International consensus on the assessment of bruxism: Report of a work in progress.

In 2013, consensus was obtained on a definition of bruxism as repetitive masticatory muscle activity characterised by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible and specified as either sleep bruxism or awake bruxism. In addition, a grading system was proposed to determine the likelihood that a certain assessment of bruxism actually yields a valid outcome. This study discusses the need for an updated consensus and has the following aims: (i) to further clarify the 2013 definition and to develop separate definitions for sleep and awake bruxism; (ii) to determine whether bruxism is a disorder rather than a behaviour that can be a risk factor for certain clinical conditions; (iii) to re-examine the 2013 grading system; and (iv) to develop a research agenda. It was concluded that: (i) sleep and awake bruxism are masticatory muscle activities that occur during sleep (characterised as rhythmic or non-rhythmic) and wakefulness (characterised by repetitive or sustained tooth contact and/or by bracing or thrusting of the mandible), respectively; (ii) in otherwise healthy individuals, bruxism should not be considered as a disorder, but rather as a behaviour that can be a risk (and/or protective) factor for certain clinical consequences; (iii) both non-instrumental approaches (notably self-report) and instrumental approaches (notably electromyography) can be employed to assess bruxism; and (iv) standard cut-off points for establishing the presence or absence of bruxism should not be used in otherwise healthy individuals; rather, bruxism-related masticatory muscle activities should be assessed in the behaviour's continuum.

Longitudinal Multilevel Modeling of Facial Pain, Muscle Tension, and Stress.

The role of masticatory muscle activation on pain in temporomandibular muscle and joint disorders (TMJD) is controversial. This single-group, prospective panel study examined the relationships among masticatory muscle tension, emotional distress, and TMJD pain in a sample of 7,023 observations obtained from 171 individuals using longitudinal multilevel modeling. Three main hypotheses were tested. The first posited that emotional distress and muscle tension directly influenced pain (hypothesis 1a: Distress → TMJD Pain; hypothesis 1b: Muscle Tension → TMJD Pain). The second posited that emotional distress directly influenced muscle tension (Distress → Muscle Tension), and the third posited that the effect of emotional distress on pain was mediated by muscle tension (Distress → Muscle Tension → TMJD pain). We also examined the fit of the data to possible alternative models. All the data used in this study were collected via an experience sampling methodology. The fit of the preferred models was better than that of the alternative models, with the preferred models explaining large proportions of the data, especially for level 2 variance (hypothesis 1a = 41% variance; hypothesis 1b = 69% variance; hypothesis 2 = 48% variance). In the mediation model, the addition of muscle tension to the model reduced the impact of emotional distress. The findings support a causal role for masticatory muscle tension in TMJD pain. Clinically, the results suggest that addressing tension and other oral parafunctions in those diagnosed with TMJDs should be an important part of the conservative, noninvasive care of individuals diagnosed with the myofascial pain or arthralgia of TMJD.

Bruxism defined and graded: an international consensus.

To date, there is no consensus about the definition and diagnostic grading of bruxism. A written consensus discussion was held among an international group of bruxism experts as to formulate a definition of bruxism and to suggest a grading system for its operationalisation. The expert group defined bruxism as a repetitive jaw-muscle activity characterised by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible. Bruxism has two distinct circadian manifestations: it can occur during sleep (indicated as sleep bruxism) or during wakefulness (indicated as awake bruxism). For the operationalisation of this definition, the expert group proposes a diagnostic grading system of 'possible', 'probable' and 'definite' sleep or awake bruxism. The proposed definition and grading system are suggested for clinical and research purposes in all relevant dental and medical domains.

Assessment of cytotoxicity and DNA damage exhibited by siloranes and oxiranes in cultured mammalian cells.

The potential reactivity and structural properties of oxiranes (epoxides) are advantageous when considering polymers for medical devices. However, epoxy compounds are widely known to have genotoxic properties. The objective of the study was to evaluate the cytotoxicity and primary DNA damage effects induced by oxiranes and siloranes, silicon containing oxiranes. The siloranes, Ph-Sil, Tet-Sil, and Sil-Mix and the oxiranes Cyracure UVR-6105 and 1,3-bis[2-(2-oxiranylmethyl) phenoxy]pentane (OMP-5) were dissolved in organic solvents and dilutions containing less than 0.5% solvent were used in biological assays. The concentration that reduced the viability of 50% (TC(50)) of L929 cells was measured using the MTT assay and guided the selection of subtoxic doses for evaluation of DNA damage. Ph-Sil was more cytotoxic than OMP-5, Cyracure UVR-6105 and Sil-Mix. However, the TC(50) value of Tet-Sil could not be determined due to its poor solubility. DNA damage was evaluated in the sister chromatid exchange (SCE) assay with CHO cells, and the alkaline comet assay with L929 cells. In contrast to the siloranes, the oxiranes exhibited significant increases (p>0.05) in SCE frequencies and DNA migration relative to their solvent controls. Our findings support previous reports that siloranes have low genotoxic potential and can be suitable components for development of biomaterials.

Headache and temporomandibular disorders: evidence for diagnostic and behavioural overlap.

To assess the diagnostic and behavioural overlap of headache patients with temporomandibular disorders (TMD), individuals recruited from the general population with self-described headaches were compared with non-headache controls. The examination and diagnostic procedures in the Research Diagnostic Criteria (RDC) for TMD were applied to both sets of subjects by a blinded examiner. Following their examination, subjects used experience sampling methods to obtain data on pain, tooth contact, masticatory muscle tension, emotional states and stress. Results showed that a significantly higher proportion of the headache patients received an RDC/TMD diagnosis of myofascial pain than non-headache controls. Headache patients also reported significantly more frequent and intense tooth contact, more masticatory muscle tension, more stress and more pain in the face/head and other parts of the body than non-headache controls. These results are similar to those reported for TMD patients and they suggest that headache patients and TMD patients overlap considerably in diagnosis and oral parafunctional behaviours.

In vitro comparison of conventional film and direct digital imaging in the detection of approximal caries.

OBJECTIVES: To compare the diagnostic accuracy of conventional film, unenhanced direct digital and inversion grayscale direct digital imaging in the detection of approximal caries. METHODS: 150 approximal surfaces of extracted permanent molars and premolars were selected for the study on the basis of varying lesion depth. The teeth were radiographed using Ektaspeed Plus film; digital images were made with a Schick CMOS-APS sensor. 7 examiners evaluated 58 randomized images of each modality. Histological sectioning of the teeth was used to verify the presence and extent of decay. RESULTS: No significant difference was found between the diagnostic accuracies of the three imaging modalities (P=0.226). Analysis of the diagnostic accuracy of the three modalities on lesion depth showed no statistically significant interaction; however, the main effect of the lesion depth was significant (P<0.001, eta(2)=0.936). CONCLUSIONS: The overall diagnostic accuracy of the three modalities in the detection of approximal carious lesions was comparable. All three modalities performed poorly in the detection of enamel lesions.

Reduction in parafunctional activity: a potential mechanism for the effectiveness of splint therapy.

Interocclusal splints may be an effective modality in the management of temporomandibular disorders (TMD), but there is little evidence regarding the mechanism by which splints work. This study tested the hypothesis that pain reduction produced by splints is associated with reduction in parafunctional activity. In a two-group, single-blinded randomized clinical trial, patients diagnosed with myofascial pain received full coverage hard maxillary stabilization splints. Patients were instructed to maintain or avoid contact with the splint for the 6 weeks of active treatment. Patients who decreased the intensity of tooth contact were expected to show the greatest alleviation of pain, and those who maintained or increased contact were expected to report lesser reductions in pain. Experience-sampling methodology was used to collect data on pain and parafunctional behaviours at pre-treatment and during the final week of treatment. Patients were reminded approximately every 2 h by pagers to maintain/avoid contact with the splint. The amount of change in intensity of tooth contact accounted for a significant proportion of the variance in pain change scores. Patients who reduced tooth contact intensity the most reported greater relief from pain. Splints may produce therapeutic effects by reducing parafunctional activities associated with TMD pain.

Effects of interocclusal appliances on EMG activity during parafunctional tooth contact.

To test the hypothesis that a flat plane interocclusal appliance affects the electromyographic (EMG) activity of the temporalis and masseter muscles in pain-free individuals, maxillary splints were fabricated for 20 individuals who reported no history, signs or symptoms of myofascial pain or arthralgia as determined by two trained, independent examiners. Subjects were instructed to establish light tooth contact, maximum clenching, and moderate clenching with/without the splint in place (as determined by random assignment) while EMG data from the left and right temporalis and masseter muscles were recorded. A 5-min biofeedback training session to relax the masticatory muscles was followed by a repetition of the tooth contact/clenching tasks with/without the splint in place. With the splint in place, the activity of the temporalis muscles decreased for all tasks, significantly for the left and right temporalis under maximal clenching and for the right temporalis under moderate clenching. In contrast, the activity of the masseter muscles increased under light and moderate clenching (significantly for the left masseter under moderate clenching) and decreased slightly under maximal clenching. The effectiveness of interocclusal appliances may be due to mechanisms other than redistribution of adverse loading.

Biocompatibility of hydroxylated metabolites of BISGMA and BFDGE.

Unpolymerized dental monomers can leach out into the oral biophase and are bioavailable for metabolism. We hypothesize that metabolites would be less toxic than parent monomers. We first identified the formation of metabolites from bisphenol F diglycidyl ether (BFDGE) and Bisphenol A glycidyl methacrylate (BISGMA) after their exposure to liver S9 fractions. Then, the metabolites and parent compounds were subjected to in vitro cytotoxicity, mutagenicity, and estrogenicity studies. Bisphenol A bis(2,3-dihydroxypropyl) ether and bisphenol F bis(2,3-dihydroxypropyl) ether were the hydroxylated metabolites of BISGMA and BFDGE, respectively. Cytotoxicity against L929 cells showed that the metabolites were significantly (p < 0.05) less cytotoxic than the parent monomers. Only BFDGE was mutagenic in the Ames assay with strain TA100 of Salmonella typhimurium. Parent and metabolite compounds did not stimulate estrogen-dependent MCF-7 cell proliferation above solvent controls. These results indicated that the hydroxylated metabolites were non-mutagenic, non-estrogenic, and less cytotoxic than their parent monomers.

In vitro biocompatibility of oxirane/polyol dental composites with promising physical properties.

OBJECTIVES: Visible light cure oxirane/polyol resins of Cyracure UVR-6105 with pTHF-250 has been previously shown useful for development of dental composites. This oxirane/polyol (4016) in combination with other oxiranes were formulated into composites (4016E, 4016G and 4016GB) containing 72.9-74.9% quartz filler. The main objective of the study was to evaluate some of the physical properties and the biocompatibility of the composites. RESULTS: PhotoDSC analysis of composites demonstrated twice the enthalphy values of Z100 (31J/g). Composites 4016E and 4016G showed compressive strengths similar to Z100 (337+/-35Mpa), P>0.05. Discs of composite 4016E, containing Epon 825 oxirane (E), and composite 4016G containing Araldite GY 281 oxirane (G) were non-cytotoxic (-) while the composite 4016GB, containing G and Ebecryl 1830 (B), was mildly (+) cytotoxic to L929 cells in the agar diffusion assay. Seven-day extracts of 4016GB composite were cytotoxic while extracts of 4016E and 4016G were less cytotoxic to L929 cells in the MTT assay. Extracts were obtained from 7 day incubations of composite (3 cm(2) surface area/ml) in acetone or ethanol/saline (1:20) at 37 degrees C. All composite extracts were non-mutagenic to Ames strains TA100, TA98, TA97a and TA1535. The overall results with composite 4016GB suggest that leachable components were cytotoxic but non-mutagenic. With the exception of oxirane components, G and E, the oxirane Cyracure UVR-6105 and other components were non-mutagenic. From cytotoxicity studies, the photoinitiator, Sarcat CD 1012, was the most cytotoxic (TC(50)=14 microM) component. Components G (TC(50)=17 microM), E (TC(50)=50 microM) and B (TC(50)=151 microM) were significantly (p < 0.05) more cytotoxic than Cyracure UVR-6105 (1488 microM) and the polyol, pTHF-250 (TC(50)=6072 microM). SIGNIFICANCE: Favorable results obtained with composites 4016G and 4016E indicates that suitable oxirane/polyol formulations can be designed and optimized for development of dental composites with acceptable mechanical properties and biocompatibility. However, leachable analysis of extracts obtained from longer incubation periods is needed before final conclusions could be drawn about the leachability of oxirane components.

Aromatic dental monomers affect the activity of cholesterol esterase.

The dental restorative monomer, BISGMA (2,2-bis[4-(2-hydroxy-3-methacryloxypropoxy)phenyl]propane), and bisphenol A diglycidyl ether (BADGE) increase the velocity of the reaction catalyzed by pancreatic cholesterol esterase (CEase, bovine). The metabolite of these monomers, bisphenol A bis(2,3-dihydroxypropyl) ether, and a common plasticizer, di-2-ethylhexyl phthalate (DEHP), also increase the velocity of CEase-catalyzed ester hydrolysis. BISGMA at concentrations of 1.5-8.0 microM increases the velocity to 126-169% of its value in the absence of BISGMA. Increasing BISGMA above 8 microM caused no further increase in velocity. BADGE at 7-25 microM increases the velocity to 112-205% of its value without BADGE. The metabolite of BISGMA and BADGE at concentrations of 2.0-7.1 microM increases the velocity to 103-113% of its value without metabolite. DEHP at concentrations of 0.52-4.3 microM increases the velocity to 108-187% of its value without DEHP. On the other hand, bisphenol A dimethacrylate is a competitive inhibitor of CEase, with a K(i) of 3.1 microM.

Laser irradiation of bone: III. Long-term healing following treatment by CO2 and Nd:YAG lasers.

BACKGROUND: Relative few reports exist concerning healing of laser created osteotomies over an extended period of time. The purpose of this study was to evaluate long-term healing, from 21 to 63 days, of osteotomy defects in the rat tibia created with the Nd:YAG and CO2 in the presence of a surface cooling spray of air/water. METHODS: The experimental model consisted of 15 large Sprague-Dawley rats. Six treatment modalities were randomly distributed among 6 tibial recipient sites: 1) a negative control (no treatment); 2) a positive control (bur osteotomy); 3) CO2 laser at 5 W (860 J/cm2); 4) CO2 laser at 6 W (1,032 J/cm2); 5) Nd:YAG laser at 5 W (714 J/cm2); and 6) Nd:YAG laser at 7 W (1,000 J/cm2). All laser irradiation was delivered in the presence of a surface coolant consisting of air (15 psi) and sterile water. Five animals were sacrificed at each of 3 time intervals: 21, 35, and 63 days post-treatment. Multiple histologic sections from each treatment site were examined by light microscopy using hematoxylin and eosin Goldner's trichrome stains, and polarized light and evaluated for presence of a char layer, heat induced cracking, heat related alterations in cells or tissue matrix, and osseous regeneration. RESULTS: Healing was severely delayed in all laser treated sites compared to positive control sites. Of the laser treated sites, those irradiated by CO2 laser at 5 W (780 J/cm2) exhibited the greater amount of bone regeneration. At best, however, only a small percentage of sections from any of the laser treated specimens showed evidence of bone regeneration within the ablation defect regardless of the post-treatment time interval. CONCLUSIONS: Under the conditions of this study, the osseous healing response was severely delayed by CO2 and Nd:YAG laser irradiation of bone, even in the presence of a surface cooling spray of air/water.

Effects of dental resins on TNF-alpha-induced ICAM-1 expression in endothelial cells.

Many reports have demonstrated inflammation after the placement of dental restorations. To explain this side-effect, we studied a biomarker in the inflammatory response. The intercellular adhesion molecule-1 (ICAM-1) is a key mediator for recruitment of leukocytes to the site of inflammation. Therefore, we investigated whether methacrylates (a BISGMA-based dental resin, BISGMA, and MAA) and Cyracure UVR 6105, an epoxy monomer, could alter ICAM-1 expression in unstimulated and TNF-alpha-stimulated endothelial cells. Six-well plates with monolayers of human umbilical vein cells, ECV 304 (ATCC CRL 1998), were exposed to TNF-alpha (1 ng/mL) in the presence and absence of subtoxic and TC50 doses of chemicals for 24 hrs at 37 degrees C/5% CO2. Several doses of TNF-alpha (0.5-2 ng/mL) were coincubated with 100 microL of undiluted aqueous dental resin extracts. Cells were harvested and stained with mAB FITC-conjugated anti-human ICAM-1 (CD54). ICAM-1 expression was measured by flow cytometry. Cells expressed basal levels of ICAM-1, which was up-regulated by TNF-alpha but was not changed by all samples studied. Except for UVR 6105, the methacrylates significantly decreased ICAM-1 expression in TNF-alpha-stimulated cells. These findings suggest that methacrylates may decrease the recruitment of leukocytes to sites of inflammation.

Evaluation of a digital measurement tool to estimate working length in endodontics.

The purpose of the study was to compare the segmental measurement tool from the Shick Technologies CDR digital system with the conventional film radiography measurement technique to determine preoperative working length. Natural extracted human teeth with varying degrees of root curvature were used. All teeth were imaged using the Shick Technologies CDR direct digital system and conventional E-speed film. Measurements from digital radiography and conventional film were compared with measurements made directly from the endodontic files. The Wilks' Lambda multivariate test was used. The mean measurement of each modality was compared with the other and with the gold standard. The test showed statistically significant differences between the two modalities at p<0.05. The mean measurements for both modalities were not significantly different from the gold standard. The modality most closely approaching the gold standard was the conventional film.

A comparison of palatal adaptation in acrylic resin denture bases using conventional and anchored polymerization techniques.

PURPOSE: The study investigated the effects of palatal depth and a resin anchoring system on the adaptation of denture base resin to the master cast after compression molding and heat polymerization. MATERIALS AND METHODS: Forty-eight virtually identical polymethyl methacrylate dentures were fabricated on master casts with either a deep or shallow palatal vault. One half of the master casts of each palate type were altered by the addition of anchoring holes along the posterior land area, as well as perpendicularly in the midsaggital area. Anchoring holes were made with a #8 round bur to a depth of 5 mm. Twenty-four hours after polymerization, the bases on their casts were sectioned at the posterior border and evaluated for degree of adaptation using a traveling microscope. Maladaptation at the interface of the denture base and master cast was measured at predetermined mediolateral locations. A split-plot analysis of variance (alpha = 0.05) was performed followed by a post-hoc Dunn Multiple Comparison Test. RESULTS: In general, depth of the palatal vault did not significantly influence denture palatal discrepancy (p =.0780), but the use of the anchoring system significantly reduced mean gap distances (p =.000). At lateral and midpalate locations, gap distances between the denture bases and their casts were reduced from approximately 0.3 mm to approximately 0.1 mm when the anchoring system was used. CONCLUSIONS: Mean gap distances for steep palate dentures were significantly less than shallow palate dentures at vestibule and lateral palate locations, and anchoring holes placed in an edentulous master cast along the posterior land area and at the midline significantly improved the adaptation of denture bases.

In vitro toxicity of spiroorthocarbonate monomers designed for non-shrinking dental restoratives.

In development of photopolymerized expanding monomers with epoxy resin systems, there is a need for reactive expanding monomers that exert a good biocompatibility profile. The objective of this study was to evaluate the in vitro toxicology of new spiroorthocarbonates designed to be expanding monomers. The expanding monomers investigated were: trans/trans-2,3,8,9-di(tetramethylene)-1,5,7,11-tetraoxaspiro[5,5] undecane (DTM-TOSU), 5,5-diethyl-19-oxadispiro-[1,3-dioxane-2,2'-1,3-dioxane-5',4'-bicy clo[4.1.0]heptane] (DECHE-TOSU); 3,9-diethyl-3,9-dipropionyloxy methyl-1,5,7,11-tetraoxaspiro[5.5]undecane (DEDPM-TOSU); and 3,9-diethyl-3,9-diacetoxy methyl-1,5,7,11-tetraoxaspiro[5.5]undecane (DAMDE-TOSU). The in vitro toxicology of these monomers measured their cytotoxicity and mutagenicity potential. Succinic dehydrogenase (SDH) activity in the MTT assay was used to assess the toxic dose that kills 50% of cells (TC50) for all the monomers. Their mutagenic potential was measured in the Ames Salmonella assay with and without metabolic activation. Two solvents, DMSO and acetone, were used to validate effects. Appropriate controls included the solvents alone. All the expanding monomers in this study were less cytotoxic than BISGMA (p < 0.01), a commercial component of dental restoratives. The relative cytotoxicity of the expanding monomers in DMSO was defined in the following order: DTM-TOSU (more toxic) > DECHE-TOSU > DEDPM-TOSU > DAMDE-TOSU. Each was significantly different from the other (p < 0.05). Overall, the TC50 values of all expanding monomers were significantly greater in DMSO than in acetone (p < 0.05). However, for BISGMA this trend was opposite. For mutagenicity results, the expanding monomers were non-mutagenic and there was no solvent effect on this outcome. The non-mutagenicity and low cytotoxicity profile of these expanding monomers suggests their potential for development of biocompatible non-shrinking composites.

Effect of parafunctional clenching on temporomandibular disorder pain and proprioceptive awareness.

This study tested the hypothesis that parafunctional clenching increases pain, can lead to a diagnosis of temporomandibular disorder (TMD) pain, and can produce reductions in proprioceptive awareness. Twenty individuals participated in EMG biofeedback training sessions on the left and right temporalis and masseter muscles. No subjects had TMD prior to training. Subjects were randomly assigned to either a Decrease group, who were instructed to maintain EMG activity below 2 microV during training, or an increase group, who were instructed to maintain EMG activity above 10 microV. To test the impact of parafunctional clenching on proprioceptive awareness, all subjects were instructed to barely touch their teeth together while EMG activity was recorded pre- and post-training. Three subjects assigned to the Increase group and no subjects assigned to the Decrease group were diagnosed with TMD pain following training. Self-reported pain post-training was significantly higher for the Increase group. Parafunctional clenching did not affect performance in the proprioceptive test.

Emotional factors in temporomandibular joint disorders.

The chronic pain of many temporomandibular disorders is associated with multiple changes in emotional function and activities of daily living. Temporomandibular disorders (TMD) are similar to other chronic pain disorders in their impact on patients. Depression is probably the most common emotional state associated with chronic pain, although anxiety disorders also can be associated with TMD. The probability of emotional problems appears to be greatest in those individuals diagnosed with myofascial pain and least in those with disk displacement. Dental practitioners are encouraged to seek professional liaisons with mental health professionals who can assist them in managing chronic pain patients.

A meta-analysis of EMG biofeedback treatment of temporomandibular disorders.

AIMS: Outcome evaluations of treatments incorporating electromyographic (EMG) biofeedback for temporomandibular disorders (TMD) have been conducted for more than 2 decades. The purpose of this study was to review the available literature to determine the efficacy of biofeedback-based treatments and to estimate treatment effect sizes. METHODS: A literature search located 13 studies of EMG biofeedback treatment for TMD, including 6 controlled, 4 comparative treatment, and 3 uncontrolled trials. Three types of outcome were examined: patient pain reports, clinical exam findings, and ratings of global improvement. RESULTS: Five of the 6 controlled trials found EMG biofeedback treatments to be superior to no treatment or psychologic placebo controls for at least 1 of the 3 types of outcome. Data from 12 studies contributed to a meta-analysis that compared pre- to posttreatment effect sizes for EMG biofeedback treatments to effect sizes for control conditions. Mean effect sizes for both reported pain and clinical exam outcomes were substantially larger for biofeedback treatments than for control conditions. In addition, 69% of patients who received EMG biofeedback treatments were rated as symptom-free or significantly improved, compared with 35% of patients treated with a variety of placebo interventions. Follow-up outcomes for EMG biofeedback treatments showed no deterioration from posttreatment levels. CONCLUSION: Although limited in extent, the available data support the efficacy of EMG biofeedback treatments for TMD.