Pei Feng Lim

Clinical Findings and Pain Symptoms as Potential Risk Factors for Chronic TMD: Descriptive Data and Empirically Identified Domains from the OPPERA Case-Control Study

Clinical characteristics might be associated with temporomandibular disorders (TMD) because they are antecedent risk factors that increase the likelihood of a healthy person developing the condition or because they represent signs or symptoms of either subclinical or overt TMD. In this baseline case-control study of the multisite Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) project, 1,633 controls and 185 cases with chronic, painful TMD completed questionnaires and received clinical examinations. Odds ratios measuring association between each clinical factor and TMD were computed, with adjustment for study-site as well as age, sex, and race/ethnicity. Compared to controls, TMD cases reported more trauma, greater parafunction, more headaches and other pain disorders, more functional limitation in using the jaw, more nonpain symptoms in the facial area, more temporomandibular joint noises and jaw locking, more neural or sensory medical conditions, and worse overall medical status. They also exhibited on examination reduced jaw mobility, more joint noises, and a greater number of painful masticatory, cervical, and body muscles upon palpation. The results indicated that TMD cases differ substantially from controls across almost all variables assessed. Future analyses of follow-up data will determine whether these clinical characteristics predict increased risk for developing first-onset pain-related TMD PERSPECTIVE: Clinical findings from OPPERAs baseline case-control study indicate significant differences between chronic TMD cases and controls with respect to trauma history, parafunction, other pain disorders, health status, and clinical examination data. Future analyses will examine their contribution to TMD onset.

Perceived intensity and unpleasantness of cutaneous and auditory stimuli: an evaluation of the generalized hypervigilance hypothesis.

ABSTRACT According to the Generalized Hypervigilance Hypothesis (GHH) of McDermid et al. [15], the unpleasantness of sensory stimuli, rather than their modality, determines whether they will be perceptually amplified in hypervigilant persons. In a test of this idea, ratings of the intensity of sensations evoked by cutaneous and auditory stimuli were obtained from individuals with chronic myofascial pain (fibromyalgia, temporomandibular disorders), and from (less hypervigilant) healthy control participants. In each modality, the stimuli spanned a wide intensity range, with the weakest stimuli being affectively neutral and the strongest being distinctly unpleasant, as determined by unpleasantness ratings. The pain patients showed robust perceptual amplification of the cutaneous pressure stimuli, and modest amplification of the auditory stimuli. In both cases, perceptual amplification extended to even the lowest stimulus intensities, a result that is not consistent with the predictions of the GHH. An alternative formulation, the attentional gain control model of hypervigilance, is proposed, according to which those types of stimuli that are associated with pain are amplified because of the attention that is habitually directed toward them.

Clinical orofacial characteristics associated with risk of first-onset TMD: the OPPERA prospective cohort study.

UNLABELLED Case-control studies have documented clinical manifestations of chronic temporomandibular disorder (TMD), whereas clinical predictors of TMD development are largely unknown. We evaluated 41 clinical orofacial characteristics thought to predict first-onset TMD in a prospective cohort study of U.S. adults aged 18 to 44 years. During the median 2.8-year follow-up period, 2,737 people completed quarterly screening questionnaires. Those reporting symptoms were examined and 260 people were identified with first-onset TMD. Univariate and multivariable Cox regression models quantified associations between baseline clinical orofacial measures and TMD incidence. Significant predictors from baseline self-report instruments included oral parafunctions, prior facial pain and its life-impact, temporomandibular joint noises and jaw locking, and nonspecific orofacial symptoms. Significant predictors from the baseline clinical examination were pain on jaw opening and pain from palpation of masticatory, neck, and body muscles. Examiner assessments of temporomandibular joint noise and tooth wear facets did not predict incidence. In multivariable analysis, nonspecific orofacial symptoms, pain from jaw opening, and oral parafunctions predicted TMD incidence. The results indicate that only a few orofacial examination findings influenced TMD incidence, and only to a modest degree. More pronounced influences were found for self-reported symptoms, particularly those that appeared to reflect alterations to systems beyond the masticatory tissues. PERSPECTIVE OPPERAs prospective cohort study identifies predictors of first-onset TMD comprising self-reported orofacial symptoms and examination findings. The results suggest a complex pattern of TMD etiology that is influenced by disorders locally, in masticatory tissues, and systemically, in pain-regulatory systems.

Development of Temporomandibular Disorders is associated with greater bodily pain experience

ObjectivesThe aim of this study is to examine the difference in the report of bodily pain experienced by patients who develop temporomandibular disorders (TMD) and by those who do not develop TMD over a 3-year observation period. MethodsThis is a 3-year prospective study of 266 females aged 18 to 34 years initially free of TMD pain. All patients completed the Symptom Report Questionnaire (SRQ) at baseline and yearly intervals, and at the time they developed TMD (if applicable). The SRQ is a self-report instrument evaluating the extent and location of pain experienced in the earlier 6 months. Statistical analysis was carried out using repeated measures ANOVA. ResultsOver the 3-year period, 16 patients developed TMD based on the Research Diagnostic Criteria for TMD. Participants who developed TMD reported more headaches (P=0.0089), muscle soreness or pain (P=0.005), joint soreness or pain (P=0.0012), back pain (P=0.0001), chest pain (P=0.0004), abdominal pain (P=0.0021), and menstrual pain (P=0.0036) than Participants who did not develop TMD at both the baseline and final visits. Participants who developed TMD also reported significantly more headache (P=0.0006), muscle soreness or pain (P=0.0059), and other pains (P=0.0188) when they were diagnosed with TMD compared with the baseline visit. DiscussionThe development of TMD was accompanied by increases in headaches, muscle soreness or pain, and other pains that were not observed in the Participants who did not develop TMD. Participants who developed TMD also report higher experience of joint, back, chest, and menstrual pain at baseline.

Relationship Between Temporomandibular Disorders, Widespread Palpation Tenderness, and Multiple Pain Conditions: A Case-Control Study

UNLABELLED The multiple bodily pain conditions in temporomandibular disorders (TMD) have been associated with generalized alterations in pain processing. The purpose of this study was to examine the relationship between the presence of widespread body palpation tenderness (WPT) and the likelihood of multiple comorbid pain conditions in TMD patients and controls. This case-control study was conducted in 76 TMD subjects with WPT, 83 TMD subjects without WPT, and 181 non-TMD matched control subjects. The study population was also characterized for clinical pain, experimental pain sensitivity, and related psychological phenotypes. Results showed that: 1) TMD subjects reported an average of 1.7 comorbid pain conditions compared to .3 reported by the control subjects (P < .001); 2) Compared to control subjects, the odds ratio (OR) for multiple comorbid pain conditions is higher for TMD subjects with WPT [OR 8.4 (95% CI 3.1-22.8) for TMD with WPT versus OR 3.3 (95% CI 1.3-8.4) for TMD without WPT]; 3) TMD subjects with WPT presented with reduced pressure pain thresholds (PPTs) in both cranial and extracranial regions compared to TMD subjects without WPT; and 4) TMD subjects with WPT reported increased somatic symptoms. These findings suggest that pain assessment outside of the orofacial region may prove valuable for the classification, diagnosis, and management of TMD patients. PERSPECTIVE TMD subjects with WPT experience a greater level of multiple comorbid pain conditions, compared to TMD subjects without WPT and non-TMD controls. Integration of bodily pain assessments can be informative for evaluation, diagnosis, and management of TMD.

Temporomandibular Joint Disorders

Temporomandibular joint disorder (TMJD) is a musculoskeletal pain condition affecting the TMJ, masticatory muscles, and/or associated structures. It is characterized by spontaneous pain and jaw function-induced pain in the TMJ and muscles of mastication. Conditions comorbid with TMJD include fibromyalgia, irritable bowel syndrome, chronic headache, interstitial cystitis, and chronic tinnitus. The risk factors consistently associated with TMJD are female gender, depression, and preexisting pain conditions. While TMJD pain is estimated to be 1.5–2 times more common in women than in men, the influence of gender on the diagnosis and treatment of TMJD is yet to be evaluated. Future studies identifying the environmental, genetic, biological, and psychosocial risk factors which seem to ‘protect’ the male sex from the development of TMJD will better the prevention and management of this multifaceted disorder.

Persistent pain after endodontic therapy

A middle-aged woman visited a clinician with the chief complaint that her tooth hurt despite having been treated several times by an endodontist to whom she had been referred. Over the previous year, the endodontist had performed nonsurgical endodontic therapy on her maxillary right first molar and six months later performed surgical endodontic therapy (that is, an apicoectomy and a retrograde root canal filling) in an attempt to resolve her pain. However, this treatment was unsuccessful. The patient then sought a second opinion from another dentist, who advised her to have the tooth extracted and an implant placed; however, she chose not to pursue these treatment options. The patient reported that her pain intensity had not changed since she underwent the original endodontic treatment. Analgesics such as ibuprofen and acetaminophen had little or no effect on her pain. The clinical examination did not reveal any dental pathology. A periapical radiograph of the tooth and a cone-beam computed tomographic scan of the quadrant failed to identify any pathological lesion that could have contributed to her pain. What are the most likely explanations for this situation?