[Oral care in patients with ALS: an exploratory study]. / Mondverzorging bij patiënten met ALS: een verkennend onderzoek.

For this exploratory study, ALS patients and their partners/caregivers were interviewed to find out what problems they encounter when performing oral care. In addition, the tooth brushing procedure was recorded on video. Most mentioned by the six patients was that the performance of oral care is hampered by the loss of motor skills and by the gag reflex. They also mentioned various adjustments that would ease dental visits. Three of the four partners indicated that an instructional video would have additional value, and two partners said they sometimes felt insecure whether they were performing oral care properly. The five videos showed that there are major differences regarding tooth brushing duration, which surfaces are being brushed, and the brushing technique. This study shows that there are several ways in which oral care is performed in ALS patients. Furthermore, not all caregivers are aware of how oral care should be performed.

Is dopaminergic medication dose associated with self-reported bruxism in Parkinson's disease? A cross-sectional, questionnaire-based study.

OBJECTIVES: It is not clear whether dopaminergic medication influences bruxism behaviour in patients with Parkinson's disease (PD). Therefore, the aims are to investigate (i) the prevalence of possible (i.e., self-reported) bruxism (sleep and awake) in PD patients, and (ii) whether the use of dopaminergic medication and other factors (viz., demographic characteristics, PD-related factors, and possible consequences of bruxism) are associated with possible bruxism (sleep or awake). MATERIALS AND METHODS: This study concerns a secondary analysis of an earlier published study. Three hundred ninety-five PD patients (67.9 ± 8.6 years of age; 58.7% males) were included. The levodopa equivalent daily dosage (LEDD) was used as a measure of the dopaminergic medication level. Subsequently, a logistic regression analysis was performed for the dependent variables 'awake bruxism' and 'sleep bruxism', with the following predictors: gender, age, LEDD, time since PD diagnosis, temporomandibular disorder (TMD) pain, jaw locks, and tooth wear. RESULTS: The prevalence of possible awake and sleep bruxism was 46.0% and 24.3%, respectively. Awake bruxism was associated with sleep bruxism (OR = 8.52; 95% CI 3.56-20.40), TMD pain (OR = 4.51; 95% CI 2.31-8.79), and tooth wear (OR = 1.87; 95% CI 1.02-3.43). Sleep bruxism was associated with tooth wear (OR = 12.49; 95% CI 4.97-31.38) and awake bruxism (OR = 9.48; 95% CI 4.24-21.19). Dopaminergic medication dose was not associated with awake bruxism (OR = 1.0; 95% CI 0.99-1.00) or sleep bruxism (OR = 1.0; 95% CI 0.99-1.00). CONCLUSION: Bruxism is a common condition in PD patients, but is not associated with the dopaminergic medication dose. CLINICAL RELEVANCE: (Oral) health care providers should be alerted about the possibility of sleep and awake bruxism activity in PD patients, along with this activity's possible negative health outcomes (viz., TMD pain, tooth wear).

[Parkinson's disease, temporomandibular disorders and bruxism: A pilot study]. / De ziekte van Parkinson, temporomandibulaire disfunctie en bruxisme.

Even though bruxism and Parkinson's disease have much in common, a possible relationship between them has not been established. The aim of this study was to gain more insight into a possible relationship between bruxism and temporomandibular disorders on the one hand and Parkinson's disease on the other. For this study, 708 people (368 with Parkinson's disease or parkinsonism and 340 controls) fully completed a questionnaire. The questionnaire included a selective Dutch translation of the questions from the Diagnostic Criteria for TMD (DC/TMD), complemented with a question about tooth wear. The chi-square test and independent samples t test were used for the data analysis. The results showed patients with Parkinson's disease or parkinsonism reported pain resulting from temporomandibular disorders and bruxism when asleep and awake significantly more often than the controls. When facial pain was reported, patients with Parkinson's disease or parkinsonism had a higher mean pain score than the controls. In conclusion, this study showed a relationship between Parkinson's disease or parkinsonism on the one hand and bruxism on the other. Furthermore, the study revealed a relationship between Parkinson's disease or parkinsonism on the one hand and pain resulting from temporomandibular disorders on the other.

[Singing is not associated with temporomandibular disorders]. / Zingen gaat niet gepaard met kaakklachten.

This research investigated whether vocalists report pain-related forms of temporomandibular disorders (TMDs) and temporomandibular joint (TMJ) sounds more often than musicians who do not load their masticatory system while playing. In addition, we investigated which risk indicators were associated with TMDs among musicians. A total of 1,470 musicians from 50 different music ensembles completed a questionnaire, including 306 vocalists (the group investigated) and 209 musicians who do not load their jaw while playing (the control group). The prevalence of self-reported TMD pain among the vocalists was 21.9%, compared with 12.0% in the control group. 19.6% of the vocalists reported TMJ sounds versus 14.8% of the controls. From the multiple regression model, taking into account the effect of confounders, such as age and gender, singers were not shown to report TMD pain and jaw joint sounds more often than non-singers. Various forms of physical workload were, however, positively associated with the presence of self-reported TMDs among musicians, namely the intensity of harmful oral habits with TMD pain and TMJ sounds, the number of hours of daily practice with TMD pain, and the number of years of playing experience with TMJ sounds.

Delayed-onset muscle soreness in human masticatory muscles increases inhibitory jaw reflex responses.

The effects of masticatory muscles' overloading on jaw-motor control are not yet fully clarified. Therefore, it was tested whether eccentric and concentric exercises of the human masticatory muscles would influence inhibitory jaw reflex responses. Eleven participants (6 males, 5 females) performed 6, 5-minutes bouts of eccentric-concentric contractions. Before, immediately after, 24 hours, 48 hours and 1 week afterwards, visual analogue scale (VAS) scores for jaw muscle fatigue and pain, maximum voluntary bite force (MVBF) and inhibitory jaw reflexes were recorded. Reflex data were analysed with the cumulative sum control chart error box method. Immediate and delayed masticatory muscle fatigue and pain were provoked. Further, 24 hours after the exercises, MVBF tended to decrease (P = .056), suggesting that delayed-onset muscle soreness (DOMS) was provoked in the masticatory muscles. In addition, the inhibitory jaw reflex showed a delayed increase in size 24 hours after the exercise (P < .05). In conclusion, DOMS provoked in the masticatory muscles alters jaw motor control by inducing a delayed increase in the size of the inhibitory jaw reflex.

Comparison of the outcomes of dynamic/static tests and palpation tests in TMD-pain patients.

In addition to palpation tests, dynamic/static tests have been proposed to complement temporomandibular disorders (TMD) patients' evaluation in the clinical setting. The aim of this study was to assess the intra- and inter-observer reliability of the palpation tests and of the dynamic/static tests, and to determine whether those tests would yield comparable outcomes in terms of pain diagnoses. Ninety-eight (N = 98) consecutive adult patients were examined during 2 clinical sessions by 2 independent examiners, based on muscle and joint palpation techniques described in the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). They also underwent dynamic/static tests. The intra-observer reliability of palpation tests was generally poor, with fair-to-good to excellent ICC values only for the superior masseter and intra-oral sites. The inter-observer reliability of palpation was fair-to-good for muscles, but it was poor for the TMJ lateral pole. Both intra- and inter-observer reliability for the dynamic/static tests varied from fair-to-good to excellent. The intra-observer reliability for muscle pain diagnoses based on palpation tests was between poor and fair-to-good, whereas the inter-observer reliability was excellent. The intra-observer reliability for pain diagnoses based on dynamic/static tests was fair-to-good, and the inter-observer reliability varied from fair-to-good to excellent. CONCLUSIONS: Some features of the dynamic/static tests make them potentially more useful than palpation tests for selected clinical purposes, such as discriminating between joint and muscle pain as well as monitoring symptoms course. Thus, findings from this investigation suggest that both tests should be included in the TMD diagnostic algorithms.

Evidence-based review on temporomandibular disorders among musicians.

BACKGROUND: Playing a musical instrument that loads the masticatory system has frequently been linked to temporomandibular disorders (TMDs). Previous literature reviews on this topic do not conform to the current standards of evidence-based medicine. AIMS: To investigate the effects of playing a musical instrument (i.e. violin/viola and wind instruments) or singing on the presence of TMDs, based on evidence derived from observational studies. METHODS: Databases of Medline, Web of Science and Google Scholar were searched using MeSH and other relevant terms. For each study, a quality assessment was undertaken using a modified version of the Newcastle-Ottawa Scale (NOS). RESULTS: Fifteen relevant papers were identified for inclusion in this review. Of the seven possible points that could be scored with the NOS, the majority of these studies scored under half. Based on the available evidence, the purported relationship between the playing of specific musical instruments and TMDs was not as evident as reported in previous literature reviews. CONCLUSIONS: There is limited evidence to conclude that playing a wind instrument is a hazard to the temporomandibular system. Furthermore, there is no available evidence to suggest that vocalists experience more TMDs than controls. The studies that investigated the presence of TMDs among violists and violinists yielded ambiguous outcomes; some studies reported no association between the playing of these instruments and the presence of signs and symptoms of TMDs, whereas in studies where a clinical examination was performed (though of lower methodological quality), an association was found.

Self-Reported bruxism and associated factors in Israeli adolescents.

Little is known about the epidemiological characteristics of sleep and awake bruxism (SB and AB) in adolescents. The aims of the study were: to assess the prevalence rates of self-reported SB and AB in Israeli adolescents; to determine the associations between SB/AB and several demographical, exogenous and psychosocial factors in Israeli adolescents; and to investigate the possible concordance between SB and AB. The study made use of a questionnaire. The study population included 1000 students from different high schools in the centre of Israel. Prevalence of self-reported SB and AB in the Israeli adolescents studied was 9·2% and 19·2%, respectively. No gender difference was found regarding the prevalence of SB and AB. Multiple variable regression analysis revealed that the following predicting variables were related to SB: temporomandibular joint sounds (P = 0·002) and feeling stressed (P = 0·001). The following predicting variables were related to AB: age (P = 0·018), temporomandibular joint sounds (P = 0·002), oro-facial pain (P = 0·006), and feeling stressed (P = 0·002) or sad (P = 0·006). A significant association was found between SB and AB; that is, an individual reporting SB had a higher probability of reporting AB compared with an individual who did not report SB (odds ratio = 5·099). Chewing gum was the most common parafunction reported by adolescents. The results of this study demonstrate that self-reports of AB and SB are common in the Israeli adolescents population studied and are not related to gender. The significant correlation found between SB and AB may be a confounding bias that affects proper diagnosis of bruxism through self-reported questionnaires only.

Factors associated with temporomandibular disorders pain in adolescents.

To gain a better understanding of temporomandibular disorders (TMD) pain in adolescents, it is important to study the factors associated with its presence. Therefore, the aim of this study was to investigate potential predictors for TMD pain in adolescents, thereby including a diversity of factors from the biopsychosocial model to determine the strongest predictors. The sample of this cross-sectional study consisted of 1094 adolescents. The presence of TMD pain was assessed using the RDC/TMD, Axis I. Apart from demographical characteristics, the roles of parafunctional habits, psychosocial aspects, menarche and other bodily pain complaints were evaluated. Single and multiple logistic regression models were used to identify associations between the predictor variables and TMD pain. Painful TMD had a prevalence of 25·5%. Logistic regression analyses showed that TMD pain was associated with sleep bruxism (OR = 1·8 95% CI = 1·34-2·34), awake bruxism (OR = 2·1 95% CI = 1·56-2·83), other parafunctional habits (OR = 2·2 95% CI = 1·17-4·08) and bodily pain complaints (OR = 5·0 95% CI = 3·48-7·28). Parafunctional habits and other bodily pain complaints may play an important role in the presence of TMD pain in adolescents. Of course, it remains unclear whether the observed associations between the investigated factors and the adolescent's TMD pain have a true causal linkage.

Do sleep hygiene measures and progressive muscle relaxation influence sleep bruxism? Report of a randomised controlled trial.

The aim of this study was to assess the effects of sleep hygiene measures combined with relaxation techniques in the management of sleep bruxism (SB) in a double-blind, parallel, controlled, randomised clinical trial design. Sixteen participants (mean ± s.d. age = 39·9 ± 10·8 years) were randomly assigned to a control group (n = 8) or to the experimental treatment group (n = 8). Participants belonging to the latter group were instructed to perform sleep hygiene measures and progressive muscle relaxation techniques for a 4-week period. Two polysomnographic recordings, including bilateral masseter electromyographic activity, were made: one prior to the treatment and the other after the treatment period. The number of bruxism episodes per hour, the number of burst per hour and the bruxism time index (i.e. the percentage of total sleep time spent bruxing) were established as outcome variables. No significant differences could be observed between the outcome measures obtained before and after the 4-week period, neither for the sleep bruxism variables nor for the sleep variables. Within the limitations of this study, it was concluded that there is no effect of sleep hygiene measures together with progressive relaxation techniques on sleep bruxism or sleep over a 4-week observation period.

Is there an association between temporomandibular disorders and playing a musical instrument? A review of literature.

Temporomandibular disorders (TMDs) have a multifactorial etiology. Among others, parafunctions and oral habits have been suggested as important initiating and perpetuating factors. Playing a musical instrument that loads the masticatory system, like wind instruments and the violin or viola, has been suggested to be part of this group of etiological factors. However, the evidence base for this suggestion is lacking. Therefore, the aim of this study was to review the literature on the possible association between playing a musical instrument and developing and/or having a TMD. A PubMed search, using the query ['Music'(Mesh) AND 'Craniomandibular Disorders'(Mesh)], yielded 19 articles, 14 of which were included in this review. Six of 14 papers had a case-control or pre-test-post-test design; the remaining eight papers were case reports of expert opinions. The former papers were analysed and tabulated according to the PICO (Patient/population-Intervention-Control/comparison-Outcome/results) system; the latter ones were only summarised and tabulated. All articles with a case-control or pre-test-post-test design suggested a possible association between TMD and playing a musical instrument, especially the violin and viola. However, no clear-cut conclusion could be drawn as to whether playing a musical instrument is directly associated with TMD, or only in combination with other factors. More and better research on this topic is needed, as to enable a better counselling and possibly even a better treatment of the suffering musician.

[Distinguishing temporomandibular pain from other types of orofacial pain based on a questionnaire]. / Onderscheid tussen temporomandibulaire pijn en andere vormen van orofaciale pijn op basis van een vragenlijst.

This study investigated whether, apart from the usual tools for the diagnosis of temporomandibular pain, a questionnaire can distinguish between temporomandibular pain and other types of orofacial pain, based on the biopsychosocial model. 509 patients, who reported orofacial pain in an online questionnaire, were divided into 2 groups based on a clinical examination: patients with temporomandibular pain and patients with orofacial pain in whom temporomandibular pain was excluded. Logistic regression analyses showed that the 2 patient groups did not differ from each other with regard to the majority of biological and psychological aspects of the biopsychosocial model. However, patients with temporomandibular pain reported bruxism and non-specific pain more often, and reported a higher intensity of pain. This study showed that a questionnaire can aid in distinguishing patients with temporomandibular pain from patients with other types of orofacial pain.

[Assessing the clinical competence of dental students]. / Het beoordelen van de klinische competenties van studenten tandheelkunde.

Nowadays, the competences of dental students are tested more on the basis of quality of their achievements than the quantity. 'Objective Structured Clinical Examinations' (OSCEs) can be used in a pre-clinical phase to test these clinical competences. For the clinical phase, the general examination and the digital portfolio have been developed. Tests are used to stimulate the learning process and to determine whether students are ready for the next step; in addition, the quality of the programme is protected by the set of examinations. The results of the last 5 general examinations reveal the pattern that the number of correct answers increases as the study progresses. The Amsterdam Academic Centre for Dentistry (ACTA) introduced a digital portfolio which was evaluated 1 year later with the help ofan anonymous questionnaire. Students judged the use of the digital portfolio in the clinic to be useful but also costly in time.

[Synovial chondromatosis of the temporomandibular joint. A systematic review of the literature on its characteristics]. / Synoviale chondromatose van het temporomandibulaire gewricht. Een systematisch literatuuronderzoek naar de kenmerken.

Synovial chondromatosis of the temporomandibular joint is a disease which occurs rarely. A systematic review of the literature was carried out to identify its demographical, etiological, radiological, and clinical characteristics. A total of 191 case presentations were discovered. The mean age of patients was 47. The disease has been identified more frequently in women than in men. A part from pre-auricular swelling, the most frequently reported clinical characteristics resembled those of temporomandibular disorders. Abnormalities on radiographs were often evident. Insufficient evidence was found that trauma or rheumatoid arthritis plays a role in the development of this disease. Given the similarities with temporomandibular disorders, synovial chondromatosis should be considered in the differential diagnosis of patients suffering from complaints of temporomandibular dysfunction.

[Myogenous temporomandibular pain: treat with care!]. / Myogene temporomandibulaire pijn: behandelen met aandacht!

For the treatment of myogenous temporomandibular pain, a clinician can choose from among a wide variety of possibilities. Unfortunately, a paper summarizing the effectiveness of all these forms of treatment does not yet exist. The aim of this paper is to provide specific advice for dentists concerning the treatment of patients with myogenous temporomandibular pain by means of a systematic review of the relevant literature. The results of this review of the literature suggest that all forms of treatment selected, including treatment with placeboes, are equally effective in reducing myogenous temporomandibular pain. In order to avoid liability issues, it is advisable to choose for a restrained, reversible form of treatment. The dentist and the patient must, in this respect, be aware that the pain can continue after treatment (albeit at a reduced level) or can return after a period of time.

Principles for the management of bruxism.

The management of bruxism has been the subject of a large number of studies. A PubMed search, using relevant MeSH terms, yielded a total of 177 papers that were published over the past 40 years. Of these papers, 135 were used for the present review. Apparently, research into bruxism management is sensitive to fashion. Interest in studying the role of occlusal interventions and oral splints in the treatment of bruxism remained more or less constant over the years: between 1966 and 2007, approximately 40-60% of the papers dealt with this subject. The percentage of papers that dealt with behavioural approaches, on the other hand, declined from >60% in the first 2 decades (1966-1986) to only slightly >10% in the most recent decade (1997-2007). In the latter period, >40% of the papers studied the role of various medicines in the treatment of bruxism, while in the preceding decade (1987-1996), only approximately 5% of the studies dealt with the pharmacological management of bruxism. Unfortunately, a vast majority of the 135 papers have a too low level of evidence. Only 13% of the studies used a randomized clinical trial design, and even these trials do not yet provide clinicians with strong, evidence-based recommendations for the treatment of bruxism. Hence, there is a vast need for well-designed studies. Clinicians should be aware of this striking paucity of evidence regarding management of bruxism.

Myofascial temporomandibular disorder pain, parafunctions and psychological stress.

Associations of evening and morning masticatory muscle pain and nocturnal electromyography (EMG) activity with psycho-behavioural factors and occlusal splint therapy were studied during a 20-week study-protocol. Over a period of almost 2 years, only eight of the 120 eligible patients were willing to enroll the study protocol. Further, four of the eight participants dropped out during the study, and approximately 20-30% of the nocturnal EMG recordings failed. Because of the impractical and unworkable nature of the protocol, the study was prematurely terminated and the results of the four remaining individuals are reported here as single-patient clinical trials. Univariate and multiple regression analyses revealed that in three of the four patients, changes in nocturnal EMG activity were associated with the period of splint therapy. However, no associations were found between the changes in nocturnal EMG activity and the observed changes in muscle pain. In two patients, the changes in muscle pain were associated with the period of splint therapy and with the changes in psychological stress. Within the limitations of single-patient clinical trials, it can be concluded that changes in chronic masticatory muscle pain seem to be more related to changes in psychological stress than to those in parafunctional activities.

Effects of masticatory muscle fatigue without and with experimental pain on jaw-stretch reflexes in healthy men and women.

OBJECTIVE: To examine the effects of experimentally evoked masticatory muscle fatigue, without and with experimental muscle pain, on the short-latency jaw-stretch reflex, using a randomised crossover design. METHODS: Reflexes were evoked in both the masseter and temporalis muscles in 15 men and 13 women. The study was performed in two blocks, both containing 3 experimental conditions (before, directly after, and 15 min after provocation). Provocation consisted of a fatiguing chewing test, followed by an intramuscular injection of either isotonic saline (IS; non-painful) or hypertonic saline (HS; painful). RESULTS: No significant effects of the experimental condition 'fatigue+IS' were found for any of the reflex outcome variables. For each muscle, the 'fatigue+HS' condition yielded significantly higher normalized reflex amplitudes than the other conditions. Several muscles displayed gender differences regarding both onset latency and normalized reflex amplitude. CONCLUSIONS: Experimentally evoked mild-to-moderate muscle fatigue does not modulate the human jaw-stretch reflex. On the other hand, experimental muscle pain, evoked after the performance of a fatiguing chewing test, does yield a facilitation of this reflex. The gender differences found in both onset latency and peak-to-peak amplitude stress the need to take gender into consideration in future jaw reflex studies. SIGNIFICANCE: The sensitivity of the human jaw-stretch reflex can be modulated by HS-induced muscle pain; not by muscle fatigue that is provoked by intense chewing.

Recognition of internal derangements.

One of the most common symptoms of temporomandibular disorders is an internal derangement (ID). The aim of this study was to test the inter-observer reliability of the recognition of IDs by means of auscultation, palpation or both. To that end, 120 women and 100 men were screened by two trained examiners for the presence of IDs. Anterior disc displacement was diagnosed in 14% of the cases and hypermobility in 12%. In 4% of the cases, the ID was classified as 'other'. The inter-rater reliability (Cohen's kappa) was moderate for the presence of an ID for all techniques, while for the classification into type, an almost perfect reliability was found for the combined technique. It was concluded that the type of ID can best be established with the combination of auscultation and palpation; for the establishment of an ID as such, any of the three techniques would suffice.

Craniomandibular pain, oral parafunctions, and psychological stress in a longitudinal case study.

In a single case study, the most frequently suggested contributing factors to craniomandibular pain, viz., oral parafunctions and psychological stress, were studied in more detail. During a 13-week study period, questionnaires were completed, in which, among others, jaw muscle pain, bruxism behaviour, and experienced/anticipated stress were noted. During about 40% of the nights, nocturnal masticatory muscle activity (NMMA) was recorded, using single-channel electromyography (EMG). The number of NMMA events per recorded hour was scored, using a detection threshold of 10% of the maximum voluntary contraction level. This threshold was established in a separate study, in which EMG was compared with polysomnography. Stepwise regression analyses indicated, that morning jaw muscle pain could be explained by evening jaw muscle pain for 64% and by alcohol intake for another 2%. In turn, evening jaw muscle pain was explained by daytime clenching for 56% and by vacuum sucking of the tongue for an additional 6%. Finally, daytime clenching was significantly explained by experienced stress for 30%. Data of the recorded nights showed, that variations in NMMA did not contribute to variations in morning jaw muscle pain. This case study corroborates the paradigm that experienced stress may be related to daytime clenching and, in turn, to evening and morning jaw muscle pain.