Earl Sommers

Brief group cognitive-behavioral intervention for temporomandibular disorders

&NA; Temporomandibular disorders (TMD) are currently viewed as an interrelated set of clinical conditions presenting with signs and symptoms in masticatory and related muscles of the head and neck, and the soft tissue and bony components of the temporomandibular joint. Epidemiologie and clinical studies of TMD confirm its status as a chronic pain problem. In this report we present results from a randomized clinical trial which compared, at 3‐ and 12‐month follow‐ups, the effects of usual TMD treatment on TMD pain and related physical and psychological variables with the effects of a cognitive‐behavioral (CB) intervention delivered to small groups of patients before usual TMD treatment began. The purpose of this study was to determine whether a minimal CB intervention followed by dental TMD treatment enhanced the effects of usual clinical dental treatment. A second purpose of the study was to determine whether patients classified as high in somatization and psychosocial dysfunction would respond less favorably to this minimal intervention than would those low in somatization and dysfunction. Patients who participated in the CB intervention followed by usual treatment showed greater long‐term decreases in reported pain level and pain interference in daily activities than did patients who received only usual treatment. The benefits of CB intervention were not seen when the CB and UT groups were compared at 3‐month follow‐up. During the 3–12‐month follow‐up interval, however, the UT group maintained essentially the same level of improvement in characteristic pain while the CB group continued to improve, as hypothesized. During this same follow‐up interval, the CB group also showed a strong trend toward continued improvement in pain interference. Such effects were not observed for depression, somatization, or clinical measures of jaw range of motion. Additionally, as hypothesized, dysfunctional chronic pain patients did not appear to benefit from the brief CB intervention. Intent to treat analyses were also performed to assess generalizability of the results.

Age-related Salivary Flow Rate Changes in Controls and Patients with Oral Lichen Planus

Unstimulated whole saliva and stimulated whole, parotid, and labial minor gland saliva samples were collected from 25 patients with oral lichen planus and from 25 age- and sex-matched controls between the ages of 25 and 87 years. All subjects did not smoke or chew tobacco, had no serious illnesses, and were unmedicated. There were no significant differences in flow rates between the two groups. However, a significant age-related decrease in labial minor gland saliva flow rate was found in both the lichen planus group and the controls. Flow rates of unstimulated and stimulated whole saliva and stimulated parotid saliva were not related to age in either group.

An epidemiologic evaluation of two diagnostic classification schemes for temporomandibular disorders

Few diagnostic classification schemes for temporomandibular disorders (TMD) have been applied systematically to examine the prevalence of various subtypes of TMD in clinic or community populations. In this study, computer algorithms were developed for classifying subjects according to the scheme of Eversole and Machado (1985) and a classification scheme recently developed in our own research at the University of Washington. The diagnostic algorithms were applied to clinical examination data for (1) persons without TMD pain (community controls) and (2) persons reporting TMD pain in the prior 6 months (community subjects with pain), identified in a random sample survey of a health maintenance organization (HMO) population, as well as (3) clinic patients seeking treatment for TMD through the same HMO. Prevalence rates for myofascial pain dysfunction in clinic patients were much higher under the University of Washington approach, whereas rates of internal derangement (type I) and degenerative joint disease were similar under the two schemes. These similar prevalence rates were not, however, accompanied by high concordance between the two schemes. These results highlight the complexities of differential diagnosis of TMD in field research, and suggest that further evaluation of alternative diagnostic schemes is warranted.

Short-term effect of two therapeutic methods on myofascial pain and dysfunction of the masticatory system

In conclusion, a short-term intervention with IS therapy was found to result in a substantial decrease in facial pain for most of the subjects treated. Generally, groups were not found to be significantly different in respect to palpation pain change from session 1 to session 2. Neither therapy significantly altered the range of mouth opening. EMG findings were variable but suggest that RI therapy may alter muscle myoelectric activity. From these findings, ice and stretch of the masticatory and neck musculature would appear to be a good short-term adjunctive therapy to control pain with little apparent risk of negative effects.

Pharmacological Management of Recurrent Oral Mucosal Ulceration

SummaryA number of diseases can cause recurrent intraoral ulceration. This review focuses principally on drug management of intraoral ulceration associated with local and systemic conditions most likely to be observed on an outpatient basis by the general practitioner. These consist of recurrent aphthous stomatitis, erosive lichen planus, benign mucous membrane pemphigoid (BMMP), erythema multiforme, Behçet’s disease, allergic stomatitis and infection. Information is provided on a spectrum of medication found useful in ulcer management, including topical antimicrobial and antifungal agents, topical and systemic corticosteroids, topical and systemic analgesics, and systemic immunosuppressive and anxiolytic drugs, plus details of dosage, important adverse reactions and interactions. A treatment guide for management of recurrent aphthae is presented. The reader is presumed to be familiar with differential diagnosis and the importance of establishing an accurate impression before starting drug therapy.

Temporomandibular Disorders: Variation in Clinical Practice

This research describes the extent of variability in diagnosis and treatment of temporomandibular disorders (TMD) and relates this variability to treatment outcomes. A health maintenance organization sequentially referred 145 patients with orofacial pain and dysfunction to two TMD clinics. The two clinics differed substantially in their use of tomography (applied to 28% vs. 64% of all patients), and varied moderately in diagnoses assigned to the patient groups. There was large variation in selection of treatments including appliances for bruxism (64% vs. 5%), mandibular repositioning (10% vs. 25%), and joint stabilization (3% vs. 30%); anti-inflammatory medications (44% vs. 19%) and analgesics (16% vs. 2%); and subsequent referral for dental or orthodontic treatment (1% vs. 42%). The differences in diagnostic and therapeutic practice that were found were not associated with important differences in patient-reported pain and dysfunction at 1-year follow-up. These data indicate the need for systematic approaches to identifying, evaluating, and modifying variation in health care practices for common presenting problems lacking reliable methods of evaluation and generally accepted clinical standards for choice of treatments.

Sialochemistry of Whole, Parotid, and Labial Minor Gland Saliva in Patients with Oral Lichen Planus

This study was undertaken to determine whether oral lichen planus in otherwise healthy patients is associated with sialochemical abnormalities. Unstimulated and stimulated whole saliva, stimulated parotid saliva, and stimulated labial minor gland saliva were collected from 25 patients with oral lichen planus and from 25 age- and sex-matched controls. Flow rate and salivary concentrations of immunoglobulins A and G, albumin, amylase, lysozyme, lactoferrin, and total protein were determined by standard analytical techniques. Concentrations of inorganic components including sodium, potassium, calcium, chloride, and phosphate were also measured. No significant differences were found between the lichen planus patients and the controls. These findings do not support an association between oral lichen planus and salivary dysfunction in otherwise healthy patients.

Longitudinal Stability of Common TMJ Structural Disorders

The longitudinal course of temporomandibular joint (TMJ) disc displacement (DD) and degenerative joint disease (DJD) has never been conclusively described with magnetic resonance imaging and computed tomography, respectively. This 8-y observational study’s objective was to assess the longitudinal stability of DD and DJD among 401 subjects. The Validation Project provided baseline measures; follow-up was performed in the TMJ Impact Project. With magnetic resonance imaging, 2 radiologists rendered a consensus diagnosis of normal/indeterminate, DD with reduction, or DD without reduction. Computed tomography consensus diagnoses included normal/indeterminate, grade 1 DJD, or grade 2 DJD. Radiologist reliability was assessed by kappa; a Hui-Walter model was used to estimate, after accounting for diagnostic disagreement, the frequency of diagnostic progression and reversal. Permutation tests were used to test the statistical influence of concurrent baseline diagnoses on diagnostic changes at follow-up. Of 789 baseline joint-specific soft tissue diagnoses of DD, 598 (76%) joints showed no change; 109 (14%) demonstrated progression; and 82 (10%) had reversal. Of 794 joints with baseline joint-specific hard tissue diagnoses of DJD, progression was observed in 122 (15%) joints, no change in 564 (71%), and reversal in 108 (14%). Radiologist reliability (kappa) was 0.73 (95% CI, 0.64 to 0.83) for DD and 0.76 (95% CI, 0.68 to 0.83) for DJD. After accounting for the influence of diagnostic disagreement, progression of hard tissue diagnoses in the right TMJ occurred in 15.2% of subjects (95% CI, 10.5% to 20.8%) and reversal in 8.3% (95% CI, 4.9% to 12.3%); results were similar for soft tissue diagnoses and the left TMJ. Concurrent baseline soft tissue diagnoses were associated with hard tissue diagnostic changes at follow-up (P < 0.0001). Baseline hard tissue diagnoses showed no statistical association with soft tissue changes at follow-up (P = 0.11). Longitudinally, 76% of baseline TMJ soft tissue diagnoses and 71% of the baseline hard tissue diagnoses remained stable. Diagnostic reversal and progression were confirmed for both soft and hard tissues.

Sigmoid colon perforation: Result of accidental swallowing of a toothpick

Acute surgical abdomen is a very serious situation that arises in various medical conditions. Common among them are appendicitis, foreign-body ingestion, and intestinal obstruction or perforation. These complications usually require emergency abdominal surgery. A case of rectal bleeding accompanied by acute surgical abdomen following the accidental ingestion of a toothpick is described in this report.

Permeability of the thermometer sheath when taking oral temperatures.

Oral mercury-in-glass thermometers are contaminated with each use and must be decontaminated prior to reuse. It has been shown that the application of a thermometer sheath prevents contamination of the rectal thermometer. The purpose of the present study is to evaluate sheathed thermometers for contamination after oral use on dentulous patients. One hundred sterile sheathed thermometers were distributed into four groups and subjected to in vitro and in vivo conditions. After clinical use 80% of the sheathed thermometers became contaminated, while not one of those exposed to microorganisms in vitro was contaminated. The cause for contamination was shown to be perforation of the sheath by the dentition. Thus the thermometer sheath is ineffective in preventing contamination of the mercury-in-glass thermometer when used for obtaining oral temperatures from dentulous patients. Sheathed mercury-in-glass thermometers should be decontaminated after each oral use.