The effectiveness of stabilization appliance therapy among patients with myalgia

BACKGROUND

The efficacy of stabilization appliance therapy for masticatory muscle pain is debated. Therefore, there are currently no clear usage standards. We analyzed patient factors influencing its efficacy and characterized masticatory muscle pain subtypes to determine appropriate therapy candidates.

METHODS

This case series study recruited patients diagnosed with local myalgia or myofascial pain and used variables related to temporomandibular disorders in the analysis. We used temporary appliance to screen patients for sleep bruxism for 2 weeks. Afterwards, we initiated therapy with stabilization appliances. Efficacy was evaluated via tenderness intensity during muscle palpation and the treatment satisfaction score after 2 months of treatment.

RESULTS

We analyzed 62 (91%) patients. Tenderness upon muscle palpation was mitigated in 27 patients. Mitigated tenderness odds ratios were 0.035 for myofascial pain, 0.804 for 15-item Patient Health Questionnaire scores, and 1.915 for facet length. Thirty-nine patients expressed satisfaction; satisfaction odds ratios were 0.855 for 9-item Patient Health Questionnaire scores, 1.606 for facet length, and 4.023 for awake bruxism awareness.

CONCLUSIONS

Stabilization appliance therapy is most effective for patients with awake bruxism awareness, local myalgia, long facets, and no psychosocial risk factors.

Degenerative Disease of the Temporomandibular Joint and Pain-Dysfunction Syndrome

It is proposed that pain-dysfunction syndrome and degenerative disease ofthe temporomandibular joint may both be expressions of the same problem, i.e, repetitive overload of the joint system. Acceptance of this proposal will explain the contrasting, although often successful, methods of treatment.

The relationship between pathological wear of teeth and temporomandibular joint dysfunction

OBJECTIVE

Temporomandibular joint dysfunction (TMJD) is quite frequent pathology in population. In scientific literature pathological tooth wear (PTW) is listed among the predisposing factors of it.

MATERIAL AND METHODS

During the survey 189 primary patients of dental department in polyclinic of Panevezys city were examined. According to the tooth wear degree 2 groups have been formed: control group (grade 0-1) withouth TMJ dysfunction; and experimental group (grade 2-4) with presumable TMJD.

RESULTS

In experimental group tooth wear of anterior and posterior region increases with age respectively (p<0.05). It was also found that centric occlusion (CO) and relative rest heights difference increases with age in the control group (p<0.05) as well as the experimental group (p=0.001). In patients with diagnosed TMJD the difference between heights in CO and relative rest was bigger than in patients without TMJD (p=0.039). In the experimental group TMJD was diagnosed the most of patients grade-4 in 90%. The most common symptom is joint sounds was observed in 72.2%.

CONCLUSIONS

35-50 and over 50 age groups of patients had a higher first molars degree of wear than the younger ones. In patients with diagnosed TMJD the difference between heights in CO and relative rest was bigger than in patients without TMJD. TMJD symptoms and of posterior teeth pathological wear interface hypothesis confirmed. In the experimental group TMJD was diagnosed the most common in 90% of patients grade-4. The most common symptom is "Nutcracker" of experimental group patients 77.2%.

[Zygomatic arch fracture extended to the glenoid fossa: a cause of TMJ pain]

INTRODUCTION

Fractures of the zygomatic arch extended to the glenoid fossa are rare and seldom reported.

OBSERVATION

A 26-year-old man with a slightly dislocated fracture of the zygoma associated with trismus, and localized pain in the right Temporo-Mandibular Joint (TMJ) on palpation, but without any condylar fracture. The craniofacial CT scan revealed a fracture of the zygoma extended to the glenoid fossa. The treatment was an intraoral reduction of the zygoma and screw fixation of the glenoid fossa lateral region.

DISCUSSION

The risk of delayed healing by mobilization of the bone fragments was opposed to the risk of TMJ ankylosis due to a prolonged immobilization of the joint. Osteosynthesis of the fracture was finally chosen.

[The peculiarities of petrotympanic fissure topography in Costen syndrome and possible causes of its development]

A complex study of morphometric characteristics of the articular surfaces of the temporomandibular joint and the examination of the peculiarities of the petrotympanic fissure topography were performed on 138 samples of skulls of adult individuals with intact occlusion, complete anodontia and different forms of cranial skull (dolicho-, meso- and brachicranial). No distinct differences in studied parameters were found between the studied groups. However, in the hypsicranial group the petrotympanic fissure was found to pass more often through the medial third of the mandibular fossa, which may be a predisposing anatomical factor for Costen syndrome. Due to the fact that in anodontia the parameters characterizing the articular surfaces of the temporomandibular joint, are significantly changed, the immediate cause of the Costen syndrome are the changes of the articular surfaces of the temporomandibular joint, primarily the reduction in the size of mandibular condyle, which is accompanied by its pathological displacement and compression of the chorda tympani.

[Complex prosthetic rehabilitation of a patient with temporomandibular dysfunction. Case report]

There are varying opinions regarding the contribution of occlusal interferences to the development and progression of temporomandibular dysfunction (TMD). Several studies have demonstrated that the use of occlusal adjustment might prevent the development of TMD and the exacerbation of its symptoms. Since the aetiology of TMD is multiple, the prosthodontic treatment cannot always be sufficient, but tends to be effective in some cases. The present article describes a case of a complex prosthetic rehabilitation of a patient with TMD that originates from her previous prosthesis, resulting in reduced vertical dimension. Treatment included the registration of vertical and horizontal dimensions of occlusion by gothic arch (arrow-point) tracing. Degrees of the mandibular movement were recorded by digital axiograph (ARCUSdigma-KaVo) and transferred to a semi-adjustable articulator (KaVo Protar 5B). Appropriate vertical and horizontal occlusal dimensions and individual mandibular movements were then transferred to the final prosthesis.

[The relationship between centric relation-maximum intercuspation disharmony and temporomandibular dysfunction in class II patients]

OBJECTIVE

To investigate the relationship between the degree of displacement of centric relation-maximum intercuspation (CR-MI) and temporomandibular dysfunction (TMD) in Class II patients.

METHODS

The questionnaire and clinical examination were administered in 107 Class II patients and students, using the Helkimo index (Di and Ai). The differences in condylar position between CR and MI in all three spatial planes were measured using the Condyle Position Indication (CPI).

RESULTS

Di positively correlated with degree of CR-MI displacement in all five displacement (P < 0.05), while Ai positively correlated with degree of CR-MI displacement except horizontal displacement. Di and Ai significantly correlated with degree of CR-MI discrepancy in all five displacement (P < 0.05); With the increasing of Di and Ai rank, the degree of CR-MI displacement and CR-MI discrepancy increased. Also, symptoms of TMD were significantly correlated with the degree of CR-MI displacement and CR-MI discrepancy except horizontal displacement (P < 0.05). Severer CR-MI displacement and CR-MI discrepancy were observed in patients who had TMD symptoms.

CONCLUSION

In Class II patients, degree of CR-MI displacement is an important factor of TMD, and correlated with the severity of TMD.

Bruxism and TMD disorders of everyday dental clinical practice

Bruxism, as an etiological factor for the development of TMD, includes different disorders of the TMJ and the masticatory muscles, exhibiting pain and disruption of the stomatognathic functions. Our goal was to study patients with bruxism and TMD from everyday dental clinical practice, in terms of diagnosis, identification of etiological factors, classification and treatment of these disorders. We treated 120 patients, divided into 2 groups of 60 patients. The first group had disorders of the TMJ, and the second of the masticatory muscles. The groups were divided into subgroups of 20 patients with dislocation of the articular disk with or without reduction and inflammation of TMJ. The second group was organized from patients with myofascial pain, myositis and muscular trismus. Our conservative treatment consisted of patient education, NSAID, myorelaxants, fabrication of prosthetics, repositioning and stabilization splints. The progress of the patients was followed immediately after the delivery of the prosthetics and the splint, after 1, 6 and 12 months. The results showed that in patients with disorders of the TMJ there were visible signs of recovery after 6 months in 68.3% patients, and in 85% after 12 months. In the second group we achieved faster results with the elimination of symptoms. Patients with afflictions of the muscles in 88.3% of cases noticed relief of symptoms even after 6 months and in 98.3% after 12 months. As therapists we concluded that timely treated complications of bruxism and TMD prevent the destruction of the TMJ, masticatory muscles and the entire stomatognatic system.

Temporomandibular disorders after orthognathic surgery in patients with mandibular prognathism with depression as a risk factor

OBJECTIVE

To examine the prevalence of temporomandibular disorders (TMD) after orthodontic-surgical treatment in patients with mandibular prognathism and analyze psychosocial variables related to TMD.

MATERIALS AND METHODS

The case-control study comprised 40 patients with mandibular prognathism who underwent combined orthodontic-surgical treatment (orthognathic surgery group). Forty-two patients with untreated mandibular prognathism served as a control group. Research diagnostic criteria for temporomandibular disorders was used in order to assess the clinical diagnosis of TMD (Axis I) and to estimate depression, somatization and patient's disability related to chronic pain (Axis II).

RESULTS

The overall prevalence of TMD was not significantly different between the groups. Myofascial pain was significantly higher, while arthralgia, arthritis and arthrosis was significantly lower in the orthognathic group compared with the controls (90.5% vs 50.0%, 0.0% vs 27.8%, respectively) (p < 0.05). Females in orthognathic surgery group showed higher prevalence of TMD (p < 0.05) and myofascial pain (p < 0.01) and increased level of chronic pain (p < 0.05) in comparison with post-operative males. No significant difference in chronic pain, somatization and depression scores was found between investigated groups. With respect to presence of TMD within the groups depression was higher in untreated subjects with dysfunction (p < 0.05).

CONCLUSION

Prevalence of TMD immediately after completion of orthodontic-surgical treatment for mandibular prognathism is similar to frequency of dysfunction in untreated subjects, is significantly higher in females and is most commonly myogenic. Furthermore, females show an increased level of chronic pain post-operatively. Somatization and depression levels do not differ between patients with corrected prognathism and untreated prognathic patients.

Reducing chronic masseter and temporalis muscular hyperactivity with computer-guided occlusal adjustments

Muscle hyperactivity is a potential source of symptomatology in patients with temporomandibular disorders. Various occlusal adjustment procedures have been advocated to reduce hyperactivity. A new, measurement-driven, occlusal adjustment procedure, known as immediate complete anterior guidance development (ICAGD), has been shown through nonsimultaneous electromyography to lessen masticatory muscle hyperactivity effectively by reducing posterior disclusion time to <0.4 sec in all mandibular excursions. This reduction, in turn, lessens the volume of periodontal ligament compressions that create additive and excessive functional muscle contractions via a feedback mechanism involving the trigeminal nerve. This case report describes the treatment of chronic muscular hyperactivity with a computer-guided ICAGD enameloplasty and simultaneously recorded electromyography. Follow-up visits showed that after reduction, the pretreatment levels of excursive muscular hyperactivity were lessened and lasting. This result is caused by the shorten ed posterior disclusio time resulting in an equally reduced time to muscle shutdown.

A stepwise multiple regression model to assess the odds ratio between myofascial pain and 13 occlusal features in 238 Italian women

OBJECTIVE

To quantify the relative risk of multiple occlusal variables for muscular disorders of the stomatognathic system.

METHOD AND MATERIALS

Thirteen occlusal features were clinically assessed by the same three operators: partial unilateral posterior reverse articulation, anterior open occlusal relationship, vertical anterior overlap (normal value < 4 mm), complete unilateral posterior reverse articulation, anterior overjet (normal value < 5 mm), incisor midline discrepancy (normal value < 2 mm), Angle Class I canine and molar relationship; plus dynamic occlusion features such as length and symmetry of retruded contact position-intercanine position (RCP/ICP) slides (normal value < 2 mm), occlusal guidance patterns, and mediotrusive and laterotrusive interferences. The sample consisted of 156 women with only muscular disorders according to the Group I Research Diagnostic Criteria for temporomandibular disorders and 82 healthy women (control group). A stepwise multiple logistic regression model was used to identify the significant correlation between occlusal features and disease.

RESULTS

The odds ratio for myofascial pain was 2.6 for absence of canine guidance, 2.0 for laterotrusive interference, 2.3 for mediotrusive interference, and 1.9 for reverse articulation. Other occlusal variables did not reveal statistical significance. The percentage of the total log likelihood for myofascial pain explained by the significant occlusal factors was acceptable with a Nagelkerke R2 = 0.2. The final model including the significative occlusal features revealed an optimal discriminant capacity to predict patients with myofascial pain with a sensitivity of 62.2%, or healthy subjects with a specificity of 93.6%, and an accuracy of 82.8%.

CONCLUSIONS

Few occlusal features show a significative predictive value for myofascial pain.

Joint sounds in complete denture wearers. Literature review

Long-term denture wearers can present with prosthesis instability, reduced occlusal vertical dimension and incorrect positioning of the jaw. This can lead to muscular changes and joint vibration. This study presents the main considerations related to joint vibrations in partially or totally edentulous patients. Occlusal treatment improves the disc-condyle relationship in the mandibular fossa. Furthermore, a detailed clinical exam and anamnesis must be performed to identify the dysfunction and its etiology, so that appropriate treatment can be provided.

Role of psychosocial factors in the etiology of temporomandibular disorders: relevance of a biaxial diagnosis

AIM

The prevalence of temporomandibular disorders (TMD) is higher among women than men, indicating a multifactorial role for gender-related differences in the etiology of TMD: physiological hormonal differences, inflammatory response to stress, and sociocultural differences in response to pain. The aim of this study was to draw a biobehavioral picture of the TMD patient based on Research Diagnostic Criteria for TMD (RDC/TM) Axis II diagnosis and analysis of gender-related differences.

METHODS

Between January 2006 and January 2008, 362 subjects were consecutively enrolled from patients who presented at the Clinic for Temporomandibular Disorders, School of Dental Medicine, University of Pavia, because of orofacial pain, limitation or joint sounds on mandibular movement. Of the 362 subjects evaluated, 308 met the inclusion criteria.

RESULTS

The average age of the study population was 41 years; the female: male ratio was 4:1. When stratified according to chronic pain intensity grade and gender, 26% of the women had grade I, 36.4% grade II, 17% grade III, and 9.7% grade IV; 34.4% of the men had grade I, 32.8% grade II, 6.5% grade III, and 3.3% grade IV. Depression was moderate in 35 women and in 6 men and severe in 138 women and in 24 men; somatization was moderate in 59 women and in 20 men and severe in 143 women and in 19 men.

CONCLUSIONS

Gender-related differences may be considered risk factors for TMD; psychological characteristics, including somatization, depression, and anxiety related to gender, appear to have a significant impact on the prevalence of TMD.

Occlusal features and masticatory muscles activity. A review of electromyographic studies

OBJECTIVE

Since there is no consensus on the association between occlusion and temporomandibular disorders (TMDs), the aim of the present paper was to conduct a review of electromyographic studies, in order to asses the relationship between various occlusal features and masticatory muscles' activity.

MATERIAL AND METHODS

An exhaustive MEDLINE computer search was performed to identify all experimental studies present in the English literature describing the relationship between the electromyographyc evaluation of patients and their occlusal morphology.

RESULTS

The search methodology provided a total of 102 abstracts and from these 11 full reports were required as full text. Of the 11 articles selected, 8 studied the variation of the muscular activity as a consequence of the experimental introduction of occlusal disturbances whereas the remaining three studies estimated the electrical muscular characteristics without any artificial alteration of the occlusal morphology.

CONCLUSION

The results obtained seem to suggest that occlusal features can affect the electrical signals recordings of masticatory muscles. Further researches are strongly requested to realize if this altered muscular activity can turns in the occurrence of TMDs.

Relationship between the frequency of sleep bruxism and the prevalence of signs and symptoms of temporomandibular disorders in an adolescent population

PURPOSE

The relationship between sleep bruxism (SB) and temporomandibular disorders (TMD) is unclear. This study aimed to estimate SB prevalence in an adolescent population and to investigate the relationship between SB frequency and prevalence of TMD signs/symptoms.

MATERIALS AND METHODS

First-year students at a high school in Okayama, Japan, were recruited in 2005, with 195 subjects responding. The SB detection device was a miniature disposable device (BiteStrip, SLP) that indicated the total SB events per night on a 4-grade score. The subjects were divided into severe and nonsevere SB groups with SB frequency cutoffs. The subjects were examined for temporomandibular joint (TMJ) noise during mouth opening/closing, tenderness of the masticatory/cervical muscles, and range of TMJ condylar movement. The presence/absence of headache and shoulder stiffness was also determined by the interview. The odds ratio (OR) and confidence interval (CI) were calculated to test the relationship between SB frequency, gender difference, and presence of the TMD signs/symptoms by multiple regression analysis.

RESULTS

Severe SB (more than 125 events per night) was significantly related to the presence of TMJ clicking (OR: 3.74, CI: 1.22-11.49, P = .02), while gender (male) was not related to the presence of TMJ clicking. Severe SB was not related to headache, though gender (male) was significantly related to headache (OR: 2.52, Cl: 1.04-6.11, P= .04) in these subjects.

CONCLUSION

These results suggest that the presence of TMJ clicking was closely related to severe SB in an adolescent population.

Association between rhythmic masticatory muscle activity during sleep and masticatory myofascial pain: a polysomnographic study

AIMS

To test for an association between rhythmic masticatory muscle activity during sleep, as assessed according to polysomnographic criteria for sleep bruxism (RMMA-SB), and myofascial pain (MFP), as well as the chance of occurrence of MFP in patients with RMMA-SB.

METHODS

Thirty MFP patients (diagnosed according to the Research Diagnostic Criteria for Temporomandibular Disorders) and 30 age- and gender-matched asymptomatic controls underwent a polysomnographic examination. Also, any self-reporting of daytime clenching (DC) was registered in 58 of these subjects.

RESULTS

Most MFP patients reported mild or moderate pain (46.67% and 43.33%, respectively), and only 3 (10%) reported severe pain. Pain duration ranged from 2 to 120 months (mean 34.67 +/- 36.96 months). Significant associations were observed between RMMA-SB and MFP as well as between DC and MFP.

CONCLUSIONS

(1) RMMA-SB is significantly associated with MFP; (2) although RMMA-SB represents a risk factor for MFP, this risk is low; and (3) DC probably constitutes a stronger risk factor for MFP than RMMA-SB.

Computerized occlusal analysis technology and Cerec case finishing

Computerized occlusal analysis is becoming the principal tool available to clinicians with which to understand functional and parafunctional forces of occlusal contact, contact timing sequences, and occlusal surface interface pressures, which arise as teeth mill against each other during mandibular movements. Because recent research on articulating paper has revealed that articulating paper mark size does not measure occlusal forces predictably, the modern clinician needs to employ an occlusal contact measuring device that can reliably determine aberrant occlusal force concentrations and time prematurities. Computerized occlusal analyses can be used to guide the operator as to which tooth contact locations require appropriate occlusal adjustments. When inserting Cerec restorations, computerized occlusal analysis can be employed to target excessive force concentrations and time premature contacts to better preserve the Cerec materials, than can be accomplished with "articulating paper-only" occlusal adjusting. This paper describes the evolution of computerized occlusal analysis, the system attributes, and illustrates its use in case-finishing Cerec bonded lingual guidance veneers.

Delayed temporomandibular joint pain and dysfunction induced by whiplash trauma: a controlled prospective study

BACKGROUND

The Quebec Task Force on Whiplash-Associated Disorders urged for controlled, prognostic studies of symptoms after whiplash trauma. The authors conducted a study that met the design requirements to enhance knowledge about short-term and long-term temporomandibular joint (TMJ) pain, dysfunction or both induced by whiplash trauma.

METHODS

The authors studied 60 consecutive patients who had neck symptoms after whiplash trauma and were seen at a hospital emergency department. They followed up 59 subjects one full year later. At the inceptive examination and at follow-up, each subject completed a self-administered questionnaire, followed by a comprehensive interview. Fifty-three frequency-matched control subjects followed the same protocol concurrently.

RESULTS

The incidence of new symptoms of TMJ pain, dysfunction or both between the inceptive examination and follow-up was five times higher in subjects (34 percent) than in control subjects (7 percent). The frequency of TMJ pain increased significantly in female subjects, as did the frequency of TMJ symptoms that were reported to be the main complaint. At the follow-up, 20 percent of all subjects reported that TMJ symptoms were their main complaint.

CONCLUSIONS

Our results suggest that one in three people who are exposed to whiplash trauma is at risk of developing delayed TMJ symptoms that may require clinical management.

CLINICAL IMPLICATIONS

Awareness of a significant risk for delayed onset of TMJ symptoms after whiplash trauma is crucial for making adequate diagnoses, prognoses and medicolegal decisions.

Treatment of severe bilateral temporomandibular joint ankylosis in adults: our protocol

AIM

In order to evaluate the reliability of interpositional gap arthroplasty with temporalis myofascial flap the authors retrospectively analysed the data of 5 patients suffering from bilateral temporomandibular ankylosis operated on with this technique.

METHODS

The preoperative assessment included evaluation of pain during function, interference with eating and the maximal interincisal distance. All patients received bony ankylosis removal, interposition of a finger-shaped temporalis myofascial flap in the articular gap and coverage with temporoparietal fascial flap as a new capsule. In the postoperative period an aggressive physiotherapy was carried on for at least 6 months.

RESULTS

All cases experimented release of pain (evaluated by a Visual Analogue Scale method), a return to a normal diet and a stable improvement in mouth opening during the follow-up period.

CONCLUSIONS

This technique should be considered a reliable method to avoid relapse of ankylosis and to stabilize postoperative results.

Description of prosthetic treatment in case of neurofibromatosis in the course of Recklinghausen disease. Case course

Neurofibromatosis is a hereditary autosomal predominating disease occuring in one out of every 2000 or 3300 alive births. The classical form of neurofibromatosis was described by von Recklinghausen in 1882. The disease is a gene mutation, where the anomalies affect mesoderm and neuroectoderm. The paper presents the therapeutic treatment method for the case of lacking teeth restoration in a patient diagnosed with known form ofneurofibromatosis NF-1 in Recklinghausen disease.

[Diagnosis of temporo-mandibular joint dysfunction caused by occlusion pathology and treatment of such patients]

Patients with temporo-mandibular joint (TMJ) dysfunction need complex treatment that includes prosthetic treatment in intrajoint relation stabilization. In cases of TMJ pathology it is necessary to examine patients and make axiography, function analysis, MPI-analysis, magnetic resonance tomography and zonography of TMJ, electromyography of the masticatory muscles. The authors examined 47 patients with TMJ dysfunction, 43 of them had occlusion pathology. We managed to eliminate the dysfunction symptoms and to receive stable result of the treatment in all the patients.

Temporomandibular joint pain and dysfunction

Pain caused by temporomandibular disorders originates from either muscular or articular conditions, or both. Distinguishing the precise source of the pain is a significant diagnostic challenge to clinicians, and effective management hinges on establishing a correct diagnosis. This paper examines terminology and regional anatomy as it pertains to functional and dysfunctional states of the temporomandibular joint and muscles of mastication. A review of the pathophysiology of the most common disorders is provided. Trends in evaluation, diagnosis, treatment, and research are presented.

A psychological study on patients with masticatory muscle disorder and sleep bruxism

Sleep bruxism (SB) has been believed to be related to stress and psychosocial factors, however their implicit relationship has remained unclear. This study was conducted on patients visiting our clinic with SB and masticatory muscle disorders (MMD) for the purpose of clarifying personality and behavioral traits. This study was conducted on patients of MMD visiting our clinic. The Rosenzweig Picture-Frustration study was performed on each patient. Twenty-seven (27) patients were divided into two groups: 17 patients with SB and 10 patients without. The SB group showed a significantly lower level of E (extrapunitive) reaction than the nonSB group. SB patients showed a significantly higher level of M (impunitive) reaction than those without SB. Concerning the directions of aggression, the percentage of E-A (extraaggression) was significantly lower in SB patients than in those without. On the other hand, the percentage of I-A (intraaggression) was significantly higher in patients with SB than those without. Our study found a new aspect of the patients with MMD and SB: they are not only intraaggressive, but are also unable to be extrapunitive and extraaggressive. Consequently, they are unable to demonstrate adequate self-assertiveness in stressful situations.

Sleep and depression as risk indicators for temporomandibular disorders in a cross-cultural perspective: a case-control study

PURPOSE

We conducted this case-control study to determine the role of 2 neuropsychologic variables (sleep and depression) as possible risk indicators for the development of temporomandibular disorders (TMD).

MATERIALS AND METHODS

Neuropsychologic tests, traditional signs and symptoms of TMD, and social and economic variables were analyzed. Seventy-two predominantly muscle-related TMD patients (Research Diagnostic Criteria for TMD groups Ia, Ib, and IIIa) and 30 age- and sex-matched pain-free controls were included in the population.

RESULTS

Overall, TMD patients had statistically significantly higher sleep and depression scores on the Sleep Assessment Questionnaire and on the Brazilian Portuguese version of the Beck Depression Inventory, with odds ratios of 5 and 1.6, respectively. These results remained unchanged even after controlling for 8 confounders in the logistic regression analysis. Spontaneous pain and pain on palpation (grade 2 or higher) were also statistically significantly worse in TMD patients. In the forward-step logistic regression analysis, we also found that the combination of our best TMD predictors (ie, sleep, cigarettes, alcohol) had a better predictive value (percent agreement = 78.69%) than when the variables were analyzed alone.

CONCLUSION

Sleep and depression are considered important risk indicators for the development of TMD.

Oral appliance management of obstructive sleep apnea: a case report

Obstructive sleep apnea (OSA) and snoring are common related conditions with major health and social implications. OSA is a progressive disease with symptoms of daytime sleepiness and chronic cardiovascular morbidity A mandibular advancement oral appliance is the only nonsurgical management modality available if continuous positive airway pressure (CPAP) cannot be tolerated. A patient who had been diagnosed with OSA was successfully treated but developed a posterior open bite and symptomatic temporomandibular joints (TMJ). An integrated approach to managing his OSA and TMJ conditions enabled him to have a comfortable and stable bite and to continue using his obstructive sleep apnea appliance. Management of OSA with an oral appliance should be handled by a dentist who is trained and experienced in the overall care of oral health, temporomandibular joints, dental occlusion, and associated structures. A team approach starting with the diagnosis of OSA by a physician and management by a dentist is described.

Chiropractic treatment of temporomandibular disorders using the activator adjusting instrument and protocol

OBJECTIVE

To describe the chiropractic management of a 30-year-old woman with temporomandibular joint (TMJ) pain and to discuss the general etiology and management of TMJ conditions.

CLINICAL FEATURES

The patient suffered from daily unremitting jaw pain for 7 years, which was the apparent sequela of a series of 8 root canals on the same tooth. Pain radiated from her TMJ into her shoulder and was accompanied by headache, tinnitus, decreased hearing, and a feeling of congestion in her right ear. Symptoms were not reduced by medication or other dental treatments. OUTCOME AND INTERVENTION: The patient underwent a series of chiropractic treatments using the instrument and protocol of Activator Methods, International. During the first 5 months, her VAS rating of jaw pain decreased from 60 (on a scale of 0 to 100) to 9, her ability to eat solid foods increased, headache intensity and frequency diminished, and her maximum mouth opening without pain measurement increased from 22 to 28 mm. Overall, 20 months of chiropractic treatment along with 2 concurrent months of massage therapy yielded slow but continual progress that finally resulted in total resolution of all symptoms except some fullness of the right cheek.

CONCLUSION

Use of the Activator Methods protocol of chiropractic treatment was beneficial for this patient and merits further study in similar cases.

Tiagabine May Reduce Bruxism and Associated Temporomandibular Joint Pain

Tiagabine is an anticonvulsant gamma-aminobutyric acid reuptake inhibitor commonly used as an add-on treatment of refractory partial seizures in persons over 12 years old. Four of the 5 cases reported here indicate that tiagabine might also be remarkably effective in suppressing nocturnal bruxism, trismus, and consequent morning pain in the teeth, masticatory musculature, jaw, and temporomandibular joint areas. Tiagabine has a benign adverse-effect profile, is easily tolerated, and retains effectiveness over time. Bed partners of these patients report that grinding noises have stopped; therefore, the tiagabine effect is probably not simply antinociceptive. The doses used to suppress nocturnal bruxism at bedtime (4-8 mg) are lower than those used to treat seizures.

Temporomandibular disorders in association with scuba diving

OBJECTIVE

To determine the prevalence of temporomandibular disorders (TMD) in scuba divers and to identify the risk factors for the development of pain in the stomatognathic system before and after diving by the use of a questionnaire.

DESIGN

: Retrospective cohort study based on questionnaires.

PARTICIPANTS

A total of 296 active divers, aged 18 to 65 years, participating in scuba diving meetings in Heidelberg, Germany.

INTERVENTIONS

Each diver answered a questionnaire containing 29 questions, predominantly on symptoms of TMD.

MAIN OUTCOME MEASURES

The data collected from the divers were calculated by the use of logistic regression tests. Risk factors for the development of TMD were evaluated.

RESULTS

Clenching seemed to be the greatest risk factor for pain while holding the mouthpiece and for pain in the masticatory muscle system after diving. Limited mouth opening and clenching were responsible for the development of pain in the temporomandibular joint after the dive. The prevalence of TMD-related symptoms was higher in women before, during, and after the dive.

CONCLUSIONS

Individuals exhibiting TMD-related symptoms seem to be at the greatest risk of developing pain in the masticatory muscle system and/or the temporomandibular joint during or after the dive.

Jacob's disease associated with temporomandibular joint dysfunction: a case report

Jacob's disease is regarded a rare condition in which a joint formation is established between an enlarged mandibular coronoid process and the inner aspect of the zygomatic body. Chronic temporomandibular joint (TMJ) disk displacement has been proposed as etiological factor of coronoid process enlargement. We present a 23-year-old woman with long-standing TMJ dysfunction and restricted interincisal opening, who developed a progressive zygomatic asymmetry. The patient underwent treatment by intraoral coronoidectomy and homolateral TMJ arthroscopy in the same surgery. The histopathological diagnosis of the coronoid sample was cartilage-capped exostoses with presence of articular fibrous cartilage. Although the low prevalence of this entity, it should be considered as a possible diagnosis in patients with progressive limitation of mouth opening, although a TMJ syndrome may be present as a cause of this entity.

[Oral problems in divers]

Divers can have several oral problems. Firstly, problems caused by pressure changes. These are barodontalgia and odontocrexis. Barodontalgia is toothache by barotrauma. Odontocrexis is restorations coming lose or breaking or tooth fractures by expansion of air beneath restorations. Other problems can occur by cements used to fix casted restorations, by inflammations in the orofacial region, and by not yet fully healed oral wounds. Secondly, there are problems related to the diver's mouthpiece. To keep the mouthpiece in place, the mandible has to be forced in a forward position. Holding this position often and for long periods of time, may develop or aggravate temporomandibular dysfunction. Insufficient fit of the mouthpiece may induce oral mucosal lesions. Therefore, it is recommended to produce individual diver mouthpieces. It is also recommended to produce individual diver mouthpieces for complete dentures wearing divers and for divers with fixed orthodontic appliances.

[Case with implant restorations for mandibular bilateral free-end space for establishing occlusal support]

PATIENT

A 55-year-old female patient was treated with a removable partial denture for the mandibular bilateral free-end space. Since the patient did not wear the removable partial denture because of discomfort, the remaining teeth were mobile. She also complained of temporomandibular joint pain on both sides. Implant therapy was planned for the mandibular bilateral free-end space to reestablish the proper occlusal support.

DISCUSSION

After setting the implant restorations for the mandibular bilateral free-end space, mobility of the remaining teeth and temporomandibular joint pain disappeared. During the observation period after treatment, no biological and biomechanical problems appeared.

CONCLUSION

Implant therapy is effective not only for establishing the occlusal support but also for re-establishing the stability of remaining teeth.

Relationship between oral parafunctional/nutritive sucking habits and temporomandibular joint dysfunction in primary dentition

The aim of this study was to evaluate the relationship between nutritive and parafunctional habits and the presence of temporomandibular dysfunction (TMD) in children with primary dentition.

METHODS

Ninety nine children, aged 3-5 years, were examined to check for the presence or absence of signs and symptoms of TMD (headache, preauricular pain, earache, masticatory muscle tenderness, deviation on opening, occlusal interference and asymmetric movement of the mandible), oral parafunctions (bruxism, nail biting, finger/thumb sucking, speech alteration, mouth breathing, pacifier and atypical swallowing) and nutritive habits (breast- or bottle-feeding) through interview and clinical examination. The results were submitted to descriptive statistical analysis and Fisher's exact test.

RESULTS

The results showed that only atypical swallowing was positively related to TMD (P < 0.0001); other oral parafunctional and nutritive habits were not related to TMD.

CONCLUSIONS

It was concluded that parafunctional habits, with the exception of atypical swallowing, and feeding methods were not determinants for the presence of signs and/or symptoms of TMD in the sample of children included in the study.

Oral parafunctions and positive clinical examination findings

STATEMENT OF PROBLEM

Oral parafunctional activity can be fatigued and painful masticatory muscles and/or pain in the temporomandibular joints. There is controversial discussion in the literature as to what role parafunctional activity plays in the multi-causal pathologic process.

PURPOSE

The purpose of this study was to determine any association between the level of parafunctional habits versus the level of mandibular dysfunction and to test the hypothesis that TMD/bruxer patients have significantly increased muscle tension and joint pain.

MATERIAL AND METHODS

There were 307 subjects (140 males und 167 females) selected for this investigation. 299 subjects were examined regarding any relationships between clenching and the incidence of muscle sensitivity. The age of subjects ranged from 20 to 54 years old, with a mean age of 35.4. 114 subjects had at least one sign of temporomandibular disorders (tenderness/pain on palpation of the joints or muscles, TMJ sounds, pain or deviation during maximum mouth opening (active/passive).

RESULTS

81 subjects admitted to clenching, while 218 said they did not. Among the "non-clenchers", 68.8% had no sensitive muscles, 31.2% indicated sensitive masticatory muscles. Those who clenched their teeth were distributed as follows: 53.1% were diagnosed with bilateral masticatory muscle sensitivity, 46.9% showed no such indications. The two groups were not homogeneously divided, with regard to pain/discomfort (p = 0.001; Fisher's precision test).

CONCLUSION

This study found a statistically solid relationship between the incidence of "clenching" and muscle palpation findings, as well as between sensitivity in the mandibular joints from lateral and to cranial and dorsal with positive muscle palpation findings. The agreement between sensitivity of the masticatory musculature and the mandibular joint demonstrates that intensive clenching can predominantly lead to pathologic phenomena in the muscles or joints.

Fabrication of a custom diving mouthpiece using a thermoforming material

Scuba divers may suffer from temporomandibular joint dysfunction and related problems associated with the use of commercially available diving mouthpieces. Several authors have recommended that custom diving mouthpieces be fabricated for relieving the symptoms of diver's mouth syndrome. The lost wax technique is commonly used for this purpose but may be time-consuming and is technically complicated. This article describes a simplified technique using thermoforming material for fabricating a custom diving mouthpiece.

Advantages of intraoral verticosagittal ramus osteotomy in skeletofacial deformity patients with temporomandibular joint disorders

PURPOSE

This preliminary study was performed to clarify the usefulness of intraoral verticosagittal ramus osteotomy (IVSRO) in patients with temporomandibular joint (TMJ) disorders.

PATIENTS AND METHODS

We examined 34 sides in 19 consecutive patients with dentofacial deformities with TMJ dysfunction undergoing IVSRO. Preoperatively, 15 patients had TMJ sounds bilaterally and 4 had sounds unilaterally. Five sides in 3 patients had pain in the TMJ, and 4 sides in 3 patients had masticatory muscle pain. The TMJ symptoms, including TMJ sounds, pain in the TMJ, and masticatory muscle pain in each patient, were assessed clinically before and approximately 12 months after IVSRO. Magnetic resonance imaging was also performed to determine joint status, including determination of the positions of the condyle and disc.

RESULTS

The symptoms of the TMJ after 12 months of orthodontic treatment showed marked improvements, with the disappearance of the TMJ sounds in 94% of the sides examined. Pain in the TMJ improved in 4 of 5 sides, and pain of the masticatory muscle improved in 3 of 4 sides. With regard to the relative positions of the condyle and disc on magnetic resonance imaging, 6 of 8 joints and 5 of 7 joints showed improvement in anterior disc displacement with and without reduction, respectively. The direction and mean amount of movement in the distal segment were 8 mm in setback, 4 mm in advance, and 5 mm counterclockwise.

CONCLUSION

IVSRO is potentially as useful for the treatment of TMJ disorders in orthognathic surgery patients as is intraoral vertical ramus osteotomy, and IVSRO can be used selectively in cases in which intraoral vertical ramus osteotomy is contraindicated.

Quantification of the relative risk of multiple occlusal variables for muscle disorders of the stomatognathic system

STATEMENT OF PROBLEM

There is no consensus on the association between occlusion and temporomandibular disorders (TMD).

PURPOSE

The purpose of this study was to quantify the relative risk of multiple occlusal variables for muscle disorders of the stomatognathic system.

MATERIAL AND METHODS

Eight occlusal features: retruded contact position (RCP) to maximum intercuspation (MI) slide length, vertical overlap, horizontal overlap, unilateral posterior reverse articulation, anterior open occlusal relationship, incisor dental midline discrepancy, mediotrusive interferences, and laterotrusive interferences, were clinically assessed by the same trained operator. The sample consisted of 81 women with a Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) axis I diagnosis of muscle disorder, for example myofascial pain, with or without limited opening, and 48 healthy women (control group). A stepwise multiple logistic regression was used to identify the significant associations between occlusal features and disease.

RESULTS

A slide from the retruded contact position to maximum intercuspation > or =2 mm and mediotrusive interferences were the only 2 occlusal features significantly associated with the presence of myofascial pain according to the RDC/TMD criterion symptoms. The odds ratio for myofascial pain was 2.57 for a slide from RCP to MI > or =2 mm and 2.45 for mediotrusive interferences. The percentage of the total log likelihood for myofascial pain explained by the significant occlusal factors amounted to 10.8% (Nagelkerke's R2=0.108). The multifactorial model, including the 2 significant occlusal factors, showed an acuracy to predict disease of 66.7% (sensitivity 71.6%; specificity 58.3%).

CONCLUSION

Occlusal features showed a low predictive value to detect muscle disorders of the stomatognathic system. Multifactorial complex pathologies, such as TMD, should be studied using multivariate statistical analyses, as univariate models may overestimate some resulting associations.

Screening for psychosocial risk factors in patients with chronic orofacial pain

BACKGROUND

The authors compiled information about recent advances in screening for psychosocial risk factors considered to be yellow flags for potentially poor outcomes among patients with chronic orofacial pain (most commonly temporomandibular disorders).

TYPES OF STUDIES REVIEWED

The authors conducted MEDLINE searches for the period 1995 through 2002 using the terms "temporomandibular disorders," "assessment" and "psychological," as well as "primary care," "screening" and "psychological disorders." They also searched personal files for relevant articles.

RESULTS

Psychosocial dysfunction is prevalent among patients with chronic orofacial pain. Yellow flags include high levels of disability; psychological disorders; and prolonged or excessive use of opiates, benzodiazepines, alcohol or other drugs. The authors identified several reliable, valid and brief patient self-administered questionnaires that can be used to screen for these yellow flags. Some of these are the Research Diagnostic Criteria/ Temporomandibular Disorders Axis II, Alcohol Use Disorders Identification Test and Patient Health Questionnaire.

CLINICAL IMPLICATIONS

Dentists can improve the quality of care for patients with chronic orofacial pain by screening for psychosocial risk factors and by referring patients with risk factors for psychological or psychiatric assessment and treatment.

The prevalence of temporomandibular joint dysfunction in the mixed dentition

A functional and articular examination was carried out of 136 children (70 boys, 66 girls) aged from 6 to 12 years (6 years 1 month to 12 years 9 months), all presenting with a malocclusion in the mixed dentition and who had not yet received orthodontic treatment. The aim of the study was to examine the prevalence of signs of temporomandibular joint dysfunction (TMD) in this population and to evaluate the possible relationship between certain 'individual' parameters and TMD signs. The results showed an elevated prevalence of muscle tenderness, particularly in the lateral pterygoid muscle, which was found to be sensitive in 80.9 per cent of patients. Muscle tenderness had a tendency to increase with age and was greater on the right side. Temporomandibular joint sounds were present in 35.3 per cent of the subjects and more frequent in girls and in older children. Of the children who presented a mandibular deviation on maximal opening (19.8 per cent), 13.2 per cent had a predominance of opening deviation towards the left. Retruded contact position interferences were present in 57.4 per cent of the children and 72.1 per cent presented lateral and protrusive interferences. Assessment of the maximal amplitudes of mandibular movements did not reveal any limitations. These results indicate that few relationships exist between individual parameters and TMD signs.

Depressive symptoms in Asian TMD patients and their association with non-specific physical symptoms reporting

BACKGROUND

The expression of depression in Asian temporomandibular disorder (TMD) patients may differ from that of their Caucasian counterparts. This study examined the prevalence of depressive symptoms and their association with non-specific physical symptoms (NPSs) reporting in Asian patients.

METHODS

Two hundred and fifty-five Asian TMD patients (68 males; 187 females) with a mean age of 33.0 years were selected for this study. Research diagnostic criteria (RDC)/TMD history questionnaire was input directly into computers by patients using the NUS TMDv.1.1 software. Symptom Checklist 90 (SCL-90) depression and NPS scales were generated online and automatically archived for statistical analysis. Data were subjected to ANOVA/Scheffe's test and Pearson's correlation at significance level 0.05 and 0.01, respectively.

RESULTS

43.1 and 50.6% of the patients scored moderate-to-severe on the depression and NPS scales, respectively. The percentage of patients with diffuse physical symptoms remained high (45.5%), even after pain items were excluded from the computation. NPS scores ranged from 0.34 to 1.64, while depression scores ranged from 0.27 to 1.21. A significant and positive correlation (r = 0.74) was observed between depression and NPS scores.

CONCLUSIONS

The prevalence of depressive symptoms and NPSs was lower in Asian TMD patients. Psychological distress experienced by female Asian TMD patients was comparable to their male counterparts. Results also suggest that depressive symptomatology is associated with the reporting of multiple NPSs.

Prevalence of temporomandibular dysfunction in a group of scuba divers

BACKGROUND

Temporomandibular dysfunction (TMD) has been reported to be a common problem in divers, with a prevalence of up to 68%. No evidence for this is available.

OBJECTIVE

To investigate the prevalence of TMD in divers.

METHOD

Sixty three subjects were asked to retrospectively complete a questionnaire on symptoms of TMD after diving in warm and cold water areas and in daily life.

RESULTS

The prevalence of TMD was greater in female divers. The prevalence of TMD while diving was about 26%, comparable to that experienced in daily life.

CONCLUSION

Improvements in mouthpiece design and lighter demand valves mean that TMD is now probably exacerbated by diving rather than caused by it.