Revised evaluation objectives of the Korean Dentist Clinical Skill Test: a survey study and focus group interviews

PURPOSE: This study aimed to propose a revision of the evaluation objectives of the Korean Dentist Clinical Skill Test by analyzing the opinions of those involved in the examination after a review of those objectives. METHODS: The clinical skill test objectives were reviewed based on the national-level dental practitioner competencies, dental school educational competencies, and the third dental practitioner job analysis. Current and former examinees were surveyed about their perceptions of the evaluation objectives. The validity of 22 evaluation objectives and overlapping perceptions based on area of specialty were surveyed on a 5-point Likert scale by professors who participated in the clinical skill test and dental school faculty members. Additionally, focus group interviews were conducted with experts on the examination. RESULTS: It was necessary to consider including competency assessments for "emergency rescue skills" and "planning and performing prosthetic treatment." There were no significant differences between current and former examinees in their perceptions of the clinical skill test's objectives. The professors who participated in the examination and dental school faculty members recognized that most of the objectives were valid. However, some responses stated that "oromaxillofacial cranial nerve examination," "temporomandibular disorder palpation test," and "space management for primary and mixed dentition" were unfeasible evaluation objectives and overlapped with dental specialty areas. CONCLUSION: When revising the Korean Dentist Clinical Skill Test's objectives, it is advisable to consider incorporating competency assessments related to "emergency rescue skills" and "planning and performing prosthetic treatment."

Ultrasonographic examination of masticatory muscles in patients with TMJ arthralgia and headache attributed to temporomandibular disorders.

This study used ultrasonography to compare the thickness and cross-sectional area of the masticatory muscles in patients with temporomandibular joint arthralgia and investigated the differences according to sex and the co-occurrence of headache attributed to temporomandibular disorders (HATMD). The observational study comprised 100 consecutive patients with TMJ arthralgia (71 females and 29 males; mean age, 40.01 ± 17.67 years) divided into two groups: Group 1, including 86 patients with arthralgia alone (60 females; 41.15 ± 17.65 years); and Group 2, including 14 patients with concurrent arthralgia and HATMD (11 females; 33.00 ± 16.72 years). The diagnosis of TMJ arthralgia was based on the diagnostic criteria for temporomandibular disorders. The parameters of the masticatory muscles examined by ultrasonography were subjected to statistical analysis. The pain area (2.23 ± 1.75 vs. 5.79 ± 2.39, p-value = 0.002) and visual analog scale (VAS) score (3.41 ± 1.82 vs. 5.57 ± 12.14, p-value = 0.002) were significantly higher in Group 2 than in Group 1. Muscle thickness (12.58 ± 4.24 mm) and cross-sectional area (4.46 ± 2.57 cm2) were larger in the masseter muscle than in the other three masticatory muscles (p-value < 0.001). When examining sex-based differences, the thickness and area of the masseter and lower temporalis muscles were significantly larger in males (all p-value < 0.05). The area of the masseter muscle (4.67 ± 2.69 vs. 3.18 ± 0.92, p-value = 0.004) and lower temporalis muscle (3.76 ± 0.95 vs. 3.21 ± 1.02, p-value = 0.049) was significantly smaller in Group 2 than in Group 1. An increase in VAS was significantly negatively correlated with the thickness of the masseter (r = - 0.268) and lower temporalis (r = - 0.215), and the cross-sectional area of the masseter (r = - 0.329) and lower temporalis (r = - 0.293). The masseter and lower temporalis muscles were significantly thinner in females than in males, and their volumes were smaller in patients with TMJ arthralgia and HATMD than in those with TMJ arthralgia alone. HATMD and decreased masseter and lower temporalis muscle volume were associated with increased pain intensity.

Comparison of ultrasonography-based masticatory muscle thickness between temporomandibular disorders bruxers and temporomandibular disorders non-bruxers.

To compare masticatory muscle thickness in patients with temporomandibular disorders (TMDs) during rest and clenching, and by body position, using ultrasonography. This prospective study included 96 patients with TMD (67 females, 29 males; mean age: 40.41 ± 17.88 years): group 1, comprising 66 patients with TMD without bruxism (TMD_nonbruxer), and group 2, comprising 30 patients with concurrent TMD and bruxism (TMD_bruxer). In patients with TMD, bruxism was correlated with the presence of tinnitus, muscle stiffness, sleep problems, psychological stress, and restricted mouth opening. The masseter muscle significantly thickened during clenching (11.16 ± 3.03 mm vs 14.04 ± 3.47 mm, p < 0.001), whereas the temporalis muscle showed no significant increase in thickness from resting to clenching in an upright position (7.91 ± 1.98 vs 8.39 ± 2.08, p = 0.103). Similarly, during clenching in the supine position, the masseter muscle was significantly thicker compared with rest (11.24 ± 2.42 vs 13.49 ± 3.09, p < 0.001), but no significant difference was observed in temporal muscle thickness (8.21 ± 2.16 vs 8.43 ± 1.94, p = 0.464). In comparison between two groups, the average thickness of the masseter muscle was greater among TMD_bruxers than among TMD_nonbruxers in both the upright and supine positions (all p < 0.05). In the generalized lineal model, female sex (B = - 1.018, 95% confidence interval [CI] - 1.855 to - 0.181, p = 0.017) and bruxism (B = 0.868, 95% CI 0.567 to 1.169, p = 0.048) significantly predicted changes in masseter muscle thickness. Female sex (B = - 0.201, 95% CI - 0.299 to - 0.103, p = 0.011), increased age (B = - 0.003, 95% CI - 0.005 to 0.000, p = 0.038), and muscle stiffness (B = - 1.373, 95% CI - 2.369 to - 0.376, p = 0.007) were linked to decreased temporal muscle thickness. Comparing TMD nonbruxer and bruxer muscle thicknesses in upright and supine positions revealed significant increased thickness in the masseter muscle during clenching but not in the temporalis muscle. Masseter muscle thickness varied significantly by sex, body position, and resting/clenching, notably influenced by bruxism. These findings emphasize the relevance of these factors in clinical examinations of patients with TMD.

Age-related radiomorphometric changes on panoramic radiographs.

OBJECTIVES: We aimed to analyse age-related anatomical changes in teeth and mandibular structures using panoramic radiographs. MATERIALS AND METHODS: We included 471 subjects aged 13-70 years (mean, 35.12 ± 18.72 years). Panoramic radiographs were used to record intraoral condition and radiomorphometric parameters. After grouping the subjects by age decade, descriptive statistics and analysis of variance were performed to assess age-related patterns. RESULTS: The number of missing teeth, endodontically treated teeth, full veneer crowns, and implant prosthesis increased with age (all p < .05). The prevalence of periodontitis significantly increased after the 40s and was the highest in the 60s (57.1%). The maxillary canine root was the longest in the 10s and 20s (p < .001). With age, the mandibular canal and mental foramen moved towards the alveolar bone crest, on the opposite side of the mandibular inferior border. The pulp area and pulp-to-tooth ratio of maxillary/mandibular first molars were significantly higher in the 10s and 20s than in other age groups (all p < .05). CONCLUSIONS: We provided comprehensive information on age-related anatomical changes in teeth and mandibular structures based on panoramic radiographs. Various radiographic parameters showed specific changes with increasing age. Assessing these age-related changes can be useful in determining an individual's age, and may aid in medico-legal and forensic judgments.

Prediction of painful temporomandibular joint osteoarthritis in juvenile patients using bone scintigraphy.

The study aims to evaluate whether bone scintigraphy is effective in diagnosing temporomandibular joint (TMJ) osteoarthritis (OA) in juvenile patients. A retrospective study was conducted with 356 consecutive patients with TMJ-OA who were clinically assessed according to the Research Diagnostic Criteria for Temporomandibular Disorders. Patients were assigned to three groups based on their ages: Group 1: aged 12-16 years; Group 2: aged 17-19 years; and Group 3: aged 20 years. Additionally, we performed qualitative and quantitative analyses of bone scintigraphy images for the TMJ uptake ratio of the involved joint. The diagnostic rate of TMJ-OA (n = 356, 100%), and the overall presence of subjective pain (n = 282, 77.3%) was closest to the results of bone scintigraphy (n = 333, 91.2%). In addition, reported TMJ pain was significantly associated only with the results of bone scintigraphy and not with the results of panoramic radiography or cone beam computed tomography (CBCT) in all age groups. With CBCT as the reference standard, the optimal cutoff values of the uptake ratio for the diagnosis of TMJ-OA were 2.171 and 2.017 in Groups 1 and 2, respectively (P value < 0.05). Our results suggest that bone scintigraphy can be considered a useful modality for diagnosing TMJ-OA in juvenile patients.

Orofacial complex regional pain syndrome: pathophysiologic mechanisms and functional MRI.

Complex regional pain syndrome (CRPS) is one of the most challenging chronic pain conditions and is characterized by burning pain, allodynia, hyperalgesia, autonomic changes, trophic changes, edema, and functional loss involving mainly the extremities. Until recently, very few reports have been published concerning CRPS involving the orofacial area. We report on a 50-year-old female patient who presented with unbearable pain in all of her teeth and hypersensitivity of the facial skin. She also reported intractable pain in both extremities accompanied by temperature changes and orofacial pain that increased when the other pains were aggravated. In the case of CRPS with trigeminal neuropathic pain, protocols for proper diagnosis and prompt treatment have yet to be established in academia or in the clinical field. We performed functional magnetic resonance imaging for a thorough analysis of the cortical representation of the affected orofacial area immediately before and immediately after isolated light stimulus of the affected hand and foot and concluded that CRPS can be correlated with trigeminal neuropathy in the orofacial area. Furthermore, the patient was treated with carbamazepine administration and stellate ganglion block, which can result in a rapid improvement of pain in the trigeminal region.

Peripheral interactions between cannabinoid and opioid receptor agonists in a model of inflammatory mechanical hyperalgesia.

Activation of opioid and cannabinoid receptors expressed in nociceptors induces effective antihyperalgesia. In this study, we examined whether combinations of opioid and cannabinoid receptor agonists directed at the injured site would enhance therapeutic effectiveness. Behavioral pharmacology experiments were performed to compare the effects of DAMGO, a selective agonist for µ-opioid receptor (MOR), ACPA, a specific agonist for CB1, and combinations of DAMGO and ACPA in attenuating complete Freund's adjuvant (CFA)-induced mechanical hyperalgesia in the rat hindpaw. DAMGO (1µg-1mg) or ACPA (1µg-2mg) was administered into the inflamed paw when mechanical hyperalgesia was fully developed. When administered individually, DAMGO and ACPA dose-dependently reversed the mechanical hyperalgesia. DAMGO displayed a lower ED50 value (57.4±2.49µg) than ACPA (111.6±2.18µg), but ACPA produced longer lasting antihyperalgesic effects. Combinations of DAMGO and ACPA also dose-dependently attenuated mechanical hyperalgesia, but the antihyperalgesic effects were partial and transient even at high doses. Using isobolographic analysis, we determined that combined treatment with DAMGO and ACPA produced antagonistic effects with the observed ED50 of 128.4±2.28µg. Our findings showed that MOR and CB1 agonists directed at the inflamed site effectively attenuate mechanical hyperalgesia when administered individually, but exert opposing effects when administered together. The antagonistic interactions between the two classes of drugs at the inflamed site suggest distinct mechanisms unique to peripheral nociceptors or inflamed tissue, and therefore require further studies to investigate whether the therapeutic utility of the combined drug treatments in chronic pain conditions can be optimized.

Muramyl dipeptide activates human beta defensin 2 and pro-inflammatory mediators through Toll-like receptors and NLRP3 inflammasomes in human dental pulp cells.

PURPOSE: The expression levels of intracellular pyrin domain-containing 3 (NLRP3) and microbial pattern-recognition receptors, such as nucleotide-binding oligomerization domain 2 (NOD2), have been reported in human dental pulp cells (HDPCs) and inflamed dental pulp tissue, but the role of NLRP3 and Toll-like receptors (TLRs) in the production of human beta defensin 2 (hBD2) and inflammatory cytokines against invading pathogens remains poorly defined. The aim of this study was to determine whether the NOD2 ligand muramyl dipeptide (MDP) upregulates hBD2 and inflammatory cytokines and whether this response is dependent on TLRs and NLRP inflammasomes in HDPCs. METHODOLOGY: The effects of MDP on the expression of hBD2, TLRs, inflammasomes, and pro-inflammatory mediators in HDPCs were examined using Western blotting and reverse transcription-polymerase chain reaction. Levels of pro-inflammatory cytokines, such as nitric oxide (NO) and prostaglandin E2 (PGE2), were determined by enzyme-linked immunosorbent assay. RESULTS: MDP upregulated hBD2, TLR2, and TLR4 mRNAs and protein levels in a dose- and time-dependent manner. TLR2 and TLR4 neutralizing blocking antibodies and NOD2- and hBD2-specific small interfering RNAs (siRNAs) attenuated the MDP-induced production of NO, PGE2, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and IL-8 and upregulated inducible nitric oxide synthase (iNOS) and cyclooxygenase 2 (COX2) in HDPCs. Additionally, MDP activated inflammasome-related genes, such as NLRP3, caspase 1, apoptotic speck protein containing a caspase recruitment domain, and IL-1ß. Furthermore, silencing of the NLRP3 gene using a siRNA significantly decreased the MDP-induced expression of hBD2 and cytokines, such as iNOS-derived NO, COX2, PGE2, TNF-α, IL-6, and IL-8. CONCLUSION: These results suggest that NOD2 activates the TLR2, TLR4, and NLRP3 inflammasome-signaling pathways in HDPCs to induce the production of multiple inflammatory mediators and antimicrobial peptides, which in turn promote pulp immune defense against microbial challenge. CLINICAL RELEVANCE: The TLR and NLRP3 inflammasome pathways may represent an important modulatory mechanism of immune defense responses during the progression of pulpitis. Our results suggest that local inhibition of NLRP3 and TLRs may reduce the impact of cytokine-mediated host destructive processes in pulpitis.

Masseter inflammation differentially regulates three nitric oxide synthases in the rat trigeminal subnucleus caudalis.

OBJECTIVE: The aim of the present study was to evaluate changes in expression levels of three nitric oxide synthases (NOSs), namely inducible NOS (iNOS), neuronal NOS (nNOS) and endothelial NOS (eNOS), in the subnucleus caudalis of the trigeminal sensory nuclear complex (Vc) under experimental myositis conditions. DESIGN: Male Sprague Dawley rats were injected with an inflammatory agent, complete Freund's adjuvant (CFA), or capsaicin in the masseter muscle. The brainstem region containing the Vc was extracted at both immediate (30 and 60 min) and longer (1, 3, 7 days) time points to examine the changes in the three NOS protein levels via the Western blot technique. Subsequently, the RT-PCR experiments were carried out to verify the changes in iNOS mRNA. RESULTS: Following the injections of CFA, there were no significant changes in the level of the three NOS proteins at the immediate time points. However, there was a significant upregulation of iNOS mRNA and protein 3 days after CFA-induced inflammation. Neither nNOS nor eNOS showed significant changes in the protein level at any of the longer time points. Capsaicin injection in the masseter, which we recently reported to upregulate all three NOS at the immediate time points, did not result in significant changes at longer time points. CONCLUSION: Acute and chronic muscle inflammation differentially modulates the expression of the three NOS in the Vc. These data suggest that the contribution of each NOS in craniofacial muscle pain processing under inflammatory conditions may be anticipated with distinct temporal profiles.

Cytoprotective and anti-inflammatory effects of melatonin in hydrogen peroxide-stimulated CHON-001 human chondrocyte cell line and rabbit model of osteoarthritis via the SIRT1 pathway.

Melatonin has potent antioxidant, analgesic, and antinociceptive properties. However, the effects of melatonin against oxidative stress-induced cytotoxicity and inflammatory mediators in human chondrocytes remain poorly understood. This study examined the effects and underlying mechanism of melatonin in hydrogen peroxide (H(2) O(2) )-stimulated human chondrocytes and rabbit osteoarthritis (OA) model. Melatonin markedly inhibited hydrogen peroxide (H(2) O(2) )-stimulated cytotoxicity, iNOS, and COX-2 protein and mRNA expression, as well as the downstream products, NO and PGE(2) . Incubation of cells with melatonin decreased H(2) O(2) -induced Sirtuin 1 (SIRT1) mRNA and protein expression. SIRT1 inhibition by sirtinol or Sirt1 siRNA reversed the effects of melatonin on H(2) O(2) -mediated induction of pro-inflammatory cytokines (NO, PGE(2) , TNF-α, IL-1ß, and IL-8) and the expression of iNOS, COX-2, and cartilage destruction molecules. Melatonin blocked H(2) O(2) -induced phosphorylation of PI3K/Akt, p38, ERK, JNK, and MAPK, as well as activation of NF-κB, which was reversed by sirtinol and SIRT1 siRNA. In rabbit with OA, intra-articular injection of melatonin significantly reduced cartilage degradation, which was reversed by sirtinol. Taken together, this study shows that melatonin exerts cytoprotective and anti-inflammatory effects in an oxidative stress-stimulated chondrocyte model and rabbit OA model, and that the SIRT1 pathway is strongly involved in this effect.

Peripheral AMPA receptors contribute to muscle nociception and c-fos activation.

In this study, involvement of peripheral AMPA receptors in mediating craniofacial muscle pain was investigated. AMPA receptor subunits, GluR1 and GluR2, were predominantly expressed in small to medium size neurons but more GluR2 positive labeling were encountered in trigeminal ganglia (TG) of male Sprague Dawley rats. A greater prevalence of GluR2 is reflected by the significantly higher percentage of GluR2 than GluR1 positive masseter afferents. Nocifensive behavior and c-fos immunoreactivity were assessed from the same animals that received intramuscular mustard oil (MO) with or without NBQX, a potent AMPA/KA receptor antagonist. Masseteric MO produced nocifensive hindpaw shaking responses that peaked in the first 30s and gradually diminished over a few minutes. There was a significant difference in both peak and overall MO-induced nocifensive responses between NBQX and vehicle pre-treated rats. Subsequent Fos studies also showed that peripheral NBQX pre-treatment effectively reduced the MO-induced neuronal activation in the subnucleus caudalis of the trigeminal nerve (Vc). These combined results provide compelling evidence that acute muscle nociception is mediated, in part, by peripherally located AMPA/KA receptors, and that blockade of multiple peripheral glutamate receptor subtypes may provide a more effective means of reducing muscular pain and central neuronal activation.

Hypertonic saline-induced muscle nociception and c-fos activation are partially mediated by peripheral NMDA receptors.

In this study, the animal model of hypertonic saline (HS) infusion protocol was developed and utilized to test the hypothesis that HS causes peripheral release of glutamate, and that blockade of peripheral NMDA receptors significantly reduces HS-induced nocifensive behavior and central neuronal activation. Nocifensive behavior and c-fos immunoreactivity, as a marker of central neuronal activation, were assessed from the animals that received intramuscular HS infusion with and without the NMDA receptor antagonist, MK-801. HS infusion (20 microl/min for 10 min) in the rat masseter produced prolonged nocifensive hindpaw shaking responses that peaked in the first minute and gradually diminished over the infusion period. The HS induced nocifensive behavior was dose-dependently attenuated by MK-801 pretreatments (0.3 mg/kg and 0.1 mg/kg), but not by vehicle pretreatment (isotonic saline; ISO), in the masseter muscle. HS infusion produced a significant number of Fos positive neurons in the ispsilateral subnucleus caudalis (Vc). Subsequent immunohistochemical studies showed that peripheral MK-801 pretreatment effectively reduced the HS induced neuronal activation in the Vc. These results provide compelling evidence that HS-induced muscle nociception is mediated, in part, by peripheral release of glutamate, and that blockade of peripheral glutamate receptors may provide effective means of preventing central neuronal activation.