Yuri Martins Costa

Additional effect of occlusal splints on the improvement of psychological aspects in temporomandibular disorder subjects: A randomized controlled trial

OBJECTIVE To measure the effect of occlusal splints as an additional treatment on psychological aspects in temporomandibular disorder patients. DESIGN A randomized controlled trial was performed comprising 60 adults diagnosed with masticatory myofascial pain according the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). The participants were divided equally into 2 treatment groups, which received only counselling (Group 1) or occlusal splints in addition to counselling (Group 2). The assessments occurred at baseline and at 2 and 5 months after treatment. The outcomes were symptoms of anxiety and depression, as well as pain catastrophizing. Two-way ANOVA, Friedman and Mann-Whitney tests were used to perform the statistical analysis, considering a significance level of 5%. RESULTS In relation to the baseline assessment, 60% of the subjects had at least mild anxiety and 25% had at least mild depression, and the mean and standard deviation (SD) of pain catastrophizing was 2.41 (1.33) for Group 1 and 2.06 (1.04) for Group 2. Comparisons between baseline and the fifth-month evaluation showed an improvement in anxiety and depression symptoms only in Group 2 (p<0.05). Otherwise, there was a significant reduction in pain catastrophizing in both groups (p<0.05), with a mean (SD) of 1.14 (1.28) for Group 1 and 0.76 (0.82) for Group 2. CONCLUSION Minimally invasive strategies could provide an improvement in the psychological aspects of temporomandibular disorder patients, and the use of an occlusal splint seems to hasten the manifestation of these effects.

Neck disability is associated with masticatory myofascial pain and regional muscle sensitivity.

OBJECTIVE The primary aims of this study are to compare neck disability in masticatory myofascial pain subjects versus asymptomatic controls, and to evaluate the correlation between neck disability and muscle pain. DESIGN Two groups composed this case-control study: a symptomatic group comprised of 27 subjects diagnosed with masticatory myofascial pain, as determined by the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), and a control group comprised of 28 asymptomatic subjects. The collected variables were pain intensity (visual analogue scale), pressure pain threshold of the temporomandibular joint, anterior temporalis, masseter, sternocleidomastoid muscle, upper trapezius and Achilles tendon (digital dynamometer, kgf/cm(2)), and neck disability (Neck Disability Index). Statistical analysis included Students t-test and the Pearson product-moment correlation coefficient (5% significance level and 95% confidence interval). RESULTS The symptomatic group showed greater neck disability with a mean (SD) of 11.8 (7), as compared with 2.8 (2.4) for the asymptomatic group (p<0.05). A negative correlation was found between neck disability and pressure pain threshold of the anterior temporalis (r=-0.4, 95% CI -0.6 to -0.15, p=0.002), the sternocleidomastoid (r=-0.35, 95% CI -0.56 to -0.09, p=0.007) and the upper trapezius (r=-0.37, 95% CI -0.58 to -0.12, p=0.005). CONCLUSION Our results reinforced the clinical interconnection between masticatory and cervical structures, insofar as subjects with masticatory myofascial pain reported greater neck disability, which, in turn, was correlated with regional muscle sensitivity.

Coronoid process hyperplasia: an unusual cause of mandibular hypomobility.

A large number of disorders affecting the masticatory system can cause restriction of mouth opening. The most common conditions related to this problem are those involving the temporomandibular joint (TMJ) and the masticatory muscles, when facial pain also is an usual finding. Congenital or developmental mandibular disorders are also possible causes for mouth opening limitation, although in a very small prevalence. Coronoid process hyperplasia (CPH) is an example of these cases, characterized by an excessive coronoid process growing, where mandibular movements become limited by the impaction of this structure on the posterior portion of the zygomatic bone. This condition is rare, painless, usually bilateral and progressive, affecting mainly men. Diagnosis of CPH is made based on clinical signs of mouth opening limitation together with imaging exams, especially panoramic radiography and computerized tomography (CT). Treatment is exclusively surgical. This paper presents a case of a male patient with bilateral coronoid process hyperplasia, initially diagnosed with bilateral disk displacement without reduction, and successfully treated with intraoral coronoidectomy. It is emphasized the importance of differential diagnosis for a correct diagnosis and, consequently, effective management strategy.

Headaches and myofascial temporomandibular disorders: overlapping entities, separate managements?

There are relevant clinical overlaps between some of the painful temporomandibular disorders (TMD) and headache conditions that may hamper the diagnostic process and treatment. A non-systematic search for studies on the relationship between TMD and headaches was carried out in the following databases: PubMed, Cochrane Library and Embase. Important pain mechanisms contributing to the close association and complex relationship between TMD and headache disorders are as follows: processes of peripheral and central sensitisation which take place in similar anatomical areas, the possible impairment of the descending modulatory pain pathways and the processes of referred pain. In addition, the clinical examination does not always provide distinguishing information to differentiate between headaches and TMD. So, considering the pathophysiology and the clinical presentation of some types of headache and myofascial TMD, such overlap can be considered not only a matter of comorbid relationship, but rather a question of disorders where the distinction lines are sometimes hard to identify. These concerns are certainly reflected in the current classification systems of both TMD and headache where the clinical consequences of diagnosis such as headache attributed to or associated with TMD are uncertain. There are several similarities in terms of therapeutic strategies used to manage myofascial TMD and headaches. Considering all these possible levels of interaction, we reinforce the recommendation for multidisciplinary approaches, by a team of oro-facial pain specialists and a neurologist (headache specialist), to attain the most precise differential diagnosis and initiate the best and most efficient treatment.

Quantitative methods for somatosensory evaluation in atypical odontalgia

A systematic review was conducted to identify reliable somatosensory evaluation methods for atypical odontalgia (AO) patients. The computerized search included the main databases (MEDLINE, EMBASE, and Cochrane Library). The studies included used the following quantitative sensory testing (QST) methods: mechanical detection threshold (MDT), mechanical pain threshold (MPT) (pinprick), pressure pain threshold (PPT), dynamic mechanical allodynia with a cotton swab (DMA1) or a brush (DMA2), warm detection threshold (WDT), cold detection threshold (CDT), heat pain threshold (HPT), cold pain detection (CPT), and/or wind-up ratio (WUR). The publications meeting the inclusion criteria revealed that only mechanical allodynia tests (DMA1, DMA2, and WUR) were significantly higher and pain threshold tests to heat stimulation (HPT) were significantly lower in the affected side, compared with the contralateral side, in AO patients; however, for MDT, MPT, PPT, CDT, and WDT, the results were not significant. These data support the presence of central sensitization features, such as allodynia and temporal summation. In contrast, considerable inconsistencies between studies were found when AO patients were compared with healthy subjects. In clinical settings, the most reliable evaluation method for AO in patients with persistent idiopathic facial pain would be intraindividual assessments using HPT or mechanical allodynia tests.

Headache Attributed to Masticatory Myofascial Pain: Clinical Features and Management Outcomes.

AIMS To describe the characteristics of headaches attributed to temporomandibular disorders (TMD) and assess the effects of two management strategies used for the management of TMD on headache intensity and frequency. METHODS The initial sample (n=60) of this randomized controlled trial comprised patients with masticatory myofascial pain according to the Research Diagnostic Criteria for TMD (RDC/TMD), and headache. The patients were divided into two groups: group 1 received only counseling for behavioral changes, and group 2 received counseling and an occlusal appliance. A 5-month follow-up period included three assessments. TMD-related headache characteristics, eg, headache intensity (scored on a visual analog scale [VAS]) and frequency were measured by a questionnaire. Two-way analysis of variance, chi-square, Friedman, and Mann-Whitney tests were used to test for differences considering a 5% significance level. RESULTS The main clinical features of headache attributed to masticatory myofascial pain were the long duration (≥4 hours), frontotemporal bilateral location, and a pressing/tightening quality. Forty-one subjects (group 1, 17 subjects; group 2, 24 subjects) were included in the final analysis. There was a reduction in headache intensity and frequency, with no significant differences between groups (P>.05). The mean (±SD) baseline VAS was 7.6 (±2.2) for group 1 and 6.5 (±1.6) for group 2; final values were 3.1 (±2.2) (P<.001) and 2.5 (±2.3) (P<.001), respectively. CONCLUSION Headache attributed to masticatory myofascial pain was mainly characterized by long duration, frontotemporal bilateral location, and a pressing/tightening quality. Also, counseling and behavioral management of masticatory myofascial pain improved headache, regardless of the use of an occlusal appliance.

Primary headaches interfere with the efficacy of temporomandibular disorders management

OBJECTIVES: This cross-sectional study aimed to evaluate the influence of Primary Headache (PH) on efficacy of a Temporomandibular Disorders (TMD) conservative therapy and its association with the presence of self-reported parafunctional habits. SAMPLE AND METHODS: Sample was composed of 400 medical records, divided into four groups: I) Muscular TMD (n=64); II) Muscular TMD+PH (n=48); III) Muscular TMD+Articular TMD (n=173); IV) Muscular TMD+Articular TMD+PH (n=115). All groups had undergone a TMD therapy for three months with a stabilization appliance and counseling for habits and behavioral changes, with no specific headache management. Current pain intensity and existence or not of self-reported bruxism were assessed. Repeated measures ANOVA and Chi-Square test followed by Odds were used for statistical analysis, with a significance level of 5%. RESULTS: results of this study showed that: (1) A conservative therapy with stabilization appliance and counseling for habits and behavioral changes was effective in the TMD pain relief; (2) Groups with an additional diagnosis of PH had worsened the pain improvement significantly; and (3) no association between the presence of self-reported bruxism and PH was found. CONCLUSIONS: this study could elucidate the important effect that headache may have on the TMD management.

Agreement of the International Classification of Sleep Disorders Criteria with polysomnography for sleep bruxism diagnosis: A preliminary study

Statement of problem. Validated questionnaires and guidelines for assessing sleep bruxism (SB) that can be administered by dentists in clinical practice are still lacking. Purpose. The purpose of this preliminary study was to compare the third edition of the International Classification of Sleep Disorders (ICSD‐3) criteria for diagnosing SB with the results of the gold standard polysomnography (PSG) examination. Material and methods. Twenty consecutive postgraduate students and staff at Bauru School of Dentistry, University of São Paulo, Bauru, Brazil, participated. Each participant underwent interview, clinical assessment, and a PSG evaluation. Bruxers and nonbruxers were identified based only on the PSG analysis. The validity of the ICSD‐3 criteria was assessed by receiver operating characteristics curve analysis, area under the curve (AUC), likelihood ratios (LR), and the diagnostic odds ratio (DOR). Results. The ICSD‐3 diagnostic criteria items for SB had fair to moderate concordance with the PSG diagnosis, with AUC ranging from 0.55 to 0.75. The best value of agreement was the association of SB more than once a week with transient morning jaw muscle pain or fatigue with a moderate but significant agreement with the PSG diagnosis of SB (AUC=0.75), with 90% specificity, positive LR=6, and DOR=13.5. When the frequency of self‐reported SB increased to more than 4 times a week, the combination of this finding with tooth wear also had high values of agreement with the PSG diagnosis of SB (AUC= 0.75, +LR=6, DOR=13.6). Conclusions. The report of regular or frequent SB and the presence of (1) incident of abnormal tooth wear or (2) incidents of transient morning jaw muscle pain or fatigue were the best discriminatory items of ICSD‐3 for SB diagnosis.

Headache attributed to masticatory myofascial pain: impact on facial pain and pressure pain threshold

There is no clear evidence on how a headache attributed to temporomandibular disorder (TMD) can hinder the improvement of facial pain and masticatory muscle pain. The aim of this study was to measure the impact of a TMD-attributed headache on masticatory myofascial (MMF) pain management. The sample was comprised of adults with MMF pain measured according to the revised research diagnostic criteria for temporomandibular disorders (RDC/TMD) and additionally diagnosed with (Group 1, n = 17) or without (Group 2, n = 20) a TMD-attributed headache. Both groups received instructions on how to implement behavioural changes and use a stabilisation appliance for 5 months. The reported facial pain intensity (visual analogue scale--VAS) and pressure pain threshold (PPT--kgf cm(-2)) of the anterior temporalis, masseter and right forearm were measured at three assessment time points. Two-way anova was applied to the data, considering a 5% significance level. All groups had a reduction in their reported facial pain intensity (P < 0·001). Mean and standard deviation (SD) PPT values, from 1·33 (0·54) to 1·96 (1·06) kgf cm(-2) for the anterior temporalis in Group 1 (P = 0·016), and from 1·27 (0·35) to 1·72 (0·60) kgf cm(-2) for the masseter in Group 2 (P = 0·013), had significant improvement considering baseline versus the 5th-month assessment. However, no differences between the groups were found (P > 0·100). A TMD-attributed headache in patients with MMF pain does not negatively impact pain management, but does change the pattern for muscle pain improvement.

Acupuncture therapeutic protocols for the management of temporomandibular disorders

BACKGROUND AND OBJECTIVES: For most cases, temporomandibular disorders should be treated by a non-invasive, interdisciplinary and integrative process. In traditional Chinese medicine, acupuncture is an excellent tool aiming at treating and healing this disease. This study was a critical literature review to observe the efficacy of traditional Chinese acupuncture to treat muscular temporomandibular disorders and to identify primary acupoints. CONTENTS: Pubmed, LILACS, Scielo and Cochrane databases were queried to identify scientific articles relevant for the study. Articles were selected from January 2000 to May 2013. A total of 125 articles were found and 21 were included. Acupuncture treatment alone or as additional therapy, or even compared to other techniques, was superior and effective to improve pain and function of patients with temporomandibular disorders and most commonly used acupoints were IG4, E6, E7 and F3. CONCLUSION: This study has shown that acupuncture is a technique recommended by national and international literature to treat muscular temporomandibular disorders, promoting pain relief and/or total intensity, improvement of joint movements and oral function and decrease of masticatory muscles hyperactivity.