Anxiety and depression in patients with chronic temporomandibular pain and in controls

Clustering profiles of demographic and clinical characteristics and the oral health impact of individuals with temporomandibular disorders

OBJECTIVE

To identify profiles of demographic, clinical, and oral health impact characteristics of individuals with temporomandibular disorder (TMD).

METHODS

Four hundred ninety-six TMD patients (260 females) and 30 young controls were included. Sociodemographic, clinical, and Oral Health Impact Profile (OHIP-14) data were gathered and analyzed by Cluster, ANOVA, and regression analyses.

RESULTS

Three clusters were identified: "Pain and depression symptoms" with participants with higher pain, depression, and OHIP-14 scores (59% females); "Chronic diseases" included older participants with current chronic diseases and medical treatment; "Healthier individuals" included younger individuals with lower chronic diseases, pain, and depression frequencies, whose OHIP-14 scores did not differ from controls (p = 0.079). OHIP-14 scores were predicted by age, pain, and depression.

CONCLUSION

Distinct profiles of individuals with TMD were identified, emphasizing the complex interactions between coping ability, general health, and psychosocial aspects that must be monitored.

Prevalence of psychological disorders in patients with temporomandibular disorders: A systematic review and meta-analysis

STATEMENT OF PROBLEM

Temporomandibular disorders (TMDs) affect the muscles of mastication, the temporomandibular joint, and associated structures. They are generally classified as muscular or articular and are the main cause of pain in the orofacial region, eventually causing psychological problems. However, the real burden of psychological disorders is unknown.

PURPOSE

The purpose of this systematic review and meta-analysis was to assess the prevalence of psychological disorders in patients with TMDs.

MATERIAL AND METHODS

The study was conducted through a bibliographic search carried out without initial limit until July 2021 in the following electronic databases: MEDLINE/PubMed, Scopus, and PsycINFO. Clinical observational studies investigating depression and somatization in patients with TMD diagnosed by the Diagnostic Research for Temporomandibular Disorders (RDC/TMD) criteria in muscular, articular, and disc disorders were included. A descriptive analysis of the included studies and a meta-analysis for the prevalence data were performed for the synthesis of evidence.

RESULTS

A total of 2320 studies were found, of which 48 complete articles were assessed for eligibility and 22 were included in the analysis. The general prevalence of depression and moderate and severe somatization in patients diagnosed with TMD was estimated at 43.0% (95% confidence interval (CI), 36.0% to 50.0%) and 60.0% (95% CI 52.0 - 67, 0%). The average overall score for depression was estimated at 0.92 (95% CI, 0.69-1.15), being classified as moderate depression. The average overall score for somatization was estimated at 1.09 (95% CI, 0.81-1.36), being classified as severe somatization. All analyses showed high heterogeneity (I2>90%). Based on the quality assessment, 80.9% of studies included in the review had low to moderate risk of bias.

CONCLUSIONS

Patients with TMDs who seek clinical care show a high prevalence of depression and somatization.

Association between psychological stress and mandibular condyle structure: an analytical cross-sectional study

OBJECTIVE

The potential influence of psychological factors on temporomandibular joint disorders has been clinically documented. To date, all research examining the impact of psychological stress on the temporomandibular joint has been conducted on animals. This study aims to explore the relationship between psychological stress and the structure of the human mandibular condyle.

METHODS

This cross-sectional study was performed on individuals, who were referred to the radiology division of 5th Azar Hospital for head and neck Computed Tomography (CT) scans. All participants completed a perceived stress questionnaire to determine their level of stress. Bone density and cortical bone thickness were measured as indicators of mandibular condyle structure. Based on multi-slice CT scan data, bone density was calculated in the anterior, middle, and posterior mandibular condyle. The cortical bone thickness was also measured at the anterior and posterior mandibular condyle. Statistical analysis was performed in R 4.0.2 software.

RESULTS

Seventy individuals, aged 18-59 years, participated in this study. The CT scans revealed a decrease in Hounsfield units (HU) and bone mineral density (BMD) in both the anterior and posterior regions. However, in the high-stress group, there was no significant difference in cortical bone thickness in the anterior and posterior regions of the condyle, nor in HU and BMD in the middle region of the condyle. An inverse correlation was observed between BMD and perceived stress in the anterior, middle, and posterior regions of both condyles.

CONCLUSION

The current findings indicate that recent psychological stress is associated with changes in the structure of the condyle.

Association between anxiety and temporomandibular dysfunction in adult patients - a systematic review

OBJECTIVE

Anxiety tends to increase muscle tension and painful symptoms; however, its symptoms can be associated with temporomandibular dysfunction (TMD). Therefore, it is crucial for professionals to identify the presence of both comorbidities and determine whether they are related. This study aims to systematically evaluate the literature and answer the question: "Is there an association between anxiety and TMD in adults?"

METHODS

The study followed the PRISMA protocol and was registered in PROSPERO. The custom search was performed in PubMed, Embase, Scopus, and Lilacs databases, as inclusion criteria observational studies that evaluated the association between anxiety and TMD in adults.

RESULTS

A total of 1640 articles were found. After removing duplicates, 988 were evaluated by title and abstract. Of these, 28 were selected for reading in full, of which 13 were included in the present review.

CONCLUSION

The association of anxiety with TMD is positive, except for the minority indicating a low relationship between the disorders, which is explained by neuroscience.

Is There a Relationship between Salivary Cortisol and Temporomandibular Disorder: A Systematic Review

BACKGROUND

This systematic review examines and evaluates the relationship between salivary cortisol levels and temporomandibular disorder (TMD) in young adult patients.

METHOD

Six databases-PubMed, Scopus, Web of Science, Google Scholar, ProQuest, and Cochrane Library-were utilized to screen eligible studies. A systematic search was performed based on PECO questions and eligibility criteria. The research question for this review was "Do salivary cortisol levels correlate with TMD in individuals aged 18-40?" The risk of bias for quality assessment was determined by the Cochrane tool. PRISMA guidelines were followed while performing this review.

RESULT

A total of fourteen studies were included in this review. Of these, eleven were observational studies (four cross-sectional and seven case-control), and three were randomized control trials. Eleven of the included studies presented a low to moderate risk in the qualitative synthesis. The total sample size of the included studies was 751 participants. The included studies suggest higher salivary cortisol levels in TMD patients than in healthy individuals.

CONCLUSIONS

The findings of this review indicate higher salivary cortisol levels in adult patients with TMD than in healthy controls. Thus, supportive psychological treatment and clinical modalities should be provided to patients with TMD. Moreover, higher-quality studies with low heterogeneity are required to support this finding.

The association of T102C (rs6313) polymorphism in the 5-HT2A receptor gene with temporomandibular disorders and anxiety in a group of Turkish population

OBJECTIVE

To investigate the relationship between T102C (rs6313) polymorphism in the 5-hydroxytryptamine receptor-2A (5HTR2A) gene and temporomandibular disorder (TMD) and anxiety.

METHODS

This observational case-control study included 80 patients and 70 healthy controls. TMD was diagnosed using the criteria for TMD (DC/TMD). Anxiety was assessed with the Beck anxiety scale. A genotyping study of HTRR2A T102C (rs6313) gene polymorphism was performed from genomic DNA isolated from blood.

RESULTS

The TMD group had higher anxiety scores than the control group (p < .05). The TMD group was similar to the control group regarding genotype and allele frequencies. However, the polymorphic CC genotype was more common in those with high anxiety (p < .05).

CONCLUSION

There was no clear evidence of an association between TMD and the T102C polymorphism in HTR2A and TMD. However, anxiety is closely related to the T102C polymorphism in HTR2A.

Genetically predicted major depression causally increases the risk of temporomandibular joint disorders

Objective

Observational studies have reported that mental disorders are comorbid with temporomandibular joint disorder (TMD). However, the causal relationship remains uncertain. To clarify the causal relationship between three common mental illnesses and TMD, we conduct this Mendelian Randomization (MR) study.

Methods

The large-scale genome-wide association studies data of major depression, bipolar disorder and schizophrenia were retrieved from the Psychiatric Genomics Consortium. The summary data of TMD was obtained from the Finn-Gen consortium, including 211,023 subjects of European descent (5,668 cases and 205,355 controls). The main approach utilized was inverse variance weighting (IVW) to evaluate the causal association between the three mental disorders and TMD. Five sensitivity analyses including MR-Egger, Maximum Likelihood, Weighted median, MR. RAPS and MR-PRESSO were used as supplements. We conducted heterogeneity tests and pleiotropic tests to ensure the robustness.

Results

As shown by the IVW method, genetically determined major depression was associated with a 1.65-fold risk of TMD (95% CI = 1.10-2.47, p < 0.05). The direction and effect size remained consistent with sensitivity analyses. The odds ratios (ORs) were 1.51 (95% CI = 0.24-9.41, p > 0.05) for MR-Egger, 1.60 (95% CI = 0.98-2.61, p > 0.05) for Weighted median, 1.68 (95% CI = 1.19-2.38, p < 0.05) for Maximum likelihood, 1.56 (95% CI = 1.05-2.33, p < 0.05) for MR. RAPS, and 1.65 (95% CI = 1.10-2.47, p < 0.05) for MR-PRESSO, respectively. No pleiotropy was observed (both P for MR-Egger intercept and Global test >0.05). In addition, the IVW method identified no significant correlation between bipolar disorder, schizophrenia and TMD.

Conclusion

Genetic evidence supports a causal relationship between major depression and TMD, instead of bipolar disorder and schizophrenia. These findings emphasize the importance of assessing a patient's depressive status in clinical settings.

Validity and internal consistency of four scales in patients with TMD: PHQ8, GAD7, PHQ15 and JFLS20

OBJECTIVES

The aim of this cross-sectional study was to explore the structural validity and internal consistency reliability of General Anxiety Disorder-7, Patient Health Questionnaire-8, 15 and Jaw Functional Limitation Scale-20 in patients with chronic pain of temporomandibular disorders.

MATERIALS AND METHODS

Validity and reliability were assessed in 129 patients diagnosed according to the diagnostic criteria for temporomandibular disorders. Structural validity was explored using factor analysis, and internal consistency by calculating Cronbach α.

RESULTS

Confirmatory factor analysis revealed a suitable 2-factor model for Patient Health Questionnaire-8, with Cronbach α of 0.89, and 0.86. One and 2-factor models were suitable for General Anxiety Disorder-7, with overall Cronbach α of 0.93 for the 1-factor model, and 0.91 and 0.84 for both factors in a 2-factor model. A 4-factor solution was appropriate for Patient Health Questionnaire-15, with Cronbach α of 0.72, 0.57, 0.71 and 0.73 for each factor separately. Exploratory factor analysis was conducted to explore the factor structure of Jaw Functional Limitation Scale 20, and a 3-factor solution was appropriate.

CONCLUSIONS

This study provides positive evidence of structural validity and internal consistency of these questionnaires in patients with pain of temporomandibular disorders. However, additional testing is required to explore further psychometric properties.

Effect of propranolol on temporomandibular joint pain in repeatedly stressed rats

Stress substantially increases the risk of developing painful temporomandibular disorders (TMDs) by influencing the release of endogenous catecholamines. Propranolol, an antagonist of β-adrenergic receptors, has shown potential in alleviating TMD-associated pain, particularly when the level of catecholamines is elevated. The aim of this study was to explore whether intra-articular propranolol administration is effective in diminishing temporomandibular joint (TMJ) pain during repeated stress situations. Additionally, we investigated the effect of repeated stress on the expression of genes encoding β-adrenoceptors in the trigeminal ganglion. In the present study, rats were exposed to a stress protocol induced by sound, then to the administration of formalin in the TMJ (to elicit a nociceptive response), followed immediately afterward by different doses of propranolol, after which the analgesic response to propranolol was evaluated. We also assessed the levels of beta-1 and beta-2 adrenergic receptor mRNAs (Adrb1 and Adrb2, respectively) using reverse transcription-quantitative PCR (RT-qPCR). Our findings revealed that propranolol administration reduces formalin-induced TMJ nociception more effectively in stressed rats than in non-stressed rats. Furthermore, repeated stress decreases the expression of the Adrb2 gene within the trigeminal ganglion. The findings of this study are noteworthy as they suggest that individuals with a chronic stress history might find potential benefits from β-blockers in TMD treatment.

Causal relationship between psychiatric traits and temporomandibular disorders: a bidirectional two-sample Mendelian randomization study

OBJECTIVES

This study was to investigate the causal relationship between temporomandibular disorders (TMD) and psychiatric disorders by Mendelian randomization (MR) analysis.

MATERIALS AND METHODS

A two-sample bidirectional MR analysis was adopted to systematically explore the causal relationship between TMD and eight psychiatric traits, including anxiety disorder (AD), panic disorder (PD), major depressive disorder (MDD), neuroticism, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), bipolar disorder (BIP), and schizophrenia (SCZ). Inverse variance weighted (IVW), weighted median, and MR-Egger regression were used in my study. Furthermore, we also performed three sensitivity analyses to illustrate the reliability of the analysis.

RESULTS

Two psychiatric traits have risk effects on TMD: PD (OR = 1.118, 95% CI: 1.047-1.194, P = 8.161 × 10-4, MDD (OR = 1.961, 95% CI: 1.450-2.653, P = 1.230 × 10-5). Despite not surpassing the strict Bonferroni correction applied (P > 0.00625), we could think that there was a suggestive causal effect of neuroticism and SCZ increasing the risk of TMD. On the reverse MR analysis, we found no significant evidence of causal effects of TMD on these psychiatric traits. Except for heterogeneity in the causal analysis for SCZ on TMD, no heterogeneity and horizontal pleiotropy were detected in the other analyses.

CONCLUSIONS

Our two-sample MR study has provided further evidence of PD and MDD being related to a higher risk of TMD.

CLINICAL RELEVANCE

These findings highlight the importance of closely monitoring mental traits during future TMD treatments to prevent an increased risk of TMD.

Temporomandibular treatments are significantly efficient in improving otologic symptoms

Symptoms of temporomandibular disorders (TMD) could be present as otologic symptoms like earache and dizziness in some patients. In most cases, these symptoms are not recognized because otolaryngologists fail to diagnose TMD as a source of the problem. This investigation was conducted to evaluate the effect of TMD treatments on the otologic symptoms which after taking history and clinical examinations seemed to be related to TMD. In the present study, the patients who were complaining of otalgia, ear fullness, tinnitus, hearing loss, and dizziness were evaluated by an ear fellow. Forty patients who had no known otologic or other primary causes to explain their symptoms, were referred to the orofacial pain clinic with the possible diagnosis of TMD. If the diagnosis was confirmed by an orofacial pain specialist, a combination of TMD treatments was administered to each case and the patients were followed up. The results showed that following implementation of treatment protocols for TMD, more than 50% of the patients reported complete or partial recovery in the second follow-up (p < 0.05). The most common otologic symptom of the referred cases was earache, and the most common associated complaint was neck pain. All the patients had one or more parafunctional habits. This study showed that TMD treatments were significantly efficient in improving otologic symptoms partially or completely and the authors concluded that for the patients with otolaryngologic unexplained symptoms, an overhaul examination is needed to assess TMD as a possible cause of the patient complaint. It is recommended that in cases with unexplained otologic symptoms, otolaryngologists care more about the neck trigger points (TP) and ask about the patient's parafunctional habits. Otolaryngologists and dentists need to be aware of the risk of developing otologic symptoms caused by these habits or cervical TPs.

Association of stress, anxiety, and depression levels with sleep quality in patients with temporomandibular disorders

OBJECTIVE

To examine the psychological symptoms of TMD and their effects on sleep quality in patients with temporomandibular disorders.

METHODS

The study was carried out with 425 consecutive TMD patients who sought care at the oral and maxillofacial surgery clinic of a faculty of dentistry. Perceived Stress Scale-14, Beck Anxiety Scale, and Beck Depression Scale were used to evaluate the psychological state. Sleep quality was evaluated with the Pittsburgh Sleep Quality Index.

RESULTS

The mean sleep score of all participants was 6.52. As the level of anxiety and depression increased, the scores of both total sleep quality and sleep quality components increased significantly p < 0.01. On the other hand, those with poor sleep quality had significantly higher stress, anxiety, and depression levels than those with good sleep quality p < 0.01.

CONCLUSION

Negative emotional situations such as stress, anxiety, and depression seriously impair sleep quality in TMD patients.

Therapy for Temporomandibular Disorders: 3D-Printed Splints from Planning to Evaluation

INTRODUCTION

This article describes the authors' digital workflow-based method for fabricating intraoral occlusal splints, from planning to the evaluation phase.

MATERIALS AND METHODS

In our protocol, first, we had a registration phase. This included taking digital impressions, determining the centric relation (CR) position with the deprogrammer Luci Jig, and using the digital facebow for measuring the individual values. The laboratory phase was next, which included planning and manufacturing with a 3D printer. The last phase was delivery, when we checked the stability of the splint and adjusted the occlusal part.

RESULT

The average cost is lower for a fully digital splint than for conventional methods. In terms of time, there was also a significant difference between the classic and digital routes. From a dental technical point of view, the execution was much more predictable. The printed material was very rigid and, therefore, fragile. Compared to the analog method, the retention was much weaker.

CONCLUSION

The presented method permits time-efficient laboratory production, and may also be performed chairside in a dental office. The technology is perfectly applicable to everyday life. In addition to its many beneficial properties, its negative properties must also be highlighted.

Fractional amplitude of low-frequency fluctuation changes of specific cerebral regions in patients with toothache: A functional magnetic resonance imaging study

BACKGROUND

Previous studies have indicated that pain-related diseases can result in significant functional alterations in the brain. However, differences in spontaneous brain activity in toothache (TA) patients remain unclear.

OBJECTIVE

To investigate altered spontaneous brain activity in patients with TA and its underlying mechanisms using the resting-state functional magnetic resonance imaging-fractional amplitude of low-frequency fluctuation (rsfMRI-fALFF) technique.

METHODS

Twelve patients with TA and 12 non-toothache controls (NTCs) (matched for sex, age, and level of education) were enrolled. Spontaneous cerebral activity variations were investigated using the rsfMRI-fALFF technique in all individuals. The mean fALFF values of the TA patients and NTCs were classified using receiver operating characteristic (ROC) curves. The correlations between fALFF signals of distinct brain regions and clinical manifestations of TA patients were evaluated using Pearson's correlation analysis.

RESULTS

TA patients showed lower fALFF values in the left superior frontal gyrus, medial; right superior frontal gyrus, dorsolateral; and left median cingulate and paracingulate gyri (LDCG) than the NTCs. Moreover, ROC curve analysis indicated that the area under the curve of each cerebral region studied had high accuracy. Besides, in the TA group, the visual analog scale score was negatively correlated with fALFF signal values of the LDCG (r = .962, p < .001).

CONCLUSION

Abnormal spontaneous activity was detected in numerous brain regions in patients with TA, which may be valuable for understanding the brain processing mechanism underlying TA. These regional changes in brain activity may serve as effective clinical indicators of TA.

Temporomandibular disorders and neck pain in primary headache patients: a retrospective machine learning study

OBJECTIVES

To evaluate the linkage underpinning different clinical conditions as painful TMD and neck pain in patients affected by primary headaches.

MATERIALS AND METHODS

In this machine learning study, data from medical records of patients with headaches as migraine, tension-type headache (TTH) and other primary ones, referring to a University Hospital over a 10-year period were analysed. VAS was used to evaluate the intensity of the TMD and neck pain. Moreover, the magnetic resonance imaging was used to supplement the clinical data.

RESULTS

A total of 300 patients (72 male, 228 female), mean aged 37.78 ± 5.11 years, were included. Higher TMD and neck pain VAS in migraine patients were reported. The machine learning analysis focussed on type of primary headache demonstrated that a higher TMD VAS was correlated to migraine, whereas a higher neck pain VAS was correlated to TTH or migraine. Concerning the TMD type, arthrogenous and mixed TMD were correlated to mild-moderate TMD pain (depending on neck pain intensity), whereas myogenic TMD was correlated to moderate-severe TMD pain.

CONCLUSIONS

Machine-learning approach highlighted the complexity of diagnosis process and demonstrated that neck pain might be an influential variable on the belonging to different group of headaches in TMD patients.

Temporomandibular disorder severity and its association with psychosocial and sociodemographic factors in Turkish adults

BACKGROUND

There is a lack of awareness regarding temporomandibular disorder (TMD) and its association with psychological and sociodemographic factors in the Turkish population. This study aimed to evaluate the relationship between signs/symptoms of anxiety-depression, sociodemographic factors, parafunctional habits, bruxism, and the presence and severity of the symptoms of TMD in Turkish adults.

METHODS

The participants completed an online questionnaire consisting of sociodemographic questions, the Fonseca Anamnestic Index, and the Patient Health Questionnaire-4.

RESULTS

The mean age of the 2580 participants was 35.29 ± 12.70 years, and 63.3% were women. The frequency of the participants who showed symptoms of TMD was 69.8%. The severity of TMD symptoms was significantly greater in participants who had signs/symptoms of anxiety and depression (p < 0.05). Sociodemographic and psychological data showed an association between the presence and severity of the symptoms of TMD and sex (OR 1.52, 95% confidence interval (CI) 1.26-1.85), parafunctional habits (OR 2.64, 95% CI 2.36-2.99), bruxism (OR 3.14, 95% CI 1.78-4.90), signs/symptoms of anxiety (OR 2.30, 95% CI 1.76-3.00), and signs/symptoms of depression (OR 1.90, 95% CI 1.48-2.42).

CONCLUSIONS

The results of the present study suggest that females and those who report bruxism, parafunctional habits, and signs/symptoms of anxiety-depression are more likely to show symptoms of TMD with different severity.

Current Trends in the Management of Temporomandibular Joint Dysfunction: A Review

The temporomandibular joint (TMJ) is a synovial bi-condylar joint with 3 degrees of freedom. One-third of the adult population reportedly suffers from temporomandibular joint dysfunction (TMD). Females are more commonly affected than males. Almost 50% of TMD patients do not require any intervention, and the symptoms are self-limiting within one year after the onset; however, 75-80% of adults suffering from TMD require medical intervention and it takes up to three years for the complete remission of the symptoms. The clinical features of TMD are clenching, clicking, and locking of the jaw, and occlusion due to faulty posture. Based on the diagnostic criteria for temporomandibular disorder (DC/TMD) criteria proposed in the year 2014, the classification of TMD is done based on axis I and axis II diagnoses. This review aims to provide an overview of TMD and examine available treatment strategies for TMD. Various conservative treatment methods have been proven to be effective, including self-care strategies, dental treatment strategies, pharmacological treatment, physical therapy modalities, manual mobilization, electrotherapy and dry needling, relaxation techniques, intra-articular injections, cognitive behavioral therapy, and surgical corrections.

Association between temporomandibular disorders and anxiety: A systematic review

Temporomandibular Joint Dysfunction (TMD) is an umbrella term that includes musculoskeletal and neuromuscular conditions affecting the temporomandibular joint. The present systematic review aimed to verify whether there is a specific association between TMD and anxiety. The searches were carried out in electronic databases, including PubMed, Scopus, Web of Science, and LILACS, without restrictions on publication date and language. The acronym PECO was used, whose participants (P) were humans exposed to TMD (E), compared to participants without TMD (C) and the presence of anxiety as an outcome (O). After the search retrieval, the duplicates were removed, and the articles were evaluated by title and abstract, following our inclusion and exclusion criteria; then, the papers were read and thoroughly assessed. After selection, the methodological quality was performed using the Newcastle-Ottawa Scale (NOS) for observational studies. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool was used to assess the level of evidence. A total of 710 studies were found, and 33 articles were considered eligible and were included for the qualitative synthesis and the level of evidence assessment. The studies confirmed the association between anxiety and DTM, although there was a low certainty of evidence among the selected studies. Most articles showed a low risk of bias. Although the limitations of this systematic review, it suggested a significant association between anxiety and TMD, as well as highlights possible directions for future research.

Alexithymia and facial emotion recognition in patients with craniofacial pain and association of alexithymia with anxiety and depression: a systematic review with meta-analysis

Background

We aimed to determine the presence of alexithymia in patients with craniofacial pain (CFP) compared with asymptomatic individuals. Our secondary aims were to assess the relationship of alexithymia with anxiety and depression levels, as well as to assess the presence of facial emotion recognition deficit.

Methods

Medline, Scielo and Google Scholar were searched, with the last search performed in 8 September 2021. Standardized mean differences (SMDs) and 95% CIs were calculated for relevant outcomes and were pooled in a meta-analysis using the random effects model. In addition, meta-analyses of correlations and a meta-regression of alexithymia with depression and anxiety were performed.

Results

Regarding alexithymia, assessed through the Toronto Alexithymia Scale (TAS), the results showed significant differences, with higher values in patients compared with asymptomatic individuals, with a large clinical effect (SMD 0.46; 95% CI [0.22–0.71]; heterogeneity-Q 66.86; p < 0.001; inconsistency (I²) = 81%). We found statistically significant correlations with a small clinical effect of alexithymia with anxiety and depression. The meta-regression showed no significant association between the TAS and anxiety or depression. With respect to facial emotion recognition, the results showed statistically significant differences, with greater recognition difficulty in patients compared with asymptomatic individuals, with a large clinical effect (SMD −1.17; 95% CI [−2.01 to −0.33]; heterogeneity-Q 2.97; p = 0.080; I² = 66%).

Conclusions

Patients with CFP showed alexithymia with moderate evidence. There was also moderate evidence indicating that these patients had significant deficits in facial emotion recognition compared with asymptomatic individuals. Furthermore, alexithymia showed statistically significant correlations with anxiety and depression levels.

Effects of ischemic compression and instrument-assisted soft tissue mobilization techniques in trigger point therapy in patients with rotator cuff pathology: randomized controlled study

PURPOSE

To compare the ischaemic compression (IC) and instrument-assisted soft tissue mobilization (IASTM) in the treatment of MTrPs in addition to standard rehabilitation program in patients with rotator cuff tears.

METHODS

Participants with rotator cuff tears were included the study (n = 46). Patients were randomly divided into two groups; which were Group 1 (IC + standard rehabilitation program (n = 23)), and Group 2 (IASTM + standard rehabilitation program (n = 23)) groups. Pain were assessed by visual analog scale (VAS). Range of motion (ROM) was assessed by a universal goniometer. Active MTrPs were assessed according to the Travel and Simons criteria. Pressure pain threshold (PPT) were assessed by a digital algometer. Function were evaluated by the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) and American Shoulder and Elbow Surgeons Standardised Shoulder Assessment (ASES) Form. Anxiety and depression were evaluated by the Hospital Anxiety and Depression (HAD) scale. Satisfaction was assessed by the Global Rating of Change scale after 6 weeks treatment.

RESULTS

After the treatment, pain, ROM and the DASH, ASES, HAD scores improved in both groups (p < 0.05). The active MTrPs of 2 muscles, PPT of 4 muscles and DASH in Group 1 significantly improved compared to Group 2 (p < 0.05).

CONCLUSION

Although patients with low functionality accumulated in the IC group, the IC is more effective than the IASTM in increasing the PPT and functional improvement according to the results of the DASH score.

Spinal CCK contributes to somatic hyperalgesia induced by orofacial inflammation combined with stress in adult female rats

In some chronic primary pain conditions such as temporomandibular disorder (TMD) and fibromyalgia syndrome (FMS), mild or chronic stress enhances pain. TMD and FMS often occur together, but the underlying mechanisms are unclear. The purpose of this study was to investigate the role of cholecystokinin (CCK) in the spinal cord in somatic hyperalgesia induced by orofacial inflammation combined with stress. Somatic hyperalgesia was detected by the thermal withdrawal latency and mechanical withdrawal threshold. The expression of CCK₁ receptors, CCK₂ receptors, ERK1/2 and p-ERK1/2 in the spinal cord was examined by Western blot. After the stimulation of orofacial inflammation combined with 3 day forced swim, the expression of CCK₂ receptors and p-ERK1/2 protein in the L4-L5 spinal dorsal horn increased significantly, while the expression of CCK₁ receptors and ERK1/2 protein remained unchanged. Intrathecal injection of the CCK₂ receptor antagonist YM-022 or mitogen-activated protein kinase (MAPK) kinase (MEK) inhibitor PD98059 blocked somatic hyperalgesia induced by orofacial inflammation combined with stress. Intrathecal administration of the MEK inhibitor blocked somatic sensitization caused by the CCK receptor agonist CCK8. The CCK₂ receptor antagonist YM-022 significantly reduced the expression of p-ERK1/2. These data indicate that upregulation of CCK₂ receptors through the MAPK pathway contributes to somatic hyperalgesia in this comorbid pain model. Thus, CCK₂ receptors and MAPK pathway may be potential targets for the treatment of TMD comorbid with FMS.

Anxiety Assessment in Orofacial Pain Patients

Objectives The aim of the present study was to assess the anxiety level in patients with orofacial pain and to compare it with patients without any orofacial pain.

Materials and Methods The survey-based study was conducted that included a total of 100 patients who were divided into two groups: 50 patients with orofacial pain and 50 patients without pain. Questionnaire in a local language, that is, Marathi, was formulated based on Modified Dental Anxiety Scale (MDAS) and Hospital Anxiety and Depression Scale (HADS). Data was then subsequently collected and evaluated according to the score of MDAS and HADS.

Results A total of 78 patients were evaluated according to the questionnaire survey. Highly significant correlation was found between anxiety level and pain present in patient on the MDAS-anxiety level scale(p = 0.001). Also, a significant correlation was observed between anxiety level and pain present in patient on the HADS-anxiety level (p = 0.007). A significant correlation was found between gender and pain anxiety level in patients on the MDAS-anxiety level (p = 0.009).

Conclusion Anxiety level in patients with orofacial pain can be assessed with MDAS and HADS. Specific types of anxiety-related concerns definitely occur at higher levels in orofacial pain patients in comparison to patients without pain. Greater attention needs to be employed on understanding of anxiety level in orofacial pain patients. This is detrimental in acceptance of treatment by patient and ultimately affects outcome. Anxiety level assessment helps in better understanding of apprehension among the patients with orofacial pain, and enables better delivery of appropriate care and intervention.

Smiling, Yawning, Jaw Functional Limitations and Oral Behaviors With Respect to General Health Status in Patients With Temporomandibular Disorder-Myofascial Pain With Referral

Background: The temporomandibular joint is the one of the most important joints in the human body. It enables numerous orofacial functions such as mastication, swallowing, breathing, speech, emotional communication, and facial expressions. The aim of the study was to evaluate the prevalence of jaw functional limitations and oral behaviors with respect to general health status in patients with temporomandibular joint disorders—myofascial pain with referral.

Materials and methods: The study group consisted of 50 individuals (37 females and 13 males) with complete natural dentition. The average age was 23.36 years with ± 0.30 as a standard error. All subjects underwent clinical examination and were diagnosed with myofascial pain with referral according to the Diagnostic Criteria for Temporomandibular Disorders. The survey was conducted in connection with the Jaw Functional Limitation Scale-8 (JFLS-8), Jaw Functional Limitation Scale-20 (JFLS-20), Patient Health Questionnaire-4 (PHQ-4), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-15 (PHQ-15), and Oral Behaviors Checklist (OBC).

Results: The most common functional problems in the entire study group were chewing tough food and yawning. In terms of gender, statistically significant differences were noted for chewing tough food and smiling (p = 0.015451; p = 0.035978, respectively). With respect to Bonferroni correction and Benjamini-Hochberg procedure, the observed differences were not statistically significant. There were no statistically considerable differences in mastication, mandibular mobility, verbal and emotional communication, or global limitations (p > 0.05). Over half (56%) of the respondents had depression of varying severity. Somatic symptoms of different severity were found in 78% of the patients, and 44% of the respondents declared anxiety disorders. The score of the Oral Behavior Checklist (OBC = 27.18) highlighted a high tendency for developing craniomandibular disorders.

Conclusion: Patients with myofascial pain with referral, demonstrated a disturbed biopsychosocial profile. The restrictions in yawning and smiling as well as limitations in mastication, mobility, verbal and emotional communication, and global limitations appear to be significant predictors of craniomandibular dysfunction. Depression, stress, and somatic disorders are important factors predisposing patients to the occurrence of myofascial pain with referral. The progression of oral behaviors may indicate the role of somatosensory amplification.

Prevalence of self-reported pain-related temporomandibular disorders and association with psychological distress in a dental clinic setting

Objectives

To investigate the prevalence of self-reported pain-related temporomandibular disorders (TMDs) and its association with psychological status in a dental clinic setting.

Methods

In this cross-sectional study, patients were asked to complete a TMD pain screener and the Patient Health Questionnaire-4 (PHQ-4). Correlations between symptoms of pain-related TMDs and PHQ-4 scores were analysed using Spearman’s correlation test. Symptoms of pain-related TMDs were compared between four groups of participants with different psychological profiles using the Kruskal–Wallis test followed by multiple comparisons. The level of significance was adjusted using the Dunn–Bonferroni test.

Results

The prevalence of self-reported pain-related TMDs was 22.2%. TMD pain score was positively correlated with PHQ-4 score. The high anxiety and the comorbidity groups had significantly higher TMD pain scores than the controls.

Conclusion

There was a high prevalence of self-reported pain-related TMDs, which was correlated with scores on all psychological assessment scales. Symptoms of pain-related TMDs were significantly greater in patients with high anxiety scores, regardless of depression level.

Psychosocial aspects in temporomandibular disorder: clinical case report

Introduction

Temporomandibular disorders have a considerable prevalence, with a significant impact on physical and psychosocial factors [1]. It contributes to high socioeconomic costs, which are generally associated with comorbidities such as depression and other psychological factors [2,3]. The Diagnostic Criteria for Temporomandibular Disorders is based on a bi-mechanical model of pain with two axes: physical signs and symptoms (axis I) and psychological factors (axis II). Psychological factors such as catastrophizing pain, psychic distress, guiding beliefs, beliefs related to painful perception, depressed or anxious mood, and passive coping are all related to an increased pain perception, increased levels of disability, in patients with chronic pain with temporomandibular disorders [3,5]. Psychosocial factors were also identified as predictors of treatment outcome in patients with temporomandibular disorders [6]. We consider that somatic awareness is an important sensory-discriminative factor to be taken into account in this group of patients. The aim of this case study is to analyse if the identification of psychosocial aspects contributes in controlling the temporomandibular symptoms.

Material and methods

A case study of a 25-year-old female patient with generalised headache, generalised myofascial pain (III) in the head and neck region, self-reported awake and sleep bruxism and important psychological factors related to catastrophic pain and anxiety, all described during the initial interview. The patient can positively correlate beginning of the manifestation of the painful symptoms with relevant psychosocial and drastic, in her own words, family changes. Pain intensity and headache are measured with numeric pain rating scale (NPRS) and the patient is submitted to one session of physical therapy per week. The treatment plan consisted of cognitive-behavioral therapy with a first appointment based on education, habits recognition and modification, the patient was medicated with muscle relaxants and off label gabapentine, physiotherapy and psychotherapy. All the assumptions of the Helsinki Declaration have been fulfilled and an informed consent for clinical case of Clinica Dentária Egas Moniz approved by the ethic commission of Instituto Universitário Egas Moniz.

Results

Three months after (12 sessions of physical therapy) the beginning of the treatment plan, the biggest breakthrough was the ability of the patient to identify psychological situations that trigger the exacerbation of pain. The patient referred absence of headache, a significant reduction of myofascial pain (I) located in the masseter and in the temporal of about 70% of the pain scale and changed from myofascial pain to local myalgia.

Discussion and conclusion

Psychosocial factors are frequently present in patients with temporomandibular disorders and their evaluation, grading and consequent intervention become important for the prognosis and resolution of the case.The assessment of psychosocial aspects should be considered in all patients with temporomandibular disorders in order to analyse, case by case, whether they are relevant for controlling their symptoms. It will be important to carry out a experimental study with a larger sample to verify whether the obtained results point in the same direction.

Transient Receptor Potential (TRP) Ion Channels in Orofacial Pain

Orofacial pain, including temporomandibular joint disorders pain, trigeminal neuralgia, dental pain, and debilitating headaches, affects millions of Americans each year with significant population health impact. Despite the existence of a large body of information on the subject, the molecular underpinnings of orofacial pain remain elusive. Two decades of research has identified that transient receptor potential (TRP) ion channels play a crucial role in pathological pain. A number of TRP ion channels are clearly expressed in the trigeminal sensory system and have critical functions in the transduction and pathogenesis of orofacial pain. Although there are many similarities, the orofacial sensory system shows some distinct peripheral and central pain processing and different sensitivities from the spinal sensory system. Relative to the extensive review on TRPs in spinally-mediated pain, the summary of TRPs in trigeminally-mediated pain has not been well-documented. This review focuses on the current experimental evidence involving TRP ion channels, particularly TRPV1, TRPA1, TRPV4, and TRPM8 in orofacial pain, and discusses their possible cellular and molecular mechanisms.

Temporomandibular Disorders: Fundamental Questions and Answers

This review aimed to present the current evidence-based answers to a questionnaire which was developed to evaluate the beliefs and knowledge of dental professionals concerning temporomandibular disorder (TMD). A literature review was conducted using the PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane, Google Scholar, and Scopus search engines from January 1980 to June 2020 corresponding to TMD diagnosis, causes, management, and consequences. A total of 50 articles were considered relevant and selected for full review. The etiology of TMD is multifactorial and complicated and involves several direct and indirect factors. Orthodontic treatment does not appear to either prevent or relieve TMD to a great degree. Nevertheless, condylar and occlusal stability reduces the risk of TMD development. As a result, an assessment of the function of masticatory system prior to beginning orthodontic therapy is fundamental. If signs and symptoms of TMD are significantly present, they should be managed before any orthodontic intervention. Moreover, psychological disorders are strongly associated with joint and facial pain. Thus, professionals who work with chronic TMD patients need to be aware of the psychological aspects of chronic pain and refer the patient for psychological evaluation when warranted. Future research elucidating a cause-effect relationship and neurobehavioral processes underlining chronic pain should be performed.

Dry Needling and Acupuncture in Treatment of Dance-Related Injuries, MD, and PT Perspectives

Dancers frequently present to health care professionals with musculoskeletal impairments. The role of the health care practitioner, whether physician, physical therapist, or acupuncturist, is to decrease pain and restore function in the short term and to restore adaptive potential and neural connectivity in the long term. When dysfunction is treated, pain improves. Acupuncture and dry needling improve tissue perfusion by improving vasomotor control and can improve strength by removing motor inhibition. Acupuncture and dry needling are safe, complementary modalities aimed at improving the function of the dancer.

Field-testing a psychosocial assessment scoring form for TMD patients - summarizing axis II instruments

Background

The etiology of temporomandibular disorders (TMD) can be explained on the basis of a biopsychosocial model. However, psychosocial assessment is challenging in daily dental practice. The purpose of the current study was to field-test the practicability of a novel psychosocial assessment scoring form regarding the reliability of scoring procedures and the opinion of examiners. The working hypotheses were that the scoring results of inexperienced undergraduate students were similar to the results collected by a gold standard and that the scoring form was easy to use.

Methods

A psychosocial assessment scoring form was developed in accordance with guidelines of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), including results of the Graded Chronic Pain Scale (GCPS), Patient Health Questionnaires (PHQ), and Generalized Anxiety Disorders (GAD). Inexperienced operators (undergraduate students) examined patients with TMD-associated complaints and rated the practicability of the scoring form. The scoring results were recalculated by two experienced operators and a consensus was defined as a gold standard. Reliability coefficients were determined comparing results of the gold standard and the inexperienced operators.

Results

Sixty-five examiners used the scoring form to obtain results for patients with TMD-associated complaints. Of the patients, 78.8% received a diagnosis according to DC/TMD decision trees. Two-thirds of the operators (62.9%) stated that the form was easy to complete, and 83.0% would use it in their dental practice. The reliability coefficients ranged between 0.81–1.00.

Conclusions

Within the limitations of the present study, the psychosocial assessment scoring form seems to be an easy-to-use and practicable tool. The vast majority of the inexperienced examiners recommended the application.

The Case for Comorbid Myofascial Pain-A Qualitative Review

Myofascial pain syndrome is widely considered to be among the most prevalent pain conditions, both in the community and in specialized pain clinics. While myofascial pain often arises in otherwise healthy individuals, evidence is mounting that its prevalence may be even higher in individuals with various comorbidities. Comorbid myofascial pain has been observed in a wide variety of medical conditions, including malignant tumors, osteoarthritis, neurological conditions, and mental health conditions. Here, we review the evidence of comorbid myofascial pain and discuss the diagnostic and therapeutic implications of its recognition.

Manual therapy and exercise in temporomandibular joint disc displacement without reduction. A systematic review

OBJECTIVE

The aim of this systematic review was to analyze the effectiveness of exercise and manual therapy interventions in patients with disc displacement without reduction.

METHOD

The authors performed a systematic review of Medline, EMBASE, PEDro, CINAHL, and Google Scholar databases. Two independent reviewers conducted the eligibility and quality assessment of studies. Interventions based on exercise and manual therapy regarding pain intensity and maximum mouth opening as primary outcomes were examined.

RESULTS

Ten articles were included, according to the inclusion criteria. Most of the interventions showed statistically significant improvements in the primary outcomes.

CONCLUSION

Results show that interventions based on therapeutic exercise or manual therapy may be beneficial and play a role in the treatment of disc displacement without reduction. Limited evidence suggests that exercise significantly improves mouth opening in comparison to splints. Due to the heterogeneity of the included studies, these results should be interpreted with caution.

Nrf2/ARE is a key pathway for curcumin-mediated protection of TMJ chondrocytes from oxidative stress and inflammation

Temporomandibular joint osteoarthritis (TMJ OA) is a complex multifactorial disease that can be induced by inflammation and oxidative stress. Curcumin has been reported to have anti-inflammatory and antioxidant properties. Herein, the anti-inflammatory and antioxidant mechanisms of curcumin in TMJ OA were investigated. Curcumin treatment inhibited the expression of the inflammation mediators IL-6, iNOS, and COX-2 and of the matrix-degrading proteinases MMP-1, MMP-3, MMP-9, MMP-13, ADAMTS-4, and ADAMTS-5 and upregulated the mRNA levels of the cartilage anabolic factors COL2A1 and ACAN after IL-1β treatment. Curcumin treatment also decreased oxidative stress injury following IL-1β stimulation. Pathway analysis demonstrated that the ROS/Nrf2/HO-1-SOD2-NQO-1-GCLC signaling axis is a key axis through which curcumin activates the Nrf2/ARE pathway in TMJ inflammatory chondrocytes. Curcumin-induced anti-inflammatory and cartilage protective effects were significantly abrogated by specific Nrf2 siRNA. In vivo results demonstrated that curcumin treatment protected TMJ articular cartilage from progressive degradation. Our experimental results indicate that curcumin inhibits inflammation, oxidative stress, and the matrix degradation of TMJ inflammatory chondrocytes through the Nrf2/ARE signaling pathway, thereby exerting cartilage protective effects. This study provides insight into potential therapeutic approaches for TMJ OA.

Depression and Resting Masticatory Muscle Activity

Background: The aim of this study was to determine the influence of moderate depression determined based on Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMDs) Axis II on the bioelectrical resting activity of temporal muscles and masseter muscles. Methods: The research participants were 68 healthy adult women. Of these, 46 people h (mean age: 22 ± 1 year) who had no temporomandibular disorders were selected for the research. They were divided based on results from RDC/TMDs (Axis II: scale’s measurement) into the study group with a moderate level of depression (23 people), rest of participants without symptoms of depression were classified to control group (23 people). The resting activity of temporal muscles and masseter muscles was examined by using BioEMGIII electromyograph. Two statistical analyses were used: Shapiro–Wilk test and Mann–Whitney U test. Results: Despite higher mean tensions of temporal muscles and masseter muscles in the group with depression, results findings were not statistically significant (p > 0.05). Conclusions: Moderate depression determined based on the RDC/TMDs II axis questionnaire is not related to the resting activity of selected masticatory muscles. Further research should be continued on a larger group of respondents in order to establish the relationship between psychological factors and bioelectrical parameters of the masticatory muscles.

[Modern views on the relationship between psychoemotional state and the bioelectrical activity of facial muscles]

The paper presents a review of the literature data reflecting the relevance and current views on the problem of facial feedback. It considers the relationship between the bioelectric activity of facial muscles and neuropsychic stress. The modern issues dedicated to the study of the correlation between the indicators assessing the tonic activity of facial muscles and psycho-emotional stress are highlighted. Particular emphasis is placed on the scientific concept of emotional proprioception, according to which facial muscle activity through the trigeminal and facial nerves affects the emotional centers of the brain, by improving or worsening the emotional state. The currently known methods for the correction of psychoemotional states, which are based on the feedback mechanism, are analyzed. The possibilities of using neuromuscular relaxation of the facial muscles to correct psychoemotional conditions are considered.

Relationship between temporomandibular dysfunctions, sleep disorders, and anxiety among dentistry students

Introduction: This study aimed to evaluate the relationship between temporomandibular dysfunction (TMD), anxiety, and sleep disorder (DS) among dentistry students, relating the periods in which they are enrolled.Methods: The study consisted of 90 students: Group 1: 30 first-period students; Group 2: 30 fifth-period students; Group 3: 30 students from the ninth period. The participants responded to the RDC/TMD, Fletcher & Luckett questionnaires, and the Beck Anxiety Inventory to analyze symptoms of TMD, DS, and anxiety.Results: There was an association between TMD, DS, and the period studied. When related to moderate and severe anxiety, the group that had the highest incidence was Group 1 (first period students).Conclusion: The apprehension for what is new can influence the TMD and DS indices, while the greater concern for academic/professional performance can generate higher levels of anxiety.

[Myofascial pain syndrome in the dysfunction of the temporomandibular joint]

AIM

Selection of the clinical characteristics of pain syndrome in the orofacial region in temporomandibular joint pain dysfunction syndrome (TMJ PDS).

MATERIAL AND METHODS

One hundred and two patients with TMJ PDS were examined using the Verbal Descriptive Pain Rating Scale of the orofacial area. The Clinical Index of TMJ dysfunction (CID) by Helkimo M. was used for objectification of the level of musculo-tonic disorders in the area of the chewing muscles. The psychopathological status of patients with TMJ PDS was assessed with HRDS and SCL-90-R.

RESULTS

A significant proportion of patients with TMJ PDS, in addition to algic symptoms, have hypertonus of the facial muscles, the nature and severity of which require not only a special diagnostic assessment, but also follow-up treatment. The analysis of data allowed us to identify three clinical groups of patients: with isolated (muscular-tonic), neurological symptoms; with mixed (combination of muscular-tonic and somatoform manifestations) neurological and psychopathological symptoms and with somatoform symptoms.

CONCLUSION

Patients with TMJ PDS are clinically heterogeneous and require clinical differentiation, distinguishing the common group of patients with muscular dysfunction accompanied by pain and emotional response to it (anxiety and minor depressive symptoms) and the group of patients with a somatoform disorder (and manifestations as general anxiety).

Is there a relationship between psychological factors and TMD?

INTRODUCTION

Medical students are in a very demanding environment and are affected by high degree of stress. High levels of anxiety can affect a student's academic performance and also increase the risk of other health-related problems. This study aims to evaluate, thanks to the intensity of stress manifestations (4DSQ) together with the sense of coherence (SOC), the prevalence of TMD and oral parafunctions in students enrolled in the University of Medical Sciences. Moreover, it aims to evaluate the relationship between the psychosocial manifestations of stress and sense of coherence in relation to gender.

MATERIALS AND METHODS

A total of 324 students of Poznań University of Medical Sciences participated in this study. Students were assessed using a three-part questionnaire: one was to assess symptoms of TMD, the second part was 4DSQ, and the third was a SOC Questionnaire.

RESULTS

About one-third of the students in this study presented symptoms of TMD and perceived more intensively symptoms of distress, anxiety, somatization, and depression. They presented a higher level of somatic symptoms and a lower level of Sense of Coherence than students without TMD symptoms.

CONCLUSION

There is a strong negative relationship between the sense of coherence and the level of perceived distress, anxiety, somatization, and depression. Female students attending Medical School showed a higher level of somatization of stress but with a higher capacity to overcome challenges as compared to men.

The effectiveness of trigger point treatment in rotator cuff pathology: A randomized controlled double-blind study

BACKGROUND

Studies have emphasized the importance of the presence of myofascial trigger points (MTrPs) in patients with rotator cuff pathologies and the high frequency of MTrPs in rotator cuff muscles.

OBJECTIVE

Evaluate the effectiveness of the treatment of active MTrPs in patients with rotator cuff pathologies.

METHODS

Fifty-three patients with rotator cuff tear were randomized into two groups. All patients received the same standard conservative treatment twice a week for 6 weeks. Patients in Group 1 additionally received ischemic compression (IC) of MTrPs. Pain, range of motion (ROM), function, and anxiety and depression were assessed. MTrPs in rotator cuff muscles were assessed manually, and the number of MTrPs on the shoulder complex was counted.

RESULTS

There were no significant differences between the groups in terms of changes in resting/activity/night pain, ROM, function, or anxiety and depression (p> 0.05). Pain scores improved only in Group 1. However, the total number of MTrPs was significantly decreased in Group 1 (p= 0.001).

CONCLUSION

A six-week course of IC helps treat active MTrPs. A standard conservative treatment program reduced pain and increased function; the addition of MTrP treatment did not improve clinical outcomes in patients with rotator cuff pathologies.

Rates of Physician Coprescribing of Opioids and Benzodiazepines After the Release of the Centers for Disease Control and Prevention Guidelines in 2016

IMPORTANCE

The Centers for Disease Control and Prevention guidelines in 2016 recommended avoiding concurrent use of opioids and benzodiazepines.

OBJECTIVE

To determine whether the release of the guidelines was associated with changes in coprescription of opioids and benzodiazepines.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used claims data obtained from a US national database of medical and pharmacy claims for 3 598 322 adult commercially insured patients and 1 299 142 Medicare Advantage (MA) beneficiaries with no recent history of cancer, sickle cell disease, or hospice care who ever used prescribed opioids during the study period, January 1, 2014, through March 31, 2018.

EXPOSURES

Overlapping opioid and benzodiazepine prescriptions filled.

MAIN OUTCOMES AND MEASURES

The extent (proportion of person-months with any overlapping days of prescription of opioids and benzodiazepines) and intensity (proportion of days with opioids prescribed where benzodiazepines were also available) of coprescription.

RESULTS

Of 4 897 464 patients (with 13.4 million person-months of opioid use), the total number of unique commercially insured individuals was 3 598 322 (1 974 731 women [54.9%]), and the total number of unique MA beneficiaries was 1 299 142 (770 256 women [59.3%]). Among 128 576 participants experiencing chronic pain episodes, more than one-half of person-months of long-term opioid use occurred in women (52.7% of person-months among those with commercial insurance and 62.4% of person-months among MA beneficiaries). The median (interquartile range) age of the participants was 51 (41-58) years for patients in the commercial insurance group and 70 (61-77) years for those in the MA group. The mean (SE) extent of coprescription was 23.0% (0.18%) for the commercial insurance group and 25.7% (0.18%) for the MA group. The extent of coprescription decreased in the targeted guideline population-individuals with long-term opioid use-after the guideline release (postguideline slope, -0.95 percentages point per year [95% CI, -1.44 to -0.46 percentage points per year] for the commercial insurance group and -1.06 percentage points per year [95% CI, -1.49 to -0.63 percentage points per year] for the MA group). Nontargeted short-term episodes of opioid use were associated with no change or small declines in trend (for the MA group, postguideline slope of 0.47 percentage point per year [95% CI, 0.35-0.59 percentage point per year]; for the commercial insurance group, postguideline slope of -0.05 percentage point per year [95% CI, -0.12 to 0.02 percentage point per year]). High coprescribing intensity was seen, with 79.3% (95% CI, 78.9%-79.6%) of opioid prescription days in the commercial insurance group and 83.9% (95% CI, 83.7%-84.2%) in the MA group overlapping with benzodiazepines. There was no change in the intensity of coprescribing. Intensity of coprescription was higher when the same clinician prescribed opioids and benzodiazepines.

CONCLUSION AND RELEVANCE

This study observed a reduction in the extent but not intensity of coprescribing of benzodiazepines for patients with long-term opioid use.

Widespread mechanical pain hypersensitivity in patients with chronic migraine and temporomandibular disorders: relationship and correlation between psychological and sensorimotor variables

OBJECTIVE

This study aimed to assess mechanical hyperalgesia in the trigeminal and extra-trigeminal regions in patients with chronic migraine (CM) and temporomandibular disorders (TMD) in comparison to asymptomatic subjects and to determine the association between sensorimotor variables and psychological and disability variables and evaluate the prediction of a sensorimotor variables though psychological and disability variables in patients with CM and TMD.

MATERIAL AND METHODS

A total of 52 subjects with concomitant CM and TMD and 30 asymptomatic subjects were included in the study. The pressure pain threshold (PPT), maximal mouth opening (MMO) and a series of self-reported factors were compared.

RESULTS

There were 52 CM and TMD (92.3% women and 7.7% men; age = 46.2 ± 9.5) and 30 asymptomatic subjects (80% women and 20% men; age = 47.4 ± 10). Differences were found between patients with CM and TMD and asymptomatic participants (p < .01) when comparing the PPTs in the trigeminal and extra-trigeminal regions. The PPT for the trigeminal region was predicted by depressive symptoms (variance of 18%) as well as disability and craniofacial pain (variance of 20%). The extra-trigeminal region PPT was predicted by depressive symptoms (variance of 10%), and pain-free MMO was predicted by disability and craniofacial pain (variance of 24%).

CONCLUSIONS

This study suggests that patients with CM and TMD present with generalized mechanical hyperalgesia. In addition, an association between sensorimotor, psychological and disability variables was observed.

Pain relief following a single-dose intra-articular injection of methylprednisolone in the temporomandibular joint arthralgia-A multicentre randomised controlled trial

Background

Temporomandibular joint (TMJ) arthralgia is a painful condition assumed to be associated with local inflammation.

Objective

The objective of the present study was to determine the efficacy for reducing pain of a single‐dose intra‐articular (IA) injection of methylprednisolone to the TMJ. The hypothesis was that methylprednisolone would effectively reduce TMJ pain.

Methods

This randomised, double‐blind, parallel‐group, multicentre, controlled study included visits for enrolment, treatment and 4‐week follow‐up. The study included patients 18 years and older who had been diagnosed with unilateral TMJ arthralgia. All participants were randomly assigned to receive 1 mL IA injections of methylprednisolone or saline. The primary outcome was change in recorded pain intensity on a visual analogue scale (VAS) at maximum jaw opening, analysed in the per protocol population.

Results

In total, 54 patients were randomly assigned to single‐dose IA injections with methylprednisolone (n = 27) or saline (n = 27). Between baseline and the 4‐week follow‐up, VAS‐rated pain intensity at maximum jaw opening decreased from a mean of 61.0 (95% confidence interval [CI]: 50.1; 70.7) to 33.9 (95% CI: 21.6; 46.2) in the methylprednisolone group and from 59.6 (95% CI: 50.7; 65.9) to 33.9 (95% CI: 23.8; 43.9) in the saline group. The between‐group difference was not significant (P = 0.812). Treatment‐related adverse events were doubled in the methylprednisolone group.

Conclusion

Methylprednisolone provided no additional benefit for reducing pain, but caused more harm compared with saline following a single‐dose IA injection in patients with TMJ arthralgia.

Gi protein functions in thalamic neurons to decrease orofacial nociceptive response

Orofacial pain includes neuronal pathways that project from the trigeminal nucleus to and through the thalamus. What role the ventroposterior thalamic complex (VP) has on orofacial pain transmission is not understood. To begin to address this question an inhibitory G protein (Gi) designer receptor exclusively activated by a designer drug (DREADD) was transfected in cells of the VP using adeno-associated virus isotype 8. Virus infected cells were identified by a fluorescent tag and immunostaining. Cells were silenced after injecting the designer drug clozapine-n-oxide, which binds the designer receptor activating Gi. Facial rubbing and local field potentials (LFP) in the VP were then recorded in awake, free moving Sprague Dawley rats after formalin injection of the masseter muscle to induce nociception. Formalin injection significantly increased LFP and the nociceptive behavioral response. Activation of DREADD Gi with clozapine-n-oxide significantly reduced LFP in the VP and reduced the orofacial nociceptive response. Because DREADD silencing can result from Gi-coupled inwardly-rectifying potassium channels (GIRK), the GIRK channel blocker tertiapin-Q was injected. Injection of GIRK blocker resulted in an increase in the nociceptive response and increased LFP activity. Immunostaining of the VP for glutamate vesicular transporter (VGLUT2) and gamma-aminobutyric acid vesicular transporter (VGAT) indicated a majority of the virally transfected cells were excitatory (VGLUT2 positive) and a minority were inhibitory (VGAT positive). We conclude first, that inhibition of the excitatory neurons within the VP reduced electrical activity and the orofacial nociceptive response and that the effect on excitatory neurons overwhelmed any change resulting from inhibitor neurons. Second, inhibition of LFP and nociception was due, in part, to GIRK activation.

Effects of trait anxiety, somatosensory amplification, and facial pain on self-reported oral behaviors

OBJECTIVES

Oral behaviors are activities, like gum chewing, teeth clenching, and biting of objects, that go beyond normal functioning demands and contribute to the onset of temporomandibular disorders (TMD). Somatosensory amplification refers to the tendency to experience somatic sensations as intense, noxious, and disturbing and is related to bodily hypervigilance. Clinical experience suggests that individuals with bodily hypervigilance also present with occlusal hypervigilance and continuously check their occlusion. This study aimed at investigating whether somatosensory amplification and trait anxiety, a characteristic correlated with hypervigilance, are associated with a greater incidence of oral behaviors, and verifying how self-reported facial TMD pain affect this relationship.

MATERIALS AND METHODS

The State-Trait Anxiety Inventory, the Somatosensory Amplification Scale, the Oral Behavior Checklist (OBC), and the TMD-Pain Screener Questionnaire were filled out by 255 University students with self-reported facial TMD pain (PAIN group; 47 subjects, 24.8 ± 4.2 years) and without pain (CTR group; 208 subjects, 26.0 ± 4.8 years) using a web survey.

RESULTS

Trait anxiety, somatosensory amplification, and OBC scores were greater in the PAIN than CTR group (all p < 0.05). Trait anxiety and somatosensory amplification were positively associated with the frequency of oral behaviors, as measured with the OBC (all p < 0.05). A significant effect of the interaction study group*trait anxiety (p = 0.028) on OBC scores was found.

CONCLUSIONS

Individuals with greater trait anxiety and somatosensory amplification report more frequent oral behaviors. The relationship between anxiety and oral behaviors is affected by concurrent facial pain.

CLINICAL RELEVANCE

Individuals with increased trait anxiety and concurrent facial pain report more frequent oral behaviors than those without pain. Clinicians should evaluate patients' anxiety and somatosensory amplification before starting dental treatment.