Somatosensory and psychosocial profile of patients with painful temporomandibular joint clicking

Hypervigilance to pain and sleep quality are confounding variables in the infrared thermography examination of the temporomandibular joint and temporal and masseter muscles

OBJECTIVES

Verify whether hypervigilance to pain (HP) and sleep quality (SQ) are confounding variables in the infrared thermography (IT) examination of the temporomandibular joint and temporal and masseter muscles.

METHODS

A cross-sectional and analytical study was conducted, collecting HP and SQ data from 80 participants without temporomandibular disorders (TMD), performing their IT and another 40 participants with TMD. For the selection of participants with and without TMD, the TMD Pain Screener questionnaire and axis I of the Diagnostic Criteria for Temporomandibular Disorders were applied. SQ was verified using the Pittsburgh Sleep Quality Index (PSQI) questionnaire. For the HP assessment the Pain Vigilance and Awareness Questionnaire (PVAQ) was applied. And the IT was performed through a FLIR infrared sensor camera, model T650 Infrared.

RESULTS

No significant correlations were found between SQ and the temperatures of the areas of interest (P > .05), and regarding HP, a statistically significant positive correlation was found with the dimensionless (ρ = 0.289) and non-dimensionless (ρ = 0.223) asymmetries of temporal muscle temperatures. In the temperature comparisons between the participants without TMD and the participants with TMD, significant differences were found (P < .05), also when the group without TMD was controlled according to both HP and SQ (P < .05), with higher temperatures found in the TMD group.

CONCLUSIONS

HP and SQ can be considered confounding variables in IT examination of the temporomandibular region.

Knowledge and awareness about temporomandibular disorder among dentists in India: Questionnaire study and review

AIM

Temporomandibular disorders (TMD) comprise ailments involving the jaw joint (temporomandibular joint) and its associated anatomical structures. The complexity involved in TMD is primarily due to its broad spectrum of conditions, clinical signs and symptoms variability, and multifactorial etiology. Considering the above, the present study was performed to help understand the prevailing knowledge and awareness of TMD among Indian dentists in the context of the new specialty "orofacial pain".

SETTINGS AND DESIGN

Questinnaire study and review.

MATERIALS AND METHODS

The questionnaire was distributed using a web-based portal nationwide among Indian dentists. Dentists were invited to participate, clearly stating that the intent and purpose of the questionnaire was to record the existing knowledge and awareness concerning temporomandibular disorders among Indian dentists. The questionnaire was segregated into three sections: pathogenesis, diagnosis, and management of TMDs. The questions were recorded using a Likert three-point scale (1=agree; 2=disagree; 3=not aware). 310 dentists participated in the survey, among which 105 were general dentists (BDS [Bachelor of Dental Surgery] graduates), and 205 were dentists with specialist training (MDS [Masters of Dental Surgery] graduates).

STATISTICAL ANALYSIS USED

The results obtained from the study participants was used to calculate the percentage and frequency, following which tabulations were made based on graduate type and clinical experience. The values obtained from all three sections were recorded, and the responses were analysed using Pearson's Chi-Square test with statistical significance kept at P < 0.05.

RESULTS

Results of the study disclosed that only 58.1% of general dentists and 46.8% of specialists were confident in handling temporomandibular disorder patients. Splint therapy was the preferred treatment modality for general dentists, whereas dentists with specialist training preferred occlusal rehabilitation.

CONCLUSION

The results of the current survey indicate that Indian dentists lack sufficient training in dental schools on all three sections and face difficulty diagnosing and treating TMDs.

Somatosensory and psychosocial profile of migraine patients: A cross-sectional study

BACKGROUND

Migraine is a chronic neurological disorder that involves the brain, characterized by a series of abnormal neuronal networks interacting at different levels of the central and peripheral nervous system. Furthermore, it is known that psychosocial features contribute to the exacerbation and chronicity of symptoms.

OBJECTIVE

To compare the somatosensory and psychosocial profiles of migraine patients with a control group.

METHODS

We conducted a cross-sectional study comparing the somatosensory and psychosocial profiles of patients with migraine and healthy volunteers. A total of 52 women were included. For the somatosensory profile, Mechanical Detection Threshold (MDT), Pressure Pain Threshold (PPT), Temporal Summation (TS), and Conditioned Pain Modulation (CPM) in the trigeminal and extra-trigeminal areas were evaluated. Psychosocial profiles were assessed using questionnaires, the Central Sensitization Inventory, the Generalized Anxiety Disorders, the Pain Catastrophizing Scale, and the Tampa Scale of Kinesiophobia. Mann-Whitney U test was used to compare differences in the profiles between groups. The significance level was set at 5%.

RESULTS

Migraine patients showed a loss of somatosensory function in the trigeminal area for MDT (p = 0.019, r = 0.34 and p = 0.011, r = 0.37 for the ophthalmic nerve and masseter muscle respectively), lower PPT in trigeminal and extra-trigeminal areas (p < 0.001, r=>0.60) and less efficient CPM (p < 0.001, r=>0.60). No statistically significant differences were found in the TS (p=>0.05). Statistically significant differences were found in all psychosocial variables (p = <0.001 r=>0.60).

CONCLUSION

Migraine patients showed loss of somatosensory function, lower pressure pain threshold, and an inhibitory pro-nociceptive profile with high scores on central sensitization and fear of movement compared to the control group.

Sex differences in descending control of nociception (DCN) responses after chronic orofacial pain induction in rats and the contribution of kappa opioid receptors

Descending control of nociception (DCN), a measure of efficiency of descending pain inhibition, can be assessed in animals by the combined application of test and conditioning noxious stimuli. Evidence from pre-clinical and clinical studies indicates that this mechanism of pain control may differ between sexes and might be impaired in many chronic pain states. However, little is known about sex differences in DCN efficiency in models of acute and chronic orofacial pain. Herein, we first evaluated DCN responses in male and female rats by the applying formalin into the upper lip or capsaicin into the forepaw as the conditioning stimulus, followed by mechanical stimulation (Randall-Selitto) of the hind paw as the test stimulus. The same protocol (i.e., capsaicin in the forepaw followed by mechanical stimulation of the hind paw) was evaluated in male and female rats on day 3 after intraoral incision and on day 15 and 30 after chronic constriction injury of the infraorbital nerve (CCI-ION). Additionally, we assessed the effect of the kappa opioid receptor (KOR) antagonist Norbinaltorphimine (nor-BNI) on DCN responses of female nerve-injured rats. This study shows that naïve female rats exhibit less efficient DCN compared to males. Postoperative pain did not alter DCN responses in female and male rats, but CCI-ION induced loss of DCN responses in females but not in males. Systemic pretreatment with nor-BNI prevented the loss of DCN induced by CCI-ION in female rats. The results reveal sex differences in DCN responses and female-specific impairment of DCN following chronic orofacial pain. Moreover, the findings suggest that, at least for females, blocking KOR could be a promising therapeutic approach to prevent maladaptive changes in chronic orofacial pain.

Botulinum toxin-A effects on pain, somatosensory and psychosocial features of patients with refractory masticatory myofascial pain: a randomized double-blind clinical trial

The antinociceptive effect of BoNT-A have been well documented in animal studies; however, results of few but well-designed randomized placebo-controlled clinical trials about BoNT-A efficacy in masticatory myofascial pain (MFP) are inconsistent. Therefore, the present randomized, double-blind, placebo-controlled clinical trial evaluated the efficacy of BoNT-A in patients with refractory MFP. Twenty-eight patients with pain reduction of less than 30% despite conservative treatment and with an average pain intensity of > 50 mm on the visual analogue scale (VAS) participated. Patients were randomly assigned to receive a total of 80 U of BoNT-A or saline solution (SS) injected into the masseter and anterior temporalis muscles. Pain intensity (VAS), quantitative sensory testing (QST), conditioned pain modulation (CPM), and psychosocial status were examined. Follow-up was performed at 1 and 6 months. For repeated-measure comparisons between evaluation times, Friedman test with Bonferroni correction was used for pain and somatosensory variables and the Wilcoxon test for the psychosocial variables. The Mann-Whitney test was used for all comparisons between groups. The BoNT-A group had a significant decrease in pain intensity at follow-ups compared with the SS group (p < 0.001). QST assessment revealed higher pressure pain threshold values in the masseter muscle for BoNT-A group compared to SS (p < 0.03) at all follow-ups. No differences were found for mechanical pain threshold and wind-up ratio values (p > 0.05) in the entire study. The BoNT-A group presented the most efficient CPM effect (p < 0.03) only at the 1 month follow-up in the masseter muscle. There was a significant time effect for BoNT-A in all psychosocial variables (p < 0.05) and a drug effect in the Central Sensitization Inventory (p < 0.01), Pittsburgh Sleep Quality Index (p < 0.004), and Healthy Survey 36 (p < 0.05) at 6 months follow-up. The study demonstrates that a single injection-session of BoNT-A has positive effects on the hall pain spectrum of patients with refractory masticatory myofascial pain.

The Relationship between Kinesiophobia, Emotional State, Functional State and Chronic Pain in Subjects with/without Temporomandibular Disorders

Although there is growing evidence that kinesiophobia is correlated with temporomandibular disorders (TMD), its relationship with other characteristic TMD comorbidities, such as depression, anxiety, functional limitations, and pain in the TMD population, has rarely been investigated. This study aims to evaluate the relationship between kinesiophobia, emotional state, functional state and chronic pain in subjects both with and without TMD. A total of 94 subjects participated in the study and were divided into two groups (47 subjects each)-TMD (subjects with temporomandibular disorders) and nTMD (asymptomatic controls)-on the basis of the RDC/TMD protocol. All measurements were taken with self-administered questionnaires: TSK-TMD for kinesiophobia, PHQ-9 and GAD-7 for psychoemotional state, JFLS-20 for jaw functional limitations, and GCPS for chronic pain. The prevalence of kinesiophobia in the TMD group was 38.3% for moderate risk, and 61.7% for high risk. The TMD group showed significantly higher scores in all categories (kinesiophobia, depression, jaw functional limitations and chronic pain), with the exception of anxiety which was right at the cut-off point. Moreover, a significant correlation was found between kinesiophobia (TSK-TMD) and jaw functional limitations (JFLS-20). Results of this study could provide new insight into the relationship between kinesiophobia and TMD, further improving the diagnosis process.

Individual Dimensions of Pain Catastrophizing Do Not Mediate the Effect of Sociodemographic and Psychological Factors on Chronic Orofacial Pain Severity, Interference, and Jaw Limitation: A Structural Equation Modeling Approach

Pain catastrophization (PC), involving rumination, magnification, and helplessness, can be viewed as a coping strategy associated with chronic pain. PC is considered a driving force in mediating pain-related outcomes, but it is still unclear whether PC mediates the relationship between psychological and sociodemographic factors with chronic pain when considered in a single model. Using baseline data from a parent study, this study examined the effect of positive and negative psychological and sociodemographic factors on pain severity, interference, and jaw limitation mediated by the PC dimensions in a sample of 397 temporomandibular disorder (TMD) participants using structural equation modeling (SEM). SEM revealed that pain severity regressed on age, sex, education, and income; interference regressed on positive and negative psychological factors, education, and income; and jaw limitation regressed on age. The PC dimensions did not individually mediate these relationships. Although they jointly mediated the relationships between negative psychological factors and pain severity and between age and pain interference, the effect size was small, suggesting that PC is not a critical factor in mediating TMD pain outcomes. Reducing negative cognitions, not just PC, may be of greatest benefit to the most vulnerable TMD populations. PERSPECTIVE: This study examines sociodemographic and psychological factors that affect orofacial pain, finding that the pain catastrophizing dimensions do not mediate these relationships. Understanding which factors most strongly affect pain outcomes will help identify targets for intervention to produce the greatest benefit for the most vulnerable persons suffering from pain.

Counselling treatment versus counselling associated with jaw exercises in patients with disc displacement with reduction-a single-blinded, randomized, controlled clinical trial

OBJECTIVE

To compare effectiveness of counselling program versus counselling program plus jaw exercises to reduce pain and click in patients with temporomandibular joint disc displacement with reduction (DDWR).

MATERIALS AND METHODS

Patients were divided into two groups: instructions for temporomandibular disorders (TMD) plus jaw exercises (test, n = 34), only TMD instructions (control, n = 34). Pain was analyzed by palpation (RDC/TMD). It was investigated if the click caused discomfort. Both groups were evaluated at baseline, 24 h, 7 days, and 30 days' post treatment.

RESULTS

The click was present in 85.7% (n = 60). In 30-day evaluation, there was a statistically significant difference between groups in the right median temporal muscle (p = 0.041); and there was a statistically significant difference in treatment self-perception (p = 0.002) and click's discomfort (p < 0.001).

CONCLUSION

The exercise with recommendations showed better results, resolution of the click, and self-perception of the treatment effectiveness.

CLINICAL RELEVANCE

This study presents therapeutic approaches that are easy to perform and that can be monitored remotely. In view of the current stage of the global pandemic, these treatment options become even more valid and useful.

CLINICAL TRIAL REGISTER

This clinical trial was registered at Brazilian Clinical Trials Registry (ReBec) under protocol RBR-7t6ycp ( http://www.ensaiosclinicos.gov.br/rg/RBR-7t6ycp/ ), Date of registration: 26/06/2020.

Comparison of the Efficacy of Two Protocol Treatments in Patients with Symptomatic Disc Displacement without Reduction: A Randomized Controlled Trial

The aim of this study was to compare the effectiveness of arthrocentesis followed by hyaluronic acid infiltration treatment (ASH) and mandibular exercise therapy (MET) in patients with symptomatic disc displacement without reduction (DDwoR) by examining pain intensity (VAS), mandibular range of motion (MO), and quality of life (QoL). Fifty-two patients were randomly allocated into two groups, MET (N = 26) and ASH (N = 26), and therapy was applied at the baseline and one month after. Patients were followed up at 1 and 12 months after the baseline assessment. Clinical and patient-reported outcomes were compared at the baseline, 1-month follow-up, and 12-month follow-up. The study found no significant differences in VAS and MO between the ASH and MET groups at the baseline. However, while not significant, it was noted that the ASH group showed higher values for MO. Regarding OHIP-14 at 1 month of follow-up, the ASH group showed significant improvements in physical pain (p > 0.01), physical and psychological disability (p = 0.043 and p = 0.029), and handicap (p = 0.033). At the 12-month follow-up, the ASH group showed significant improvements in functional limitation, psychological discomfort, psychological disability, and handicap (p = 0.008, p = 0.001, p = 0.001, p = 0.005, respectively). ASH treatment did not reduce pain or improve mandibular range of motion more than physical therapy in patients with symptomatic DDwoR. However, ASH could be preferable given its positive long-term effects on patients' quality of life. The clinician's main objective is to prioritize the treatment plan order with a focus on the patient's quality of life. Accordingly, healthcare professionals should consider ASH as a treatment option for patients with symptomatic DDwoR who desire long-term improvement in their quality of life.

Focus Groups to Inform the Development of a Patient-Reported Outcome Measure (PROM) for Temporomandibular Joint Disorders (TMDs)

BACKGROUND

Understanding symptoms of temporomandibular joint disorders (TMDs) can help doctors and patients document, monitor, and manage the disease and help researchers evaluate interventions. Patients with TMDs experience symptoms ranging from mild to severe, primarily in the head and neck region. This study describes findings from formative patient focus groups to capture, categorize, and prioritize symptoms of TMDs towards the development of a patient-reported outcome measure (PROM).

METHODS

We conducted ten focus groups with 40 men and women with mild, moderate, and severe TMD. Focus groups elicited descriptions of symptoms and asked participants to review a list of existing patient-reported outcomes (PROs) from the literature and patient advisor input and speak to how those PROs reflect their own experience, including rating their importance.

RESULTS

We identified 52 distinct concepts across six domains: somatic, physical, social, sexual, affective, and sleep. Focus groups identified the ability to chew and eat; clicking, popping, and other jaw noises; jaw pain and headaches; jaw misalignment or dislocation; grinding, clenching, or chewing, including at night; and ear sensations as most important. Participants with severe TMDs more often reported affective concepts like depression and shame than did participants with mild or moderate TMDs.

CONCLUSION

Findings support PROM item development for TMDs, including selecting existing PROMs or developing new ones that reflect patients' lived experiences, priorities, and preferred terminology. Such measures are needed to increase understanding of TMDs, promote accurate diagnosis and effective treatment, and help advance research on TMDs.

Is there any association between sleep disorder and temporomandibular joint dysfunction in adults? - A systematic review

OBJECTIVE

To answer the question, "Is there any association between sleep disorder and temporomandibular joint dysfunction (TMD) in adults?"

METHODS

This study followed PRISMA guidelines and was registered in PROSPERO. As eligibility criteria, observational studies that evaluated the association between sleep disorder and TMD were included. Exclusion criteria included a) studies that evaluated sleep quality and not the association of sleep disorders with TMD, b) experimental studies, book chapters, conference proceedings, and systematic reviews. The Joanna Briggs Institute tool was used to assess the risk of bias.

RESULTS

In the literature search, 3425 articles were found. After the exclusion of duplicates, 2752 were selected for reading the title and abstract, of which 26 were read in full, and 18 met eligibility criteria.

CONCLUSION

The association of sleep bruxism with TMD is controversial. While, for obstructive sleep apnea, insomnia, snoring, and gastroesophageal reflux, the analyzed studies showed a positive association.

Prevalência de cinesiofobia e catastrofização em pacientes com disfunção temporomandibular

RESUMO Objetivo: identificar a frequência e os níveis de cinesiofobia e catastrofização em pacientes com Disfunção Temporomandibular que realizaram terapia fonoaudiológica. Métodos: a amostra compreendeu pacientes com Disfunção Temporomandibular muscular e mista com predominância muscular, grupo de estudo e adultos saudáveis, o grupo controle. Os instrumentos utilizados foram: Diagnostic Criteria for Temporomandibular Disorders, Escala Tampa para Cinesiofobia e Escala de Catastrofização da Dor. A análise estatística foi composta do Teste de Mann-Whitney para comparar as médias entre os grupos de cada escala e o teste de Coeficiente de Correlação de Spearman para analisar a correlação entre as escalas em cada grupo e sua significância. Resultados: foi identificado um alto índice de catastrofização da dor no grupo de estudo em comparação ao grupo controle. Quanto à cinesiofobia, houve maior índice positivo para essa variável no grupo de estudo e menor para o grupo controle. Além disso, identificou-se correlação moderada e positiva entre a cinesiofobia e catastrofização no grupo de estudo. Conclusão: Pacientes com Disfunção Temporomandibular possuem níveis de cinesiofobia e catastrofização mais altos que pacientes que não foram diagnosticados com o distúrbio.

Prevalence of kinesiophobia and catastrophizing in patients with temporomandibular disorders

ABSTRACT Purpose: to identify the frequency and levels of kinesiophobia and catastrophizing in patients with temporomandibular disorders who had been submitted to speech-language-hearing therapy. Methods: the sample comprised patients with myogenous (predominantly) and mixed temporomandibular disorders in the study group and healthy individuals in the control group. The instruments used were the Diagnostic Criteria for Temporomandibular Disorders, Tampa Scale for Kinesiophobia, and Pain Catastrophizing Scale. Statistical analyses were performed with the Mann-Whitney test (to compare the means on each scale between the groups) and the Spearman’s correlation coefficient test (to analyze the correlation between the scales in each group and its significance). Results: the study group had a higher pain catastrophizing index than the control group. Likewise, the study group had greater kinesiophobia positive indices, whereas the control group had lower ones. A moderate positive correlation was also identified between kinesiophobia and catastrophizing in the study group. Conclusion: patients presented with temporomandibular disorders have higher levels of kinesiophobia and catastrophizing than subjects not diagnosed with the disorder.

Oral behaviors, bruxism, malocclusion and painful temporomandibular joint clicking: is there an association?

The present cross-sectional case-control study aimed to determine if there is an association between specific oral behaviors, sleep bruxism (SB), awake bruxism (AB), and painful temporomandibular joint (TMJ) clicking. Ninety individuals were dived into three groups; Group 1 (n = 30): painful TMJ clicking; Group 2 (n = 30): painless TMJ clicking; and Group 3 (n = 30): control group. The following clinical data were studied: oral behaviors (unilateral chewing, gum chewing, nail biting, foreign objects biting, leaning with jaw against the hand, and sleeping in a position that pressures the jaw), SB, AB (including the frequency in 10 days, evaluated by ecological momentary assessment), and malocclusions investigated based on clinical inspections (anterior open bite, posterior cross-bite, abnormal overbite/overjet, occlusal guidance, mediotrusive and/or laterotrusive interferences, retruded contact position to maximum intercuspation slide, missing posterior teeth). All statistical tests (Kolmogorov-Smirnov, chi-square, and one-way ANOVA) were performed with a 5% significance level. Group 1 had the highest frequency of and a significant association with leaning with jaw in the hand, sleeping position that pressures the jaw, gum chewing, nail biting, and AB (p<0.05). Gum chewing, nail biting, and AB were associated with Group 2 only when compared to Group 3 (p<0.05). No significant difference among groups was found for other behaviors (unilateral chewing and foreign objects biting), SB, and all malocclusions (p>0.05). It can be concluded that patients with painful TMJ clicking had a higher frequency of and a significant association with some specific harmful behaviors and AB.

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.