A 6-year clinical assessment of electronic facial thermography.

OBJECTIVE: To report the findings a 6-year clinical application of ET on patients with orofacial pain. METHODS: ET was conducted (in a blinded manner) using an Agema 870 unit at 0.1 degree C thermal accuracy. A newly devised thermal classification system was applied: 'normal' when zone delta T was from 0.0 to +/-0.25 degree C, "hot' when zone delta T was > +0.35 degree C, 'cold' when zone delta T was < -0.35 degree C, and 'equivocal' when zone delta T was +/-(0.26-0.35) degree C. Study populations consisted of 164 dental patients mainly with diagnostic problems and 164 matched (control) subjects. RESULTS: Our prospective, matched study determined that subjects with 'hot' thermograms had the clinical diagnoses of sympathetically maintained pain, peripheral nerve mediated pain, TMJ arthropathy, and maxillary sinusitis. Subjects with 'cold' thermograms were found to have the clinical diagnoses of peripheral nerve-mediated pain and sympathetically independent pain. Subjects with 'normal' thermograms were found to have the clinical diagnosis of cracked tooth syndrome, trigeminal neuralgia, pretrigeminal neuralgia, or psychogenic facial pain. The new system of thermal classification resulted in 92% (301 of 328) agreement in classification of pain patients and matched controls. CONCLUSION: These studies suggest that ET has promise in aiding the formation of a differential diagnosis of orofacial pain and may help in understanding mechanisms of pain as well as directing therapies.

Thermographic assessment of neuropathic facial pain.

Ongoing pain, intermittent sharp pain, or intermittent dull aching pain around the teeth can evoke the suspicion of tooth pathology. However, when no dental cause can be found clinically or radiographically, the differential diagnosis involving neuropathic pain and pulpal pathology is still a challenge. Neuropathic facial pains are still too often misdiagnosed as tooth pain of dental origin, resulting in unnecessary dental extraction or endodontic therapy. The purpose of this study was to determine if electronic thermography was able to differentiate neuropathic facial pains presenting as toothache from pulpal pathology. Electronic thermography was used to compare asymptomatic subjects and subjects with neuropathic facial pains. Asymptomatic subjects and subjects with trigeminal neuralgia, pre-trigeminal neuralgia, and pulpal pain without periapical pathology showed no thermographic difference in the territory of the pain complaint when compared to the opposite nonpainful side. Patients with sympathetically maintained traumatic trigeminal neuralgia (atypical odontalgia) and half of the group with sympathetically independent traumatic trigeminal neuralgia presented with "hot" thermograms. The other half of the patients with sympathetically independent traumatic trigeminal neuralgia displayed "cold" thermograms in the area of their pain complaints. Electronic thermography was the least selective test for the group showing "cold" thermogram patterns (80% agreement with the thermographic characterization criteria). These data suggest that electronic thermography may be helpful in differentiating neuropathic pains from pulpal pathology.

Is atypical odontalgia a psychological problem?

Several authors have asserted that psychological factors are the underlying cause of atypical odontalgia. However, objective evidence is lacking to support this claim. In this study, the Minnesota Multiphasic Personality Inventory was used to assess psychological functioning of an atypical odontalgia population. Means of the standard scores for each Minnesota Multiphasic Personality Inventory scale were within normal ranges. Standard scores for atypical odontalgia profiles compared with standard scores for a chronic headache group (matched for age, sex, and chronicity) were similar and scales for both groups were within normal ranges. These findings fail to support psychological dysfunction as a primary condition associated with patients suffering from atypical odontalgia.

Atypical odontalgia.

Atypical odontalgia describes atypical facial pain in apparently normal teeth. Unfortunately, dentists usually consider this diagnosis only after the failure of invasive treatment. Atypical odontalgia patients are typified by women in their mid-40s who complain of persistent pain in one or more premolar or molar teeth. They associate pain with dental procedures or trauma to the region. While the cause of atypical odontalgia is uncertain, deafferentation pain appears to be a plausible mechanism. This article reviews relevant aspects of this perplexing pain problem. To help avert the untimely diagnosis of atypical odontalgia, identifying inclusion criteria are presented.

Guidelines for the treatment of temporomandibular disorders.

These guidelines include the usual and customary treatment approaches recommended for each of the diagnostic categories described in a previous article on the examination and diagnosis of temporomandibular disorders. The current article describes when it is appropriate to use initial therapy, behavior modification therapy, pharmacotherapy, occlusal appliances, physical therapy, and surgical treatment for temporomandibular disorders. The physical therapy procedures described include various exercises as well as pain-relief techniques such as vapocoolant spray, massage, electrical stimulation of muscles and nerves, ultrasound, and trigger-point injections. Pharmacotherapy using muscle relaxant, nonsteroidal anti-inflammatory, tricyclic antidepressant, and narcotic pain medications are also discussed. Occlusal stabilization and repositioning appliances are reviewed as well. Finally, the broad indications for arthroscopic surgery, open surgery, and steroid injections are described.

Electronic thermography in the diagnosis of atypical odontalgia: a pilot study.

Atypical odontalgia (AO) is a dental condition that is usually diagnosed by exclusion after failure of multiple dental treatments. A functional definition of AO includes (1) continuous pain in and about a tooth or teeth, (2) pain present for longer than 4 months, (3) inadequate local cause (no abnormality detected on dental radiographs), and (4) anesthetic blockade gives equivocal relief of toothache. The purpose of this study was to assess the potential role of electronic thermography in the diagnosis of AO. Results from measurements of facial thermal symmetry indicated that normal subjects = 83.5%, AO group = 65.8% (p less than 0.01). Electronic thermography interpreted by thermography experts has promise as a diagnostic test for AO among patients with toothache for which the dentist can find no convincing dental explanation.

Dentists' ability to detect psychological problems in patients with temporomandibular disorders and chronic pain.

Do patients with temporomandibular disorders (TMD) have significant psychosocial problems? Research efforts have sought to determine if these problems exist, and if so, how they influence treatment outcome. Even when psychosocial factors do influence treatment outcome, identifying them by formal psychological tests can be time consuming and costly. Dentists' impressions of the psychological status of these patients were tested to determine if they are an effective method for screening psychological factors thought to influence treatment outcome. The results suggested that a screening procedure based on dentists' impressions from an initial examination do not adequately identify psychological problems in patients with TMD.

Guidelines for the examination and diagnosis of temporomandibular disorders.

These guidelines propose performance criteria for the history and examination of patients with temporomandibular (TM) disorders. Pertinent diagnostic subcategories are identified, and the comprehensive history and review of systems are described. The examination procedures include documentation of temporomandibular and craniocervical range of motion, TM joint sounds, and the recording of muscle and joint tenderness. The TM disorders addressed include muscle problems such as myalgia, protective splinting or trismus, spasm, myositis, dyskinesia, muscle contracture, hypertrophy, and bruxism. Temporomandibular joint disorders addressed include disk-condyle incoordination, restricted condyle translation, open condyle dislocation, arthralgia, osteoarthritis, polyarthritis, and traumatic joint injury. Disorders of mandibular mobility such as ankylosis, adhesions, fibrosis, skeletal obstruction, and hypermobility are also described. Finally, disorders of maxillomandibular growth, including masticatory muscle hypertrophy, atrophy, neoplasia, maxillomandibular hypoplasia, condylar agenesis, maxillomandibular hyperplasia, and condyle hypertrophy are described.

The prevalence of dental attrition and its association with factors of age, gender, occlusion, and TMJ symptomatology.

Dental attrition severity in 222 young adults was assessed from dental casts as the sum of the most severe facet in each arch segment. The attrition scores were compared by age, gender, bruxism awareness, prior bite adjustment, orthodontic class, maxillomandibular relationship, and temporomandibular dysfunction symptoms. Awareness of bruxism was not associated with the wear scores and should not be used to define bruxist groups. Attrition scores did not differ significantly between age groups, indicating that notable attrition, when present, often occurs early. Men had higher attrition scores than women (p less than 0.01), despite fewer signs and symptoms. Dental attrition was not associated with the presence or absence of TMJ clicking, TMJ tenderness, or masticatory muscle tenderness. Class II division 2 males had laterotrusive attrition scores lower than those of Class III (p less than 0.05). Class III females had lower incisor attrition scores than did other Angle Classes (p less than 0.05). Discernible dental attrition in a non-patient population was not associated with signs and symptoms of temporomandibular disorders, nor with the occlusal factors studied. These results are compatible with the findings in other studies that point to bruxism as a centrally induced phenomenon common to all people and unrelated to local factors.

Temporomandibular disorders. Part III: Occlusal and articular factors associated with muscle tenderness.

Two complete classes of freshman dental and dental hygiene students, 120 men and 102 women (mean age 23.9 years), were assessed for the presence of masticatory pain or dysfunction by questionnaire, clinical examination, and evaluation of dental casts. The purpose of these examinations was to determine potential relationships between clinical muscle tenderness, occlusal relationships, and signs of TMJ dysfunction. Awareness of muscle tenderness increased with the number of muscle sites involved (p less than or equal to .025) but 80% of clinically tender subjects were unaware of any tenderness (p less than or equal to .01). In comparison, subjects with generalized clinical muscle tenderness more often reported TMJ clicking that was not verified at the time of clinical examination (p less than or equal to .001). Occlusal factors, except in highly selective categories, were not associated with muscle tenderness. All subjects with moderate or severe TMJ tenderness had clinically tender muscle sites, whereas subjects with generalized muscle tenderness (greater than or equal to 4 sites) had more severe TMJ tenderness (p less than or equal to .01). Subjects with localized (p less than .05) or generalized muscle tenderness (p less than .05) had more TMJ clicking than those without muscle tenderness. TMJ clicking was reported more commonly than muscle pain among subjects who were clinically determined to have both muscle tenderness and TMJ clicking (p less than or equal to .001). TMJ dysfunction was verified more often in subjects with more localized muscle tenderness (p less than or equal to .025). Although occlusal factors were not good predictors of muscle tenderness, intracapsular signs of TMJ disorders and muscle tenderness were often associated.

Temporomandibular disorders. Part II: Occlusal factors associated with temporomandibular joint tenderness and dysfunction.

Two complete classes of freshman dental and dental hygiene students, 120 men and 102 women (mean age 23.9 years) were assessed for the presence of masticatory pain or dysfunction by questionnaire, clinical examination, and evaluation of dental casts according to strict criteria. The purpose was to identify the degree of association between observable signs of TMJ disorders and selected combinations of occlusal variables. TMJ tenderness was more frequent in class II, division 2 than in class I (p less than .05), but overall was not associated with occlusal factors such as deep overbites, length of a symmetric RCP-ICP slide, and unilateral contact in RCP. Overall, clicking was not associated with Angle class, deep overbite, length of symmetric RCP-ICP slide, or unilateral RCP contact. Among subjects with unilateral RCP contact, those with no clinically obvious RCP-ICP slide (p less than .005) and those with asymmetric slides (p less than .05) had more TMJ clicking than subjects with symmetric slides. Luxation clicking of the condyle over the articular eminence on wide opening was absent in class II, division 2 subjects, but was most frequent in subjects with some teeth in unilateral posterior crossbite, particularly when this was a unilateral condition (p less than .001). Certain occlusomorphologic conditions may require less adaptation in the TMJs. This article indicates that an ICP anterior to the RCP in association with bilateral occlusal stability may be protective.

Temporomandibular disorders. Part I: Functional status, dentomorphologic features, and sex differences in a nonpatient population.

Freshman dental and dental hygiene students, 120 men and 102 women (mean age 23.9 years), were assessed for the presence of masticatory pain or dysfunction by questionnaire, clinical examination, and evaluation of dental casts according to strict criteria. The purpose was to identify and analyze the level of signs and symptoms in a nonpatient population and describe occlusal variation. The prevalence of TMJ signs and symptoms was notable even though two thirds reported only mild or early symptoms, with only 3% reporting severe symptoms. This population was noted for the absence of locking, the low frequency of severe pain or severe TMJ dysfunction, and the low prevalence of restricted ranges of mandibular movement and TMJ crepitation. Women showed significantly more headache, TMJ clicking and tenderness, and muscle tenderness than men. Men were noted for the absence of severe and widespread muscle tenderness and severe TMJ tenderness. TMJ clicking was not always clinically confirmable in subjects with widespread muscle tenderness. This group was considered compatible with previous epidemiologic findings, and also matches the age range of most subjects seeking treatment for TMJ disorders. Therefore, the subjects in the study were considered a representative group of young adults and suitable for study of the possible associations between early signs of TMJ disorders and variables of morphologic malocclusion, which are discussed in Parts II and III of this article.

Relationship of mandibular condylar position to dental occlusion factors in an asymptomatic population.

This article investigates the influence of occlusion on condylar position as seen on TMJ tomograms in a group of 44 young adults with no histories of orthodontic or occlusal therapy and no objective signs of masticatory dysfunction; the sample was screened from a population of 253 students. Nonconcentric condylar position at ICP was a feature of Class II malocclusion with significantly more anterior positions in Class II, Division 1 than in Class I. Condylar position was unrelated to the amount of sagittal RCP-ICP slide, although most slides were less than 0.5 mm. The frequency of lateral slides was low, but was mildly related to bilaterally asymmetric condylar positions. Position was unrelated to the degree of overbite, which ranged from 0 to 10 mm. Bilateral condylar position asymmetry was not related to the direction of dental midline discrepancy, which ranged from 0 to 2 mm. No open bites or mandibular overjets were seen in this asymptomatic normal sample.

Histomorphometry of age and sex changes in mandibular condyles of young human adults.

Changes in cartilage, subchondral bone and their interface were studied using sagittal (6-8 micron thick) sections from the lateral, central, and medial parts of 21 condyles (11 males and 10 females; aged 18-36 years). The presence of undifferentiated mesenchymal (UM) cells in the proliferative zone of the cartilage was noted. Five condyles were judged to be immature because they had hypertrophic cartilage, cartilage resorption and bone formation at the cartilage-bone interface, no compact bone in their anterior and the superior regions, and the many cartilage rests in subchondral bone. Four of these immature specimens were from males. Immature specimens had quantitatively thicker cartilage (p less than 0.01), thinner subchondral bone (p less than 0.005), and less bone, more vascular spaces and more cartilage rests, both at the cartilage-bone interface and in the subchondral bone (p less than 0.001). Of the 16 mature condyles, the older had fewer UM cells in the proliferative layer, thicker compact bone (p less than 0.05), less vascular spaces at the cartilage-bone interface (p less than 0.05) and more bone and less vascular spaces in the compact bone (p less than 0.05 and p less than 0.01 respectively). No significant differences were found between mature condyles of males and females, but females had more UM cells, less hyperplastic cartilage and fewer irregularities at the cartilage-bone interface.