Håkan Lundh

Effects of botulinum toxin on neuromuscular transmission in the rat.

1. Botulinum toxin (BoTx) type A partially blocks spontaneous transmitter release from nerve terminals in the rat. Minature end‐plate potentials (m.e.p.p.s) are present at all end‐plates, initially with a low frequency but increasing with time after posoning. Their amplitude distribution is at first skew with a predominace of very small m.e.p.p.s but, after a few days, larger than normal m.e.p.p.s appear. 2. Tetanic nerve stimulation, Black Widow Spider Venom, the Caionophore A 23187 or mechanical damage to nerve terminals increases the frequency of m.e.p.p.s and alters the amplitude distribution of m.e.p.p.s towards a normal Gaussian one; the m.e.p.p. size approaches that seen at normal end‐plates. This was seen at any time after poisoning. 3. Nerve stimulation gives rise to end‐plate potentials (e.p.p.s) of low amplitude and high failure rate. Statistical analysis indicates that evoked release is quantal in nature and follows Poisson statistics, quantum size being initially very small, but after a few days approaching normal size. Short‐term tetanic nerve stimulation reversibly increases the quantum content of e.p.p.s and during early stages of paralysis long‐term (2 hr) stimulation causes an apparently permanent increase in quantum size. 4. Raising the extracellular Ca concentration from 2 to 16 mM increases the frequency of m.e.p.p.s in normal muscle but not in BoTx poisoned ones. K‐free medium or ouabain, which are believed to raise the intracellular Ca concentration in nerve terminals, similarly increases m.e.p.p. frequency in normal but not in poisoned muscles. When the Ca‐ionophore A 23187 is used together with high extracellular Ca (greater than 4 mM) massive release of transmitter occurs from poisoned terminals. 5. The extracellular Ca concentration which causes a certain level of transmitter release in reponse to nerve impulses is considerably higher at BoTx poisoned end‐plates than at normal ones. The slope value for Ca dependence of transmitter release is about 1‐5 compared with about 3 at normal end‐plates. 6. Tetraethylammonium (TEA) greatly increases the amount of transmitter released by nerve impulses and restores neuromuscular transmission during all stages of poisoning, although it has not effect on spontaneous transmitter release. In the presence of TEA the power relation between Ca concentration and quantum content at the BoTx poisoned end‐plate is similar to that seen at normal end‐plates. 7. It is suggested that in BoTx poisoning the mechanism for transmitter release has a reduced sensitivity to Ca, and the level for activation by intracellular Ca is elevated. Once the intracellular concentration of Ca is raised to this level, by tetanic nerve stimulation, mechanical injury to nerve terminals, the Ca‐ionophore or the prolongation of the nerve action potential with TEA, augmented transmitter release occurs, similar to that which occurs in normal nerve terminals at a lower level of Ca.

Antagonism of the paralysis produced by botulinum toxin in the rat ☆: The effects of tetraethylammonium, guanidine and 4-aminopyridine

The injection of botulinum toxin type A into the hind-leg of adult rats causes complete paralysis of the leg lasting for several weeks. In the extensor digitorum longus (EDL) muscle transmitter release is reduced to a level of less than 1% of normal. Tetraethylammonium (TEA) and guanidine in concentrations of about 3 mM restore, in EDL muslces in vitro, neuromuscular transmission to about the normal level, provided that the external calcium concentration is 4 mM or higher. 4-Aminopyridine (4-AP) has similar restorative effect but is about 20-30 times more potent. Unlike TEA and guanidine, 4-AP is effective when the ambient calcium concentration is 2 mM; this drug is therefore also active in vivo. The intravenous injection of 4-AP (5 mg/kg body weight) restores neuromuscular transmission from complete paralysis by botulinum toxin to a normal level as shown by the recording of almost normal twitch and tetanic tensions in the EDL muscle. In rats paralysed by a lethal dose of botulinum toxin, the intraperitoneal administration of 4-AP restores general motor activity, the effect lasting 1-2 hours. A study of the effects of these drugs on spontaneous and evoked transmitter release suggests that all three compounds increase the level of free calcium inside the nerve terminals. In botulinum poisoning the transmitter release mechanism appears to be intact, but a reduced sensitivity to calcium has been shown (Cull-Candy et al. 1976), and this could explain why the drugs restore evoked transmitter release in botulinum poisoning.

Effects of 4-aminopyridine on neuromuscular transmission.

4-Aminopyridine (4-AP) powerfully increases transmitter release from motor nerve terminals of rat and frog skeletal muscle in response to single nerve impulses. The drug also enhances transmitter release during repetitive nerve activity but, at D-tubocurarine-blocked endplates, only the first impulses cause increased transmitter release at stimulation frequencies at or above 50 Hz. At magnesium- and botulinum-poisoned endplates, 4-AP potentiates transmitter release at every stimulus during tetanic nerve stimulation and restores neuromuscular transmission. Spontaneous transmitter release in the rat is not affected by the drug, but at some frog endplates miniature endplate potential (mepp) frequency increases. The drug has no post-synaptic action, as evidenced by its lack of effect on amplitude or time course of mepps. Decreasing the temperature from 37 to 15 degrees C does not abolish the effect of 4-AP on neuromuscular transmission. In the presence of 4-AP, single nerve impulses produce repetitive spontaneous activity in the nerve terminal of the frog nerve-muscle preparation. Experiments on the mode of action of 4-AP suggest that the drug increases transmitter release by enhancing the influx of calcium ions during depolarization of the nerve terminal.

Temporomandibular joint disk displacement without reduction. Treatment with flat occlusal splint versus no treatment.

A flat occlusal splint has been extensively used in the treatment of patients with temporomandibular joint disk displacement without reduction, but no studies with untreated controls have assessed its effect. We randomly assigned 51 patients with temporomandibular joint pain and arthrographically verified disk displacement without reduction to be treated with a flat occlusal splint or to serve as untreated control subjects in a 12-month clinical trial. Pain symptoms disappeared in about one third of the patients in each group. Another third of the patients in the control group improved. Sixteen percent of the patients in the control group and 40% of the patients treated with a flat occlusal splint were worse at the end than at the beginning of the study. Joint pain and muscle tenderness decreased more frequently in the nontreatment controls than in the treatment group. A statistically significant benefit of a flat occlusal splint over nontreatment control subjects could not be identified in this study of patients with painful disk displacement without reduction. The use of a flat occlusal splint in this patient group should therefore be reconsidered.

A three-year follow-up of patients with reciprocal temporomandibular joint clicking

It has been suggested in the literature that reciprocal temporomandibular joint clicking progresses to locking, but little information is available on the longitudinal course of this stage of internal derangement. Seventy patients with reciprocal clicking were therefore followed for 3 years. Reciprocal clicking remained unchanged in fifty patients (71%) and disappeared in twenty patients (29%). Fourteen patients (20%), in whom clicking disappeared, attained normal mouth opening, whereas locking developed in six patients (9%). At the initial examination, these six patients had more pain, more frequent joint tenderness, greater frequency of missing molar support and more often dental abrasion on the affected side than the patients who did not develop locking. It was concluded that reciprocal clicking does not usually progress to locking. However, locking is more likely to occur in patients who initially have pronounced pain, joint tenderness, dental abrasion, and no molar support on the affected side.

Temporomandibular joint pathosis related to sex, age, and dentition in autopsy material

The purpose of this autopsy study was to test the hypotheses that temporomandibular joint (TMJ) arthrosis is more common in women than in men, increases with age, and is more common in edentulous persons than in those with natural teeth. Two hundred forty-eight TMJs removed at autopsy from 224 fresh cadavers were investigated macroscopically with dissection or cryosectioning. Age was found to be a significant factor in prediction of TMJ arthrosis (p < 0.001) and of disk perforation (p < 0.05). No significant association was found between morphologic changes in the TMJ and the factor of sex for the whole group. Disk displacement and disk perforation were, however, more common in the joints of women than men in the group of persons 80 years of age or older (p < 0.05). There were significant associations (p < 0.001) between arthrosis, disk displacement, disk deformation, and disk perforation. There were no statistically significant differences in the prevalence of morphologic changes in the joints from persons with 10 or more natural teeth in each jaw compared with those from persons without natural teeth. The results of this study showed that TMJ arthrosis is more frequent in older than in younger persons. TMJ disk displacement generally appears necessary for the development of perforations. The findings of this study indicate that sex and dentition are not major factors for the development of TMJ pathosis in elderly individuals.

Morphologic changes in the temporomandibular joint in different age groups: An autopsy investigation

Comparisons among several temporomandibular joint autopsy studies indicate that the frequency of arthrosis and disk displacement is higher in elderly persons. The aim of this study was to investigate type, frequency, and location of morphologic changes in temporomandibular joint autopsy specimens divided into two groups according to age and to determine the differences between the two groups. For this purpose 68 temporomandibular joints were removed from 37 persons at autopsy. Group I (young) consisted of 36 specimens belonging to 19 persons with a mean age of 30 years (range, 16 to 39 years). Group II (elderly) consisted of 32 specimens from persons with a mean age of 68 years (range, 55 to 78 years). Significant differences between the two groups were observed with respect to several of the morphologic changes that were evaluated. The results of this study suggest that the frequency of morphologic changes such as deviation in form, arthrosis, perforations, disk displacement, disk deformation, and adhesions is higher in the temporomandibular joints of elderly persons.

Clinical findings related to morphologic changes in TMJ autopsy specimens

Numerous temporomandibular joint autopsy studies have been presented in the literature for the last two decades, but signs and symptoms of temporomandibular disorders before death were not available. To investigate the clinical significance of morphologic changes in the temporomandibular joint, 19 persons were clinically examined for signs and symptoms of temporomandibular disorders. The temporomandibular joints were subsequently analyzed macroscopically at autopsy and statistically associated with history and clinical findings. The average time between clinical examination and autopsy was 12 months. Signs and symptoms of temporomandibular disorders were not common findings for these persons. Morphologically, 31 of the 34 joints showed different forms of changes such as deviation in form, arthrosis, disk displacement, disk deformation, and adhesions. Crepitation showed a significant association with arthrosis. It was concluded that the association between pain and dysfunction and joint morphology is complex and gross morphologic alterations can be present in the absence of temporomandibular joint pain and dysfunction.

Botulinum toxin and 4-aminoquinoline induce a similar abnormal type of spontaneous quantal transmitter release at the rat neuromuscular junction

Intracellular recordings from botulinum toxin type A (BoTx)-poisoned extensor digitorum longus muscles from adult rats have shown that the toxin initially reduced the frequency of miniature endplate potentials (m.e.p.ps) to about 1/200 of normal. After a few days the m.e.p.p. frequency rose and was subsequently maintained at a level of about 1/3 of that at normal endplates. Depolarization of the nerve terminals with 20-30 mM KCl-Ringer initially failed to affect the frequency of m.e.p.ps and later caused only a 2-3--fold increase in their frequency. The temperature dependence of m.e.p.p. frequency at BoTx-poisoned endplates had a Q10 of about 12 compared to 2-3 for normal junctions. The time to peak of a population of m.e.p.ps at Botx-poisoned junctions was prolonged as compared to normal and fast- and slow-rising m.e.p.ps originated within the same post-synaptic membrane field area. M.e.p.ps in BoTx-poisoned muscles resembled the m.e.p.ps which 4-aminoquinoline (4-AQ) has been shown to induce in normal muscle, and we therefore examined and compared these two release processes for acetylcholine. Procedures known to markedly affect m.e.p.p. frequency at normal junctions, such as nerve terminal depolarization or changes in extra- and intracellular Ca2+ concentrations, failed to affect m.e.p.p. frequency in BoTx-poisoned muscles and similarly the frequency of m.e.p.ps induced by 4-AQ in normal muscle. Tonicity changes in the extracellular medium altered m.e.p.p. frequency in both the experimental conditions, but in a direction opposite to that at normal junctions. The temperature dependence of the frequency of 4-AQ-induced m.e.p.ps was similar to that of m.e.p.ps at BoTx-poisoned junctions. It is concluded that BoTx poisoning induces an abnormal type of spontaneous quantal transmitter release, characterized by being insensitive to nerve terminal depolarization and to transmembrane Ca2+ fluxes. This transmitter release has characteristics similar to that previously described for the release induced, at normal junctions, by 4-AQ.

Clinical signs of temporomandibular joint internal derangement in adults: An epidemiologic study☆

This study investigated the frequency and distribution of clinical signs of temporomandibular joint (TMJ) internal derangement in an adult non-TMJ patient population. Four hundred three persons who participated in an epidemiologic investigation were examined for clinical signs of TMJ internal derangement by four examiners who followed a standardized form. Clinical signs of internal derangement were found in 76 persons (19%). Twenty-nine persons (7%) had reciprocal clicking and 47 (12%) had a history of clicking replaced by limitation of mouth opening with deviation to the affected side. Reciprocal clicking was associated with TMJ pain during mouth opening and with limitation of jaw movement. A history of clicking replaced by limitation of mouth opening with deviation to the affected side was associated with pain during mouth opening, limitation of opening, and palpatory tenderness of the TMJ. The study indicates that clinical signs of TMJ internal derangement are present in nearly one fifth of non-TMJ patients. Those with clinical signs of internal derangement frequently also have subjective symptoms but they have not sought treatment for these symptoms.