Journal of Oral & Facial Pain and Headache, 04/2009

The aim of this Focus Article is to review critically the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) for the recognition of an anterior disc displacement with reduction (ADDR) in the temporomandibular joint (TMJ). This evaluation is based upon the experience gained through the careful analysis of mandibular movement recordings of hundreds of patients and controls with or without an ADDR. Clinically, it is a challenge to discriminate between the two most prevalent internal derangements of the TMJ: ADDR and symptomatic hypermobility. It is due to the very nature of these derangements that they both show clicking on opening and closing (reciprocal clicking), making reciprocal clicking not a distinguishing feature between these disorders. However, there is a difference in timing of their opening and closing clicks. Unfortunately, it is not feasible to use this difference in timing clinically to distinguish between the two internal derangements, because it is the amount of mouth opening at the time of the clicking which is clinically noted, not the condylar translation. Two other criteria proposed by the RDC/TMD for the recognition of an ADDR are the 5-mm difference in mouth opening at the time of the opening and closing clicks, and the detection of joint sounds on protrusion or laterotrusion in case of non-reciprocal clicking. These, however, run the risk of false-positive or negative results and therefore have no great diagnostic value. Instead, it is recommended that the elimination of clicking on protrusive opening and closing be examined in order to distinguish ADDRs from symptomatic hypermobility. Keywords: anterior disc displacement, clinical examination, mandibular movement recordings, RDC/TMD, temporomandibular joint

Aim: To compare the efficacy of 0.75% levobupivacaine with that of 3% mepivacaine for pain control after surgical removal of impacted mandibular third molars. Methods: Forty-two subjects (23 females and 19 males, mean age 23.5 ± 4) underwent surgical removal of third molars in two separate sessions. Within each patient, levobupivacaine was used to anesthetize one extraction side and for the other side, mepivacaine. Onset of anesthesia, duration of surgery, lip numbness, timing of pain appearance and analgesic consumption were evaluated. Results: There were no significant differences in onset of anesthesia, duration of surgical procedure, and lower lip numbness between the two groups (P > .05). Timing of pain appearance and of first drug consumption was significantly lower in the mepivacaine group (P .05). Patients with levobupivacaine anesthesia had significantly lower visual analog (VAS) pain scores at 1 and 2 hours postoperatively than those with mepivacaine anesthesia. Conclusion: Levobupivacaine is a valid alternative to traditional local anesthetics for surgical removal of lower third molars. It presents better pain relief when compared to mepivacaine in the immediate postoperative period as evidenced by lower VAS scores. Keywords: anesthesia, levobupivacaine, oral surgery, postoperative pain, third molar

Aims: To assess whether pain-related awakenings occur with persistent orofacial pain conditions and whether it is related to pain severity. Methods: Reports of pain-related awakening were prospectively collected at initial interview, prior to treatment, during a 24-month period from 328 patients with orofacial pain. The pain conditions were diagnosed according to the International Headache Society, the American Academy of Orofacial Pain, and the Research Diagnostic Criteria for Temporomandibular Disorders. Results: Pain-related awakening was significantly correlated to pain intensity (odds ratio [OR] 1.5, 95% confidence intervals [CI] 1.3-1.8; P .001), the total muscle tenderness score (OR 1.1, 95% CI 1.01-1.14; P = .03), and the presence of lacrimation (OR 4.6, 95% CI 1.7-12.3; P = .002) but not to the clinical diagnosis. Two groups of patients were specifically examined; patients with masticatory myofascial pain (MMP) and patients with classical trigeminal neuralgia (CTN). Twenty-eight of the 120 MMP patients (23.3%) reported pain-related awakening and this was associated with a high muscle tenderness score (OR 1.13, 95% CI 1.01-1.3; P = .02) and unilaterality of pain (OR 3.9, 95% CI 1.2-12.3; P = .02). Seven of the 31 patients with CTN (22.6%) reported pain-related awakenings. Continuous background pain was the most significant parameter associated with awakening (OR 26, 95% CI 1.1-594; P .05). Conclusion: Persistent orofacial pain often induced pain-related awakening and this was significantly associated with pain intensity. Keywords: myofascial pain, sleep, trigeminal neuralgia

Aims: To evaluate the prevalence of pain associated with temporomandibular disorders (TMD) in obstructive sleep apnea syndrome (OSAS) patients referred for oral appliance therapy. Methods: Eighty-seven patients (46 men and 41 women), between 18 and 65 years of age, with an apnea-hypopnea index (AHI) of > 5 and 30 (events by sleep hour), and body mass index (BMI) of = 30 Kg/m2 were evaluated according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) to determine the presence of signs and symptoms of TMD. Statistical analyses included correlations assessed by Pearson's test. Results: Fifty-two percent of patients presented symptoms of TMD. Thirty-two patients (average age 47 ± 11 years, AHI 17.3 ± 8.7, BMI 25.9 ± 3.8 kg/m2) completed the study. According to the Scoring Protocol for Graded Chronic Pain (Axis II-RDC/TMD), 75% of the patients presented chronic pain related to TMD, categorized as low disability grade I ( 50 points for pain intensity, and 3 disability points). The most common TMD diagnosis was myofascial pain with and without limited mouth opening and arthralgia (50%). Conclusion: The high prevalence of TMD in the current study indicates that patients with OSAS referred for oral appliance therapy require specific evaluation related to TMD. Keywords: oral appliance, prevalence, side effects, sleep apnea, temporomandibular disorders

Aims: To investigate the time courses of myofascial temporomandibular disorder (TMD) pain and mandibular function impairment (MFI), and to identify predictive factors associated with these time courses. Methods: During a 12-month period following conservative TMD treatment, the time courses of myofascial TMD pain and pain-related disabilities were assessed by questionnaires. Ninety-six myofascial TMD patients participated, of whom 70 completed the study. Before treatment (baseline data), Characteristic Pain Intensity (CPI), MFI, parafunctional activities, and psychological status were assessed, and at completion of treatment and at 3, 6, 9, and 12 months, CPI and MFI were scored again. Individual time courses in scores were analyzed using linear growth modeling. Results: Baseline values of CPI had a positive correlation with CPI during follow-up (P = .002), whereas the influences of reported parafunctions and of pain elsewhere on CPI scores were close to significance (P = .058 and .06, respectively). Patients with a low somatization score showed a further decline in CPI during follow-up (P = .027), whereas patients with a high score showed a gradual increase (P = .030). Baseline values of MFI were positively correlated with MFI scores during the follow-up period (P = .000). The influence of reported parafunctions on MFI was not significant (P = .174), but that of pain elsewhere was (P = .004). The trend for a further decline in MFI values during follow-up was close to significance (P = .063) for patients with low somatization scores. Patients with high somatization scores showed a significant increase in MFI values (P = .007). Conclusion: Baseline reports of pain and impairment, oral parafunctional activities, pain elsewhere in the body, and somatization are associated with the severity and time course of myofascial TMD complaints following treatment. Keywords: mandibular function impairment, myofascial TMD pain, prognosis, time course

Aims: To evaluate the effectiveness of acupuncture in treating symptoms associated with myofascial pain of the jaw muscles. Methods: Twenty-eight subjects over the age of 18 and diagnosed with chronic myofascial pain of the jaw muscles were randomized to receive real (n = 16) or sham (n = 12) acupuncture. Prior to treatment, each subject clenched his or her teeth for 2 minutes. Acupuncture or sham acupuncture was then administered at the Hegu large intestine 4 (LI4) acupoint for 15 minutes. Real acupuncture was given by penetrating the needle through a sticky foam pad at the acupoint. Sham acupuncture was conducted by pricking the skin, without penetration, with a shortened, blunted acupuncture needle through a foam pad placed away from the acupoint. General head and neck pain ratings were obtained before and after treatment on a numerical rating scale. A mechanical pain stimulus on the masseter muscle was given before and after treatment and rated on a visual analog scale to measure pain tolerance level. Paired t tests were performed to detect significant changes in pain levels. Results: Subjects receiving real acupuncture experienced a significant reduction in jaw pain (P = .04), jaw/face tightness (P = .04), and neck pain (P = .04), and a significant increase in pain tolerance of the masseter muscle (P = .001). Subjects were not able to determine whether they received real or sham acupuncture (P = .69). No significant pain reductions were observed in the sham acupuncture group. Conclusion: A single acupuncture session using one acupoint at Hegu large intestine 4 significantly reduced most myofascial pain endpoints when compared to sham acupuncture. Keywords: acupuncture, analgesia, Hegu large intestine 4, myofascial pain, placebo, sham

Giant cell arteritis (GCA) is a systemic vasculitis involving medium and large-sized arteries, most commonly the extracranial branches of the carotid artery. Early diagnosis and treatment are essential to avoid severe complications. This article reports on a GCA case and discusses how the orofacial manifestations of GCA can lead to misdiagnosis of GCA as temporomandibular disorder. GCA should be included in the differential diagnosis of orofacial pain in the elderly based on the knowledge of related signs and symptoms, mainly jaw claudication, hard end-feel limitation of range of motion, and temporal headache. Keywords: Giant cell arteritis, jaw claudication, temporomandibular disorders, trismus