Journal of Oral & Facial Pain and Headache, 02/2014

Fibromyalgia is a syndrome characterized by chronic widespread pain, stiffness, nonrestorative sleep, fatigue, and comorbid conditions. Recognition of the condition and its associated medications and challenges, along with knowledge of treatment modifications and precautions in drug prescription, can ensure safe and effective delivery of oral health care in fibromyalgia patients. The everevolving research into the condition makes it necessary for the oral health care provider to be informed about the current state of the literature and treatment standards regarding the management of fibromyalgia patients. This article reviews the epidemiology, etiology, pathophysiology, and clinical presentation of fibromyalgia, as well as therapeutic advances. Also highlighted are issues that are important to the oral health care provider, including orofacial manifestations and oral health care considerations for patients with fibromyalgia. Keywords: dental considerations, fibromyalgia, medical management, oral health care

Aims: To compare the effectiveness of adding cyclobenzaprine, tizanidine, or placebo to patient education and a self-care management program for patients with myofascial pain and specifically presenting with jaw pain upon awakening. Methods: Forty-five patients with a diagnosis of myofascial pain based on the guidelines of the American Academy of Orofacial Pain participated in this 3-week study. The subjects were randomly assigned into one of three groups: placebo group, TZA group (tizanidine 4 mg), or CYC group (cyclobenzaprine 10 mg). Patients were evaluated for changes in pain intensity, frequency, and duration by using the modified Severity Symptoms Index and changes in sleep quality with the use of the Pittsburgh Sleep Quality Index. Data were analyzed by ANOVA and post-hoc or nonparametric statistical tests as appropriate. Results: All three groups had a reduction in pain symptoms and improvement of sleep quality based on a comparison of pretreatment and treatment scores. However, no significant differences among the groups were observed at the posttreatment evaluation. Conclusion: The use of tizanidine or cyclobenzaprine in addition to self-care management and patient education was not more effective than placebo for the management of patients with myofascial jaw pain upon awakening. Keywords: cyclobenzaprine, myofascial pain, orofacial pain, sleep, tizanidine

Aims: To evaluate the effectiveness of a prefabricated appliance and compare it to the effectiveness of a stabilization appliance in patients with temporomandibular joint (TMJ) pain. Methods: This randomized, controlled multicenter study comprised 48 patients diagnosed with TMJ arthralgia according to the Research Diagnostic Criteria for Temporomandibular Disorders. The effectiveness of a prefabricated appliance (Relax), worn by half of the patients (referred to as the R group), was compared to the effectiveness of a stabilization appliance, worn by the other half of patients (S group). Treatment outcome was assessed according to the recommendations by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) on an intent-to-treat basis. To analyze the differences between groups, the chi-square test and the Mann-Whitney U test were used, while the Friedman analysis of variance (ANOVA) on ranks was used for the analyses between baseline data and follow-up measurements, all with a significance level set at P .05. Results: There were no differences between the groups at baseline. A 30% reduction of pain intensity was reported by 62.5% of the R group and 58.3% of the S group at the 10-week follow-up; 58% and 50.3%, respectively, at the 6-month follow-up; and 41.7% in both groups at 12 months. At the 12-month follow-up, pain intensity had decreased and physical function had improved in both groups (P .005 and P .016, respectively), without significant group differences. Emotional function (depression and nonspecific physical symptoms) did not change. Overall improvement of "better" to "symptom-free" was observed in 67% of the R group and 58% of the S group. No side effects occurred. Conclusion: The effectiveness of the prefabricated appliance seems to be similar to that of the stabilization appliance in alleviating TMJ pain. Since the prefabricated appliance requires only one visit for construction, it is convenient for both the general practitioner and for the patient. Keywords: arthralgia, headache, long-term follow-up, occlusal appliance, temporomandibular disorders

Aims: To compare the masticatory and cervical muscle tenderness and pain sensitivity in the hand (remote region) between patients with temporomandibular disorders (TMD) and healthy controls. Methods: Twenty female subjects were diagnosed with chronic TMD, and 20 were considered healthy. Subjects completed the Neck Disability Index and Limitations of Daily Functions in a TMD questionnaire. Tenderness of the masticatory and cervical muscles and pain sensitivity in the hand were measured using an algometer. Three-way mixed analysis of variance (ANOVA) evaluated differences in muscle tenderness between groups. One-way ANOVA compared pain sensitivity in the hand between groups. Effect sizes were assessed using Cohen guidelines. Results: Significantly increased masticatory and cervical muscle tenderness and pain sensitivity in the hand were found in subjects with TMD when compared with healthy subjects. Moderate to high effect sizes showed the clinical relevance of the findings. Conclusion: The results of this study have highlighted the importance of assessing TMD patients not only in the craniofacial region but also in the neck and other parts of the body. Future studies should focus on testing the effectiveness of treatments addressing the neck and the pain sensitivity in the hand in patients with TMD. Keywords: masticatory muscles, muscle pain sensitivity, neck disability, neck muscles, temporomandibular disorders

Aims: To evaluate the severity of temporomandibular disorders (TMD) of women in the municipality of Araraquara (Brazil) as well as the contribution of the perception of oral health, mandibular functional limitation, and sociodemographic variables on the severity of TMD. Methods: The participants were interviewed by telephone. Information regarding age, marital status, economic level, education, and use and type of dental prostheses was surveyed. To evaluate TMD severity, mandibular functional limitation and perception of oral health, Fonseca's Anamnesic Index (IAF), the Mandibular Function Impairment Questionnaire (MFIQ), and the General Oral Health Assessment Index (GOHAI) were used. To evaluate the contribution of these variables on TMD severity, a structural equation model (SEM) was fitted to the data and assessed by usual goodnessof- fit indices. Results: A total of 701 women with a mean age of 44.36 years (SD = 16.31) participated. According to the IAF, 59.6% (95% confidence interval = 56.0%-63.2%) of the women were classified as having TMD, of which 63.9% presented light, 26.8% moderate, and 9.3% severe TMD. Mandibular functional limitation was low in 91.0% of the women, moderate in 7.1%, and severe in 1.9%. Goodness-of-fit for the structural model was adequate. The predictors explained 43% of the variation in the TMD severity, with significant contributions of the variables dental prostheses (β = -.008; P = .006), perception of oral health (β = -.43; P .001), and mandibular functional limitation (β = .014; P = 014). Conclusion: The severity of TMD among Brazilian women was greater in nonusers of dental prostheses and was also associated with greater mandibular functional limitation and poor perception of oral health. Keywords: oral health, scales, structural equation modeling, temporomandibular disorders (TMD), women

Aim: To evaluate the preemptive analgesia of ketoprofen in comparison with diclofenac after mandibular third molar surgery. Methods: This study was a double-blind, randomized clinical trial. Forty patients were randomized into two treatment groups (each with 20 patients) by using a series of random numbers: group A received ketoprofen 100 mg and group B received diclofenac 75 mg, all intramuscularly. Surgery was done 30 minutes after analgesic treatments. The durations of analgesia, pain intensity, analgesic consumption, and side effects were evaluated. The statistical analysis was done using the chi-square, Student t, Mann-Whitney U, and Log-Rank tests. Results: The duration of analgesia was longer in the ketoprofen group when compared with the diclofenac group. The number of patients taking the first rescue analgesic at 6 hours was lower in the ketoprofen group in comparison with the diclofenac group. Patients who received ketoprofen had lower pain intensity compared with patients who received diclofenac. Conclusion: Intramuscular ketoprofen 100 mg is more effective than intramuscular diclofenac 75 mg after mandibular third molar extraction when used as a preemptive analgesic. Keywords: dental pain, diclofenac, ketoprofen, third molar surgery

Aims: To investigate the association between experimental tooth clenching and the release of β-endorphin in patients with myofascial temporomandibular disorders (M-TMD) and healthy subjects. Methods: Fifteen M-TMD patients and 15 healthy subjects were included and assigned an experimental tooth-clenching task. Venous blood was collected and pain intensity was noted on a visual analog scale. The masseter pressure pain threshold (PPT) was assessed 2 hours before the clenching task and immediately after. A mixed-model analysis of variance was used for statistical analyses. Results: Significant main effects for time and group were observed for pain intensity and PPT, with significantly lower mean values of pain intensity (P .001) and PPT (P .01) after the clenching task compared with baseline. M-TMD patients had significantly higher pain intensity (P .001) and significantly lower PPT (P .05) than healthy subjects. No significant time or group effects were observed for the level of β-endorphin. Neither pain intensity nor PPT correlated significantly with β-endorphin levels. Conclusion: This experimental tooth-clenching task was not associated with significant alterations in β-endorphin levels over time, but with mechanical hyperalgesia and low to moderate levels of pain in healthy subjects and M-TMD patients, respectively. More research is required to understand the role of the β-endorphinergic system in the etiology of M-TMD. Keywords: beta-endorphin, bruxism, masseter muscle, temporomandibular joint disorders

Tuberculosis (TB), an infectious disease caused by Mycobacterium tuberculosis, continues to be a major health problem worldwide. Primary TB infection is mostly pulmonary, but it may also occur in the lymph nodes, abdomen, skin, meninges, joints, and central nervous system. TB in the head and neck region usually occurs in the cervical lymph nodes, but is extremely rare in the temporomandibular joint (TMJ). This rarity increases the risk for not considering TB in the differential diagnosis of patients presenting with TMJ pain. This article describes an unusual case of a 53-year-old man with painful swelling in the right preauricular area accompanied by difficulty in mouth opening. After surgical exploration, histopathologic findings revealed TB in the TMJ. The findings of this case highlight the importance of considering TB in the differential diagnosis of TMJ pain, especially for patients from endemic areas, patients who have lived or visited those areas, or patients with a preauricular swelling in the TMJ area. Keywords: extrapulmonary tuberculosis, preauricular swelling, temporomandibular joint, temporomandibular disorders

Burning Mouth Syndrome (BMS) is a chronic painful disorder characterized by unremitting bilateral burning oral pain often associated with taste abnormalities and complaints of dry mouth. The diagnosis is made by history and symptom presentation in the absence of an identifiable cause or oral lesion. It is commonly seen in perimenopausal women but is also seen in men, and is considered a smallfiber neuropathy. Management can be challenging and few effective treatments are available. This article presents a case report of stellate ganglion blockade as a treatment for recalcitrant pain from BMS. Keywords: burning mouth syndrome, neuropathic pain stellate ganglion injection, small-fiber neuropathy, trigeminal nerve