Association of decrease in insula fMRI activation with changes in trait anxiety in patients with craniomandibular disorder (CMD).

Patients with chronic pain and especially with craniomandibular disorder (CMD) show specific psychopathology in trait anxiety. In a previous longitudinal functional imaging study on CMD we found that the anterior insula was modulated by successful therapy intervention and pain relief. We here intended to investigate possible associations between anterior insula fMRI-activation during occlusal movements and trait anxiety over a splint therapy approach in patients with CMD. Three fMRI-investigations of a craniomandibular occlusion task were performed together with pain score evaluations and scoring of trait anxiety (State -Trait Anxiety Inventory; STAI) before, after two weeks and after three months of a DIR-mandibular splint therapy in a small group (n = 9) of CMD patients. Patients showed increased anxiety levels before therapy assessed with the STAI and the depression and anxiety scale (DASS). Besides of relevant reduction in pain the STAI decreased over time. Reduction in STAI was associated with anterior insular fMRI-activation reduction on both hemispheres. We conclude that the anxiety driven anticipation of pain related to occlusal trigger is processed in the anterior insula and might therefore be a main driver of therapeutic intervention by the splint therapy in CMD.

[Craniomandibular disorder/dysfunction. Characteristics and disorders of the masticatory organ]. / Craniomandibularis diszfunkció. A rágószerv sajátosságai és muködési zavarai.

The practising physician often meets patients with pain located in different parts of the face and facial skull, mouth opening restriction or other motion disorder of the mandible. It is not always easy to identify and explain the cause. It is not widely known among doctors that most of these problems are due to masticatory dysfunction. There is a special group of patients showing functional disorders and there are some others who present a variety of different symptoms and visit several doctors. The masticatory organ, a functional unit of the human organism has a definite and separate task and function. In the early years of life it is capable of adaptation, while later on it tends to compensation. The authors outline the functional anatomy of the masticatory organ and the characteristics of multicausal pathology, the dynamics of the process of the disease and their interdisciplinary aspects. They discuss the basic elements of craniomandibular dysfunction. Based on the diagnostic algorithm, they summarize treatment options for masticatory function disorders. They emphasize the importance that physicians should offer treatment, especially an irreversible treatment, without a diagnosis. It occurs very often that the causes are identified after the patients become symptom-free due to treatment. The aim of this report is to help the general practitioners, dentists, neurologists, ear-nose-throat specialists, rheumatologists or any other specialists in the everyday practice who have patients with different symptoms such as pain in the skull, acoustic phenomenon of the joint or craniomandibular dysfunction.

Disorders of the masticatory muscles.

Muscle disorders involving the masticatory muscles have been considered analogous to skeletal muscle disorders throughout the body. However, emerging research has shed new light on the varied etiology, clinical presentation, diagnosis, and treatment of myofascial pain and masticatory muscle disorders. This article reviews the etiology and classification of regional masticatory muscle disorders, the clinical examination of the patient, and evidence-based treatment recommendations.

The concurrency of temporal tendinitis with TMD.

Temporomandibular disorder (TMD) is a type of orofacial pain that can originate from a number of craniofacial mandibular structures. These include the TM joints, the muscles of mastication, related nerves, tendons, ligaments, bones and teeth. Symptoms include impaired jaw function, TM joint noises and pain, limited opening, often with jaw deviations or deflections to the affected side. Temporal tendinitis is a disorder of the fibrous insertion of the temporalis muscle tendons on the coronoid process of the mandible that is characterized by both inflammation and degeneration. Sometimes, temporal tendinitis can be the primary disease entity, but the authors found that it frequently coexists with TMD. This retrospective study was undertaken to determine the prevalence of temporal tendinitis with TMD. The charts of 449 patients diagnosed with TMD were reviewed to determine the incidences of temporal tendinitis. The referred pain sites and their incidences were also determined.

Revised definition of neuropathic pain and its grading system: an open case series illustrating its use in clinical practice.

The definition of neuropathic pain has recently been revised by an expert committee of the Neuropathic Pain Special Interest Group of the International Association for the Study of Pain (NeuPSIG) as "pain arising as direct consequence of a lesion or disease affecting the somatosensory system," and a grading system of "definite," "probable," and "possible" neuropathic pain has been introduced. This open case series of 5 outpatients (3 men, 2 women; mean age 48 +/- 12 years) demonstrates how the grading system can be applied, in combination with appropriate confirmatory testing, to diagnosis neuropathic conditions in clinical practice. The proposed grading system includes a dynamic algorithm that enhances the physician's ability to determine with a greater level of certainty whether a pain condition is neuropathic. Its clinical use should be further validated in prospective studies.

Influence of psychopathologies on craniomandibular disorders.

Psychopathologies play a role in the etiology and maintenance of craniomandibular disorders (CMD). In this study, the craniomandibular index was applied to valuate signs and symptoms of CMD in 60 dentate patients, who were assigned to 2 groups: symptomatic (n=35) and asymptomatic (n=25). An interview on psychopathologies was carried out with the aim to detect the presence of some mood disorders, such as depression, dysthymic and bipolar I disorders. Among these disturbances, depression was the most significant aspect to be reported (p<0.05) since it was present in most symptomatic patients. This important interaction was also significantly correlated (p<0.05) with the Palpation Index. These results suggest that psychopathological aspects could increase muscle tenderness and pain in addition to sleep dysfuntions and other physical complaints. Therefore, psychopathologies should be regarded as an important aspect in patients with orofacial pains.

Influence of psychopathologies on craniomandibular disorders

Psychopathologies play a role in the etiology and maintenance of craniomandibular disorders (CMD). In this study, the craniomandibular index was applied to valuate signs and symptoms of CMD in 60 dentate patients, who were assigned to 2 groups: symptomatic (n=35) and asymptomatic (n=25). An interview on psychopathologies was carried out with the aim to detect the presence of some mood disorders, such as depression, dysthymic and bipolar I disorders. Among these disturbances, depression was the most significant aspect to be reported (p<0.05) since it was present in most symptomatic patients. This important interaction was also significantly correlated (p<0.05) with the Palpation Index. These results suggest that psychopathological aspects could increase muscle tenderness and pain in addition to sleep dysfuntions and other physical complaints. Therefore, psychopathologies should be regarded as an important aspect in patients with orofacial pains.

Os transtornos psíquicos podem desempenhar um importante papel na etiologia e manutenção das desordens craniomandibulares (DCM). Desta forma, neste estudo, foi aplicado o índice craniomandibular (ICM), o qual permite detectar a presença de sinais e sintomas de DCM em 60 pacientes totalmente dentados. Estes pacientes foram divididos em dois grupos: sintomáticos (n=35) e assintomáticos (n=25). Um teste psiquiátrico foi administrado para diagnosticar patologias psíquicas pertencentes ao DSM-IV, como a depressão e os transtornos distímico e bipolar I. Das patologias psíquicas relacionadas aos transtornos de humor, a depressão mostrou uma relação estatisticamente significante (p<0,05) com os pacientes sintomáticos para DCM. Ao analisar o índice de palpação separadamente, essa relação se manteve significante (p<0,05) numa escala crescente de valores, demonstrando a ação destes transtornos sobre a sintomatologia dolorosa muscular. Assim sendo, os transtornos mentais exerceriam uma influência considerável na etiologia da DCM, na medida em que potencializariam a dor. Isso ocorreria em função do aumento da tensão muscular, dos distúrbios do sono e de outras alterações fisiológicas advindas destes transtornos.

Factores asociados a disfunción craneomandibular en una población de un centro de salud / Factors associated with temporomandibular disorder in a health centre’s population

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[Chronic tinnitus and craniomandibular disorders. Effectiveness of functional therapy on perceived tinnitus distress]. / Chronischer Tinnitus und kraniomandibuläre Dysfunktionen. Einfluss funktionstherapeutischer Massnahmen auf die Tinnitusbelastung.

BACKGROUND: Whether the co-occurrence of signs and symptoms of a craniomandibular disorder (CMD) and chronic tinnitus are coincidental or causal is controversial. Therefore, the effects of splint therapy and self-therapy on perceived tinnitus were evaluated. PATIENTS AND METHODS: Fifty-nine patients with chronic tinnitus were divided into three groups. In a cross-over design, two groups received the two different treatments and were compared with a control group. All patients received the initial basic tinnitus therapy. RESULTS: No significant correlation was established between the groups receiving treatment and the control group that would validate a link between tinnitus and CMD. CONCLUSION: The results of this study suggest a coincidental relationship between the two complexes of symptoms.

Fatigue and fatigue-related symptoms in an orofacial pain population.

OBJECTIVES: The aims of this study were to investigate the presence and magnitude of self-reported fatigue and fatigue-related symptoms and to determine whether fatigue can be distinguished as a unique clinical symptom in a sample of patients diagnosed with chronic temporomandibular joint or masticatory muscle pain. STUDY DESIGN: Fifty-five chronic TMD patients and 55 age-, sex-, and education-matched healthy volunteers completed a battery of 4 different fatigue measures as well as the SCL90-R, MPI, and PSQI. RESULTS: Fatigue and fatigue-related symptoms were reported significantly more often by chronic TMD patients than by healthy volunteers. MANCOVAs with somatization, depression, anxiety, general activity level, and sleep disturbances as covariates eliminated the differences between patients and controls. Stepwise regression showed that fatigue and fatigue-related symptoms did not appear to be a unique clinical symptom of TMD patients, but merely emerged as somatic symptoms accounted for by somatization and depression. CONCLUSION: Fatigue and fatigue related symptoms may be symptoms of somatization and depression in this sample of chronic TMD patients.

The functional relationship between the craniomandibular system, cervical spine, and the sacroiliac joint: a preliminary investigation.

The hypothesis of a functional coupling between the muscles of the craniomandibular system and the muscles of other body areas is still controversial. The purpose of this pilot study was to examine whether there is a relationship between the craniomandibular system, the craniocervical system and the sacropelvic region. To test this hypothesis, the prevalence and localization of dysfunction of the cervical spine and the sacroiliac joint were examined in a prospective, experimental trial. Twenty healthy students underwent an artificial occlusal interference, which caused an occlusal interference. The upper cervical spine (CO-C3) and the sacroiliac joint were examined before, during and after this experimental test. The primary outcome with these experimental conditions was the occurrence of hypomobile functional abnormalities. In the presence of occlusal interference, functional abnormalities were detected in both regions examined and these changes were statistically significant. The clinical implications of these findings may be that a complementary examination of these areas in CMD patients could be useful.

Combined effect of vestibular and craniomandibular disorders on postural behaviour.

A correlation has been reported in the dental literature between temporomandibular disorders and musculoskeletal abnormalities, however, the question whether they modify body postural sway remains controversial. In the present investigation, the Craniomandibular Index was used to evaluate the clinical extension of temporomandibular joint dysfunction and related problems in 40 patients with normal vestibular function and in 42 patients with peripheral vestibular disorders. Balance function was assessed by static posturography and body sway area was measured in two conditions: i) eye open, and g) eye closed. Data were compared to those of 40 healthy subjects. Postural control showed a significantly different behaviour between groups with an increase in average body sway in patients with craniomandibular disorders as opposed to controls (p < 0.005). Although the involvement of the stomatognathic apparatus was not quantitatively different in the two groups of patients, those also presenting a peripheral vestibular disorder exhibited greater average body sway than patients with only craniomandibular disorders (p < 0.005). The latter showed a greater average body sway than controls only in the trial with eyes closed (p < 0.05). The results demonstrated that craniomandibular alterations could produce moderate postural instability in patients with a normal vestibular function. Conversely, their association with peripheral vestibular disorders becomes a real challenge to the upright quiet stance probably due to a negative effect of somatosensory origin on the vestibulo-spinal reflex impairment.

The influence of voluntary muscle contractions upon the onset and modulation of tinnitus.

OBJECTIVE: To evaluate the frequency of tinnitus onset (in normal subjects) and modulation (in tinnitus patients) during muscle contractions, estimating possible risk factors. MATERIAL AND METHOD: This case-control study enrolled 121 tinnitus patients and 100 healthy volunteers who underwent medical history, ENT examination and 16 maneuvers of muscular contraction (head, neck and limbs). Modulation data were compared between patients with and without normal audiometry, well-defined diagnosis and symptoms of craniomandibular disorders. RESULTS: The ability to modulate tinnitus (65.3%) was significantly higher than that to originate tinnitus (14.0%). The head and neck musculature was significantly more efficient than that of the limbs. Audiometric pattern, well-defined etiology and symptoms of craniomandibular disorders showed no relation to tinnitus modulation. CONCLUSIONS: Somatic modulation is a characteristic aspect of tinnitus.

Psychological distress in chronic craniomandibular and cervical spinal pain patients.

Recent studies to chronic pain have shown that the number of painful body areas is related to the level of psychological distress. Therefore, the first aim of this study was to analyse differences in level of psychological distress between craniomandibular pain patients with or without cervical spinal pain. In this analysis, the number of painful body areas below the cervical spine was also taken into account. The second aim was to determine psychological differences between subgroups of craniomandibular pain patients. In this study, 103 out of 250 persons with or without craniomandibular pain were included in the final analyses. Patients who suffered from both craniomandibular and cervical spinal pain showed higher levels of psychological distress, as measured with the Symptom Checklist 90 (SCL-90) than patients with local craniomandibular pain and persons without pain. Further, a positive relationship was found between the number of painful body areas below the cervical spine, as measured on a body drawing, and the SCL-90 scores. No psychological differences were found between myogenous and arthrogenous craniomandibular pain patients. In conclusion, chronic craniomandibular pain patients with a coexistent cervical spinal pain showed more psychological distress compared to patients with only a local craniomandibular pain and asymptomatic persons.

[Epidemiologic study of patients with craniomandibular disorders. Report of data and clinical findings]. / Studio epidemiologico su un gruppo di pazienti con disordini craniomandibolari. Analisi dei dati e delle caratteristiche cliniche.

BACKGROUND: The purpose of this retrospective study was to identify the subjective and objective characteristics of a population referred to a clinic for diagnosis and treatment of orofacial pain and/or temporomandibular disorders. METHODS: Beginning in 1993, 825 patients, consecutively referred to the University of Naples Federico II , were examined and their records entered into a database. These data were collected by trained clinicians. Diagnostic subgroups were identified following the Research Diagnostic Criteria for temporomandibular disorders (RDC). RESULTS: Seventy-nine percent of patients were female, the mean age of the sample was 31.3+/-13 years (range: 5 to 74 years), most of patients were between 15 and 39 years of age. Based on diagnostic subgroups, patients were divided into: patients affected with myogenous pain (59%), arthrogenous pain (13%), arthrogenous and myogenous pain (16%) and fibromyalgia (4%). Sixty-three percent of the sample reported recent headaches, 53% reported parafunction, and 28% reported a previous trauma. Eighty-one percent reported spontaneous pain, which was chronic in 83% of them. The majority of patients (78%) presented a relatively high cultural BACKGROUND. CONCLUSIONS: These data appear to agree with other epidemiologic studies and depict the TMD treatment-seeking population as a predominantly female population during child-bearing years with multiple chronic pain complaints.