Longitudinal Stability of Common TMJ Structural Disorders.

The longitudinal course of temporomandibular joint (TMJ) disc displacement (DD) and degenerative joint disease (DJD) has never been conclusively described with magnetic resonance imaging and computed tomography, respectively. This 8-y observational study's objective was to assess the longitudinal stability of DD and DJD among 401 subjects. The Validation Project provided baseline measures; follow-up was performed in the TMJ Impact Project. With magnetic resonance imaging, 2 radiologists rendered a consensus diagnosis of normal/indeterminate, DD with reduction, or DD without reduction. Computed tomography consensus diagnoses included normal/indeterminate, grade 1 DJD, or grade 2 DJD. Radiologist reliability was assessed by kappa; a Hui-Walter model was used to estimate, after accounting for diagnostic disagreement, the frequency of diagnostic progression and reversal. Permutation tests were used to test the statistical influence of concurrent baseline diagnoses on diagnostic changes at follow-up. Of 789 baseline joint-specific soft tissue diagnoses of DD, 598 (76%) joints showed no change; 109 (14%) demonstrated progression; and 82 (10%) had reversal. Of 794 joints with baseline joint-specific hard tissue diagnoses of DJD, progression was observed in 122 (15%) joints, no change in 564 (71%), and reversal in 108 (14%). Radiologist reliability (kappa) was 0.73 (95% CI, 0.64 to 0.83) for DD and 0.76 (95% CI, 0.68 to 0.83) for DJD. After accounting for the influence of diagnostic disagreement, progression of hard tissue diagnoses in the right TMJ occurred in 15.2% of subjects (95% CI, 10.5% to 20.8%) and reversal in 8.3% (95% CI, 4.9% to 12.3%); results were similar for soft tissue diagnoses and the left TMJ. Concurrent baseline soft tissue diagnoses were associated with hard tissue diagnostic changes at follow-up ( P < 0.0001). Baseline hard tissue diagnoses showed no statistical association with soft tissue changes at follow-up ( P = 0.11). Longitudinally, 76% of baseline TMJ soft tissue diagnoses and 71% of the baseline hard tissue diagnoses remained stable. Diagnostic reversal and progression were confirmed for both soft and hard tissues.

Cephalometric analysis and long-term outcomes of orthognathic surgical treatment for obstructive sleep apnoea.

The aim of this study was to describe skeletal and posterior airway changes after orthodontic treatment and surgical jaw advancement, and to evaluate whether there is a correlation between increasing advancement and a long-term reduction in obstructive sleep apnoea (OSA). Lateral cephalograms and polysomnography (apnoea-hypopnoea index, AHI) were collected from patients treated with bilateral sagittal split osteotomy (BSSO) or maxillomandibular advancement (MMA) in combination with orthodontics. Patients completed a questionnaire and the Epworth Sleepiness Scale (ESS) to assess long-term outcomes. Descriptive statistics for cephalometric measurements and linear regression were performed to find estimates of the final OSA (AHI and ESS) as a function of mandibular advancement. Forty-three patients with surgical advancement of the maxilla (5.2mm) and mandible (8.3mm) had a 4-mm increase in posterior airway. Thirty-three patients completed the long-term survey (6.3±2.6 years after treatment); 91% reported a reduction of OSA and were pleased with their facial appearance. The maxillomandibular and posterior airway increased. There was no evidence of a linear relationship between greater amounts of mandibular advancement and improvement of OSA. Patients with less than 10mm advancement had successful objective short-term and subjective long-term OSA reduction.

Stenting unprotected left main coronary artery stenosis in heart transplant patients--the good, bad, and the ugly.

The major cause of late death following orthotopic heart transplantation is coronary artery vasculopathy. Approximately 50% of heart transplant patients have coronary artery vasculopathy 5 years post-transplantation. With advances in interventional cardiology technology, heart transplant patients with selected lesions are now undergoing intravascular stenting with acute-gain and late-loss rates similar to stenting in non-transplanted patients. We describe 3 consecutive cases of stenting unprotected left main coronary artery disease in orthotropic heart transplant patients. With follow-up to 3 years and no evidence of restenosis, these results suggest that stenting unprotected left main coronary artery lesions in heart transplant patients can be performed with excellent immediate and long-term results.

CQI longitudinally applied to integrated service outcomes.

Citing data collected between 1987 and 1994 at the St. Paul-Ramsey Medical Center, Ramsey Clinic and Ramsey Foundation, Paul A. Sommers, Ph.D., executive vice president and chief administrative officer of Ramsey, Michael G. Luxenberg, president of Professional Data Analysts, and Eric. P. Sommers of the River Falls Clinic, write how CQI has been introduced. The key is the application of inferential evaluation.

Clinical diagnostic criteria for TMD. New classification permits multiple diagnoses.

One of the first to permit multiple diagnoses, this new TMD classification scheme offers guidelines for clinicians and those conducting clinical field studies. The scheme was applied to a TMD population, with control subjects.

Temporomandibular joint findings in pediatric populations and young adults: a critical review.

The etiology, diagnosis and treatment of temporomandibular joint (TMJ) pain and dysfunction is a controversial subject. There are varying opinions regarding the contribution of occlusion (malocclusion) to the development of mandibular dysfunction and further, the contribution of occlusal alterations (orthodontic and restorative) to the development of pain and dysfunction. Epidemiologic investigations suggest there is a high incidence of subjective and objective symptoms in the pediatric population. Observations on incisal relationships, condyle position and joint sounds, and comparisons to controls seem to suggest that these factors are not the cause of pain or dysfunction. The purpose of this review is: (1) to bring the clinician's attention existing published information reporting the presence of symptoms in children, (2) to evaluate selected information in young adults, (3) to question anecdotal information on the etiology of TMJ problems. It is not in the purview of this paper to determine the overall etiology of TMJ dysfunction.

An epidemiologic evaluation of two diagnostic classification schemes for temporomandibular disorders.

Few diagnostic classification schemes for temporomandibular disorders (TMD) have been applied systematically to examine the prevalence of various subtypes of TMD in clinic or community populations. In this study, computer algorithms were developed for classifying subjects according to the scheme of Eversole and Machado (1985) and a classification scheme recently developed in our own research at the University of Washington. The diagnostic algorithms were applied to clinical examination data for (1) persons without TMD pain (community controls) and (2) persons reporting TMD pain in the prior 6 months (community subjects with pain), identified in a random sample survey of a health maintenance organization (HMO) population, as well as (3) clinic patients seeking treatment for TMD through the same HMO. Prevalence rates for myofascial pain dysfunction in clinic patients were much higher under the University of Washington approach, whereas rates of internal derangement (type I) and degenerative joint disease were similar under the two schemes. These similar prevalence rates were not, however, accompanied by high concordance between the two schemes. These results highlight the complexities of differential diagnosis of TMD in field research, and suggest that further evaluation of alternative diagnostic schemes is warranted.

Epidemiology of signs and symptoms in temporomandibular disorders: clinical signs in cases and controls.

An epidemiologic study of clinical signs and symptoms of temporomandibular disorders (TMD) was conducted with a probability sample of adults enrolled in a major health maintenance organization (HMO). This report presents data from a first wave field examination and interview conducted by trained, calibrated dental hygienist field examiners. Significant gender differences for vertical jaw opening measures were observed but no significant age differences were found for the distribution of clinically relevant findings. Clinic cases showed smaller amounts of vertical range of jaw motion but did not differ from community cases or controls on extent of lateral, protrusive, or retrusive mandibular movements; on classification of occlusion; or on dentally related variables. Clinic cases had more pain during all jaw excursions as well as during muscle and joint palpation. Joint clicking sounds were also observed more frequently in clinic cases.

Pharmacological management of recurrent oral mucosal ulceration.

A number of diseases can cause recurrent intraoral ulceration. This review focuses principally on drug management of intraoral ulceration associated with local and systemic conditions most likely to be observed on an outpatient basis by the general practitioner. These consist of recurrent aphthous stomatitis, erosive lichen planus, benign mucous membrane pemphigoid (BMMP), erythema multiforme. Behçet's disease, allergic stomatitis and infection. Information is provided on a spectrum of medication found useful in ulcer management, including topical antimicrobial and antifungal agents, topical and systemic corticosteroids, topical and systemic analgesics, and systemic immunosuppressive and anxiolytic drugs, plus details of dosage, important adverse reactions and interactions. A treatment guide for management of recurrent aphthae is presented. The reader is presumed to be familiar with differential diagnosis and the importance of establishing an accurate impression before starting drug therapy.

Short-term effect of two therapeutic methods on myofascial pain and dysfunction of the masticatory system.

In conclusion, a short-term intervention with IS therapy was found to result in a substantial decrease in facial pain for most of the subjects treated. Generally, groups were not found to be significantly different in respect to palpation pain change from session 1 to session 2. Neither therapy significantly altered the range of mouth opening. EMG findings were variable but suggest that RI therapy may alter muscle myoelectric activity. From these findings, ice and stretch of the masticatory and neck musculature would appear to be a good short-term adjunctive therapy to control pain with little apparent risk of negative effects.

An experimental study of the control of the gag reflex with nitrous oxide.

Gagging represents a management problem during dental procedures. A controlled, double blind experiment on human volunteers evaluated the efficacy of nitrous oxide for suppressing experimentally-induced gagging. The ability of the subjects to tolerate palatal and oropharyngeal stimulation was evaluated by measuring the distance of the anatomic palatal and oropharyngeal structure which produce gagging. It was observed that under N(2)O/O(2) inhalation subjects tolerated a significantly more intrusive (deeper) oropharyngeal stimulation than under control conditions.

Temporomandibular disorders. Variation in clinical practice.

This research describes the extent of variability in diagnosis and treatment of temporomandibular disorders (TMD) and relates this variability to treatment outcomes. A health maintenance organization sequentially referred 145 patients with orofacial pain and dysfunction to two TMD clinics. The two clinics differed substantially in their use of tomography (applied to 28% vs. 64% of all patients), and varied moderately in diagnoses assigned to the patient groups. There was large variation in selection of treatments including appliances for bruxism (64% vs. 5%), mandibular repositioning (10% vs. 25%), and joint stabilization (3% vs. 30%); anti-inflammatory medications (44% vs. 19%) and analgesics (16% vs. 2%); and subsequent referral for dental or orthodontic treatment (1% vs. 42%). The differences in diagnostic and therapeutic practice that were found were not associated with important differences in patient-reported pain and dysfunction at 1-year follow-up. These data indicate the need for systematic approaches to identifying, evaluating, and modifying variation in health care practices for common presenting problems lacking reliable methods of evaluation and generally accepted clinical standards for choice of treatments.

Long-term periodontal status after orthodontic treatment.

This study evaluated the clinical periodontal status of persons who had completed orthodontic therapy at least 10 years previously (study) and compared the findings to those of adults with untreated malocclusions (control). Subjects in the study (n = 112; 63 female subjects, 49 male subjects; mean age 29.3 +/- 4.2 [SD] years) and control (n = 111; 62 female subjects, 49 male subjects; mean age 32.9 +/- 6.5 years) populations underwent a comprehensive periodontal examination that consisted of measurements taken at six points around the circumference of each tooth: (1) plaque, (2) visual inflammation, (3) bleeding after probing, (4) pocket depth, (5) gingival recession, and (6) loss of connective tissue attachment. Data from the individual measuring points were organized into 14 different combinations of either tooth types or surface locations; each was subjected to a four-way ANOVA partitioned on group (study vs. control), sex, socioeconomic status, and malocclusion type. The results showed that differences in age distribution within the groups were affecting the comparisons between the groups. Consequently, the groups were balanced for age and analyses were done to investigate group differences by means of multiple regression techniques. The comparisons showed no significant differences between the groups for any of the periodontal variables. It was concluded that orthodontic treatment during adolescence had no discernible effect upon later periodontal health.

Sialochemistry of whole, parotid, and labial minor gland saliva in patients with oral lichen planus.

This study was undertaken to determine whether oral lichen planus in otherwise healthy patients is associated with sialochemical abnormalities. Unstimulated and stimulated whole saliva, stimulated parotid saliva, and stimulated labial minor gland saliva were collected from 25 patients with oral lichen planus and from 25 age- and sex-matched controls. Flow rate and salivary concentrations of immunoglobulins A and G, albumin, amylase, lysozyme, lactoferrin, and total protein were determined by standard analytical techniques. Concentrations of inorganic components including sodium, potassium, calcium, chloride, and phosphate were also measured. No significant differences were found between the lichen planus patients and the controls. These findings do not support an association between oral lichen planus and salivary dysfunction in otherwise healthy patients.

An empirical investigation of the role of pornography in the verbal and physical abuse of women.

In studies of male aggressiveness and pornography, social psychologists have found evidence to support the theory that consumption of pornography by males increases their aggressiveness and antisocial attitudes toward women. The research reported here studied the presence of pornography and both sexual and nonsexual violence in the lives of two groups of women: a group of battered women drawn from shelters and counseling groups, and a comparison group of women from a mature university population. It was found that the partners of the battered women read or viewed significantly greater amounts of pornographic materials than did the partners of the comparison group. In addition, 39% of the battered women (in contrast to 3% of the comparison group) responded in the affirmative to the question, "Has your partner ever upset you by trying to get you to do what he'd seen in pornographic pictures, movies, or books?" It was also found that battered women experienced significantly more sexual aggression at the hands of their partners than did the women in the comparison group.

Hyperoxic lung injury in mice: a possible protective role for prostacyclin.

Arachidonic acid metabolites have biologic properties that can mimic the pulmonary changes produced by hyperoxic exposure, but little information is available regarding their importance in this setting. The role of prostacyclin (PGI2) and thromboxane (Tx) A2 in oxygen-induced lung injury was evaluated by exposing mice to 100% oxygen for up to 4 days and measuring plasma and bronchoalveolar lavage (BAL) fluid concentrations of 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha), a metabolite of PGI2, and TxB2, a metabolite of TxA2. To determine whether a relationship exists between changes in these arachidonic acid metabolites and the severity of the lung injury, we also measured mortality, BAL protein concentration, BAL angiotensin-converting enzyme (ACE) activity, and plasma lactate dehydrogenase activity, and we examined lung sections by light and electron microscopy. After 3 days of exposure to 100% oxygen, microscopic and biochemical changes consistent with mild lung damage were found, but there was no increase in either plasma or BAL 6-keto-PGF1 alpha concentration. On day 4, severe lung damage was present. and BAL 6-keto-PGF 1 alpha level increased threefold (P less than 0.001). The level of TxB2 in BAL fluid did not change on any day. Twice-daily administration of either a high (5 mg/kg) or a low (1 mg/kg) dose of indomethacin reduced BAL concentrations of 6-keto-PGF1 alpha, and it resulted in increased mortality and higher BAL protein concentration and BAL ACE activity. These data suggest that TxA2 has little if any role in the pathogenesis of oxygen-induced lung injury, whereas prostacyclin may play a protective role.

Arthrographically assisted splint therapy: a 6-month follow-up.

After repositioning splint therapy, 51 patients were evaluated for a minimum of 6 months. Forty-five (88%) of the patients were considered to have been treated successfully, whereas six (12%) patients required surgery to correct meniscal displacement. A detailed analysis of signs and symptoms before and after splint treatment is in progress.