Journal of Oral & Facial Pain and Headache, 01/1998

In this study, pain was induced in the masseter muscle by tonic infusion of hypertonic saline (5%) for up to 800 seconds in 12 healthy men. Subjects continuously scored the pain intensity on a 10-cm visual analogue scale. Mastication ipsilateral and contralateral to the infusion side was quantitatively assessed with the use of jaw-tracking and electromyograph recordings of jaw-closing muscles before, during, and after periods of constant muscle pain intensity. The maximum voluntary occlusal force (MVOF) during short static contractions also was monitor ed. Jaw movements and electromyographic data were divided into single masticatory cycles and analyzed on a cycle-by-cycle basis to account for intercycle variability. In all subjects, tonic infusion (mean VAS ± SE, 4.6 ± .3 cm). MVOF was significantly affected by muscle pain (P .0005), with significantly lower MVOF during pain compared to prepain and postpain (P .05). In a significant number of masticatory cycles, the averaged electromyograph activity of all jaw-closing muscles during their agonist function was decreased for both ipsilateral and contralateral painful mastication (P .05). These electromyographic changes are probably a reflection of the natural bilateral recruitment pattern of jaw-closing muscles during mastication. Significant changes in jaw movements during painful mastication could not be detected with the present jaw-tracking device, but further studies with more accurate and sensitive devices are needed.

The purpose of this study was (1) to evaluate the reproducibility of two masticatory muscle and joint tenderness detection methods; (2) to evaluate the reproducibility of maximum mandibular movement measurements; and (3) to investigate factors influencing examiner agreement. The tenderness assessment procedures involved application of a standard pressure for 2 seconds over four anatomically defined masticatory muscle sites, one control forehead site, and two temporomandibular joint sites on each side of the face. One technique utilized a pressure algometer (PAP), while the other technique required that a trained examiner apply pressure with the index fingertip (FPP). Seventy-two subjects (36 patients and 36 controls) were evaluted in a single-blind study design. Control subjects were matched for age, gender, and race with temporomandibular disorder subjects. Each subject was examined twice with each of the described methods in a randomized, fully balanced sequence by calibrated examiners. Tenderness levels were determined by the subject via self-report of pain upon pressure using a standard set of verbal descriptors. Maximum pain-free, active, and passive opening, and maximum active right and left lateral movements were measured using a millimeter ruler. Intraclass correlation coefficients (ICC) for the tenderness assessment methods ranged from 0.220 to 0.739 for the FPP method and from 0.391 to 0.880 for the PAP method. ICCs for mandibular movement measurement were much less variable, ranging from 0.59 to 0.68 for lateral movement and from 0.78 to 0.93 for opening movement. These results indicate good to excellent agreement between calibrated examiners for mandibular movement measurement and for tenderness assessment methods at two masseter (ie, superficial and deep) and the anterior temporalis sites. Only fair agreement was found for the middle temporalis and lateral TMJ capsule sites using these methods.

This study focuses on the influence of trait anxiety and mood variables on changes in tooth pain threshold following two similar methods of somatic afferent stimulation, one familiar (manual acupuncture) and one unfamiliar (low-frequency transcutaneous electrical nerve stimulation [low-TENS]). Twenty-one acupuncture responders, treated for long-lasting orofacial muscular pain but naive to low-TENS, were selected for the study. In a n experimental session, acupuncture and low-TENS were randomly given during two periods separated by a rest int erval. Tooth pain thresholds (PT) were measured before and after stimulation with a computerized electrical pulp tester. Trait anxiety and depression were assessed with psychometric forms before the experimental session in all patients, whereas momentary mood was assessed in 10 randomly selected patients with visual analogue scales during and after the two types of stimulation. Following acupuncture, the group average PT increased significantly, whereas no significant change was observed following low-TENS. Higher scores on trait anxiety correlated significantly with a low PT increase following low-TENS, and higher ratings of stress correlated significantly with a low PT increase following acupuncture. This indicates that the magnitude of analgesia induced by these methods may be modified by psychologic factors like anxiety and stress.

The aim of this study was to investigate common symptoms and divergent features in fibromyalgia (FS) and masticatory myofascial pain (MFP) in patients affected by cran iomandibular disorders. Twenty-three women with MFP and 23 women with FS were studied. All patients were examined by a dentist and by a rheumatologist. Craniomandibular disorders were assessed with a subjective symptoms questionnaire, detailed history interview, joint function examination, and manual palpation of masticatory and cervical muscles. The Middlesex Hospital Questionnaire was used to obtain personality profiles of the patients. The craniomandibular disorders questionnaire revealed various similarities in the two groups, the most striking of which were pain during mandibular function, articular noises, and headache. Both groups had muscle lpain upon palpation; the mean scores (on a 0 to 4 scale) did not differ significantly between the two groups and ranged between 1.39 (SD 1.2) and 2.86 (SD 0.75). The mean value of active mouth opening was 40.9 mm (SD 9.1) in MFP patients and 44.6 mm (SD 7.2) in FS patients, while the mean value of passive opening was 49.6 mm (SD 6.0) in MFP pati ents and 49.8 mm (SD 3.5) in FS patients. These values did not differ significantly between the two groups, bu t did differ from the normal population, similar to the trend of the psychologic profile. The authors conclude that the physician should be alert to the need to conduct interdisciplinary evaluations in the diagnosis and management of FS and of MFP.

Recently developed Research Diagnostic Criteria for Temporoman dibular Disorders (RDC/TMD) have been shown to be reliable for diagnosing and assessing TMD in U.S. and Swedish adult populations; however, few studies have focused on clinical examination methods and diagnostic criteria for use with children and adolescents. The rpesent study used a sample of 50 Swedish children and adolescents, aged 12 to 18 years, to evaluate usefulness and reliability of existing and spcially developed measures and methods for assessing and diagnosing TMD in youth. Subjects underwent repeated clinical exams by two calibrated examiners to assess signs and symptoms per the RDC/TMD, and they responded to a specially developed self-admi nistered questionnaire that addressed location and frequency of TMD-related pain and of pain medications. Interexaminer and intraexaminer reliability was assessed for clinical examination, questionnarie items, and diagnosis. Reliability values ranged from acceptable to excellent for the RDC/TMD clinical exam and questionnaire, and from good to excellent reliability for measuring virtually all modified clinical parameters of TMD assessed in these young patients.

Over a 7-year period, 12 patients experienced recurrence of primary head and neck cancers preceded by severe orofacial pain. Pain began within 6 months following treatment in 10 of 12 patients and was progressive in 11 of 12 patients. Six patients died from recurrence, five within 2 years following onset of pain. No clear indication of malignant disease was evident despite clinical examination, plain radiography, magnetic resonance imaging, and computed tomography. Pain was often mistaken for denture irritation. Frequently, no area of irritation was apparent.

Knowledge about the different kinds of treatment provided to patients with nonmalignant musculoskeletal facial pain is limited. The present study was based on 206 consecutive patients who were referred to a university-based tertiary care clinic for the diagnosis and management of persistent facial pain. Its purpose was to get information about the number and spcialty of providers consulted by pateints prior to their referral, and to follow the underlying treatment-seeking patterns. The results showed that on average 4.88 providers from 44 different categories were consulted. A general dentist or a dental specialist was seen by about 70% of patients. For patients whose first provider was a dentist, the most likely subsequent provider was another dentist. Conversely, if the first provider was a physician, chances were greater that the subjsequent provider was a physician rather than a dentist. Among the nondental therapies patients received, physical therapy was chosen most frequently (42.2%). More than 60% of patients had at least one nondental treatment; however, the majority of these patients experienced two or more different types of such therapy (eg, chiropractic, osteopathic, relaxation training). Patients' satisfaction with care and treatment was moderate, since only 18.5% of the patients were very satisfied, while 27.7% were dissatisfied or very dissatisfied. The present findings, which corroborate a recent study from the Kansas City, Missouri, region, indicate that patients with persistent facial pain see a large number of different providers, and that nonmedical/nondental treatment approaches are common. The moderate satisfaction experienced with any of the therapies points out that much needs to be done before this patient population is served satisfactorily.

Associations between treatment need for temporomandibular disorders (TMD) and age, gender, stress, and diagnostic subgroup were analyzed in ad adult Finnish population sample of 506 subjects. When analyzed separately, the associat ion between TMD treatment need and all the studied factors was statistically significant. This finding is in accordance with earlier results. When the studied factors were included into an explanatory model, however, the picture changed. The logistic regerssion analysis revealed that diagnostic subgroup was the strongest predictor for the TMD treatment need. Total stress score significantly added to the explanatory power of the model, but age and gender did not. The commonplace observation that women show more signs and symptoms of TMD see ms to be explainable by their higher stress scores and by the type of symptoms.

Because of a lack of substantial scientific data, the efficacy of occlusal therapy for the management of temporomandibular disorders (TMD) is still controversial. Of a total of 1405 consecutive TMD patients examined over the last 10 years, 369 (26.3%) were determined to have completed treatment at least 1 year before the present survey. A sample questionnaire was mailed to each patient in this sample population. The questionnaire failed to reach 46 patients; of the 323 patients who received the questi onnaire, 260 (80.5%) responded. The mean duration of time between their last visit and this survey was 3.7 years. The questionnarie elicited information on treatment outcomes, present treatment needs, and current signs and symptoms. Participants were divided into two treatment groups: (a) those who underwent some occlusal therapies (Phase II) following successful reversible therapies (Phase I) (20 men and 114 women); and (b) those who underwent reversible therapy only (33 men and 93 women). Participants were further differentially diagnosed into five diagnostic subgroups of TMD, based on the clinical examination at the initial visit, tomography, and, for some patients, magnetic resonance imaging. The subgroups included myalgia, arthralgia, anterior disc displacement with and without reduction, and osteoarthritis/osteoarthrosis. Only 12.3% of the total population surveyed reported lack of improvement to an acceptable level and further need for treatment. The remaining patients reported satisfactory results in the reduction of TMD symptomatology and no furthe rneed for treatment, because their symptoms had either disappeared or improved to an acceptable level. Regardless of treatment groups and diagnostic subgroups, the current subjective signs and symptoms were negligible in most patients, and mean mouth openings were in the normal range. No particular diagnostic subgroups seemed to have significantly better outocme following Phase II occlusal therapy. These results suggest that the majortiy of TMD signs and symptoms improve to an acceptable level with only reversible therapy, and the long-term value of additional occlusal therapy following reversible therapy is minimal. Therefore, permanent occlusion-changing therapies apparently are not generally needed to maintain TMD symptom reduction over time.