Clinical implications of sex in acute temporomandibular disorders

Wear Management of Colored Foils for the Assessment of Sleep Bruxism Patterns-A Prospective, Randomized Crossover Study

The assessment of bruxism relies on clinical examinations, questionnaires, and polysomnography. The additional use of colored foils (BruxChecker^®) could enable a more precise evaluation of bruxing patterns. To assess differences between use of the foils during stress periods or just on consecutive nights and to determine a reasonable duration of using the foils, 28 patients were classified according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and were randomly assigned to wearing the 12 foils for six consecutive nights (alternately in the upper and lower jaw; "consecutive") or six nights within one month following days of high stress ("stress") in a crossover design. The sizes of the attrition areas were measured with ImageJ. Stress was evaluated using the Perceived Stress Scale. The Stress Coping Questionnaire (SVF-120) was used for assessing habitual stress coping strategies. Areas of attrition increased significantly from day 1/2 to 5/6, both for the upper and lower jaw. Molars in the mandible had significantly larger attrition areas than in the maxilla. No significant differences were detected between "consecutive" and "stress" phases. The foils were suitable for differentiating teeth more or less affected by bruxism and were able to show that areas of attrition increased with days, indicating that some adaptation takes place and several days of wearing the foils are required to show the full picture. However, no differences between low/moderate- and high-stress phases were detected.

The Role of Pain Inflexibility and Acceptance among Headache and Temporomandibular Disorders Patients

Temporomandibular disorders (TMD) and headache are complex. This study aims to assess the association between TMD, headache, and psychological dimensions such as psychological inflexibility and pain acceptance. The sample consisted of 120 participants following a non-probabilistic convenience sampling strategy through a direct invitation to the patients attending our facilities and their relatives (n = 61 diagnosed with headache, n = 34 diagnosed with TMD-headache, n = 25 control group). Diagnostic Criteria for Temporomandibular Disorders (DC-TMD), International Classification of Headache Disorders (ICHD-3 beta version), Chronic Pain Acceptance Questionnaire (CPAQ-8), and Psychological Inflexibility in Pain Scale (PIPS) were used as assessment tools. One-way ANOVA, multiple regression analysis (MRA), and the Johnson-Neyman approach were run by IBM SPSS, version 27 (IBM^® Company, Chicago, IL, USA). The significance level was 0.05. One third of our sample presented with headache with TMD. Females were predominant. Males with headache, no systemic disease, less pain severity but higher frequency, living longer with the disease and having sensitive changes, showed higher pain acceptance. When headache occurs with TMD, women with higher education, no headache family history, less pain, and no motor changes showed higher pain acceptance. Patients with both conditions are more liable to have chronic pain and pain inflexibility. Pain intensity and willingness explain 50% of the psychological inflexibility in the headache group. In our sample, individuals suffering from both conditions show greater pain inflexibility, implicating more vivid suffering experiences, leading to altered daily decisions and actions. However, further studies are needed to highlight this possible association.

Infrared thermography assessment of patients with temporomandibular disorders

OBJECTIVES

To assess patients with and without temporomandibular disorders (TMD) infrared thermography according to the differences in thermal radiance using quantitative sensitivity and specificity tests; and to evaluate the thermal asymmetry and the correlation of the thermal intensity with the intensity of pain upon palpation.

METHODS

This cross-sectional study performed a quantitative evaluation of clinical and thermographic examinations. The volunteers were evaluated for the presence of TMD using RDC/TMD (Diagnostic Research Criteria for Temporomandibular Disorders), and were divided into two groups: TMD group (n = 45); control group (n = 41), composed of volunteers without TMD, according to the Fonseca Anamnestic Index. The images were assessed for selected regions of interest for the masseter, anterior temporal and TMJ muscles. The mean values ​​of the areas of both groups were compared under the receiver operating characteristic curve. Spearman correlation analysis (non-parametric data) between pain level and mean temperature, by region, and the Pearson's χ² test was used to verify the association between the presence of temperature and pain asymmetry. The level of significance was set at p < 0.05.

RESULTS

Both Groups, with and without TMD, presented with absolute and non-dimensional mean temperature without statistical differences (p>0.05). When correlating temperature with intensity of pain upon palpation, a negative correlation was observed for the masseter muscle.

CONCLUSION

Infrared Thermography resulted in low area under the curve, making it difficult to differentiate TMD via thermographic analysis. The intensity of pain upon palpation in patients with TMD may be accompanied by a decrease in local temperature.

Effect of educational and self-care therapies on masticatory performance of women with painful temporomandibular disorder

Abstract Introduction Temporomandibular disorders (TMD) can compromise masticatory performance due to the presence of pain, muscular dysfunction and limitation of mandibular movements. Substantial improvements in TMD pain can be achieved through therapeutic approaches including education and self-care. Objective The aim of the present study was to investigate the impact of these treatment modalities in the masticatory performance of women with painful TMD. Material and method Fifty-two women were randomly divided into three groups: Control Group (CG); Education Group (received education about TMD) (EG); Self-Care and Education Group (received education about TMD and instructions self-care therapies) (SEG). The education instructions about TMD and self-care therapies were transmitted through a video and printed illustrative material. The masticatory performance was evaluated through the sieves method with natural tested foods in the evaluation periods: baseline evaluation, 30 days after and 60 days of follow-up. Data were analyzed and used with a one-way ANOVA parametric test for mean comparison of CG, EG and SEG groups (α = 0.05). Result The masticatory performance of the participants was similar, irrespective of the proposed treatments, at baseline (p=.604), 30 days (p=.450) and 60 days (p=.669). Conclusions The results indicated that treatment with educational and self-care therapies over a period of 60 days had no impact on the masticatory performance of women with painful TMD.

Clinical study of splint therapeutic efficacy for the relief of temporomandibular joint discomfort

PURPOSE

This study aimed to evaluate the relationship between displacement of the mandibular condyle/disc due to occlusal splint insertion with splint therapy and changes in discomfort of the temporomandibular joint (TMJ), and to clarify the relationships between the outcomes over time of temporomandibular discomfort and TMJ magnetic resonance imaging (MRI) findings at the initiation of splint therapy.

MATERIALS AND METHODS

A total of 75 patients admitted to hospital with discomfort around the TMJ were evaluated. A visual analogue scale for TMJ discomfort was administered during visits for approximately 3 months following the initiation of splint therapy. At the start of splint therapy, magnetic resonance imaging (MRI) was performed with and without splint insertion, and condyle and disc movements were evaluated. Disc balance, disc position and function, disc configuration, joint effusion, osteoarthritis, and bone marrow were evaluated. Linear regression and multiple regression analyses were used to clarify relationships between changes in discomfort and the factors evaluated.

RESULTS

There was no significant correlation between TMJ discomfort and condyle/disc movement with splint insertion. TMJ discomfort was significantly relieved by splint therapy regardless of temporomandibular MRI findings. Unilateral anterior disc displacement and marked or extensive joint effusion fluid were significantly improved with splint therapy.

CONCLUSION

Discomfort tended to remit with splint therapy regardless of temporomandibular MRI findings. Improvement of TMJ discomfort appears more likely to occur in patients with unilateral anterior disc displacement and with an apparent organic disorder, such as a joint effusion.

Association of temporomandibular disorder symptoms with anxiety and depression in Portuguese college students

We investigated the prevalence of temporomandibular disorder (TMD) and its association with anxiety and depression among 1,493 Portuguese college students (age 17-69 years) at Piaget Institute. The assessment instruments were the Fonseca Anamnestic Questionnaire and the Hospital Anxiety and Depression Scale. TMD was present in 633 (42.4%) students, and anxiety or depression was present in 456 (30.5%) students. Regarding the association of TMD with anxiety and depression, 280 of the 633 students (61.4%) with TMD symptoms also had signs of anxiety or depression (P < 0.001). As compared with men, women had an odds ratio of 1.9 (95% confidence interval: 1.53-2.46; P < 0.001) for TMD. As compared with students without signs of anxiety or depression, students with such signs had an odds ratio of 3.1 (95% confidence interval: 2.42-3.84; P < 0.001) for TMD. College students from various fields of study and regions of Portugal had a high prevalence of TMD, which was significantly associated with anxiety and depression.

Temporomandibular dysfunction syndrome: A prospective study of 255 consecutive patients

Objective

To determine the relationship between temporomandibular dysfunction syndrome (TMDS), sex and pain severity.

Methods

Data were collected prospectively from consecutive patients with TMDS. Patients were divided into four subgroups according to signs and symptoms: myofascial pain; intra-articular disorders; extra-articular disorders; degenerative disorders. Intergroup sex distribution differences were evaluated, the pain severity between the four subgroups was compared, and the rates of bruxism and inco-ordination were measured. A visual analogue scale was used to rate the pain.

Results

A total of 255 patients with TMDS were included in the study. A significantly higher rate of extra-articular disorders was found in male patients. Bruxism was found to be significantly more common in females than in males. There was no significant difference in the prevalence of inco-ordination based on sex. The overall pain score was higher in females than in males, but there was no significant difference. The pain score was significantly higher in patients in the degenerative disorders subgroup, compared with other subgroups.

Conclusions

There was no relationship between TMDS and pain and sex. Pain scores were significantly higher in the degenerative disorders subgroup, compared with other subgroups.

Effect of low-level laser therapy on pain levels in patients with temporomandibular disorders: a systematic review

Temporomandibular disorders (TMD) are characterized by the presence of temporomandibular joint (TMJ) and/or masticatory muscle pain and dysfunction. Low-level laser is presented as an adjuvant therapeutic modality for the treatment of TMD, especially when the presence of inflammatory pain is suspected.

Prospective study of a group of pre-university students evaluating anxiety and depression relationships with temporomandibular disorders

OBJECTIVES

The aim of this prospective longitudinal study was to evaluate the relationships between anxiety, depression, and temporomandibular disorders (TMD) in a sample of pre-university students submitted to a stressful event.

STUDY DESIGN

153 students from a pre-university course (82 females and 71 males between 16 and 31 years old) were given a survey about TMD symptoms and a survey about anxiety and depression scale at the beginning and the end of the preparatory course (August 2009-T1, and November 2009-T2).

RESULTS

Results were analyzed using a chi-square test and Odds Ratio (OR), significance level of α = 0.05. Statistical significance were found to depression rates in students with TMD (16% on T1 and 26% on T2, p = 0.001) as well as in general sample (12% on T1 and 22% on T2, p = 0.009), anxiety and TMD symptoms presented constant rates in both periods. Increased risk of having TMD were found in participants with anxiety (OR 2.6 in T2 and 5.6 in T1) and depression (2.0 in T2 and 3.3 in T1), but only anxiety reach statistical significance in both periods.

CONCLUSIONS

TMD symptoms were a fluctuating variable that exchange between some individuals of this study. Independently of the TMD, depression rates significant increased in the evaluated period. Finally, anxiety was the psychological symptom related to the increased risk of having TMD. Key words:Temporomandibular disorders, anxiety, depression, orofacial pain, hospital anxiety and depression scale.

Persistent orofacial muscle pain

The pathophysiology of persistent orofacial myalgia has been the centre of much controversy. In this article we suggest a novel descriptive term; 'persistent orofacial muscle pain' (POMP) and review current evidence that supports the hypothesis that the induction of POMP involves the interplay between a peripheral nociceptive source in muscle, a faulty central nervous system component and decreased coping ability. In this context it is widely accepted that a complex interaction of variable intrinsic and extrinsic factors act to induce POMP and dysfunction.

Muscle disorders and dentition-related aspects in temporomandibular disorders: controversies in the most commonly used treatment modalities

This review explores the aetiology of temporomandibular disorders and discusses the controversies in variable treatment modalities.Pathologies of the temporomandibular joint (TMJ) and its' associated muscles of mastication are jointly termed temporomandibular disorders (TMDs).TMDs present with a variety of symptoms which include pain in the joint and its surrounding area, jaw clicking, limited jaw opening and headaches. It is mainly reported by middle aged females who tend to recognize the symptoms more readily than males and therefore more commonly seek professional help.Several aetiological factors have been acknowledged including local trauma, bruxism, malocclusion, stress and psychiatric illnesses. The Research Diagnostic Criteria of the Temporomandibular Disorders (RDC/TMD) is advanced to other criteria as it takes into consideration the socio-psychological status of the patient.Several treatment modalities have been recommended including homecare practices, splint therapy, occlusal adjustment, analgesics and the use of psychotropic medication; as well as surgery, supplementary therapy and cognitive behavioural therapy. Although splint therapy and occlusal adjustment have been extensively used, there is no evidence to suggest that they can be curative; a number of evidence-based trials have concluded that these appliances should not be suggested as part of the routine care.Surgery, except in very rare cases, is discouraged since it is the most invasive alternative; recent studies have shown healthier outcome with cognitive behavioural therapy.

Maximal bite force in young adults with temporomandibular disorders and bruxism

Parafunctional habits, such as bruxism, are contributory factors for temporomandibular disorders (TMD). The aim of this study was to evaluate the maximal bite force (MBF) in the presence of TMD and bruxism (TMDB) in young adults. Twelve women (mean age 21.5 years) and 7 men (mean age 22.4 years), composed the TMDB group. Ten healthy women and 9 men (mean age 21.4 and 22.4 years, respectively) formed the control group. TMD symptoms were evaluated by a structured questionnaire and clinical signs/symptoms were evaluated during clinical examination. A visual analogical scale (VAS) was applied for stress assessment. MBF was measured with a gnatodynamometer. The subjects were asked to bite 2 times with maximal effort, during 5 seconds, with a rest interval of about one minute. The highest values were considered. The data were analyzed with Shapiro-Wilks W-test, descriptive statistics, paired or unpaired t tests or Mann-Whitney tests when indicated, and Fisher's exact test (p < 0.05). TMDB women presented lower values of MBF as compared to those presented by TMDB men and by the control group. MBF for TMDB men was similar to that of the control group. The proportion of TMDB women with muscle pain and facial/teeth/head pain upon waking up was significantly higher than that of men. Control women presented significantly lower stress scores than the others. It was concluded that MBF was reduced in TMDB women, as they presented more signs and symptoms. Men presented higher MBF values than women, but TMD and bruxism did not significantly decrease MBF. Stress was not an influencing factor for TMD and bruxism in men.

TMD chronic pain and masseter silent period in psychiatric patients on antidepressive therapy

The aim of the study was to evaluate the long-term effects of antidepressive therapy on chronic pain and related disability, and masseter silent period in psychiatric depressive patients with temporomandibular disorders (TMD). The study included hospitalized psychiatric depressive patients on antidepressive therapy protocol (tetracyclic antidepressant-maprotiline and anxiolytic-diazepam) (n=30) and non-psychiatric patients seeking prosthodontic treatment (control group, n=38). TMD were diagnosed by Research Diagnostic Criteria for temporomandibular disorders proposed by Dworkin and LeResche. The surface electromyography was recorded from left and right masseter muscles and masseter inhibitory reflex (masseter silent period) was recorded after mechanical stimulation. The incidence of TMD appearance was very similar, of approximately 40% in both group of patients. The results of the study also indicated a higher prevalence of joint related TMD, a lower prevalence of muscular subtype of TMD and a lower grade of chronic pain and related disability in the psychiatric group of patients on antidepressive therapy in comparison with findings in the control group. In the patients on antidepressive therapy with TMD masseter silent period was not prolonged , while in the control group of patients with TMD the prolongation of the silent period was observed. The study provided evidence that long-term, combined therapy (maprotiline and diazepam) in psychiatric depressive patients significantly modulated signs and symptoms of TMD in comparison with the control group.

Sex-related differences in NMDA-evoked rat masseter muscle afferent discharge result from estrogen-mediated modulation of peripheral NMDA receptor activity

In the present study, the hypothesis that sex-related differences in glutamate-evoked rat masseter muscle afferent discharge may result from estrogen-related modulation of peripheral N-methyl-d-aspartate (NMDA) receptor activity and/or expression was tested by examining afferent fiber discharge in response to masseter injection of NMDA and the expression of NR2A/B subunits by masseter ganglion neurons in male and female rats. The results showed that injection of NMDA into the masseter muscle evoked discharges in putative mechanonociceptive afferent fibers and increased blood pressure that was concentration-dependent, however, a systemic action of NMDA appeared responsible for increased blood pressure. NMDA-evoked afferent discharge was significantly greater in female than in male rats, was positively correlated with plasma estrogen levels in females and was significantly greater in ovariectomized female rats treated with a high dose (5 mug/day) compared with a low dose (0.5 mug/day) of estrogen. Pre-treatment of high dose estrogen-treated-ovariectomized female rats with the Src tyrosine kinase inhibitor PP2 did not affect NMDA-evoked afferent discharge. NMDA-evoked afferent discharge was attenuated by the antagonists ketamine and ifenprodil, which is selective for NR2B containing NMDA receptors. Fewer masseter ganglion neurons expressed the NR2A (16%) subunit as compared with the NR2B subunit (38%), which was expressed at higher frequencies in intact female (46%) and high dose estrogen-treated ovariectomized female (60%) rats than in male (31%) rats. Taken together, these results suggest that sex-related differences in NMDA-evoked masseter afferent discharge are due, at least in part, to an estrogen-mediated increase in expression of peripheral NMDA receptors by masseter ganglion neurons in female rats.

Multidimensional approach to the differences between muscular and articular temporomandibular patients: coping, distress, and pain characteristics

OBJECTIVE

This study analyzes the differences in psychological variables and symptomatology between temporomandibular disorder diagnosis subgroups.

STUDY DESIGN

The sample included 114 temporomandibular disorder patients that were evaluated in coping, distress, and temporomandibular characteristics. Diagnostic muscular (n = 58) and articular (n = 56) subgroups were compared in these variables through a MANCOVA.

RESULTS

Muscular patients show a higher level of general distress, specifically in the anxiety and somatization subscales and a more active coping style, with a tendency of a minor use of humor and a higher number of parafunctional habits, specifically, biting nails, hangnails, and lips.

CONCLUSION

We discuss the differences found in order to design the targets of the psychological intervention of temporomandibular patients.

Anxiety and personality traits in patients with muscle related temporomandibular disorders

This study tested the hypothesis that muscle related temporomandibular disorder patients with cervical muscle pain exhibit greater degree of psychological distress compared with patients without cervical muscle pain and controls. Thirty-eight muscle related temporomandibular disorder patients including 10 patients with cervical muscle pain and 41 healthy individuals as controls participated in the study. State and trait anxiety levels were assessed with the Spielberger's state and trait anxiety inventory. Personality traits (extroversion, neuroticism, psychoticism and social desirability) were assessed using the Eysenck's personality questionnaire, and the pain intensities described over the muscles were recorded using a 100 mm visual analogue scale. The muscle related temporomandibular disorder patients, in general, exhibited significantly higher degrees of neuroticism and trait anxiety. The patients with cervical muscle pain demonstrated a significantly higher level of psychoticism compared with the patients without cervical muscle pain and the controls and a significantly higher state anxiety level than the controls. They also demonstrated higher pain intensities in masseter and temporalis muscles compared with patients without cervical muscle pain. It has been suggested that either subjects with psychological distress are prone to temporomandibular disorders, or psychological distress is a manifestation of existing chronic pain conditions. The present findings demand further investigations and broader approach in management, as muscle related temporomandibular disorder patients with cervical muscle pain were both physically and psychologically compromised to a greater degree compared with patients without cervical muscle pain.

Signs and symptoms of temporomandibular disorders in adolescents

The aim of this study was to verify the prevalence of signs and symptoms of temporomandibular disorders (TMD) in adolescents and its relationship to gender. The sample comprised 217 subjects, aged 12 to 18. The subjective symptoms and clinical signs of TMD were evaluated, using, respectively, a self-report questionnaire and the Craniomandibular Index, which has 2 subscales; the Dysfunction Index and the Palpation Index. The results of muscle tenderness showed great variability (0.9-32.25%). In relation to the temporomandibular joint, tenderness of the superior, dorsal and lateral condyle regions occurred in 10.6%, 10.6% and 7.83%, respectively, of the sample. Joint sound during opening was present in 19.8% of the sample and during closing in 14.7%. The most prevalent symptoms were joint sounds (26.72%) and headache (21.65%). There was no statistical difference between genders (p > 0.05), except for the tenderness of the lateral pterygoid muscles, which presented more prevalence in girls. In conclusion, clinical signs and symptoms of TMD can occur in adolescents; however, gender influence was not perceived.

Psychological variables and temporomandibular disorders: distress, coping, and personality

OBJECTIVE

This study analyzes the psychological variables of distress, personality, and coping that are related to the diagnosis based on the Research Diagnostic Criteria for temporomandibular disorder. Study design An age and sex-matched controlled study conducted with a convenience sample (n=89) in a tertiary care facility.

RESULTS

The MANCOVA between the muscular (n=47), articular (n=42), and control groups (n=100) showed that the muscular group differed from the control group, obtaining higher levels of distress, anxiety, and depression, and minor use of positive reinterpretation and humor as coping strategies; the articular group also showed higher distress, less positive reinterpretation, and a lower interest in the search of instrumental social support than the control group. The coping predictor of distress in both temporomandibular groups was behavioral disengagement; however, the personality predictors differed. Neuroticism and depression were present in the muscular group, whereas conscientiousness and self-discipline were in the articular group.

CONCLUSION

Temporomandibular disorder patients have different psychological features than control subjects. There are also some differences between the diagnostic groups that should be considered to address the treatment of these patients.

Widespread pain as a risk factor for dysfunctional temporomandibular disorder pain

Widespread pain has been found to be a risk factor for onset and persistence of temporomandibular disorder (TMD) pain. The aim of this cohort study was to determine if widespread pain is associated with interference and disability related to TMD pain. Three hundred and ninety-seven TMD patients were interviewed at 1 and 2 years following enrollment. Dysfunctional TMD pain was defined as grades IV, III and II with any disability points on the graded chronic pain scale (GCPS). Widespread pain was defined by the number of pain sites (0-4: head, back, stomach, chest) outside the masticatory system. Multivariable logistic regression analysis, controlling for the effects of age, education, depression, baseline GCPS, and time since study enrollment, was used to examine the relationship between widespread pain and risk of onset or maintenance of dysfunctional TMD pain during follow-up. Among women without dysfunctional TMD pain at baseline, widespread pain was a risk factor for development of dysfunctional TMD pain (odds ratio (OR): 1.9, 95% confidence interval (CI): 1.2-2.8, P=0.003). However, there was no association between widespread pain and onset of dysfunctional TMD pain among men (OR: 1.0, 95% CI: 0.4-2.8, P=0.95) or maintenance of dysfunctional TMD among either women (OR: 1.0, 95% CI: 0.8-1.4, P=0.85) or men (OR: 0.4, 95% CI: 0.1-3.2, P=0.40). Widespread pain was independently and highly associated with risk of developing pain-related disability among women who did not have pain dysfunction at baseline, but was not predictive of risk of onset of dysfunctional TMD pain among men or maintenance of dysfunctional pain among either women or men.