Amitriptyline treatment of chronic pain in patients with temporomandibular disorders

Randomized clinical trials of amitriptyline will require data from pilot studies to be used for sample size estimates, but such data are lacking. This study investigated the 6-week and 1-year effectiveness of low dose amitriptyline (10-30 mg) for the treatment of patients with chronic temporomandibular disorder (TMD) pain. Based on clinical examination, patients were divided into two groups: myofascial and mixed (myofascial and temporomandibular joint disorders). Baseline pain was assessed by a Visual Analogue Scale (VAS) for pain intensity and by the McGill Pain Questionnaire (MPQ). Depression was assessed by the Beck Depression Inventory (BDI) short form. Patient assessment of global treatment effectiveness was obtained after 6 weeks and 1 year of treatment by using a five-point ordinal scale: (1) worse, (2) unchanged, (3) minimally improved, (4) moderately improved, (5) markedly improved. The results showed a significant reduction for all pain scores after 6 weeks and 1 year post-treatment. The depression scores changed in depressed but not in non-depressed patients. Global treatment effectiveness showed significant improvement 6 weeks and 1 year post-treatment. However, pain and global treatment effectiveness were less improved at 1 year than at 6 weeks.     

Dentists' ability to detect psychological problems in patients with temporomandibular disorders and chronic pain

Do patients with temporomandibular disorders (TMD) have significant psychosocial problems? Research efforts have sought to determine if these problems exist, and if so, how they influence treatment outcome. Even when psychosocial factors do influence treatment outcome, identifying them by formal psychological tests can be time consuming and costly. Dentists' impressions of the psychological status of these patients were tested to determine if they are an effective method for screening psychological factors thought to influence treatment outcome. The results suggested that a screening procedure based on dentists' impressions from an initial examination do not adequately identify psychological problems in patients with TMD.     

Acute and chronic postural abnormalities as related to craniofacial pain and temporomandibular disorders

This article has focused primarily on the etiology of CFP and TMD that begins extrinsic to the stomatognathic system and may represent the causative factors behind continued patient complaints after medical and dental intervention. A close professional relationship between the dentist and physical therapist is essential. The knowledgeable physical therapist, through direct interaction with the patient's bodymind, can assist with facilitating change, restoring function, and increasing awareness. New ways of efficiently posturing and moving cannot be learned readily until old bodymind patterns are recognized. From here, the exciting mutual journey of discovery begins and the process continues to unfold for the therapist and client alike.     

Stress as a factor in muscle and temporomandibular joint pain

Stress-induced muscle hyperactivity has been proposed as a major aetiological factor in the production of pain in the muscles of mastication and the temporomandibular joints. In the present study, a total of fifty-two patients with joint or muscle pain were evaluated for stress with the Derogatis Stress Profile (DSP). The muscle pain group (n = 24) had higher clinician ratings of psychological factors, stress and chronicity. The muscle-pain group also had higher Environmental Stress scores on the DSP, more intense pain, and more activity impairment than the joint-pain group (n = 28). The results of multiple regression analysis suggest an association between pain, depression, and impairment of activity in the muscle-pain group but not in the joint-pain group. The overall results further suggest that muscle pain develops at 'normal' levels of stress.     

Reorganization of muscle activity in patients with chronic temporomandibular disorders

ObjectiveTo investigate whether reorganization of muscle activity occurs in patients with chronic temporomandibular disorders (TMD) and, if so, how it is affected by symptomatology severity.MethodsSurface electromyography (sEMG) of masticatory muscles was made in 30 chronic TMD patients, diagnosed with disc displacement with reduction (DDR) and pain. Two 15-patient subgroups, with moderate (TMDmo) and severe (TMDse) signs and symptoms, were compared with a control group of 15 healthy subjects matched by age. The experimental tasks were: a 5 s inter-arch maximum voluntary clench (MVC); right and left 15 s unilateral gum chewing tests. Standardized sEMG indices characterizing masseter and temporalis muscles activity were calculated, and a comprehensive functional index (FI) was introduced to quantitatively summarize subjects’ overall performance. Mastication was also clinically evaluated.ResultsDuring MVC, TMDse patients had a significantly larger asymmetry of temporalis muscles contraction. Both TMD groups showed reduced coordination between masseter and temporalis muscles’ maximal contraction, and their muscular activity distribution shifted significantly from masseter to temporalis muscles. During chewing, TMDse patients recruited the balancing side muscles proportionally more than controls, specifically the masseter muscle. When comparing right and left side chewing, the muscles’ recruitment pattern resulted less symmetric in TMD patients, especially in TMDse. Overall, the functional index of both TMDmo and TMDse patients was significantly lower than that obtained by controls.ConclusionsChronic TMD patients, specifically those with severe symptomatology, showed a reorganized activity, mainly resulting in worse functional performances.     

Diagnostic efficiency of high-resolution ultrasonography in patients with chronic temporomandibular disorders

Purpose

Temporomandibular disorders (TMDs) affect 8–12 % of the adolescent and adult population, resulting in patient discomfort and affecting quality of life. Despite the growing incidence of these disorders, an effective screening modality to detect TMDs is still lacking. Although magnetic resonance imaging is the gold standard for imaging of the temporomandibular joint (TMJ), it has a few drawbacks such as cost and its time-consuming nature. High-resolution ultrasonography is a non-invasive and cost-effective imaging modality that enables simultaneous visualization of the hard and soft tissue components of the TMJ. This study aimed to evaluate the correlations between the clinical signs and symptoms of patients with chronic TMJ disorders and their ultrasonographic findings, thereby enabling the use of ultrasonography as an imaging modality for screening of TMDs.

Methods

Twenty patients with chronic TMDs were selected according to the Research Diagnostic Criteria for TMDs. Ultrasonographic imaging of individual TMJs was performed to assess the destructive changes, effusion, and disc dislocation. Fisher’s exact test was used to examine the correlations between the findings obtained from the ultrasonographic investigation and the clinical signs and symptoms.

Results

There was a significant correlation between pain and joint effusion as well as between clicking and surface erosion.

Conclusions

The present findings suggest that ultrasonography can be used as a screening modality to assess the hard and soft tissue changes in patients presenting with signs and symptoms of TMDs.

     

Pulpalgia contributing to temporomandibular disorder-like pain: a literature review and case report

BACKGROUND: Dentists need to be cognizant that temporomandibular disorder (TMD) -like pain can be caused by a tooth pulpalgia. The author provides suggestive symptom characteristics and definitive diagnostic techniques. CASE DESCRIPTION: A patient had severe bilateral TMD-like pain, which increased when something cold touched a premolar and when the patient lay down, and which awakened her several times every night. The author identified the offending tooth and administered a ligamentary injection along the tooth, which eliminated her bilateral TMD-like pain. Occlusal adjustment of her tooth reduced her pain, and subsequent endodontic therapy eliminated her pain. To the author's knowledge, this is the first report of a pulpalgia in a posterior tooth causing bilateral TMD-like pain. CLINICAL IMPLICATIONS: Pulpalgia may cause symptoms that mimic TMD or may contribute to TMD signs and symptoms. When patients with TMD-like pain report feeling increased pain due to a cold stimulus' coming into contact with a tooth, practitioners should ensure that a pulpalgia is not contributing to their pain.     

急慢性颞下颌关节紊乱病患者临床疼痛特征对比研究

目的:探讨急、慢性颞下颌关节紊乱病(TMD)患者的临床疼痛特征。方法:纳入TMD患者68例(急性30例,慢性38例),使用视觉模拟量表评价患者的疼痛强度,短式McGill疼痛调查表评价患者的疼痛感觉和感受。结果:①静止和功能状态下急、慢性组组内男女患者之间疼痛强度的差异无统计学意义(P>0.05);②静止状态下急、慢性组患者疼痛强度的差异无统计学意义(P>0.05);③功能状态下女性患者急性组疼痛强度高于慢性组(P<0.05);④急性组患者常用胀痛、触痛、刺痛、持续固定痛来描述疼痛,慢性组患者常用的词汇是胀痛、痉挛牵扯痛、绞痛、持续固定痛;⑤急性组患者有15人(占50.00%)在情感项主要选择害怕和软弱无力,慢性组患者有29人(占76.32%)在情感项主要选择厌烦和软弱无力。结论:急、慢性TMD患者疼痛强度多为轻度和中度;急、慢性TMD患者对疼痛的感觉和感受有所不同。     

Swallowing changes related to chronic temporomandibular disorders

Objectives

To investigate whether chronic temporomandibular disorder (TMD) patients showed any changes in swallowing compared to a control group. Moreover, it was examined whether swallowing variables and a valid clinic measure of orofacial myofunctional status were associated.

Material and methods

Twenty-three patients with chronic TMD, diagnosed with disc displacement with reduction (DDR) and pain, according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), and 27 healthy volunteers (control group) were compared. Surface electromyography (EMG) of the temporalis, masseter, sternocleidomastoid, and suprahyoid muscles was performed during swallowing tasks of thin liquid (10 and 15 mL) and spontaneous saliva. Data were normalized.

Results

Compared to the control group, TMD patients showed a prolonged duration of swallowing for liquid and saliva and required a longer time to reach the activity peak and half the integral. While the overall mean value of the relative peaks was similar for the groups, the suprahyoid peak was significantly lower in the TMD group during swallowing of liquid. Moreover, TMD patients recruited the jaw elevator muscles proportionally more than controls. The orofacial myofunctional status was moderately correlated with EMG parameters.

Conclusion

Patients with chronic TMD showed temporal prolongation and changes in the relative activity of the muscles during the swallowing tasks.

Clinical relevance

The present results contribute additional evidence regarding the reorganization of muscle activity in patients with chronic TMD.

     

Self-efficacy is associated with pain, functioning, and coping in patients with chronic temporomandibular disorder pain

AIMS: To examine the psychometric characteristics of a measure of self-efficacy for managing temporomandibular disorders (TMD) and to determine whether scores on this measure were related to pain, disability, and psychological distress in patients with chronic TMD pain. METHODS: Patients seeking treatment for chronic TMD pain (n = 156, 87% female, mean age = 37 years) completed measures assessing pain, disability, mental health, pain-coping strategies, and self-efficacy for managing their pain. RESULTS: The self-efficacy measure, which was adapted from arthritis research, demonstrated good psychometric characteristics (Cronbach's alpha = 0.91, minimal floor and ceiling effects, and validity). Greater self-efficacy was associated with significantly (P < .05) lower levels of pain, disability, and psychological distress. Self-efficacy remained significantly associated with disability and mental health measures even after controlling for demographic variables and pain intensity. In addition, patients with higher self-efficacy reported significantly (P < .05) greater use of an active, adaptive chronic pain-coping strategy (task persistence) and less use of a passive, maladaptive chronic pain-coping strategy (rest). CONCLUSION: Self-efficacy for managing pain appears to be important in the adjustment of patients with chronic TMD pain. Research is needed to determine whether treatments designed to increase self-efficacy improve TMD patient outcomes.     

Convergence defects in patients with temporomandibular disorders

The aim of this study is to show the presence of a correlation between ocular convergence defects (OCD) and temporomandibular disorders (TMD) among a group of adult subjects. The group studied was made up of 48 subjects (12 males and 36 females). The average age was 35 with a range of 19-45 years of age. The subjects presented with TMD and muscular pain and/or dysfunction. Forty-eight subjects with TMD for the case study were matched by gender and age to 48 control subjects seeking routine dental care (control group). All the subjects were examined by the same orthoptist who classified the ocular convergence degree using two tests. The first test evaluated the distances (in centimeters) of the convergence near point (3-4 cm: normal; 5-7 cm: sufficient; > 7 cm: insufficient). The second test assessed the fusional convergence using a Berens prism test (> 25 diopters: normal; between 18-25: sufficient; < 18 diopters: insufficient). In the TMD group, 36 subjects (75%) showed a compromise of convergence: 13 (36%) were classified in the 5-7 degree range and 23 (48%) in the > 7 cm degree range. The Berens test showed ten subjects (28%) in the group < 18D and 26 (72%) in the group 18-25D. The control-group presented ten (21%) subjects with compromise of convergence: three classified in the group < 18D and seven in the group 18-25D. The TMD subjects presented a higher statistical percentage (p < 0.0001) of ocular convergence defects. The TMD patients also reported a strong association referred to specific signs and symptoms, i.e., limited maximal opening or myofascial pain. There were some subjective reports also of headaches and torcicollis (neck stiffness) which appeared significantly more frequently in subjects with a compromise of convergence. The study showed a much higher prevalence of ocular convergence defects in patients with head, neck, and shoulder pain.     

颞下颌关节紊乱病患者的症状自评量表调查

目的通过对颞下颌关节紊乱病（TMD）患者的症状自评量表（SCL-90）各因子进行分析，了解其精神心理状态。方法338例就诊于北京大学口腔医学院颞下颌关节病及口颌面痛诊治中心的TMD患者填写SCL-90，采用t检验和单组设计定量资料的多元方差分析，将患者和普通人群的SCL-90各因子得分进行比较。结果①TMD患者SCL-90中的躯体化、强迫、焦虑、敌意、恐怖、精神病性因子得分高于普通人群，差异有统计学意义（P〈0．05）；②伴有精神心理障碍的TMD患者比例为23％；③对338份患者SCL-90进行可靠性分析，得出可靠系数为0．958。结论我国TMD患者的精神心理障碍问题不容忽视。SCL-90作为判断TMD患者是否伴有某些精神心理障碍的量表，在我国同样具有较好的适用性。     

Psychologic status in patients with temporomandibular disorders

PURPOSE: The aim of this study was to investigate diferrences in the prevalence of depression and somatization scores in temporomandibular disorder (TMD) patients. MATERIALS AND METHODS: One hundred fifty-four patients with single and/or multiple RDC/TMD diagnoses were classified into 7 groups based on Axis I criteria. Somatization and depression scores from the Symptom Checklist-90 were compared between groups. RESULTS: The results of this investigation indicate that patients with myofascial pain and arthralgia psychologically differed from those with disc displacement. These results were in accordance with findings that support the notion that the pain induces psychologic sequelae, at least in relation to depression and somatization. CONCLUSION: It was concluded that psychologic factors play an important role in etiopathogenesis of TMD, as demonstrated by an increase in levels of depression and somatization in TMD patients.     

Electromyographic activity in patients with temporomandibular disorders

Evaluation of masticatory muscle activity by surface electromyography (EMG) is a valuable tool for diagnosing dysfunction of the masticatory apparatus. However, controversy exists with regard to the usefulness of the EMG for patients with temporomandibular disorders (TMD). Forty patients with TMD were subjected to surface EMG of the masticatory muscles. These patients had consulted because of temporomandibular pain and clicks. In most cases (75%), the symptoms affected the patient's left side. Overall mean resting activity was 2.52 microV+/-1.25 microV (s.d.), which is slightly higher than in comparable healthy subjects (1.92+/-1.20 microV). Mean resting activity was highest in the anterior digastric muscle (3.49 microV) on the left side. Overall mean activity during clenching was 66.77+/-35.22 microV, which is about half that observed in healthy subjects (110.30+/-82.97 microV). During leftward movement of the jaw, activity was on average highest in the left digastric, while during rightward movement, activity was on average highest in the right anterior temporal (AT). Our results thus indicate that patients with temporomandibular joint (TMJ) disorder show: (1) a slight increase in basal tone; (2) a significantly reduced capacity for clenching; and (3) an apparently paradoxical inhibition of the dysfunctional-side AT during movement of the mandible towards that side.     

Tooth contact in patients with temporomandibular disorders

Both experimental and retrospective studies suggest a link between parafunctions and pain in temporomandibular disorder (TMD) patients. To investigate the role of parafunctions in TMD, experience sampling methodology was used as a prospective test of the hypothesis that patients with TMD have higher levels of tooth contact and tension than non-TMD controls. Three groups of TMD patients and a group of normal controls carried pagers for one week, were contacted approximately every two hours by an automated calling system, and completed questionnaires assessing tooth contact, tension, and pain at each contact. Results showed that tooth contact was much more frequent among normal controls than is commonly presumed. Patients with myofascial pain with/without arthralgia reported more frequent contact, higher intensity contact, and more tension than patients with disk displacement or normal controls. Increased masticatory muscle activity responsible for tooth contact and tension may be an important mechanism in the etiology and maintenance of the myofascial pain and arthralgia of TMD.     

Palpation and pressure pain threshold: reliability and validity in patients with temporomandibular disorders

This study assessed the interexaminer reliability and validity of palpation (PA) and pressure pain threshold (PPT) of the temporomandibular joint (TMJ) and the masseter and temporalis muscles in patients with temporomandibular disorders (TMD) and asymptomatic controls. Eighty (80) subjects were distributed into two groups: Group 1 consisted of 40 TMD patients with muscular and joint pain selected by RDC/TMD Axis I; and Group 2 (control) with 40 asymptomatic individuals. Training and calibration of examiners was undertaken prior to testing. Mean reliability values were 0.64 and 0.78 (PPT), and 0.59 and 0.75 (PA), for patients and controls, respectively. Results showed statistically significant differences (p<0.001), for PA and PPT among TMD patients compared with the control. The results also showed acceptable specificity values (above 0.90), although sensitivity had low values. The tests had low diagnostic validity to discriminate between patients and controls, with low positive predictive values (PPV).