Reny de Leeuw

Internal Derangements of the Temporomandibular Joint

This article discusses several types of internal derangements of the temporomandibular joint. It includes definitions, clinical characteristics, and management options. Nonsurgical and surgical treatment strategies are discussed taking into consideration the latest evidence-based literature.

Cerebral activation during thermal stimulation of patients who have burning mouth disorder: an fMRI study.

Abstract The pathophysiology of burning mouth disorder (BMD) is not clearly understood, but central neuropathic mechanisms are thought to be involved. The aim of this study was to gain insight into the pathophysiology associated with BMD by using functional magnetic resonance imaging (fMRI). Areas of brain activation following thermal stimulation of the trigeminal nerve of eight female patients with BMD (mean age 49.1 ± 10.1) were mapped using fMRI and compared with those of eight matched pain‐free volunteers (mean age 50.3 ± 12.3). Qualitative and quantitative differences in brain activation patterns between the two study groups were demonstrated. BMD patients displayed greater fractional signal changes in the right anterior cingulate cortex (BA 32/24) and bilateral precuneus than did controls (p < 0.005). The control group showed larger fractional signal changes in the bilateral thalamus, right middle frontal gyrus, right pre‐central gyrus, left lingual gyrus, and cerebellum than did the BMD patients (p < 0.005). In addition, BMD patients had less volumetric activation throughout the entire brain compared to the control group. Overall, BMD patients displayed brain activation patterns similar to those of patients with other neuropathic pain conditions and appear to process thermal painful stimulation to the trigeminal nerve qualitatively and quantitatively different than pain‐free individuals. These findings suggest that brain hypoactivity may be an important feature in the pathophysiology of BMD.

Radiographic signs of temporomandibular joint osteoarthrosis and internal derangement 30 years after nonsurgical treatment

The aim of this study was to evaluate with radiographs the long-term status of temporomandibular joints that were treated nonsurgically for reducing disk displacement (group 1) or permanent disk displacement (group 2) 30 years ago. Transcranial and transpharyngeal radiographs were made before (T1), 2 to 4 years after (T2), and 30 years after (T3) nonsurgical treatment in 65 former patients with temporomandibular joint osteoarthrosis. To control the results for aging 35 matched subjects (group 3) underwent the same radiographic examination. The number and severity of radiographically visible degenerative changes increased significantly from T1 through T2 to T3 in group 1 and in group 2. The increase in these changes was not simply caused by aging, because in approximately three quarters of the temporomandibular joints in group 3, no radiographically visible degenerative changes were found. At all occasions group 2 showed significantly more severe changes than group 1. At T3 in 64% of the temporomandibular joints in group 1, no or only slight radiographically visible degenerative changes were observed, whereas in 86% of the temporomandibular joints in group 2, moderate to severe changes were observed. A persisting reducing disk displacement in part of the temporomandibular joints in group 1 might explain this significant difference. In 79% of the temporomandibular joints with moderate to severe radiographically visible degenerative changes at T1, no or only slight progression in the extent of these changes was seen between T2 and T3. Apparently a radiographically stable end stage may be reached within a few years after permanent displacement in most cases. It was concluded that in temporomandibular joints with reducing disk displacement, no or only slight radiographically visible degenerative changes develop, even if this condition persists for several decades. On the other hand, in temporomandibular joints with permanent disk displacement, radiographically visible degenerative changes are extensive in the vast majority of cases.

Hard and soft tissue imaging of the temporomandibular joint 30 years after diagnosis of osteoarthrosis and internal derangement

PURPOSE This article describes the clinical and imaging findings in the temporomandibular joints (TMJs) of patients 30 years after the initial diagnosis of osteoarthrosis and internal derangement. PATIENTS AND METHODS Fifty-five TMJs with a history of osteoarthrosis and internal derangement and 37 contralateral TMJs that were asymptomatic 30 years ago were examined in 46 former patients. To visualize degenerative changes of the bony parts of the TMJ, transpharyngeal and transcranial radiographs were made; to visualize disc position, sagittal T1-weighted magnetic resonance (MR) images were made. For comparison, 22 TMJs of an age-matched control group without complaints related to the masticatory system were similarly examined. RESULTS Thirty years after the initial diagnosis of osteoarthrosis and internal derangement, clinical signs in former patients hardly differed from those of control subjects. radiographic signs were significantly more common and more severe in former patients. A high percentage of osteoarthrosis and internal derangement was seen on MRI in both TMJs with a history of osteoarthrosis and internal derangement and in the contralateral TMJs. It appeared that osteoarthrosis and internal derangement in the contralateral TMJs had developed asymptomatically in most cases. None of the patients had required treatment for the contralateral TMJ; only one fourth of the patients had noticed symptoms. In the control subjects, osteoarthrosis and internal derangement were infrequently seen. A significant correlation was found between disc position and the severity of radiographically detectable degenerative changes of the TMJ. CONCLUSIONS It was concluded that 30 years after initial diagnosis there were few clinical signs of osteoarthrosis and internal derangement, although radiographic signs were extensive. Bilateral osteoarthrosis and internal derangement, with one symptomatic and one asymptomatic TMJ, is a common phenomenon. Moderate to severe radiographically detectable degenerative changes may be the only sign of an underlying internal derangement.

Differential Diagnosis of Temporomandibular Disorders and Other Orofacial Pain Disorders

There are many types of pain conditions that are felt in the orofacial structures. Most of the conditions treated by the dentist are associated with the teeth, periodontal structures, and associated mucosal tissues. This article focuses on the differential diagnosis of other common pain conditions the dentist will likely face, such as temporomandibular disorders, neuropathic pain disorders, and common headaches; and the clinical presentation of each. Controlling or reducing pain can be accomplished by controlling perpetuating factors such as parafunctional habits and by some simple behavioral modifications. Finally, this article offers some simple treatment considerations.

Self-regulatory deficits in fibromyalgia and temporomandibular disorders

&NA; Chronic pain conditions such as fibromyalgia (FM) and temporomandibular disorders (TMDs) are accompanied by complex interactions of cognitive, emotional, and physiological disturbances. Such conditions are complicated and draining to live with, and successful adaptation may depend on ability to self‐regulate. Self‐regulation involves capacity to exercise control and guide or alter reactions and behavior, abilities essential for human adjustment. Research indicates that self‐regulatory strength is a limited source that can be depleted or fatigued, however, and the current study aimed to show that patients with FM and TMD are vulnerable to self‐regulatory fatigue as a consequence of their condition. Patients (N = 50) and pain‐free matched controls (N = 50) were exposed to an experimental self‐regulation task followed by a persistence task. Patients displayed significantly less capacity to persist on the subsequent task compared with controls. In fact, patients exposed to low self‐regulatory effort displayed similar low persistence to patients and controls exposed to high self‐regulatory effort, indicating that patients with chronic pain conditions may be suffering from chronic self‐regulatory fatigue. Baseline heart rate variability, blood glucose, and cortisol predicted persistence, more so for controls than for patients, and more so in the low vs. high self‐regulation condition. Impact of chronic pain conditions on self‐regulatory effort was mediated by pain, but not by any other factors. The current study suggests that patients with chronic pain conditions likely suffer from chronic self‐regulatory fatigue, and underlines the importance of taking self‐regulatory capacity into account when aiming to understand and treat these complex conditions.

Traumatic Stressors and Post-Traumatic Stress Disorder Symptoms in Headache Patients

Objective.—The aim of this study was to assess the prevalence of significant traumatic stressors and post‐traumatic stress disorder (PTSD) symptoms in a headache population.

TMJ articular disc position and configuration 30 years after initial diagnosis of internal derangement

PURPOSE This study evaluates disc position and configuration on magnetic resonance imaging (MRI) in temporomandibular joints (TMJs) with a long history of internal derangement. PATIENTS AND METHODS Sagittal T1-weighted MRIs of 55 TMJs that were diagnosed with internal derangement approximately 30 years ago were made with the mouth closed and open, and the position and configuration of the articular disc were determined. For comparison, a control group consisting of 15 asymptomatic TMJs without clinical signs of internal derangement or of other TMJ disorders were studied in the same way. RESULTS Anterior disc position was found in 90% of the TMJs with a history of internal derangement. Reducing disc displacement was found in one third of these TMJs, whereas permanent displacement was found in two thirds. In four joints, no disc was discernible. In one of the joints of the control group, a permanent disc displacement was found; normal disc position was found in all other joints of the control group. A biconcave disc configuration, which was considered normal, was found only in TMJs with normal disc position or with reducing discs. CONCLUSION It was concluded that, after 30 years of displacement, the TMJ disc can be clearly identified on MRI in most cases. If the disc becomes permanently displaced, its configuration deviates from the normal biconcave configuration, and its anteroposterior length decreases. Convex and folded appearances of the disc are common in this situation. However, the disc usually maintains its biconcave configuration as long as it resumes its position on top of the condyle during mouth opening, even if this condition lasts for several decades.

Individual differences and self-regulatory fatigue: optimism, conscientiousness, and self-consciousness

Ability to self-regulate varies and self-regulatory strength is a limited source that can be depleted or fatigued. Research on the impact of individual differences on self-regulatory capacity is still scarce, and this study aimed to examine whether personality factors such as dispositional optimism, conscientiousness, and self-consciousness can impact or buffer self-regulatory fatigue. Participants were patients diagnosed with chronic multi-symptom illnesses (N = 50), or pain free matched controls (N = 50), randomly assigned to either a high or low self-regulation task, followed by a persistence task. Higher optimism predicted longer persistence (p = .04), and there was a trend towards the same effect for conscientiousness (p = .08). The optimism by self-regulation interaction was significant (p = .01), but rather than persisting despite self-regulatory effort, optimists persisted longer only when not experiencing self-regulatory fatigue. The effects of optimism were stronger for controls than patients. There was also a trend towards a similar conscientiousness by self-regulation interaction (p = .06). These results suggest that the well-established positive impact of optimism and conscientiousness on engagement and persistence may be diminished or reversed in the presence of self-regulatory effort or fatigue, adding an important new chapter to the self-regulation, personality, and pain literature.

Complications of frontal sinus fractures with emphasis on chronic craniofacial pain and its treatment: a review of 43 cases.

PURPOSE Frontal sinus fractures constitute 5% to 12% of all facial fractures. The optimal management of frontal sinus fractures is controversial but involves preserving the function of the nasofrontal ducts when feasible. We reviewed the postoperative complications of a series of 43 patients treated surgically for frontal sinus fractures. MATERIALS AND METHODS The data from 43 patients treated from 2000 to 2006 were reviewed. The information reviewed included patient age and gender, mechanism of injury, type of frontal sinus injury, associated facial injuries, treatment method, and complications. The institutional review board approved the present study. RESULTS The average patient age was 32.5 years; 36 were men and 7 were women. Of the 43 patients, 23 (53.5%) had had anterior table fractures and 20 (46.5%) had had both anterior and posterior table fractures. Postoperative complications occurred in 7 patients (16.3%). Of these 7 patients, 2 experienced continued headache and pain and required surgical removal of infected hardware, 3 also experienced frequent headaches and pain in the frontal-temporal region, 1 had a post-traumatic deformity, and 1 developed periorbital cellulitis and abscess formation within the frontal sinus. CONCLUSION Frequent headaches and complaints of continued pain were the most common complications experienced by our series of patients. We also reviewed treatment strategies for postoperative follow-up and treatment of chronic pain.