Reliability of an intraoral extension for intraoral palpation and assessment of mechanical sensitivity of the temporal tendon.

BACKGROUND: The temporal tendon is a structure often compromised in patients suffering from temporomandibular disorders (TMD), yet its intraoral location makes a standardised assessment difficult. OBJECTIVES: To evaluate the variability and accuracy to target force of a newly designed intraoral extension for a palpometer device (Palpeter, Sunstar Suisse) when compared to manual palpation, in addition to clinically assessing the mechanical sensitivity and referred sensations of the temporal tendon in healthy individuals. METHODS: Experiment 1: 12 individuals were asked to target on a scale 0.5, 1 and 2 kg, for 2 and 5 s by using five different methods (Palpeter, Palpeter with three different extension shapes and manual palpation). Experiment 2: 10 healthy participants were recruited for a randomised double-blinded assessment by applying pressure of 0.5, 1 and 2 kg to the right temporal tendon with the three extensions and manual palpation. Participants rated the intensity of their sensation/pain on a 0-50-100 numeric rating scale (NRS), unpleasantness on a 0-100 NRS, and if present, they rated and drew the location of referred sensations. Repeated measures analysis of variance (ANOVA) was used in both experiments to compare differences between palpation methods. Tukey's HSD tests were used for the post hoc comparisons, and p values below .05 were considered significant. RESULTS: Experiment 1: The extensions showed no significant differences between them regarding reliability and accuracy for all forces and durations (p > .05). The manual method was significantly less reliable and accurate when compared to the other methods (p < .05). Experiment 2: There were no significant differences between the Palpeter extensions regarding pain intensity or unpleasantness NRS scores (p > .05), but all the extensions had significantly increased pain intensity and unpleasantness when compared to manual palpation (p < .05). Similarly, the frequency of referred sensations was similar between extensions but increased when compared to manual palpation. CONCLUSIONS: The new Palpeter extensions proved to be significantly more accurate and have lower test-retest variability than the manual method in a non-clinical setting. Clinically, they showed no significant differences in NRS scores for pain intensity nor unpleasantness, with no major differences in referred sensations, making any of the extensions suitable for clinical testing of the temporal tendon in future studies.

Remote physical examination for temporomandibular disorders.

ABSTRACT: There is a need to further develop telemedicine approaches because of the immediate and perhaps long-term consequences of the coronavirus disease 2019. Thus, a remote protocol for assessment of patients with temporomandibular disorders (TMD) was developed, and the agreement of this protocol was compared with the guidelines of the Diagnostic Criteria for TMD (DC/TMD). A total of 16 individuals were first assessed by a reference standard examination (RSE) and 3 other examinations applied in a random order by 3 examiners: standard physical examination (standard examination), physical examination keeping 2-m distance (physical distanced examination), and examination conducted with the aid of video communication technology (video communication examination). The primary outcomes were the diagnoses of myalgia of the masseter and temporalis muscles and arthralgia. The diagnoses of intra-articular joint disorders were considered secondary outcomes because of a less impact on psychosocial functioning and quality of life when compared with the pain-related diagnoses. The Fleiss kappa coefficient and its 95% confidence interval were computed to determine the level of agreement in diagnoses between each examination protocol and the RSE. There was substantial to almost perfect agreement between the RSE and all the examination protocols for the diagnoses of myalgia (0.86-1.00) and arthralgia (0.74-0.87) (P < 0.001). On the other hand, there was an overall poor agreement (0.30-0.58) between the RSE and all the protocols for the diagnosis of disk displacement with reduction. Remote assessment of patients with pain-related TMD is feasible and presents a high degree of accuracy.

Local anaesthesia decreases nerve growth factor induced masseter hyperalgesia.

The aim of this investigation was to evaluate the effects of local anaesthesia on nerve growth factor (NGF) induced masseter hyperalgesia. Healthy participants randomly received an injection into the right masseter muscle of either isotonic saline (IS) given as a single injection (n = 15) or an injection of NGF (n = 30) followed by a second injection of lidocaine (NGF + lidocaine; n = 15) or IS (NGF + IS; n = 15) in the same muscle 48 h later. Mechanical sensitivity scores of the right and left masseter, referred sensations and jaw pain intensity and jaw function were assessed at baseline, 48 h after the first injection, 5 min after the second injection and 72 h after the first injection. NGF caused significant jaw pain evoked by chewing at 48 and 72 h after the first injection when compared to the IS group, but without significant differences between the NGF + lidocaine and NGF + IS groups. However, the mechanical sensitivity of the right masseter 5 min after the second injection in the NGF + lidocaine group was significantly lower than the second injection in the NGF + IS and was similar to the IS group. There were no significant differences for the referred sensations. Local anaesthetics may provide relevant information regarding the contribution of peripheral mechanisms in the maintenance of persistent musculoskeletal pain.

Consensus-based clinical guidelines for ambulatory electromyography and contingent electrical stimulation in sleep bruxism.

As yet, there are still no evidence-based clinical diagnostic and management guidelines for ambulatory single-channel EMG devices, like the BUTLER® GrindCare® (GrindCare), that are used in patients with sleep bruxism. Therefore, a consensus meeting was organised with GrindCare developers, researchers, and academic and non-academic clinicians experienced with the use of ambulatory EMG devices. The aim of the meeting was to discuss and develop recommendations for clinical guidelines for GrindCare usage, based on the existing clinical and research experience of the consensus meeting's participants. As an important outcome of the consensus meeting, clinical guidelines were proposed in which an initial 2-week baseline phase with the device in its inactive (non-stimulus) mode for habituation and assessment of the number of jaw-muscle activities is followed by a 4-week active phase with contingent electrical stimuli suppressing the jaw-muscle activities. As to avoid the commonly reported reduction in sensitivity to the stimuli, a 2-week inactive phase is subsequently installed, followed by a repetition of active and inactive phases until a lasting reduction in the number of jaw-muscle activities and/or associated complaints has been achieved. This proposal has the characteristics of a single-patient clinical trial. From a research point of view, adoption of this approach by large numbers of GrindCare users creates a great opportunity to recruit relatively large numbers of study participants that follow the same protocol.

Masseter corticomotor excitability is decreased after intramuscular administration of nerve growth factor.

BACKGROUND: Quantification of motor-evoked potentials (MEPs) can contribute to better elucidate the central modulation of motor pathways in response to nociceptive inputs. The primary aim of this study was to assess the modulatory effects of nerve growth factor (NGF) injection on masseter corticomotor excitability. METHODS: The healthy participants of this randomized, double blind placebo-controlled experiment were assigned to have injected into the right masseter muscle either NGF (n = 25) or isotonic saline (IS, n = 17). The following variables were assessed at baseline and 48 hr after the injection: right masseter MEP amplitude and corticomotor mapping and clinical assessment of jaw pain intensity and function. Repeated Measures ANOVA was applied to the data. RESULTS: NGF caused jaw pain and increased jaw functional disability after the injection (p < 0.050). Also, the participants in the NGF group decreased the MEP amplitude (p < 0.001) but the IS group did not present any significant modulation after the injection (p > 0.050). Likewise, the participants in the NGF group reduced corticomotor map area and volume (p < 0.001), but the IS group did not show any significant corticomotor mapping changes after the injection (p > 0.050). Finally, there was a significant correlation between the magnitude of decreased corticomotor excitability and jaw pain intensity on chewing 48 hr after the NGF injection (r = -0.51, p = 0.009). CONCLUSION: NGF-induced masseter muscle soreness can significantly reduce jaw muscle corticomotor excitability, which in turn is associated with lower jaw pain intensity and substantiates the occurrence of central changes that most likely aim to protect the musculoskeletal orofacial structures. SIGNIFICANCE: Intramuscular administration of nerve growth factor into masseter muscle causes inhibitory corticomotor plasticity, which likely occurs to prevent further damage and seems associated with lower pain intensity on function.

Revisited relationships between probable sleep bruxism and clinical muscle symptoms.

OBJECTIVES: Sleep bruxism (SB), characterized by repetitive jaw-muscle activity during sleep, is often suggested as a cause of temporomandibular disorders (TMD), orofacial pain, and headache. This study aimed to challenge the relationship between jaw-muscle electromyographic (EMG) activity during sleep and jaw muscle symptoms including pain by modulation of the levels of EMG activity. Contingent electrical stimulation (CES) using a portable single-channel EMG device was applied at different stimulus intensities to inhibit jaw muscle activity. MATERIALS AND METHODS: Sixty probable sleep-bruxers, screened and confirmed by a 2-week use of a portable EMG device, were randomly allocated into one of 3 groups (High/Low/Placebo CES). At baseline and after 2 weeks CES intervention, the participants were asked to score pain intensity, as well as unpleasantness, fatigue, tension, soreness and stiffness in their jaw muscles, on 0-10 numerical rating scales (NRS). RESULTS: Only in the High CES group, the number of EMG events/hour was significantly decreased (P = 0.024). Although the NRS scores of pain did not change, interestingly the NRS scores of unpleasantness (P = 0.037), tension (P < 0.001) and soreness (P = 0.004) in the High CES group and tiredness (P = 0.002) and soreness (P = 0.006) in the Low CES group were significantly decreased after the CES intervention compared to baseline. CONCLUSION: High intensity CES demonstrated inhibitory effect on masticatory muscle EMG activity during sleep and was associated with significant decreases in jaw muscle symptoms (unpleasantness/tiredness/soreness) but not pain responses. These findings challenge the traditional concept that probable sleep bruxism is directly related to pain but appears related to more unspecific muscle symptoms.

Sleep Bruxism and Pain.

Bruxism is an oral behavior that may lead to repetitive jaw-muscle activity characterized by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible with 2 distinct circadian manifestations: sleep bruxism or awake bruxism. They share common risk factors and lead to similar consequences for the masticatory system but may have different etiology and pathophysiology. This oral behavior has been associated with tooth wear, masticatory muscle tenderness, headaches, and painful temporomandibular disorders. Available scientific evidence does not support the view that bruxism is a direct cause of pain, which should be taken into account when treating/managing patients.

Spontaneous jaw muscle activity in patients with acquired brain injuries-Preliminary findings.

PATIENTS: High or excessive parafunctional jaw muscle activity is a frequent complication of acquired brain injury (ABI) and may have some similarities to bruxism. Bruxism has been associated with increased tooth wear, masseter hypertrophy and headaches. The aim of this observational study was to identify the levels of jaw muscle activity from fourteen ABI patients having different functional and cognitive levels in their early phase of neurological rehabilitation (according to their Ranchos Los Amigos Scale (RLAS) score). Nine patients were severely cognitive impairement (RLAS score 1-3): with no or little response to any external stimuli due to low arousal and five patients were with RLAS score 4-8: depending on responses to stimuli and confusion level i.e. defining that patients had enough arousal to respond and react and therefore were able to follow the instructions. A single-channel electromyographic (EMG) device was used to assess the jaw muscle EMG activity in ABI patients for two hours continuously at two different days. DISCUSSION: The mean (±SD) jaw muscle activity observed in patients with ABI was 46.9±6.5 EMG events/h with a wide range between 1-163 EMG events/h but with no significant difference between days (P=0.230). CONCLUSION: Irrespective of functional and cognitive ability scores patients with ABI had a wide range of EMG activity. The use of ambulatory single-channel EMG devices might open a path for further studies to determine levels of jaw muscle activity associated with potential side effects in ABI patients.

Systematic Mapping of Pressure Pain Thresholds of the Masseter and Temporalis Muscles and Assessment of Their Diversity Through the Novel Application of Entropy.

AIMS: To assess the diversity of pressure pain thresholds (PPTs) within the masseter and temporalis muscles by using the novel concept of entropy and to assess the differences in PPT scores between different sites of the masseter and temporalis muscles. METHODS: In this randomized, single-blinded study, the left and right masseter and temporalis muscles of 14 healthy volunteers were divided into 15 sites each, and the PPT was assessed for each of these sites. PPT assessments were performed in two different sessions. Entropy and center of gravity (COG) values were calculated for the PPTs of each muscle. Repeated measures analysis of variance was used to assess differences between muscles, sides, and sites for PPT, entropy, and COG scores. RESULTS: The main findings were: (1) PPT scores varied significantly between the masseter and temporalis muscles and within each of these muscles; (2) entropy values of PPT scores were not different between the masseter and temporalis muscles; and (3) COG values of PPT scores varied statistically, but these changes do not seem to be clinically relevant. CONCLUSION: The results of this study suggest that the anatomical layout of the masseter and temporalis muscles has implications for mechanical pain sensitivity and that areas have different sensitivities within these muscles. Furthermore, reference values for the entropy of PPTs in healthy individuals have been estimated, and comparing these values with those of patients with muscle-related pain conditions can provide quantitative information about the spatial heterogeneity of mechanical pain sensitivity, which may be a valuable clinical outcome measure.

Effects of Experimental Pain and Lidocaine on Mechanical Somatosensory Profile and Face Perception.

AIMS: To assess the effects of experimental muscle pain and topical lidocaine applied to the skin overlying the masseter muscle on the mechanical somatosensory profile and face perception of the masseter muscle in healthy participants. METHODS: A total of 28 healthy participants received a 45-minute application of a lidocaine or placebo patch to the skin overlying the masseter muscle followed by one injection of 0.2 mL sterile solution of monosodium glutamate. Measurements were taken four times during each session of quantitative sensory testing (QST) (T0 = baseline, T1 = 45 minutes after patch application, T2 = immediately after glutamate injection, and T3 = 25 minutes after the glutamate injection), and the following variables were measured: mechanical detection threshold (MDT), mechanical pain threshold (MPT), pressure pain threshold (PPT), pain report (pain on palpation, pain spreading on palpation, and pain intensity), pain drawing, and perceptual distortion. Multi-way within-subjects analysis of variance (ANOVA) was applied to the data. RESULTS: The highest MDTs were present at T2 (F = 49.28, P < .001), the lowest PPTs were present at T2 and T3 (F = 21.78, P < .001), and the largest magnitude and area of perceptual distortion were reported at T2 (F > 6.48, P < .001). CONCLUSION: Short-lasting experimental muscle pain was capable of causing loss of tactile sensitivity as well as perceptual distortion of the face, regardless of preconditioning with a topical lidocaine patch. Short-term application of a lidocaine patch did not significantly affect the mechanical somatosensory profile.

Entropy of Masseter Muscle Pain Sensitivity: A New Technique for Pain Assessment.

AIMS: To test whether manipulation of mechanical pain sensitivity (MPS) of the masseter muscle is reflected in quantitative measures of entropy. METHODS: In a randomized, single-blinded, placebo-controlled design, 20 healthy volunteers had glutamate, lidocaine, and isotonic saline injected into the masseter muscle. Self-assessed pain intensity on a numeric rating scale (NRS) was evaluated up to 10 minutes following the injection, and MPS was evaluated after application (at 5 minutes and 30 minutes) of three different forces (0.5 kg, 1 kg, and 2 kg) to 15 different sites of the masseter muscle. Finally, the entropy and center of gravity (COG) of the pain sensitivity scores were calculated. Analysis of variance was used to test differences in means of tested outcomes and Tukey post hoc tests were used to adjust for multiple comparisons. RESULTS: The main findings were: (1) Compared with both lidocaine and isotonic saline, glutamate injections caused an increase in peak, duration, and area under the NRS pain curve (P < .01); (2) A pressure of 2 kg caused the highest NRS pain scores (P < .03) and entropy values (P < .02); (3) Glutamate injections caused increases in entropy values when assessed with 0.5 kg and 1.0 kg but not with 2.0 kg of pressure; and (4) COG coordinates revealed differences between the x coordinates for time (P < .01) and time and force for the y coordinates (P < .01). CONCLUSION: These results suggest that manipulation of MPS of the masseter muscle with painful glutamate injections can increase the diversity of MPS, which is reflected in entropy measures. Entropy allows quantification of the diversity of MPS, which may be important in clinical assessment of pain states such as myofascial temporomandibular disorders.

Diagnostic validity of self-reported measures of sleep bruxism using an ambulatory single-channel EMG device.

PURPOSE: Self-reported measures have been widely used to indicate the presence of possible and probable sleep bruxism (SB) in both research and clinical situations. However, few studies have attempted to assess the diagnostic validity of this approach. The aim of this study was to estimate the diagnostic validity of self-reported measures of SB using an ambulatory single-channel electromyographic (EMG) device. METHODS: A total of 115 participants were enrolled and examined by standardized Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) including two questions related to SB: self-reported SB and morning-jaw symptoms. An ambulatory single-channel EMG device (GrindCare3™, Medotech A/S) was used for measuring jaw-muscle EMG activity during sleep for seven consecutive nights. Cut-off values for different measures of EMG activity (average, maximum and minimum) and the coefficient of variation (CV) were selected to divide participants into two groups, with higher or lower EMG activity or CV values. The sensitivity and specificity for each question and combination of them were calculated. RESULTS: Self-reported SB had the highest sensitivity (compared with morning-jaw symptoms) for all measures of EMG activity and CV, although the values were low to modest (average: 76.0%, maximum: 76.9%, minimum: 77.3%, CV: 61.0%). The specificity was low for both the questions related to the different measures of EMG activity and CV (35.1-52.4%). CONCLUSIONS: This study indicated that the diagnostic validity of self-reported measures of SB was low to modest using an ambulatory EMG device assessment as a reference. Using only self-reported measures for the assessment of SB may not have a high validity, which should be taken into consideration in the clinical evaluation of patients.

Sleep bruxism: an updated review of an old problem.

Objective To provide an update on what is known about bruxism and some of the major clinical highlights derived from new insights into this old problem in dentistry. Materials and methods A selective, non-systematic but critical review of the available scientific literature was performed. Results There are two main different types of bruxism, which are related to different circadian periods (sleep and awake bruxism) that may differ in terms of pathophysiology, but they share some common signs and symptoms. Approximately one out of 10 adult individuals may suffer from bruxism, but not all bruxers may need treatment. Bruxism is complicated to diagnose in the clinic and self-report of bruxism may not necessarily reflect the true presence of jaw muscle activity. Better understanding has been acquired of bruxism relationships with sleep stages, arousal responses and autonomic function with the help of polysomnography and controlled sleep studies. Meanwhile, there is still much more to learn about awake bruxism. With the available scientific knowledge it is possible to systematically assess the effects of bruxism and its potential risk factors for oral and general health. Moreover, we can be aware of the realistic possibilities to manage/treat the patient suffering from bruxism. Conclusion Bruxism is a parafunctional activity involving the masticatory muscles and probably it is as old as human mankind. Different ways have been proposed to define, diagnose, assess the impact and consequences, understand the pathophysiology and treat or manage bruxism. Despite the vast research efforts made in this field, there are still significant gaps in our knowledge.

Intramuscular temperature modulates glutamate-evoked masseter muscle pain intensity in humans.

AIMS: To determine whether glutamate-evoked jaw muscle pain is altered by the temperature of the solution injected. METHODS: Sixteen healthy volunteers participated and received injections of hot (48°C), neutral (36°C), or cold (3°C) solutions (0.5 mL) of glutamate or isotonic saline into the masseter muscle. Pain intensity was assessed with an electronic visual analog scale (eVAS). Numeric rating scale (NRS) scores of unpleasantness and temperature perception, pain-drawing areas, and pressure pain thresholds (PPTs) were also measured. Participants filled out the McGill Pain Questionnaire (MPQ). Two-way or three-way repeated measures ANOVA were used for data analyses. RESULTS: Injection of hot glutamate and cold glutamate solutions significantly increased and decreased, respectively, the peak pain intensity compared with injection of neutral glutamate solution. The duration of glutamate-evoked pain was significantly longer when hot glutamate was injected than when cold glutamate was injected. No significant effect of temperature on pain intensity was observed when isotonic saline was injected. No effect of solution temperature was detected on unpleasantness, heat perception, cold perception, area of pain drawings, or PPTs. There was a significantly greater use of the "numb" term in the MPQ to describe the injection of cold solutions compared to the injection of both neutral and hot solutions. CONCLUSION: Glutamate-evoked jaw muscle pain was significantly altered by the temperature of the injection solution. Although temperature perception in the jaw muscle is poor, pain intensity is increased when the muscle tissue temperature is elevated.

Effect of contingent electrical stimulation on jaw muscle activity during sleep: a pilot study with a randomized controlled trial design.

OBJECTIVE: To determine the effect of contingent electrical stimulation (CES) on jaw muscle activity during sleep in a double-blinded randomized controlled trial (RCT). MATERIALS AND METHODS: Eleven patients with myofascial TMD (mean age 37 years) and with a clinical diagnosis of bruxism were included. EMG activity (Grindcare®) was recorded from the anterior temporalis muscle during sleep and analyzed online. Jaw muscle activity related to clenching or grinding triggered an electrical square-wave pulse train (450 ms) adjusted to a clear, but non-painful intensity. TMD patients were randomized into two groups: active treatment with CES or no CES (placebo). Number of EMG episodes/hour sleep was the primary outcome parameter. The following variables were assessed as secondary outcome parameters; number of painful muscles, maximum pain-free jaw opening, characteristic pain intensity, depression scores and Oral Health Impact Profile scores. Numerical Rating Scale scores for self-reported pain and muscle tension were registered for at least 4 nights per week during the experiment. RESULTS: The number of EMG episodes/hour sleep was significantly reduced (52 ± 12%) in the CES group during the sessions with CES (ANOVA: p = 0.021) compared to baseline. There were no significant differences in the secondary outcome parameters (ANOVA: p > 0.513) or pain or muscle tension scores between groups (p = 0.645). The average duration of sleep hours during the nights with and without CES was not significantly different (p = 0.646). CONCLUSIONS: These results demonstrate a significant inhibitory effect of CES on jaw muscle EMG activity during sleep in a RCT, but with no effects on self-reported pain.

Comparison of glutamate-evoked pain between the temporalis and masseter muscles in men and women.

Pain in myofascial temporomandibular disorder (TMD) can affect both the masseter and temporalis muscles. Glutamate injection into the masseter muscle evokes pain that is greater in men than in women and this pain is attenuated by co-injection of the N-methyl-d-aspartate (NMDA) receptor antagonist ketamine (10 mmol/L) in men. Animal studies suggested that pain induced by peripheral NMDA receptor activation could differ between the temporalis and masseter muscles and between men and women. The study aims were to investigate differences in glutamate-evoked pain between these muscles and the effectiveness of ketamine to attenuate glutamate-evoked pain in both genders. Pain and mechanical sensitivity were induced in 2 sessions of an experiment in 14 women and 16 men by repeated injections of glutamate (0.5 mol/L) with and without ketamine (20 mmol/L) into the masseter and temporalis muscles. Two injections were applied into the same masseter muscle and 2 injections into the same anterior temporalis muscle at each session. Visual analogue scale (VAS) pain intensities and pain drawing areas were assessed. Glutamate-evoked pain and pain drawing area were significantly greater from the temporalis muscle than from the masseter muscle (P<.02) in both genders. Women reported significantly greater glutamate-evoked masseter muscle pain than men (P<.03). Co-injection of ketamine, at higher dose than previously used, was equally effective in attenuating glutamate-evoked pain from both muscles in both genders (P<.01). The current findings indicate that the characteristics of pain generated by intramuscular injection of glutamate vary for different masticatory muscles and may be partially generated through activation of peripheral NMDA receptors.

Interstitial glutamate concentration is elevated in the masseter muscle of myofascial temporomandibular disorder patients.

AIM: To determine if myofascial temporomandibular disorder (TMD) pain patients have elevated interstitial concentrations of glutamate in the masseter muscle. METHODS: Thirteen patients (3 men, 10 women) diagnosed with myofascial TMD pain and 10 (2 men, 8 women) age-matched healthy controls participated in a single microdialysis session. Microdialysis was performed in the patients in the most painful point of the masseter muscle, while in the healthy subjects a standardized point in the muscle was chosen. Two microdialysis samples were collected over 40-minute epochs. A blood sample was also taken for analysis of plasma glutamate concentration. Numeric rating scale (NRS) scores of pain intensity and unpleasantness, McGill Pain Questionnaire data, pain drawing areas, pressure pain thresholds, pressure pain tolerances, maximum voluntary bite force, and maximum voluntary mouth opening were collected as secondary measurements. RESULTS: The median concentration of glutamate in the masseter muscle of the myofascial TMD pain patients (7.5 ± 2.6 ΜM) was significantly higher (P < .023, Mann-Whitney test) than the concentration in healthy controls (0.5 ± 0.4 ΜM). There were, however, no significant correlations between glutamate concentrations in the masseter muscle and NRS pain scores. Plasma concentrations of glutamate were similar in patients and healthy controls. CONCLUSIONS: The present study demonstrates a marked increase in interstitial glutamate concentration in the masseter muscle of myofascial TMD pain patients. These novel findings suggest that peripheral glutamate could be involved in the pathophysiology of myofascial TMD pain.

Effect of peripheral NMDA receptor blockade with ketamine on chronic myofascial pain in temporomandibular disorder patients: a randomized, double-blinded, placebo-controlled trial.

AIMS: To investigate the effects of local intramuscular injection of the N-methyl-D-aspartate (NMDA) receptor antagonist ketamine on chronic myofascial pain and mandibular function in temporomandibular disorder patients. METHODS: Fourteen myofascial temporomandibular disorder pain patients (10 women and 4 men) were recruited. The subjects completed 2 sessions in a double-blinded randomized and placebo-controlled trial. They received a single injection of 0.2 mL ketamine or placebo (buffered isotonic saline [NaCl], 155 mmol/L) into the most painful part of the masseter muscle. The primary outcome parameters were spontaneous pain assessed on an electronic visual analog scale and numeric rating scale. In addition, numeric rating scale of unpleasantness, numeric rating scale of pain relief, pressure pain threshold, pressure pain tolerance, completion of a McGill Pain Questionnaire and pain drawing areas, maximum voluntary bite force and maximum voluntary jaw opening were obtained. Paired t tests and analysis of variance were performed to compare the data. RESULTS: There were no main effects of the treatment on the outcome parameters except for a significant effect of time for maximum voluntary bite force (analysis of variance; P = .030) and effects of treatment, time, and interactions between treatment and time for maximum voluntary jaw opening (analysis of variance; P < .047). CONCLUSION: These results suggest that peripheral NMDA receptors do not play a major role in the pathophysiology of chronic myofascial temporomandibular disorder pain. Although there was a minor effect of ketamine on maximum voluntary jaw opening, local administration may not be promising treatment for these patients.

Glutamate-evoked jaw muscle pain as a model of persistent myofascial TMD pain?

OBJECTIVE: Compare pain-related measures and psychosocial variables between glutamate-evoked jaw muscle pain in healthy subjects (HS) and patients with persistent myofascial temporomandibular disorder (TMD) pain. DESIGN: Forty-seven female HS and 10 female patients with persistent myofascial TMD pain participated. The HS received an injection of glutamate into the masseter muscle to model persistent myofascial TMD pain. Participants filled out a coping strategies questionnaire (CSQ), the symptom checklist 90 (SCL-90) and McGill pain questionnaire (MPQ). Pain intensity was assessed on an electronic visual analogue scale (VAS). Pain-drawing areas, numerical rating scale (NRS) scores of unpleasantness, pressure pain thresholds (PPTs) and pressure pain tolerance (PPTOL) were measured. Unpaired t-tests and correlation tests were used for analyses. RESULTS: The groups were significantly different when comparing the CSQ scores of control, decrease, diverting attention, increase of behavioural activities and somatization. The peak VAS pain, NRS of unpleasantness and MPQ scores were not significantly different between groups, but PPT and PPTOL were significantly lower in the TMD patients. Significant positive correlations were found in the TMD patients between peak VAS pain and CSQ catastrophizing score and SCL-90 somatization. The scores of PPTs and PPTOLs, in patients showed positive correlations with CSQ reinterpreting pain sensations scores and PPTs correlated with CSQ praying/hoping scores. CONCLUSIONS: Glutamate-evoked pain responses in HS and persistent myofascial TMD pain have similar sensory-discriminative and affective-unpleasantness components but differ in psychosocial features. This study suggests that experimental designs based on glutamate injection into muscle can provide an appropriate model for elucidating persistent myofascial pain conditions.

Effect of a peripheral NMDA receptor antagonist on glutamate-evoked masseter muscle pain and mechanical sensitization in women.

AIMS: To test the hypothesis that local injection of the N-methyl-D-aspartate (NMDA) receptor antagonist ketamine would significantly attenuate glutamate-evoked masseter mechanical sensitization and muscle pain in healthy young women either taking oral contraceptives (W+OC) or not taking oral contraceptives (W-OC). METHODS: Experimental pain was evoked in 47 healthy female subjects (W+OC, n=25; W-OC, n=22) by 2 injections of glutamate (0.2 mL, 1 mol/L) into the masseter muscle. A first injection of glutamate alone was followed by a second injection, 35 minutes later, of glutamate combined with ketamine (0, 1, or 10 mmol/L). Evoked pain intensity was scored on a 10-cm electronic visual analog scale (VAS). Distribution of perceived pain was drawn on a lateral view of the face (pain drawing). Masseter muscle pressure pain thresholds (PPT) and pressure-pain tolerances (PPTOL) were determined bilaterally before and at regular time intervals after injections. Analyses of variance (ANOVA) were used to test the data. RESULTS: There were no main effects of ketamine on any of the VAS pain parameters or on the pain drawing (ANOVAs: P > .055). Furthermore, there were no differences in PPT, PPTOL, VAS peak pain, duration, overall VAS pain, or pain drawing when W-OC were compared with W+OC (ANOVAs: P > .087). Repeated injection of glutamate alone significantly decreased PPT and PPTOL (ANOVAs: P < .001); however, this effect was not significantly attenuated by ketamine. CONCLUSIONS: Peripherally administered ketamine had no effect on glutamate-evoked masseter muscle pain and sensitization in healthy young women, which contrasts with recent observations in healthy young men. Further studies will be needed to reveal the mechanisms that underlie this apparent sex-related difference in ketamine-mediated analgesia.