Blepharospasm-oromandibular dystonia syndrome (Brueghel's syndrome). A variant of adult-onset torsion dystonia?

Thirty-nine patients with the idiopathic blepharospasm-oromandibular dystonia syndrome are described. All presented in adult life, usually in the sixth decade; women were more commonly affected than men. Thirteen had blepharospasm alone, nine had oromandibular dystonia alone, and 17 had both. Torticollis or dystonic writer's camp preceded the syndrome in two patients. Eight other patients developed toritocollis, dystonic posturing of the arms, or involvement of respiratory muscles. No cause or hereditary basis for the illness were discovered. The evidence to indicate that this syndrome is due to an abnormality of extrapyramidal function, and that it is another example of adult-onset focal dystonia akin to spasmodic torticollis and dystonic writer's cramp, is discussed.

The efficacy of oral splints in the treatment of myofascial pain of the jaw muscles: a controlled clinical trial

Oral splints are widely used in the treatment of myofascial pain of masticatory muscles, even though their mechanism of action is unknown. The present study evaluated the therapeutic efficacy of splints using a parallel, randomized, controlled and blind design. Following a sample size estimation, 63 subjects were recruited and assigned to 3 groups: (1) passive control: full occlusal splint worn only 30 min at each appointment; (2) active control: palatal splint worn 24 h/day; and (3) treatment: full occlusal splint worn 24 h/day. On each of 7 visits over 10 weeks, subjects rated on 100 mm visual analogue scales their pain intensity and unpleasantness at rest and after experimental mastication. The effect of pain on the quality of life was also rated on category scales. All pain ratings decreased significantly with time, and quality of life improved for all 3 groups. However, there were no significant differences between groups in any of the variables. These data suggest that the gradual reduction in the intensity and unpleasantness of myofascial pain, as well as the improvement of quality of life during the trial, was non-specific and not related to the type of treatment.

Botulinum toxin injection for the treatment of oromandibular dystonia

Dystonia is a neurologic disorder characterized by abnormal, involuntary movements causing twisting and turning postures; it is postulated to be a disorder of central motor processing. The dystonias, when classified by region of the body involved, have been characterized as focal, segmental, and generalized. Focal dystonia can affect jaw mechanics, leading to forceful contraction of the jaw muscles and resulting in inappropriate deviation of the jaw. Localized injections of botulinum toxin have been used successfully in the management of other focal or segmental dystonias. We have treated 20 oromandibular dystonia patients with botulinum toxin. Six patients had only jaw and tongue involvement; 11 had blepharospasm and jaw involvement; and three had jaw involvement as part of a more generalized dystonia. Five patients had been diagnosed originally and treated as having temporomandibular joint syndrome. All but one of the patients had improvement of their symptoms with the toxin injections. The patients averaged 47% improvement with the injections.

Is the jaw-opening reflex a valid model of pain?

Tooth pulp shock does not produce only pain; low intensity stimulation results in a non-painful sensation that is termed pre-pain. In animals low intensity tooth pulp shock does not evoke escape behavior; the similarity of the animal escape/detection threshold ratio with the human pain/pre-pain threshold ratio is evidence that pre-pain and pain may be present in animals as in humans. Both pre-pain and pain may arise from the activation of a common afferent modality. The TP-JOR does not correlate with the degree of pain experienced under all conditions. The TP-JOR threshold is at or near the sensory detection threshold, at stimulation intensities which evoke pre-pain. Under normal conditions both the magnitude of the TP-JOR response and the degree of pain experienced increase with increasing stimulation intensity. The TP-JOR and the tooth pulp-evoked pain are affected in parallel by sensory habituation and both appear to relay in the rostral trigeminal complex. There are no cases where the TP-JOR is suppressed and pain is still experienced from tooth pulp shock; the suppression of the TP-JOR may therefore be an accurate index of analgesia. However, in humans treatments that produce analgesia have not been shown to produce suppression of the TP-JOR. Thus, the TP-JOR that persists following analgesic treatments is not a reliable index of either analgesia or pain.

The use of intraoral dexamethasone after extraction of mandibular third molars

All oral surgeions have encountered problems associated with edema, trismus, and pain after intraoral procedures. In third-molar surgery, pain and trismus are often directly proportional to edema. Therefore, in the patient with minimal edema, pain and trismus should be proportionally reduced. Parenteral use of the corticosteroid dexamethasone, given as a transoral injection at the time of operation, appears to be effective in the prevention of postoperative edema.

Effect of occlusal splints on TMJ symptomatology

The clinical response of TMJ symptomatology to full-coverage occlusal splints, when used as the only means of treatment, was evaluated. The symptomatology recorded during the last postoperative visit was compared to the initial visit. The response of the different symptoms to the use of the occlusal splint was analyzed statistically using a chi-square test. A statistically significant difference (p = .03) was only found when comparing those groups having only pain or dysfunction symptomatology. The response favored the remission of pain. However, every symptom was improved with the use of an occlusal splint. It was concluded that: 1. Both pain and dysfunction symptomatology will benefit from the occlusal splint therapy. 2. The pain response will be significantly better than the dysfunction response when the patient is treated with an occlusal splint. 3. Eighty percent of the patients suffering from a TMJ syndrome will improve or be cured when the only form of treatment is the use of a full-coverage occlusal splint.

Focal dystonia of the jaw and the differential diagnosis of unilateral jaw and masticatory spasm

The clinical features, differential diagnosis and treatment of unilateral spasms of the jaw and masticatory muscles are discussed and illustrated by eight cases of unilateral jaw spasms of various aetiologies. These include focal dystonia of the jaw, hemimasticatory spasm with and without facial hemiatrophy, paroxysmal events in multiple sclerosis and tetany. Attention is particularly drawn to four cases of unilateral dystonia of the jaw which has not been described before.

Temporalis fascia grafts for facial and nasal contour augmentation

For the past 70 years, fascial grafts have been used in reconstructive surgery mainly because of their tensile strength. Although the thigh (fasciae latae) has been the principal donor site, fascia taken from the temporalis muscle has the advantages of (1) ease of harvest under local anesthesia, (2) usually being in the same operative field, (3) minimal postoperative discomfort, and (4) negligible residual scar deformity. These grafts can be effectively used as the sole source of contour augmentation of facial depressions in primary as well as secondary rhinoplasty. Such grafts undergo an initial uniform shrinkage (approximately 20 percent) during the first 4 to 6 weeks postoperatively due to compaction and condensation of the fibrous tissue of the fascia, after which the grafts stabilize and become firm. Concavities should be overcorrected accordingly. No inflammation or encapsulation has been seen clinically or histologically in 18 patients followed for periods ranging from 6 to 18 months.

Musculo-articular disorders of the stomatognathic system in school children examined according to clinical criteria

The present investigations were undertaken for establishing the frequency of musculo-articular disorders of the stomatognathic system in healthy children as well as determining their features and degree. The study covered 500 children from Warsaw's primary schools--250 children aged 6-8 years and 250 aged 13-15 years. An incidence of disorder of 56-4 and 67-6% was found in the groups of younger and older children, respectively; their number and severity being significantly higher among the latter. The chi-square test showed no relation between the disorders of the temporomandibular joint and malocclusion or the premature loss of teeth in the group of younger children; in the older group the correlation was significant but of very low degree. The suggestion is made that the correlation between musculo-articular disorders, malocclusions and loss of teeth, is probably determined by the length of time during which the dysfunction is exerting its effect.

Prevalence of spontaneous lingual-facial-buccal dyskinesias in the elderly

The prevalence of spontaneous lingual-facial-buccal movements was determined in 661 patients between the ages of 50 and 79 without neuroleptic exposure or known CNS disease. The prevalence was 0.8% between ages 50 and 59, 6% between ages 60 and 69, and 7.8% between ages 70 and 79.

Edentulous orodyskinesia

Twelve of 75 (16%) edentulous patients (mean age, 62 years) were found to have orofacial dyskinesias. Tooth extraction averaged 12 years before the onset of movements. No dentures were present in 50% of dyskinetic patients and in 9.5% of edentulous patients without dyskinesia. Movements of the lips, tongue, and jaw were marked in 3 patients and mild in 9. Functional disability was minimal. None of 75 elderly patients (mean age, 68 years) without tooth extractions had oral dyskinesias.

Neural mechanisms of temporomandibular joint and masticatory muscle pain: a possible role for peripheral glutamate receptor mechanisms

The purpose of the present review is to correlate recent knowledge of the role of peripheral ionotropic glutamate receptors in the temporomandibular joint and muscle pain from animal and human experimental pain models with findings in patients. Chronic pain is common, and many people suffer from chronic pain conditions involving deep craniofacial tissues such as temporomandibular disorders or fibromyalgia. Animal and human studies have indicated that the activation of peripheral ionotropic glutamate receptors in deep craniofacial tissues may contribute to muscle and temporomandibular joint pain and that sex differences in the activation of glutamate receptors may be involved in the female predominance in temporomandibular disorders and fibromyalgia. A peripheral mechanism involving autocrine and/or paracrine regulation of nociceptive neuronal excitability via injury or inflammation-induced release of glutamate into peripheral tissues that may contribute to the development of craniofacial pain is proposed.

Biofeedback in the treatment of long-term temporomandibular joint pain: an outcome study

Eleven patients with long-term pain related to the temporomandibular joint (TMJ) were trained in tension awareness and relaxation using feedback of muscle tension level in the masseter through a digital display. At a follow-up examination 4-15 months after the termination of treatment, 8 of the 11 patients were totally symptom-free or significantly better; 1 patient was slightly better, and there was no effect for 2 patients. Possible reasons for failure and sex differences are discussed.

The effect of mandibular advancement appliances on awake upper airway and masticatory muscle activity in patients with obstructive sleep apnoea

BACKGROUND

There is little understanding of how dental appliances, designed to posture the mandible forwards, act on pharyngeal airway dilatory and masticatory muscles in patients with obstructive sleep apnoea (OSA). This study evaluates, in a prospective cohort design, the effect of mandibular advancement splints (MAS) on awake genioglossus (GG), geniohyoid (GH) and masseter (M) muscle activity.

METHODS

Fifty OSA patients received a custom-made removable Herbst MAS appliance, adjusted for maximum therapeutic benefit, as judged by subjective improvement. Awake electromyographic (EMG) activity was recorded at baseline and with the MAS in situ, by using bipolar surface electrodes in patients seated upright and in the natural head position. The lower splint was modified to facilitate the placement of the intra-oral bipolar surface electrodes used to record GG EMG activity.

RESULTS

Significant increases in GG (P = 0.041), GH (P<0.001) and M (P<0.001) muscle activity accompanied placement of the MAS.

CONCLUSIONS

These findings support the contention of a physiological role, which may act to augment the anatomical action of MAS.

A descriptive survey of signs and symptoms associated with the myofascial pain-dysfunction syndrome

The signs and symptoms of 56 patients with myofascial pain-dysfunction syndrome were tabulated. Patients were classified by age, sex, education and professional background, frequency of complaints of pain, occlusal relationships, oral habits, and specific muscles that were tender on palpation. A coincidence of stress and tension and the onset of myofascial pain was observed. It is suggested that myofascial pain may be more common in women than in men. Muscle tenderness was associated particularly with the masseter, temporal, and lateral and medial pterygoid muscles.

Masseter inhibitory reflex in movement disorders. Huntington's chorea, Parkinson's disease, dystonia, and unilateral masticatory spasm

Evoked by electrical stimulation of the mental nerve, the masseter inhibitory reflex consists of an early and a late silent period (SP1 and SP2), which interrupt the voluntary electromyographic (EMG) activity in the masseter muscle. We recorded the masseter inhibitory reflex and measured its latency, depth of suppression, duration and recovery cycle to paired stimuli, in patients with Huntington's chorea. Parkinson's disease, dystonia, or unilateral masticatory spasm. In patients with Huntington's chorea the reflex data and recovery cycle were normal. In patients with Parkinson's disease or dystonia, although the reflex data were normal, SP2 recovered far more rapidly than it did in control subjects. This is possibly due to hypoactivity of an inhibitory control of the polysynaptic chain of ponto-medullary interneurons that mediate SP2. In patients with unilateral masticatory spasm, both SP1 and SP2 were absent. Suppression is probably absent because this involuntary movement originates at a point along the peripheral course of the nerve.

Mandibular asymmetry and its relation to pain dysfunction

Fifty-three subjects were examined for mandibular asymmetry using measurements from submental-vertex and frontal cephalograms. All subjects displayed malocclusions and were examined for sensitivity of the muscles of mastication to palpation. The amount of pretreatment pain to muscle palpation was then correlated to the degree of asymmetry found. No statistically significant correlation was shown between mandibular asymmetry and muscle sensitivity. The following conclusions were drawn from this study: 1. There was no correlation between the amount of mandibular morphologic asymmetry and the amount of facial pain elicited from muscle palpation. 2. In the sample used, asymmetry seemed to be the rule rather than the exception. 3. The clinician needs to be aware of asymmetry in all three planes of space in order to plan his occlusal treatment in advance and prepare patients for possible compromise. 4. Class II molar and canine relationships may be more difficult to correct on the patient's right side than on his left, provided there is no compensation from glenoid fossa position or the maxillary dentition.

Needling therapies in the management of myofascial pain of the masticatory muscles: A network meta-analysis of randomised clinical trials

OBJECTIVE

A network meta-analysis (NMA) of randomised clinical trials (RCTs) was performed aiming to compare the treatment outcome of dry needling, acupuncture or wet needling using different substances in managing myofascial pain of the masticatory muscles (TMD-M).

METHOD

An electronic search was undertaken to identify RCTs published until September 2019, comparing dry needling, acupuncture or wet needling using local anaesthesia (LA), botulinum toxin-A (BTX-A), granisetron, platelet-rich plasma (PRP) or passive placebo versus real active placebo in patients with TMD-M. RCTs meeting the inclusion criteria were stratified according to the follow-up time: immediate post-treatment to 3 weeks, and 1 to 6 months post-treatment. Outcome variables were post-treatment pain intensity, increased mouth opening (MMO) and pressure threshold pain (PPT). The quality of evidence was rated according to Cochrane's tool for assessing risk of bias. Mean difference (MD) was used to analysed via frequentist NMA using Stata software.

RESULTS

Twenty-one RCTs involving 959 patients were included. The quality of evidence of the included studies was low or very low. There was significant pain decrease after PRP when compared to an active/passive placebo and acupuncture. There was a significant improvement of MMO after LA (MD = 3.65; CI: 1.18-6.1) and dry needling therapy (MD = 2.37; CI: 0.66-4) versus placebo. The three highest ranked treatments for short-term post-treatment pain reduction in TMD-M (1-20 days) were PRP (95.8%), followed by LA (62.5%) and dry needling (57.1%), whereas the three highest ranked treatments at intermediate-term follow-up (1-6 months) were LA (90.2%), dry needling (66.1%) and BTX-A (52.1%) (all very low-quality evidence). LA (96.4%) was the most effective treatment regarding the increase in MMO followed by dry needling (72.4%).

CONCLUSION

Based on this NMA, one can conclude that the effectiveness of needling therapy did not depend on needling type (dry or wet) or needling substance. The outcome of this NMA suggests that LA, BTX-A, granisetron and PRP hold some promise as injection therapies, but no definite conclusions can be drawn due to the low quality of evidence of the included studies. This NMA did not provide enough support for any of the needling therapies for TMD-M.