Journal of Oral & Facial Pain and Headache, 02/2011

Aims: To use magnetic resonance imaging (MRI) and voxel-based morphometry (VBM) to search for evidence of altered brain morphology in patients with temporomandibular disorders (TMD). Methods: Using VBM, regional gray and white matter volume was investigated in nine TMD patients and nine carefully matched healthy controls. Results: A decrease in gray matter volume occurred in the left anterior cingulate gyrus, in the right posterior cingulate gyrus, the right anterior insular cortex, left inferior frontal gyrus, as well as the superior temporal gyrus bilaterally in the TMD patients. Also, white matter analyses revealed decreases in regional white matter volume in the medial prefrontal cortex bilaterally in TMD patients. Conclusion: These data support previous findings by showing that TMD, like other chronic pain states, is associated with changes in brain morphology in brain regions known to be part of the central pain system. Keywords: anterior cingulate gyrus, central sensitization, chronic pain, neuroimaging, voxel-based morphometry

Aims: To acquire a deeper understanding of adolescents' experiences of living with temporomandibular disorder (TMD) pain. Methods: Twenty-one adolescents with TMD pain, aged 15 to 19, were strategically selected from a group of patients referred to an orofacial pain clinic. The patients were examined and received diagnoses per the Research Diagnostic Criteria for TMD. One-on-one interviews that followed a semistructured protocol focused on the patient's experiences of living with TMD pain. The interviews were recorded and transcribed verbatim, followed by content analysis to obtain a deeper understanding of adolescents' experiences living with TMD pain. Results: Content analysis led to the overall theme "Adolescents with TMD live with recurrent pain; physical problems and daily demands form a vicious circle that causes adolescents to oscillate between hope and despondency." The latent content forming the theme is grounded in three categories that evolved from 13 subcategories. For instance, five subcategories-headache; headache on awakening; jaw and tooth pain; constant thoughts of pain; and popping, cracking, clicking, and locking-formed the category that was labeled TMD pain is recurrent. The latent interpretation, ie, the meaning, of this category was that adolescents with TMD pain constantly thought about the pain, even when it was absent. Conclusion: TMD pain is a substantial problem for affected adolescents and has consequences for all aspects of their lives. In this study, the adolescents were able to talk openly and introduce issues outside of the interview protocol. Qualitative analysis deepens our understanding of the adolescent patient with TMD pain. Keywords: adolescents, content analysis, headache, interview, TMD pain

Aim: To examine differences between idiopathic continuous orofacial neuropathic pain (ICONP) patients and chronic masticatory muscle pain (MMP) patients for psychosocial functioning and sleep quality. Methods: Archival data were used to compare 81 ICONP patients to 81 age- and sex-matched chronic MMP patients on pain severity, life interference, life control, and affective distress measures from the Multidimensional Pain Inventory (MPI), a global severity index of psychological symptoms from the Symptom Checklist-90-R (SCL-90-R), Posttraumatic Stress Disorder Checklist-Civilian (PCL-C), and overall sleep quality from the Pittsburgh Sleep Quality Index (PSQI). MANOVA, MANCOVA, and chi-square analysis were used to investigate differences between the two groups in the psychosocial and sleep variables. Results: The ICONP group reported greater pain severity (P = .013) and more life interference (P = .032) than the MMP group, while the MMP group reported higher levels of global psychological symptoms (P = .005) than the ICONP group. After controlling for pain severity, however, the MMP group demonstrated greater affective distress (P = .014) than the ICONP group, and life interference was no longer significantly different between the groups. ICONP patients were more likely to report a traumatic life event (P = .007). Conclusion: Although ICONP patients are likely to present more intense pain and report that their pain causes more interference in their lives, MMP patients are more likely to present with higher levels of overall psychological symptoms. The greater levels of pain severity reported by ICONP patients appear to be partially responsible for their higher levels of reported life interference. Keywords: masticatory muscle pain, neuropathic pain, orofacial pain, psychosocial, sleep quality Full Text PDF File | Order Article

Aims: To evaluate retrospectively the efficacy of administering an anticonvulsant medication, clonazepam, by dissolving tablets slowly orally before swallowing, for the management of burning mouth syndrome (BMS). Methods: A retrospective clinical records audit was performed of patients diagnosed with BMS between January 2006 and June 2009. Patients were prescribed 0.5 mg clonazepam three times daily, and changes were made to this regimen based on their individual response. Patients were asked to dissolve the tablet orally before swallowing and were reviewed over a 6-month period. Pain was assessed by patients on an 11-point numerical scale (0 to 10). A nonparametric (Spearman) two-tailed correlation matrix and a two-tailed Mann-Whitney test were performed. Results: A total of 36 patients (27 women, 9 men) met the criteria for inclusion. The mean (± SEM) pain score reduction between pretreatment and final appointment was 4.7 ± 0.4 points. A large percentage (80%) of patients obtained more than a 50% reduction in pain over the treatment period. One patient reported no reduction in pain symptoms, and one third of the patients had complete pain resolution. Approximately one third of patients experienced side effects that were transient and mild. Conclusion: This pilot study provides preliminary evidence that the novel protocol of combined topical and systemic clonazepam administration provides an effective BMS management tool. Keywords: burning, clonazepam, oral, systemic, topical

Aims: To evaluate the prevalence of unexplained extraoral symptoms in a group of patients with burning mouth syndrome (BMS) and compare the prevalence with that in patients with oral lichen planus (OLP) and age- and gender-matched controls. Methods: The occurrence of extraoral symptoms was analyzed in a group of 124 BMS patients, a group of 112 oral lichen planus (OLP) patients, and a group of 102 healthy patients. Oral symptoms were collected by a specialist in oral medicine and a general dentist, while data concerning unexplained extraoral symptoms were gathered by each specialist ward, ie, ophthalmology, gynecology, otolaryngology, gastroenterology, neurology, cardiology, internal medicine, and dermatology. A Fisher exact test (α = .05) and Kruskal-Wallis test (α = .05) were performed for statistical analysis. Results: In the BMS group, 98 (96.1%) patients reported unexplained extraoral symptoms, while 4 (3.9%) patients reported only oral symptoms. A painful symptomatology in different bodily regions was reported more frequently by BMS patients (83.3%) than by OLP patients (1.8%) and healthy patients (11.7%) (P .0001). The differences in the overall unexplained extraoral symptoms between BMS (96.1%) and OLP patients (9.3%) (P .0001) and between BMS (96.1%) and healthy patients (15.7%) (P .0001) were statistically significant. The unexplained extraoral symptoms in BMS patients consisted of pain perceived in different bodily areas (odds ratio [OR]: 255; 95% confidence interval [CI]: 58.4-1112), ear-nose-throat symptoms (OR: 399.7; 95%CI: 89.2-1790), neurological symptoms (OR: 393; 95% CI: 23.8-6481), ophthalmological symptoms (OR: 232.3; 95% CI: 14.1-3823), gastrointestinal complaints (OR: 111.2; 95% CI: 42.2-293), skin/gland complaints (OR: 63.5; 95% CI: 3.8-1055), urogenital complaints (OR: 35; 95% CI: 12-101), and cardiopulmonary symptoms (OR: 19; 95% CI: 4.5-82). Conclusion: The great majority of BMS patients presented with several additional unexplained extraoral comorbidities, indicating that various medical disciplines should be involved in the BMS diagnostic process. Furthermore, the results suggest that BMS may be classified as a complex somatoform disorder rather than a neuropathic pain entity. Keywords: BMS, burning mouth syndrome, extraoral symptoms, somatic comorbidities

Aims: To analyze and quantify the sociodemographic, behavioral, and clinical factors influencing the oral pain and eating difficulties reported by Spanish 35- to 44-year-old adults and more elderly people in the most recent Spanish National Oral Health Survey. Methods: Pain and chewing difficulties were gathered in a Likert-scale format from a representative sample of the Spanish general population between the ages of 35 and 44 years (n = 540) and 65 to 74 years (n = 540). Risk factors were identified using bivariate analysis, after which the crude association between risk factors (sociodemographic, behavioral, and clinical) and outcome variables (pain and eating problems) was assessed by adjusted odds ratios, calculated by means of multivariate logistic regression. Results: In the 35- to 44-year-old adults, eating problems were mainly associated with caries and prosthetic treatment needs and oral pain by the number of decayed teeth. In the more elderly individuals, eating problems and oral pain were influenced by prosthetic needs and the number of missing teeth. Female sex was seen to be a risk factor for suffering pain and eating restrictions. Additionally, several independent variables such as social class, place of residence, brushing habits, or periodontal needs became nonsignificant after logistic regression modelling. Conclusion: According to this high-specificity regression model, caries and prosthetic treatment needs should be considered key factors in determining the oral well-being of the Spanish population. Missing teeth represent the most relevant influencing factor for the elderly and decayed teeth for younger adults. Keywords: eating difficulties, epidemiological studies, oral health-related quality of life, oral pain, self-assessment

Aims: To test the hypothesis that oral parafunctions and symptomatic temporomandibulair joint (TMJ) hypermobility are risk factors in adolescents for both anterior disc displacement with reduction (ADDR) and intermittent locking. Methods: Participants were two hundred sixty 12- to 16-year-old adolescents (52.3% female) visiting a university clinic for regular dental care. ADDR and symptomatic TMJ hypermobility were diagnosed using a structured clinical examination. During the anamnesis, reports of intermittent locking and of several parafunctions were noted, eg, nocturnal tooth grinding, diurnal jaw clenching, gum chewing, nail biting, lip and/or cheek biting, and biting on objects. The adolescents' dentitions were examined for opposing matching tooth-wear facets as signs of tooth grinding. Risk factors for ADDR and intermittent locking were first assessed using univariate logistic regression and then entered into a stepwise backward multiple model. Results: While in the multiple model, ADDR was weakly associated only with increasing age (P = .02, explained variance 8.1%), intermittent locking was weakly correlated to diurnal jaw clenching (P = .05, explained variance 27.3%). Conclusion: In adolescence, diurnal clenching may be a risk factor for intermittent locking while age may be a risk factor for ADDR. Symptomatic TMJ hypermobility seems to be unrelated to either ADDR or to intermittent locking. Keywords: anterior disc displacement, human, internal derangement, oral parafunctions, symptomatic TMJ hypermobility, temporomandibular joint

Aims: To establish a quantitative sensory testing (QST) profile in the trigeminal (V) area and test for site and gender differences in healthy humans. Methods: A standardized QST protocol was applied on 15 healthy men (age range: 18 to 25 years old) and 15 age-matched women, and the sensitivity was examined bilaterally in facial sites supplied by the infraorbital (V2) and mental (V3) nerves. The cold detection threshold (CDT), cold pain threshold (CPT), warm detection threshold (WDT), heat pain threshold (HPT), thermal sensory limen (TSL), mechanical detection threshold (MDT), mechanical pain sensitivity (MPS), mechanical pain threshold (MPT), dynamic mechanical allodynia (ALL), windup ratio (WUR), pressure pain threshold (PPT), and vibration detection threshold (VDT) were determined. Data were tested with ANOVAs for repeated measures and post-hoc comparisons were calculated using Bonferroni tests. Results: There were significant gender differences with lower threshold (higher sensitivity) in women for CDT (P = .030) and PPT (P = .006). A significantly lower threshold (higher sensitivity) was detected for HPT (P .001), and significantly higher thresholds (lower sensitivity) for VDT (P .001) and CDT (P .001) in V2 compared to V3. There were no significant right-to-left side differences for any of the QST parameters. Conclusion: Application of this standardized QST protocol may allow for a better understanding of the underlying mechanisms from somatosensory phenotypes and provide basic information for the study of sensory dysfunctions in the V area. Keywords: craniofacial pain, gender difference, human, quantitative sensory testing (QST), trigeminal system

Myxomas of the maxillary sinus are uncommon benign tumors arising from the primitive mesenchyme. They may be related to dental malformations or missing teeth but may also occur without any abnormalities. They usually result in facial deformity manifested by slow, painless bony expansion. Although these tumors are well-circumscribed, they are more extensive than they appear due to their local aggressiveness and bone erosion. Therefore, it should be widely resected with maximal preservation of surrounding structures to prevent recurrence. This article reports a case of myxoma of the maxillary sinus and nighttime facial pain in a 33-year-old male who underwent curettage following debridement with a microdebrider via an intranasal endoscopic approach and surgery involving a modified Caldwell-Luc approach. Keywords: maxillary sinus, myxoma