Clear aligner therapy and symptoms of temporomandibular disorders: a case report.

The etiology of temporomandibular disorders (TMDs) is remarkably diverse. This case report highlights the use of clear aligners as a probable cofactor of TMD in an adult patient. A 56-year-old woman who presented with a chief concern of crowding was missing teeth in both arches and had generalized tooth wear, an indistinct history of temporomandibular joint musculoskeletal pain, and a self-reported history of clenching. Based on the patient's preferences, clear aligner therapy (CAT) was initiated with a limited treatment goal of providing improved esthetics by reducing the overjet, expanding the arches, and aligning the anterior teeth. A few weeks into CAT, the patient developed acute masticatory facial pain. Therefore, the course of CAT was adjusted in favor of an individualized protocol to alleviate her occlusal symptoms until orthodontic treatment was completed. Dental providers must consider the potential contributory role of CAT in TMDs in patients who adapt poorly to occlusal changes and offer a patient-centered approach to manage the problem.

Trigeminal Traumatic Neuroma: a Comprehensive Review of the Literature Based On a Rare Case.

PURPOSE OF REVIEW: Traumatic neuromas in general, and trigeminal traumatic neuromas in particular, are relatively rare entities originating from a damage to a corresponding nerve or its branches. This manuscript is a comprehensive review of the literature on trigeminal traumatic neuromas based on an interesting and challenging case of bilateral intraoral lesions. RECENT FINDINGS: The diagnosis for this patient was bilateral trigeminal traumatic neuromas. It is possible that these patients have a genetic predisposition to the development of these lesions. It is a neuropathic pain condition and may mimic dental and other trigeminal pain entities. Topical treatment with lidocaine gel, utilizing a custom-made neurosensory stent, rendered the patient significant and sustained pain relief. Trigeminal traumatic neuromas present a diagnostic challenge even to a seasoned clinician, due to the complex clinical features that may mimic other entities. Topical medications such as local anesthetics may be a good viable alternative to systemic medications to manage the pain associated with the condition. Early identification of the lesion and the associated pain helps in the succinct management of symptomatic trigeminal traumatic neuromas.

Evolution of occlusion and temporomandibular disorder in orthodontics: Past, present, and future.

Occlusion has been an important consideration in orthodontics since the beginning of the discipline. Early emphasis was placed on the alignment of the teeth, the stability of the intercuspal position, and the esthetic value of proper tooth positioning. These factors remain important to orthodontists, but orthopedic principles associated with masticatory functions must also be considered. Orthopedic stability in the masticatory structures should be a routine treatment goal to help reduce risk factors associated with developing temporomandibular disorders.

The incidence and prevalence of temporomandibular disorders and posterior open bite in patients receiving mandibular advancement device therapy for obstructive sleep apnea.

PURPOSE: This study aims to evaluate the incidence and prevalence of temporomandibular disorders (TMD) in patients receiving a mandibular advancement device (MAD) to treat obstructive sleep apnea using the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). In addition, it also aims to assess the development of posterior open bite (POB). MATERIALS AND METHODS: Data from 167 patients were evaluated at baseline, from 159 patients after 118 days (visit II), from 129 patients after 208 days (visit III), and from 85 patients after 413 days (visit IV). The presence of TMD symptoms was evaluated through a questionnaire. TMD signs were assessed using the RDC/TMD. Clinical evaluation assessed for the presence of POB. RESULTS: The prevalence of TMD was 33/167 (19.8 %) at baseline. After an initial decrease to 14.5 % on visit II, the prevalence increased to 19.4 % on visit III and finally demonstrated a decrease to 8.2 % on visit IV. The incidence of TMD was 10.6 % on visit II. This decreased on further visits and only two (1.9 %) patients developed TMD from visit III to visit IV. POB was found to develop with an average incidence of 6.1 % per visit. The prevalence of POB was 5.8 % on visit II, 9.4 % on visit III, and 17.9 % on visit IV. CONCLUSION: The use of MADs may lead to the development of TMD in a small number of patients. Nevertheless, these signs are most likely transient. Patients with pre-existing signs and symptoms of TMD do not experience significant exacerbation of those signs and symptoms with MAD use. Furthermore, these may actually decrease over time. POB was found to develop in 17.9 % of patients; however, only 28.6 % of these patients were aware of any bite changes.

Differences in psychosocial functioning and sleep quality between idiopathic continuous orofacial neuropathic pain patients and chronic masticatory muscle pain patients.

AIM: To examine differences between idiopathic continuous orofacial neuropathic pain (ICONP) patients and chronic masticatory muscle pain (MMP) patients for psychosocial functioning and sleep quality. METHODS: Archival data were used to compare 81 ICONP patients to 81 age- and sex-matched chronic MMP patients on pain severity, life interference, life control, and affective distress measures from the Multidimensional Pain Inventory (MPI), a global severity index of psychological symptoms from the Symptom Checklist-90-R (SCL-90-R), Posttraumatic Stress Disorder Checklist-Civilian (PCL-C), and overall sleep quality from the Pittsburgh Sleep Quality Index (PSQI). MANOVA, MANCOVA, and chi-square analysis were used to investigate differences between the two groups in the psychosocial and sleep variables. RESULTS: The ICONP group reported greater pain severity (P = .013) and more life interference (P = .032) than the MMP group, while the MMP group reported higher levels of global psychological symptoms (P = .005) than the ICONP group. After controlling for pain severity, however, the MMP group demonstrated greater affective distress (P = .014) than the ICONP group, and life interference was no longer significantly different between the groups. ICONP patients were more likely to report a traumatic life event (P = .007). CONCLUSION: Although ICONP patients are likely to present more intense pain and report that their pain causes more interference in their lives, MMP patients are more likely to present with higher levels of overall psychological symptoms. The greater levels of pain severity reported by ICONP patients appear to be partially responsible for their higher levels of reported life interference.

Use of a structural equation model for prediction of pain symptoms in patients with orofacial pain and temporomandibular disorders.

AIMS: To develop and test a biopsychosocial model using structural equation modeling for predicting orofacial pain symptoms in a sample of patients with masticatory muscle pain (MMP). METHODS: Data were collected from clinic records of 251 adult patients who presented for initial evaluation to the Orofacial Pain Center at the University of Kentucky College of Dentistry and were subsequently diagnosed with MMP. Data were used to fit a model relating stressors, psychological distress, arousal, sleep problems, oral parafunction, and pain symptoms. Items from the Multidimensional Pain Inventory (MPI) and the IMPATH:TMJ, a comprehensive biopsychosocial assessment of patients with temporomandibular disorders (TMD), were used to construct a measurement model of five latent variables. RESULTS: Estimation of the model indicated a good fit to the data and significant associations between stressors, psychological distress, arousal, sleep problems, and pain symptoms. Sleep problems partially mediated the relation between arousal and pain symptoms. Contrary to hypotheses, no association occurred between oral parafunction and pain symptoms, possibly indicating that any relationship between oral parafunction and pain symptoms may not exist. CONCLUSION: Results from the model tested in the present study are an additional step toward developing a more comprehensive biopsychosocial model explaining the nature and etiology of MMP in orofacial pain and TMD. With additional development and testing, it may also serve as an aid to planning interventions, especially psychosocial interventions targeting stress management, psychophysiological regulation, psychological distress, and sleep problems.

The prevalence of clinical diagnostic groups in patients with temporomandibular disorders.

The aim of this study was to observe the prevalence of diagnostic groups of temporomandibular disorders (TMD) in patients who were referred or sought treatment for TMD and/or orofacial pain in a private clinic. The clinical records of 357 patients were evaluated and selected based on inclusion/exclusion criteria; the mean age was 32 years. A clinical examination was performed and the diagnosis was based on the American Academy of Orofacial Pain criteria. Results showed that 86.8% of patients were women and 93.3% of the patients presented more than one diagnosis. The most frequent chief complaint (n = 216, chi2 = 30.68, p = 0.001) and total diagnosis realized (n = 748, chi2 = 14.14, p = 0.001) were muscle related. We concluded that women seek treatment for dysfunction/disorders of orofacial structures more than men do; patients seeking specialized treatment have more than one diagnosis and muscle dysfunction is more prevalent than intra-articular disorders.

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.

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.

The classification of orofacial pains.

This article highlights the process of making the proper orofacial pain diagnosis. A classification is presented based on the clinical characteristics of the pain complaint and the structure by which it emanates. It is meant to serve as a road map for the clinician, which will help him or her establish the correct diagnosis, thereby allowing the selection of the proper treatment.

Critical Commentary 1: Reliability and Validity of the DC/TMD Axis I.

No abstract available.

Prevalence and impact of post-traumatic stress disorder symptoms in patients with masticatory muscle or temporomandibular joint pain: differences and similarities.

AIMS: To evaluate temporomandibular disorder (TMD) patients for differences between masticatory muscle (MM) and temporomandibular joint (TMJ) pain patients in the prevalence of posttraumatic stress disorder (PTSD) symptoms and evaluate the level of psychological dysfunction and its relationship to PTSD symptoms in these patients. METHODS: This study included 445 patients. Psychological questionnaires included the Symptom Check List-90-Revised (SCL-90-R), the Multidimensional Pain Inventory, the Pittsburgh Sleep Quality Index, and the PTSD Check List Civilian. The total sample of patients was divided into 2 major groups: the MM group (n = 242) and the TMJ group (n = 203). Each group was divided into 3 subgroups based on the presence of a stressor and severity of PTSD symptoms. RESULTS: Thirty-six patients (14.9%) in the MM group and 20 patients (9.9%) in the TMJ group presented with PTSD symptomatology (P = .112). Significant differences were found between the MM and the TMJ group in several psychometric domains, but when the presence of PTSD symptomatology was considered, significant differences were mostly maintained in the subgroups without PTSD. MM and TMJ pain patients in the "positive PTSD" subgroups scored higher on all SCL-90-R scales (P < .001) than patients in the other 2 subgroups and reached levels of distress indicative of psychological dysfunction. TMJ pain patients (58.3%; P = .008) in the positive-PTSD subgroups were more often classified as dysfunctional. Both positive-PTSD subgrounps of the MM and TMJ groups presented with more sleep disturbance (P < .005) than patients in the other 2 subgroups. CONCLUSION: A somewhat elevated prevalence rate for PTSD symptomatology was found in the MM group compared to the TMJ group. Significant levels of psychological dysfunction appeared to be linked to TMD patients with PTSD symptoms.

Craniofacial pain as the sole symptom of cardiac ischemia: a prospective multicenter study.

BACKGROUND: Craniofacial pain can be the only symptom of cardiac ischemia. Failure to recognize its cardiac source can put the patient's life at risk. The authors conducted a study to reveal the prevalence of, the distribution of and sex differences regarding craniofacial pain of cardiac origin. METHODS: The authors prospectively selected consecutive patients (N = 186) who had had a verified cardiac ischemic episode. They studied the location and distribution of craniofacial and intraoral pain in detail. RESULTS: Craniofacial pain was the only complaint during the ischemic episode in 11 patients (6 percent), three of them who had acute myocardial infarction (AMI). Another 60 patients (32 percent) reported craniofacial pain concomitant with pain in other regions. The most common craniofacial pain locations were the throat, left mandible, right mandible, left temporomandibular joint/ear region and teeth. Craniofacial pain was pre-ponderantly manifested in female subjects (P = .031) and was the dominating symptom in both sexes in the absence of chest pain. CONCLUSIONS: Craniofacial pain commonly is induced by cardiac ischemia. This must be considered in differential diagnosis of toothache and orofacial pain. CLINICAL IMPLICATIONS: Because patients who have AMI without chest pain run a higher risk of experiencing a missed diagnosis and death, the dentist's awareness of this symptomatology can be crucial for early diagnosis and timely treatment.

Joint intracapsular disorders: diagnostic and nonsurgical management considerations.

This article reviews common intracapsular temporomandibular disorders encountered in the dental practice. It begins with a brief review of normal temporomandibular joint anatomy and function followed by a description of the common types of disorders known as internal derangements. The etiology, history, and clinical presentation of each are reviewed. Nonsurgical management is presented based on current long-term scientific evidence.

Nervus intermedius neuralgia: a case report.

Nervus intermedius neuralgia (NIN) is an uncommon disorder that affects a sensory branch of the facial nerve. This condition usually provokes a very intense and stabbing pain localized in the depth of the ear canal. Due to the close anatomical proximity, temporomandibular joint (TMJ) pathologies should be included in the differential diagnosis. The treatment of NIN has not been established, although it seems reasonable that the therapeutic approaches used in other more common craniofacial neuralgias, such as trigeminal neuralgia, should be effective. In this paper, the authors present a case report of a female patient diagnosed with NIN who was successfully managed with pharmacological treatment.

Persistent idiopathic facial pain following dental implant placement: a case report.

The present case report depicts the management of a patient with persistent idiopathic facial pain following the placement of 2 dental implants in the mandibular anterior alveolar ridge. After 15 months of unsuccessful diagnosis and management, the patient was seen at the Orofacial Pain Unit of the Oral Surgery and Implantology master's degree program of the University of Barcelona. Seven months after treatment onset, a combination of nortriptyline, clonazepam, and relaxation procedures has successfully controlled the patient's facial pain symptoms.

The clinical usefulness of surface electromyography in the diagnosis and treatment of temporomandibular disorders.

BACKGROUND: This article presents a comprehensive review of the recent literature regarding the scientific support for the use of surface electromyography (SEMG) in diagnosing and treating temporomandibular disorders (TMDs). TYPES OF STUDIES REVIEWED: The authors conducted a Medline search involving human studies using the key words "surface electromyography or electromyography" and "masticatory muscles or temporomandibular disorders or craniomandibular disorders." They also reviewed relevant articles regarding the clinical usefulness of SEMG based on reliability, validity, sensitivity and specificity, as well as additional references included in some of the articles. RESULTS: The clinical use of SEMG in the diagnosis and treatment of TMD is of limited value when one considers reliability, validity, sensitivity and specificity as measurement standards. SEMG does not appear to contribute any additional information beyond what can be obtained from the patient history, clinical examination and, if needed, appropriate imaging. CONCLUSIONS: Clinically, the determination of the presence or absence of TMD does not appear to be enhanced by the use of SEMG. However, the modality may be useful in a meticulously controlled research setting. CLINICAL IMPLICATIONS: SEMG has limited value in the detection or management of TMD and in some instances may lead to unnecessary dental therapy as a solution for those disorders.