Whole unstimulated salivary flow rate decreases during acute stressful condition.

OBJECTIVE: To examine the influence of acute stress on salivary flow using a validated stressor paradigm. STUDY DESIGN: This uniform crossover study consisted of 40 healthy adults who underwent the Trier Social Stress Test, consisting of a 5-minute mental arithmetic task (MAT), and a nonstressful task (NST), consisting of a 5-minute free speech task. The order of the tasks was counterbalanced and unstimulated whole saliva (UWS) was measured in 2 groups of 20 participants during each 5-minute task condition, with a 10-minute washout period between tasks. At baseline, mathematical ability was self-reported and psychological distress was measured using the Symptom Checklist-90-Revised. Heart rate (HR) and breathing rate (BR) were recorded during each task. RESULTS: Age, sex, HR, BR, and psychological distress were similar between groups at baseline (P > .05). During the MAT, HR increased significantly and mean UWS flow rate decreased significantly compared with the NST (P < .001). CONCLUSIONS: An acute psychobiological stressor task was associated with a rapid decrease in salivary flow in adults. Thus, stress can contribute to reduced salivary flow and should be considered as a factor during the diagnostic workup of patients who complain of a dry mouth.

Bruxism and oro-facial pain not related to temporomandibular disorder conditions: Comorbidities or risk factors?

INTRODUCTION: Bruxism has historically been of particular interest to the field of dentistry, primarily due to the inferred damage it may cause to the dentition and supporting periodontal structures. The definition of bruxism itself has undergone multiple changes over time. In addition, the effects of bruxism as it relates to oro-facial pain conditions has remained a debatable topic. PURPOSE: To review the available literature relating to bruxism and non-temporomandibular disorder (TMD) pain conditions. METHODS: A literature search was conducted with the assistance of an expert librarian. The following databases were reviewed: PubMed, MEDLINE, EMBASE and Google Scholar. For additional references, articles were also retrieved by hand search from the selected papers. Any articles that were not published in English, or the focus were related to temporomandibular disorders were excluded. CONCLUSIONS: While bruxism and certain headache conditions do tend to occur together frequently, evidence relating to any clear common pathophysiological mechanism has yet to be fully elucidated. Robust evidence as it relates to the relationship between bruxism and other non-TMD oro-facial pains is also lacking.

Evolution of adherence and self-reported symptoms over 36 months with mandibular advancement device therapy for obstructive sleep apnea: a retrospective study.

STUDY OBJECTIVES: Mandibular advancement devices (MAD) constitute a feasible option for management of mild-to-moderate obstructive sleep apnea (OSA) and in severe cases, when indicated. As a chronic condition, the management of OSA with MAD requires long-term patient adherence to treatment. The aim of the study was to investigate adherence to MAD therapy during a 36-month observation period in relation to changes in self-reported symptoms and objective response to therapy. METHODS: Retrospective chart review of patients referred to the Orofacial Pain Clinic (University of Kentucky) between 2016 and 2021 for management of OSA with MAD was performed. Based on a posttreatment sleep study with MAD in situ, participants were subdivided into optimal response (> 50% reduction of baseline apnea-hypopnea index) and suboptimal response (< 50% reduction of baseline apnea-hypopnea index) groups. Outcomes included self-reported adherence to MAD use, self-reported OSA symptoms including snoring, apneic episodes, tiredness upon awakening, fatigue, and sleep quality (on a 100-mm numerical rating scale), and daytime sleepiness (0-24 on the Epworth Sleepiness Scale). Intragroup and intergroup differences at different time points over a 36-month observation period were assessed with one-way and repeated-measures analysis of variance. RESULTS: Of 54 participants included (46.3% female, age 64.4 ± 10.71 years), 30 (55.6%) achieved optimal response and 24 (44.4%) achieved suboptimal response. At baseline, participants with optimal response differed from those with suboptimal response in apnea-hypopnea index (P = .007), snoring (P = .026), and sleep quality (P = .042). Although fluctuating in both groups, no difference was found over time in adherence (7 nights/wk, 7 h/night) and in OSA symptoms (all P > .05). CONCLUSIONS: Adherence to MAD was maintained over 36 months regardless of fluctuation in self-reported OSA symptoms and effectiveness of MAD therapy. CITATION: Sangalli L, Yanez-Regonesi F, Moreno-Hay I. Evolution of adherence and self-reported symptoms over 36 months with mandibular advancement device therapy for obstructive sleep apnea: a retrospective study. J Clin Sleep Med. 2024;20(4):487-496.

Classification and Diagnosis of Temporomandibular Disorders and Temporomandibular Disorder Pain.

Designing classification systems and developing diagnostic criteria for temporomandibular disorders is difficult. An appreciation of the utility and applicability of these entities requires an understanding of the importance of each, the differences between the two, and how they may be optimally operationalized for both clinical and research activities in light of their inherent advantages and limitations. In addition, consideration for adopting newer approaches, such as following ontological and precision-based medicine principles, accounting for genetics/epigenetic and neurobiological factors, and the inclusion of biomarkers will potentially result in more thorough and comprehensive classification systems and diagnostic criteria.

Diagnostic accuracy of a portable device (Bruxoff®) to measure sleep bruxism.

BACKGROUND: Diagnosis of sleep bruxism (SB) challenges clinicians every day due to multiple forms of assessment tools available, including self-reported questionnaires, clinical examinations, portable devices and laboratory polysomnography (PSG). PSG has become the gold standard for evaluating SB, but it can be limited due to cost and restricted accessibility which often is characterised by long waiting times. Hence, there is a need for the development of a reliable method that can assess SB in a simple and portable manner, which would offer acceptable sensitivity and specificity to evaluate SB. OBJECTIVE: The objective of this study was to investigate reliability and validity of the Bruxoff® device for the diagnosis of SB compared to the PSG. METHODS: Forty-nine subjects underwent one night of polysomnographic study with simultaneous recording with the Bruxoff® device. Rhythmic masticatory muscle activity (RMMA) index was scored according to published criteria. Pearson correlation, Bland-Altman plot and receiver operating characteristic (ROC) curve outcomes were used to quantify the agreement between both methods. RESULTS: Receiver operating characteristic analysis showed an acceptable accuracy for the Bruxoff® with sensitivity of 83.3% and specificity of 72% when the cut-off was set at two events per hour. Pearson correlation analysis showed a nearly significant correlation between PSG and Bruxoff® for RMMA index (r = .282 p = .071) and for total SB episodes per night (r = .295 p = .058). Additionally, the Bland-Altman plot revealed a consistent and systematic difference in the measurement of events between devices. CONCLUSION: The Bruxoff® device appears to be a promising diagnostic method for clinical use, but further study is needed.

The impact of the COVID-19 pandemic on orofacial pain practice: Perceptions from a convenience sample of orofacial pain practitioners.

BACKGROUND: COVID-19 has had a substantial impact on people's lives. Increasing evidence indicates that patients with chronic pain particularly are being affected; however, few articles have examined how the pandemic has affected the care or clinical presentation of patients with orofacial pain. The aim of this study was to describe COVID-19-related changes in referral patterns and numbers, in patient demographics, in patients' seeking treatment for problems, and in administrative procedures in 3 orofacial pain clinical settings. METHODS: Practitioners participating in the American Academy of Orofacial Pain webinar titled "Practicing Orofacial Pain, Headache, and Sleep Care During the COVID-19 Pandemic" completed a voluntary anonymous online survey. Survey respondents completed general questions related to their orofacial pain practices and about perceptions of their patients' symptoms. For statistical analysis, the authors calculated frequencies and used analysis of variance for continuous variables or Likert scale variables and the χ2 test for dichotomous or categorical variables. Statistical significance was set at P value of .05 or below. RESULTS: Practitioners noted an increase in new patients with orofacial pain. Of the participants, 33% indicated the onset of their patients' pain was often or extremely often related to COVID-19. The 5 most common symptoms that providers felt were aggravated in their patients were masticatory muscle myalgia, anxiety, tension-type headache, bruxism, and insomnia or fragmented sleep. CONCLUSION: The COVID-19 pandemic has resulted in a marked increase in the number of patients seeking consultation for orofacial pain and associated symptoms. PRACTICAL IMPLICATIONS: Because of the COVID-19 pandemic, orofacial pain practitioners have noticed an increase in orofacial pain symptoms across practice settings.

Self-reported improvement in obstructive sleep apnea symptoms compared to treatment response with mandibular advancement device therapy: a retrospective study.

PURPOSE: Mandibular advancement device (MAD) is recognized as the treatment option for management of obstructive sleep apnea (OSA) in mild-moderate cases or those unable to tolerate positive airway pressure therapy. Post-treatment sleep study is recommended to establish MAD efficacy when maximal therapeutic benefit is achieved based on OSA symptom improvement or maximum anatomical protrusion. The aim of this study was to investigate the difference between responders and non-responders in OSA symptom improvement and predictors of treatment success. METHODS: Medical charts of patients referred to the Orofacial Pain Clinic between 2016 and 2021 for management of OSA with MAD were retrospectively evaluated. Participants with post-treatment sleep study with MAD in situ were included. Participants were categorized as responders according to different criteria: 50% reduction in apnea-hypopnea index (AHI) compared to baseline; post-treatment AHI ≤ 10 with ≥ 50% reduction from baseline; AHI ≤ 5 with ≥ 50% reduction. OSA symptoms included snoring, apneas, sleep quality, tiredness upon awakening, daytime sleepiness, and subjective improvement. Differences in pre- and post-treatment variables within/between groups and predictors were analyzed with t test and logistic regression. RESULTS: Among 53 participants (30 females), mean age was 64.2 ± 10.7 and pre-treatment was AHI 23.3 ± 17.2. Depending upon the criteria, responders ranged between 26 and 57%. At first follow-up after MAD delivery, non-responders reported less tiredness upon awakening (p = 0.003), better sleep quality (p = 0.005), and greater subjective improvement (p = 0.012) than responders. Among significant OSA symptoms, tiredness upon awakening, poorer sleep quality, and less subjective improvement were consistently found as predictors of treatment response. CONCLUSION: Subjective improvement, sleep quality, and tiredness upon awakening significantly improved in non-responders at first follow-up compared to responders, according to the strictest definition of treatment response. Therefore, a post-treatment sleep study is crucial to confirm proper management of OSA with MAD.

Optimizing Mandibular Advancement Maneuvers during Sleep Endoscopy with a Titratable Positioner: DISE-SAM Protocol.

Mandibular advancement devices (MAD) are an effective alternative treatment to CPAP. Different maneuvers were performed during drug sleep-induced endoscopy (DISE) to mimic the effect of MAD. Using the Selector Avance Mandibular (SAM) device, we aimed to identify MAD candidates during DISE using a titratable, reproducible, and measurable maneuver. This DISE-SAM protocol may help to find the relationship between the severity of the respiratory disorder and the degree of response and determine the advancement required to improve the collapsibility of the upper airway. Explorations were performed in 161 patients (132 males; 29 females) with a mean age of 46.81 (SD = 11.42) years, BMI of 27.90 (SD = 4.19) kg/m2, and a mean AHI of 26.51 (SD = 21.23). The results showed no relationship between severity and MAD recommendation. Furthermore, there was a weak positive relationship between the advancement required to obtain a response and the disease severity. Using the DISE-SAM protocol, the response and the range of mandibular protrusion were assessed, avoiding the interexaminer bias of the jaw thrust maneuver. We suggest prescribing MAD as a single, alternative, or multiple treatment approaches following the SAM recommendations in a personalized design.

Telehealth Increases Access to Brief Behavioral Interventions in an Orofacial Pain Clinic During the COVID-19 Pandemic: A Retrospective Study.

OBJECTIVE: The aim of the study was to test whether patients with orofacial pain were more likely to start and complete a brief psychological intervention for managing certain chronic orofacial pain conditions (physical self-regulation [PSR]) via telehealth (during the COVID-19 pandemic) vs. in-person (before the COVID-19 pandemic). The exploratory aim was to describe demographic factors that could influence patients' likelihood of starting and completing PSR. METHODS: Retrospective medical charts of all patients seen at a university-affiliated tertiary orofacial pain clinic between July-December 2019 (in-person; before the pandemic) and July-December 2020 (telehealth; during the pandemic) were reviewed. Charts were examined for demographic information and to compare the number of patients who started and completed PSR during each study period (chi-squared test). RESULTS: Of 248 new patients seen in the clinic during the 2019 period, 25 started PSR in-person (10.08%). Of 252 new patients seen during the 2020 period, 53 started PSR via telehealth (21.03%). Patients were more likely to start PSR (odds ratio = 6.21, p < 0.001, 95% confidence interval = 2.499 to 15.435) and more likely to complete all three sessions of PSR (odds ratio = 5.69, p < 0.001, 95% confidence interval = 2.352 to 13.794) when it was offered via telehealth than when it was offered in-person. Among those who started PSR via telehealth, patients from metropolitan areas were more likely to start the intervention than those from non-metropolitan areas (p = 0.045). CONCLUSIONS: Offering brief psychological pain interventions via telehealth in tertiary orofacial pain clinics has demonstrated feasibility and may improve patients' willingness to participate in psychological treatments. Results need to be replicated with prospective data, as modality was confounded with the pandemic in the present study.

Is there an association between otologic symptoms and temporomandibular disorders?: An evidence-based review.

BACKGROUND: The aim of this article is to discuss the scientific evidence available on the pathophysiology and management of otologic complaints in patients with temporomandibular disorders (TMDs). TYPES OF STUDIES REVIEWED: The authors conducted an electronic search in MEDLINE, Web of Science and ScienceDirect and retrieved all the relevant peer-reviewed journal articles available in English on the topic. No time restriction was applied. RESULTS: No consensus exists on the management of otologic symptoms in patients with concomitant TMD. The scientific evidence suggests that conservative or reversible TMD therapy might provide relief. However, this evidence is scarce and low, thus further studies with larger sample sizes and better designed methodological frameworks are needed. Until such evidence is available, dentists and orofacial pain specialists should treat TMD patients using current guidelines and refer those with otologic symptoms to an otolaryngologist. PRACTICAL IMPLICATIONS: Given the wide range of potential pathophysiologies and treatments for each otologic symptom described in the TMD patient, close collaboration with otolaryngologists is essential to achieve the best patient care.

Effects of mandibular advancement device for obstructive sleep apnea on temporomandibular disorders: A systematic review and meta-analysis.

The clinical practice guidelines do not give precise indications on the use of mandibular advancement devices (MAD) for obstructive sleep apnea (OSA) patients when they suffer from temporomandibular disorders (TMD). The aim of this systematic review was to evaluate the effects of MADs on prevalence of TMD signs and symptoms in adult OSA patients. The study protocol was registered under the PROSPERO register and an electronic search was performed in several databases. All types of studies evaluating TMD prevalence on adult patients wearing MAD for OSA were included and independently evaluated by two investigators. The quality of evidence was evaluated using the grading of recommendations assessment, development and evaluation and the risk of bias by the risk of bias in non-randomized studies of interventions tool or the Cochrane collaboration's tool. For each study included, the difference in means and 95% CI was calculated between baseline and follow-up. Twelve studies were included. The meta-regression analysis showed that patients with pre-existing signs and symptoms of TMD do not experience significant exacerbation of symptoms using the MAD. The presence of TMD does not appear to be routine contraindication for the use of MAD used for the management of OSA.

Intraoral Administration of Botulinum Toxin for Continuous Dentoalveolar Neuropathic Pain: A Case Series.

AIMS: To examine the analgesic effect, safety, and tolerability of intraoral administration of onabotulinum toxin A (BoNT/A) in patients suffering from intractable continuous dentoalveolar neuropathic pain. METHODS: Eight patients (six women and two men) of ages ranging from 21 to 73 years (mean [standard deviation] 52.4 [16.1] years) suffering from continuous dentoalveolar pain for a mean duration of 5.8 (4.4) years received a submucosal injection of 10 to 25 units of BoNT/A into the vestibular mucosa surrounding the painful site. Pain intensity levels were recorded using a verbal rating scale (VRS). Safety and tolerability of BoNT/A were measured based on patient self-report, including any adverse effects reported by the patient at the injection site. RESULTS: Five of eight patients reported positive pain reduction. In this group, mean pain intensity on a 0-10 VAS was 4.8 (2.2) at baseline and 2.6 (2.1) at postinjection. The analgesic effect was maximal between 7 and 14 days postinjection and lasted for 1 to 8 weeks before subsequently returning to the pre-injection levels. No adverse effects were reported at the injection sites. One patient noted transient partial hemi-facial paralysis. CONCLUSION: These results suggest the potential therapeutic benefit of BoNT/A in the management of continuous dentoalveolar neuropathic pain. Further investigations conducted via well-controlled studies in the area of orofacial pain are warranted.

Analysis of Surface Roughness, Fracture Toughness, and Weibull Characteristics of Different Framework-Veneer Dental Ceramic Assemblies after Grinding, Polishing, and Glazing.

PURPOSE: To compare the surface roughness and biaxial flexural strength of dental ceramics obtained after chairside surface modification by mechanical polishing procedures, versus laboratory reglazing. MATERIALS AND METHODS: Discs (16 × 1.5 ± 1.6 mm) (N = 90) of various framework-veneering combinations were fabricated: D/FC: lithium disilicate/feldspathic ceramic; Z/AL: zirconium dioxide/aluminous ceramic; N/FC: noble alloy/feldspathic ceramic; N/FF: noble alloy feldspathic with fluorapatite; B/FC: base alloy/feldspathic ceramic; B/FF: base alloy/feldspathic ceramic with fluorapatite. In each group 10 specimens were ground using a diamond bur (46 µm) and five were polished with silicone-reinforced disc polishers (25 µm). Surface roughness (Ra) was measured using contact profilometry. After thermocycling in artificial saliva (6000 cycles, 5 to 55 ± 5°C), biaxial flexural strength was measured using "piston-on-three ball" test. The data (N) were analyzed using one-way ANOVA, Bonferroni, and Tukey's posthoc tests. Weibull distribution values were calculated. RESULTS: Surface roughness was significantly higher in the ground group only (p < 0.0001). Mean fracture toughness was significantly lower for chipping (RK: 287, HS: 22, ISO: 1099 MPa) than for total fracture (p < 0.05), (RK: 841, HS:64, ISO: 3222 MPa). For chipping, Weibull distribution presented the highest shape value (m) for D/FC (3.82-5.07) and for total fracture for B/FC (3.69-4.6). CONCLUSION: Chairside surface polishing restored veneer ceramic roughness and mechanical strength to the level of glazing. Feldspathic ceramic with fluorapatite presented better polishing results than conventional feldspathic ceramic did. Ceramic fused to metal was more resistant than lithium disilicate or zirconium dioxide framework-veneer assemblies. Lithium disilicate framework veneered with feldspathic ceramic presented more durability against chipping. CLINICAL IMPLICATIONS: After chairside occlusal modifications in the surfaces of cemented all-ceramic or fused-to-metal FDPs, mechanical polishing procedures should always be carried out.

Continuous Dentoalveolar Neuropathic Pain Response to Repeated Intravenous Ketamine Infusions: A Case Report.

This article describes a case of continuous dentoalveolar neuropathic pain in which relief was obtained following repeated administration of intravenous infusions of a subanesthetic dose of ketamine. A 50-year-old female presented in 2006 with a 1-year history of constant sharp pain in the gingiva surrounding the maxillary left second premolar and second molar rated as 10/10 on a pain intensity scale. After multiple systemic medications failed to adequately manage the patient's pain, partial pain reduction was obtained (4/10) with daily use of methadone 50 mg in combination with application of a topical compound including lidocaine, amitriptyline, and carbamazepine to the affected area as needed. In July 2012, for reasons unrelated to the neuropathic pain condition, the patient underwent extraction of the maxillary right second premolar under intravenous sedation. Initially, a subanesthetic dose of ketamine was added to the sedation regimen for postoperative pain management; however, due to subsequent improvement of the dentoalveolar neuropathic pain, repeated intravenous infusions were recommended for further pain management. The patient's neuropathic pain condition was successfully managed by a total of five intravenous ketamine infusions repeated over a 4-year period of time. The patient's daily use of methadone was progressively reduced and finally discontinued. This case suggests a possible role for intravenous infusions of subanesthetic doses of ketamine as an adjuvant management option in patients suffering from intractable dentoalveolar continuous neuropathic pain conditions.

CAD/CAM Conic Crowns for Predictable Retention in Implant-Supported Prostheses.

PURPOSE: To evaluate CAD/CAM conic crowns to obtain a reversible and predictable retention in implant-supported prostheses. MATERIALS AND METHODS: Five 1- to 8-degree CAD/CAM abutments and their respective copings (n = 40) were designed and manufactured to measure the retention strength (in N) on a Zwick/Roell testing frame. RESULTS: The mean retention strength values found, in descending order of cone angle, were as follows: 8 degrees, 21.02 N; 7 degrees, 23.16 N, 28 N, and 36.40 N; 6 degrees, 40.46 N; 5 degrees, 66.36 N; 4 degrees, 61.23 and 76.12 N; 3 degrees, 93.44 N, 103.21 N, and 112.04 N; 2 degrees, 154.20 N; and 1 degree, 204.74 N, 261 N, and 293.40 N. These data describe a high-intensity ratio with a curvilinear trend that can be used to develop predictive models. CONCLUSION: With the limits of this study, it can be concluded that retention strength increased as the cone angle decreased. The data described a curve from which two predictive models were developed to find retention strength from the cone angle used and the cone angle that would be needed to deliver a given retention strength. This study is the first step in searching for an alternative to cemented and screw-retained implant-supported prostheses and new retaining elements in implant-retained prostheses.

Influence of orthodontic treatment on temporomandibular disorders. A systematic review.

OBJECTIVES: The aim of this literature systematic review was to evaluate the possible association between malocclusions, orthodontic treatment and development of temporomandibular disorders. MATERIAL AND METHODS: A search was carried out on PubMed-Medline database from January 2000 to August 2013 using the keywords "orthodontics and temporomandibular disorders", "orthodontics and facial pain" and "malocclusion and temporomandibular disorders". Human studies included in the study were those assessing signs and symptoms of temporomandibular disorders in relation to orthodontic treatment. MATERIAL AND METHODS: A search was carried out on PubMed-Medline database from January 2000 to August 2013 using the keywords "orthodontics and temporomandibular disorders", "orthodontics and facial pain" and "malocclusion and temporomandibular disorders". Human studies included in the study were those assessing signs and symptoms of temporomandibular disorders in relation to orthodontic treatment. RESULTS: The search strategy resulted in 61 articles. After selection according to the inclusion/exclusion criteria 9 articles qualified for the final analysis. The articles which linked orthodontics and development of temporomandibular disorders showed very discrepant results. Some indicated that orthodontic treatment could improve signs and symptoms of temporomandibular disorders, but none of them obtained statistically significant differences. CONCLUSIONS: According to the authors examined, there is no evidence for a cause-effect relationship between orthodontic treatment and temporomandibular disorders, or that such treatment might improve or prevent them. More longitudinal studies are needed to verify any possible interrelationship. Key words:Malocclusion and temporomandibular disorders, orthodontics and facial pain, orthodontics and temporomandibular disorders, temporomandibular disorders, temporomandibular dysfunction.

Nonsteroidal anti-inflammatory drugs and antihypertensives: how do they relate?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely available as over-the-counter medications, despite their numerous side effects and drug interactions. The aim of this article is to increase awareness of the hypertensive potential of NSAIDs and their interference with antihypertensives. Patients with hypertension appear to be more susceptible than normotensive individuals to the blood pressure-increasing effect of NSAIDs. Most studies have found that short-term use of NSAIDs does not pose a major risk for hypertension or increase in cardiovascular disease in healthy individuals. The calcium channel blockers and ß-blockers seem to be least affected by the concomitant use of NSAIDs. A dentist must weigh the benefits and disadvantages of using NSAIDs in patients taking antihypertensive drugs. For those who may be at greater risk, such as patients with hypertension and the elderly, careful selection of the class of NSAID and close monitoring are appropriate measures, especially if long-term use is anticipated.