuroma mimicking odontogenic pain. A 61-year-old man presented with pain in the lower left quadrant. Medical history revealed peripheral neuropathy and prior exposure to Agent Orange. Diagnostic testing on teeth #19, #20, and #21 ruled out an odontogenic cause for the pain. Brushing of a specific region of the face elicited pain that resembled the patient's chief concern. The patient was referred to a craniofacial pain center with the tentative diagnosis of trigeminal neuralgia. Treatment for trigeminal neuralgia was not successful, prompting referral to the neurosurgery department where magnetic resonance imaging was performed.

Results

Magnetic resonance imaging revealed a moderate-size, lobular, left cerebellopontine angle mass lesion consistent with acoustic neuroma with compression of the left trigeminal nerve secondary to the lesion.

Conclusions

Acoustic neuroma can cause tooth pain secondary to compression of the trigeminal nerve.     

Effects of low‐level laser therapy on burning mouth syndrome

To investigate low‐level laser therapy (LLLT) applied to treat burning mouth syndrome (BMS). This prospective, comparative, partially blinded, single‐centre, clinical trial of GaAlAs Laser, with 815 nm wavelength, included 44 BMS patients divided randomly into three groups: Group I (n = 16): GaAlAs laser 815 nm wavelength, 1 W output power, continuous emissions, 4 s, 4 J and fluence rate 133·3 J cm^?2; Group II (n = 16): GaAlAs infrared laser, 815 nm wavelength, 1 W output power, continuous emissions, 6 s, 6 J and fluence rate 200 J cm^?2; Group III (n = 12) placebo group, sham laser. All groups received a weekly dose for 4 weeks. Pain intensity was recorded using a 10‐cm visual analogue scale; patients responded to the oral health impact profile (OHIP‐14), xerostomia severity test and the hospital anxiety–depression scale (HAD). These assessments were performed at baseline, 2 and 4 weeks. LLLT decreased pain intensity and improved OHIP‐14 scores significantly from baseline to 2 weeks in groups I and II compared with the placebo group. No statistically significant differences were found from 2 to 4 weeks. Overall improvements in visual analogue scale (VAS) scores from baseline to the end of treatment were as follows: Group I 15·7%; Group II 15·6%; Group III placebo 7·3%. LLLT application reduces symptoms slightly in BMS patients.     

Effect of mouth breathing on masticatory muscle activity during chewing food

The aim of this study was to examine the effect of mouth breathing on masticatory muscle activity during chewing food. Masseter muscle activity during chewing of a rice ball was recorded in 45 adult volunteers (three women), identified as nose breathers. Surface electrodes were placed on the skin according to the orientation of the masseter muscle to record the activity of this muscle while the subjects chewed the food until swallowing. Each activity was recorded twice, once with nose breathing and once with mouth breathing induced by nasal obstruction. The integrated and mean electromyography values for mouth breathing were significantly lower than the values for nose breathing (P < 0·05). The resting and total duration of chewing were significantly prolonged (P < 0·05) and the active duration significantly shorter (P < 0·05) when breathing through the mouth compared with the nose. Significantly more chewing strokes were counted for mouth breathing compared with nose breathing (P < 0·05). Taken together, the results indicate that mouth breathing decreases chewing activity and reduces the vertical effect upon the posterior teeth.     

Somatosensory evaluation in Dysfunctional Syndrome patients

Many chronic pain patients are refractory to treatment, which leads to the suspicion that somehow they are not fully effective and probably some mechanism of pain generation and/or maintenance is still unknown. The aim of this cross‐sectional study was to provide evidence‐based data on pain mechanisms in different types of chronic pain conditions. Eighty women, with 18–65 years old, were included, divided into four groups: myofascial pain of the masticatory muscles (n = 20), fibromyalgia (n = 20), chronic daily headache and healthy volunteers (n = 20). All patients were submitted to quantitative sensory tests: pressure pain threshold, mechanical detection threshold, mechanical pain threshold, ischaemic pain tolerance, cold pain sensitivity, aftersensation, wind‐up ratio and conditioned pain modulation. Current perception threshold was also determined (Neurometer CPT/C – Neurotron^®). Three different zones were evaluated: trigeminal (masseter muscle), cervical and extratrigeminal (thenar eminence). Data were recorded and subjected to statistical analysis (anova , Tukey and Student's t‐tests). Masticatory myofascial pain, fibromyalgia and chronic daily headache individuals presented lower pressure pain thresholds than healthy volunteers (P = 0·00). Chronic daily headache individuals had a significantly higher mechanical detection threshold than healthy volunteers (P = 0·01). Individuals of the symptomatic groups showed lower values for mechanical pain threshold and for ischaemic pain tolerance (P = 0·00) than healthy volunteers. The ability to activate the mechanism of endogenous modulation is impaired in women with fibromyalgia and myofascial pain (P = 0·00). These results reinforce evidence of central sensitisation and impaired endogenous modulation system in individuals with myofascial pain, fibromyalgia and chronic daily headache.     

Peripheral and Central Mechanisms of Trigeminal Neuropathic and Inflammatory Pain

While physiological pain (nociceptive pain) has a protective role in warning of potential tissue damage in response to a variety of noxious stimuli, pathological pain (neuropathic and inflammatory pain) serves no such meaningful purpose. Injury/inflammation in the peripheral tissue that innervates the trigeminal nerve may also alter the properties of trigeminal somatic sensory pathways, causing behavioral hypersensitivity (e.g., pathological pain) and induce pain abnormality caused by noxious stimulation (hyperalgesia) or normally innocuous stimulation (allodynia). These hypersensitivities to nociception are caused by changes in the excitability of trigeminal ganglion neurons (peripheral sensitization), which alter sensory information processing in spinal trigeminal spinal subnucleus caudalis (SpVc)/upper cervical spinal cord (C_1–2) neurons (central sensitization). More is being learned about the activation of peripheral and central glia that play an important role in creating and maintaining pathological pain. This review therefore focuses on the possible sites for sensitization of nociceptive signaling through pain pathways that contribute to trigeminal pathological pain and also discuss potential therapeutic targets in neuron-glial interactions for preventing trigeminal neuropathic and inflammatory pain.     

The effects of manual therapy and exercise directed at the cervical spine on pain and pressure pain sensitivity in patients with myofascial temporomandibular disorders

Summary No studies have investigated the effects of the treatments directed at the cervical spine in patients with temporomandibular disorders (TMD). Our aim was to investigate the effects of joint mobilization and exercise directed at the cervical spine on pain intensity and pressure pain sensitivity in the muscles of mastication in patients with TMD. Nineteen patients (14 females), aged 19–57 years, with myofascial TMD were included. All patients received a total of 10 treatment session over a 5‐week period (twice per week). Treatment included manual therapy techniques and exercise directed at the cervical spine. Outcome measures included bilateral pressure pain threshold (PPT) levels over the masseter and temporalis muscles, active pain‐free mouth opening (mm) and pain (Visual Analogue Scale) and were all assessed pre‐intervention, 48 h after the last treatment (post‐intervention) and at 12‐week follow‐up period. Mixed‐model anovas were used to examine the effects of the intervention on each outcome measure. Within‐group effect sizes were calculated in order to assess clinical effect. The 2 × 3 mixed model anova revealed significant effect for time (F = 77·8; P < 0·001) but not for side (F = 0·2; P = 0·7) for changes in PPT over the masseter muscle and over the temporalis muscle (time: F = 66·8; P < 0·001; side: F = 0·07; P = 0·8). Post hoc revealed significant differences between pre‐intervention and both post‐intervention and follow‐up periods (P < 0·001) but not between post‐intervention and follow‐up period (P = 0·9) for both muscles. Within‐group effect sizes were large (d > 1·0) for both follow‐up periods in both muscles. The anova found a significant effect for time (F = 78·6; P < 0·001) for changes in pain intensity and active pain‐free mouth opening (F = 17·1; P < 0·001). Significant differences were found between pre‐intervention and both post‐intervention and follow‐up periods (P < 0·001) but not between the post‐intervention and follow‐up period (P > 0·7). Within‐group effect sizes were large (d > 0·8) for both post‐intervention and follow‐up periods. The application of treatment directed at the cervical spine may be beneficial in decreasing pain intensity, increasing PPTs over the masticatory muscles and an increasing pain‐free mouth opening in patients with myofascial TMD.     

Effects on jaw function shortly after whiplash trauma

Normal jaw function involves muscles and joints of both jaw and neck. A whiplash trauma may disturb the integrated jaw‐neck sensory‐motor function and thereby impair chewing ability; however, it is not known if such impairment is present shortly after a neck trauma or develops over time. The aim was to evaluate jaw function after a recent whiplash trauma. Eighty cases (47 women) were examined within 1 month after a whiplash trauma and compared to 80 controls (47 women) without neck trauma. Participants completed the Jaw disability checklist (JDC) and Neck Disability Index (NDI) questionnaires and performed a 5‐minute chewing test. Elicited fatigue and pain during chewing were noted, and group differences were evaluated with Fisher's exact test and Mann‐Whitney U‐test. Compared to controls , cases had higher JDC (P < .0001) and NDI scores (15% vs 2%, P < .0001), and reported more fatigue (53% vs 31%, P = .006) and pain (30% vs 10%, P = .003) during the chewing test. Cases also had a shorter onset time for fatigue and pain (both P = .001) Furthermore, cases reporting symptoms during chewing had higher JDC and NDI scores compared to cases not reporting symptoms (both P = .01). Symptoms mainly occurred in the trigeminal area for both groups, but also in spinal areas more often for cases than for controls. Taken together, the results indicate that jaw‐neck sensory‐motor function is impaired already within 1 month after a whiplash trauma. The association between neck disability and jaw impairment underlines the close functional relationship between the regions, and stresses the importance of multidisciplinary assessment.     

Tactile sensory and pain thresholds in the face and tongue of subjects asymptomatic for oro‐facial pain and headache

The aim of this study was to examine the tactile sensory and pain thresholds in the face, tongue, hand and finger of subjects asymptomatic for pain. Sixteen healthy volunteers (eight men and eight women, mean age 35·7 years, range 27–41) participated. Using Semmes–Weinstein monofilaments, the tactile detection threshold (TDT) and the filament‐prick pain detection threshold (FPT) were measured at five sites: on the cheek skin (CS), tongue tip (TT), palm side of the thenar skin (TS), dorsum of the hand (DH) and the finger tip (FT). The difference between the tactile sensory and pain threshold (FPT–TDT) was also calculated. Both for the TDT and FPT, TT and DH had the lowest and highest values, respectively. As for the FPT–TDT, there were no significant differences among the measurement sites. As the difference between FPT and TDT (FPT–TDT) is known to be an important consideration in interpreting QST (quantitative sensory testing) data and can be altered by neuropathology, taking the FPT–TDT as a new parameter in addition to the TDT and FPT separately would be useful for case–control studies on oro‐facial pain patients with trigeminal neuralgia, atypical facial pain/atypical odontalgia and burning mouth syndrome/glossodynia.     

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.     

Trigeminal convergence from human teeth: influence of contralateral stimulation and stimulus frequency on the pain perception threshold

The arrangement of trigeminal nerve fibres and their secondary and subsequent neurones in the central nervous system is incompletely understood, but primary neurones from teeth pass to the trigeminal spinal nucleus on the same side. This means that stimulation of adjacent teeth on one side of the mouth could be associated with spatial summation in the trigeminal spinal nucleus, and this should reduce the intensity of stimulation required to reach the pain perception threshold. If the two teeth stimulated were on opposite sides of the mouth, no spatial summation would be possible at that level, so the pain perception threshold would be relatively higher. To test the hypothesis, electrical stimuli were applied to the teeth of human subjects who were able to indicate when the pain perception threshold was reached. This threshold was determined for single teeth and also for a series of teeth. The series started with an upper canine and extended tooth by tooth to the contralateral canine. The threshold value for two or more teeth was called the multiple value (M) and this was compared with the added individual values (A) for the same number of teeth. The $\text{M}\text{A}$ ratio thus obtained was not decisively affected by stimulation being extended to teeth across the midline.The investigation was made using two stimulation frequencies, 50 and 7 Hz. and the same result was obtained in each series. However, the peak current values were consistently higher when the lower frequency was used. This result had been predicted, and is explained by there being less opportunity for temporal summation at the synapses when using the lower frequency.     

Influence of orthodontic appliances on visual attention to smiling faces by eye-tracking evaluation

The influence of wearing orthodontic appliances on visual attention to smiling faces is not well understood. The purpose of this study was to investigate how laypeople viewed a frontal posed smiling face with orthodontic appliances compared with orthodontists. Frontal posed smiling facial photographs of 10 female models without an appliance or wearing clear tray, ceramic, or metal appliances were taken, and areas of interest (AOIs) for the eyes, nose, and mouth were determined. Visual attention from 43 laypeople and 42 orthodontists was evaluated for each image using an eye-tracking system. Total fixation time for each AOI was calculated and analyzed by three-way repeated measures analysis of variance and Tukey–Kramer multiple comparison tests (P < 0.05). The layperson group spent significantly more time looking at the mouth with ceramic and metal brackets than without brackets, similar to the orthodontist group (P < 0.001 and 0.001, respectively). Though the orthodontist group spent significantly more time looking at the mouth with metal brackets than the mouth with ceramic brackets (P < 0.040), no significant difference was noted in the layperson group. Under all appliance conditions, the layperson group spent significantly more and less time looking at the eyes and mouth than the orthodontist group, respectively (P < 0.001 and 0.001, respectively). These findings suggest that it may help patients who will start orthodontic treatment to understand an individual’s interest in the appearance of the orthodontic appliance, and orthodontists to counsel patients at the orthodontic appliance selection stage during the diagnosis.     

Dental pain and oral health-related quality of life in individuals with severe dental anxiety

Objectives: To analyze the prevalence and level of dental pain among adult individuals with severe dental anxiety (DA), and the association between dental pain and oral health-related quality of life (OHRQoL).

Methods: The study was based on 170 adult individuals with DA referred to a specialized DA clinic. All patients answered a questionnaire including questions on DA (DAS, DFS), OHRQoL (OIDP) and dental pain. An adapted clinical examination and a panoramic radiograph revealed the present oral status.

Results: The prevalence of dental pain was high (77.6%) and among those reporting pain the intensity was high (49.0–61.0 on a VAS). One or more problems during the last 6 months with the mouth or teeth affecting the individual’s daily activities were reported in 85.3% of the participants. Individuals who reported dental pain had lower OHRQoL compared with those who did not report dental pain (p?p?p?=?.008).

Conclusion: This study revealed a high prevalence and a high level of dental pain among adult individuals with severe DA. Having dental pain was associated with poor OHRQoL.