Diagnostic criteria for temporomandibular disorders-INfORM recommendations: Comprehensive and short-form adaptations for adolescents.

BACKGROUND: The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for use in adults is in use worldwide. Until now, no version of this instrument for use in adolescents has been proposed. OBJECTIVE: To present comprehensive and short-form adaptations of the adult version of DC/TMD that are appropriate for use with adolescents in clinical and research settings. METHODS: International experts in TMDs and experts in pain psychology participated in a Delphi process to identify ways of adapting the DC/TMD protocol for physical and psychosocial assessment of adolescents. RESULTS: The proposed adaptation defines adolescence as ages 10-19 years. Changes in the physical diagnosis (Axis I) include (i) adapting the language of the Demographics and the Symptom Questionnaires to be developmentally appropriate for adolescents, (ii) adding two general health questionnaires, one for the adolescent patient and one for their caregivers and (iii) replacing the TMD Pain Screener with the 3Q/TMD questionnaire. Changes in the psychosocial assessment (Axis II) include (i) adapting the language of the Graded Chronic Pain Scale to be developmentally appropriate for adolescents, (ii) adding anxiety and depression assessment that have been validated for adolescents and (iii) adding three constructs (stress, catastrophizing and sleep disorders) to assess psychosocial functioning in adolescents. CONCLUSION: The recommended DC/TMD, including Axis I and Axis II for adolescents, is appropriate to use in clinical and research settings. This adapted first version for adolescents includes changes in Axis I and Axis II requiring reliability and validity testing in international settings. Official translations of the comprehensive and short-form to different languages according to INfORM requirements will enable a worldwide dissemination and implementation.

Diagnostic criteria for temporomandibular disorders-INfORM recommendations: Comprehensive and short-form adaptations for children.

BACKGROUND: The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) are used worldwide in adults. Until now, no adaptation for use in children has been proposed. OBJECTIVE: The aim of this study was to present comprehensive and short-form adaptations of Axis I and Axis II of the DC/TMD for adults that are appropriate for use with children in clinical and research settings. METHODS: Global Delphi studies with experts in TMDs and in pain psychology identified ways of adapting the DC/TMD for children. RESULTS: The proposed adaptation is suitable for children aged 6-9 years. Proposed changes in Axis I include (i) adapting the language of the Demographics and the Symptom Questionnaires to be developmentally appropriate for children, (ii) adding a general health questionnaire for children and one for their parents, (iii) replacing the TMD Pain Screener with the 3Q/TMD questionnaire and (iv) modifying the clinical examination protocol. Proposed changes in Axis II include (i) for the Graded Chronic Pain Scale, to be developmentally appropriate for children, (ii) adding anxiety and depression assessments that have been validated in children and (iii) adding three constructs (stress, catastrophising and sleep disorders) to assess psychosocial functioning in children. CONCLUSION: The recommended DC/TMD, including Axis I and Axis II, for children aged 6-9 years, is appropriate for use in clinical and research settings. This adapted the first version for children includes changes in Axis I and Axis II changes requiring reliability and validity testing in international settings. Official translations to different languages according to INfORM requirements will enable a worldwide dissemination and implementation.

Diagnostic criteria for temporomandibular disorders in children and adolescents: An international Delphi study-Part 2-Development of Axis II.

BACKGROUND: Unlike the psychosocial assessment established for adults in the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), a standardised psychosocial assessment for children and adolescents with TMD complaints has not yet been established. OBJECTIVES: To develop a new standardised instrument set to assess the psychosocial functioning in children and adolescents by adapting the psychosocial status and pain-related disability (Axis II) of the adult DC/TMD and by including new instruments. METHODS: A modified Delphi method was used to survey 23 international TMD experts and four international experts in pain-related psychological factors for consensus regarding assessment tools for psychosocial functioning and pain-related disability in children and adolescents. The TMD experts reviewed 29 Axis II statements at round 1, 13 at round 2 and 2 at round 3. Agreement was set at 80% for first-round consensus level and 70% for each of the second and third rounds. The psychological experts completed a complementary Delphi survey to reach a consensus on tools to use to assess more complex psychological domains in children and adolescents. For the psychological experts, the first round included 10 open-ended questions on preferred screening tools for depression, anxiety, catastrophising, sleep problems and stress in children (ages 6-9 years old) and adolescents (ages 10-19 years old) as well as on other domains suggested for investigation. In the second round, the psychological experts received a 9-item questionnaire to prioritise the suggested instruments from most to least recommended. RESULTS: The TMD experts, after three Delphi rounds, reached consensus on the changes of DC/TMD to create a form to evaluate Axis II in children and adolescents with TMD complaints. The psychological experts added tools to assess depression and anxiety, sleep disorders, catastrophising, stress and resilience. CONCLUSION: Through international expert consensus, this study adapted Axis II of the adult DC/TMD to assess psychosocial functioning and pain-related disability in children and adolescents. The adapted Axis II protocols will be validated in the target populations.

Frequency of Four-dimensional Oral Health Problems across Dental Fields - a Comparative Survey of Slovenian and International Dentists.

OBJECTIVES: To compare the frequency of patients' oral health problems and prevention needs among Slovenian and international dentists with the aim to validate the four oral health-related quality of life (OHRQoL) dimensions across six clinical dental fields in all World Health Organization (WHO) regions. METHODS: An anonymous electronic survey in the English language was designed using Qualtrics software. A probability sampling for Slovenia and a convenience sampling strategy for dentist recruitment was applied for 31 countries. Dentists engaged in six dental fields were asked to categorize their patients' oral health problems and prevention needs into the four OHRQoL dimensions (Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact). Proportions of patients' problems and prevention needs were calculated together with the significance of Slovenian and international dentists' differences based on dental fields and WHO regions. RESULTS: Dentists (n=1,580) from 32 countries completed the survey. There were 223 Slovenian dentists (females: 68%) with a mean age (SD) of 41 (10.6) years and 1,358 international dentists (females: 51%) with a mean age (SD) of 38 (10.4). Pain-related problems and prevention needs were the most prevalent among all six dental fields reported by dentists; Slovenian (37%) and 31 countries (45%). According to Cohen, differences between Slovenia, the broader European Region, and 31 countries were considered non-significant (<0.1). CONCLUSION: According to the dentists' responses, the frequency of patients' oral health problems and prevention needs are proportionate between Slovenia and 31 countries, regionally and globally. The four OHRQoL dimensions can be considered universal across all dental fields.

Pediatric patients' reasons for visiting dentists in all WHO regions.

BACKGROUND: Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact are the four oral health-related quality of life (OHRQoL) dimensions (4D) or areas in which oral disorders impact pediatric patients. Using their dentists' assessment, the study aimed to evaluate whether pediatric dental patients' oral health concerns fit into the 4D of the Oral Health-Related Quality of Life (OHRQoL) construct. METHODS: Dentists who treat children from 32 countries and all WHO regions were selected from a web-based survey of 1580 international dentists. Dentists were asked if their pediatric patients with current or future oral health concerns fit into the 4D of the Oral Health-Related Quality of Life (OHRQoL) construct. Proportions of all pediatric patients' oral health problems and prevention needs were computed. FINDINGS: Data from 101 dentists treating children only and 523 dentists treating children and adults were included. For 90% of pediatric patients, their current oral health problems fit well in the four OHRQoL dimensions. For 91% of oral health problems they intended to prevent in the future were related to these dimensions as well. Both numbers increased to at least 96% when experts analyzed dentists´ explanations of why some oral health problems would not fit these four categories. CONCLUSIONS: The study revealed the four fundamental components of dental patients, i.e., the four OHRQoL dimensions (Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact) are also applicable for pediatric patients, regardless of whether they have current or future oral health concerns, and should be considered when measuring OHRQoL in the pediatric dental patient population.

Diagnostic criteria for temporomandibular disorders (DC/TMD) for children and adolescents: An international Delphi study-Part 1-Development of Axis I.

BACKGROUND: Since in children and adolescence prevalence is assessed mainly on self-reported or proxy-reported signs and symptoms; there is a need to develop a more comprehensive standardised process for the collection of clinical information and the diagnosis of TMD in these populations. OBJECTIVE: To develop new instruments and to adapt the diagnostic criteria for temporomandibular disorders (DC/TMD) for the evaluation of TMD in children and adolescents. METHOD: A modified Delphi method was used to seek international consensus among TMD experts. Fourteen clinicians and researchers in the field of oro-facial pain and TMD worldwide were invited to participate in a workshop initiated by the International Network for Orofacial Pain and Related Disorders Methodology (INfORM scientific network) at the General Session of the International Association for Dental Research (IADR, London 2018), as the first step in the Delphi process. Participants discussed the protocols required to make physical diagnoses included in the Axis I of the DC/TMD. Thereafter, nine experts in the field were added, and the first Delphi round was created. This survey included 60 statements for Axis I, and the experts were asked to respond to each statement on a five-item Likert scale ranging from 'Strongly disagree' to 'Strongly agree'. Consensus level was set at 80% agreement for the first round, and at 70% for the next. RESULTS: After three rounds of the Delphi process, a consensus among TMD experts was achieved and two adapted DC/TMD protocols for Axis I physical diagnoses for children and adolescents were developed. CONCLUSION: Through international consensus among TMD experts, this study adapted the Axis I of the DC/TMD for use in evaluating TMD in children and adolescents.

Why Patients Visit Dentists - A Study in all World Health Organization Regions.

OBJECTIVE: The dimensions of oral health-related quality of life (OHRQoL) Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact are the major areas where patients are impacted by oral diseases and dental interventions. The aim of this study was to evaluate whether dental patients' reasons to visit the dentist fit the 4 OHRQoL dimensions. METHODS: Dentists (N = 1580) from 32 countries participated in a web-based survey. For their patients with current oral health problems, dentists were asked whether these problems were related to teeth, mouth, and jaws' function, pain, appearance, or psychosocial impact or whether they do not fit the aforementioned 4 categories. Dentists were also asked about their patients who intended to prevent future oral health problems. For both patient groups, the proportions of oral health problems falling into the 4 OHRQoL dimensions were calculated. RESULTS: For every 100 dental patients with current oral health problems, 96 had problems related to teeth, mouth, and jaws' function, pain, appearance, or psychosocial impact. For every 100 dental patients who wanted to prevent future oral health problems, 92 wanted to prevent problems related to these 4 OHRQoL dimensions. Both numbers increased to at least 98 of 100 patients when experts analyzed dentists' explanations of why some oral health problems would not fit the four dimension. For the remaining 2 of 100 patients, none of the dentist-provided explanations suggested evidence against the OHRQoL dimensions as the concepts that capture dental patients' suffering. CONCLUSION: Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact capture dental patients' oral health problems worldwide. These 4 OHRQoL dimensions offer a psychometrically sound and practical framework for patient care and research, identifying what is important to dental patients.

Chronic Neuropathic Pain: It's about the Rhythm.

The neural mechanisms underlying the development and maintenance of chronic neuropathic pain remain unclear. Evidence from human investigations suggests that neuropathic pain is associated with altered thalamic burst firing and thalamocortical dysrhythmia. Additionally, experimental animal investigations show that neuropathic pain is associated with altered infra-slow (<0.1 Hz) frequency oscillations within the dorsal horn and somatosensory thalamus. The aim of this investigation was to determine whether, in humans, neuropathic pain was also associated with altered infra-slow oscillations within the ascending "pain" pathway. Using resting-state functional magnetic resonance imaging, we found that individuals with orofacial neuropathic pain have increased infra-slow oscillatory activity throughout the ascending pain pathway, including within the spinal trigeminal nucleus, somatosensory thalamus, thalamic reticular nucleus, and primary somatosensory cortex. Furthermore, these infra-slow oscillations were temporally coupled across these multiple sites and occurred at frequencies similar to calcium waves in activated astrocytes. The region encompassing the spinal trigeminal nucleus also displayed increased regional homogeneity, consistent with a local spread of neural activity by astrocyte activation. In contrast, no increase in oscillatory behavior within the ascending pain pathway occurred during acute noxious stimuli in healthy individuals. These data reveal increased oscillatory activity within the ascending pain pathway that likely underpins increased thalamocortical oscillatory activity, a self-sustaining thalamocortical dysrhythmia, and the constant perception of pain. Significance statement: Chronic neuropathic pain is associated with altered thalamic firing and thalamocortical dysrhythmia. The mechanisms responsible for these changes remain unknown. In this study, we report in individuals with neuropathic pain increased oscillatory neural activity within the ascending pain pathway with evidence that these changes result from altered neural-astrocyte coupling. We propose a series of neural and glial events after nerve injury that result in the generation of altered thalamocortical activity and a persistent neuropathic pain state. Defining the underlying mechanisms responsible for neuropathic pain is critical if we are to develop more effective treatment regimens.

Experimental jaw muscle pain increases pain scores and jaw movement variability in higher pain catastrophizers.

AIMS: To investigate differences between higher and lower pain catastrophizers in the effects of hypertonic saline-evoked jaw muscle pain on pain perception and jaw movement. METHODS: Repetitive open/close jaw movements were recorded in 28 asymptomatic participants (20 men, 8 women; ages 25 to 62 years) during continuous infusion of 5% hypertonic saline or isotonic saline into the right masseter muscle. All participants completed the McGill Pain Questionnaire; the Depression, Anxiety and Stress Scales; and the Jaw Function Limitation Scale. They were divided into two groups depending on the median Pain Catastrophizing Scale score. Statistical analyses involved multivariate analysis of variance, independent samples or paired t tests, and Pearson correlations (statistical α: P < .05). RESULTS: Pain intensity, unpleasantness, perceived area, and pain rating indices were significantly (P < .05) elevated in higher pain catastrophizers during hypertonic saline-evoked pain in comparison with lower catastrophizers. The higher catastrophizers exhibited significantly (P < .05) slower jaw velocity than the lower catastrophizers during hypertonic saline infusion in comparison with IS infusion. In comparison with lower catastrophizers, there was a significantly greater change in the percentage of coefficient of variation between hypertonic saline and isotonic saline infusions in higher catastrophizers for closing velocity and opening and closing amplitude. CONCLUSION: The increased reported pain intensity, pain areas, and pain rating indices are consistent with enhanced central sensitization processes in high-catastrophizing individuals. The slower velocity and greater variability of repetitive jaw movements in higher pain catastrophizing individuals in acute experimental pain may reflect changes in motor coordination as an example of avoidance behavior for the jaw motor system.

Unraveling the effects of plasticity and pain on personality.

UNLABELLED: Chronic pain resulting from physical stressors is often accompanied by psychological disorders such as depression. Although depressive disorders are associated with changes in brain anatomy, it remains unknown if changes in brain anatomy associated with increased state depression levels also occur in patients with chronic pain. When individuals are experiencing physical stressors such as ongoing pain, depressive personality traits may predispose them to develop depressive states. The aim of this study was to use brain morphometry to determine the interaction among chronic pain, state and trait depression, and regional brain structure. We investigated regional gray matter volume in 42 chronic pain patients and 35 controls using voxel-based morphometry of T1-weighted anatomical images. Significant relationships between regional gray matter volume and state or trait depressive values were determined. In chronic pain patients, state depression scores were significantly correlated to subtle changes in the thalamus and the cingulate, dorsolateral prefrontal, and hippocampal cortices. These same brain regions were also significantly correlated to trait depressive scores. Unexpectedly, gray matter volumes in these regions were not correlated to trait depressive scores in healthy controls. Because trait depressive values were not correlated to gray matter in controls, but were so in chronic pain patients, these data strongly suggest that subtle changes in brain anatomy can evoke changes in individuals' trait depression values. If these regional gray matter changes are severe enough, changes in an individual's personality trait may result. PERSPECTIVE: This study demonstrates anatomical brain alterations associated with both state and trait depression in chronic pain patients. Because our study reveals that trait depression is not correlated to the anatomy of these regions in healthy controls, ongoing pain itself may result in anatomical changes that in turn can alter an individual's personality.

Trigeminal nerve anatomy in neuropathic and non-neuropathic orofacial pain patients.

UNLABELLED: Trigeminal neuralgia, painful trigeminal neuropathy, and painful temporomandibular disorders (TMDs) are chronic orofacial pain conditions that are thought to have fundamentally different etiologies. Trigeminal neuralgia and neuropathy are thought to arise from damage to or pressure on the trigeminal nerve, whereas TMD results primarily from peripheral nociceptor activation. This study sought to assess the volume and microstructure of the trigeminal nerve in these 3 conditions. In 9 neuralgia, 18 neuropathy, 20 TMD, and 26 healthy controls, the trigeminal root entry zone was selected on high-resolution T1-weighted magnetic resonance images and the volume (mm(3)) calculated. Additionally, using diffusion-tensor images (DTIs), the mean diffusivity and fractional anisotropy values of the trigeminal nerve root were calculated. Trigeminal neuralgia patients displayed a significant (47%) decrease in nerve volume but no change in DTI values. Conversely, trigeminal neuropathy subjects displayed a significant (40%) increase in nerve volume but again no change in DTI values. In contrast, TMD subjects displayed no change in volume or DTI values. The data suggest that the changes occurring within the trigeminal nerve are not uniform in all orofacial pain conditions. These structural and volume changes may have implications in diagnosis and management of different forms of chronic orofacial pain. PERSPECTIVE: This study reveals that neuropathic orofacial pain conditions are associated with changes in trigeminal nerve volume, whereas non-neuropathic orofacial pain is not associated with any change in nerve volume.

The effects of capsaicin-induced intraoral mucosal pain on jaw movements in humans.

AIMS: To determine whether mucosal pain, evoked through a novel topical capsaicin model, has an effect on jaw movement and whether psychologic factors have an association with any pain-induced movement effects. METHODS: Mandibular movement was recorded from 26 asymptomatic subjects during free opening and closing, resistant opening jaw movements, and free and standardized chewing, at baseline and in test sessions while the subjects were wearing a custom maxillary mouthguard coated with either capsaicin cream (pain group, 13 subjects) or placebo cream (control group, an additional 13 subjects). All subjects completed the Depression Anxiety Stress Scales (DASS) and the Pain Catastrophizing Scale (PCS). Statistical analyses were made with independent t tests and bivariate correlation analyses. RESULTS: Capsaicin induced moderate pain in the pain group, but there were no significant differences between the two groups in the change of kinematic variables from baseline except for a significantly greater increase from baseline in the number of chewing cycles per second (chewing rate) for free (t = 2.74, P = .011) and standardized chewing (t = 2.10, P = .047) in the pain group compared with the control group. In the pain group, the DASS anxiety score was negatively correlated (r = -.70, P = .007), with the change of mean opening velocity from the baseline to the test session in the free opening task, and the DASS depression score was negatively correlated to the increase of chewing rate in the free chewing task from the baseline to the test session (r = -.56, P = .046). CONCLUSION: Capsaicin-induced mucosal pain resulted in a significant increase in chewing rate but had no effect on amplitude or velocity in opening/closing jaw movements and chewing. Anxiety and depression scores correlated negatively with velocity in free opening jaw movement and chewing rate, respectively.

Jaw-movement smoothness during empty chewing and gum chewing.

A major goal of motor coordination is the production of a smooth movement. Jerk-cost, which is an inverse measure of movement smoothness, has been evaluated during gum chewing in previous studies. However, the effect of the gum bolus is still unclear. The aims of this study were to compare the jerk-cost values of normal gum chewing with those of empty chewing. Thirteen subjects undertook, empty chewing, then chewing of gum, and then a second empty chewing. Jerk-cost was calculated from an accelerometer attached to the skin of the mentum. There was a significantly higher smoothness (i.e. lower jerk-cost, P < 0.05) during the opening and second-half closing phases in empty chewing compared with gum chewing. There were no significant differences in jerk-costs (i.e. opening or closing) between the first and the second empty-chewing sequences. These results suggest that the influence of the mechanical effects of tooth contact on jerk-cost is not restricted just to the occlusal phase of chewing, but rather the effect influences the entire opening and closing phases of chewing.

Development and validation of a screening checklist for temporomandibular disorders.

AIMS: To develop and validate a short screening tool for temporomandibular disorders (TMD) from the comprehensive Research Diagnostic Criteria for TMD (RDC/TMD) assessment. METHODS: Complete RDC/TMD assessments of four subject groups (96 TMD; 102 dental pain; 68 headache; 115 no-pain patients) were compared. Classification tree and multiple logistic regression analyses were utilized to develop the tool. To test external validity, a further 54 TMD and 51 non-TMD subjects whose diagnoses had been established by RDC/TMD assessment were reassessed with the new screening tool. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios (LRs) were calculated for the screening tool in the validation set of subjects. RESULTS: A short TMD checklist was developed. This screening instrument had sensitivity of 94.4% (95% confidence intervals [CI], 84.9% to 98.1%), specificity of 94.1% (95% CI, 84.1% to 98%), PPV of 94.4% (95% CI, 84.9% to 98.1%), NPV of 94.1% (95% CI, 84.1% to 98%), and positive and negative LRs of 16.056 (95% CI, 5.346 to 48.219) and 0.059 (95% CI, 0.02 to 0.178) in an independent validation set. CONCLUSION: A short TMD screening checklist with high validity has been developed. This checklist may have good utility in general practice as a primary screening tool for TMD.

Chewing in temporomandibular disorder patients: an exploratory study of an association with some psychological variables.

AIMS: To compare kinematic parameters (ie, amplitude, velocity, cycle frequency) of chewing and pain characteristics in a group of female myofascial temporomandibular disorder (TMD) patients with an age-matched control female group, and to study correlations between psychological variables and kinematic variables of chewing. METHODS: Twenty-nine female participants were recruited. All participants were categorized according to the Research Diagnostic Criteria for TMD (RDC/TMD) into control (n = 14, mean age 28.9 years, SD 5.0 years) or TMD (n = 15, mean age 31.3 years, SD 10.7) groups. Jaw movements were recorded during free gum chewing and chewing standardized for timing. Patients completed the Depression, Anxiety, and Stress Scales (DASS-42), the Pain Catastrophizing Scale (PCS), the Fear of Pain Questionnaire-III (FPQ-III), and the Pain Self-Efficacy Questionnaire (PSEQ). Statistical analyses involved evaluation for group differences, and correlations between kinematic variables and psychological questionnaire scores (eg, depression, anxiety, stress) and pain intensity ratings. RESULTS: Velocity and amplitude of standardized (but not free) chewing were significantly greater (P < .05) in the TMD group than the control group. There were significant (P < .05) positive correlations between pain intensity ratings and velocity and amplitude of standardized chewing but not free chewing. There were significant (P < .05) positive correlations between depression and jaw amplitude and stress and jaw velocity for standardized but not free chewing. CONCLUSION: This exploratory study has provided data suggesting that psychological factors, manifesting in depression and stress, play a role in influencing the association between pain and motor activity.

Jaw motor plasticity in health and disease.

The human jaw's structure-function relationships are complex. A recent example of this complexity is the lateral pterygoid muscle which we now consider as a single unit made up of functional regions with activity in each dependent on the biomechanical demands of the task. We have also characterised the effects on the jaw motor system of pain or exercise, as examples of how the jaw motor system adapts. Synchronised jaw tracking and electromyographic acquisition systems were used to study the effects on jaw muscle activity of experimentally induced masseter muscle pain or resistance exercises during goal-directed tasks. With both interventions, subjects were able to perform the same movement with different muscle co-activation strategies. In future, the biomechanical effects on the orofacial structures of motor changes with pain/exercise interventions may be investigated with mathematical jaw modelling. Such models could propose clinical interventions that could alter jaw motor function to reduce adverse joint and muscle loads.

From movement to models: a tribute to professor Alan G. Hannam.

This tribute article to Professor Alan G. Hannam is based on 7 presentations for him at the July 1, 2008 symposium honoring 3 "giants" in orofacial neuroscience: Professors B. J. Sessle, J. P. Lund, and A. G. Hannam. This tribute to Hannam's outstanding career draws examples from his 40-year academic career and spans topics from human evolution to complex modeling of the craniomandibular system. The first presentation by W. Hylander provides a plausible answer to the functional and evolutionary significance of canine reduction in hominins. The second presentation, by A. McMillan, describes research activities in the field of healthy aging, including findings that intensity-modulated radiotherapy improves the health condition and quality of life of people with nasopharyngeal carcinoma in comparison to conventional radiotherapy. The developments in dental imaging are summarized in the third paper by E. Lam, and an overview of the bite force magnitude and direction while clenching is described in the fourth paper by M. Watanabe. The last 3 contributions by G. Langenbach, I. Staveness, and C. Peck deal with the topic of bone remodeling as well as masticatory system modeling, which was Hannam's main research interest in recent years. These contributions show the considerable advancements that have been made in the last decade under Hannam's drive, in particular the development of an interactive model comprising, in addition to the masticatory system, also the upper airways. The final section of the article includes a final commentary from Professor Hannam.

Effects of experimental pain on jaw muscle activity during goal-directed jaw movements in humans.

To study the effects of masseter muscle pain on jaw muscle electromyographic (EMG) activity during goal-directed tasks. Mandibular movement was tracked and EMG activity was recorded from bilateral masseter, and right posterior temporalis, anterior digastric, and inferior head of lateral pterygoid muscles in 22 asymptomatic subjects at postural jaw position, and during three tasks: (a) protrusion, (b) contralateral (left), (c) open jaw movement. Tasks were performed during three conditions: control (no infusion), test 1 [continuous infusion into right masseter of 4.5% hypertonic saline to achieve 30-60 mm pain intensity on 100-mm visual analog scale (VAS)], and test 2 (isotonic saline infusion; in 16 subjects only); the sequence of hypertonic and isotonic saline was randomized. The average EMG root-mean-square values at 0.5 mm increments of mid-incisor-point displacement were analysed using linear mixed effects model statistics (significance: P < 0.05). Right masseter hypertonic saline infusion resulted in significantly (P < 0.0005) more pain (mean +/- SD VAS 47.3 +/- 14.3 mm) than isotonic infusion (12.2 +/- 17.3 mm). Although there was evidence of inter-subject variation, the principal EMG findings were that the significant effects of hypertonic saline-induced pain on EMG activity varied with the task in which the muscle participated irrespective of whether the muscle was an agonist or an antagonist in the tasks. The direction of the hypertonic saline-induced pain effect on EMG activity (i.e., whether the hypertonic saline-induced EMG activity was less than or greater than control EMG activity) could change with the magnitude of jaw displacement. Hypertonic saline infusion had no significant effect on postural EMG activity in any of the recorded jaw muscles. The data suggest that under constrained goal-directed tasks, the pattern of pain-induced changes in jaw muscle EMG activity is not clear cut, but can vary with the task performed, jaw displacement magnitude, and the subject being studied.

Orofacial pain and jaw muscle activity: a new model.

Two major theories proposed to explain the effect of pain on muscle activity are the Vicious Cycle Theory and the Pain Adaptation Model. Comprehensive reviews demonstrate conflicting or limited evidence in support of a critical aspect of the Vicious Cycle Theory, namely that pain leads to increased muscle activity. The Pain Adaptation Model proposes that changes in muscle activity limit movement and thereby protect the sensorimotor system from further injury. This model is generally considered the most appropriate explanation of the effect of pain on muscle function. Although there is much literature consistent with the model, there are a number of lines of evidence that appear inconsistent with it. Possible reasons for the lack of consistency between studies include the functional complexity of the sensorimotor system (eg, the possibility of different pain effects at different sites within functionally heterogeneous muscles), and the multidimensional nature of pain. The latter consists of sensory-discriminative, cognitive-evaluative, and motivational-affective components, where factors such as pain location, intensity, and characteristics and other supraspinal/suprabulbar influences may modify the effects of pain on motor activity. The variety of changes in electromyographic (EMG) activity features during pain suggests that pain and motor function are not hardwired. The authors propose that the existing Pain Adaptation Model is a subset of a broader model that could be called the Integrated Pain Adaptation Model. Given the recent view of pain as a homeostatic emotion requiring a behavioral response, this new model states that pain results in a new, optimized recruitment strategy of motor units that represents the individual's integrated motor response to the sensory-discriminative, motivational-affective, and cognitive-evaluative components of pain. This recruitment strategy aims to minimize pain and maintain homeostasis.