Oro-facial pain and temporomandibular disorders classification systems: A critical appraisal and future directions.

It is a difficult undertaking to design a classification system for any disease entity, let alone for oro-facial pain (OFP) and more specifically for temporomandibular disorders (TMD). A further complication of this task is that both physical and psychosocial variables must be included. To augment this process, a two-step systematic review, adhering to PRISMA guidelines, of the classification systems published during the last 20 years for OFP and TMD was performed. The first search step identified 190 potential citations which ultimately resulted in only 17 articles being included for in-depth analysis and review. The second step resulted in only 5 articles being selected for inclusion in this review. Five additional articles and four classification guidelines/criteria were also included due to expansion of the search criteria. Thus, in total, 14 documents comprising articles and guidelines/criteria (8 proposals of classification systems for OFP; 6 for TMD) were selected for inclusion in the systematic review. For each, a discussion as to their advantages, strengths and limitations was provided. Suggestions regarding the future direction for improving the classification process with the use of ontological principles rather than taxonomy are discussed. Furthermore, the potential for expanding the scope of axes included in existing classification systems, to include genetic, epigenetic and neurobiological variables, is explored. It is therefore recommended that future classification system proposals be based on combined approaches aiming to provide archetypal treatment-oriented classifications.

Self-management programmes in temporomandibular disorders: results from an international Delphi process.

Self-management (SM) programmes are commonly used for initial treatment of patients with temporomandibular disorders (TMD). The programmes described in the literature, however, vary widely with no consistency in terminology used, components of care or their definitions. The aims of this study were therefore to construct an operationalised definition of self-management appropriate for the treatment of patients with TMD, identify the components of that self-management currently being used and create sufficiently clear and non-overlapping standardised definitions for each of those components. A four-round Delphi process with eleven international experts in the field of TMD was conducted to achieve these aims. In the first round, the participants agreed upon six principal concepts of self-management. In the remaining three rounds, consensus was achieved upon the definition and the six components of self-management. The main components identified and agreed upon by the participants to constitute the core of a SM programme for TMD were as follows: education; jaw exercises; massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. This Delphi process has established the principal concepts of self-management, and a standardised definition has been agreed with the following components for use in clinical practice: education; self-exercise; self-massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. The consensus-derived concepts, definitions and components of SM offer a starting point for further research to advance the evidence base for, and clinical utility of, TMD SM.

Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders.

There is a need to expand the current temporomandibular disorders' (TMDs) classification to include less common but clinically important disorders. The immediate aim was to develop a consensus-based classification system and associated diagnostic criteria that have clinical and research utility for less common TMDs. The long-term aim was to establish a foundation, vis-à-vis this classification system, that will stimulate data collection, validity testing and further criteria refinement. A working group [members of the International RDC/TMD Consortium Network of the International Association for Dental Research (IADR), members of the Orofacial Pain Special Interest Group (SIG) of the International Association for the Study of Pain (IASP), and members from other professional societies] reviewed disorders for inclusion based on clinical significance, the availability of plausible diagnostic criteria and the ability to operationalise and study the criteria. The disorders were derived from the literature when possible and based on expert opinion as necessary. The expanded TMDs taxonomy was presented for feedback at international meetings. Of 56 disorders considered, 37 were included in the expanded taxonomy and were placed into the following four categories: temporomandibular joint disorders, masticatory muscle disorders, headache disorders and disorders affecting associated structures. Those excluded were extremely uncommon, lacking operationalised diagnostic criteria, not clearly related to TMDs, or not sufficiently distinct from disorders already included within the taxonomy. The expanded TMDs taxonomy offers an integrated approach to clinical diagnosis and provides a framework for further research to operationalise and test the proposed taxonomy and diagnostic criteria.

Whole cigarette smoke promotes human gingival epithelial cell apoptosis and inhibits cell repair processes.

BACKGROUND AND OBJECTIVE: Smoking cigarettes increases the risk of developing various types of human diseases, including cancers and periodontitis. As gingival epithelial cells are known to play an active role in innate immunity via the secretion of a wide variety of mediators, and as these cells are the first ones exposed to environmental stimuli such as cigarette smoke, we sought to investigate the effects of whole cigarette smoke on normal human gingival epithelial cells and tissue. MATERIAL AND METHODS: Human gingival epithelial cells were extracted from healthy nonsmokers and used either as a monolayer or as an engineered human oral mucosa to investigate the effect of whole cigarette smoke on cell growth, apoptosis and wound repair/migration. RESULTS: Our findings show that when gingival epithelial cells were exposed once to whole cigarette smoke, this resulted in a significant inhibition of cell growth through an apoptotic pathway, as confirmed by an increase of Bax and a decrease of Bcl-xL and caspase-3 activity. Cigarette smoke also inhibited epithelial cell migration. These effects may explain the disorganization of the engineered human oral mucosa tissue when exposed to whole cigarette smoke. CONCLUSION: Exposure to whole cigarette smoke markedly inhibits epithelial cell growth through an apoptosis/necrosis pathway that involves Bax and Bcl-xL proteins and caspase-3 activity. Cigarette smoke also disrupts epithelial cell migration, which may negatively affect periodontal wound healing.

Recommendations from the International Consensus Workshop: convergence on an orofacial pain taxonomy.

This 2·5-day workshop was organized by the International RDC/TMD Consortium Network of the International Association for Dental Research and the Orofacial Pain Special Interest Group of the International Association for the Study of Pain. Workshop participation was by invitation based on representation within the field, which included the Consortium Network, the Orofacial Pain Special Interest Group, the National Institute for Dental and Craniofacial Research, American Academy of Orofacial Pain, the European Academy of Craniomandibular Disorders, and the International Headache Society; other disciplines included radiology, psychology, ontology, and patient advocacy. The workshop members were divided into workgroups that reviewed core literature describing the properties of the RDC/TMD, provided recommendations for revision, and suggested relevant research directions. The goals of this workshop were to (i) finalize the revision of the RDC/TMD into a Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), which would be more appropriate for routine clinical implementation, (ii) provide a broad foundation for the further development of suitable diagnostic systems for not only TMD but also oro-facial pain as well, and (iii) provide research recommendations oriented towards improving our understanding of TMD and oro-facial pain. This report provides the full description of the workshop and Executive Summary, and it acknowledges the participants and sponsors.

Topical application of a corticosteroid destabilizes the host-parasite relationship in an experimental model of the oral carrier state of Candida albicans.

Using an experimental model in the mouse we have shown that both local and central lines of defense, involving CD4+ T cells, participate in a dynamic interaction to maintain a long-term carrier state of Candida albicans in the oral cavity. We have tested the impact of a predisposing factor to oral candidiasis in the form of a topical application of a corticosteroid (Topsyn gel) to the oral mucosa for 75 mice twice a day for a 20-day period. Very rapidly after the treatment was initiated, i.e. on day 4, the residual population of Candida increased up to 40-fold and by day 21, the population was 400-fold that of the carrier state. The resident population of intraepithelial CD4+ T cells in the oral mucosa virtually disappeared during the treatment. A topical corticosteroid application also resulted in a massive depletion of T cells in the lymph nodes and in the transient abrogation of the DTH reaction to Candida antigens. On cessation of treatment, normal levels of both Candida and intraepithelial CD4+ T cells were also quickly restored. These results suggest that resistance to superficial invasion by Candida is linked to the presence of an oral mucosal line of defense and that topical application of corticosteroids may dramatically shift the host-parasite relationship in favor of Candida.

Jaw pain prevalence among French-speaking Canadians in Québec and related symptoms of temporomandibular disorders.

The purpose of this study was to assess the prevalence and pattern of self-reported TMD jaw pain in a randomized stratified sample from the general population living in the Province of Québec, Canada. Through a telephone survey, standardized questions were asked to 897 French-speaking respondents, aged 18 years old and over, regarding frequency, severity, daily pattern of jaw pain, presence of difficulty in opening, joint clicking, and sleeping problems. All prevalence estimates were adjusted to the sociodemographic distribution of the non-institutionalized population. The results indicate that TMD jaw pain is self-reported by 30% of the general population; however, the prevalence of cases reporting frequent episodes (quite often or very often) is estimated at 7%, with more than two-thirds (69%) of the respondents in this subgroup experiencing moderate to severe pain. The prevalence rates of frequent difficulty in opening and joint clicking were estimated at 9% and 4%, respectively. Approximately one in four subjects with frequent episodes of jaw pain also reported frequent joint clicking or difficulty in opening, and a strong association (Gamma coefficient > 0.6) was found among all three TMD symptoms. Our data suggest that the prevalence of clinically significant TMD-related jaw pain (frequent jaw pain of moderate to severe intensity) is approximately 5% in the general population of the Province of Québec. In the nine months preceding the survey, about 2% of the total population sought treatment for a TMD symptom.

The reproducibility of muscle and joint tenderness detection methods and maximum mandibular movement measurement for the temporomandibular system.

The purpose of this study was (1) to evaluate the reproducibility of two masticatory muscle and joint tenderness detection methods; (2) to evaluate the reproducibility of maximum mandibular movement measurements; and (3) to investigate factors influencing examiner agreement. The tenderness assessment procedures involved application of a standard pressure for 2 seconds over four anatomically defined masticatory muscle sites, one control forehead site, and two temporomandibular joint sites on each side of the face. One technique utilized a pressure algometer (PAP), while the other technique required that a trained examiner apply pressure with the index fingertip (FPP). Seventy-two subjects (36 patients and 36 controls) were evaluated in a single-blind study design. Control subjects were matched for age, gender, and race with temporomandibular disorder subjects. Each subject was examined twice with each of the described methods in a randomized, fully balanced sequence by calibrated examiners. Tenderness levels were determined by the subject via self-report of pain upon pressure using a standard set of verbal descriptors. Maximum pain-free, active, and passive opening, and maximum active right and left lateral movements were measured using a millimeter ruler. Intraclass correlation coefficients (ICC) for the tenderness assessment methods ranged from 0.220 to 0.739 for the FPP method and from 0.391 to 0.880 for the PAP method. ICCs for mandibular movement measurement were much less variable, ranging from 0.59 to 0.68 for lateral movement and from 0.78 to 0.93 for opening movement. These results indicate good to excellent agreement between calibrated examiners for mandibular movement measurement and for tenderness assessment methods at two masseter (i.e., superficial and deep) and the anterior temporalis sites. Only fair agreement was found for the middle temporalis and lateral TMJ capsule sites using these methods.

Reproducibility of examiner performance for muscle and joint palpation in the temporomandibular system following training and calibration.

The purpose of this investigation was to assess examiner ability to consistently perform specific tasks related to muscle and joint palpation. Four trained and calibrated examiners were asked 1) to deliver index finger pressures within a high (1.5-2.1 kg) and low (0.5-1.1 kg) target pressure range and 2) to precisely locate one joint palpation and four muscle sites. After passing a calibration test, the performance of the examiners was monitored during the course of a replicability study assessing the consistency of clinical findings during repeated exams for TM disorders. (1) Index finger pressure was regularly tested over a 3-month period with a hand held pressure algometer, and the reading of each trial was recorded. Data analysis showed a high proportion of trials within the pressure range (overall 89.5%). Examiner performance across target range of pressures was statistically different for success rate and mean pressure delivered. The differences in the mean finger pressure delivered by each examiner (intraexaminer variation) was low and varied from 0.12 to 0.22 kg/cm2 for the desired range of pressures. (2) Paired examiners were asked to independently and sequentially mark palpation sites over the forehead, superficial and deep masseter, anterior temporalis, and lateral capsule of the temporomandibular joint. Replicability of site locations was assessed by measuring, with a boley gauge, the distance between sites selected by the paired examiners. Except for the superficial masseter and the anterior temporalis, the paired examiners selected palpation sites within a distance of 7 mm more than 85% of the time.(ABSTRACT TRUNCATED AT 250 WORDS)

Validity of a brief questionnaire in screening asymptomatic subjects from subjects with tension-type headaches or temporomandibular disorders.

Clinical investigations of temporomandibular disorders require objective, repeatable methods for screening diseased subjects from non-diseased control subjects. This study evaluated whether information gathered from a short, public domain questionnaire was useful in distinguishing temporomandibular disorder subjects (n = 216) from non-temporomandibular disorder controls (n = 69) and tension-type headache subjects (n = 22). The questionnaire consisted of eight questions relating to jaw pain (i.e., location of pain, precipitating factors, and temporal pattern of pain) and five questions relating to jaw function (i.e., joint noises, locking, and difficulty in opening). There were five possible answers to each question which ranged from 0 (no symptoms) to 4 (unbearable or constant symptoms). The total scores for the eight pain questions and the five jaw function questions were used to determine the questionnaire's sensitivity and specificity in each group, and ROC curves were plotted to identify the best cutoff point for disease presence or absence. Results showed that the questionnaire reliably distinguished between the control group and temporomandibular disorder group with 90.3%-97.7% sensitivity and 95.7%-100% specificity at cutoff values between 5 and 9. These results support the use of the questionnaire as a primary screening tool for general practice and as a supplementary screening tool for clinical temporomandibular disorder studies. However, results also showed that the questionnaire was unable to distinguish easily between TMD subjects and temporalis region tension-type headache subjects.

Sleep disorders and the dental patient: an overview.

This article is intended to briefly describe common sleep disorders of interest to the dental profession and to render general management guidelines. Topics include sleep-related bruxism, xerostomia, hypersalivation, gastroesophageal reflux, apnea, and the effect of orofacial pain on sleep quality. The term sleep-related is used instead of the term nocturnal because some of the activities described can occur with daytime sleep.

Curriculum structure: principles and strategy.

This report provides general guidelines for the structure of a curriculum, followed by specific advice on the principles of learning and teaching, the process of restructuring and change leadership and management. It provides examples of several educational philosophies, including vertical and horizontal integration. It discusses the use of competence, learning outcomes, level of degree and assessment and provides a number of recommendations. It does not seek to be prescriptive of time allocation to disciplines within a curriculum. Although this report has been written primarily for those who will develop an undergraduate curriculum, the information may be sufficiently generic to apply to the recent development in graduate entry ('shortened dental' or 'accelerated') courses and to postgraduate degree planning and higher education certificate or diploma courses for other dental care professionals (auxiliaries). The report may have a European bias as progress is made to converge and enhance educational standards in 29 countries with different educational approaches - a microcosm of global collaboration.

The utility and validity of current diagnostic procedures for defining temporomandibular disorder patients.

This paper describes the evolution of different concepts of classifying and defining Temporomandibular Disorders (TMD) for both clinical and research settings. The literature is reviewed with respect to the utility and validity of the different questionnaire and examination procedures that have been used to assess TMD patients. The presented view is that many of these procedures have not been validated, that there is a lack of standardization in the use of the procedures themselves, and that an ideal method of classifying this broad group of patients into better-defined subgroups has not yet been developed. More standardized and better-defined research by trained and calibrated researchers is needed worldwide to elucidate these subgroups so that a better and widely agreed upon research classification system can be developed for widespread use. It also seems clear that as research requirements for defining TMD patient subgroups become more stringent over time, it may not be practical for the clinician to implement them on a day-to-day basis in his or her practice. As such, a practical utilitarian definition of the common subtype of TMD patients is also needed which parallels any research grouping, so that data from research are valuable and generalizable to the practicing clinician.

Contraindications to vasoconstrictors in dentistry: Part I. Cardiovascular diseases.

This article reviews the main contraindications of vasoconstrictors in cardiac patients, notably unstable angina, recent myocardial infarction, recent coronary artery bypass surgery, refractory arrhythmias, untreated or uncontrolled hypertension, and untreated or uncontrolled congestive heart failure. Extensive survey of the literature has been completed, giving specific guidelines for a rational use of vasoconstrictors in this category of medically compromised patients.

Contraindications to vasoconstrictors in dentistry: Part II. Hyperthyroidism, diabetes, sulfite sensitivity, cortico-dependent asthma, and pheochromocytoma.

Dentists are aware of contraindications to the use of vasoconstrictors in patients with cardiovascular diseases. However, there are some other noncardiac conditions we should know. This article discusses the absolute contraindications to the use of vasoconstrictors in patients with a history of hyperthyroidism, diabetes, allergy to sulfites, asthma, and pheochromocytoma.

Sulfite, asthma and vasoconstrictors.

The use of vasoconstrictors in dentistry has always been a topic of controversy for the medically compromised patient. Over the past few years, dentists have been warned not to use local anesthetics with vasoconstrictors in asthmatic patients. In this article, the authors question the rationale behind these recommendations and explain why the warning should be restricted to steroid-dependent asthmatic patients.

Contraindications to vasoconstrictors in dentistry: Part III. Pharmacologic interactions.

This article discusses the relative contraindications to the use of vasoconstrictor in patients currently medicated with tricyclic antidepressants, monoamine oxidase inhibitors, phenothiazines and beta-blockers. It reviews drug interactions and emphasizes potential detrimental systemic effects that epinephrine contained in local anesthetics can have when administered concomitantly with these drugs. Finally, special considerations are expressed concerning patients who abuse illicit drugs such as cocaine.

Proteolytic activation of the interleukin-1beta precursor by Candida albicans.

Chronic inflammation rather than invasion is characteristic of some forms of superficial candidiasis such as denture stomatitis. We hypothesized that Candida albicans may play a critical role in the pathogenesis of inflammatory lesions observed in chronic candidiasis by activating the proinflammatory cytokine interleukin-1beta (IL-1beta) from epithelial stores of the precursor. The aim of this study was therefore to demonstrate the proteolytic cleavage and activation of the inactive precursor of IL-1beta (pro-IL-1beta) by C. albicans. After incubation of either blastospores or hyphae with the inactive precursor, proteolytic cleavage was monitored by sodium dodecyl sulfate-polyacrylamide gel electrophoresis Western immunoblotting analysis, and the biological activity of the cleavage products was tested in a bioassay. We report here that late-stationary-growth-phase blastospores as well as hyphae of C. albicans, but not exponentially growing cells, can efficiently cleave pro-IL-1beta to yield fragments of molecular masses compatible with mature biologically active IL-1beta (17 to 19 kDa). Assays conducted in the presence of selected proteinase inhibitors suggest that the cleavage of pro-IL-1beta involves the participation of one or more aspartyl proteinases. Cleavage products showed a dose-dependent IL-1beta-like activity in a thymocyte proliferation bioassay, which was inhibited by anti-IL-1beta neutralizing antibodies. The present data thus suggest a role for C. albicans proteinases in the activation and maintenance of the inflammatory response at epithelial surfaces.