Journal of Oral & Facial Pain and Headache, 04/1997

The McGill Pain Questionnaire is an instrument that is widely used to assess the multidimensional experience of pain. Although it was introduced more than 20 years ago, limited information is available about its use in patients suffering from persistent facial pain. The aim of this study was to investigate the response patterns of persistent facial pain patients to the McGill Pain Questionnaire, to correlate these patterns with patients' beliefs about the seriousness of the condition, and to compare the findings with data reported from other painful conditions. The study sample consisted of 200 consecutive female patients referred to a tertiary care facial pain clinic. The Pain Rating Index scores of the McGill Pain Questionnaire subscales and the total number of words chosen by these patients closely matched the summary scores reported by Wilkie et al, who pooled data from seven pain conditions (cancer, chronic back, mixed chronic, acute/postoperative, labor/gynecological, dental, and experimentally induced) in their meta-analysis. On the other hand, when the data collected in this study were compared with those from specific clinical subsets, such as cancer patients, chronic back pain patients, or dental patients, differences in McGill Pain Questionnaire scores could be identified. Differences were also found in the choice of specific pain descriptors. More than 20% of the faci al pain patients selected radiating and pressing ; thi s was not the case for those suffering from other pain conditions. Facial pain patients who felt that their condition was more serious or different from what the treatment providers had told them had a greater likelihood of choosing specific word categories of the McGill Pain Questionnaire.

The purpose of this study was to determine the relationship between tongue position and mandibular muscle activity. Thirty-three subjects (28 women) between the ages of 18 and 34 years (mean = 22.1 years) with no prior inju ry to or pain in the jaw, mouth, or tongue participated in the study. Subjects were asked to rest quietyly while baseline electroymyographic recordings were made from the temporalis, masseter, and suprahyoid muscle regions. Afterwards, subjects were randomly assigned to conditions requiring them to position the tongue either against the anterior palate or on the floor of the mouth, making sure the tip does not press against any part of the mouth. The results indicated that right temporalis activity was higher when the tongue was positioned against the roof of the mouth than when it was either at baseline or resting on the floor of the mouth (P .03). A similar pattern of results was observed for the suprahyoid muscle group (P .01). There were no significant differences in masseter muscle activity as a function of tongue position (Ps > .20). These findings suggest caution in labeling the rest position of the tongue and indicate that further study of the relationship between tongue position and orofacial pains is needed.

Temporalis muscle activity in tension-type headache subjects ( n = 36) and in matched nonheadache controls (n = 36) was evaluated in this study. Subjects' cumulative temporalis muscle activity was recorded every 30 minutes for 3 days and nights using an electromyographic recorder. Analysis of variance showed that neither the waking nor the sleeping overall muscle activity levels for these two groups were statistically different. When the waking EMG data were dichotomized into function and nonfunction activites, a significant difference was found between groups during jaw function (ie, chewing and talking). These data suggest that headache subjects are using their temporalis muscles with less efficiency than nonheadache subjects during function. This elevated EMG is more likely a consequence of pain (via protective splinting or guarding) rather than a cause in tension-type headache sufferers.

In patients with myofascial pain, painful trigger points are often treated using dry needling and local anesthetic injections. However, the therapeutic effect of these treatments has been poorly quantified, and the mechanism underlying the effect is poorly understood. In a randomized, double-blind, double-placebo clinical trial, a pressure alogmeter was used to measure pain-pressure thresholds in the masseter and temporalis muscles of 30 subjects aged 23 to 53 years with myofascial pain in the jaws, before and after a series of dry needling treatments. local anesthetic injections, and simulated dry needling and local anesthetic treatments (treatment group A: Procaine + simulated dry needling; treatment group B: dry needling + simulated local anesthetic; control group C: simulated local anesthetic + simulated dry needling). Subjects rated pain intensity and unpleasantness using visual analogue scales, and the data were analyzed using analysis of variance. Pain pressure thresholds increased slightly after treatment, irrespective of the treatment modality. Pain intensity and unpleasantness scores decreased significantly at the end of treatment in all groups. There were no statistically significant between-group differences in pain pressure thresholds and visual analogue scale scores at the end of treatment. The findings suggest that the general improvement in pain symptoms was the result of nonspecific, placebo-related factor s rather than a true treatment effect. Thus, the therap eutic value of dry needling and Procaine in the management of myofascial pain in the jaw muscles is questionable.

The natural course of untreated nonreducing disc displacement of the temporomandibular joint was evaluated in 52 patients (total of 57 affected temporomandibular joints). The association between the clinical findings at the initial visit and the outcome at 12 months for the age, range of motion for maximum mouth opening, intercuspal-occlusal relationship, morphology of the mandibular fossa and the articular eminence, and the locking d uration was evaluated. Good resolution was seen in 59.6% of the patients. The patients with good resolution were significantly younger than those with poor resolution (P .05, two-tailed t test); however, there were no differences in any other factors between the patients with good resolution and those with poor resolution. Natural resolution of clinical signs and symptoms was suggested for the majority of patients with nonreducing disc displacement of the TMJ, and a younger age at the initial visit appears to be a positive factor in the prognosis.

The predictive value of radiographic tomoraphy was assessed using magnetic resonance imaging as a definitive test of TMJ soft-tissue status in a predominantly asymptomatic adolescent sample. Eighty-two TMJs in 41 subjects (mean age = 12.5 years, range = 10 to 17 years) were independently evaluated using axially corrected tomography and magnetic resonance imaging. Tests of comparison and correlation were performed. Correspondence of tomographic classifciation to magentic resonance imaging classification on nondisplacement (55%), reducing internal derangement (35%), or nonreducing internal derangement (10%) showed a significant relationship (P .05). Tomography as a diagnostic test of abnormal disc position had a sensitivity of 0.43, a specificity of 0.80, a positive predictive value of 0.64, and a negative predictive value of 0.63. Tomography is inappropriate as a diagnostic test for TMJ internal derangement.

The purpose of this study was to determine if there was a difference between the temporomandibular condylar movement patterns of a symptomatic adult population and those of an asymptomatic adult population. Thirty-five volunteers who were not seeking treatment for TMD underwent two different assessments for TMD signs and symptoms: (1) a self-administered questionnaire and (2) a clinical examination. Based on the information obtained from the questionnaires, subjects were divided into reported-symptomatic and reported-asymptomatic groups. Based on the investigator's clinical evaluation of the same subjects, subjects were divided into clinically symptomatic and clinically asymptomatic groups. To compare condylar movement patterns, both groups of subjects then had their mandibular border condylar movements measured bilaterally using a sagittal recording device during maximum opening, maximum protursion, and maximum left and right excursion movements. The patterns were separated into two broad groups, symmetric and asymmetic. Symmetric gliding movements were defined as uninterrupted bilaterally mirror-like patterns of each donyle with a difference between left and right total length excursion not exceeding 2 mm during opening in the sagittal plane or horizontal plane. Our results show that 63% of the subjects who reported clinically asymptomatic for TMD demonstrated asymmetric condylar movements. However, 100% of the patients (n = 5) who reported clinically symptomatic for TMD exhibited asymmetric condylar movements. This finding suggests that, while a very high percentage of TMD subjects will have asymmetric condylar movements, condylar movements alone are not necessarily diagnostic of TMD, and the sagittal recording device may alert the clinician to abnormal movements.

The influence of previous trauma in the management of patients with temporomandibular disorders (TMD) is controversial. The objectives of htis study were to compare treatment regimens and outcomes in motor vehicle accident trauma-related versus non-trauma-related TMD patients. Files of 50 trauma and 50 matched nontrauma TMD patients were reviewed. Information concerning treatment received, progress of symptoms with treatment, and findings from the final examination were recorded. As a whole group, posttraumatic TMD patients tended to receive more types of treatment (P .0001), have more medications prescribed (including analgesics, P .001; nonsteroidal anti- inflammatory drugs, P = .001), have more oral medicine clinic visits (P = .07) over a longer period of time (P = .06), and have a poorer treatment otucome (P .001) as compared to the nontrauma group. When the patients were separated into TMD diagnostic classifciation subsets, only some of htese differences between trauma and nontrauma patients were seen, but the subset group sizes were small and only a few of the groups could be compared. There did not seem to be a significant effect from settling insurance claims prior to the last clinic visit. Trauma may be an important prognostic factor in the management of some TMD patients.

An open-label trial of clonidine, an a2-adrenergic agonist, was prescribed for patients with a clinical diagnosis of oral neuropathic pain or neuralgia involving the oral cavity. Clonidine (0.2 mg/g) was prepared in a cream base and applied four times daily to the site of pain. Seventeen patients were assessed: 10 were diagnosed with neuropathic pain, and 7 with neuralgia. Two of the 17 patients had complaints overlapping both neuropathic and neuralgic pain. In the patients with neuropathic pain, an overall mean reduction in severity of burning of 3% (on a 10-point visual analogue scale) was reported. Half of these patients reported clinical improvement; however, no patients reported complete resolution of symptoms. Of the patients with characteristics of neuralgia, 57% improved; and in those who reported improvement, a mean reduction of approximately 54% was reported. In the 4 patients with neuralgia who responded, a 94% reduction in pain was reported, with complete resolution of pain in 2 patients. This open-label clinical trial suggests that topical clonidine may be effective in the management of some patients with oral neuralgia-like pain, but may have a more limited effect in those paitents with oral neuropathic pain. Besides type of pain, no other variables predicted which of the patients would achieve pain reduction with topical clonidine. Although confirmation of cli nical efficacy requires double-blind clinical studies, this initial trial suggests that further study is warranted.

Certain types of jaw-muscle pain may be managed with pharmacologic treatment. This study evaluated the effect of topical and systemic nonsteroidal anti-inflammatory drugs on acute postexercise jaw-muscle soreness. Ten men without temporomandibular disorders performed six 5-minute bouts of submaximal eccentric jaw exercise. The outcome variables were pressure pain thresholds and pain tolerance thresholds at the masseter muscles, and maximum voluntary occlusal force. Surface electromyography from the masseter muscles was used to assess the development of muscle fatigue during the exercise period. Three treatment modalities were tested in a placebo-controlled, double-blind approach: (A) placebo gel and placebo tablets; (B) nonsteroidal anti-inflammatory drug gel (2 g, 5% ibuprofen) and placebo tablets; and (C) placebo gel and nonsteroidal anti-inflammatory drug tablets (400 mg ibuprofen). The subjects used their medication 3 times a day for 3 days in the post-exercise period. In the exercise period, the mean power frequency of the electromyography signal, pressure pain threshold, pain tolerance threshold, and maximum voluntary occlusal force decreased significantly (analysis of variance, P .01). In the postexercise period, the effect of treatment on pressure pain thresholds was significant (F[2,9] = 4.41, P = .02). On day 3, treatment with topical nonsteroidal anti-inflammatory drugs was assoicated with significantly higher pressure pain thresholds as compared to treatment with systemic nonsteroidal anti-inflammatory drugs (P .05) and placebo (P .05). Treatment effects on pain tolerance thresholds and on maximum voluntary occlusal force were nonsignificant. The results demonstrated that repeated eccentric jaw exercise caused muscle fatigue and low levels of postexercise pain and soreness. Topical nonsteroidal anti-inflammatory drugs seem to have some advantages over systemic nonsteroidal anti-inflammatory drugs for management of exercise-induced jaw-muscle pain.