Manejo das disfunções temporomandibulares. Parte I: tratamento conservador / Management of temporomandibular joint disorders. Part I: conservative treatment

Objetivo: Apresentar as modalidades de tratamentos conservadoras e minimamente invasivas mais usadas disponíveis no arsenal terapêutico das desordens temporomandibulares (DTM). Revisão da literatura: Os objetivos do tratamento invariavelmente incluem redução da dor, diminuição das atividades parafuncionais e restauração da função. Dentre as alternativas conservadoras e minimamente invasivas, podemos citar os dispositivos interoclusais, exercícios terapêuticos, eletrofototermoterapia, agulhamento seco e infiltração de anestésicos locais em pontos gatilho, injeção de sangue autógeno para controle da luxação mandibular, terapia cognitivo comportamental, toxina botulínica, viscossuplementação, controle farmacológico da dor aguda e crônica. As DTMs afetam uma proporção significativa da população. Somente após o fracasso das opções não invasivas é que devem ser iniciados tratamentos mais invasivos e irreversíveis. No entanto, algumas condições, como a anquilose e neoplasias, por exemplo, são essencialmente tratadas cirurgicamente e tentativas de tratamentos conservadores podem trazer piora na qualidade de vida ou risco de morte. Considerações finais: Uma abordagem de equipe multidisciplinar para o manejo é essencial no cuidado fundamental de todos os pacientes com DTM, para que o tratamento possa ser especificamente adaptado às necessidades individuais do paciente.

Aim: To present the most widely used conservative and minimally invasive treatment modalities available in the therapeutic arsenal for temporomandibular disorders (TMD). Literature review: Treatment goals invariably include pain reduction, reduction of parafunctional activities and restoration of function. Among the conservative and minimally invasive alternatives, we can mention interocclusal devices, therapeutic exercises, electrophototherapy, dry needling and infiltration of local anesthetics in trigger points, autogenous blood injection to control mandibular dislocation, cognitive behavioral therapy, botulinum toxin, viscosupplementation, pharmacological control of acute and chronic pain. TMD affects a considerable proportion of the population. Only after non-invasive options have failed should more invasive and irreversible treatments be initiated. However, some conditions, such as ankylosis and neoplasms, for example, are treated surgically and attempts at conservative treatments can lead to worsening quality of life or risk of death. Conclusions: A multidisciplinary team approach to management is essential in the fundamental care of all TMD patients, so that treatment can be specifically tailored to the patient's individual needs.

Manejo das disfunções temporomandibulares. Parte II: tratamento cirúrgico / Management of temporomandibular joint disorders. Part II: surgical treatment

Objetivo: Apresentar as modalidades de tratamentos cirúrgicas mais usadas disponíveis no arsenal terapêutico das desordens temporomandibulares (DTMs). Revisão da literatura: As DTMs são muito frequentes e são responsáveis ​​por dor e desconforto em um número importante de pacientes. A avaliação e o diagnóstico são as chaves para determinar um plano de manejo adequado dessas doenças. Embora o tratamento conservador seja bem-sucedido na maioria dos pacientes, os tratamentos cirúrgicos podem ser a única opção para aqueles que não respondem ao tratamento conservador ou para casos com indicação cirúrgica inicial como, por exemplo, algumas neoplasias articulares. Dentre as alternativas cirúrgicas, podemos citar a artrocentese, artroscopia, reposicionamento do disco articular por cirurgia aberta, discectomia e tratamentos cirúrgicos para hipermobilidade e anquilose da articulação temporomandibular. Considerações finais: A seleção adequada dos casos é requisito obrigatório para uma intervenção cirúrgica bem-sucedida, a fim de alcançar o resultado desejado do tratamento, como alívio dos sintomas e melhora da função.

Aim: To present the most commonly used surgical treatment modalities available in the therapeutic arsenal for temporomandibular disorders (TMD). Literature review: TMD is very common and is responsible for pain and dysfunction in a significant number of patients. Assessment and diagnosis are key to determining a management plan for these diseases. Although conservative treatment is successful in most patients, surgical treatments may be the only option for those who do not respond to conservative treatment or for some cases with an initial surgical indication, such as some joint neoplasms. Surgical alternatives include arthrocentesis, arthroscopy, repositioning of the articular disc by open surgery, discectomy and surgical treatments for temporomandibular joint hypermobility and ankylosis. Conclusions: Proper case selection is the mandatory requirement for successful surgical intervention in order to achieve the desired treatment outcome, such as symptom relief and improved function.

Trastornos temporomandibulares en adolescentes con hábitos parafuncionales / Temporomandibular disorders in adolescents with parafunctional habits i: en

Introducción: Los trastornos temporomandibulares en adolescentes pueden ser ocasionados por hábitos parafuncionales, que probablemente dan lugar a diferentes manifestaciones en los componentes del sistema estomatognático. Objetivo: Caracterizar a los adolescentes con trastornos temporomandibulares y hábitos parafuncionales según variables epidemiológicas y clínicas. Métodos: Se realizó un estudio observacional, descriptivo y transversal de 74 adolescentes (15-18 años de edad) del Instituto Preuniversitario Antonio Alomá Serrano, perteneciente al área de salud del Policlínico Docente José Martí en Santiago de Cuba, desde noviembre del 2021 hasta marzo del 2022. Resultados: Se halló que 88,1 % de los integrantes de la serie presentaron alteraciones leves, 11,9 %, moderadas y 20,3 % no tuvo ninguna. De los 59 pacientes con trastornos temporomandibulares, 74,6 % eran del sexo femenino, con prevalencia de las alteraciones leves (76,9 %). El hábito referido con más frecuencia fue la onicofagia (50,8 %), seguida de la queilofagia (47,5 %). De los adolescentes que presentaban bruxismo, 71,4 % mostró una disfunción moderada; sin embargo, en aquellos con disfunción leve predominó la práctica de la onicofagia (53,8 %). Conclusiones: La mayoría de los adolescentes con más de un hábito parafuncional presentaron trastornos temporomandibulares.

Introduction: Temporomandibular disorders in adolescents can be caused by parafunctional habits that probably lead to different manifestations in the stomatognathic system՚s components. Objective: To characterize the adolescents with temporomandibular disorders and parafunctional habits according to epidemiologic and clinical variables. Methods: An observational, descriptive and cross-sectional study of 74 adolescents (15-18 years) from Antonio Alomá Serrano Senior High School, belonging to the health area of José Martí University Polyclinic in Santiago de Cuba, was carried out from November, 2021 to March, 2022. Results: It was found that 88.1% of the members in the series presented light alterations, 11.9% presented moderate changes and 20.3% didn't have any changes. Of the 59 patients with temporomandibular disorders, 74.6% were women, with prevalence of the light alterations (76.9%). The habit referred with more frequency was nail biting (50.8%), followed by cheilophagia (47.5%). Of the adolescents that presented bruxism, 71.4% showed a moderate dysfunction; however, in those with light dysfunction the practice of nail biting prevailed (53.8%). Conclusions: Most of the adolescents with more than one parafunctional habit presented temporomandibular disorders.

Relación entre el grado de ansiedad (autoevaluación de ansiedad estado/rasgo [STAI]) y el grado de trastorno temporomandibular (índice anamnésico de Fonseca) en una población mexicana / Relationship between the degree of anxiety (state/trait anxiety self-assessment [STAI]) and the degree of temporomandibular disorder (Fonseca anamnestic index) in a Mexican population

Introducción: en la actualidad la ansiedad es uno de los síndromes clínicos más frecuentes y la relación directa con el trastorno temporomandibular (TTM) ha sido el punto de partida para diversos estudios, además del motivo de consulta más común para el clínico. Objetivos: evidenciar la relación existente entre el grado de ansiedad y el TTM. Material y métodos: se realizó un estudio descriptivo, transversal y observacional con una muestra de 220 individuos. Utilizando el cuestionario de autoevaluación de ansiedad estado/rasgo (STAI) para medir el grado de ansiedad y el cuestionario índice anamnésico de Fonseca (IAF) para medir el grado de TTM. Resultados: de las personas que participaron en el estudio, 36.8% presentan ansiedad leve, 27.7% ansiedad moderada, 21.8% ansiedad mínima y 13.6% ansiedad severa, siendo los hombres con mayor porcentaje de ansiedad moderada (33.7%) y las mujeres mayor tendencia a la ansiedad severa (16.4%). de los pacientes, 42.3% refieren no presentar ningún grado de disfunción; 30% disfunción leve, 18.6% disfunción moderada, y solo 8.6% disfunción grave. Conclusión: se encontró una relación directa, correlacionándose gradualmente a mayor nivel de ansiedad, mayor grado de TTM

Introduction: anxiety is currently one of the most frequent clinical syndromes and the direct relationship with temporomandibular disorder (TMD) has been the starting point for various studies as well as the most common reason for consultation for the clinician. Objectives: to demonstrate the relationship between the degree of anxiety and TMD. Material and methods: a descriptive, cross-sectional and observational study was carried out with a sample of 220 individuals. Using the state/trait anxiety self-assessment questionnaire (STAI) to measure the degree of anxiety and the Fonseca anamnestic index questionnaire (IAF) to measure the degree of TMD. Results: 36.8% of the people who participated in the study present mild anxiety, 27.7% moderate anxiety, 21.8% minimal anxiety and 13.6% severe anxiety, the men having a higher percentage of moderate anxiety (33.7%) and women greater tendency to severe anxiety (16.4%). 42.3% of patients report not presenting any degree of dysfunction; 30% mild dysfunction, 18.6% moderate dysfunction, and only 8.6% severe dysfunction. Conclusion: a direct relationship was found, gradually correlating to a higher level of anxiety, a higher degree of TMD (AU)

Natural reversal of mandibular condylar cartilage histological damage caused by chronic unpredictable moderate stress in rats / 口腔疾病防治

Objective @#To investigate the histological damage recovery of temporomandibular joint condylar cartilage caused by chronic unpredictable moderate stress, aiming to provide an experimental basis for the prevention and treatment of temporomandibular disorder.@*Methods @#This animal experiment was approved by the Laboratory Animal Ethical Inspection, School of Stomatology, The Fourth Military Medical University (No. 2020081). 60 male SD rats were randomly divided into control group, stress group, and 2-, 4- and 8-week post-stress recovery groups. Rats were subjected to chronic unpredictable moderate stress (CUMS) for 8 weeks including damp sawdust for 24 hours, tilted cage for 12 hours, noise for 4 hours, light/dark cycle reversal, water immersion, tail clamp, and restraint stress. The serum assessment, behavioral tests, histological and ultrastructural observation were performed 2-, 4- and 8-weeks after stress factors were removed. Serum levels of adrenocorticotropic hormone (ACTH) and corticosterone (CORT) were determined with ELISA. The sucrose preference test (SPT) and the forced swim test (FST) were used to assess the depressive-like behavior. The expression level of interleukin-1α (IL-1α) and matrix metalloproteinases-3 (MMP-3) were determined by Immunohistochemistry and Western blot.@*Results @#At the end of 8 weeks of CUMS, the serum levels of CORT and ACTH were significantly higher in stress group compared with control group (P<0.01). The sucrose preference decreased significantly and the immobility time increased significantly in the stressed rats compared with those in the control group, indicating a successful establishment of CUMS. The condylar cartilage showed significant degenerative changes, with disorganized collagen fibers and reduced proteoglycan synthesis on the cartilage surface. IL-1α and MMP-3 were expressed in the intracellular and extracellular matrix of the condylar cartilage, and their expression levels were increased (P<0.01). After 2 weeks of stress removal, the serum levels of CORT and ACTH were decreased but higher than control group (P<0.01), and behavioral changes were still different from the control group (P<0.01); the loosened collagen fibers could still be seen on the surface of condylar cartilage, and some free cell areas were visible within the proliferative layer; additionally, IL-1α and MMP-3 expression in the condyle was reduced in all layers of cartilage when compared with the stress group, but was still higher than in the control group (P<0.01). After 4 weeks of stress removal, the serum levels of CORT and ACTH changes returned to normal levels and behavioral changes were still different from control group (P<0.05); a few collagen fibers could be seen on the surface of the condylar cartilage and the expressions of IL-1α and MMP-3 decreased significantly compared with the stress group (P<0.01), with the similar level of IL-1α (P>0.05) and higher expression of MMP-3 comparing with the control group (P<0.01). After 8 weeks of stress removal, behavioral changes returned to normal levels, with no statistically significant differences compared with the control group (P>0.05). The condylar collagen fibers increased and showed a corrugated pattern, and no serious subchondral bone damage as well as irreversible damage occurred. Both of the expression levels of IL-1α and MMP-3 approached those of the control group after 8 weeks of stress removal (P>0.05). @*Conclusion@# The behavioral changes and condylar cartilage damage caused by CUMS could be self-repaired. The decline in IL-1α and MMP-3 expression may be one of the intrinsic mechanisms of this self-repair process.

Test-retest reliability of the isometric contraction test (IC test) of the masticatory muscles in subjects with and without temporomandibular muscle disorders

Abstract Recently, the DC/TMD has become an essential tool for the diagnosis of temporomandibular disorders (TMD). However, as they fail to include functional activities, new assessment proposals have emerged, such as the isometric contraction test (IC test) of the masticatory muscles, which uses muscle contractions to identify muscular TMD. Objective This study aimed to determine the test-retest reliability of the IC test. Methods A total of 64 participants (40 women and 24 men) completed the IC test administered by two different physical therapists on two non-consecutive days. Cohen's kappa (k), PABAK, and percent agreement (PA) between days were estimated. Results The IC test showed good to excellent test-retest reliability values (k>0.77; PABAK>0.90), both globally and individually for the muscles evaluated, and PA>90%, therefore above the thresholds for clinical applicability. However, the global assessment of myofascial pain and the evaluation of the medial pterygoid muscle showed slightly lower reliability values. Conclusion The IC test is reliable for the assessment of subjects with muscular TMD, both in terms of the global assessment and the evaluation of each muscle, which supports its clinical applicability. Care should be taken when assessing myofascial pain globally and when evaluating the medial pterygoid in all types of pain.

Quality of life assessment in patients with temporomandibular disorder with stabilization splints and home therapeutic exercises: a randomized clinical trial / Avaliação da qualidade de vida em pacientes com desordem temporomandibular com uso da placa estabilizadora e exercícios terapêuticos caseiros: um ensaio clínico randomizado

Objective: The present study aimed to evaluate the quality of life in TMD patients with the use of Stabilization Splints (SSs) and Home Therapeutic Exercises (HTEs) guidance. Material and Methods: The study was a clinical, randomized, controlled, prospective, and interventional trial. The screening included dentate patients of both genders, diagnosed with TMD through the RDC/TMD questionnaire with no TMJ osteoarthritis and/or osteoarthrosis. To assess the quality of life, the Short-Form Health Survey (SF-36) questionnaire was applied to all patients (n=70), randomized into a test group with SS and a control group with HTE. The evaluations of both questionnaires were performed before and after the intervention of 12 weeks. Results: The comparisons between pre- and post-intervention intragroups were performed by the non-parametric Wilcoxon test with a 5% significance level. There was a frequency distribution of the responses to the 36 items of the SF-36 questionnaire and comparisons between times. In the test group, 49 patients received a SS and did HTEs. In the control group, 21 patients performed HTEs. In the statistical analysis, among the eight domains, three were identified with significant scores: pain, mental health, and vitality. Conclusion: It was found that there was an improvement in pain and quality of life after the treatment of TMD with a SS and HTE (AU)

Objetivo: O presente estudo teve como objetivo avaliar a qualidade de vida em pacientes com DTM com o uso de placas de estabilização (SSs) e orientação de exercícios terapêuticos domiciliares (HTEs). Material e Métodos: O estudo foi um ensaio clínico, randomizado, controlado, prospectivo e intervencionista. A triagem incluiu pacientes dentados de ambos os sexos, diagnosticados com DTM através do questionário RDC/TMD sem osteoartrite e/ou osteoartrose da ATM. Para avaliar a qualidade de vida, o questionário Short-Form Health Survey (SF-36) foi aplicado a todos os pacientes (n=70), randomizados em grupo teste com SS e grupo controle com HTE. As avaliações de ambos os questionários foram realizadas antes e após a intervenção de 12 semanas. Resultados:As comparações intragrupos pré e pós-intervenção foram realizadas pelo teste não paramétrico de Wilcoxon com nível de significância de 5%. Houve distribuição de frequência das respostas aos 36 itens do questionário SF-36 e comparações entre os tempos. No grupo controle, 21 pacientes realizaram HTEs. Na análise estatística, dentre os oito domínios, três foram identificados com escores significativos: dor, saúde mental e vitalidade. Conclusão: Verificou-se que houve melhora da dor e da qualidade de vida após o tratamento da DTM com SS e HTE.(AU)

Influencia de la ansiedad en el desarrollo de los trastornos temporomandibulares

Introducción: Los trastornos temporomandibulares constituyen un problema de salud importante en Cuba, la causa es de carácter multifactorial, actualmente se sabe que los factores psicosociales juegan un papel importante, sobre todo en lo que se refiere a la adaptación al dolor y su recuperación. Objetivo: Identificar la relación entre los trastornos temporomandibulares y los distintos niveles de ansiedad en pacientes pertenecientes al Consultorio Médico de la Familia No. 10 del área Norte de la provincia de Sancti Spíritus, Cuba, durante el período enero de 2019 a enero de 2020. Método: Se realizó un estudio observacional analítico del tipo casos y controles. El universo fue de 109 pacientes. La muestra quedó integrada por 80 pacientes distribuidos en 40 casos y 40 controles. Las variables estudiadas fueron: edad, sexo, trastornos temporomandibulares, signos y síntomas, ansiedad. Los trastornos temporomandibulares se diagnosticaron a través del Índice de Helkimo y la ansiedad mediante la aplicación del Inventario de Ansiedad Rasgo-Estado (IDARE). Se aplicó la prueba de asociación estadística Ji-cuadrado. Resultados: Predominaron los pacientes del sexo femenino en un 55 % y el 51,25 % en el rango de edad de 40-59 años. Los signos y síntomas más frecuentes en pacientes con trastornos temporomandibulares fueron el dolor en la articulación temporomandibular y en músculos masticatorios para un 85 % y 80 %, respectivamente. La mayoría de los casos presentaron niveles altos de ansiedad como estado en un 52,5 %. Conclusiones: Los distintos niveles de ansiedad predispusieron al origen y mantenimiento de los trastornos temporomandibulares en los pacientes estudiados.

Introduction: The temporomandibular disorders constitute an important health problem in Cuba. Today, it´s well known that the psychosocial factors play an important role in it, especially, with regard to pain adaptation and recovery. Objective: Identification of the relationship between temporomandibular disorders and different levels of anxiety in patients belonging to the Family Medical Clinic No. 10 located at the Northern Area of the Sancti Spíritus province, Cuba, during the period January 2019 to January 2020. Method: An analytical observational study of case-control type was carried out. The population was comprised of 109 patients. The sample consisted of 80 patients distributed in 40 cases and 40 controls. The variables studied were at following: age, sex, temporomandibular disorders, signs and symptoms, anxiety. Temporomandibular disorders were diagnosed through the Helkimo Index and anxiety through the application of the State-Trait Anxiety Inventory (STAI). The Chi-squared statistical association test was applied. Results: Female patients were predominant (55%) and 51.25% were in the age range of 40-59 years. The most frequent signs and symptoms in patients with temporomandibular disorders were pain in the temporomandibular joints and in muscles of mastication for 85 % and 80 %, respectively. Most of the cases (52.5 %) presented high levels of anxiety. Conclusions: The different levels of anxiety predisposed to the origin and maintenance of temporomandibular disorders in all the patients studied.

Introdução: As disfunções temporomandibulares constituem um importante problema de saúde em Cuba, a causa é multifatorial, atualmente sabe-se que os fatores psicossociais desempenham um papel importante, principalmente no que diz respeito à adaptação à dor e sua recuperação. Objetivo: Identificar a relação entre as disfunções temporomandibulares e os diferentes níveis de ansiedade em pacientes pertencentes ao Consultório Médico de Família nº 10 da zona Norte da província de Sancti Spíritus, Cuba, durante o período de janeiro de 2019 a janeiro de 2020. Método: Foi realizado um estudo observacional analítico do tipo caso e controle. O universo foi de 109 pacientes. A amostra foi composta por 80 pacientes distribuídos em 40 casos e 40 controles. As variáveis estudadas foram: idade, sexo, disfunção temporomandibular, sinais e sintomas, ansiedade. As disfunções temporomandibulares foram diagnosticadas por meio do Índice de Helkimo e a ansiedade por meio da aplicação do Inventário de Ansiedade Trait-State (IDARE). Foi aplicado o teste de associação estatística Qui-quadrado. Resultados: Pacientes do sexo feminino predominaram em 55% e 51,25% na faixa etária de 40 a 59 anos. Os sinais e sintomas mais frequentes em pacientes com disfunção temporomandibular foram dor na articulação temporomandibular e nos músculos mastigatórios para 85% e 80%, respectivamente. A maioria dos casos apresentou níveis elevados de ansiedade como estado em 52,5%. Conclusões: Os diferentes níveis de ansiedade predispõem à origem e manutenção das disfunções temporomandibulares nos pacientes estudados.

Research progress on the structural features, treatments, and association with temporomandibular disorder in patients with skeletal class Ⅲ malocclusion with mandibular deviation / 口腔疾病防治

@#Skeletal angle class Ⅲ malocclusion with mandibular deviation involves the rotation and translation of the cranial base, maxilla, mandible, and soft tissue. It compromises the patients’ appearance and stomatognathic function. The treatment outcome is not satisfactory, and correct evaluation is of great significance. The causal relationship between skeletal Class Ⅲ with mandibular deviation and TMD remains controversial. This review focuses on the structural alterations of hard and soft tissue, the etiology, the choice of treatment methods, and the association with TMD in patients with skeletal class Ⅲ malocclusion with mandibular deviation. The results show that mandibular deviation is a complex disease with unclear etiology. It involves morphological changes, rotation and displacement of the cranial base, maxilla and mandible, morphological changes of the soft tissue, and occlusal changes, which also compromise the temporomandibular joint and mandibular function. Skeletal Class Ⅲ malocclusion is common in patients with mandibular deviation. Early treatment is needed; however, the treatment methods vary. The correct evaluation of the morphological changes of soft and hard tissues leading to facial asymmetry is the premise of treatment. Orthodontic and orthognathic treatment (combined with soft tissue repair when necessary) is an effective method for the treatment of skeletal class Ⅲ malocclusion with mandibular deviation. In addition, there is a close relationship between mandibular deviation and TMD, which needs to be fully considered in the design of treatment.

Depression, somatization, and sleep disorders as risk factors for temporomandibular disorders development: a population-based case-control study / Depressão, somatização e distúrbios do sono como fatores de risco para o desenvolvimento de disfunções temporomandibulares: um estudo de controle de casos baseado na população / Depresión, somatización y trastornos del sueño como factores de riesgo para el desarrollo de trastornos temporomandibulares: un estudio de casos y controles de base poblacional

The objective of this study was to determine the association between temporomandibular disorders (TMD) with depression, somatization and sleep disorders in the city of Maringá, Brazil. A total of 1,643 participants were selected from the Brazilian Unified Health System (SUS). Of these, the test group consisted of 84 participants who had moderate or severe limitations due to TMD pain and the control group consisted of 1,048 participants with no pain. There was a highly statistically significant difference (p<0.001) between cases and controls regarding depression (82.1 versus 37.4%), somatization (84.5 versus 31.4%), and sleep disorders (84.6 versus 36.4%), in moderate to severe levels. The levels of moderate to severe depression, somatization and sleep disorders were significantly higher in TMD subjects with high TMD pain disability. The risk of developing TMD increased 4 to 5 times when the individual has moderate to severe levels of depression, somatization, and sleep disorders.

O objetivo deste estudo foi determinar a associação entre disfunções temporomandibulares (DTM) com depressão, somatização e distúrbios do sono na cidade de Maringá, Brasil. Foram selecionados 1.643 participantes atendidos no Sistema Único de Saúde (SUS). Desses, o grupo caso foi formado por 84 participantes que apresentaram limitações moderada ou grave devido à dor na DTM e o grupo controle foi formado por 1.048 participantes com ausência de dor. Verificou-se diferença estatisticamente significativa (p<0,001) entre casos e controles em relação à depressão (82,1 versus 37,4%), somatização (84,5 versus 31,4%) e distúrbios do sono (84,6 versus 36,4%), em níveis moderados a graves. Os níveis de depressão moderada a grave, somatização e distúrbios do sono foram significativamente mais altos em indivíduos com DTM com alta incapacidade devido à dor por DTM. O risco de desenvolver DTM aumentou quatro a cinco vezes quando o indivíduo apresenta níveis moderados a graves de depressão, somatização e distúrbios do sono.

El objetivo de este estudio fue determinar la asociación entre los trastornos temporomandibulares (TMD) con la depresión, la somatización y los trastornos del sueño en la ciudad de Maringá, Brasil. Un total de 1.643 participantes fueron seleccionados del Sistema Único de Salud (SUS) de Brasil. (SUS). De estos, el grupo de casos fue formado por 84 participantes que presentaban limitaciones moderadas o graves debido al dolor TMD y el grupo de control estaba formado por 1.048 participantes sin dolor. Hubo una diferencia estadísticamente significativa (p <0,001) entre casos y controles con respecto a depresión (82,1 frente a 37,4%), somatización (84,5 frente a 31,4%) y trastornos del sueño (84,6 frente a 36,4%), en niveles moderados a severos. Los niveles de depresión moderada a grave, somatización y trastornos del sueño fueron significativamente más altos en personas con TMD con alta discapacidad por dolor en TMD. El riesgo de desarrollar TMD aumenta de 4 a 5 veces cuando el individuo tiene niveles moderados a severos de depresión, somatización y trastornos del sueño.

TNF-α levels and presence of SNP-308G/A of TNF-α gene in temporomandibular disorder patients

ABSTRACT Introduction: Temporomandibular disorder (TMD) refers to a group of conditions that compromise the harmonious movement and function of the temporomandibular joint, masticatory muscles, and associated structures. The etiopathogenesis of TMD is multifactorial but not well-understood, with the role of genetic factors still being unclear. Objective: This review aims to summarize the results of studies that evaluated TNF-α levels and the -308G/A TNF-α polymorphism in TMD patients. This study emphasizes the importance of a more selective treatment involving TNF-α inhibitors that can potentially reduce inflammation and pain, and improve quality of life. Methods: The MEDLINE/PubMed database, Cochrane Library, and Web of Science database were searched for case-control studies published until September 2020 that compared levels of TNF-α or presence of its -308G/A polymorphism in TMD patients and healthy individuals. Results: Six case-control studies were identified with a total of 398 TMD patients, aged between 12 and 78 years. The control group consisted of 149 subjects, aged between 18 and 47 years. The occurrence of TMD was predominant in females. Majority of studies found high TNF-α levels in TMD patients, compared to the control group. One of these studies found a positive correlation between the GA genotype and the development of TMD. Conclusion: Majority of the TMD patients showed elevated TNF-α levels, and a possible explanation for this could be the presence of the -308G/A polymorphism.

RESUMO Introdução: A disfunção temporomandibular (DTM) é definida como um grupo de alterações que comprometem a articulação temporomandibular, os músculos mastigatórios e as estruturas associadas. A etiopatogenia da DTM é multifatorial, e o papel dos fatores genéticos permanece obscuro. Objetivo: A presente revisão teve como objetivo descrever as contribuições de estudos que avaliaram os níveis de TNF-α e o polimorfismo -308 G/A em pacientes com DTM. Esse estudo enfatizou a importância de um tratamento mais completo envolvendo os inibidores do TNF-α que podem potencialmente reduzir a inflamação e a dor, contribuindo para melhorar a qualidade de vida do paciente. Métodos: As pesquisas foram realizadas nas bases de dados MEDLINE/PubMed, Cochrane Library e Web of Science, em busca de estudos de caso-controle publicados até setembro de 2020 que avaliassem os níveis de TNF-α e seu polimorfismo -308 G/A nos pacientes com DTM e em controles saudáveis. Resultados: Seis estudos de caso-controle foram identificados, com um total de 398 pacientes com DTM, e a idade variou de 12 a 78 anos. O grupo controle consistiu de 149 indivíduos e sua idade variou, aproximadamente, de 18 a 47 anos. O sexo feminino foi predominante. A maioria das pesquisas encontrou níveis elevados de TNF-α nos pacientes, em comparação com os controles. Um estudo encontrou uma associação positiva entre o genótipo GA e o desenvolvimento de DTM. Conclusão: A maioria dos pacientes com DTM demonstrou predisposição a uma maior produção de TNF-α, e isso poderia ser explicado pela presença do polimorfismo -308 G/A.

Nas trincheiras da disfunção temporomandibular: estudo de vivências / At the forefront of the temporomandibular dysfunction: a study of experiences

Resumo Como abordar uma doença que traz vivências tão singulares e fazê-lo sem dissociações com as relações, as condições de vida e sociedade? A Disfunção temporomandibular (DTM) é um grupo de desordens crônicas difíceis de diagnosticar e prover tratamento. Como em outras doenças similares, tais dificuldades podem agravar o impacto negativo sobre a saúde. O estudo busca identificar vivências de usuários de serviços de saúde com DTM, visando contribuir com as práticas de reflexão e manejo para a questão. Foi desenvolvido um estudo qualitativo, de caráter otobiográfico, a partir de entrevistas com pessoas em tratamento de DTM. Parte-se da premissa nietzschiana de que o processo de subjetivação é alimentado por vivências; portanto, o método busca a identificação de traços dessas vivências nos textos produzidos a partir da transcrição das entrevistas. As vivências dos pacientes foram agrupadas em cinco trincheiras: nomeação; frustrações; escondido; tristeza, medo e morte; e destinos. Uma variedade de efeitos negativos foi descrita através dos três primeiros estágios, enquanto em destinos, emergem as sensações de bem-estar. Destaca-se o valor do espaço profissional-usuário, que expressa a potência de criação de modos inovadores e sensíveis de lidar com os processos de saúde-doença.

Abstract How does one address an ailment related to such unique experiences without dissociating it from relationships, living conditions and society? Temporomandibular Disorder (TMD) is one of a group of chronic disorders that are difficult to diagnose and provide treatment. As in other similar ailments, such difficulties may accentuate a negative impact on health. The study seeks to identify experiences of health service users with TMD, aiming to contribute to reflection and management practices for the issue. A qualitative otobiographical study was developed, using interviews with people undergoing TMD treatment. Based on the Nietzschean premise that the process of subjectivation is fed by experiences, the method seeks to identify traces of these experiences through the texts resulting from the interviews. Patients' experiences were grouped into five categories: recognition; frustrations; concealment; sadness, fear and death; and destinies. A variety of negative effects have been described in the first three stages, whereas the last one, namely destinies, elicits feelings of well-being. The value of the interactive (professional-user) space, which expresses itself as the power to create innovative and sensitive ways of dealing with health-disease processes, needs to be highlighted.

Avaliação eletromiográfica da musculatura mastigatória e da coluna cervical com uso de placa oclusal: relato de caso / Electromyographic evaluation of masticatory and cervical musculature with occlusal splint: case report

Objetivo: Avaliar a atividade elétrica de músculos mastigatórios e cervicais e sua inter-relação na estabilização da cadeia crânio cervico umeral com uso da placa oclusal, por meio da avaliação eletromiográfica. Relato de caso: Paciente sexo feminino, 39 anos, queixando-se de dores na cabeça, faciais e cervicais, com prejuízo em suas atividades diárias. Relatou apertar os dentes durante o dia e a noite e ser uma pessoa muito ansiosa. Pratica exercício físico de 5 a 6 vezes por semana. Foi submetida ao tratamento com placa oclusal estabilizadora. O exame eletromiográfico foi realizado nos músculos masseter e trapézio, bilateralmente. A coleta de dados foi realizada antes da instalação da placa e passados 90 dias de uso. Considerações finais: Após o tempo de tratamento, foi relatado redução do comportamento de apertamento noturno e diurno dos dentes, redução do nódulo muscular antes visível na região supraescapular, eliminação das dores e melhor rendimento muscular durante a prática de atividade física.(AU)

Objective: To evaluate the electrical activity of masticatory and cervical muscles and their relationship in the stabilization of the craniocervicohumeral chain using a occlusal splint, through electromyographic evaluation. Case report: Female patient, 39 years old, complaining of headaches, facial and cervical pain, with impairment in her daily activities. She reported teeth clenching during the day and night, and being a very anxious person. She practices physical exercise 5 to 6 times a week. She underwent treatment with a stabilizing occlusal splint. The electromyographic examination was performed on the masseter and trapezius muscles, bilaterally. Data was collected before occlusal splint installation and after 90 days of use. Final considerations: After the treatment period, it was reported a reduction in the behavior of nocturnal and daytime teeth clenching, reduction of the muscle nodule previously visible in the suprascapular region, elimination of pain and better muscle performance during the practice of physical activities.(AU)

Treatment of Serious Occlusal Instability Associated with Temporomandibular Disorders (TMDs) Through Implant and Dynamic Occlusal Schemes Rehabilitation. A Case Report

ABSTRACT: A case report of 35 years old male patient, partially edentulous with occlusal instability, Disc Displacement with Reduction (DDWR), Local Muscle Soreness (LMS) and Alteration of vertical dimension is presented. Rehabilitation was planned to achieve predictability of long-term treatment, providing static and dynamic occlusal stability. A therapeutic occlus ion with premature contact in the right premolar sector was planned. Implants and cemented/screwed crowns were used to obtain contacts in the molar area. The restoration of dynamic occlusal schemes was made by direct adhesive technique in the anterior sector and Curve of Spee (COS) compensation with temporary anchoring for molar inclusion was used. Patient presents objective and subjective improvements associated with the treatment performed. Temporomandibular disorder is stabilized and controlled by a specialist.

RESUMEN: Se presenta el caso clínico de un paciente masculino de 35 años, parcialmente desdentado con inestabilidad oclusal, Desplazamiento Discal con Reducción (DDWR), Dolor Muscular Local (LMS) y Alteración de la dimensión vertical. La rehabilitación se planificó para lograr la previsibilidad del tratamiento a largo plazo, proporcionando estabilidad oclusal estática y dinámica. Se planificó una oclusión terapéutica con contacto prematuro en el sector premolar derecho. Se utilizaron implantes y coronas cementadas / atornilladas para obtener contactos en la zona de los molares. La restauración de esquemas oclusales dinámicos se realizó mediante técnica de adhesivo directo en el sector anterior y se utilizó compensación de Curva de Spee (COS) con anclaje temporal para inclusión molar. El paciente presenta mejoras objetivas y subjetivas asociadas al tratamiento realizado. El trastorno temporomandibular es estabilizado y controlado por un especialista.

Three-dimensional morphological changes in the temporomandibular joints of patients with anterior disc displacement with reduction / 华西口腔医学杂志

OBJECTIVES@#To investigate the differences in the temporomandibular joints (TMJs) between patients with anterior disc displacement with reduction (ADDwR) and asymptomatic subjects by using 3D morphometric measurements.@*METHODS@#A total of 15 patients with ADDwR and 10 asymptomatic subjects were enrolled. Then, 3D models of the maxilla and mandible were reconstructed using MIMICS 20.0. Nine morphologic parameters of TMJs on both sides were measured on the 3D solid model. The differences in the parameters were analyzed between the patients and the asymptomatic subjects and between the left and right sides of each group.@*RESULTS@#The horizontal and coronal condylar angles on the ipsilateral side of the patients were significantly greater than those of the asymptomatic subjects (@*CONCLUSIONS@#ADDwR will increase the condylar angles to be significantly greater than the normal level and decrease SRA and articular spaces to be significantly smaller than the normal level. The condyles will be displaced upward, closer to the fossa.

Catastrofização e atenção plena na disfunção temporomandibular: estudo correlacional / Catastrophization and mindfulness in temporomandibular disorder: correlational study

A catastrofização é um constructo multidimensional que apresenta três dimensões: magnificação, ruminação e desamparo, segundo a Escala de catastrofização da Dor (Pain Catastrophizing Scale - PCS), sendo um importante mediador da dor crônica pelo modelo de medo e evitação de Vlaeyen e Lipton e definindo a entrada no ciclo de cronificação da dor. Estudos que analisaram a relação entre catastrofização e mindfulness pela Five Facets Mindfulness Questionnaire (FFMQ), apontam essa intervenção como um possível mediador da catastrofização. Porém como essas facetas de mindfulness se associam com as subescalas da catastrofização ainda não foi estudado. O objetivo deste estudo observacional e transversal foi verificar como se dá a associação de mindfulness e catastrofização, principalmente como os níveis de mindfulness e suas facetas se relacionam com as subdimensões magnificação, ruminação e desamparo. O intuito do aprofundamento do conhecimento dessa relação é gerar subsídios para o desenvolvimento e aplicação de intervenções baseadas em mindfulness direcionadas para as subdimensões da catastrofização e ser assim mais diretivo e assertivo na abordagem, aprimorando a qualidade de vida da população com dor crônica com mais eficácia. Foram recrutadas mulheres entre 18 e 45 anos (N=52) que apresentavam Disfunção Temporomandibular crônica segundo critérios do Critério Diagnóstico para Desordens Temporomandibulares (Diagnostic Criteria for Temporomandibular Disorders - DC/TMD) e após a assinatura dos termos de consentimento livre e esclarecido foram aplicados os Questionários Sociodemográfico, Escala de Catastrofização da Dor (PCS) e Questionário das Cinco Facetas de Mindfulness (FFMQ). Apresentaram correlação significante e de forma inversa a subescala magnificação com as facetas não reagir e não julgar e com a pontuação total da FFMQ. A pontuação total da PCS apresentou correlação inversa com a faceta não reagir. As demais não apresentaram correlação. Na análise de regressão logística, foi constatado que a cada ponto obtido no domínio descrever positivo é esperado um aumento de 1,67 vezes na chance de ocorrência de desamparo e para cada comorbidade aumenta em 12,9 vezes a chance de apresentar desamparo. O presente estudo fornece a possível existência de associações entre as habilidades mensuradas enquanto facetas de mindfulness com as subdimensões da catastrofização, sendo necessário considerar essas relações na abordagem das intervenções baseadas em mindfulness para essa população. É possível que estratégias baseadas em mindfulness que desenvolvam o não julgar e o não reagir sejam benéficas para pessoas com dor crônica que apresentem catastrofização com altas pontuações na magnificação na redução do comportamento catastrófico. Da mesma forma, os resultados indicam que o uso de técnicas de mindfulness que aprimorem o descrever positivo pode ser prejudicial para os catastróficos com desamparo. Esse trabalho pode ajudar no estudo e desenvolvimento de intervenções baseadas em mindfulness que considerem essas relações tornando mais direcionada e eficaz a abordagem na população com dor crônica

Catastrophizing is a multidimensional construct that presents three dimensions: magnification, rumination and helplessness, according to the Pain Catastrophizing Scale - PCS, being an important mediator of chronic pain by the model of fear and avoidance by Vlaeyen and Lipton and defining the entry into the pain chronification cycle. Studies that analyzed the relationship between Catastrofization and Mindfulness using the Mindfulness Five Facets Questionnaire (FFMQ), point to this intervention as a possible mediator of catastrophization. However, how these facets of mindfulness are associated with the subscales of catastrophization has not yet been studied. The objective of this observational and cross-sectional study is to verify how the association of mindfulness and catastrophization occurs, especially as the levels of mindfulness and their facets are related to magnification, rumination and helplessness sub-dimensions. The aim of deepening the knowledge of this relationship is to generate subsidies for the development and application of treatment based on mindfulness directed at the sub-dimensions of catastrophization and thus be more directive and assertive in the approach, improving the quality of life of the population with chronic pain more effectively. Women between 18 and 45 years old (N = 52) who had chronic temporomandibular disorder were recruited according to the criteria of the Diagnostic Criteria for Temporomandibular Disorders (Diagnostic Criteria for Temporomandibular Disorders - DC / TMD) and after signing the free and informed consent terms, the Sociodemographic Questionnaires, Pain Catastrophization Scale (PCS) and the Five Facets of Mindfulness Questionnaire (FFMQ) were completed. The magnification subscale showed a significant and inverse correlation with the facets not reacting and not judging and with the total FFMQ score. Total evaluation of the PCS presented an inverse correlation with the facet not reacting. The others are not correlated. In the logistic regression analysis, it was found that for each point added in the domain describes positive, a 1.67-fold increase in the chance of helplessness is expected, and for each comorbidity the chance of having helplessness increases by 12.9 times. The present study offers the possible existence of associations between the skills measured as facets of mindfulness with the sub-dimensions of catastrophization, and it is necessary to consider these relationships when approaching mindfulness-based techniques for this population. It is possible that based on mindfulness that develop not judging and not reacting are beneficial for people with chronic pain who have catastrophization with high scores on magnification in reducing catastrophic behavior. Likewise, the results indicate that the use of mindfulness techniques that enhance the positive, can be harmful to catastrophic people with helplessness. This work can help in the study and development of enlightened mindfulness that considers these relationships making the approach in the population with chronic pain more targeted and effective

Affective relationships as predictors of TMD symptoms in young adults / Relações afetivas como preditoras de sintomas de DTM em adultos jovens

Abstract Introduction Orofacial pain is a critical TMD symptom that can influence physical and social capacity. Objective To evaluate the association of temporomandibular disorders (TMD) symptoms with affective relationships and demographic variables in young adults. Material and method A cross-sectional study involving 395 young adults was developed. Diagnostic Criteria for TMD, anxiety, and depression were collected from questionnaires. The Dental Health Component of the Index of Orthodontic Treatment Need measures the orthodontic treatment need. Questionnaires also contained questions related to the previous orthodontic treatment. Logistic regression models were adjusted, estimating crude odds ratio with the 95% confidence intervals. The variables with p<0.20 in the analyses were assessed in a multiple logistic regression model, remaining with p≤0.10. Result There was no significant association of TMD symptoms with sex, age, medication use for pain, previous orthodontic treatment, orthodontic treatment need, anxiety, and depression (p>0.05). Individuals without an affective relationship are 1.78 (95%CI: 0.99-3.17) times more likely to report TMD symptoms. Conclusion Affective relationships showed an association with TMD symptoms in young adults.

Resumo Introdução A dor orofacial é um sintoma crítico da DTM que pode influenciar a capacidade física e social. Objetivo Avaliar a associação dos sintomas das desordens têmporomandibulares (DTM) com as relações afetivas e variáveis demográficas em adultos jovens. Material e método Estudo transversal envolvendo 395 adultos jovens foi realizado. Os critérios diagnósticos para DTM, ansiedade e depressão foram coletados a partir de questionários. O Componente de Saúde Bucal do Índice de Necessidade de Tratamento Ortodôntico mensurou a necessidade de tratamento ortodôntico. Os questionários também continham questões relacionadas ao tratamento ortodôntico anterior. Modelos de regressão logística foram ajustados, estimando odds ratio bruto com os intervalos de confiança de 95%. As variáveis com p<0.20 nas análises foram avaliadas em modelo de regressão logística múltipla, permanecendo as variáveis com p≤0.10. Resultado Não houve associação significativa dos sintomas de DTM com sexo, idade, uso de medicamentos para dor, tratamento ortodôntico prévio, necessidade de tratamento ortodôntico, ansiedade e depressão (p>0.05). Indivíduos sem relacionamento afetivo têm 1.78 (IC95%:0.99-3.17) vezes mais chance de relatar sintomas de DTM. Conclusão Os relacionamentos afetivos mostraram associação com os sintomas de DTM em adultos jovens.

The effect of biofeedback on pain and sleep in a patient with temporomandibular disorder. Case report / Efeito do biofeedback na dor e no sono de paciente com disfunção temporomandibular. Relato de caso

ABSTRACT BACKGROUND AND OBJECTIVES: Literature has shown that behavioral and educational modalities are effective options in the treatment of chronic pain, including temporomandibular disorder, and techniques such as biofeedback have been used for single therapy or in combination for effective pain control in these individuals. Furthermore, the severity of symptoms is related to relevant prognostic factors, such as quality of life, emotional states and sleep quality. The aim of the present study was to evaluate the effect of the biofeedback audiovisual technique on pain control and sleep quality in a patient with temporomandibular disorder. CASE REPORT: Female patient, 34 years old, with Temporomandibular Disorder. The DC/TMD (Diagnostic Criteria for Temporomandibular Disorders) Axis I, diagnostic was applied, and the patient was classified with more than one subtype of temporomandibular disorders: local myalgia and myofascial pain with reference, in addition to neck pain as a comorbidity. CONCLUSION: In this case, the biofeedback treatment was effective both in reducing pain intensity and improving sleep quality.

RESUMO JUSTIFICATIVA E OBJETIVOS: A literatura tem demonstrado que as modalidades comportamentais e educacionais são opções efetivas no tratamento da dor crônica, inclusive da disfunção temporomandibular, e técnicas como o biofeedback vêm sendo utilizadas como terapia isolada ou em combinação para um controle efetivo da dor nesses indivíduos. Além disso, a gravidade dos sintomas tem correlação com fatores de relevância para o prognóstico, como a qualidade de vida, estados emocionais e qualidade do sono. O objetivo deste estudo foi avaliar o efeito da técnica do biofeedback audiovisual no controle da dor e na qualidade do sono em paciente com disfunção temporomandibular muscular. RELATO DO CASO: Paciente do sexo feminino, 34 anos, com disfunção temporomandibular. O critério diagnóstico DC/TMD (Diagnostic Criteria for Temporomandibular Disorders) Eixo I foi aplicado, sendo a paciente classificada com mais de um subtipo de disfunção temporomandibular: mialgia local e dor miofascial com referência, além de cervicalgia como comorbidade. CONCLUSÃO: No caso clínico apresentado a terapia com biofeedback foi efetiva na redução da intensidade da dor e melhoria da qualidade do sono.

Sequential Approach to Differential Diagnosis of TMJ Disorder from Other Oro Facial Muscles Pain – A Systematic Review

This systematic review (SR) synthesises recent evidence and assesses the methodological quality of published SRs in the Differential diagnosis of temporomandibular disorders (TMD). A systematic literature search was conducted in the PubMed, Cochrane Library, and Bandolier databases for 1987 to September 2019. Three investigators evaluated the methodological quality of each identified SR using two measurement tools: The assessment of multiple systematic reviews (AMSTAR) and level of research design scoring. Thirty-one SRs met inclusion criteria and 28 were analysed: 20 qualitative SRs and eight meta-analysis.The main aim of this article is to Differential diagnose the pain which is not related to any dental disease. Most of dental clinician have problem to diagnose TMD (Temporomandibular Disorders) and Orofacial Muscle pain. The approach of this article is to simplify the differential diagnosis for better and fast treatment of the respective disease by classifying various TMJ related and muscle related problems

Association between -1607 1g/2g polymorphism of mmp1 and temporomandibular joint anterior disc displacement with reduction

Abstract Anterior disc displacement with reduction (DDWR) is considered one of the most common disorders within the temporomandibular joint (TMJ), with a prevalence of 41% in adults. Matrix metalloproteinases play an important role in the degradation of the TMJ and the matrix metalloproteinase 1 (MMP1) 1607 1G/2G polymorphism increases the local expression of MMP1 thus leading to accelerated degradation of the extracellular matrix. The objective of this study was to evaluate the association between the 1607 1G/2G polymorphism of MMP1 gene and DDWR in a group of Mexican individuals from western Mexico. A total of 67 unrelated individuals, between the ages of 18 and 36 years, of both genders, were included in this study. Study participants with DDWR were required to meet the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), while a second control group of 90 individuals without DDWR were also included. Both groups were required to have paternal and maternal ancestry (grandparents) of the same geographic and ethnic region. Genotypes were determined using the nested PCR technique. The 1G/2G polymorphism was found in 68.7%, followed by 2G/2G in 25.4% and 1G/1G in 6.0% of the cases group. While the prevalence in the control group was 55.5% for the 1G/2G polymorphism, 26.6% for 1G/1G and 17.7% for 2G/2G. An association was found between the 2G allele of the 1607 1G/2G polymorphism of MMP1 gene and the presence of DDWR in the patients of western Mexico.

Resumo O deslocamento anterior do disco com redução (DADR) é considerado um dos distúrbios mais comuns na articulação temporomandibular (ATM), com prevalência de 41% em adultos. As metaloproteinases da matriz desempenham um papel importante na degradação da ATM e o polimorfismo 1607 1G/2G da metaloproteinase da matriz 1 (MMP1) aumenta a expressão local da MMP1, levando à degradação acelerada da matriz extracelular. O objetivo deste estudo foi avaliar a associação entre o polimorfismo 1607 1G/2G do gene MMP1 e a DADR em um grupo de indivíduos mexicanos do oeste do México. Um total de 67 indivíduos não relacionados, com idades entre 18 e 36 anos, de ambos os sexos, foram incluídos neste estudo. Os participantes do estudo com DADR foram obrigados a cumprir os Critérios de Diagnóstico de Pesquisa para Disfunções Temporomandibulares (CDP/DTM), enquanto um segundo grupo controle de 90 indivíduos sem DADR também foi incluído. Ambos os grupos tinham ascendência paterna e materna (avós) da mesma região geográfica e étnica. Os genótipos foram determinados pela técnica de nested PCR. o polimorfismo 1G/2G foi encontrado em 68,7%, seguido por 2G/2G em 25,4% e 1G/1G em 6,0% do grupo de casos. Enquanto a prevalência no grupo controle foi de 55,5% para o polimorfismo 1G/2G, 26,6% para 1G/1G e 17,7% para 2G/2G. Foi encontrada uma associação entre o alelo 2G do polimorfismo 1607 1G/2G do gene MMP1 e a presença de DADR nos pacientes do oeste do México.