Journal of Craniomandibular Function, 04/2016

Bruxism represents a classical paradox in the fields of dentistry and the life sciences. In the clinic, most dentists have experienced bruxism, and have ideas and beliefs about what it is and how to treat it. Yet bruxism has been very difficult to define and operationalize, and not least from a research perspective, to understand the manifestations of normal physiology and pathophysiological consequences. This selective review will present and discuss some of the current issues and controversies related to the phenomenon of bruxism. Notwithstanding the importance of rigorous systematic reviews for the advancement of this field, the purpose of this narrative review is rather to stimulate critical thinking and question old dogmas and paradigms; moreover, it serves to increase awareness of new opportunities for the assessment and management of bruxism. First, the efforts related to definition and classification will be discussed. Second, the normal physiology of bruxism behavior and the potential pathophysiological consequences of bruxism will be reviewed, with particular focus on craniomandibular pain. Third, the assessment of bruxism will be described using self-reports, clinical examination, and additional tools such as polysomnographic (PSG) recordings and ambulatory electromyographic (EMG) devices. Finally, a short review on the treatment versus the management of bruxism will be presented, with special focus on the novel proposal to use so-called contingent electrical stimulation for the relaxation of the jaw muscles. Keywords: bruxism, electromyography, trigeminal physiology, craniofacial pain, contingent electrical stimulation

Tooth wear is a multifactorial condition, leading to the loss of dental hard tissue, ie, enamel and dentin. Tooth wear can be divided into the subtypes mechanical wear (attrition and abrasion), and chemical wear (erosion). Due to its multifactorial etiology, tooth wear can manifest in many different ways. The condition can therefore be difficult to diagnose and manage. A systematic approach is a sine qua non. In the Tooth Wear Evaluation System (TWES) described in this article (the first in a series of two), all the necessary tools for a clinical guideline are presented in various modules. This allows the clinician to perform a state-of-the-art diagnosis, in both a general practitioner and a referral setting. To avoid the risk of cumbersome usage, the clinician can select only those modules appropriate in a given setting. The modules of the TWES match each other, which is indispensable and essential when different modules are being compared. With the TWES, it is possible to recognize the problem (qualification), grade its severity (quantification), diagnose the likely causes, and monitor (the progress of) the condition. In addition, a proposal for the classification of tooth wear is made. Further, it is possible to determine when to start a treatment, decide which kind of treatment to apply, and estimate the level of difficulty of a restorative treatment. In this first article, the diagnostic modules and proposed classification system are described. Keywords: clinical guideline, diagnosis, qualifying, quantifying, classification, tooth wear

Neuropathic pain is a common concomitant complaint in patients with temporomandibular disorders (TMDs). Careful analysis of the often diverse complex of symptoms is crucial to the correct diagnosis of these cases. Definition of the individual elements of the clinical picture, classification of the nature of the pain (acute, persistent or chronic) as well as decision-making regarding the choice of rehabilitative modalities, the respective therapeutic targets, and the type of specialists to consult for co-treatment are also key elements of successful treatment. The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis II screening instruments are used to assess the prognosis of the individual symptoms. The treatment goals should be reassessed at predetermined times over the course of treatment to modify the treatment path as needed in the event of failure. This article describes the case of a 61-year-old woman who presented with pain in the left maxilla region. The pain had persisted for the previous 5 years and was classified as a combination of persistent myogenic pain and neuropathic pain. Despite a poor initial prognosis (pain of > 5 years' duration, multiple surgeries in the painful region, multilocular pain), her pain, including her neuropathic pain, disappeared over the course of TMD treatment, and the outcome has been stable for 4 years. This case report invites critical discussion on the course of patient management. Keywords: temporomandibular disorders, TMD, myalgia, neuropathic pain, persistent pain

The further development of the scientific knowledge base of functional diagnostics also affects the sector of non-instrumental diagnostics. In this area, examinations are now scientifically established, which - unlike clinical functional analysis - examine the tissue of the masticatory system under loading. The various individual tests in Germany are summarized under the umbrella heading: "Manual Structural Analysis". The catalogue of service items contained in the updated German Dental Fee Schedule (GOZ) of 2012, however, hardly differs from the previous version of 1998. Dentists in Germany are required by the German Dentistry Act to practice dentistry according to the current state of science; yet this is not possible solely on the basis of the outdated content of the service items listed in the GOZ 2012. Instead, the legislator has incorporated into the GOZ 2012 the possibility of billing those dental services not listed as independent service items, according to the type, cost, and time input involved as well as the degree of difficulty of comparable services (termed "analogous services"). The present article describes the legal and scientific background as well as the consequences for implementation of the GOZ 2012 in daily clinical practice. Keywords: craniomandibular dysfunction (CMD), manual structural analysis, clinical functional analysis, manual medicine, Dental Fee Schedule (GOZ), analogous billing