Time-course of pain and salivary opiorphin release in response to oral capsaicin differ in burning mouth syndrome patients, temporomandibular disorders patients and control subjects

OBJECTIVES

Opiorphin is an analgesic peptide released by salivary glands and capsaicin an agonist of TRPV1 receptors eliciting burning sensations. The primary objective of this study was to assess opiorphin release after stimulation of the tongue by capsaicin (STC). The secondary objectives were to compare opiorphin release after STC in 3 groups of subjects [healthy (CTRL), Burning Mouth Syndrome (BMS), painful Temporomandibular disorders (TMDp)] and pain evoked by STC in these 3 groups.

MATERIALS AND METHODS

Salivary opiorphin was assessed with high-performance liquid chromatography at 3 different time points (baseline, after 5 min and 20 min of STC). Pain was self-reported on a (0-10) numeric rating scale.

RESULTS

Three groups (N = 16) of adults were recruited at the Clinical Hospital Centre and School of Dental Medicine in Zagreb. Opiorphin levels were higher (1) in TMDp compared to CTRL in 1st (2.23 ± 1.72 pg/ul vs. 0.67 ± 0.44 pg/ul, p = 0.002) and 3rd sampling (2.44 ± 2.01 pg/ul vs. 0.74 ± 0.52 pg/ul, p = 0.020) and (2) within BMS group at 3rd sampling vs. baseline (p < 0.025). Pain scores were higher in BMS compared to TMDp (p < 0.025) and CTRL (p < 0.025).

CONCLUSION

This study evidenced (1) a differential basal amount of opiorphin in two pain conditions and control subjects (2) a differential kinetic of release of opiorphin after STC in CTRL, BMS and TMDp (3) a differential pain perception after STC in BMS and TMDp vs. CTRL, which can provide a readout for animal models.

CLINICAL RELEVANCE

The specific regulation of opiorphin release in patients with orofacial painful conditions provides valuable insights for clinicians and researchers in physiology and pathology and encourages further research in this area.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04694274. Registered on 01/05/2021.

Association of oral behaviours and psychological factors with selected genotypes in pain-related TMD

OBJECTIVES

To investigate frequency of single nucleotide polymorphisms (SNPs) in pain-related temporomandibular disorders (TMDp) and to determine whether specific SNPs, psychological, psychosomatic and behavioural characteristics are predictive for pain existence and intensity (low pain intensity (LPI)/high pain intensity (HPI)).

METHODS

Genomic DNA was extracted from buccal mucosa swabs (85 TMDp;85 controls) for evaluating frequency of selected SNPs: catechol-O-methyltransferase (rs4680, rs4818), opiorphin (rs1387964), alpha subunit of voltage-gated sodium channel Nav1.1 (rs6432860) and voltage-gated sodium channel Nav1.9 (rs33985936). Participants completed questionnaires on somatosensory amplification, anxiety and depression symptoms and oral behaviours (OB).

RESULTS

Sleep-related OB frequency was higher in TMDp patients compared to controls (p = 0.008). Compared to LPI, HPI patients had higher depression (p = 0.020) and anxiety scores (p = 0.017). TMDp group showed higher frequency of CC genotype (rs1387964) than controls (12.9% vs. 3.5%, p = 0.025). Following adjustments for age, sex and sleep-related OB, the significance of the recessive model (CC vs. TC + TT) between TMDp patients and controls was retained (OR = 5.783; 95%CI: 1.454-23.004). Frequency of GG genotype (rs4680 and rs4818) was higher in HPI compared to LPI patients (40% vs. 11.4%, p = 0.006; 24% vs. 3%; p = 0.012, respectively). The difference remained significant after adjusting for age, sex, depression, anxiety and sleep-related OB (rs4680: OR = 3.621; 95%CI: 1.580-8.297; rs4818: OR = 4.919, 95%CI: 1.641-14.746).

CONCLUSION

This study has demonstrated that rs1387964 CC genotype was associated with TMDp while rs4680 GG and rs4818 GG genotypes contributed to HPI.

Opiorphin as a biomarker of orofacial conditions: a meta-analysis

The aim of this meta-analysis was to answer the following question: "Are there any differences in opiorphin biomarker concentrations between different orofacial conditions and controls?". Two reviewers searched for observational studies that evaluated the levels of opiorphin in orofacial conditions, annotated in seven main databases and three that compile gray literature. Of the 443 articles obtained initially, 8 met the inclusion criteria for quantitative analyses. Relative percentages showed a mean 24.1% higher opiorphin concentration in chronic conditions (Burning Mouth Syndrome, Oral Potentially Malignant Diseases and Temporomandibular Disorder) compared to controls; 33.2% higher opiorphin in sustained pain (Symptomatic Irreversible Pulpitis, Symptomatic Apical Periodontitis, Painful Oral Soft-tissue conditions); and 21.7% higher opiorphin after stimuli (Corneal Foreign Body, Capsaicin). Meta-analysis revealed a standardized mean difference of 0.62 [0.02, 1.22] in the absolute concentration of opiorphin in saliva for the chronic group compared to the control. The analogous values for the sustained group and the stimulated group were 2.24 [0.34, 4.14] and 0.43 [0.00, 0.85], respectively. No differences in opiorphin levels were found for 'after Local Anesthesia before Tooth Extraction' or for apicoectomy. Based on the available evidence, in general, a statistically higher level of opiorphin is found in orofacial conditions. Salivary opiorphin levels are elevated in chronic, persisted and acute pain conditions, presumably reflecting a physiological homeostatic adaptative response to different conditions such as stress or pain. Salivary opiorphin might therefore be used as a valuable biomarker in several oral disorders.

Association of Oxidative-Stress-Related Gene Polymorphisms with Pain-Related Temporomandibular Disorders and Oral Behavioural Habits

The frequency of selected polymorphisms, one in each gene coding for proteins with antioxidative properties (CAT(rs1001179), SOD2(rs4880), GPX1(rs1050450), and NQO1(rs689452)), was compared between patients suffering from pain-related temporomandibular disorders (TMDp; n = 85) and control subjects (CTR; n = 85). The same was evaluated when participants were divided with respect to oral behavioural habits frequency into high-frequency parafunction (HFP; n = 98) and low-frequency parafunction (LFP; n = 72) groups. Another aim was to investigate whether polymorphisms in these genes can be associated with participants' psychological and psychosomatic characteristics. Polymorphisms were genotyped using the genomic DNA extracted from buccal mucosa swabs and real-time TaqMan genotyping assays. No differences in genotype distribution between TMDp patients and control subjects were found. Still, TMDp patients who were homozygous for minor allele A, related to the GPX1 polymorphism rs1050450, reported significantly more waking-state oral behaviours than GA + GG genotype carriers (score: 30 vs. 23, p = 0.019). The frequency of genotype AA for rs1050450 polymorphism was higher in HFP than in LFP participants (14.3% vs. 4.2%, p  = 0.030). The most important predictors of waking-state oral behaviours were depression, anxiety, AA genotype (rs1050450), and female sex. The explored gene polymorphisms were not found to be significant risk factors for either TMDp or sleep-related oral behaviours. The association of waking-state oral behaviours with selected gene polymorphisms additionally supports previous assumptions that daytime bruxism is more closely linked to various stress manifestations, which might also be reflected through the variability related to the cellular antioxidative activity.

Sudden, Severe, Idiopathic Occlusal Relationship Change Coexisting with Pain-Related Temporomandibular Disorders: A Case Report

The article presents a case of a young female patient who sought help due to myofascial pain followed by a sudden occlusal change (anterior open bite (AOB)) that occurred shortly after the administration of a soft night guard that had been previously provided by a general dentist. Palpation of the masseter and temporal muscles elicited the presence of familiar pain. After magnetic resonance imaging of temporomandibular joints, which ruled out disc displacement, the final diagnosis was myalgia. Since the patient had myalgia and malocclusion, the therapy included treatment of both conditions. Temporomandibular disorders (TMDs) management included a combination of kinesiotherapy, pharmacotherapy, and a stabilization splint. After TMD symptoms had resolved, the patient underwent an orthodontic evaluation. Cephalometric analysis revealed skeletal class II, retrognathic face, convex profile, and normal vertical growth pattern. Orthodontic treatment included a fixed appliance with vertical intermaxillary elastics. After 19 months of treatment, both sides achieved acceptable occlusion with Class I. Since the patient had myalgia and severe malocclusion, it was important to follow a systematic diagnostic and therapeutic workflow. Although it is impossible to establish a relationship between TMD symptoms and orthodontic therapy, patients who have TMD symptoms should have their pain resolved through a conservative treatment protocol before commencement of orthodontic treatment. The beginning of orthodontic therapy comes into consideration only when the TMD pain resolves.

Association of oral behaviours' frequency with psychological profile, somatosensory amplification, presence of pain and self-reported pain intensity

OBJECTIVE

To investigate the association of the frequency of oral behaviours with psychological (anxiety, depression) and psychosomatic factors (somatosensory amplification) as well as with pain presence (Temporomandibular disorders-pain (TMDp) patients and control (CTR) participants) and pain intensity (no_low pain intensity (nLPI)/high pain intensity (HPI)).

MATERIAL AND METHODS

Fifty-four TMDp patients (48 females and 6 males; 29.13 ± 10.46 years) and 46 controls (29 females and 17 males; 28.54 ± 9.71 years) were administered Oral Behaviours Checklist (OBC), Generalized Anxiety Disorder-7 Scale, Patient Health Questionnaire-9 for depression and Somatosensory Amplification Scale. Data were analysed with respect to the presence of TMD pain and to pain intensity. Mann-Whitney test and Spearman's rank correlation were used for analyses.

RESULTS

No significant differences in examined variables between TMDp patients and CTR individuals were found. The frequency of oral behaviors (OBC total score and sleep-related oral behaviours) as well as anxiety, depression and somatosensory amplification scores were higher in HPI group when compared to nLPI group (p < .05). In univariate correlations, oral behaviours were positively correlated with somatosensory amplification (p = .001), anxiety (p < .05), depression (p < .05), female sex (p < .05) and pain intensity (p < .05) but not with pain presence. Multiple linear regression models showed that predictors for the higher frequency of oral behaviours were anxiety and female sex.

CONCLUSIONS

Oral behaviours were associated with pain intensity but not with pain presence and were primarily influenced by anxiety and female sex, suggesting that therapeutic approach should consider both, reducing pain intensity and management of the impact of psychological factors.Trial registration: ClinicalTrials.gov NCT04694274. Registered on 01/04/2021.

Profiling of Patients with Temporomandibular Disorders: Experience of One Tertiary Care Center

Objectives

The aim of this study was to assess typical and most prevalent characteristics of patients suffering from temporomandibular disorders (TMD) by a retrospective assessment of their medical records.

Material and Methods

Demographic data and data on the characteristics of TMD were collected from the existing medical documentation of 304 TMD patients (250 females and 54 males) who had been referred to the Department of Dentistry, Clinical Hospital Center Zagreb from October 2016 to October 2020 due to temporomandibular pain. For the purpose of analysis, three age groups were formed: i) "children and adolescents" (up to 19 years of age); ii) "middle age" (from 20 to 50 years of age); iii) "older age" (>50 year- olds). A two-step cluster analysis was performed with the aim of classifying TMD patients into homogenous groups.

Results

The mean age of patients whose data were included in the study was 33.8 ± 16.66, with a significantly higher age in the group of women (p<0.001). Most of the patients had chronic pain (67.4%), with the ratio in favor of chronic patients being significantly higher in women than in men (p=0.001). Data on parafunctional behavior were confirmed in 14.5% of patients. Data on the onset of symptoms during/just after orthodontic treatment were present in 14.5% of patients. Data on spontaneous pain, assessed with a visual analogue scale, were recorded in 87 patients, with a mean of 6.14 ± 1.79 and with the highest pain in the "older age" group. Physical therapy was the most common therapeutic modality (56.3%) followed by an occlusal splint (40.5%). The analysis revealed 5 different clusters in the TMD patient data set.

Conclusions

Our results are largely in line with current epidemiological knowledge on TMD. Women predominated in all age groups and most of the patients experienced chronic pain. Classifying patients into homogeneous groups using the clustering method could provide better identification of subgroups of conditions that mainly occur together in these patients, thus providing the basis for more specific management.

Treatment responses in chronic temporomandibular patients depending on the treatment modalities and frequency of parafunctional behaviour

OBJECTIVES

(i) To evaluate the effect of three different interventions on treatment outcomes and (ii) to determine how the frequency of oral parafunction influences the effectiveness of the different therapeutic modalities.

METHODS

Forty-five participants were randomly assigned into three treatment groups [physical therapy (PT), stabilisation splint (SS) and control therapy (CT)]. According to Oral Behavior Checklist score, participants were divided into "high-frequency parafunction" (HFP) and low-frequency parafunction" (LFP) group. Primary (spontaneous pain and characteristic pain intensity) and secondary outcomes (range of mouth opening, anxiety symptoms, quality of life, perceived stress and global functional limitation) were evaluated during six-month treatment period.

RESULTS

Participants in PT group showed a significant reduction in characteristic pain intensity (p = .047, η²  = 0.243) when compared to SS and CT group, but significant improvement in spontaneous pain was found in all treatment groups. Patients treated with PT and SS exhibited significantly stronger improvement in pain-free mouth opening than patients in CT group (3rd month: p=.037, η2=0.258; 6th month: p = .005, η²  = 0.383). Within-group analyses showed significant decrease of perceived stress, anxiety symptoms and global functional limitation only in PT group over a six-month treatment period. Participants with HFP presented significantly greater levels of anxiety (3rd month: p = .009, η²  = 0.275; 6th month: p = .041, η²  = 0.176) than participants with LFP. Within-group analyses, however, showed significant improvement of anxiety, but also the decrease of perceived stress and improvement of global limitation for the HFP group but not for the LFP group.

CONCLUSION

Although no treatment can be marked as superior in terms of spontaneous pain relief, PT was more effective when observing relief of characteristic pain intensity. In HFP group the reduction of anxiety, stress and functional limitation was present regardless of the applied therapy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04694274. Registered on 01/04/2021.

Topical NAVS naphthalan for the treatment of oral lichen planus and recurrent aphthous stomatitis: A double blind, randomized, parallel group study

AIM

To evaluate the effectiveness of non-aromatic very rich in steranes (NAVS) naphthalan in the treatment of oral lichen planus (OLP) and recurrent aphthous stomatitis (RAS). Null hypothesis was that there would be no difference between NAVS and topical steroids in the treatment of OLP and RAS.

METHODS

The study consisted of two sub-trials conducted as randomized, double-blind controlled studies: first included OLP patients and second patients with RAS. Patients received either NAVS or 0.05% betamethasone dipropionate. Primary outcomes were activity score (OLP patients), No of lesions and lesion diameter (RAS patients) and pain intensity (VAS) while secondary outcome included the impact of the disease on quality of life assessed by Oral health impact profile (OHIP 14).

RESULTS

No significant differences in terms of OLP clinical signs (p = 0.84, η2 = 0.001) and responses on the OHIP-14 (p = 0.81, η2 = 0.002) or on VAS (p = 0.14, η2 = 0.079) between NAVS and betamethasone groups were observed. In RAS patients, no significant differences between the groups in terms of lesion number (at days 3 and 5, p = 0.33 and p = 0.98, respectively), lesion diameter (days 3 and 5, p = 0.24 and p = 0.84, respectively) were observed. However, in NAVS group a significant reduction of lesions diameter was observed on the 3rd day, while in betamethasone group a significant reduction in lesions diameter was evident only after the 5th day. No significant differences in VAS (p > 0.05) and the OHIP-14 (p > 0.05) between groups were found.

CONCLUSION

No evidence of differences between the two compared interventions was found.

REGISTRATION

Retrospective registration of this trial was conducted in ClinicalTrials.gov on September 30, 2016; trial registration number: NCT02920658. https://clinicaltrials.gov/ct2/show/NCT02920658?term=NAVS&draw=2&rank=4.

COVID-19 pandemic and Zagreb earthquakes as stressors in patients with temporomandibular disorders

OBJECTIVE

To evaluate stress effect of COVID-19 pandemic and Zagreb earthquakes on symptoms of temporomandibular disorders (TMD).

MATERIALS AND METHODS

One hundred and two previously diagnosed TMD patients were contacted by email to participate in an online survey about impact of those events on current and/or new symptoms, perceived stress, anxiety and symptom intensity in time-points at the baseline, following pandemic and following earthquake. We compared data between earthquake-affected and non-affected respondents.

RESULTS

Response rate was 79.4%. Effects stress had on deterioration of symptoms were significantly different between earthquake-affected and non-affected (p = .024). In earthquake-affected, numerical pain rating scale (NPRS) scores significantly increased between baseline and after COVID-19 (p > .001) and between baseline and after earthquakes (p > .05). However, scores insignificantly dropped from COVID-19 to after earthquakes time-points. In earthquake-affected, positive correlation was found between impact of COVID-19 on stress and NPRS (p < .001) and between earthquakes' impact on stress and NPRS (p < .001). Earthquake-affected respondents reported significantly more new behavioral habits when compared to non-affected (p = .048).

CONCLUSIONS

A series of stressful events do not necessarily have a cumulative effect, but are likely to have a complex interaction (e.g., acute stress might trigger the protective mechanisms), which could have decreased pain scores after the earthquakes.

Long-term Effectiveness of Occlusal Splint Therapy Compared to Placebo in Patients with Chronic Temporomandibular Disorders

Purpose

The aim of this study was to compare long-term effectiveness of stabilization splint (SS) with that of placebo splint (PS) in chronic TMD patients and to investigate differences in treatment outcomes based on diagnostic subgroups [disc displacement (DD)/myofascial pain (MP)].

Materials and Methods

Thirty-four female participants, diagnosed with chronic TMD, were classified in groups: one provided with SS and other with PS and were followed for six months. Treatment outcomes included spontaneous pain [visual analogue scale (VAS)], self-perceived quality of life (OHIP-14), pain-free maximal mouth opening (MCO), maximal mouth opening (MMO), level of perceived stress (PSS), characteristic pain intensity [graded chronic pain scale (GCPS)], and functional jaw limitation [jaw functional limitation scale (JFLS)].

Results

Baseline characteristics did not differ significantly between the two groups (p>0.05). After six months of treatment the changes in spontaneous pain and OHIP-14 scores differed significantly between treatment groups (p=0.004, p=0.02 respectively), with greater reduction in SS compared to the PS group. Pain-free maximal mouth opening did not change significantly over time, however MCO values differed significantly between the two treatment groups, with greater overall values in the SS compared to the PS group (p= 0.046), as well as between TMD subgroups, with greater overall values in MP compared to DD patients (p= 0.03). In the SS group, significant difference in JFLS categories was found between baseline and after 6 months of treatment in all except emotional and verbal expression (mastication p=0.00015; vertical jaw mobility p=0.00018). No such changes in JFLS categories were observed in the PS group.

Conclusions

During 6-month period, SS was more effective than PS in reducing spontaneous pain and improving self-perceived quality of life and functional limitations of the lower jaw. Moreover, significantely higher values of pain-free mouth opening were observed in patients treated with stabilization splint. While placebo might be partly responsible for improving the symptoms of TMD, it seems that itcannot maintain a continual long-term positive therapeutic effect.

Changes in salivary oxidative status, salivary cortisol, and clinical symptoms in female patients with temporomandibular disorders during occlusal splint therapy: a 3-month follow up

Background

Differences in the expression of oxidative stress (OS) markers between female patients with temporomandibular disorders (TMD) and healthy individuals indicate that OS plays a role in the pathogenesis of TMD. Because chronic exposure to stress generates oxidative damage during continuous stimulation of the hypothalamic-pituitary-adrenal axis, we expected that higher levels of cortisol might be associated with higher oxidative damage. Our aim was to test the association between OS markers, stress perception, and salivary cortisol (SC) in chronic, female TMD patients. We tracked changes in OS markers and SC during occlusal splint therapy in order to evaluate the influence of treatment on oxidative status. We hypothesized that the effects of TMD therapy would differ among individuals depending on the source and intensity of pain.

Methods

Sixteen female patients were recruited, and 12 finished the study. Clinical assessment and saliva sampling were performed at the baseline and follow-up appointments. Repeated measures analysis of variance and Pearson’s correlation were used for analyzing the data.

Results

After 3 months, a significant reduction in afternoon total antioxidant capacity (TAC) was observed (p < 0.05). A significant reduction in afternoon malondialdehyde (MDA) (p = 0.021) and a decrease in afternoon MDA to superoxide dismutase ratios (p = 0.017) were present in high-intensity pain patients. At baseline, higher levels of perceived stress were significantly associated with higher morning cortisol (ρ = 0.67). At the end of the therapy,  reduced  perceived stress was positively correlated with morning SC changes when considering all TMD patients, but the association between perceived stress with OS markers was present only in myofascial pain (MP) group. The effect of treatment on the self-perceived quality of life was more pronounced in female MP patients while the reduction of spontaneous pain was significantly greater in high-intensity pain patients.

Conclusion

Our data indicate that occlusal splint therapy in female TMD patients contributes to increasing their capacity to remove free radicals. The question remains whether or not TAC decreases in this process as a result of avoiding unnecessary processes, once the increase in antioxidants effectively compensates for OS. The intensity and the source of pain should be considered important factors in future investigations evaluating salivary OS markers and their association with perceived stress and SC in TMD patients.

Trial registration

ClinicalTrials.gov NCT03029494. Registered on 2017-01-19.

Salivary Oxidant/Antioxidant Status in Chronic Temporomandibular Disorders Is Dependent on Source and Intensity of Pain - A Pilot Study

Temporomandibular disorders (TMD) have been associated with altered salivary oxidative status, but the relation with pain source and pain severity isn't clarified. With the aim to assess their interaction with TMD, we compared levels of selected salivary oxidative stress (OS) markers (glutathione peroxidase, superoxide dismutase, total antioxidant capacity (TAC), uric acid, 8-hydroxydeoxyguanosine, malondialdehyde) and salivary cortisol (SC) as a stress indicator, between 20 TMD patients and 15 healthy control subjects. In order to record differences relating to pain source and severity, patients were respectively classified according to specific diagnoses (myofascial pain or disc displacement (DD)), and pain intensity (high or low). TAC was significantly higher in TMD patients than in controls (morning p = 0.015; afternoon p = 0.005). Significant differences were also observed when TAC levels between high-intensity pain patients and controls were compared, as well as between DD patients and controls. In logistic regression analysis, higher levels of TAC were related to DD (morning OR: 1.66, 95%CI: 1.05-2.64, p = 0.029; afternoon OR: 2.10, 95%CI: 1.11-3.98, p = 0.021) and to high-intensity pain (morning OR: 1.81, 95%CI: 1.04-3.15, p = 0.037; afternoon OR: 1.79, 95%CI: 1.02-3.14, p = 0.043). We also found that morning SC was positively correlated with antioxidant parameters in TMD patients. Our data suggest compensatory mechanism as response to higher level of stress. This stress could be extrinsic and lead toward TMD, or intrinsic, emerging from established TMD, or could be both. The intensity and the source of pain should be considered important factors in future investigations evaluating salivary OS markers in TMD patients.

Comparison of amitriptyline with stabilization splint and placebo in chronic TMD patients: a pilot study

Objective of work

The authors conducted a clinical study to evaluate the effectiveness of amitriptyline in treatment of chronic TMD patients and to compare treatment results with stabilization splint.

Materials and Methods

Twenty-one patients with chronic TMD were included and randomly distributed into 3 groups: patients in Group A received amitriptyline, patients in Group B received placebo, and those in Group C were treated with stabilization splint. Treatment outcomes (pain assessed by a visual analogue scale (VAS), maximal comfortable mouth opening (MCO) and oral health related quality of life (OHIP-14)) were taken at baseline (before treatment), and at 1^st, 6^th and 12^th week of treatment.

Results

No statistically significant differences between the groups at baseline were found (p>0.05). VAS scores improved significantly in Group A (F=11.326, p=0.002, effect size =0.791) and in group C (F=7.343, p=0.005, effect size=0.647). Mean OHIP-14 scores decreased significantly only in Group A (F=4.417, p=0.036, effect size =0.596). In Group B, VAS and OHIP-14 scores did not change significantly over time. Subjects in Group C had a significant change in MCO relative to Group A and Group B.

Conclusion

From this pilot study it can be concluded that the use of low doses of amitriptyline for a period of 12 weeks is effective for pain management and quality of life improvement in chronic TMD patients. Stabilization splint demonstrated superiority in the management of limited mouth opening during the same period.

A Young Patient with Temporomandibular Joint Osteoarthritis: Case Report

This paper describes a case of a young patient who sought help because of pain in the right temporomandibular joint (TMJ). She also reported increasing of pain during chewing. Clinical examination revealed limited mouth opening with uncorrected deviation to the ipsilateral side. Palpation of the lateral pole of the right condyle discovered crepitus, and maximum assisted opening elicited a report of "familiar pain". The diagnosis of osteoarthritis of the TMJ (RDC / TMD criteria, Axis I, Group III) was confirmed by CBCT of TMJ. There is no "gold standard" for the management of TMD, but the need for TMD treatment has to be based on precise indications related to the presence of pain, limitation in function of the lower jaw and signs of degenerative joint disease. Conservative, reversible therapeutic procedures are considered as the first choice for TMD treatment and their task is to improve the function of the entire masticatory system. In this case patient was treated with the combination of physical therapy and stabilization splint, in order to reduce the pain and restore the normal function of the lower jaw. At 6 months’ follow-up symptoms have almost completely disappeared, while 3 years later, the patient still has no significant subjective symptoms. In the present case non-invasive therapy was sufficient to bring, otherwise recurrent nature of osteoarthritis, in complete remission and keep it like that for years.

Mandibular Range of Movement and Pain Intensity in Patients with Anterior Disc Displacement without Reduction

OBJECTIVE

Temporomandibular disorders (TMD) are the most common source of orofacial pain of a non-dental origin. The study was performed to investigate the therapeutic effect of the conventional occlusal splint therapy and the physical therapy. The hypothesis tested was that the simultaneous use of occlusal splint and physical therapy is an effective method for treatment of anterior disc displacement without reduction.

MATERIALS AND METHODS

Twelve patients (mean age =30.5 y) with anterior disc displacement without reduction (according to RDC/TMD and confirmed by magnetic resonance imaging) were randomly allocated into 2 groups: 6 received stabilization splint (SS) and 6 received both physical therapy and stabilization splint (SS&PT). Treatment outcomes included pain-free opening (MCO), maximum assisted opening (MAO), path of mouth opening and pain as reported on visual analogue scale (VAS).

RESULTS

At baseline of treatment there were no significant differences among the groups for VAS scores, as well as for the range of mandibular movement. VAS scores improved significantly over time for the SS&PT group (F=28.964, p=0.0001, effect size =0.853) and SS group (F=8.794, p=0.001, effect size =0.638). The range of mouth opening improved significantly only in the SS&PT group (MCO: F=20.971, p=0.006; MAO: F=24.014, p=0.004) (Figure 2). Changes in path of mouth opening differ significantly between the groups (p=0.040). Only 1 patient in SS&PT group still presented deviations in mouth opening after completed therapy while in the SS group deviations were present in 5 patients after completed therapy.

CONCLUSION

This limited study gave evidence that during the treatment period lasting for 6 months, the simultaneous use of stabilization splint and physical therapy was more efficient in reducing deviations and improving range of mouth opening than the stabilization splint used alone. Both treatment options were efficient in reducing pain in patients with anterior disc displacement without reduction. Despite of objectively diagnosed disruption of temporomandibular joint anatomy, physiological function was regained.

Changes in pain intensity and oral health-related quality of life in patients with temporomandibular disorders during stabilization splint therapy--a pilot study

The aim of the study was to evaluate changes in pain intensity and self-perceived quality of life in patients with temporomandibular disorders (TMD) during stabilization splint therapy. The hypothesis was that the clinical subtype of TMD, depending on whether pain is of muscular or temporomandibular joint origin, and pain chronicity (acute vs. chronic pain) differently affect treatment response. Thirty patients were included and treated with a stabilization splint in a 6-month clinical trial. Treatment outcomes included pain-free maximal mouth opening (MO), assisted maximal MO, path of MO, asymmetry in lateral excursions, spontaneous pain intensity (visual analog scale, VAS), and self-perceived quality of life (Oral Health Impact Profile, OHIP-14). Overall, VAS and OHIP-14 scores changed significantly over time (VAS: F = 80.85, p < 0.001; OHIP-14: F = 34.78, p < 0.001). After 6 months, changes in pain intensity did not differ significantly between myofascial pain (MP) and disc displacement (DD) groups (F = 0.497, p = 0.685, effect size = 0.018), or between acute pain (AP) and chronic pain (CP) patients (F = 1.856, p = 0.144, effect size = 0.064). Changes in self-perceived quality of life did not differ significantly between MP and DD groups (F = 0.213, p = 0.847, effect size = 0.008), or between AP and CP patients (F = 0.816, p = 0.489, effect size = 0.029). Linear regression analysis was used to assess the contribution of each predictor variable to the explanation of the OHIP summary score variance. Results showed pain reduction (coefficient = 0.303; 95% CI: 0.120 to 0.485) and MO increase (coefficient = 0.149; 95% CI: 0.037 to 0.260) to be independent predictors of the OHIP-14 summary score changes (R2 = 0.453), whereas other variables did not affect treatment outcome as assessed by OHIP-14. In conclusion, during 6-month stabilization splint therapy, significant changes in VAS and OHIP-14 summary scores were found. However, there were no significant differences in improvement rates between subjects with acute and chronic pain. Furthermore, no significant differences in improvement rates were found depending on whether pain was of muscular or temporomandibular joint origin.

Prevalence of torus palatinus and torus mandibularis in the Split-Dalmatian County, Croatia

Torus palatinus (TP) and torus mandibularis (TM) are non-pathological outgrowths of unclear etiology that develop from the jaw bone. The purpose of the present study was to report on the prevalence, shape and location of TP and TM in the population of the Central Dalmatian region, Croatia. The study comprised of 1679 subjects, 985 females and 694 males, age range from 9 to 99 years who were examined by clinical examination and analysis of the plaster casts. Torus palatinus was found in 42.9% subjects and torus mandibularis in 12.6% of the subjects. Spindle-shaped torus palatinus was the most frequent type (45.6%). The most frequent type of torus mandibularis was bilateral solitary torus mandibularis (35.4%). Furthermore, torus palatinus was found in 40.1% of the total number of females and in 46.8% of the total number of males, indicating a significantly higher prevalence in the male population (p = 0.006). Torus mandibularis was found in 11.3% of the female population and in 14.6% of the male population, again indicating significantly higher prevalence in the male population (p = 0.046). The results of this study show significantly higher prevalence of torus palatinus and torus mandibularis in the male subjects. Furthermore, no differences in the prevalence of either TM or TP regarding age were found.

Aging quantification on alveolar bone loss

Objectives were to measure labial alveolar resorption using Lamendin's method; to correlate the measured values of resorption with age at death; to determine whether age influences alveolar resorption, and if so, to quantify this impact. The study was performed during the 1992-1995 period in identified war casualties in Bosnia and Herzegovina. Data on the date, month and year of birth, and on the month and year of death were known in all cases. Measurements were carried out in 845 anterior monoradicular maxillary and mandibular teeth from male bodies (n=198) aged 23-69, divided into five age groups of 23-29, 30-39, 40-49, 50-59 and 60-69 years. Teeth with macroscopic pathologic lesions were excluded from analysis. Lamendin's method was used to measure the alveolar bone level on the labial aspect of the extracted teeth. Results are presented in tables. Regression analysis was used to determine the alveolar resorption increase with age. Results are also presented by the factor of alveolar resorption, where the youngest age group was divided by older age groups. In the total sample of 845 teeth, alveolar bone level of up to 3.49 mm was recorded in 740 (87.76%), of 3.50-5.99 mm in 99 (11.79%), and of > 6.00 mm in 6 (0.71%) teeth. In anterior monoradicular teeth, labial alveolar resorption increased with age and showed a regular age dependent pattern toward older age groups in mandibular but not in maxillary teeth. A > 6-mm pocket was very rarely recorded. Study results contribute to clinical practice, demonstrating that periodontology is a preventive discipline in dental medicine.

Jaw elevator silent periods in complete denture wearers and dentate individuals

Functional meaning and underlying mechanisms of jaw elevator silent period (SP) have still not been completely understood. Since complete denture wearers (CDWs) have no periodontal receptors in their jaws, the aim was to examine SPs in CDWs and to compare it with dentate individuals (DIs). Thirty six DIs (skeletal/occlusal Class I) and 24 eugnath CDWs participated. EMG signals were registered using the EMGA-1 apparatus from the left and the right side anterior temporalis (ATM) and masseter muscles (MM). Ten registrations of an open-close-clench (OCC) cycle were obtained for each individual. DIs had the average latency between 12.5 and 12.9 ms and always one single short inhibitory pause (IP) with complete inhibition of motoneurons (20.1-21.1 ms). On the other hand, in CDWs various types of SPs emerged: single or single prolonged SPs, double SPs, SPs with three IPs, periods of depressed muscle activity following the first, or the second IP, SPs with relative inhibition of motoneurons or even in several registrations the SP was missing. Unless more than one IP emerged, complete duration of inhibitory pauses (CDIP) was measured. CDIP varied from 37.17 to 42.49 ms. Average latencies were from 16.22 to 16.76 ms. Based on the results of this study it is obvious that both, the duration and the latencies were significantly longer in CDWs than in DIs (p<0.05), which can be explained by different mechanisms responsible for the muscle reflex behaviour.

Oral burning symptoms and burning mouth syndrome-significance of different variables in 150 patients

OBJECTIVES

Despite the extensive amount of published literature upon burning symptoms in patients with clinically healthy appearance of the oral mucosa, as well as burning mouth syndrome (BMS) itself, they both remain still challenging topics. The aim of this study was to determine the real prevalence of "true" BMS in comparison to other patients with burning symptoms with clinically healthy appearance of the oral mucosa and then to compare "true" BMS patients with healthy controls regarding gastritis and intake of anxiolytics and angiotensin converting enzyme inhibitors.

STUDY DESIGN

In 150 patients with burning symptoms of clinically healthy oral mucosa, local and systemic investigations were performed and they included detection of candidal infection, salivary flow rate, presence of oral galvanism and parafunctional habits as well as complete blood count, serum ferritin, serum glucose levels, serum antibodies to Helicobacter pylori together with detailed medical history with special regard to medication intake. After "true" BMS patients were identified they have been compared to the controls with regard to the presence of gastritis and the intake of anxiolytics and angiotensin converting enzyme inhibitors.

RESULTS

Our results show that gastritis were significantly more present among "true" BMS patients and that they also significantly more intake anxiolitics, when compared to the control group.

CONCLUSIONS

Our findings might lead to the conclusion that every "true" BMS patient should be referred to the gastroenterologist and psychiatrist.

The significance of salivary interleukin 6 and tumor necrosis factor alpha in patients with oral leukoplakia

It is well known that cytokines play an important role in oral diseases. Furthermore, increased levels of interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) have been reported in patients with cancer and premalignant lesions such as oral lichen planus and oral submucous fibrosis. The aim of this study was to assess salivary IL-6 and TNF-alpha levels in 30 patients with histopathologically confirmed leukoplakia (age range 24-78, mean 52.3 years) in comparison to 34 controls (age range 27-79, mean 52 years). Salivary IL-6 and TNF-alpha were determined by enzyme linked immunoadsorbent assay. Statistical analysis was performed by use of Mann-Whitney test for independent samples and values lower than 0.05 were considered as significant (p<0.05). Significantly higher levels of salivary IL-6 and TNF-alpha in patients with oral leukoplakia when compared to healthy controls were found. The levels of salivary IL-6 and TNF-alpha did not correlate with the size of leukoplakia (lesions) nor with its localization regarding high and low risk sites for malignant transformation. Levels of salivary IL-6 and TNF-alpha were not influenced by smoking habits. We can conclude that increased salivary IL-6 and TNF-alpha might play a certain role in oral leukoplakia.

The influence of age and dental status on elevator and depressor muscle activity

The objective of this study was to determine whether the muscle activity at various mandibular positions is affected by age and dental status. Thirty edentulous subjects (E), 20 young dentate individuals (G1) and 20 older dentate individuals (G2) participated in this study. Surface electromyographic (EMG) recordings were obtained from the anterior temporal (T), masseter (M) and depressor muscles (D). Muscle activity was recorded during maximal voluntary contraction (MVC), maximal opening (O(max)) and in six different mandibular positions. One way anova and the Bonferroni tests were used to determine the differences between groups. Significant differences between the three tested groups were found at MVC and O(max) for all examined muscles (P < 0.001). The differences in muscle activity in dentate subjects of different age were found in protrusion for depressor muscles (P < 0.05) and in lateral excursive positions for the working side temporal (P < 0.05) and non-working side masseter and depressor muscle (P < 0.05). There was a significant effect regarding the presence of natural teeth or complete dentures in protrusion and maximal protrusion for all muscles (P < 0.05) and in lateral excursive positions for non-working side temporal (P < 0.05) and working side masseter muscle (P < 0.05). Muscle activity at various mandibular positions depends greatly on the presence of the prosthetic appliance, as edentulous subjects had to use higher muscle activity levels (percentages of maximal EMG value) than age matched dentate subjects in order to perform same mandibular movement. Different elevator muscles were preferentially activated in the edentulous subjects when compared with dentate group in lateral excursive positions of the mandible. The pattern of relative muscle activity was not changed because of ageing.

The influence of dental status on masticatory muscle activity in elderly patients

PURPOSE

The objective of this study was to determine whether elevator and depressor muscle activity during 5 minutes of mastication is affected by the presence of a prosthetic appliance in elderly patients.

MATERIALS AND METHODS

Thirty edentulous subjects (EG) and 30 age-matched dentate subjects (DG) were studied. Surface electromyographic (EMG) recordings were obtained from the anterior temporal muscle, masseter muscle, and the submandibular group in the region of the anterior belly of the digastric muscle on the left and right sides. Muscle activity was recorded during maximal voluntary contraction (MVC) in the intercuspal position, maximal opening (Omax), and during 5 minutes of mastication. Elevator muscle activity during mastication was expressed as a percentage of maximal muscle activity in the intercuspal position (%MVC), and depressor muscle activity was expressed as a percentage of maximal opening (%Omax). The effect of 3 factors was investigated using a mixed analysis of variance design: the factor of muscle, with 6 muscles involved; the factor of time (5 minutes of mastication); and the factor of dental status, where some participants had their own natural dentition and others had complete dentures.

RESULTS

The results revealed significant effects for the factors "muscle" and e" (P < .001 for the factor "muscle"; P < .001 for the factor "time"). The time by group interaction was significant (P = .046). In the EG, muscle activity gradually decreased during the 5-minute interval of mastication, while in the DG it decreased more rapidly from the first to the third minute and then increased until the fifth minute. There was also a significant effect regarding the presence of natural teeth or complete dentures (P < .034). Complete denture wearers had higher muscle activity relative to %MVC or %Omax than dentate subjects.

CONCLUSIONS

Muscle activity during 5 minutes of mastication depended greatly on the presence of the prosthetic appliance, since edentulous subjects had to use higher potentials of muscle activity (%MVC or %Omax) than age-matched dentate subjects, and were unable to increase activity at the end of mastication. The difference in chewing patterns and activity between complete denture wearers and dentate subjects should be explained to patients prior to prosthetic treatment to help them adjust their expectations.

Influence of occlusal stabilization splint on the asymmetric activity of masticatory muscles in patients with temporomandibular dysfunction

The aim of present study was to evaluate the symmetry of masticatory muscles' activity at various clenching levels in the intercuspal position in patients with functional disorders and in healthy subjects. The purpose was also to determine the effect of full-arch maxillary stabilization splint on the asymmetry of masticatory muscle activity in patients with temporomandibular dysfunction. In this study 6 TMD patients and 12 healthy subjects were investigated. Surface EMG recordings were obtained from left and right anterior temporal, left and right masseter and from the sub-mandibular group in the region of the anterior belly of the digastric muscle on the left and right side during clenching with the maximum 100% voluntary contraction (MVC) as well as during clenching at 50% and 25% of the maximum activity in the position of maximal intercuspation of teeth. In order to quantify asymmetrical masticatory muscle activity, the asymmetry index (AI) was calculated for each subject and for each muscle from the average anterior temporal, masseter and digastric potentials recorded during each test (100% MVC, 50% MVC and 25% MVC). In the group of patients EMG recordings were repeated during and after the splint therapy. The asymmetries of masticatory muscle activity was present in both groups, but in the group of TMD patients the asymmetry indices for anterior temporal muscle at 100% MVC (p = 0.049) and 50% MVC (p = 0.031) were significantly higher. Results have shown that the use of splint suppressed the asymmetry of all muscles, as during the splint therapy the asymmetry indices were lowered. After the therapy, the level of temporal muscle symmetry during submaximal clenching in the intercuspal position increased significantly (p = 0.046). This investigation points out that electromyography may be a valuable method of documenting that asymmetric activity of masticatory muscles improves after occlusal splint therapy in patients with TMD.