Comparison of device-supported sensorimotor training and splint intervention for myofascial temporomandibular disorder pain patients.

This study was to compare the short-term therapeutic efficacy of device-supported sensorimotor training with that of standard splint therapy for patients with myofascial temporomandibular disorder (TMD) pain over a treatment period of 3 months. We tested the hypothesis that both types of intervention are equally effective for pain reduction. In addition, the electromyographic (EMG) activity of the temporal and masseter muscles was recorded under conditions of force-controlled submaximum and maximum biting in intercuspation. Of consecutive patients seeking treatment for non-odontogenic oro-facial pain, 45 patients with myofascial TMD pain (graded chronic pain status, GCPS, I and II) were randomly assigned to 2 treatment groups (sensorimotor training and conventional splint treatment). Patients were evaluated 4 times (initial examination, 2, 6 and 12 weeks later) by use of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). Electromyographic activity was recorded at the initial session and after 3 months. Ease-of-use of the treatment options was also evaluated. Significant (P < .0001) pain reduction (sensorimotor training 53%, splint therapy 40%) was achieved for both groups, with no significant differences (P > .05) between the groups. Force-controlled sub-maximum normalized electromyographic activity was significantly different between T0 and T3 for group A (sensorimotor training, P < .05) but was not significantly different for group B (splint, P > .05). For normalized maximum-biting EMG activity in intercuspation, however, a significant increase in EMG activity was observed for group A for the masseter and temporal muscles (P < .001) and for group B for the masseter muscle only (P < .001). Moreover, sensorimotor training was significantly (P < .05) less easy to use than the splint. The results of this study confirm the pain-reducing effect of sensorimotor training for patients with myofascial TMD pain (GCPS I and II). This innovative active treatment might be a promising option for TMD pain patients.

Standard and limit values of mandibular condylar and incisal movement capacity.

A clinical functional status was obtained and an instrumental analysis of functional movement patterns of the mandible using the ultrasonic Jaw Motion Analyzer (JMA, Zebris; Isny, Germany) was performed on 259 subjects (100 male, 159 female) who were part of an associated project of the representative population-based Study of Health in Pomerania (SHIP 0). Standardized bilateral "arbitrary" skin points based on anatomical skin references were assumed as posterior reference points in the joint area. The recorded movement patterns were evaluated for condylar movement capacity right and left upon mouth opening (COR and COL, in mm), the incisal right-lateral and left-lateral excursion capacity (IR and IL, in mm), the incisal opening capacity (IO, in mm), and the maximum opening angle (OA, in degrees). For the determination of the standard and limit, the following means were determined with standard deviations and 5th and 95th percentiles: COR 14.52 +/- 4.188 (7.70, 21.40); (33.40; 56.10); OA 32.16 +/- 5.954 (21.40; 41.80). The values for men vs women for IR and for OW and in the age group below 40 years vs 40 years and above for IR were statistically significantly different. Interestingly, the interval between the 5th and 95th percentile in the group with a Helkimo clinical dysfunction index of 1 and approximately the same mean value was significantly greater than in the group with Helkimo 0. Based on this standard and limit values or ranges, individually measured values of functional mandibular movement can be compared and differentiated with respect to hypomobility/limitation (< 5th percentile) or hypermobility (> 95th percentile). This serves to indicate the therapeutic direction for functional treatment to improve the jaw's movement capacity in terms of biomechanical optimization. Objective kinematic measurements can be used for additional documentation of the treatment progress during the treatment course.

Variability and reliability of muscle activity measurements during chewing.

The objective of this study was to test masseter muscle activity and its variability and reliability in terms of repeatable measurements in fully dentate and healthy volunteers during habitual chewing and deliberate unilateral chewing. Three sessions were performed on three consecutive days, each time recording kinematic data and masseter muscle EMG activities through a series of defined jaw exercises, including maximum voluntary contraction, habitual chewing, and left and right unilateral chewing. Asymmetry index (AI) and deliberate chewing index (DCI) scores were used to evaluate the activities of the left and right masseter muscles, which were separately recorded during each of these chewing exercises. DCI scores were side-specific, including two sets of values for left and right unilateral chewing. Reproducibility testing of the values obtained for all parameters revealed good to excellent reproducibility of masseter muscle activity under standardized recording conditions across the consecutive study sessions, with intra-class correlation coefficients (ICCs) ranging from 0.68 to 0.93. Different individuals were found to utilize different strategies of bilateral masseter activation during both habitual chewing and deliberate unilateral chewing.

Occlusion of artificial teeth in partial dentures in the "chewing center"--first exploratory population-based evaluations.

Occlusal performance is a substantial determinant of the quality of dental prosthetic restorations. In the follow-up (SHIP 1) to the Study of Health in Pomerania (SHIP), a representative population of 3300 subjects was studied in the first exploratory evaluation of the occlusion of artificial teeth in the chewing center (first molar region) of partial dentures. A digital analysis of interocclusal records of habitual intercuspation position (ICP) was performed using the Greifswald Digital Analyzing System (GEDAS), a software package that identifies contact points as transparent areas. 562 subjects (280 men aged 61.7 ± 11.9 years and 282 women aged 60.7 ± 10.7 years) had maxillary removable partial dentures (RPDs), and 619 (271 men aged 65.0 ± 11.5 years and 348 women aged 62.4 ± 10.6 years) had mandibular RPDs. Most RPDs were retained with either attachment retainers (11.7% maxilla, 11.7% mandible), cast clasps (38.4% maxilla, 40.7% mandible), telescopes with double crowns (15.7% maxilla, 19.1% mandible), or wrought wire clasps (16.4% maxilla, 8.2% mandible). Some had a combination of different retention elements. The mean number of artificial teeth was 7.8 ± 2.9 in the maxilla and 7.5 ± 3.0 in the mandible. Only the artificial teeth (first molars) in mandibular partial dentures showed differences in the frequency of occlusal contacts between groups (chi-square test). Of these, telescopic crown-retained RPDs had the highest frequency of occlusal contacts (74.4% at tooth 36 and 77.1% at tooth 46), and wrought wire-retained RPDs had the lowest (48.4% at tooth 36 and 45.2% at tooth 46). The results for RPDs with a free-end saddle were comparable and analogous; contact frequencies for those with an interdental saddle did not differ significantly. Notably, the overall frequency of occlusal contacts was greater for tooth 46 (62.9%) than for tooth 36. In conclusion, when replacing teeth in the chewing center, particularly in the mandible, telescopic crown-retained RPDs offer a distinct advantage in terms of occlusal contacts and thus provide better occlusal stability.

Surface EMG of the masticatory muscles (Part 3): Impact of changes to the dynamic occlusion.

The third part of this literature review on the clinical relevance of surface electromyography (EMG) of the masticatory muscles summarizes the results of clinical studies in patients with temporomandibular disorders (TMD), preferably randomized controlled trials, examining the impact of changes to the dynamic occlusion. Clenching in left and right laterotrusive positions results in decrease in EMG activity of masseter and temporalis muscles on both working and non-working side. Masseter muscle exhibits largely uniform bilateral activity in laterotrusive positions, independent of canine guidance or group function with and without non-working side contacts. There is a dominance of temporalis muscle activity on the working side and, in case of posterior contacts and balancing contacts, temporalis muscle activity increases and changes from an unilateral to a symmetrical pattern.

Surface EMG of the masticatory muscles (part 2): fatigue testing, mastication analysis and influence of different factors.

The second part of this review of the literature on the clinical significance of surface electromyography (EMG) of the masticatory muscles systematically examines the results of clinical studies in patients with temporomandibular disorders (TMD), preferably randomized controlled trials, investigating relevant aspects of EMG activity during prolonged chewing activity (fatigue effects), during the mastication process, and under the influence of different factors. Studies on the influence of factors such as gender, age, tooth status, orofacial morphology and (acute) pain, the significance of different occlusal relationships during static and dynamic occlusion, and the impact of changes in static occlusion on EMG activity of the masticatory muscles were included in the review.

[Clinical management of masticatory muscle pain: an update of the recommendations]. / Therapie bei Schmerzen der Kaumuskulatur: Aktualisierung der Empfehlungen.

Besides the different forms of odontalgia, myalgias of the masticatory muscles are the most frequent noninfectious complaints in the orofacial region. After summarizing the recommendations set forth by the Interdisciplinary Working Group of Orofacial Pain within the German Chapter of the IASP (German Pain Society), we present the current state of knowledge regarding the etiology, diagnosis, and therapeutic options, based on an extensive literature search. A systematic literature search was carried out in PubMed, the Cochrane Library, and the database of the Deutsche Zahnärztliche Zeitschrift. The results corroborate our previous recommendations that for the majority of patients pain reduction or pain relief can be achieved with noninvasive, reversible methods. Short- and long-term trials have added more evidence to the fact that different therapeutic measures have similar efficacy. In patients with chronic myalgias of the jaw muscles, involvement of a psychotherapist is crucial. Patient education, oral appliances, physiotherapeutic exercises, and acupuncture are recommended therapeutic measures, while physical therapy, pharmacotherapy, and psychological therapy received a limited recommendation.

Correlation between computer-assisted measurements of mandibular opening and closing movements and clinical symptoms of temporomandibular dysfunction.

197 subjects (74 male, 123 female) were evaluated in this Study of Health in Pomerania associated project (SHIP 0). Both a clinical functional status and an instrumental analysis of functional movement patterns of the mandible were performed in each subject, in the latter case using an ultrasonic jaw motion analysis system. Correlations between instrumental movement pattern features and clinical signs and symptoms of temporomandibular joint dysfunction (TMD), such as joint sounds, palpable impairment of jaw movement, and the termination of opening movement at the incisal point, were particularly significant (p <0.005). Correlations for TMJ crepitation sounds and joint pain on palpitation from the lateral or posterior aspect tended to be less significant (p < 0.1). No association was found for pain on jaw movement or muscle tenderness in response to pressure. A multivariate logistic regression model showed a significant correlation between Helkimo Clinical Dysfunction grades 2 and 3 and the following independent variables: frequent headaches (odds ratio [OR] 4.12; p = 0.032), frequent popping sounds in the jaw joints (OR 5.79; p = 0.012), incisal paths showing conspicuous signs of dysfunction such as deviation or deflection (OR 4.35; p = 0.05), and condylar path anomalies such as jumpy, straight/inverse or irregular tracings (OR 28.59; p = 0.006). Instrumental functional analysis of condylar path tracings allows one to draw statistically valid conclusions about the occurrence of TMD symptoms. It can be helpful to perform condylar path analysis when performing risk assessments for temporomandibular dysfunction in certain situations, particularly before prosthetic rehabilitation.

DREEM on, dentists! Students' perceptions of the educational environment in a German dental school as measured by the Dundee Ready Education Environment Measure.

OBJECTIVES: The educational climate in which future doctors are trained is an important aspect of medical education. In contrast to human medicine, it has been rather neglected in dental educational research. The aim of the study was to supplement this lack by applying and validating the Dundee Ready Education Environment Measure (DREEM) for the first time in a German-speaking sample of dental students. METHODS: All dental students at the Medical Faculty of Heinrich-Heine-University Düsseldorf were asked to complete a German adaptation of the DREEM and the Düsseldorf Mission Statement Questionnaire (DMSQ) in a paper-pencil survey. Data from 205 participants were analysed. Psychometric validation included analysis of item homogeneity and discrimination, test reliability, criterion and construct validity (convergent, factorial). RESULTS: DREEM item parameters were satisfactory, reliability (α = 0.87) and convergent validity (r = 0.66 with DMSQ) were also high. Factor analyses, however, yielded dimensions which did not fully correspond to the original DREEM subscales. Overall perception of the educational environment was positive (DREEM total score = 122.95 ± 15.52). Students in the clinical part of course rated the atmosphere more negatively, but their academic self-perception more positively than preclinical students. CONCLUSIONS: Showing satisfactory psychometric properties, DREEM proved suitable for assessing educational environments among dental students. Given the right circumstances, e.g., small and early clinically oriented classes, traditional curricula can generate positive environments.

Clinical relevance of surface EMG of the masticatory muscles. (Part 1): Resting activity, maximal and submaximal voluntary contraction, symmetry of EMG activity.

Based on a comprehensive computerized literature search supplemented by a specific manual search of the literature, the present review article focuses on concrete aspects of the application of surface electromyography (EMG) for evaluation of the masticatory muscles in general and of the masseter and anterior temporal muscles in particular, and presents the current base of knowledge on the clinical relevance of surface EMG in dental applications. In the first stage of the review, publications from the year 2000 or later reporting the results of controlled clinical trials (randomized as far as available) of patients with craniomandibular or temporomandibular disorders (TMD) were analyzed. Data from the selected publications were systematically compiled and divided into subject areas as follows: Resting activity, maximal and sub-maximal voluntary contraction, symmetry of EMG activity, and fatigue effects; EMG activity during mastication, factors (including pain) that affect EMG activity, and the impact of adjusting static and dynamic occlusal relationships; Effects of occlusal splints and other occlusal treatments. Surface electromyography is in principle a suitable tool for neuromuscular function analysis in the field of dentistry. If used according to the specific recommendations and in conjunction with a thorough and conscientious clinical history and physical examination, surface EMG measurements can provide objective, documentable, valid, and reproducible data on the functional condition of the masticatory muscles of an individual patient.

[Dental education in Germany: new concepts for the dental curriculum]. / Die zahnärztliche Ausbildung : Neue Lehrkonzepte im Studiengang Zahnmedizin.

In Germany, the dental curriculum is still based on dental licensing regulations ("Approbations-/Prüfungsordnung für Zahnärzte") from 1955. Essential changes of the dental licensing regulations have not been made for over 50 years-unlike the medical licensing regulations in Germany. Teaching and learning concepts have, nevertheless, changed considerably in medical and dental education over time. The present study delivers an analysis about reform initiatives in dental education in Germany and introduces examples of innovative projects. To be able to establish long-term and broad reforms in dental education, new licensing regulations for dentists are required. This should create a contemporary framework for education, which assigns resources and enables occupational profile development at specific locations. Thereby, compatibility with the medical curriculum has to be guaranteed just as required adaptations of admission and curricular capacity regulations for dentistry.

[Suggestion for a classification of odontalgias]. / Vorschlag einer Klassifikation der Odontalgien.

BACKGROUND: Toothache prevalence in the overall population is considerable. However, for clinical purposes, the classification schemes available do not appear to be sufficiently sophisticated. Moreover, not all known forms of dental pain are considered. A refined classification that meets current standards is therefore introduced. To facilitate diagnosis, the characteristic features of the various types of odontalgia are summarized. RESULTS: The new classification differentiates among seven different origins of pain: 1. dentinal pain (originating from the pulpal tissues), 2. pulpal pain (originating from the pulpal tissues), 3. periodontal pain, 4. alveolar-osseous pain, 5. atypical odontalgia, 6. heterotopic dental pain, 7. odontalgia associated with primary psychosocial factors. CONCLUSIONS: In our opinion, the proposed classification differentiates among the different forms of odontalgia more precisely than all previous ones. However, its viability and advantages over other available classification schemes still need to be verified in daily practice.

Surface electromyography of the masticatory muscles for application in dental practice. Current evidence and future developments.

On the basis of well-founded clinical evaluations and taking into account special methodological recommendations, surface electromyography (EMG) enables the acquisition of valid and reliable quantitative data on the functional condition of the masticatory muscles as a "neuromuscular functional analysis". On the basis of a current review of the literature, surface EMG appears to be able to deliver additional diagnostic and therapy-relevant information. Meaningful EMG data can be gained regarding resting activity, maximum muscle activation, frequency spectrum under various loading conditions, as well as bilateral symmetry of the contraction behavior of the jaw muscles. With these parameters--completed by kinematic information on movements of the mandible--it appears to be possible under clinical conditions to assess (a) the neuromuscular chewing performance after prosthetic reconstructions, (b) to record the influence of pain on the neuromuscular system, and (c) to document the individual efffect of therapeutic interventions on temporomandibular disorders.

[Therapy of temporomandibular joint pain: recommendations for clinical management]. / Therapie bei Arthralgie der Kiefergelenke: Empfehlungen zum klinischen Management.

Arthralgias of the temporomandibular joint occur rarely in their isolated form, in contrast to myalgias of the jaw muscles. Most often, arthralgias are combined with myofascial pain. Here we define relevant terms (arthralgia, arthropathy, arthritis, osteoarthritis/osteoarthrosis), describe special diagnostic aspects and provide diagnosis-related specifications. We then present current information on the clinical management of temporomandibular joint pain. A systematic literature search revealed that pain reduction or pain relief can be achieved with non-invasive reversible methods for the majority of patients. Results from short and long-term longitudinal studies show that different therapeutic methods are similarly effective. For the management of chronic forms with extensive psychosocial impairment a multidisciplinary approach is essential.

[Therapy of masticatory muscle pain: recommendations for clinical management]. / Therapie bei Schmerzen der Kaumuskulatur: Empfehlungen zum klinischen Management.

Myalgias of the masticatory muscles are the most frequent noninfectious complaints in the orofacial region. After summarizing the current knowledge on the physiology, etiology, pathophysiology, diagnosis, and differential diagnosis of masticatory muscle pain, we specifically focus on management recommendations. Results of an extensive literature search show that for the majority of patients pain reduction or pain relief can be achieved with noninvasive reversible methods. Longitudinal short- and long-term studies have revealed that different therapeutic measures are similarly effective. In patients with chronic masticatory myalgias associated with psychosocial impairment, however, additional involvement of a psychotherapist is crucial.

[Pain drawings of patients with orofacial pain. Comparison of acceptance and gain of information]. / Schemata zur Schmerzeinzeichnung bei Patienten mit orofazialen Schmerzen. Vergleich von Akzeptanz und Informationsgehalt.

AIM OF THE STUDY: The aim of this prospective multicentric study was to compare two different types of pain drawings in terms of acceptance and gain of information in patients with orofacial pain. PATIENTS AND METHODS: A total of 204 patients from 9 centers, who visited their dentist or physician for orofacial pain, received two different diagrams for pain drawings in random order. One was the original pain diagram of the Deutsche Schmerzfragebogen (German Pain Questionnaire, diagram A), and the other diagram had been developed to achieve a symmetrical representation of the body and to allow computer-assisted analysis (diagram B). This diagram was larger and contained a drawing of the head. The patients' answers were analyzed for the preference between diagrams, the number and distribution of pain areas, and the concordance between the diagrams. The results were correlated with the patients' data. RESULTS: Data from 183 patients could be analyzed: 100 of 183 patients preferred diagram B and 57 of 183 preferred diagram A, independent of gender, age, or duration of disease. Most patients reported pain in more than one area; in only 43 of 183 patients was the pain limited to the face and head. The number and distribution of pain areas were not different between the two pain diagrams. CONCLUSIONS: Detailed head and body diagrams can be used in the diagnostic evaluation of patients with orofacial pain without fear of placing excessive demands on the patients and are useful for detecting comorbidities.

[Recommendations for the standardized evaluation and classification of painful temporomandibular disorders: an update]. / Aktualisierung der Empfehlungen zur standardisierten Diagnostik und Klassifikation von Kaumuskel- und Kiefergelenkschmerzen.

BACKGROUND: In 2000, the interdisciplinary Working Group of Orofacial Pain within the German Chapter of the IASP (German Association for the Study of Pain) published recommendations for the standardized evaluation and diagnostic classification of patients with painful masticatory muscles and/or temporomandibular joints. The purpose of the present study was to critically review and update these recommendations. RESULTS: Appraisal of the relevant literature published after the release of the recommendations (up to December 2005) shows that the two-axis approach for the assessment of the somatic and psychosocial parameters of the orofacial pain experience has found wide support. Single aspects of the recommendations have been substantiated by additional scientific evidence. CONCLUSIONS: The recommendations reflect the current state of pain medicine. Therefore, they should be considered among practitioners who diagnose and manage patients suffering from temporomandibular disorders.

Efficacy of stabilization splints for the management of patients with masticatory muscle pain: a qualitative systematic review.

This study aimed at providing an answer to two clinical questions related to patients with masticatory muscle pain: 1) Does the use of a full-coverage hard acrylic occlusal appliance (stabilization splint) lead to a significant decrease of symptoms? and 2) Is the treatment success achieved with a stabilization splint more pronounced than the success attained with other forms of treatment (including placebo treatment) or no treatment? A systematic search was carried out in different electronic databases, supplemented by handsearch in four selected dental journals and by examination of the bibliographies of the retrieved articles. Thirteen publications, representing nine controlled clinical studies, could be identified. Reporting quality of most studies as assessed with the Jadad score ranged from 1 to 5. Based on the currently best available evidence it appears that most patients with masticatory muscle pain are helped by the incorporation of a stabilization splint. Nevertheless, evidence is equivocal if improvement of pain symptoms after incorporation of the intraoral appliance is caused by a specific effect of the appliance. A stabilization splint does not appear to yield a better clinical outcome than a soft splint, a non-occluding palatal splint, physical therapy, or body acupuncture. The scarcity of current external evidence emphasizes the need for more and better clinical research.

[Diagnostic imaging assessment of temporomandibular joint pain]. / Bildgebende Diagnostik bei Schmerzsymptomatik im Kiefergelenkbereich.

INTRODUCTION: In the diagnostic process imaging is frequently performed for confirmation of pain symptoms or imaging-based signs were used for conclusions on pain. Therefore, the aim of this review was to show evidence about the association between temporomandibular joint (TMJ) pain - as a subgroup of orofacial pain conditions - and findings on TMJ images. METHODS: By handsearch and computer-based search statements of clinical studies, especially of the past 20 years, were collected and critically assessed. RESULTS AND CONCLUSIONS: In the literature there exist some references to and indications for an association between TMJ pain and structure-based findings on TMJ images, i.e. morphology of the condyle, condyle-fossa relationship, form and position of the disc, signs of effusion of the upper resp. lower joint compartment, bone marrow signal abnormalities of the condyle, signal characteristics of the retrodiscal tissue. Despite some hints the relation between TMJ pain and so-called abnormalities on TMJ images remains unclear, complex and little predictive in individual cases.