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.

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 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.

Quantized magnetic confinement in quantum wires.

Ballistic quantum wires are exposed to longitudinal profiles of perpendicular magnetic fields composed of a spike and a homogeneous part. An asymmetric magnetoconductance peak as a function of the homogeneous magnetic field is found, comprising quantized conductance steps in the interval where the homogeneous magnetic field and the magnetic barrier have identical polarities, and a characteristic shoulder with several resonances in the interval of opposite polarities. The observations are interpreted in terms of inhomogeneous diamagnetic shifts of the quantum wire modes leading to magnetic confinement.

Ambulatory polysomnography for the assessment of sleep bruxism.

Ambulatory polysomnography (PSG) is introduced as a new method for assessing sleep bruxism. Nocturnal recordings of masseter electromyography (EMG), electro-encephalography, electro-oculography, electrocardiography, thoracic effort and body position allow for the detection of typical nocturnal masseter activity as well as the determination of sleep stages. Twelve patients with a clinical diagnosis of bruxism were assessed with the ambulatory PSG, all of them fulfilled diagnostic PSG criteria according to Kato et al. (Dent Clin North Am. 2001; 45: 657-684). Per hour of sleep patients showed 34.2 (+/-10.6) EMG bursts and 5.6 (+/-1.3) sleep bruxism episodes. Because of the ability to determine sleep stages and the application in the home environment the ambulatory PSG represents a cost-saving alternative to sleep laboratory investigations that might be especially useful in field studies and clinical application.

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.

[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.