Headache attributed to masticatory myofascial pain: impact on facial pain and pressure pain threshold

There is no clear evidence on how a headache attributed to temporomandibular disorder (TMD) can hinder the improvement of facial pain and masticatory muscle pain. The aim of this study was to measure the impact of a TMD‐attributed headache on masticatory myofascial (MMF) pain management. The sample was comprised of adults with MMF pain measured according to the revised research diagnostic criteria for temporomandibular disorders (RDC/TMD) and additionally diagnosed with (Group 1, n = 17) or without (Group 2, n = 20) a TMD‐attributed headache. Both groups received instructions on how to implement behavioural changes and use a stabilisation appliance for 5 months. The reported facial pain intensity (visual analogue scale – VAS) and pressure pain threshold (PPT – kgf cm^?2) of the anterior temporalis, masseter and right forearm were measured at three assessment time points. Two‐way anova was applied to the data, considering a 5% significance level. All groups had a reduction in their reported facial pain intensity (P < 0·001). Mean and standard deviation (SD) PPT values, from 1·33 (0·54) to 1·96 (1·06) kgf cm^?2 for the anterior temporalis in Group 1 (P = 0·016), and from 1·27 (0·35) to 1·72 (0·60) kgf cm^?2 for the masseter in Group 2 (P = 0·013), had significant improvement considering baseline versus the 5th‐month assessment. However, no differences between the groups were found (P > 0·100). A TMD‐attributed headache in patients with MMF pain does not negatively impact pain management, but does change the pattern for muscle pain improvement.     

Effect of hypnosis on oral function and psychological factors in temporomandibular disorders patients

Summary This study investigated the effect of hypnosis in patients with temporomandibular disorders (TMD) with focus on oral function and psychological outcomes. Forty women (mean age ± s.d.: 38·6 ± 10·8 years) suffering from TMD (mean duration 11·9 ± 9·9 years) were randomized to four individual 1‐hour sessions of either hypnotic intervention or a control condition of simple relaxation. Pain intensity was assessed three times daily on a 0–10 Numerical Rating Scale. Additional outcomes were TMD‐associated symptoms assessed by the Research Diagnostic Criteria examination form and questionnaire, psychological symptoms (Symptom Check List 60), pain coping strategies (Coping Strategies Questionnaire), sleep difficulties (Pittsburgh Sleep Quality Index) and use of analgesics. Data were analyzed with between‐groups within‐subjects anova s. The hypnosis group significantly reduced the daily NRS pain scores from 4·5 ± 2·1 at baseline to 2·9 ± 2·4 after treatment (P < 0·001) compared to the control group where no significant changes were found (4·2 ± 1·4 to 3·9 ± 1·5) (P = 0·733). Number needed to treat for a 50% pain reduction was 4·0. The hypnosis group also increased use of the coping strategy ‘reinterpreting pain sensations’ from 5·2 ± 6·9 to 10·3 ± 6·8 (P < 0·001). Both groups exhibited significant reductions in the number of painful muscle palpation sites and pain on palpation (P < 0·004), in number of awakenings due to pain (P < 0·006), and in somatization, obsessive compulsive symptoms and anxiety (P < 0·004). Hypnosis thus appears to effectively reduce some aspects of complex TMD pain.     

Occlusal tooth wear in Chinese adults with shortened dental arches

To assess associations between occlusal tooth wear and shortened dental arches (SDA) in Chinese 40 years and older subjects. From a sample of 1462 urban and rural adults, those presenting with SDA (n = 150) were compared with a control group of 65 randomly selected subjects with complete dentitions (CDA). Occlusal wear was assessed using a modified Smith and Knight index – the occlusal tooth wear index (OWTI) – and analysed using multivariate (logistic) regression. There was no significant effect from SDA on severe occlusal wear (OTWI score 3 or 4: OR = 2·016; 95% CI = 0·960–4·231; P = 0·064). Higher age was associated with severe occlusal wear (P values ≤0·007) and with higher mean OTWI scores; urban had less often severe occlusal wear than rural residents (OR = 0·519; P = 0·008). Higher mean OTWI scores were associated with rural residents, except for anterior teeth. Females had lower mean OTWI score for anterior teeth (effect = ?0·153; P = 0·030). Premolars in SDA had higher mean OTWI scores compared with those in CDA (effect = +0·213; P = 0·006). In SDA, more posterior occluding pairs (POPs) were associated with lower mean OTWI sores for anterior teeth (effect: ?0·158; P = 0·008) and higher scores for molars (effect: +0·249, P = 0·003). Subjects with SDA or CDA presented comparable occlusal wear, but premolars in SDA tend to have higher probability for having occlusal wear. Fewer numbers of POPs were associated with more wear in anterior teeth.     

A cross‐sectional study of the relationship between serum sexual hormone levels and internal derangement of temporomandibular joint

Temporomandibular disorders (TMD) are defined as clinical conditions that involve the masticatory muscles, temporomandibular joint (TMJ) or both. The aim of this study was to evaluate serum 17β‐oestradiol and progesterone levels in menstruating women affected by internal derangement of the TMJ. A total of 142 women (mean age 30·2 ± 6·7) who referred to medical diagnostic laboratory of Iranian Academic Centre for Education, Culture and Research (ACECR), Mashhad Branch, were enrolled during 2007 and 2008. Forty‐seven individuals had disc displacement with reduction (Group IIa) according to Research Diagnostic Criteria (RDC)/TMD Axis I diagnosis. Radioimmunoassay was used for the detection of serum 17β‐oestradiol and progesterone levels in all 142 subjects. The mean progesterone level was significantly higher in control group (11·6 ± 10·4 ng mL^?1) compared to women with TMD (8·4 ± 6·8 ng mL^?1, P = 0·03). No significant difference was found in two groups regarding 17β‐oestradiol level. Lower progesterone level in women with TMD can suggest the more important role of this hormone in the development of the disorder.     

Correlation between the levels of non‐specific physical symptoms and pressure pain thresholds measured by algometry in patients with temporomandibular disorders

Recent studies showed that patients with chronic TMD pain also feature increased sensitivity in other craniofacial regions, and even in remote peripheral areas, suggesting that nociceptive processing is centrally facilitated in this patient population. The aim of this study was to investigate the existence of a negative correlation between the levels of non‐specific physical symptoms and pressure pain thresholds measured by algometry at sites distant from the chief complaint of oro‐facial pain in patients with TMD. A total of 20 female patients were evaluated comprising 11 patients diagnosed with myofascial pain (Group I of RDC/TMD) and 9 patients with arthralgia (Group III of RDC/TMD), with both reporting chronic TMD pain for at least 3 months. Patients were tested by the pressure algometry technique, and, in the same visit, clinical diagnosis and levels of non‐specific physical symptoms, including pain‐related issues or not, were obtained. The raw scores were then standardised into a T‐score. The possible correlation between the dependent variable levels of non‐specific physical symptoms and pressure pain thresholds measured by algometry at sites distant from the chief complaint of oro‐facial pain was assessed with Spearman's correlation coefficient. Results were considered statistically significant, which stood a lower than 5% probability of occurring by chance (P < 0·05). A statistically significant (P = 0·02) negative correlation (?0·51) was found to exist between the levels of non‐specific physical symptoms, only if including issues involving pain‐related symptoms, and experimental pressure pain thresholds in patients with painful TMD.     

Efficacy of low‐level laser therapy in the treatment of TMDs: a meta‐analysis of 14 randomised controlled trials

This study was designed to evaluate the efficacy of low‐level laser therapy (LLLT) in the treatment of temporomandibular disorders (TMDs). We searched electronic databases and references lists of relevant articles, retrieved all of the published randomised controlled trials in regard to these issues and then performed a meta‐analysis. Fourteen highly qualified RCTs reporting on a total of 454 patients, which evaluated the effectiveness of LLLT for patients suffering from TMDs were retrieved. The results indicated that LLLT was not better than placebo in reducing chronic TMD pain (weighted mean difference = ?19·39; 95% confidence interval = ?40·80–2·03; P < 0·00001; I² = 99%). However, the LLLT provided significant better functional outcomes in terms of maximum active vertical opening (MAVO) (weighted mean difference = 4·18; 95% confidence interval = 0·73–7·63; P = 0·006; I² = 73%), maximum passive vertical opening (MPVO) (weighted mean difference = 6·73; 95% confidence interval = 01·34–12·13; P = 0·06; I² = 73%), protrusion excursion (PE) (weighted mean difference = 1·81; 95% confidence interval = 0·79–2·83; P = 0·59; I² = 0%) and right lateral excursion (RLE) (weighted mean difference = 2·86; 95% confidence interval = 1·27–4·45; P = 0·01; I² = 73%). The results of our meta‐analysis have provided the best evidence on the efficacy of LLLT in the treatment of TMDs. This study indicates that using LLLT has limited efficacy in reducing pain in patients with TMDs. However, LLLT can significantly improve the functional outcomes of patients with TMDs.     

Oral health and caries related microflora in children during the first three months following renal transplantation

There is little information on the oral health of children undergoing renal transplantation during the early transplant period. Methods. Twenty‐four children undergoing renal transplantation aged 4–13·2 years and their matched controls were recruited. The dmfs, dmft, DMFS and DMFT, plaque, gingivitis and gingival enlargement scores were recorded. The oral microflora was sampled and cultured for S. mutans, Lactobacllus species and Candida species. Results. There was a significantly lower mean dmfs (0·3 ± 0·9; P = 0·03), dmft (0·3 ± 0·9; P = 0·03), DMFS (2·3 ± 5·3; P = 0·01) and DMFT (1·5 ± 2·6; P = 0·02), respectively, in the transplant group. There was a significantly greater mean plaque score (14·7 ± 11) for the permanent dentition, at baseline only, compared with 90 days post‐transplantation (9·4 ± 10·4; P = 0·02). There was a significantly greater gingival enlargement score (1·8 ± 1·4; P = 0·04) 90 days post‐transplantation compared with baseline. The S. mutans and Lactobacillus counts were significantly lower both at baseline (P = 0·0001 and P = 0·004) and 90 days post‐transplantation (P = 0·02; and P = 0·05), respectively, compared with the controls. Conclusions. The transplant children had less active dental disease than the controls although gingival enlargement needs careful monitoring.     

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.     

Piroxicam and laser phototherapy in the treatment of TMJ arthralgia: a double‐blind randomised controlled trial

This study aimed to evaluate the efficacy of piroxicam associated with low‐level laser therapy compared with single therapies in 32 patients presenting temporomandibular joint arthralgia in a random and double‐blind research design. The sample, divided into laser + piroxicam, laser + placebo piroxicam and placebo laser + piroxicam groups, was submitted to the treatment with infrared laser (830 nm, 100 mW, 28 s, 100 J cm^?2) at 10 temporomandibular joint and muscle points on each side during four sessions concomitant to take one capsule a day of piroxicam 20 mg during 10 days. The treatment was evaluated throughout four sessions and 30 days follow‐up through visual analogue scale (VAS), maximum mouth opening and joint and muscle (temporal and masseter) pain on palpation. The results showed that all the study groups had a significant improvement in the VAS scores (P < 0·05), and there were no significant group differences. Piroxicam was effective in the reduction of joint and muscle pain on palpation (P < 0·05) and showed the lowest temporal pain (P = 0·02) at the 30‐day follow‐up. The combination of low‐level laser therapy and piroxicam was not more effective than single therapies in the treatment of temporomandibular joint arthralgia. The use of piroxicam was more effective in the following 30 days.     

Influence of culture on pain comorbidity in women with and without temporomandibular disorder‐pain

Evidence on cultural differences in prevalence and impact of common chronic pain conditions, comparing individuals with temporomandibular disorders (TMD) versus individuals without TMD, is limited. The aim was to assess cross‐cultural comorbid pain conditions in women with chronic TMD pain. Consecutive women patients (n = 122) with the index condition of chronic TMD pain diagnosed per the research diagnostic criteria for TMD and TMD‐free controls (n = 121) matched for age were recruited in Saudi Arabia, Italy and Sweden. Self‐report questionnaires assessed back, chest, stomach and head pain for prevalence, pain intensity and interference with daily activities. Logistic regression was used for binary variables, and ancova was used for parametric data analysis, adjusting for age and education. Back pain was the only comorbid condition with a different prevalence across cultures; Swedes reported a lower prevalence compared to Saudis (P < 0·01). Saudis reported higher prevalence of work reduced >50% due to back pain compared to Italians or Swedes (P < 0·01). Headache was the most common comorbid condition in all three cultures. The total number of comorbid conditions did not differ cross‐culturally but were reported more by TMD‐pain cases than TMD‐free controls (P < 0·01). For both back and head pain, higher average pain intensities (P < 0·01) and interference with daily activities (P < 0·01) were reported by TMD‐pain cases, compared to TMD‐free controls. Among TMD‐pain cases, Italians reported the highest pain‐related disability (P < 0·01). Culture influences the associated comorbidity of common pain conditions. The cultural influence on pain expression is reflected in different patterns of physical representation.     

Effects of oral care with tongue cleaning on coughing ability in geriatric care facilities: a randomised controlled trial

Methods for preventing aspiration pneumonia are needed soon in order to reduce mortality from aspiration pneumonia and promote the health of the elderly. The aim of this randomised controlled trial was to examine whether oral care with tongue cleaning improves coughing ability in elderly individuals living in geriatric care facilities. Participants comprised of 114 residents of 11 group homes and private nursing homes in Aso City in Kumamoto Prefecture. Participants were randomly assigned to either (i) a group that underwent routine oral care with tongue cleaning (intervention group; n = 58) or (ii) a group that underwent routine oral care alone (control group; n = 56). Coughing ability was evaluated by measuring peak expiratory flow (PEF) before and after 4 weeks of intervention. Before the intervention, PEF did not differ significantly between the intervention group (1·65 ± 1·11 L s^?1) and control group (1·59 ± 1·05 L s^?1; P = 0·658). However, on termination of the intervention, PEF was significantly higher in the intervention group (2·54 ± 1·42 L s^?1) than in the control group (1·90 ± 1·20 L s^?1; P = 0·014). After the intervention, PEF had increased significantly in both groups; however, this increase was significantly greater in the intervention group (0·90 ± 0·95 L s^?1) than in the control group (0·31 ± 0·99 L s^?1; P < 0·001). Oral care with tongue cleaning led to increased PEF, suggesting improved coughing ability. Oral care incorporating tongue cleaning appears to be important for preventing aspiration pneumonia.     

Improvement in patients with a TMD‐pain report. A 6‐month follow‐up study

Even though chronic TMD pain tends to persist in most patients, some chronic patients show improvement. It is largely unknown which factors contribute to the improvement of chronic pain. The aim of this study is to investigate which factors, from a biopsychosocial perspective, help to predict improvement in patients with a report of TMD pain. Methods: Subjects with a report of TMD pain were recruited in seven TMD clinics. They received a baseline questionnaire which included a wide range of possible predictors for improvement. After 6 months they received a follow‐up questionnaire which included a measure to determine which participants were ‘improved’ or ‘not improved’. To study which predictive variables were associated with improvement, multiple regression models were built. Results: From the 129 patients who responded to the baseline questionnaire, 100 patients also filled in the follow‐up questionnaire (85% women, mean age (years) ± s.d. = 46·0 ± 13·8). Fifty percentage of these subjects had improved at the 6‐month follow‐up. Pain duration was the strongest (negative) predictor for 6‐month improvement (P = 0·009). Also the number of care providers (P = 0·017) and the degree of hindrance on function (P = 0·045) helped to predict improvement. Conclusions: The duration of the TMD‐pain complaint, the number of care practitioners attended and the degree of hindrance on function (negatively) helped to predict 6‐month improvement. No evidence is found to support the role of psychological or social factors on the improvement in patients with a report of TMD pain.     

Sleep quality and facial pain in fibromyalgia syndrome

Aims:

This study aims to evaluate the sleep conditions in fibromyalgia syndrome and the influence of the temporomandibular disorders (TMDs) and fibromyalgia association in self-reported sleep quality.

Methodology:

Forty female patients with fibromyalgia (FMS) were compared with 40 healthy women [control group (CG)]. Three questionnaires were used (i.e. RDC/TMD to diagnose TMD and to determine pain intensity and disability and Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) to assess sleep conditions). Statistical analyses were performed using the Wilcoxon–Mann–Whitney test to ordinal variables, Student’s t-test to obtain the quantitative total scores of PSQI and chronic pain classification, Spearman’s rho to determine the correlation between facial pain and quality sleep, and Fisher’s exact test for other variables.

Results:

A moderate correlation between facial pain intensity and low sleep quality was found (rho?=?0·56; P<0·0001); however, TMD and FMS association did not show worse sleep quality (P>0·05). Excessive daytime sleepiness was more prevalent in FMS (37·5%; P<0·0001) besides having the worst sleep quality (PSQI?=?12·72) compared with CG (PSQI?=?4·62).

Conclusion:

Fibromyalgia patients experience intense facial pain in addition to poor sleep and high disabilities. TMD and FMS association do not appear to worsen this condition; however, facial pain intensity was correlated with low sleep quality.     

Lidocaine 20% patch vs lidocaine 5% gel for topical anaesthesia of oral mucosa

Background. Topical anaesthetics are important to provide pain control at dental injection. Aim. The aim was to evaluate the effectiveness of the intraoral topical anaesthetics lidocaine 20% patch (DentiPatch™) and lidocaine 5% gel. Design. The randomized unblinded cross-over study included 31 patients (ten boys, 21 girls) aged 13.5 ± 2.5 years. Application of lidocaine patch or gel was randomly used at first and second visit in the upper premolar region. Heart rate was measured before and at each needle insertion after 2.5, 5, and 15 min and at injection after 15 min. Discomfort and pain were expressed in visual analogue scales (VAS). Paired t-test and Mann–Whitney U-test were used for statistic analyses. Results. Heart rate at buccal injection decreased more when the patch was used (P = 0.0149). Heart rate was lower at the second visit (P = 0.0287). Patients expressed less discomfort when the patch was used on both buccal (P = 0.0150) and palatal (P = 0.0391) site. Boys had lower heart rate and VAS pain scale ratings than girls. Conclusions. Good pain control can reduce the patients’ anxiety level – expressed in heart rate – at the second appointment. The patch and gel seem to provide similar pain reduction at needle stick and injection of local anaesthetics.     

Prevalence of temporomandibular disorder signs in patients with schizophrenia

Summary The aim of this study was to determine the prevalence of temporomandibular disorder (TMD) signs in a group of institutionalized patients with schizophrenia. Three hundred thirty‐nine patients with schizophrenia were examined and compared with 107 age‐matched and gender‐matched control subjects. TMD signs were evaluated according to the Research Diagnostic Criteria to assess temporomandibular joint pain to palpation, limitation of maximum mouth opening, alteration of mouth opening pathway (deviation/deflection) and temporomandibular joint noises. In addition, tooth wear was recorded for the assessment of bruxism. The prevalence of any TMD signs was observed higher (P = 0·001) in the patients with schizophrenia (284/339, 83·7%) than in the controls (72/107, 67·3%). The prevalence of more than one TMD sign was also significantly higher (P = 0·03) in the patients with schizophrenia (131/339, 38·6%) than in the controls (29/107, 27·1%). Significant differences between the two groups were apparent for joint pain on palpation (P = 0·006), deflection (P = 0·006) and joint sounds (P = 0·002). Severe tooth wear was evident in 39·2% of the patients with schizophrenia compared with 21·2% in the control group (P = 0·001). The finding of the present study showed that, compared to control population, chronically hospitalized patients with schizophrenia seem to be more prone to the development of TMD signs and severe tooth wear and bruxism.     

Associations among temporomandibular disorders,chronic neck pain and neck pain disability in computer office workers: a pilot study

Neck pain is the most common musculoskeletal complaint among computer office workers. There are several reports about the coexistence of neck pain and temporomandibular disorders (TMD). However, there are no studies investigating this association in the context of work involving computers. The purpose of this study was to verify the association between TMD and neck pain in computer office workers. Fifty‐two female computer workers who were divided into two groups: (i) those with self‐reported chronic neck pain and disability (WNP) (n = 26) and (ii) those without self‐reported neck pain (WONP) (n = 26), and a control group (CG) consisting of 26 women who did not work with computers participated in this study. Clinical assessments were performed to establish a diagnosis of TMD, and craniocervical mechanical pain was assessed using manual palpation and pressure pain threshold (PPT). The results of this study showed that the WNP group had a higher percentage of participants with TMD than the WONP group (42·30% vs. 23·07%, χ² = 5·70, P = 0·02). PPTs in all cervical sites were significantly lower in the groups WNP and WONP compared to the CG. Regression analysis revealed TMD, neck pain and work‐related factors to be good predictors of disability (R² = 0·93, P < 0·001). These results highlighted the importance of considering the work conditions of patients with TMD, as neck disability in computer workers is explained by the association among neck pain, TMD and unfavourable workplace conditions. Consequently, this study attempted to emphasise the importance of considering work activity for minimising neck pain‐related disability.     

A comparative study of the Osstell™ versus the Osstell Mentor™ to evaluate implant stability in human cadaver mandibles

The aim of this study was to assess the primary stability of dental implants by resonance frequency analysis (RFA) using the Osstell? and Osstell Mentor? devices and to investigate the reproducibility and comparability of the results obtained with these devices. Twenty‐four Straumann implants (Straumann AG, Basel, Switzerland) were placed in the anterior mandible of 12 fresh edentulous human cadaver mandibles. The implant stability quotients (ISQs) were measured with the Osstell? and Osstell Mentor? when implants were inserted at 50% of their length and following their complete insertion. The Osstell? device measured lower scores compared with the Osstell Mentor?. This was significant for the full position (mean difference = 9·9), t (11) = 7·4, P < 0·001 and for the halfway position (mean difference = 5·9), t (11) = 2·41, P = 0·03. In con‐clusion, the Osstell? produced relatively lower ISQ scores than the Osstell Mentor?.