Audiological Evaluation of Patients With Somatosensory Tinnitus Attributed to Temporomandibular Disorders

Purpose Tinnitus and temporomandibular disorders have already been associated in the literature, but despite many studies, it is still an intriguing discussion point. This study aimed to evaluate the prevalence of hearing loss among somatosensory tinnitus patients with temporomandibular disorders and to assess the influence of tinnitus on patients' quality of life. Method An otolaryngologist examined 585 patients in order to detect and evaluate the presence of tinnitus. Subjects were evaluated using the Portuguese version of the Research Diagnostic Criteria for Temporomandibular Disorders. An analysis of the somatic component of tinnitus was performed. Tinnitus was rated according to its onset (at least 6 months) and intensity with a visual analog scale. The sample was composed of 100 patients with somatosensory tinnitus divided into two groups: Group 1 (with temporomandibular disorder, n = 85) and Group 2 (without temporomandibular disorder, n = 15). The audiological evaluation was composed of pure-tone audiometry, high-frequency audiometry, tympanometry, and transient-evoked otoacoustic emissions. The impact of tinnitus on quality of life was assessed by the Tinnitus Handicap Inventory adapted and validated to Portuguese language. Results Pure-tone audiometry did not differ with statistical significance between groups (p = .29), neither did the high-frequency audiometry results (p = .74). Tinnitus Handicap Inventory scores also did not show any differences between Groups 1 and 2 (p = .67). Conclusions Subjects with somatosensory tinnitus, who also have temporomandibular disorders, do not seem to have hearing impairment. Also, they do not have a higher quality of life handicap when compared to those without tinnitus and temporomandibular disorder.

Clinical variables associated with the presence of articular pain in patients with temporomandibular joint clicking

OBJECTIVE

To study and estimate the impact of clinical, somatosensory, and psychosocial variables associated with the concomitant presence of temporomandibular joint (TMJ) pain in patients with TMJ clicking.

MATERIALS AND METHODS

Ninety-three individuals composed the sample: patients with painful TMJ clicking (n = 47) and patients with painless TMJ clicking (n = 46). Four categories of data were evaluated: clinical features (gender, maximal interincisal distance (MID), side of complaint, age); bruxism (sleep bruxism (SB), awake bruxism (AB)); somatosensory (mechanical pain threshold (MPT), wind-up ratio (WUR), pressure pain threshold (PPT), conditioned pain modulation (CPM)); and psychosocial (Pittsburgh Sleep Quality Index (PSQI), pain vigilance and awareness questionnaire (PVAQ), Pain Catastrophizing Scale (PCS), Tampa Scale for Kinesiophobia for Temporomandibular Disorders (TSK/TMD), Oral Behaviors (OBs)).

RESULTS

Female gender, AB, WUR, CPM, PSQI, PCS, and OBs significantly (p < 0.05) increased the chance of the concomitant presence of TMJ pain in patients with TMJ clicking. On the other hand, MID, MPT, and PPT significantly (p < 0.05) decreased this chance. The other variables had no association.

CONCLUSION

It can be concluded that being a woman, having AB, hyperalgesia in WUR, less efficient CPM, poor sleep quality, pain catastrophizing, and harmful OBs significantly increased the chance of the concomitant presence of TMJ pain in patients with TMJ clicking. In the opposite, high figures of MID, MPT, and PPT decreased the chance.

CLINICAL RELEVANCE

Most patients with TMJ clicking usually postpone seeking treatment until the clicking truly disturbs or there is a concomitant presence of TMJ pain. Understanding the variables associated with this concomitance can be important in clinical practice.

Insights for temporomandibular disorders management: From psychosocial factors to genetics-A case report

AIMS

This case report aimed to discuss the multifactorial etiology and also the management of temporomandibular disorders (TMD) by addressing important associated psychosocial and biological factors, emphasizing the interaction between these factors and a probable genetic predisposition.

METHODS AND RESULTS

A 21-year-old female patient was evaluated according to Research Diagnostic Criteria for TMD and diagnosed with arthralgia, myofascial pain, disc displacement without reduction, and temporomandibular joint (TMJ) degenerative disease. TMJ alterations were confirmed through magnetic resonance imaging and cone-beam computed tomography. Pressure pain threshold of masticatory structures was evaluated using a pressure algometer. Sleep bruxism, poor sleep quality, migraine with aura, mild anxiety, and history of facial trauma were also identified through anamnesis and clinical examination. Following this, genetic analysis was performed to evaluate the presence of single nucleotide polymorphisms (SNPs) already associated with TMD: SNP COMT Val¹⁵⁸ Met (rs4680), MMP1-1607 (rs1799750), and tumor necrosis factor alpha-308 (rs1800629), which were all present. A personalized treatment for TMD management was performed, and it included self-management programs, occlusal appliance therapy, pharmacotherapy, anxiety management, and stress control. An 8-year follow-up demonstrated long-term stabilization of TMJ degenerative disease.

CONCLUSION

Genetic evaluation, added to anamnesis and clinical examination, could be useful for TMD prognosis and management.

Pain complications of oral implants: Is that an issue?

The use of oral implants as a form of replacing missing teeth in partial or total edentulous patients is considered the gold standard in oral rehabilitation. Although considered a history of success in contemporary dentistry, surgical complications may occur, as excessive bleeding, damage to the adjacent teeth and mandibular fractures. Persistent pain and abnormal somatosensory responses after the surgery ordinary healing time are also potential problems and may lead to the development of a condition named posttraumatic trigeminal neuropathic pain (PTNP). Though relatively rare, PTNP has a profound impact on patient's quality of life. Appropriated previous image techniques, effective anaesthetic procedures and caution during the surgical procedure and implant installation are recommended for the prevention of this condition. In case of the PTNP, different management modalities, including antidepressant and membrane stabilizer medications, as well as peripheral strategies, as the use of topical medication and the botulin toxin are presented and discussed.

Evaluation of pain intensity in patients treated with aligners and conventional fixed appliances: Randomized clinical trial

OBJECTIVE

This randomized clinical trial aimed to compare the pain intensity in patients treated with orthodontic aligners and conventional fixed appliances.

SETTING AND SAMPLE POPULATION

This study was a randomized clinical trial. The sample comprised 39 patients randomly allocated into 2 groups: OA (orthodontic aligners, n = 20) and FA (Fixed Appliance, n = 19).

MATERIAL AND METHODS

The pain intensity was measured by the visual analogue scale (VAS) in the following periods: T0 (baseline), T1 (seven days after appliance placement) and seven days after each return on the first (T2), third (T3) and sixth (T4) months. The following variables were also investigated in the baseline: conditioned pain modulation, anxiety levels, hypervigilance and catastrophizing. The VAS measurements between groups were compared by the Mann-Whitney test. Comparisons between periods within each group were performed by the Friedman test. Data regarding catastrophizing and hypervigilance were compared by the t test. All tests were applied at a significance level of 5%, with 95% confidence interval.

RESULTS

Both groups presented similar levels of anxiety, hypervigilance, catastrophizing and conditioned pain modulation. Both groups did not differ concerning the pain intensity in all periods. The intragroup evaluation revealed statistical differences between days in the FA group at all moments evaluated, for the OA group, similar findings between days were found for the T1 evaluation; however, at the 6-month period (T4), the pain levels varied over these days without statistical difference. Higher levels of pain were observed in the first seven days after appliance placement.

CONCLUSION

The pain intensity, usually mild, was not influenced by the appliance design, although different patterns of reported pain seem to occur between groups.

Role of inflammatory and pain genes polymorphisms in temporomandibular disorder and pressure pain sensitivity

OBJECTIVE

The aim of this study was to assess the correlation of inflammatory and pain genes polymorphisms with the presence of temporomandibular disorder (TMD) patients and with pressure pain sensitivity.

DESIGN

Data was collected from 268 consecutive subjects at Bauru School of Dentistry. Subjects aged younger than 20 years, with dental and neuropathic pain, sinusitis, cognitive and neurologic disorder were excluded. Included subjects were evaluated using the Research Diagnostic Criteria for Temporomandibular disorders and divided into two groups: TMD cases and healthy controls. Groups were submitted to pressure pain threshold (PPT) test for the temporomandibular joint, anterior temporalis and masseter muscles and genotyped for Val158Met, IL6-174, IL-1β-3954 and TNFA-308. Student's t-test and Pearson chi-square test were used to comparisons between groups. A linear multiple regression was used to evaluate the influence of genetics variables on the PPT and a bivariate analysis was used to assesses the influence of genetics variables on pain sensitivity below the PPT cut off of the structures in TMD group.

RESULTS

TMD group showed significantly lower PPT values for all structures when compared with control group (p < 0.001). SNP IL6-174 predicted higher pain sensitivity in the temporomandibular joint (p < 0.005) and in anterior temporalis muscle (p < 0.044) and SNP Val158Met in the masseter muscle (p < 0.038); when TMD group was divided according to PPT cut-off values the SNP Val158Met influenced increase pain sensibility in the masseter muscle.

CONCLUSION

TNFA-308 was associated with TMD and SNP IL6-174 and SNP Val158Met influenced pain sensitivity of patients with TMD.

Influence of self-reported physical activity and sleep quality on conditioned pain modulation in the orofacial region

OBJECTIVES

To evaluate the influence of self-reported physical activity and sleep quality on conditioned pain modulation (CPM) in the orofacial region.

MATERIALS AND METHODS

Ninety healthy participants aged 18-50 years old were evenly distributed according to the level of physical activity into low, moderate, and high level. The classification of physical activity was based on modified criteria of the International Physical Activity Questionnaire (IPAQ), considering intensity, duration, and frequency of physical activity. The Pittsburgh Sleep Quality Index (PSQI) assessed sleep quality and the individuals were then classified as good or poor sleepers. CPM was assessed using the pressure pain threshold (PPT) of the anterior temporalis as test stimulus and hand immersion in hot water as conditioning stimulus. ANOVA was applied to the data and Tukey's posttest was applied when the main effects or interactions were significant (p < 0.050).

RESULTS

There was no significant main effect of neither physical activity nor sleep quality on pain modulation. However, individuals who reported high level of physical activity and good quality of sleep had a greater pain modulation (- 0.60 ± 0.34) when compared with those who reported moderate (- 0.10 ± 0.25) and low level of physical activity (- 0.10 ± 0.52) and good sleep quality (p < 0.028).

CONCLUSIONS

Pain modulation seems to be more efficient in individuals who report a good sleep quality and a high level of physical activity.

CLINICAL RELEVANCE

Conditioned pain modulation is highly variable in healthy people. Therefore, a multifactorial approach should be taken into consideration in the evaluation of the efficacy of endogenous analgesia.

The association of self-reported awake bruxism with anxiety, depression, pain threshold at pressure, pain vigilance, and quality of life in patients undergoing orthodontic treatment

This study aimed to evaluate whether the presence of awake bruxism was associated with temporomandibular dysfunction symptoms, pain threshold at pressure, pain vigilance, oral health-related quality of life (OHRQoL), and anxiety and depression symptoms in patients undergoing orthodontic treatment.

Placebo and nocebo response magnitude on temporomandibular disorder-related pain: A systematic review and meta-analysis

OBJECTIVES

The aim of this systematic review (SR) was to answer the following question: "In adult patients with temporomandibular disorder (TMD)-related pain, what is the placebo or nocebo effect of different therapies?"

METHODS

A SR was performed with randomised clinical placebo-controlled trials on diagnosed painful TMD studies from five main databases and from three grey literature. Studies included must have sample older than 18 years, with painful TMD, which diagnosis was done by Research Diagnostic Criteria (RDC/TMD) or Diagnostic Criteria (DC/TMD).

RESULTS

Out of 770 articles obtained, 42 met the inclusion criteria for qualitative and 26 for quantitative analysis. Meta-analysis indicated mean variation on pain intensity for placebo therapy was higher on laser acupuncture with 45.5 mm point reduction, followed by avocado soya bean extract with 36 mm and amitriptyline 25 mg with 25.2 mm. Laser showed a 29% of placebo effect, as well medicine with 19% and other therapies with 26%. Possible nocebo effect of 8% pain increase was found for intra-articular injection of Ultracain.

CONCLUSIONS

Based on the available data, the placebo response could play a major effect on TMD pain management and may be responsible from 10% to 75% of pain relief. Laser acupuncture, avocado soya bean and amitriptyline promoted the higher placebo effect. Possible nocebo effect was found only for Ultracain injection with 8%.

CLINICAL RELEVANCE

Clinicians could apply such evidence to optimise pain management and judgement about treatment efficacy, and researches may find it useful when designing their investigations.

Temporomandibular joint morphology does not influence the presence of arthralgia in patients with disk displacement with reduction: a magnetic resonance imaging-based study

OBJECTIVE

The aim of this study was to compare, by using magnetic resonance imaging (MRI), temporomandibular joint (TMJ) morphology between patients with disk displacement with reduction (DDWR) with or without arthralgia and a control group and to identify which factors are associated with the concomitant presence of arthralgia in DDWR patients.

STUDY DESIGN

In this investigation, 36 TMJ MRIs were divided into 3 groups. Group 1 (n = 12) comprised patients with DDWR and arthralgia; group 2 (n = 12) comprised patients with DDWR without arthralgia; and group 3 (n = 12) was the control group. Disk and mandibular condyle morphologies; articular eminence morphology and inclination; size of the mandibular fossa; joint space size; joint effusion; bone marrow of the mandibular condyle; and the relative signal intensity of retrodiscal tissue were evaluated.

RESULTS

Fisher's exact test and 1-way analysis of variance (ANOVA) revealed no significant differences (P > .05) between groups for any variable. Logistic regression analysis showed that no anatomic variables were related to the concomitant presence of arthralgia in patients with DDWR (P > .05).

CONCLUSIONS

As evaluated on MRI scans, no significant differences in the anatomic characteristics of the TMJ were detected between DDWR patients with or without concomitant arthralgia and the control group. There were no factors associated with the concomitant presence of arthralgia in patients with DDWR.

Temporomandibular joint disc displacement with reduction: a review of mechanisms and clinical presentation

Disc displacement with reduction (DDWR) is one of the most common intra-articular disorders of the temporomandibular joint (TMJ). Factors related to the etiology, progression and treatment of such condition is still a subject of discussion. This literature review aimed to address etiology, development, related factors, diagnosis, natural course, and treatment of DDWR. A non-systematic search was conducted within PubMed, Scopus, SciELO, Medline, LILACS and Science Direct using the Medical Subjective Headings (MeSH) terms “temporomandibular disorders”, “temporomandibular joint”, “disc displacement” and “disc displacement with reduction”. No time restriction was applied. Literature reviews, systematic reviews, meta-analysis and clinical trials were included. DDWR is usually asymptomatic and requires no treatment, since the TMJ structures adapt very well and painlessly to different disc positions. Yet, long-term studies have shown the favorable progression of this condition, with no pain and/or jaw locking occurring in most of the patients.

Distribution of depression, somatization and pain-related impairment in patients with chronic temporomandibular disorders

Objective

the aim of this study was to describe the frequency of psychosocial diagnoses in a large sample of patients attending a tertiary clinic for treatment of temporomandibular disorders (TMD).

Material and Methods

six hundred and ninety-one patients who sought treatment for pain-related TMD were selected. Chronic pain-related disability (Graded Chronic Pain Scale, GCPS), depression [Symptoms Checklist-90 (SCL-90) scale for depression, DEP] and somatization levels (SCL-90 scale for non-specific physical symptoms, SOM) were evaluated through the Research Diagnostic Criteria for TMD (RDC/TMD) Axis II psychosocial assessment; TMD diagnoses were based on the Axis I criteria.

Results

the majority of patients presented a low disability or no disability at all, with only a small portion of individuals showing a severely limiting, high disability pain-related impairment (4.3%). On the other hand, abnormal scores of depression and somatization were high, with almost half of the individuals having moderate-to-severe levels of depression and three-fourths presenting moderate-to-severe levels of somatization. The prevalence of high pain-related disability (GCPS grades III or IV), severe/moderate depression and somatization was 14.3%, 44% and 74.1% respectively. Gender differences in scores of SCL-DEP (p=0.031) and SCL-SOM (p=0.001) scales were signficant, with females presenting the highest percentage of abnormal values.

Conclusion

patients with TMD frequently present an emotional profile with low disability, high intensity pain-related impairment, and high to moderate levels of somatization and depression. Therefore, given the importance of psychosocial issues at the prognostic level, it is recommended that clinical trials on TMD treatment include an evaluation of patients’ psychosocial profiles.

Muscle hardness and masticatory myofascial pain: Assessment and clinical relevance

The impression of increased muscle hardness in painful muscles is commonly reported in the clinical practice but may be difficult to assess. Therefore, the aim of this review was to present and discuss relevant aspects regarding the assessment of muscle hardness and its association with myofascial temporomandibular disorder (TMD) pain. A non-systematic search for studies of muscle hardness assessment in patients with pain-related TMDs was carried out in PubMed, Cochrane Library, Embase and Google Scholar. Mechanical devices and ultrasound imaging (strain and shear wave elastography) have been consistently used to measure masticatory muscle hardness, although an undisputable reference standard is yet to be determined. Strain elastography has identified greater masseter hardness of the symptomatic side in patients with unilateral myofascial TMD pain when compared to the contralateral side and healthy controls (HC). Likewise, shear wave elastography has shown greater masseter elasticity modulus in patients with myofascial TMD pain when compared to HC, which may be an indication of muscle hardness. Although assessment bias could partly explain these preliminary findings, future randomised controlled trials are encouraged to investigate this relationship. This qualitative review indicates that the muscle hardness of masticatory muscles is still a rather unexplored field of investigation with a good potential to improve the assessment and potentially also the management of myofascial TMD pain. Nonetheless, the current evidence in favour of increased hardness in masticatory muscles in patients with myofascial TMD pain is weak, and the pathophysiological importance and clinical usefulness of such information remain unclear.

Short-term transcutaneous electrical nerve stimulation reduces pain and improves the masticatory muscle activity in temporomandibular disorder patients: a randomized controlled trial

Studies to assess the effects of therapies on pain and masticatory muscle function are scarce.

The mobility of the upper cervical spine by flexion-rotation test in individuals with temporomandibular dysfunction

Short Communication

Occlusal changes secondary to temporomandibular joint conditions: a critical review and implications for clinical practice

The relationship between Temporomandibular Disorders (TMD) and malocclusion is an extremely critical issue in dentistry. Contrary to the old concept that malocclusion causes TMD, occlusal changes, especially those observed as sudden, may be secondary and reflect joint or muscle disorders due to the obvious connection between these structures and the dental occlusion.

TMD and chronic pain: a current view

This review aims at presenting a current view on the physiopathologic mechanisms associated with temporomandibular disorders (TMDs). While joint pain is characterized by a well-defined inflammatory process mediated by tumor necrosis factor-α and interleukin, chronic muscle pain presents with enigmatic physiopathologic mechanisms, being considered a functional pain syndrome similar to fibromyalgia, irritable bowel syndrome, interstitial cystitis and chronic fatigue syndrome. Central sensitization is the common factor unifying these conditions, and may be influenced by the autonomic nervous system and genetic polymorphisms. Thus, TMDs symptoms should be understood as a complex response which might get worse or improve depending on an individual's adaptation.

Is the Nociceptive Blink Reflex Associated with Psychological Factors in Healthy Participants?

AIMS

To evaluate the possible association between the nociceptive blink reflex (nBR) and various pain-related psychological measures: the Anxiety Sensitivity Index-3 (ASI-3), the Fear of Pain Questionnaire III (FPQ-III), the Pain Vigilance and Awareness Questionnaire (PVAQ), the Somatosensory Amplification Scale (SSAS), the Pain Catastrophizing Scale (PCS), and the Situational Pain Catastrophizing Scale (S-PCS).

METHODS

The nBR was evaluated in 21 healthy participants. It was elicited by a nociceptive-specific electrode placed over the entry zone of the right supraorbital nerve, infraorbital nerve, and mental nerve, as well as the left infraorbital nerve. The outcomes were (1) nBR measurements: (a) individual electrical sensory threshold (I0) and pain threshold (IP); (b) root mean square (RMS), area under the curve (AUC), and onset latencies of R2 responses; (c) stimulus-evoked pain on a 0 to 10 numeric rating scale (NRS); and (2) the ASI-3, the FPQ-III, the PVAQ, the SSAS, the PCS, and the S-PCS. Pearson correlation coefficient was used to evaluate the association between the means of nBR measurements from all sites and the questionnaires The significance level was set up after a Bonferroni correction (adjusted α = .8%).

RESULTS

There was no correlation for any pair of variables at the adjusted significance level (P > .008). There was only a single significant correlation at the standard significance level (P < .05), where the pain intensity (NRS) at 50% of IP presented a positive and small to moderate correlation with the PCS (r = 0.43, P = .04).

CONCLUSION

It appears that the nBR and its associated psychophysical measures are not associated with psychological factors in healthy participants.

The coexistence of paroxysmal hemicrania and temporomandibular disorder: importance of multidisciplinary approach

Paroxysmal hemicrania (PH) is a trigeminal autonomic cephalalgia, a rare primary headache characterized by unilateral periorbital and/or temporal attacks of severe intensity and short duration. In this situation, the determination of a correct diagnosis is crucial for the establishment of a proper management strategy. In the case of head and facial pain, this step is usually a big challenge since many conditions share the same features, as some primary headaches and temporomandibular disorders (TMD). The relationship between PH and TMD has not been determined. This paper describes a case of a female patient diagnosed with TMD and presenting concomitant headache attacks fulfilling the International Headache Society's criteria for PH. It is also emphasized the importance of dentist in this scenario, for many times responsible for the initial diagnosis of facial/head pain. Moreover, it is presented an integrated and simultaneously approach of both conditions, PH and TMD.