[My tongue is burning!-Glossodynia/orofacial pain disorder]. / Meine Zunge brennt! ­ Glossodynie/orofaziales Schmerzsyndrom.

Glossodynia or orofacial pain disorder is known as burning mouth syndrome. It is a therapeutic challenge. Its etiology is not well defined. Recent studies show not only a correlation with neuropathic changes, but there are also indications of comorbidities such as depression, anxiety, and carcinophobia. These can also manifest as a reaction to the disease and are not necessarily considered causative. Burning mouth syndrome poses a diagnostic challenge since its differential diagnosis is broad. With regard to dermatological aspects, lichen planus mucosae, oral leucoplakia, pemphigus vulgaris, and aphthous mouth ulcers should be considered. Diabetes, anemia, vitamin deficiency, and endocrinological influences should be considered regarding the predominance of elderly and female patients. Meta-analyses of treatment studies usually show a low level of evidence of the randomized, controlled trials. According to the literature mainly psychotherapy and antidepressants are proposed for therapy. Alpha lipoic acid as a dietary supplement shows short-term improvement and low-level laser therapy might have some benefit.

Craniofacial neuralgias.

While non-headache, non-oral craniofacial neuralgia is relatively rare in incidence and prevalence, it can result in debilitating pain. Understanding the relevant anatomy of peripheral branches of nerves, natural history, clinical presentation, and management strategies will help the clinician better diagnose and treat craniofacial neuralgias. This article will review the nerves responsible for neuropathic pain in periorbital, periauricular, and occipital regions, distinct from idiopathic trigeminal neuralgia. The infratrochlear, supratrochlear, supraorbital, lacrimal, and infraorbital nerves mediate periorbital neuralgia. Periauricular neuralgia may involve the auriculotemporal nerve, the great auricular nerve, and the nervus intermedius. The greater occipital nerve, lesser occipital nerve, and third occipital nerve transmit occipital neuralgias. A wide range of treatment options exist, from modalities to surgery, and the evidence behind each is reviewed.

A new biofeedback approach for the control of awake bruxism and chronic migraine headache: utilization of an awake posterior interocclusal device.

BACKGROUND: The relationship of bidirectional comorbidity between chronic migraine and pain in the cephalic segment led us to evaluate the improvement in reducing the pain in patients diagnosed with chronic migraine headache and awake bruxism, when undergoing treatment with a partial posterior interocclusal device designed for the management and control of awake bruxism through biofeedback. METHODS: Seventy-four patients were evaluated during the following periods: pretreatment, seven, thirty, ninety, one hundred and eighty days, and one year. The evaluation was carried out by measuring the pain in the pretreatment period and pain reduction after awake bruxism treatment, using clinical evaluation and numerical scales for pain. RESULTS: Most of the patients who complained of headache migraine pain, masticatory myofascial pain, temporomandibular joint and neck pain experienced a significant reduction in overall pain, including headaches, between t0 and t30 (p<0.0001). After 30 days of using the device, it was observed that the improvement remained at the same level without any recurrence of pain up to t90. At t180 and t360, it was observed that even with the device withdrawal (at t90) the improvement remained at the same level. CONCLUSION: The utilization of a posterior interocclusal device designed for the management and control of awake bruxism through biofeedback seems to contribute to the reduction of pain (including migraine headache) in the majority of patients, and, even with the device withdrawal (at t90), the improvement remained at the same level, suggesting the patients succeeded in controlling their awake bruxism and consequently the pains.

A new biofeedback approach for the control of awake bruxism and chronic migraine headache: utilization of an awake posterior interocclusal device / Uma nova abordagem via biofeedback para o controle do bruxismo de vigília e de enxaqueca crônica: utilização de um dispositivo interoclusal posterior em vigília

ABSTRACT Background: The relationship of bidirectional comorbidity between chronic migraine and pain in the cephalic segment led us to evaluate the improvement in reducing the pain in patients diagnosed with chronic migraine headache and awake bruxism, when undergoing treatment with a partial posterior interocclusal device designed for the management and control of awake bruxism through biofeedback. Methods: Seventy-four patients were evaluated during the following periods: pretreatment, seven, thirty, ninety, one hundred and eighty days, and one year. The evaluation was carried out by measuring the pain in the pretreatment period and pain reduction after awake bruxism treatment, using clinical evaluation and numerical scales for pain. Results: Most of the patients who complained of headache migraine pain, masticatory myofascial pain, temporomandibular joint and neck pain experienced a significant reduction in overall pain, including headaches, between t0 and t30 (p<0.0001). After 30 days of using the device, it was observed that the improvement remained at the same level without any recurrence of pain up to t90. At t180 and t360, it was observed that even with the device withdrawal (at t90) the improvement remained at the same level. Conclusion: The utilization of a posterior interocclusal device designed for the management and control of awake bruxism through biofeedback seems to contribute to the reduction of pain (including migraine headache) in the majority of patients, and, even with the device withdrawal (at t90), the improvement remained at the same level, suggesting the patients succeeded in controlling their awake bruxism and consequently the pains.

RESUMO Introdução: A relação de comorbidade bidirecional entre enxaqueca crônica e dor no segmento cefálico nos levou a avaliar a melhora na redução da dor em pacientes diagnosticados com cefaleia crônica de enxaqueca e bruxismo de vigília, quando submetidos a tratamento com dispositivo interoclusal posterior parcial projetado para o manejo e o controle do bruxismo acordado através de biorretroalimentação (biofeedback). Métodos: Setenta e quatro pacientes foram avaliados durante os seguintes períodos: pré-tratamento, sete, trinta, noventa e cento e oitenta dias, e um ano. A avaliação foi realizada por meio da avaliação da dor no período pré-tratamento e redução da dor após o tratamento do bruxismo de vigília, através de avaliação clínica e escalas numéricas de dor. Resultados: A maioria dos pacientes que se queixou de dor de cabeça com enxaqueca, dor miofascial mastigatória, articulação temporomandibular e dor no pescoço sofreu uma redução significativa na dor geral, incluindo dores de cabeça, entre t0 e t30 (p<0,0001). Após 30 dias de uso do dispositivo, observou-se que a melhora permaneceu no mesmo nível, sem recorrência da dor até t90. Em t180 e t360, observou-se que, mesmo com a retirada do dispositivo (em t90), a melhoria permaneceu no mesmo nível. Conclusão: A utilização de um dispositivo interoclusal posterior projetado para o controle do bruxismo de vigília através de biofeedback parece contribuir para a redução da dor (incluindo enxaqueca) na maioria dos pacientes, e, mesmo com a retirada do dispositivo (t90), a melhora manteve-se no mesmo nível, sugerindo que os pacientes conseguiram controlar o seu bruxismo de vigília e a dor associada a esse hábito.

Difference in Response to a Motor Imagery Task: A Comparison between Individuals with and without Painful Temporomandibular Disorders.

The aim of the study was to investigate the difference in response to a motor imagery task between individuals with and without painful temporomandibular disorders (TMDs). The participants were 24 adults with and without TMD (TMD and control group, resp.). A set of photographic images of the profile view of a person's head and neck and a hand and a foot were presented in a random order. The set consisted of six different orientations with rotations of each image at 0, 60, 120, 180, 240, and 300 degrees and included left and right representations. The participants were required to view the image and make a decision as to whether it was a left or a right side presented, that is, mental rotation (MR) task. Data were collected on 48 tasks (including left and right) at each orientation for each body part. Reaction times (RTs) for correct answers and accuracy in making the left or right judgements were recorded. The RT was slower in the TMD group than in the control group. The RT for the profile image was slower than those for the hand and foot images. For images that were 180 degrees, the RT was slower and the accuracy was lower than those for five of the other image orientations. The judgements made about the 180-degree rotated image were more inaccurate compared to images of all other orientations among all types of stimuli.

The therapeutic potential of cystathionine gamma-lyase in temporomandibular inflammation-induced orofacial hypernociception.

Hydrogen sulfide (H2S) is an endogenous neuromodulator produced mainly by the enzyme cystathionine gamma-lyase (CSE) in peripheral tissues. A pronociceptive role of endogenously produced H2S has been previously reported by our group in a model of orofacial inflammatory pain. Using the established persistent orofacial pain rat model induced by complete Freund's adjuvant (CFA) injection into temporomandibular joint (TMJ), we have now investigated the putative role of endogenous H2S modulating hypernociceptive responses. Additionally, plasmatic extravasation on TMJ was measured following different treatments by Evans blue dye quantification. Thus, rats were submitted to Von Frey and Formalin tests in orofacial region before and after pharmacological inhibition of the CSE-H2S system combined or not with CFA-induced TMJ inflammation. Pretreatment with CSE inhibitor, propargylglycine (PAG; 88.4 µmol/kg) reduced temporomandibular inflammatory pain when injected locally as well as systemically. In particular, local PAG injection seems to be more effective for hypernociceptive responses in orofacial persistent inflammation since its action is evidenced in the majority analyzed periods of the inflammatory process compared to its systemic use. Moreover, local injection seems to act on temporomandibular vascular permeability, evidenced by decreased plasmatic extravasation induced by local PAG administration. Our data are consistent with the notion that the endogenous synthetized gas H2S modulates persistent orofacial pain responses revealing the pharmacological importance of the CSE inhibitor as a possible therapeutic target for their control.

O tratamento fisioterapêutico em pacientes com placa oclusal miorrelaxante na terapia da disfunção temporomandibular: estudo clínico randomizado / Physiotherapeutic treatment in patients with myoclonus occlusal plaque in the therapy of Temporomandibular dysfunction: randomized clinical study

A disfunção temporomandibular (DTM) tem etiologia multifatorial, alguns fatores: estresse, ansiedade, alterações na coluna cervical, trauma, doenças inflamatórias crônicas e má oclusão podem desencandea-lá. Os sintomas comumente apresentados pelos indivíduos com DTM são dores nos músculos da mastigação, limitação do movimento da articulação temporomandibular, crepitações articulares durante o movimento de abertura da mandíbula e alguns pacientes apresentam enxaquecas associadas a disfunção. Diversas terapias têm sido utilizadas no tratamento e a fisioterapia utiliza diferentes modalidades no tratamento da DTM, como exercícios terapêuticos, eletroestimulação, terapia manual, dentre outros. O objetivo desse trabalho foi avaliar a efetividade do tratamento fisioterapêutico associado à placa miorrelaxante para tratamento da DTM muscular. A amostra foi composta por 21 indivíduos, estes foram divididos aleatoriamente em G1 (placa oclusal) e G2 (placa oclusal associado à fisioterapia). A análise estatística foi realizada utilizando o teste de Shapiro-Wilk, ANOVA, teste pós-hoc de Tukey e com significância de 5%. Os pacientes do grupo G2 receberam sessões de fisioterapia 2 vezes por semana, durante um período de 2 meses de tratamento, com duração de 30 min por sessão. Após o tratamento, observou-se que ambos os tratamentos foram eficazes quando considerado a Escala Visual Analógica da dor (EVA) sem que a fisioterapia mostrasse melhoras estatisticamente significativamente.(AU)

Temporomandibular disorders (TMD) has a multifactorial etiology, some factors: stress, anxiety, changes in the cervical spine, trauma, chronic inflammatory diseases and malocclusion can desencandea there. Symptoms commonly displayed by TMD patients are pain in the masticatory muscles, limitation of motion of the temporomandibular joint, crepitation joint during the opening movement of the jaw and some patients have headache associated with dysfunction. Several therapies have been used in the treatment and physiotherapy uses different modalities in the treatment of TMD, such as therapeutic exercises, electrostimulation, manual therapy, among others. The objective of this study was to evaluate the effectiveness of the physiotherapeutic treatment associated to the myorelaxant plaque for the treatment of muscular TMD. The sample consisted of 21 individuals, these were randomly divided into G1 (occlusal split) and G2 (occlusal split associated with physical therapy). Statistical analysis was performed using the Shapiro-Wilk test, ANOVA, Tukey posthoc test and with a significance of 5%. Patients in the G2 group received physiotherapy sessions twice weekly during a 2-month treatment period, lasting 30 minutes per session. After the treatment, it was observed that both treatments were considered effective when the Visual Analog Scale pain (VAS) without physical therapy showed statistically significant improvements(AU)

Melatonin Alters the Mechanical and Thermal Hyperalgesia Induced by Orofacial Pain Model in Rats.

Melatonin is a neuroendocrine hormone that presents a wide range of physiological functions including regulating circadian rhythms and sleep, enhancing immune function, sleep improvement, and antioxidant effects. In addition, melatonin has received special attention in pain treatment since it is effective and presents few adverse effects. In this study, we evaluated the effect of acute dose of melatonin upon hyperalgesia induced by complete Freund's adjuvant in a chronic orofacial pain model in Sprague-Dawley rats. Nociceptive behavior was assessed by facial Von Frey and the hot plate tests at baseline and thereafter 30, 60, and 120 min, 24 h, and 7 days after melatonin treatment. We demonstrated that acute melatonin administration alters mechanical and thermal hyperalgesia induced by an orofacial pain model (TMD), highlighting that the melatonin effect upon mechanical hyperalgesia remained until 7 days after its administration. Besides, we observed specific tissue profiles of neuroimmunomodulators linked to pain conditions and/or melatonin effect (brain-derived neurotrophic factor, nerve growth factor, and interleukins 6 and 10) in the brainstem levels, and its effects were state-dependent of the baseline of these animals.

Myofascial pain associated to trigger points: A literature review. Part 2: Differential diagnosis and treatment

During the last decades the advance in knowledge of myofascial pain has been constant in the medical and dental community. However, although several aspects have been clarified in relation to its epidemiology, clinical characteristics and etiopathogenesis, many uncertainties remain. Many clinical conditions are included in the differential diagnosis of myofascial pain associated to trigger points. A good anamnesis and clinical exploration is thus requiredin order to ensure correct diagnosis and treatment. Among the numerous treatments used in application to trigger points, the spray-and-stretch technique and direct injection targeted to such trigger points have been found to be the most effective options. In chronic cases, psychosocial intervention is required, due to the high incidence of mood disorders and/or anxiety observed in these patients, who in turn present a poorer prognosis. This underscores the importance of early diagnosis and treatment (AU)

Sustained reduction of hypertension by deep brain stimulation.

Deep brain stimulators were implanted in the left periaqueductal gray matter (PAG) and sensory thalamus for right sided neuropathic facial pain refractory to other treatments in a man aged 58 years. PAG stimulation 8 months later acutely reduced systolic blood pressure by 25 mm Hg during revision surgery. One year post procedure, ambulatory blood pressure monitoring demonstrated significant and sustained reduction in blood pressure with PAG stimulation. Mean systolic blood pressure decreased by 12.6mm Hg and diastolic by 11.0mm Hg, alongside reductions in variability of heart rate and pulse pressure. This neurosurgical treatment may prove beneficial for medically refractory hypertension.

Electroacupuntura en un caso de neuralgia postherpética con afectación de la rama oftálmica del V par craneal / Electroacupuncture in a case of postherpetic neuralgia with involvement of the ophthalmic branch of the trigeminal nerve

Neuralgia postherpética: cuadro de dolor neuropático crónico que aparece como complicación de una infección por el virus de la varicela zóster. La clínica se caracteriza por un dolor intenso y episódico. El tratamiento de elección es farmacológico, pero en un porcentaje de pacientes no se consigue una adecuada respuesta terapéutica, bien por intolerancia a los fármacos bien por inadecuado control del dolor. Se presenta el caso clínico de una paciente con una neuralgia postherpética que afecta a la rama oftálmica izquierda del V par craneal, en la cual no conseguimos un adecuado manejo del cuadro doloroso tras probar diferentes pautas farmacológicas. Ante esta situación, se inició sesiones de electroacupuntura combinadas con fármacos. Se obtuvo una mejoría progresiva de las crisis dolorosas en intensidad y frecuencia, lo que permitió la supresión del tratamiento farmacológico. Alternativa terapéutica a pacientes que no toleran los tratamientos farmacológicos para su dolor neuropático o cuando éstos son ineficaces (AU)

Postherpetic neuralgia consists of chronic neuropathic pain that appears as a complication of varicella-zoster virus infection and is characterized by intense and episodic pain. The treatment of choice is pharmacological but adequate therapeutic response is not always achieved, either due to drug intolerance or to inadequate pain control. Were port the case of a woman with postherpetic neuralgia affecting the left ophthalmic branch of the trigeminal nerve, in whom distinct drug treatments failed to achieve adequate pain control. Given this situation, electro-acupuncture sessions were started, combined with pharmacological therapy. The frequency and intensity of the pain exacerbations progressively diminished, allowing drug treatment to be discontinued. Electroacupuncture can constitute a therapeutic alternative in patients with drug intolerance or inadequate control of neuropathic pain with pharmacological treatment (AU)

Self-care behaviors associated with myofascial temporomandibular disorder pain.

AIMS: To document the frequency of self-care in a clinical sample of patients with myofascial temporomandibular disorder (TMD) pain; report the perceived relief and control of pain for each of the self-care behaviors; and to test for associations between the frequency and efficacy of each self-care behavior and pain, depression and sleep quality, as assessed during a clinical visit, and to determine whether the frequency was associated with changes in pain intensity, depression, and sleep quality 30 days later. METHODS: The sample consisted of 99 female and 27 male myofascial TMD pain patients who were participants in a multidisciplinary facial pain evaluation program. The subjects participated in a structured interview during a clinical visit and a follow-up telephone interview 30 days later. The interviews included questions about self-care, including resting, relaxation techniques, massage, hot and/or cold packs, home remedies, stretching or exercise, herbal remedies, and the use of vitamins or nutritional supplements for pain. RESULTS: The passive self-care behaviors, such as resting when experiencing pain (66%) and relaxation techniques (62%), were the most commonly used. Patients reported that hot or cold packs (5.3, 0-to-10 scale) and massage (4.7) provided the greatest relief from pain, whereas resting (4.9), relaxation (4.8), and massage (4.8) resulted in the greatest ability to control pain. The most striking finding was that initial levels of pain or change in pain were not consistently associated with self-care use; however, psychosocial outcomes of depression and sleep quality were associated with self-care frequency and reported efficacy and improved in relation to patient-reported self-care frequency. CONCLUSION: Since people with chronic myofascial TMD pain engage in a range of pain self-care strategies, clinicians need to discuss self-care with patients regularly.

Detecting mental disorders in dental patients with occlusion-related problems.

Dentists often treat patients who may be suffering from comorbid mental disorders without paying attention to their symptoms. This leads to a delay in starting the treatment of mental disorders and to inappropriate dental treatments for physical symptoms originating from mental disorders. In the present study, the ways in which dentists can easily detect mental disorders in dental patients with occlusion-related problems were examined. Fifty-three patients who visited the Occlusion Clinic of Kanagawa Dental College were interviewed by a psychiatrist and a dentist specialized in psychosomatic medicine. Thirty-five patients (66.0%) were diagnosed as having DSM-IV Axis I disorders. The demographic and psychological factors that correlate with the presence of mental disorders are duration of chief complaint, number of clinics and hospitals visited for the current symptom, total score of the General Health Questionnaire (GHQ), the scores of the anxiety and insomnia and social dysfunction subscales in the GHQ and the scores of the confusion-bewilderment and fatigue-inertia subscales in the Profile of Mood States (POMS). A logistic regression analysis indicated that number of clinics and hospitals visited markedly correlated with cormobidity of a mental disorder. This information may be useful for screening mental disorder patients. Dental patients having comorbid mental disorders should be treated both odontologically and psychologically.

Influence of temporomandibular joint pain on sleep patterns: role of nitric oxide.

Since nitric oxide is related to nociception and the sleep-wake cycle, this study sought to determine its involvement in the altered sleep pattern in a temporomandibular joint pain model by investigating the effect of the inhibitor of nitric oxide synthase (L-NAME) and that of its precursor (L-arginine). The temporomandibular joints of test animals were injected with Freund's adjuvant or saline, and their sleep was recorded. The procedure was repeated after the administration of L-NAME and L-arginine. L-NAME increased rapid eye movement (REM) sleep in the control group. The orofacial pain group showed a reduction in total sleep time and an increase in sleep latency compared with the SHAM group. L-NAME increased sleep time, non-rapid eye movement (NREM), and REM sleep and reduced sleep latency in the orofacial pain group. L-arginine did not alter sleep parameters. Thus, L-NAME improved sleep efficiency, whereas L-arginine did not modify it, suggesting the involvement of nitric oxide in painful temporomandibular joint conditions.

Understanding and managing the interaction between sleep and pain: an update for the dentist.

Pain is a symptom well known to disrupt numerous aspects of normal physical and psychological life, including work, social activities and sleep. In daily practice, general dentists and specialists are frequently confronted with issues concerning pain, as their patients seek management that integrates oral health with overall well-being. An example of a dental condition involving pain is temporomandibular disorder, which is one of the most common sources of chronic orofacial pain and which shares similarities with back pain in terms of intensity, persistence and psychosocial impact. The objective of this paper is to inform and aid the general dentist and the specialist concerned with the sleep quality of patients with orofacial pain.

Sleep cycles, TMD, fibromyalgia, and their relationship to orofacial myofunctional disorders.

Poor quality sleep is caused by many factors including orofacial myology disorders. TMJ and fibromyalgia patients demonstrate a variety of similar symptoms making diagnosis difficult. A team approach utilizing appropriate referrals is critical to successful patient treatment.