Effect of contingent vibratory stimulus via an oral appliance on sleep bruxism after the splint adaptation period.

BACKGROUND: Contingent vibratory feedback stimuli applied by a specially designed oral appliance (OA) have been reported to be effective in reducing sleep bruxism (SB). However, the inhibitory effects of the OA, which occur immediately after OA delivery, may have confounded this finding. OBJECTIVE: This study sought to shed light on the effects of vibratory stimuli on SB after the OA adaptation period, when its inhibitory effects are diminished. METHODS: Fourteen 'definite' SB patients were enrolled. A force-based bruxism detection system was utilised to trigger a vibrator attached to the OA. Masseter electromyographic activity during sleep was recorded at home using portable polysomnography. After using the OA without vibratory stimulus for 16 nights (adaptation period), intermittent vibratory stimuli were applied every other half-hour for four nights (intervention period). Electromyographic activity over 10% of the maximum voluntary contraction was regarded as a SB episode. The number and the total duration of SB episodes per hour of sleep were calculated for the sessions with and without stimuli separately and averaged for four intervention nights. The effects of stimuli on these two variables were evaluated. RESULTS: The number and the total duration of the sessions without stimuli were 5.2 episodes/h and 35.3 s/h, respectively. These values significantly decreased to 3.9 episodes/h and 15.1 s/h (p < .05) for the sessions with vibratory stimuli. CONCLUSION: Contingent vibratory stimulus via an OA may be effective for the management of SB even after adaptation to OA.

Association of masticatory muscle activity with sleep arousal and other concomitant movements during sleep.

OBJECTIVE: This study aims to verify the associations among sleep bruxism (SB), sleep arousal (SA) and concurrent body movements. MATERIAL AND METHODS: Subjects underwent a standard overnight polysomnography test and audio-video recordings. Sleep quality was evaluated according to the Rechtschaffen and Kales criteria, while SA was determined as per the American Sleep Disorders Association criteria. Analyses were performed by an external institution after masking of the subjects' information. SB was assessed based on the presence/absence of rhythmic masticatory muscle activity (RMMA) episodes, which were identified by using electromyography of the masseter muscle. The observed simultaneous movements included lower leg movement (LLM), swallowing, face scratching, head movement, body movement, eye blinking, coughing, licking, sighing, body scratching, lip sucking, somniloquy and yawning. The LLM was determined visually, as well as through an increase in the tibialis electromyogram signal. Other movements were visually assessed using audio-video recordings. The incidences of all the simultaneous movements were compared between RMMA with intercurrent SA (SAwRMMA; RMMA episode derived from a masseter electromyogram showing more than 10% of maximum voluntary contraction) and SA without RMMA (SAw/oRMMA). RESULTS: Fourteen subjects were included in this study (females/males: 4/10, mean age: 31.5 ± 5.7 years). Among these, LLM, swallowing, body movement, licking, body scratching and lip sucking were frequently observed in SAwRMMA episodes than in SAw/oRMMA episodes, significantly. However, the non-specific simultaneous movements were higher observed in SAw/oRMMA episodes than that in SAwRMMA. CONCLUSION: Our results suggest that SB is concurrently activated with LLM in relation to arousal.

Effects of a contingent vibratory stimulus delivered by an intra-oral device on sleep bruxism: a pilot study.

PURPOSE: Although sleep bruxism (SB) is one of the most important clinical problems in dental practice, there is no definitive method for controlling it. This pilot study evaluated the effects of contingent vibratory feedback stimuli using an occlusal splint for inhibition of sleep bruxism. METHODS: Thirteen subjects with clinically diagnosed SB participated after providing an informed consent. Portable polysomnographic recordings were conducted in the subjects' home environment to make a definitive SB diagnosis and to evaluate the effects of the vibratory stimuli on SB. A force-based bruxism detection system, which used a pressure-sensitive piezoelectric film embedded in the occlusal splint, was utilized to trigger vibration feedback stimuli, which was scheduled to be applied intermittently for 30 min, at 30-min intervals. RESULTS: The number of SB episodes (times/hour), the total SB duration (seconds/hour), the mean duration of SB episodes (seconds/episode), and the micro-arousal index (times/hour) were scored for each time period (with and without vibration). The effects of the vibration on these scores were tested (paired t test; p < 0.05). The number of SB episodes tended to decrease with the vibration stimuli, and the decrease in the total SB duration was statistically significant (14.3 ± 9.5 vs. 26.0 ± 20.0, p = 0.03). No substantial change was found in terms of the micro-arousal index. CONCLUSIONS: These study results suggested that the SB inhibitory system employing a vibratory stimulus might be able to suppress the total SB duration without disturbing sleep.

Modified protocol including topical minocycline in orabase to manage medication-related osteonecrosis of the jaw cases.

OBJECTIVE: Management of medication-related osteone-crosis of the jaw (MRONJ) with active infection can be a serious challenge for clinicians. Based on Association of Oral and Maxillofacial Surgeons (AAOMS) recommendations, we have tested a modified treatment protocol using topical minocycline. STUDY DESIGN: Five patients diagnosed with stage II or III MRONJ lesions were willing to consent to our protocol. In addition to conventional treatment as suggested by the AAOMS, such as, surgical debridement, chlorhexidine irrigation, and systemic antibiotics, we applied 10% minocycline to the lesions once a week for sustained local antibiotic delivery. RESULTS: All five patients reported pain relief after the first minocycline application. Complete healing occurred in three patients; case three healed completely after the third application, one case continues to improve toward resolution and one withdraws due to other non-relevant medical problem. CONCLUSIONS: In this study, we are reporting favorable results using a modified protocol with topical minocycline to treat MRONJ lesions.

Sleep bruxism frequency and platelet serotonin transporter activities in young adult subjects.

PURPOSE: To evaluate correlations between serotonin transporter (SERT) uptake ability in human peripheral platelets and sleep bruxism (SB) frequency. METHODS: Subjects were consecutively recruited from sixth-year students at Okayama University Dental School. Subjects were excluded if they (1) were receiving orthodontic treatment, (2) had a dermatological disease, (3) had taken an antidepressant within 6 months, or (4) had used an oral appliance within 6 months. SB frequency was determined as the summary score of three consecutive night assessments using a self-contained electromyography detector/analyzer in their home. Fasting peripheral venous blood samples were collected in the morning following the final SB assessment. SERT amount and platelet number were quantified via an ELISA assay and flow cytometry, respectively. Functional SERT characterization, 5-hydroxytryptamine (5-HT) uptake, maximum velocity (V max), and an affinity constant (K m ) were assessed with a [(3)H] 5-HT uptake assay. The correlations between these variables and SB level were evaluated. RESULTS: Among 50 eligible subjects (26 males, mean age 25.4 ± 2.41 years), 7 were excluded because of venipuncture failure, smoking, and alcohol intake during the experimental period. A small but significant negative correlation between SB level and [(3)H] 5-HT uptake was observed (Spearman's correlation R (2) = 0.063, p = 0.04). However, there were no significant correlations between SB level and total platelet amount, SERT, V max, and K m values (p = 0.08, 0.12, 0.71, and 0.68, respectively). CONCLUSIONS: Platelet serotonin uptake is significantly associated with SB frequency, yet only explains a small amount of SB variability.

Evidence-Based Pharmacologic Approaches for Chronic Orofacial Pain.

For neuropathic pain, the three medications to use are gabapentinoids, tricyclic antidepressants and serotonin norepinephrine reuptake inhibitors plus topical anesthetics. Beta-blockers, tricyclic antidepressants and anti-epileptic drugs are effective preventive medications for daily migraine headaches. The three FDA-approved drugs for fibromyalgia, pregabalin, duloxetine and milnacipran, are not robust. For osteoarthritis, nonsteroidal anti-inflammatories have good efficacy, and when gastritis contraindicates them, corticosteroid injections are helpful.

Soft palate length and upper airway relationship in OSA and non-OSA subjects.

BACKGROUND: The narrowest area of the airway between the posterior nasal opening and the epiglottis is usually located in the retro palatal area. Many consider this the most likely site of airway obstruction during an obstructive sleep apnea (OSA) event. The aim of this study was to investigate the differences in soft palate and airway length between OSA and non-OSA patients. METHODS: In this study, we analyzed the ratio of the soft palate and the upper airway length in 45 consecutive patients. Twenty-five had an Apnea-Hypoapnea Index of more than 5 events per hour and were classified in the OSA group (male, 19; female, 6). These patients were compared with 20 normal controls (male, 12; female, 8). Controls who complained of snoring did have sleep studies (n = 5). The other fifteen controls were clinically asymptomatic and did not have sleep studies. Medical computed tomography scans were taken to determine the length of the upper airway and the soft palate length measured in the midsagittal image. RESULTS: Soft palate length was significantly larger in OSA patients compared to controls (p = 0.009), and in men compared to women (p = 0.002). However, there were no differences in airway length. The soft palate length, as a percent of oropharyngeal airway length, was significantly larger in OSA patients compared to controls (p = < 0.0001) and in men compared to women (p = 0.02). Soft palate length increases significantly with age by 0.3 mm per year in males (after adjustment for body mass index (BMI) and OSA). Soft palate length as a percent of airway length is larger in OSA patients and increases significantly with BMI in males only after adjusting for age. CONCLUSION: In this study, OSA patients had a longer soft palate in proportion to their oropharyngeal airway compared to controls as well as men compared to women. This proportion could be used for identifying patients at risk for OSA in combination with age.

Association of genetic, psychological and behavioral factors with sleep bruxism in a Japanese population.

Sleep bruxism is a sleep-related movement disorder that can be responsible for various pains and dysfunctions in the orofacial region. The aim of the current case-control association study was to investigate the association of genetic, psychological and behavioral factors with sleep bruxism in a Japanese population. Non-related participants were recruited and divided into either a sleep bruxism group (n = 66) or control group (n = 48) by clinical diagnoses and 3-night masseter electromyographic recordings by means of a portable miniature device. The Epworth Sleepiness Scale, Temperament and Character Inventory, NEO-Five Factor Inventory and custom-made questionnaires that asked about familial aggregation, alcohol intake, caffeine intake, cigarette smoking, past stressful life events, daytime tooth-contacting habit, temporomandibular disorder, daily headache, snoring, apnea/hypopnea symptoms, leg-restlessness symptoms and nocturnal-myoclonus symptoms were administered. In addition, 13 polymorphisms in four genes related to serotonergic neurotransmission (SLC6A4, HTR1A, HTR2A and HTR2C) were genotyped. These factors were compared between case (sleep bruxism) and control groups in order to select potential predictors of sleep-bruxism status. The statistical procedure selected five predictors: Epworth Sleepiness Scale, leg-restlessness symptoms, rs6313 genotypes, rs2770304 genotypes and rs4941573 genotypes. A multivariate stepwise logistic regression analysis between the selected predictors and sleep-bruxism status was then conducted. This analysis revealed that only the C allele carrier of HTR2A single nucleotide polymorphism rs6313 (102C>T) was associated significantly with an increased risk of sleep bruxism (odds ratio = 4.250, 95% confidence interval: 1.599-11.297, P = 0.004).This finding suggests a possible genetic contribution to the etiology of sleep bruxism.

Multiple sleep bruxism data collected using a self-contained EMG detector/analyzer system in asymptomatic healthy subjects.

PURPOSE: Small, self-contained electromyographic (EMG) detector/analyzer (D/A) devices have become available for the detection of jaw muscle activity events above threshold. These devices claim to be less intrusive to the subjects sleep so it is less prone to induce disturbed sleep. The objective of this study was to evaluate for night-to-night variability and examine for a systematic alteration on the first night in EMG levels. METHODS: Ten asymptomatic healthy volunteers (mean age, 26.8 ± 3.78) were recorded for six sequential nights in their home environment using EMG D/A system. The device yields a nightly EMG level above threshold score on a 0-4 level. Because the data are categorical and nonparametric, the data of the ten subjects across six nights were submitted to a Friedman repeated measures ANOVA. The significant level was set as alpha equal to 0.05. RESULTS: The median and mode values of the subjects were tabulated and analyzed and we did not find a significant difference in EMG D/A level across the six nights (p = 0.287, Kendall's coefficient of concordance = 0.124, Friedman two-way repeated measures ANOVA). The data did show clear and substantial night-to-night variability. CONCLUSION: Substantial night-to-night variability in masseter EMG activity levels was clearly observed in our subjects. There was no evidence of a suppressed or elevated first-night effect-like variability on masseter muscle EMG level seen in these subjects using a small portable self-contained EMG detector/analyzer. These data suggest that recordings should be at least 5-6-nights duration to establish a reasonable measure of an individual's average nightly masseter EMG level.

Test-retest reliability of MRI-based disk position diagnosis of the temporomandibular joint.

This study evaluated the test-retest reliability for determining the temporomandibular joint (TMJ) disk position, diagnosed using magnetic resonance imaging (MRI). These assessments were done as a base-line measurement for a prospective cohort study, which examines the risk factors for precipitation and progression of temporomandibular disorders. Fifteen subjects (mean age, 24.2 ± 0.94 years; male/female = 8/7) were recruited from the students of Okayama University Dental School. Sagittal MR TMJ images were taken with a 1.5-T MR scanner (Magneton Vision, Siemens) in close and maximal open positions twice at about 1-week (6-11 days) interval. The images were displayed using 200% magnification on a computer screen with a commercially available image software package (OSIRIS, UIN/HCUG). Three calibrated examiners diagnosed the disk positions using the standardized criteria. The disk position of each joint was classified as normal, anterior disk displacement with or without reduction, and others. The first and second disk position diagnoses were compared, and the test-retest reliability level was calculated using the kappa index. The second disk position diagnosis was consistent with the first in 27 out of 30 joints. The calculated kappa value representing the test-retest reliability level between the first and second disk position diagnosis was 0.812. These results indicated that the test-retest reliability of MRI-based diagnosis of TMJ disk positions at about 1-week interval was substantially high, even though they were not completely consistent.

Comparing the Berlin and the ARES questionnaire to identify patients with obstructive sleep apnea in a dental setting.

PURPOSE: The aim of this study was to compare the sensitivity and specificity of two questionnaires to identify patients with obstructive sleep apnea (OSA). MATERIALS AND METHODS: Fifty-three moderate to severe OSA patients [with a respiratory disturbance index (RDI) ≥ 15] and 31 controls (RDI < 15) based on ambulatory somnographic assessment were recruited through flyers and mail at USC School of Dentistry. Each patient answered the Berlin and apnea risk evaluation system (ARES) questionnaires. The responses to the questionnaires were scored and compared for significant group differences. RESULTS: Moderate and severe OSA patients were predominantly male, older, had a larger neck size, and larger body mass index than controls. There were no significant differences in race or ethnicity between the two groups. In this study, subjects having a "high risk" ARES questionnaire were 7.9 times as likely to have OSA as subjects with "low or no risk" score (p = 0.0002). The ARES questionnaire had a sensitivity of 90.6%, specificity of 43.2%, a positive predictive value (PPV) of 73.8%, and negative predictive value (NPV) of 73.7% compared to 67.9%, 54.8%, 72%, and 50%, respectively, for the Berlin questionnaire using a cut point of RDI ≥ 15. CONCLUSIONS: In this specific patient group, not uncommon to the regular dental private practice, the ARES questionnaire performed better than the Berlin questionnaire with higher sensitivity, similar PPV, higher NPV, but lower specificity. The lower specificity could be explained in part because the ARES has been tailored to screen patients with an RDI ≥ 5, and our study included mostly mild to severe patients. In conclusion, in this specific group of subjects, the ARES questionnaire is a better choice than the Berlin questionnaire; however, the Berlin questionnaire is publicly available and the ARES screener is proprietary.

Accuracy of online symptom checkers for diagnosis of orofacial pain and oral medicine disease.

PURPOSE: The aim of this study was to compare and contrast the diagnostic accuracy of multiple online symptom checkers when used for the diagnosis of orofacial pain and oral medicine related disease vignettes. The comparison condition used in this study was the diagnostic accuracy achieved by advanced specialty residents on these same vignettes using a virtual patient system. METHODS: 27 individual disease vignettes were utilized. These vignettes had a variety of orofacial pain and oral medicine diseases. Post graduate orofacial pain and oral medicine residents at our University of Southern California interacted with their randomly assigned virtual patients were analyzed [n=574]. Virtual patient accuracy was based on whether the user selected the primary diagnosis as one of their top four choices after interviewing. Eleven English-language symptom checkers accuracy was based on whether the vignettes produced the primary diagnosis as one of their top four choices. Using these data, symptom checker and virtual patient accuracy rates were calculated. RESULTS: The primary diagnosis on virtual patient encounters was found within the top four choices a mean of 67.2% of the time. The primary diagnosis for the same vignettes entered into the 11 symptom checkers was found within the top four choices a mean of 5.9% of the time. CONCLUSIONS: The accuracy of currently available symptom checkers that patient might use for self-diagnosis of common orofacial pain and oral medicine diseases was low, this result suggest that the improved diagnostic algorithms are needed.

An artificially intelligent (or algorithm-enhanced) electronic medical record in orofacial pain.

This review examines how a highly structured data collection system could be used to create data-driven diagnostic classification algorithms. Some preliminary data using this process is provided. The data collection system described is applicable to any clinical domain where the diagnoses being explored are based predominately on clinical history (subjective) and physical examination (objective) information. The system has been piloted and refined using patient encounters collected in a clinic specializing in Orofacial Pain treatment. In summary, whether you believe a branching hybrid check-box based data collection system with built-in algorithms is needed, depends on your individual agenda. If you have no plans for data analysis or publishing about the various phenotypes discovered and you do not need pop-up suggestions for best diagnosis and treatment options, it is easier to use a semi-structured narrative note for your patient encounters. If, however, you want data-driven diagnostic and disease risk algorithms and pop-up best-treatment options, then you need a highly structured data collection system that is compatible with machine learning analysis. Automating the journey from data collection to diagnoses has the potential to improve standards of care by providing faster and reliable predictions.

Soft palate length and upper airway relationship in OSA and non-OSA subjects.

BACKGROUND: The narrowest area of the airway between the posterior nasal opening and the epiglottis is usually located in the retro palatal area. Many consider this the most likely site of airway obstruction during an obstructive sleep apnea (OSA) event. The aim of this study was to investigate the differences in soft palate and airway length between OSA and non-OSA patients. METHODS: In this study, we analyzed the ratio of the soft palate and the upper airway length in 45 consecutive patients. Twenty-five had an Apnea-Hypoapnea Index of more than five events per hour and were classified in the OSA group (male, 19; female, 6). These patients were compared with 20 normal controls (male, 12; female, 8). Controls who complained of snoring did have sleep studies (n=5). The other fifteen controls were clinically asymptomatic and did not have sleep studies. Medical computed tomography scans were taken to determine the length of the upper airway and the soft palate length measured in the midsagittal image. RESULTS: Soft palate length was significantly larger in OSA patients compared to controls (p=0.009), and in men compared to women (p=0.002). However, there were no differences in airway length. The soft palate length, as a percent of oropharyngeal airway length, was significantly larger in OSA patients compared to controls (p= <0.0001) and in men compared to women (p=0.02). Soft palate length increases significantly with age by 0.3 mm per year in males (after adjustment for body mass index (BMI) and OSA). Soft palate length as a percent of airway length is larger in OSA patients and increases significantly with BMI in males only after adjusting for age. CONCLUSION: In this study, OSA patients had a longer soft palate in proportion to their oropharyngeal airway compared to controls as well as men compared to women. This proportion could be used for identifying patients at risk for OSA in combination with age.

Prevalence and impact of sleep disorders and sleep habits in the United States.

PURPOSE: Epidemiologic studies on sleep disorders in the USA have mostly focused on specific disorders in specific groups of individuals. Most studies on sleep habits and sleep-related difficulties have focused on children and adolescents. The authors describe the prevalence of the three common physician-diagnosed sleep disorders (insomnia, sleep apnea, and restless legs syndrome (RLS)) by age, gender, and race in the US population. In addition, the authors describe the sleep habits and sleep-related difficulties in carrying routine daily activities. The authors also investigate the impact of the sleep disorders on performing routine daily activities. METHODS: Data from the 2005-2006 National Health and Nutrition Examination Survey for 6,139 individuals over the age of 16 was analyzed for sleep-related parameters. RESULTS: The prevalence was highest for sleep apnea (4.2%), followed by insomnia (1.2%) and RLS (0.4%). Hispanics and Whites reported longer sleep duration than Blacks by 24 to 30 min. The predominant sleep habits were snoring while sleeping (48%), feeling unrested during the day (26.5%), and not getting enough sleep (26%). Difficulty concentrating (25%) or remembering (18%) were the main sleep-related difficulties in our sample. Insomnia, sleep apnea, and RLS had the highest impact on concentration and memory. CONCLUSIONS: Our findings suggest that the prevalence of sleep disorders in the USA is much lower than previously reported in the literature suggesting under diagnosis of sleep disorders by primary care physicians.

Imaging modalities to access bony tumors and hyperplasic reactions of the temporomandibular joint.

Benign and malignant tumors in the temporomandibular joint (TMJ) are rare. However, when a patient presents with clinical findings such as altered occlusion or facial asymmetry, a morphologic alteration in the condyle should be ruled out. The differential diagnosis for benign hyperplastic bony lesions in the TMJ should include condylar hyperplasia, osteochondroma, osteoma, chondroma, and osteoblastoma. If malignant features are present, chondrosarcoma and osteosarcoma should be considered. For the differential diagnosis, imaging is the most noninvasive method to evaluate the integrity of the TMJ. Imaging can be classified as morphologic or functional according to the information provided. The current scientific data have shown that panoramic images have 97% sensitivity and 45% specificity for identifying hyperplastic conditions in the TMJ. The sensitivity and specificity of medical computed tomography (CT) and cone-beam CT is 70% and 100%, and 80% and 100%, respectively, for the detection of bony abnormalities. To differentiate benign and malignant bony tumors, magnetic resonance imaging has a sensitivity and specificity of 44% and 95%, respectively. The corresponding percentages for single positron emission CT are 91% and 94%, for single positron emission CT/CT are 100% and 100%, for positron emission tomography are 88% and 72%, and for positron emission tomography/CT are 100% and 97%. The combination of morphologic and functional (single positron emission CT and positron emission tomography) modalities appears to improve the sensitivity and specificity to assess a hyperplastic condyle, facilitating treatment planning and providing a better prognosis for the patient.

Validation of a simplified sham acupuncture technique for its use in clinical research: a randomised, single blind, crossover study.

OBJECTIVES: The validity of a new sham acupuncture technique was tested on acupuncture naïve healthy subjects. METHODS: The procedure was tested in accupoints LI4 and ST6 in a randomised, single blind and crossover study. The participants were blind to which technique they received. 32 healthy volunteers (15 men, 17 women, aged between 20 and 62 years, mean age 34 years) were recruited at the Universidad de la República, Uruguay. Interventions Participants were randomly assigned to one of two groups: (1) real acupuncture or (2) sham acupuncture. After 30 min, the patients were 'needled' again in a crossover design. Main outcome measures A yes/no questionnaire was used to assess the credibility and characteristics of the procedure. RESULTS: For the credibility question (do you think you received real acupuncture?) no statistically significant group differences were evident before or after the crossover. Subjects who answered yes to this question ranged from 14/16 (87.5%) before crossover to 10/16 (62.5%) after crossover for the sham and 12/16 (75%) before crossover to 15/16 (93.8%) after crossover for the real acupuncture. The question that showed a significant difference (only after crossover) was the question, "did you feel the needle penetrating the skin?"; after crossover 12/16 (75%) subjects in the real acupuncture group said yes and 2/16 (12%) subjects in the sham group said yes to this question (p<0.01). CONCLUSIONS: These data suggests that this method is credible and constitutes a simple and inexpensive technique for use as a control in clinical research in acupuncture naïve subjects.

Building an Automated Orofacial Pain, Headache and Temporomandibular Disorder Diagnosis System.

Physicians collect data in patient encounters that they use to diagnose patients. This process can fail if the needed data is not collected or if physicians fail to interpret the data. Previous work in orofacial pain (OFP) has automated diagnosis from encounter notes and pre-encounter diagnoses questionnaires, however they do not address how variables are selected and how to scale the number of diagnoses. With a domain expert we extract a dataset of 451 cases from patient notes. We examine the performance of various machine learning (ML) approaches and compare with a simplified model that captures the diagnostic process followed by the expert. Our experiments show that the methods are adequate to making data-driven diagnoses predictions for 5 diagnoses and we discuss the lessons learned to scale the number of diagnoses and cases as to allow for an actual implementation in an OFP clinic.

A mathematical model to estimate the state-specific impact of the Health Resources and Services Administration's Ryan White HIV/AIDS Program.

BACKGROUND: Access to and engagement in high-quality HIV medical care and treatment is essential for ending the HIV epidemic. The Health Resources and Services Administration's (HRSA) Ryan White HIV/AIDS Program (RWHAP) plays a critical role in ensuring that people living with diagnosed HIV (PLWH) are linked to and consistently engaged in high quality care and receive HIV medication in a timely manner. State variation in HIV prevalence, the proportion of PLWH served by the RWHAP, and local health care environments could influence the state-specific impact of the RWHAP. This analysis sought to measure the state-specific impact of the RWHAP on the HIV service delivery system and health outcomes for PLWH, and presents template language to communicate this impact for state planning and stakeholder engagement. METHODS AND FINDINGS: The HRSA's HIV/AIDS Bureau (HAB) and the Centers for Disease Control and Prevention's Division of HIV/AIDS Prevention (CDC DHAP) have developed a mathematical model to estimate the state-specific impact of the RWHAP. This model was parameterized using RWHAP data, HIV surveillance data, an existing CDC model of HIV transmission and disease progression, and parameters from the literature. In this study, the model was used to analyze the hypothetical scenario of an absence of the RWHAP and to calculate the projected impact of this scenario on RWHAP clients, RWHAP-funded providers, mortality, new HIV cases, and costs compared with the current state inclusive of the RWHAP. To demonstrate the results of the model, we selected two states, representing high HIV prevalence and low HIV prevalence areas. These states serve to demonstrate the functionality of the model and how state-specific results can be translated into a state-specific impact statement using template language. CONCLUSIONS: In the example states presented, the RWHAP provides HIV care, treatment, and support services to a large proportion of PLWH in each state. The absence of the RWHAP in these states could result in substantially more deaths and HIV cases than currently observed, resulting in considerable lifetime HIV care and treatment costs associated with additional HIV cases. State-specific impact statements may be valuable in the development of state-level HIV prevention and care plans or for communications with planning bodies, state health department leadership, and other stakeholders. State-specific impact statements will be available to RWHAP Part B recipients upon request from HRSA's HIV/AIDS Bureau.

Predicting the outcome of a physical medicine treatment for temporomandibular disorder patients.

AIMS: To investigate whether any of the pretreatment physical signs, symptoms, and responses on psychological questionnaires would predict treatment outcomes after a standardized temporomandibular disorder (TMD) treatment program. METHODS: The care provided to 157 TMD patients was a short course of physical therapy, an occlusal appliance, and over-the-counter nonsteroidal anti-inflammatory drugs (OTC NSAIDs). A multidimensional outcome assessment was performed using six variables. Follow-up data were available on 81.5% of enrolled subjects and elapsed time from initial visit to the two follow-up points was 13 +/- 4.7 and 33.6 +/- 9.8 months, respectively. Multiple regression analyses were conducted to assess the relationship between 18 predictor variables and the six outcome variables. RESULTS: The results showed that the combination of a higher initial visual analog scale (VAS) pain score plus a lower jaw function interference score was significantly associated with a reduction of VAS pain after treatment (P < .05; adjusted R2 = 0.54). Moreover, the combination of a higher initial activity limitation score plus a lower jaw function interference score was associated with a greater reduction of the activity limitation score after treatment (P < .05; adjusted R2 = 0.36). None of the other outcomes were found to relate to any of the pretreatment variables. It must be noted that no single variable was a strong predictor and the odds ratios between the above three variables and the predicted outcomes were not robust. CONCLUSION: The corollary of these results suggests that if a high degree of jaw function interference is present (eg, clicking, locking), then the prognosis of improvement with brief self-directed physical therapy, an occlusal appliance, and OTC NSAID is lower, at least within the time frame of this study.