Otalgia and aversive symptoms in temporomandibular disorders.

The term Costen's syndrome has been used in the dentomedical literature to describe a constellation of craniofacial symptoms. Since some of the same complaints have been reported in patients with "generalized" psychological distress, symptoms associated with the syndrome may not be useful in differential diagnosis of temporomandibular disorders. The present study investigated whether some somatic complaints, particularly tinnitus and dizziness, were pathognomonic in patients with chronic temporomandibular pain. Illness behavior and personality factors were studied for possible interrelationships with these symptoms. Factor analysis revealed that tinnitus and dizziness loaded on separate factors. Tinnitus loaded with nasal stuffiness, tearing, and itching of the eyelids and nose, while dizziness loaded with complaints of altered taste and smell and blurred vision. Neither was consistently related to measures of pain or to indices of illness behavior or somatic focus.

Suppression of first pain and slow temporal summation of second pain in relation to age.

BACKGROUND: Thermal stimuli delivered to skin of the arms or legs can produce a sensation of two distinct pains. These pains have been associated with activity in A-delta (first pain) and C-fiber (second pain) nociceptive fibers, respectively. Under appropriate conditions first pain decreases in intensity (adaptation) while second pain increases in intensity (slow temporal summation). Change in first and second pain to repeated stimulation of skin has not been assessed in relation to age. METHODS: Ten younger (M = 25 years) and ten older (M = 65 years) subjects participated in a study of first and second pain intensity elicited by nociceptive range heat pulses (.7 second pulses; adapting temperature 39 degrees C to a stimulus temperature of 51 degrees C) delivered to skin of arms and legs. Response times to sensations of first and second pain were assessed to provide evidence that subjects were responding to first and second pain. RESULTS: Age groups did not differ on pain intensity ratings of initial stimuli to previously unstimulated skin for either first or second pain. Older subjects failed to evidence slow temporal summation of second pain at the leg. Response times to first, but not second pain from the leg were delayed in the elderly. Response times to first and second pain at the arm did not differ with age. Auditory response times were slower in the older group. CONCLUSIONS: Age did not influence pain intensity to unadapted and unsensitized skin. Slow temporal summation of second pain was not observed at the leg in the older group, suggesting that mechanisms subserving C-fiber mediated sensitization of second order nociceptive neurons may fail with age. Longer response times to first, but not second pain in older subjects may represent an age effect on myelinated (A-delta; first pain) and not unmyelinated (C-fiber; second pain) nociceptive afferents and may represent a type of small fiber peripheral neuropathy.

Pain-related limitation in activities of daily living in patients with chronic orofacial pain: psychometric properties of a disability index.

Pain-related limitations in activities of daily living are presented for 272 patients reporting orofacial pain of the temporomandibular region using the seven-item Pain Disability Index. Results showed that the factor structure for orofacial pain patients differed little from the factor structure for outpatients visiting chronic pain clinic settings. Analysis of pain diagnostic subgroups showed that patients suffering myogenous complaints had higher scores for four of seven daily-living activities that involved pain-related limitations than patients suffering discal disorders. The factor analytical findings indicated that these patients share common pain-related limitations in activities of daily living. These findings are also consistent with previous results indicating greater pain in orofacial pain patients diagnosed with pain complaints primarily myogenous in origin than in pain patients having discal disorders.

Interexaminer comparison of bone scintigraphy and panoramic radiography of temporomandibular joints: correlation with signs and symptoms.

Panoramic radiographs of the temporomandibular joints of patients with orofacial pain were examined for evidence of pathology by three different groups of four dental specialists and by a group of four general dentists. Bone scans of the same joints were used as the "gold standard" for identification of disorder and indicated a low rate of correct readings by the four professional groups. When the symptomatic side of the complaint was used as the gold standard, there was no statistically significant association with the bone scan observations. Comparative analysis of other patient symptoms showed little agreement with panoramic radiographs and scintigraphs. Reliability estimates may be highly variable, even among clinical experts. These results show that neither radiologic technique would be definitive for diagnosis of TM disorders.

Symptom report in orofacial pain patients: relation to chronic pain, experimental pain, illness behavior, and personality.

A study was conducted to determine symptom report patterns in a heterogenous population of orofacial pain patients and to evaluate how symptom patterns relate to various dimensions of the human pain experience. Results indicated that symptoms frequently associated with chronic orofacial pain disorders can be described by four indices related to the temporomandibular joint (TMJ) and its movement; discomfort of and parafunctional activities related to the masticatory muscles; interference of pain with activities of daily living; and presence of orofacial pain unrelated to myogeneous or arthrogenous TMJ disorders. Of these four symptom indices, only the pain interference (symptom) index was related to clinical pain and illness behavior. None was related to personality. Two of the indices were influenced by diagnosis. Biomechanical symptoms and parafunctional activities appear to be insignificantly related to perceived pain intensity, pain responsiveness, illness behavior, or personality, but are related to diagnosis. The results indicated that relatively simple symptom checklists have potential utility in screening orofacial pain patients and in evaluation of treatment outcome.

Pain assessment in temporomandibular disorders.

Pain characteristics, symptoms, medication use, demographic and psychological variables were assessed in 85 patients diagnosed with temporomandibular (TM) disorders. Results showed that 46 myofascial pain dysfunction (MPD) patients responded differently from 39 temporomandibular joint (TMJ) patients for numerous measures of pain-related variables. MPD patients perceived more generalized facial pain of longer duration and were able to identify more specific symptoms associated with their pain. The only symptom variable rated higher by TMJ patients was the presence of bothersome joint noise. When asked to rate their pain at its worse, the unpleasantness of pain was significantly higher in MPD patients than reported by TMJ patients. MPD patients might be considered more psychologically distressed than TMJ patients, as shown by their higher ratings for anxiety and inability to endure the pain. Although both types of pain patients took the same categories of medications, MPD patients consumed a larger total number. Such findings suggest that the prognosis of the dysfunction for MPD patients would be less favorable than for TMJ patients.

Tinnitus and otalgia in temporomandibular disorders.

A heterogeneous group of 105 TM patients were questioned about tinnitus and otalgia at an initial visit and again at a final visit 32 months later. Analysis of data showed no statistically positive correlation between the two symptoms although most patients had difficulty in separating onset of both symptoms. Tinnitus was more common within 1 to 5 years after onset than 10 to 15 years after onset. Tinnitus appeared to be an individual problem and was neither group- nor gender-related. Few patients identified an etiology for tinnitus. The use of oral appliances seemed to reduce or eliminate symptoms and the number of patients with fluctuating tinnitus decreased by one half between visits. No change occurred for patients with severe tinnitus.

Effects of interferential current stimulation for treatment of subjects with recurrent jaw pain.

This study evaluated the effectiveness of interferential current stimulation (ICS) to decrease recurrent jaw pain and to increase maximum vertical jaw opening. Forty subjects with either a history of recurrent jaw pain of three months' duration or of constant, chronic jaw pain that recurred within the preceding two months participated in the study. Twenty subjects received three 20-minute treatments of ICS, and 20 other subjects received three 20-minute treatments with a placebo procedure. The intensity of jaw pain and the amount of maximum vertical jaw opening were the dependent measures. Scatter diagrams indicated no relationship between the intensity of jaw pain and amount of vertical jaw opening before or after treatment. Statistical tests (p less than .05) showed no significant differences in the level of jaw pain or the amount of maximum vertical jaw opening between the ICS and Placebo Groups. We concluded that a short-term ICS treatment proved no more effective than a placebo treatment for decreasing jaw pain or for increasing vertical jaw opening.

Malocclusion, masticatory muscle, and temporomandibular joint tenderness.

The Angle classification of occlusion, as well as occlusal contacts determined at retrusion, mediotrusion, laterotrusion, and protrusion were recorded from 298 dental students. Various masticatory muscles and the TM joints were palpated simultaneously for tenderness. No significant relationships were observed between (1) tenderness and Angle class or (2) tenderness and any occlusal contact. In relation to a slide between retruded contact position and intercuspal position: measurements for (a) vertical and (b) horizontal displacements, but not (c) lateral deflection, were greater in Class I students without tenderness than in Class I students with tenderness.

Occlusal therapy in the management of chronic orofacial pain.

Review of the literature indicates that most routine orofacial dysfunctions are characterized by deep pain. Various disorders of the masticatory systems, particularly musculoskeletal conditions, are thought to be triggered by occlusal disharmonies. The pain component develops following a pattern of bruxism, muscle hyperactivity, fatigue and spasm. Treatment for most disorders has been to modify the occlusion, although the rational for doing so appears questionable.CRITICAL ISSUES IN THE FIELD OF OCCLUSION RELATED TO OROFACIAL PAIN ARE REVIEWED: occlusal disharmonies, coincidence of retruded-intercuspal contact positions, non-working side interferences, maximum intercuspation of teeth, occlusal adjustment, and occlusal appliances.The studies reviewed fail to support the clinical objective of obtaining equal contact at retruded and intercuspal positions and that the lateral pterygoid muscles stabilize the temporomandibular joint. The relationship between non-working side interferences and pain dysfunction is also not readily supported by controlled studies. Occlusal adjustment appears to be unsatisfactory as a modality for management of pain: not all patients improved following treatment, some relapse occurs even with the most stable contacts, and other treatments such as intra-articular injections of corticosteroids reduced symptoms more readily. Occlusal splints seem to reduce most clinical signs and symptoms on both a short-term and long-term basis. Placement of mandibular orthopedic repositioning appliances results in reduction of pain in some patients, but usually this treatment is followed by extensive rehabilitation.Six major areas are suggested for clinical studies that attempt to relate occlusion to management of orofacial pain. These include: establishment of an ideal jaw position, sequencing of symptoms in the pain history, relationship of pain to other symptoms, development of physiological methods to assess how occlusal modification affects pain perception and pain tolerance, and determination of which treatment modalities produce the most effective relief of pain.

Electron-microscopic study of the rat masseter muscle following injection of lidocaine.

The ultrastructure of rat masseter muscle was examined at 15 min, 1 and 6 h, and 1 and 2 days following a single injection of 2% lidocaine. Lesions developed within 15 min. The plasma membrane was disrupted and invaginated. The nuclei were pyknotic and the mitochondria appeared swollen. The myofibrils separated and became disoriented. By 1 and 6 h, these changes were severe. By 1 day, the macrophages appeared in damaged myofibers. The presence of a few presumptive myoblasts signaled the onset of regeneration. By 2 days, presumptive myoblasts formed within the basement membrane. The basal lamina proved most resistant to injury. Regeneration of masseter muscle following the damage produced by lidocaine appeared discontinuous in nature. The singly nucleated presumptive myoblasts seemed to arise within the lesions.

Degenerative changes in masseter muscle following injection of lidocaine: a histochemical study.

Changes in succinic dehydrogenase, adenosine triphosphatase, and phosphorylase activities occurred in masseter muscle by 15 minutes following injection of 2% lidocaine. Abolishment of phosphorylase activity suggested an effect on the sarcoplasmic reticulum. Increased staining for succinic dehydrogenase and adenosine triphosphatase activities suggested damage to mitochondria and myofibrils, respectively. Leucine aminopeptidase and glucose-6-phosphate dehydrogenase activities appeared in macrophages.

Blinding and pinealectomy in male hamsters: Effects of pineal indoles and P-chlorophenylalanine on testes, seminal vesicles, pituitary and adrenal glands.

No antigonadotrophic (AGT) activity was found after injecting 5 methoxytryptophol (5 MTPH) or both serotonin and melatonin simultaneously in normal male hamsters or hamsters subjected to blinding, pinealectomy, or both surgical procedures. Treatment with these indoles did not induce changes in weights of testes, seminal vesicles, pituitary or adrenal glands. Reproductive organs in hamsters blinded by enucleation atrophied in spite of daily consumption of the vasodilator, Apresoline. Feeding of p-Chlorophenylalanine (PCPA) revealed this antagonist to be mildly toxic. PCPA seemed to interfere in the hypophyseal-adrenal axis: these hamsters lowt the most weight, pituitary glands were enlarged and some hyperactivity occurred in the hamsters.

Regeneration of masseter muscle following lidocaine-induced degeneration. A histochemical study.

The histoenzymatic characteristics of regenerating myofibers of rat masseter muscle following injection of 1% lidocaine, as well as morphometric and histochemical characteristics of the typical myofibers, were investigated. Myoblasts appeared initially by day 1 among numerous macrophages within the confines of degenerating myofibers. Myotubes predominated by the 3rd day. Complete regeneration of the muscle occurred by at least 45 days. Phosphorylase activity was absent at day 1 and reappeared by the 5th day when the regenerating myofibers showed slight activity. By the 15th day the myofiber types had partly differentiated; red myofibers were smaller and stained less intensely than the white myofibers. Myotubes stained uniformly for succinic dehydrogenase activity from 3 until 5 days. After 5 days this staining increased gradually. Myofiber types began differentiation by 15 days and were fully differentiated by 45 days. ATPase activity was barely evident by 1-3 days. This activity appeared uniformly low up to 5 days and increased to an intensity comparable with that of the typical myofiber by 15 days. Slight leucine aminopeptidase activity occurred in macrophages 1 day following injection. By 3 days this activity appeared in the remaining myoblasts and in the myotubes. Some activity was found in the fibroblasts. This staining intensity at 5 days was equal to that of earlier lesions. A trace of this activity was found at 7 days, and none at 15 days. Glucose-6-phosphate dehydrogenase activity was present in the macrophages by day 1. It increased by 3 days and occurred mainly in myoblasts and myotubes. This activity decreased by 5 days, and none was found by 7 days.