Journal of Oral & Facial Pain and Headache, 01/2011

This article presents a comprehensive review of the literature on the diagnosis of pain in the orofacial region of patients suffering from a cognitive impairment or a dementia. This review was based on a literature search yielding 74 papers, most of which dealt with the assessment of pain in general in nonverbal individuals, for which several observational tools were developed. Unfortunately, none of these tools have been designed for the specific assessment of orofacial or dental pain. Thus, none of them can be recommended for use in the dental setting. There is hardly any information available in the literature on how to assess orofacial and/or dental pain in patients with a cognitive impairment or a dementia. Given the expected increase in the incidence of dementia over the upcoming decades, it is of the utmost importance that dentists can use well-tested tools that can help them in the diagnosis of orofacial and dental pain in this vulnerable patient population. Such tools should incorporate specific orofacial/dental pain indicators, such as the patient holding/rubbing the painful orofacial area, limiting his/her mandibular movements, modifying his/her oral behavior, and being uncooperative/resistant to oral care. Keywords: assessment, cognitive impairment, dementia, dentistry, orofacial pain

Aims: To compare pain sensitivity between deep bite patients and a sex- and age-matched control group with normal occlusion. Methods: Pain sensitivity was assessed by injections of the excitatory amino acid glutamate into the masseter and brachioradialis muscles. Intensity of glutamate-evoked pain was scored by the subjects ( n = 60) on a 0 to 10 cm visual analog scale. Subjects drew the perceived pain area on a face and arm chart and described the quality of pain on the McGill Pain Questionnaire. Thresholds for cold detection, cold pain, cold tolerance, warmth detection, heat pain, and heat tolerance were assessed on the masseter and brachioradialis muscles. Pressure pain threshold and pain tolerance threshold were determined on the temporomandibular joint, masseter, anterior temporalis, and brachioradialis muscles. The differences between groups, age, and gender were tested by two-way ANOVA, and the significant differences were then tested for the effect of the presence of temporomandibular disorder (TMD) by linear regression. Results: Glutamate-evoked pain intensity was significantly different between groups with no gender differences. Quality of pain did not vary between groups, but significant gender-related differences were observed. Significant differences in thermal sensitivity between groups and gender were found, whereas mechanical sensitivity did not vary between groups but between genders. None of the significant differences were due to the effect of TMD. Conclusion: These data provide further evidence of gender-related differences in somatosensory sensitivity and for the first time indicate that subjects with deep bite may be more sensitive to glutamate-evoked pain and thermal stimuli. Keywords: deep bite, occlusion, orofacial pain, quantitative -sensory testing, trigeminal physiology

Aims: To compare prevalences of self-reported temporomandibular joint and muscle disorders (TMJMD)-type pain, headaches, and neck and back pains in the 2000 to 2005 US National Health Interview Survey (NHIS) by gender and age for non-Hispanic Whites (Whites), Hispanics, and non-Hispanic Blacks (Blacks). Methods: Data from the 2000 to 2005 NHIS included information on gender, age, race, ethnicity, and different common types of pain specifically: TMJMD-type pain, severe headaches/migraine, neck, and low back pains. Results: A total of 189,992 people were included: 52% female and 48% male, 73% White, 12% Hispanic, 11% Black, and 4% "Other." The overall prevalence of TMJMD-type pain was 4.6%; severe headaches/migraine was 15.4%; neck, 14.9%; and low back, 28.0%. Survey logistic regression models estimating race-specific, age-adjusted curves revealed race by age pain differences. For TMJMD-type pain, White females presented the highest prevalence at younger ages, decreasing after age 40. Prevalences for Hispanic and Black females, although lower at younger ages, increased up to age 60 and remained higher than Whites. Males showed less racial/ethnic and age variation. Severe headaches/migraines presented an age pattern similar to TMJMD-type pain for White females and little overall variation for males, but without racial differences. Neck pain showed some similarities to TMJMD-type pain: higher in Whites at younger ages, lower at older ages, with Hispanics having the highest rates after their 60's. For low back pain, the rates peaked around the sixth decade for all racial/ethnic groups. Conclusion: The patterns of TMJMD-type pain varied greatly within and across racial/ethnic groups by gender and across the adult lifespan. Similarities and differences for the other pains were noted. Keywords: age, back pain, gender, migraine/headache, neck pain, pain, prevalence, race/ethnicity, sample survey, self-report, temporomandibular joint and muscle disorders

Aims: To assess the effects of four- and six-point acupuncture on facial sensory detection thresholds to thermal and electrical stimuli. Methods: Ten healthy volunteers underwent four-point acupuncture at ST6 and LI4 bilaterally for 15 minutes. A further 10 subjects underwent six-point acupuncture by adding needling at ST2 bilaterally. Sensory testing to thermal and electrical stimuli applied to mental and infraorbital nerve dermatomes was performed at baseline, 10 minutes, 1 hour, and 1 day after needling. Results: In the mental and infraorbital nerve dermatomes, six-point acupuncture significantly increased warm threshold by a peak mean of 1.1°C to 1.4°C (repeated measures ANOVA P = .001) and this effect was significant at all time points relative to baseline (P .05). No significant effects were observed by the four-point acupuncture on warm thresholds, and neither four- nor six-point acupuncture significantly altered electrical detection thresholds. Conclusion: A dose effect, related to the number of points employed, may be present when employing acupuncture. Keywords: AB-fibers, C-fibers, electrical thresholds, warm thresholds

Aim: To investigate time-dependent variability and influence of test site and stimulation area size on intraoral cold detection, warmth detection, and heat pain thresholds. Methods: Thirty healthy volunteers (15 women and 15 men) participated. Six extra- and intraoral sites were examined, and cold detection, warmth detection, and heat pain thresholds were measured. Time variability and influence of spatial summation were also studied at one site-the tip of the tongue-three times over a 6-week period. One-way ANOVA for repeated measures and paired sample t test compared mean values and SD within and between sites for all thresholds. Results: Several between-site differences were significant (P .05). Lowest intraoral thresholds for all stimuli were measured at the tongue site, and at the tongue, thresholds for warmth detection and heat pain, but not cold detection, decreased with increasing size of stimulation area (P .05). Overall, thresholds at the tongue site varied nonsignificantly over time (P > .05). Conclusion: Test site affects orofacial thermal thresholds substantially, whereas time variability and spatial summation on the tongue appear to be modest. Keywords: facial pain, neuropathic pain, quantitative sensory -testing, reliability, thermal thresholds

Aims: To test whether an intensive chewing exercise influences the moment of disc reduction in subjects with or without reports of intermittent locking of the jaw. Methods: This experimental study included 15 subjects with a reducing anteriorly displaced disc (ADD) and with symptoms of intermittent locking and 15 subjects with a reducing ADD without such symptoms. The moment of disc reduction (MDR), quantified using mandibular movement recordings, was recorded at baseline, and after maximally 60 minutes of chewing. Thereafter, MDR was recorded again after 20 minutes of rest, and if necessary after 72 hours, in order to document return of MDR to baseline values. Results: In subjects without intermittent locking, the MDR after chewing was not different from baseline (P = .25). However, in the subjects with intermittent locking, the MDR value had increased significantly after chewing (P = .008); two subjects showed a later moment of disc reduction, and four showed a temporary loss of disc reduction. Conclusion: While intensive chewing did not influence disc reduction in subjects without intermittent locking, it caused a delay or even hampered disc reduction in approximately half of the subjects reporting intermittent locking. Keywords: anterior disc displacement, human, internal derangement, mandibular movement recordings, parafunctional activities

Aims: To compare kinematic parameters (ie, amplitude, velocity, cycle frequency) of chewing and pain characteristics in a group of female myofascial temporomandibular disorder (TMD) patients with an age-matched control female group, and to study correlations between psychological variables and kinematic variables of chewing. Methods: Twenty-nine female participants were recruited. All participants were categorized according to the Research Diagnostic Criteria for TMD (RDC/TMD) into control (n = 14, mean age 28.9 years, SD 5.0 years) or TMD (n = 15, mean age 31.3 years, SD 10.7) groups. Jaw movements were recorded during free gum chewing and chewing standardized for timing. Patients completed the Depression, Anxiety, and Stress Scales (DASS-42), the Pain Catastrophizing Scale (PCS), the Fear of Pain Questionnaire-III (FPQ-III), and the Pain Self-Efficacy Questionnaire (PSEQ). Statistical analyses involved evaluation for group differences, and correlations between kinematic variables and psychological questionnaire scores (eg, depression, anxiety, stress) and pain intensity ratings. Results: Velocity and amplitude of standardized (but not free) chewing were significantly greater (P .05) in the TMD group than the control group. There were significant (P .05) positive correlations between pain intensity ratings and velocity and amplitude of standardized chewing but not free chewing. There were significant (P .05) positive correlations between depression and jaw amplitude and stress and jaw velocity for standardized but not free chewing. Conclusion: This exploratory study has provided data suggesting that psychological factors, manifesting in depression and stress, play a role in influencing the association between pain and motor activity. Keywords: anxiety, clinical pain, depression, jaw movement, -mastication, pain adaptation model, stress, temporomandibular disorders

Aims: To study the effect of diet hardness on condylar cartilage thickness, extracellular matrix composition, and expression of matrix metalloproteinase (MMP) -3, -8 and tissue inhibitor of metalloproteinase-1 (TIMP-1), by using immunohistochemical and morphometric methods. Methods: Seventy-two female Sprague Dawley rats were exposed to different dietary hardness, from soft to hard. MMP -3, -8, and TIMP-1 expression, cartilage thickness, cell count, and expression of type II collagen were studied. Analysis of variance among treatments was carried out followed by Bonferroni's comparisons test. Results: The ratio of MMP-3 and TIMP-1 immunopositive cartilage cells were similar in all age groups, whereas the number of MMP-8 positive cells decreased with age. A change of diet from soft to hard caused a significant decrease in the number of MMP-3 and MMP-8 and an increase in TIMP-1 positive cells. Cartilage thickness and area of type II collagen-positive staining were significantly affected by diet hardness. Conclusion: The results show that a soft diet during growth increases collagenolytic activity and may increase the vulnerability of condylar cartilage. Keywords: condylar cartilage, diet hardness, mandibular condyle, MMP, TIMP

Angioleiomyoma, a benign soft tissue tumor composed of smooth muscle cells and vascular endothelium, occurs most commonly in the extremities, the lower leg being a common site of occurrence. It rarely is found in the head and neck area, especially in the nasolabial groove. Surgical excision is the gold standard for diagnosis and treatment of angioleiomyoma; a preoperative diagnosis may be difficult. Here, a case of angioleiomyoma found in the nasolabial groove and associated with toothache is presented. Keywords: angioleiomyoma, nasolabial groove