Thinking of a maladaptive occlusion as an orthopedic cumulative trauma disorder.

AIM: The authors review the possible connection between a dental malocclusion and a temporal mandibular disorder (TMD). METHODOLOGY: The authors have reflected on several patient case histories to remind us that there may be instances when a simple case of dental malocclusion could be blamed for instigating the signs and symptoms of TMD. The common denominator for this discussion is the situation of joint pain, dysfunction and/or myalgia. Patient-reported signs and symptoms, along with treatment results and progress notes were evaluated. RESULTS: The onset of TMD signs could be traced to an altered dental occlusion, which, upon maximum closure drives the mandible in a posterior direction, forcing the condylar head to now impinge upon retrodiscal tissue and the resultant muscle reflex protective response. Correction for the dentally induced malocclusion obviated the symptoms of TMD with patient-reported improved health. CONCLUSIONS: When a patient presents with signs consistent with those of a TMD, the clinician should include a review of recently placed dental restorations or occlusal equilibration to assess the patient's adaptive occlusion. Overlooking this quick evaluation on the exam checklist may lead to the clinician missing a simple treatment modality to address a TMD.

Employee contract issues for dermatologists.

Employees and employers routinely face negotiating and preparing physician employment contracts. It is important for both sides to know and understand the basic information on what a comprehensive employment contract for a dermatologist should contain. There are various employment contract provisions from both the employee's perspective and the employer's perspective that must be considered when preparing physician employment contracts. This article provides basic advice and recommendations on requirements that should be included in such contracts. It suggests legal pitfalls that can be avoided through various contract clauses.

Mandatory reporting of oral injuries indicating possible child abuse.

BACKGROUND: The dental professional may see pediatric patients who have signs of intraoral trauma, perioral trauma or both. Evaluation should include the possibility of nonaccidental, deliberately inflicted abuse. Reporting such injuries is mandated. METHODS: The authors reviewed the criminal and civil statutes in all 50 states to determine what role dental professionals are required to play in instances of abuse or neglect. RESULTS: Mandates in all 50 states require that dental professionals be aware of and report instances of child abuse and neglect to the proper state authority. State laws also protect the reporting dental professional from civil retribution. CONCLUSIONS: State laws and dental ethical duties require all dental professionals to be aware of and to report instances of child abuse or neglect. These same laws protect clinicians in this duty. It is the clinician's responsibility to help prevent ongoing injury to people who are incapable of self-protection. CLINICAL IMPLICATIONS: Clinicians should learn to recognize signs of abuse and neglect, which often involve injury to the mouth and dentition. Dental professionals are mandated to report such abuse to state child protection authorities.

The concurrency of temporal tendinitis with TMD.

Temporomandibular disorder (TMD) is a type of orofacial pain that can originate from a number of craniofacial mandibular structures. These include the TM joints, the muscles of mastication, related nerves, tendons, ligaments, bones and teeth. Symptoms include impaired jaw function, TM joint noises and pain, limited opening, often with jaw deviations or deflections to the affected side. Temporal tendinitis is a disorder of the fibrous insertion of the temporalis muscle tendons on the coronoid process of the mandible that is characterized by both inflammation and degeneration. Sometimes, temporal tendinitis can be the primary disease entity, but the authors found that it frequently coexists with TMD. This retrospective study was undertaken to determine the prevalence of temporal tendinitis with TMD. The charts of 449 patients diagnosed with TMD were reviewed to determine the incidences of temporal tendinitis. The referred pain sites and their incidences were also determined.

Combined Effects of Ephedrine-Containing Dietary Supplements, Caffeine, and Nicotine on Morphology and Ultrastructure of Rat Hearts.

Cigarette smokers have an increased risk for coronary artery disease. Nicotine present in cigarettes can adversely affect the cardiovascular system via stimulation of both sympathetic and parasympathetic neurons. Caffeine, another cardiovascular and central nervous system (CNS) stimulant, is commonly found in Ephedra and Ephedra-free dietary supplements. These caffeine-containing supplements also have been linked to cardiovascular toxicities. Although no longer on the U.S market, Ephedra-containing supplements are another source of cardiovascular and CNS stimulants, namely the ephedrine alkaloids. Together caffeine, nicotine, and ephedrine can individually stress the cardiovascular system, and an overlap of these agents is predicted in smokers and dieters. To understand the collective effects of these stimulants on the heart morphology and ultrastructure, rats were exposed to synthetic combinations of nicotine (0.2 mg/kg/day), ephedrine (0-30 mg/kg/day), and/or caffeine (0-24 mg/kg/day) as well as an extract from a caffeine-containing Ephedra supplement (Metabolife 356). After exposure for 3 days, the hearts were removed and examined for hypersensitivity myocarditis and myocardial necrosis. None of the drugs tested alone affected heart tissue morphology, nor were atypical cardiac cells observed. However, in combination, significant interactions were found between caffeine and ephedrine; the interventricular septum was most susceptible, with a significant increase in atypical cardiac cells observed. Nicotine pretreatment caused greater susceptibility to cardiotoxicity associated with combinations of caffeine + ephedrine or Metabolife, particularly in the left ventricle wall. These results indicate that sympathomimetic combinations present in Ephedra supplements may have produced cardiotoxicity reported in consumers of these products. Moreover, the presence of nicotine exacerbates these toxic effects.

Provocation testing to assist craniomandibular pain diagnosis.

Patients with TMD often present with complex pain symptoms, which can make it difficult to reach a diagnosis. Usually palpation of the masticatory muscles and TM joints, range of motion testing and imaging are used in the diagnostic process. Sometimes it is necessary to evaluate the jaw moving muscles from a functional prospective because they cannot be palpated due to inaccessibility or because they have other structures that are more superficial to them. In these instances, provocation testing can be a helpful adjunct in providing some insight into what is occurring in the area being tested and localizing a suspected source of pain. Anesthesia blocking can be used to confirm any positive findings. This article explores several provocation tests that can be used to evaluate conditions of the masticatory musculature, the TM joints and the stylomandibular ligament.

Masseter tenomyositis.

The masseter muscle is an integral part of the oral facial complex and one of the muscles of mastication. It functions with the other masticatory muscles in moving and posturing the mandible and in verbalizing, eating and swallowing. When a patient has temporomandibular dysfunction (TMD) or a myogenic disorder, the integrity of the masseter muscle can be compromised resulting in pain, malfunction, inflammation and/or swelling. A careful evaluation of the masseter muscles is necessary in facial pain patients since the pain can originate from a distant site and be referred to this area. One of the little known disorders involving the masseter and its tendinous origin is tenomyositis, in which an inflammation of the muscle and its tendon occurs. In this retrospective study, the charts of 114 consecutive patients (N = 114) were evaluated to determine the prevalence of this disorder and the reported etiology.

Comorbidity of pterygoid hamular area pain and TMD.

Often craniofacial pain subjects report a number of conflicting and overlapping symptoms that can present a confusing clinical picture. Reaching a diagnosis on these individuals can prove to be a frustrating and difficult event for both the examiner and the patient. Thus, it is incumbent on clinicians treating patients with pain in the head, face and neck areas to be familiar with the less common pain disorders to assist in the differential review. This retrospective study examines the comorbidity of pterygoid hamulus pain with temporomandibular disorders (TMD). To acquire this information, the charts of 464 subjects with TMD in a private setting were examined to determine if pterygoid hamular pain was found at the evaluation. Ninety-two patients (N=92) had positive findings. Areas of referred pain that were elicited during the examination were charted. The pterygoid hamular area should be evaluated in individuals with TMD and especially those presenting with posterior palate and throat pain.

Threshhold for recovery in the marsh halophyte Spartina alterniflora grown under the combined effects of salinity and soil drying.

A study quantifying the physiological threshhold at which Spartina alterniflora plants are able to tolerate the interactive effects of salinity and soil drying was conducted in a climate controlled greenhouse. The experiment consisted of two levels of salinity (3-5 ppt, L and 35-38 ppt, H) as well as four dynamic water levels: flooding (water level maintained 3-5 cm above the soil surface at high tide and 10 cm below the soil surface at low tide for entire study duration, F), 8-day drought (water level maintained at least 20 cm below the soil surface at high tide for 8 days then flooded, 8 days), 16-day drought (water level maintained at least 20 cm below the soil surface at high tide for 16 days then flooded, 16 days), and 24-day drought (water level maintained at least 20 cm below the soil surface at high tide for 24 days then flooded, 24 days). Plant gas exchange and growth responses were measured along with soil conditions of redox potential and water potential. Significant decreases were seen in plant gas exchange and growth in response to increases in salinity and soil drying. Survival was 100% for all flooded treatments while increased salinity combined with soil drying decreased survival to 86% in both low salt/24-day drought plants (LD24) and high salt/16-day drought plants (HD16). The lowest survival rate was seen in the high salt/24-day drought treatment (HD24) at 29%. Therefore, it appears that the critical time for recovery from the combined effects of increased salinity and soil drying may greatly diminish after two weeks from the onset of stress conditions. Consequently, if salinity continues to increase along the MRDP, marshes dominated by S. alterniflora may be more susceptible to short-term drought and likewise large-scale marsh browning.