How dental teams can help patients with temporomandibular disorders receive general dental care: An International Delphi process.

BACKGROUND: Many patients with temporomandibular disorders (TMD) find it difficult to undergo dental care due to challenges caused by their condition, previous temporomandibular joint surgery or invasive dental procedures, and the impact of comorbid conditions. Managing routine dental care for some patients with TMD can be seen as challenging by some dental practitioners. OBJECTIVE: The objective of this study was to work with patients experiencing TMD and clinicians to co-produce recommendations aimed at helping general dentists to provide routine dental care for patients with TMD. METHODS: A modified Delphi process was used to co-produce recommendations. Six patients experiencing TMD, patient advocates and seven clinicians took part, including international TMD clinicians. Two meetings were held with patient participants, mediated by a trained facilitator. Recommendations suggested by patient participants were distributed to clinicians who were asked to add additional suggestions, but not to modify patients' recommendations unless to aid clarity. Additional themes were identified from the existing literature, and the recommendations were then reviewed by the International Network for Orofacial Pain and Related Disorders Methodology (INfORM) consortium. RESULTS: Recommendations were given to support patients before, during and after dental treatment. Participants identified specific and practical recommendations to help patients with TMD receive routine dental care, but also emphasised the need for professionals to listen sensitively to patients' concerns and work with patients in an empathetic and non-judgmental way. CONCLUSION: These recommendations, co-developed with patients experiencing TMD, should help dental professionals to provide supportive general dental care for patients with TMD.

Does professional experience save teeth? A survey among prosthodontists.

OBJECTIVES: The aim of this study is to investigate the effect of clinical experience and educational background on clinical decision-making of dentists presented with two prosthodontic cases. METHODS: A questionnaire-based survey was performed among 66 prosthodontists who were divided into two groups. The first group included clinicians from Belgium, Germany, and the Netherlands covering a wide spectrum of dental experience. The second (specialized) group consisted of German dentists performing their last module of a 3-year postgraduate master program in prosthodontics. Two patient scenarios of different complexities were presented to the participants who were asked to make an educated choice among seven therapeutic options. RESULTS: Sixty-six dentists participated. For case #1, 22 therapeutic suggestions were offered within the international group (variation 54%), while 17 options were chosen in the specialized group (variation 68%). For case #2, five (variation 12%) and four (variation 16%) different therapeutic options were planned in the groups, respectively. Treatment planning in combination with implants was clearly preferred by dentists with an experience of 20 years or less. Conversely, participants with more experience favored more conventional treatments. All differences were statistically significant (p < 0.05). CONCLUSION: Clinicians' experience and educational background had a clinically relevant influence on decision-making and treatment planning. A clear preference for implant-free therapies was noted for dentists with more than two decades of professional experience. CLINICAL SIGNIFICANCE: In complex cases, clinicians with more than 20 years of professional experience tend to save questionable teeth rather than to resort to implants. This interindividual variation might less likely occur when more external evidence is taken into account during the decision-making process.

Association between temporomandibular disorders and pubertal development: A systematic review.

The aim of this systematic review (SR) was to determine the association between temporomandibular disorders (TMDs) and pubertal development. Due to the inadequacy of the conventional PICO (Population, Interventions, Comparisons and Outcome) format used for intervention-based SRs, the Joanna Briggs Institute's guidelines for synthesising evidence related to associations with a focus on aetiology were adopted. A search of the PubMed and LIVIVO databases covering the period from January 1980 to May 2018 yielded four publications, which fulfilled the inclusion criteria. Analysis of articles based on the Pubertal Development Scale showed that TMD prevalence increases with pubertal development. Although no sex difference in TMD prevalence and diagnosis was observed, more females reported TMD anamnestic variables, including accounts of temporomandibular pain during pubertal maturity. The higher prevalence of depression and somatisation during pubertal development may contribute to more TMD symptom reporting in females. More prospective studies incorporating standardised methods for diagnosing TMDs and detecting comorbid psychosocial and somatic problems are desired to further elucidate the relationship between TMDs and pubertal development.

Labrets in Africa and Amazonia: medical implications and cultural determinants.

The custom of wearing labrets has a long tradition. Labrets appeared independently several thousand years ago in various culture groups in Asia, Europe, Africa and the Americas. Today, apart from diverse body modifications as increasingly practiced in western civilisations, lip plates and plugs are found among a small number of tribal groups only in Africa and Amazonia. We summarise the history of labrets in different societies, describe medical consequences of wearing lip plates and plugs for jaws and teeth and address relevant cultural issues.

Scarification in sub-Saharan Africa: social skin, remedy and medical import.

Various forms of body modification may be observed in sub-Saharan Africa. Hypotheses and theories of scarification and tribal marking in sub-Saharan Africa are described, plus the procedure of scarification, examples from several African countries, assumed effects in prevention and treatment of diseases, and the medical risks resulting from unsterile manipulation.

Infant oral mutilation in East Africa - therapeutic and ritual grounds.

This paper reviews the practice and ritual traditions of infant oral mutilation, drawing on a literature search in PubMed and Google Scholar, historical reports, relevant textbooks, NGO materials and personal observations of the authors.

Prevalence of self-reported jaw pain in Germany: two cross-sectional surveys of the general German population.

OBJECTIVES: This study evaluated the prevalence of jaw pain as a local, regional, or widespread pain condition and its association with psychosocial variables in a large representative group of the general population from all regions in Germany. METHODS: In two representative samples consisting of 2524 and 2515 subjects, respectively, the 7-day and 3-month pain prevalences were measured by using the Regional Pain Scale (RPS). Somatic symptom burden (somatization) and pain-related depression were assessed with the Patient Health Questionnaire and the Somatic Symptom Scale, respectively. Binary logistic regression was chosen to calculate the associations between demographic and psychological clinical predictor variables with jaw pain. RESULTS: The 7-day jaw pain prevalence was 4.0 % (95 % CI = 3.2-4.8). Of the subjects with jaw pain, only 9 % had local pain (1 pain site), while the remaining 91 % reported regional pain (2-5 pain sites), or widespread pain (6-19 pain sites). The 3-month prevalence of generally present jaw pain was 0.9 % (95 % CI = 0.6-1.0). Regional or widespread pain was present in 82 % of the participants. Jaw pain was predicted by somatic symptom burden (past 7 days, OR = 1.15 [95 % CI = 1.09-1.22]; past 3 months, OR = 1.13 [95 % CI = 1.02-1.25]), but not by depression. CONCLUSIONS: Most individuals with jaw pain have additional pain in other anatomical regions. They might also exhibit a greater risk for pain-associated somatic symptom burden. CLINICAL RELEVANCE: Assessment of pain distribution in the whole body and the use of a psychometric screening questionnaire for somatic symptom burden are recommended for individuals presenting with jaw pain in a clinical setting.

Disk displacement, eccentric condylar position, osteoarthrosis - misnomers for variations of normality? Results and interpretations from an MRI study in two age cohorts.

BACKGROUND: Clinical decision-making and prognostic statements in individuals with manifest or suspected temporomandibular disorders (TMDs) may involve assessment of (a) the position of articular disc relative to the mandibular condyle, (b) the location of the condyle relative to the temporal joint surfaces, and (c) the depth of the glenoid fossa of the temporomandibular joints (TMJs). The aim of this study was twofold: (1) Determination of the prevalence of these variables in two representative population-based birth cohorts. (2) Reinterpretation of the clinical significance of the findings. METHODS: From existing magnetic resonance imaging (MRI) scans of the TMJs that had been taken in 2005 and 2006 from 72 subjects born between 1930 and 1932 and between 1950 and 1952, respectively, the condylar position at closed jaw was calculated as percentage displacement of the condyle from absolute centricity. By using the criteria introduced by Orsini et al. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 86:489-97, 1998), a textbook-like disc position at closed jaw was distinguished from an anterior location. TMJ morphology of the temporal joint surfaces was assessed at open jaw by measuring the depth of the glenoid fossa, using the method proposed by Muto et al. (J Oral Maxillofac Surg 52:1269-72, 1994). Frequency distributions were recorded for the condylar and disc positions at closed jaw. Student's t-test with independent samples was used as test of significance to detect differences of condylar positions between the age cohorts (1930 vs. 1950) and the sexes. The significance levels were set at 5%. First, the results from the measurement of the age cohorts were compared without differentiation of sexes, i.e., age cohort 1930-1932 versus age cohort 1950-1952. Subsequently, the age cohorts were compared by sex, i.e., men in cohort 1930-1932 versus men in cohort 1950-1952, and women in cohort 1930-1932 women men in cohort 1950-1952. RESULTS: In both cohorts, condylar position was characterized by great variability. About 50% of the condyles were located centrically, while the other half was either in an anterior or in a posterior position. In both female cohorts, a posterior position predominated, whereas a centric position prevailed among men. Around 75% of the discs were positioned textbook-like, while the remaining forth was located anteriorly. Age had no statistically significant influence on condylar or on disc position. Conversely, comparison between the age groups revealed a statistically significant decrease of the depth of the glenoid fossa in both older cohorts. This age-dependent changes may be interpreted as flattening of the temporal joint surfaces. CONCLUSIONS: We call for a re-interpretation of imaging findings because they may insinuate pathology which usually is not present. Instead, anterior or posterior positions of the mandibular condyle as well as an anterior location of the articular disc should be construed as a variation of normalcy. Likewise, flattening of articular surfaces of the TMJs may be considered as normal adaptive responses to increased loading, rather than pathological degenerative changes. TRIAL REGISTRATION: Not applicable.

Digital Michigan splint - from intraoral scanning to plasterless manufacturing.

AIM: To investigate whether the fully digital, plasterless fabrication of clinically usable Michigan splints can be accomplished in a time- and cost-efficient manner. MATERIALS AND METHODS: Digital scans of the maxillary and mandibular arches of 10 subjects were acquired with an intraoral scanner (3Shape, Copenhagen) and used to generate virtual models of the dental arches. Jaw relation records were made using jigs placed on the subjects' anterior teeth, and silicone registration material was referenced to the jaw models. The data sets were then sent via the company's online portal to the dental laboratory, where computer-aided design (CAD) of the Michigan-type maxillary splints was performed. After receiving the designs, the splints were milled in-office using computer-aided manufacturing (CAM) software, and finished manually. During try-in, the splints where checked for fit, retention quality, and occlusal contacts of the mandibular teeth on the splint surfaces in static and dynamic occlusion. RESULTS: Fit and retention were clinically acceptable in 10 splints and 9 splints, respectively. The number of initial occlusal contacts on the splint surfaces ranged from 4 to 16. CONCLUSIONS: The question addressed in this study can be answered in the affirmative. Some of the main advantages of digital manufacturing of Michigan splints over traditional, conventional, impression-based manufacturing are the time-efficient manufacturing process, the high material quality, and the possibility of manufacturing duplicate splints.

Motion analysis of the mandible: guidelines for standardized analysis of computer-assisted recording of condylar movements.

Mandibular movement recording has long been established as the method for the physiological design of indirect dental restorations. Condylar movement recording is the basis for individual, patient-specific programming of partially or fully adjustable articulators. The settings derived from these recordings can generally be used in both traditional mechanical and electronic virtual articulators. For many years, condylar movement recordings have also provided useful information about morphological conditions in the temporomandibular joints (TMJs) of patients with masticatory system dysfunction based on the recorded movement patterns. The latest clinical application for recorded jaw-motion analysis data consists of functional monitoring of the patient as a diagnostic and surveillance tool accompanying treatment. Published parameters for the analysis of such recordings already exist, but a standardized and practicable protocol for the documentation and analysis of such jaw-movement recordings is still lacking. The aim of this article by a multicenter consortium of authors is to provide an appropriate protocol with the documentation criteria needed to meet the requirements for standardized analysis of computer-assisted recording of condylar movements in the future.

Establishing a CAD-CAM workflow for stabilization appliances (Michigan splints).

Stabilization appliances (Michigan splints) are considered well-studied and widely adopted for managing bruxism and temporomandibular disorders (TMDs). Traditionally, these appliances have been fabricated by wax modeling and pressing resin onto casts made from irreversible hydrocolloid or silicone impressions. This article provides a detailed description of an all-digital workflow that uses intraoral scanning and computer-aided design (CAD) software to design a stabilization splint on a digital cast that can be manufactured autonomously by a computer-aided manufacturing (CAM) grinding machine in a subtractive procedure. The workflow is applicable to both dentists and technicians. Special attention is given to aspects and procedures that are important for the successful fabrication of the splint. Working without a cast can save time and money, and the use of CAD-CAM technology provides a homogeneous splint material quality.

The undeclared use of third-party service providers in academic publishing is unethical: an epistemic reflection and scoping review.

There is a substantial body of scientific literature on the use of third-party services (TPS) by academics to assist as "publication consultants" in scholarly publishing. TPS provide a wide range of scholarly services to research teams that lack the equipment, skills, motivation, or time to produce a paper without external assistance. While services such as language editing, statistical support, or graphic design are common and often legitimate, some TPS also provide illegitimate services and send unsolicited e-mails (spam) to academics offering these services. Such illegitimate types of TPS have the potential to threaten the integrity of the peer-reviewed scientific literature. In extreme cases, for-profit agencies known as "paper mills" even offer fake scientific publications or authorship slots for sale. The use of such illegitimate services as well as the failure to acknowledge their use is an ethical violation in academic publishing, while the failure to declare support for a TPS can be considered a form of contract fraud. We discuss some literature on TPS, highlight services currently offered by ten of the largest commercial publishers and expect authors to be transparent about the use of these services in their publications. From an ethical/moral (i.e., non-commercial) point of view, it is the responsibility of editors, journals, and publishers, and it should be in their best interest to ensure that illegitimate TPS are identified and prohibited, while publisher-employed TPS should be properly disclosed in their publications.

Beyond disclaimers: the need for a curation-based model of PubMed.

According to its own description, the biomedical meta-database PubMed exists "with the aim of improving health-both globally and personally." Unfortunately, PubMed contains an increasing amount of low-quality research that may detract from this goal. Currently, PubMed warns its users and protects itself from such problems with a disclaimer stating that the presence of any article, book, or document in PubMed does not imply an endorsement of, or concurrence with, its contents by the NLM, the National Institutes of Health (NIH), or the U.S. Federal Government. However, we are critical of a "disclaimer-only" stance and encourage PubMed to take further action against low-quality research being found and indexed in its database, and thus available for use. To address this problem, we offer two lines of reasoning to argue that PubMed should not function merely as a passive index of health-related research. Instead, we first argue that only trustworthy published research is able to further PubMed's goal of health improvement. Secondly, on the basis of surveys, we argue that researchers place a high level of trust in articles that are referenced in this meta-database. We cannot expect any one set of actors to ensure trustworthy content on PubMed, which requires collective responsibility among authors, peer reviewers, editors, and indexers alike. Instead, we propose a curation-based model that incorporates three mechanisms of collaborative content curation: open expert feedback on indexed content, journal auditing, and constant transparent reassessment of indexed entities.

Condylar motion analysis: a controlled, blinded clinical study on the interindividual reproducibility of standardized evaluation of computer-recorded condylar movements.

The present study investigated to what extent a systematic evaluation of electronic condylar motion recordings leads to reproducible results in different examiners. The study was based on the anonymized condylar motion recordings of 20 patients (Cadiax compact II system). These were recruited consecutively from the examinations in a center specializing in diagnosing and managing temporomandibular disorders (TMD). Four trained practitioners independently evaluated the identical movement recordings of all patients after calibration. The evaluation was based on the previously published evaluation system. The results were recorded digitally in a database. The findings were then compared, and the matching values were determined (Fleiss' Kappa). The evaluation, according to Fleiss' Kappa, showed that the consistency of the assessment of the findings among the examiners is excellent (mean value 0.88, p < 0.00001). The study shows that calibrated dentists achieved reproducible results using this evaluation system and computer-assisted reporting. Good reproducibility confirms the reliability of systematic evaluation of clinical motion analysis. The ambiguities uncovered and eliminated in the study should avoid misunderstandings in the future. Both factors establish the prerequisites for applying condylar motion analysis in clinical practice.

Muscle and joint forces under variable equilibrium states of the mandible.

It is well established that subjects without molars have reduced ability to comminute foods. However, epidemiological studies have indicated that the masticatory system is able to functionally adapt to the absence of posterior teeth. This supports the shortened dental arch concept which, as a prosthetic option, recommends no replacement of missing molars. Biomechanical modeling, however, indicates that using more anterior teeth will result in a larger temporomandibular joint load per unit of bite force. In contrast, changing bite from incisor to molar position increases the maximum possible bite force and reduces joint loads. There have been few attempts, however, to determine realistic joint loads and corresponding muscular effort during generation of occlusal forces similar to those used during chewing with intact or shortened dental arches. Therefore, joint and cumulative muscle loads generated by vertical bite forces of submaximum magnitude moving from canine to molar region, were calculated. Calculations were based on intraoral measurement of the feedback-controlled resultant bite force, simultaneous electromyograms, individual geometrical data of the skull, lines of action, and physiological cross-sectional areas of all jaw muscles. Compared to premolar and canine biting, bilateral and unilateral molar bites reduced cumulative muscle and joint loads in a range from 14% to 33% and 25% to 53%, respectively. During unilateral molar bites, the ipsilateral joints and contralateral muscles were about 20% less loaded than the opposing ones. In conclusion, unilateral or bilateral molar biting at chewing-like force ranges caused the least muscle and joint loading.

Limited evidence that acupuncture is effective for treating temporomandibular disorders.

DATA SOURCES: Medline, PubMed, The Cochrane Library 2010, CINAHL, Embase, seven Korean Medical Databases and a Chinese Medical Database (China Academic Journal, www.cnki.co.kr). STUDY SELECTION: Parallel or cross-over RCTs that assessed the efficacy of acupuncture regardless of blinding, language and type of reporting published in English, Chinese and Korean were included. Dissertations and abstracts were included provided they contained sufficient detail. Complex interventions in which acupuncture was not a sole treatment and studies with no reported clinical data were excluded. DATA EXTRACTION AND SYNTHESIS: All RCTs were obtained and read in full by two independent reviewers and data extracted according to pre-defined criteria. Quality was assessed using the Cochrane risk of bias criteria. Meta-analysis was conducted using random effect models if excessive statistical heterogeneity did not exist. Additional subgroup analysis or sensitivity analysis additionally was conducted to explore heterogeneity. Publication bias was assessed by funnel plot using the Cochrane software. RESULTS: Seven RCTs (including 141 patients) met our inclusion criteria. Six studies comparatively tested needle acupuncture against penetrating sham acupuncture, non-penetrating sham acupuncture or sham laser acupuncture, whilst the remaining study tested laser acupuncture against sham laser acupuncture. Five studies were considered to be at low risk of bias. Outcomes were reported for pain intensity, facial pain, muscle tenderness and mouth opening. CONCLUSIONS: This systematic review produced limited evidence that acupuncture is more effective than sham acupuncture in alleviating pain and masseter muscle tenderness in TMD. Further rigorous studies are, however, required to establish beyond doubt whether acupuncture has therapeutic value for this indication.

[Dentistry in Wikipedia: A quantitative and qualitative analysis]. / Die Zahnmedizin in Wikipedia: eine quantitative und qualitative Analyse.

The aim of this study was to assess the scientific quality of the 265 dental articles that were present in January 2008 in the German-language version of Wikipedia. For this purpose, the Wikipedia entries were examined for their correctness by comparing them with the current dental literature. Every article was classified as having "textbook quality", "partial textbook quality" or "missing textbook quality". Of the 261 usable articles, 28% were qualitatively comparable to a textbook, while 56% had partial textbook quality. About 16% of the articles fell into the third group. Almost half of the Wikipedia entries fulfilled the qualitative standards, whereas the remaining articles were characterized by omissions. Hence, individuals interested in dental topics should not exclusively rely on Wikipedia. For a cursory overview, however, a search in Wikipedia appears to be in order.

Medication effects on the rate of orthodontic tooth movement: a systematic literature review.

INTRODUCTION: Recently, several reviews have been published on the effects of medications on bone physiology and the clinical side effects in orthodontics. However, the effects of medications on the rate of orthodontic tooth movement have not been evaluated. METHODS: A systematic literature review on the effects of medications and dietary supplements on the rate of experimental tooth movement was performed by using PubMed (1953-Oct 2007), Web of Science, and Biosis, complemented by a hand search. RESULTS: Forty-nine articles were included in the review, but their interpretation was hindered by the variability in experimental design, magnitude of force applied during tooth movement, and medication regimens. Therapeutic administration of eicosanoids resulted in increased tooth movement, whereas their blocking led to a decrease. Nonsteroidal anti-inflammatory drugs (NSAIDs) decreased tooth movement, but non-NSAID analgesics, such as paracetamol (acetaminophen), had no effect. Corticosteroid hormones, parathyroid hormone, and thyroxin have all been shown to increase tooth movement. Estrogens probably reduce tooth movement, although no direct evidence is available. Vitamin D3 stimulates tooth movement, and dietary calcium seemed to reduce it. Bisphosphonates had a strong inhibitory effect. CONCLUSIONS: Medications might have an important influence on the rate of tooth movement, and information on their consumption is essential to adequately discuss treatment planning with patients.

Surface microbial contamination in a dental department. A 10-year retrospective analysis

Health care-associated infections may not only occur in a hospital setting, but also in dental clinics. Insufficient environmental decontamination could be one of the risk factors. In this retrospective study, we documented and analyzed the results of surface microbial contamination in a dental university-based department over an observation period of ten years. It was the aim of this investigation to identify general tendencies and potentially problematic sites on a long-term basis allowing suggestions for further improvement. Surface microbial contamination in the Department of Reconstructive Dentistry at the University Center for Dental Medicine in Basel, Switzerland, was evaluated on a regular basis using contact plates. Data gained between January 2007 and December 2016 was collected and summarized for statistical analysis. Although the overall surface microbial contamination was relatively low during the observation period, significant differences depending on localization and test sites were detected. Certain sites, such as the handle of the dentist's chair and computer surfaces, remained problematic. Continuous monitoring of surface microbial contamination can help to improve the hygiene level in a dental set-up. Further improvement might be achieved by avoiding hand-touch handles whenever possible and by relying on flat and easy-to-clean surfaces within the reach of the bacterial aerosol. However, during interventions that may pose a higher risk for the patient, additional measures should be taken by working under almost sterile conditions and by avoiding direct hand contact with problematic sites.

Motor behavior of the jaw muscles during different clenching levels.

The goals of this study were to investigate whether (i) muscle activities are affected by different feedback strategies, (ii) the balancing behavior of the neuromuscular system is influenced by different force levels, and (iii) axial loading of the posterior teeth is a realistic biomechanical conception. In 10 healthy subjects, all jaw muscles were recorded bilaterally. Intra-oral force transfer and force measurement were achieved by using a measuring device simulating natural maximum intercuspation. Under visual feedback-control, the subjects generated pure vertical and directionally unrestricted force vectors with identical force magnitude at different force levels. The force transmission characteristics under experimental occlusion were investigated by calculating the reduction point (RP) of the resultant bite force. Directionally unrestricted clenching revealed a higher activation of the musculature than pure vertical clenching and was also characterized by a distinct anterior force component. Under both test conditions, the RP moved towards a posterior position with increasing clenching forces. The results indicate an essential recruitment difference of the jaw muscles between the two clenching conditions. Pure axial loading of teeth seems to be impeded by the anterior force component during bilateral clenching. The posterior movement of the RP might prevent overloading of the temporomandibular joints and anterior teeth.