Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis.

BACKGROUND: Manual therapy (MT) and exercise have been extensively used to treat people with musculoskeletal conditions such as temporomandibular disorders (TMD). The evidence regarding their effectiveness provided by early systematic reviews is outdated. PURPOSE: The aim of this study was to summarize evidence from and evaluate the methodological quality of randomized controlled trials that examined the effectiveness of MT and therapeutic exercise interventions compared with other active interventions or standard care for treatment of TMD. DATA SOURCES: Electronic data searches of 6 databases were performed, in addition to a manual search. STUDY SELECTION: Randomized controlled trials involving adults with TMD that compared any type of MT intervention (eg, mobilization, manipulation) or exercise therapy with a placebo intervention, controlled comparison intervention, or standard care were included. The main outcomes of this systematic review were pain, range of motion, and oral function. Forty-eight studies met the inclusion criteria and were analyzed. DATA EXTRACTION: Data were extracted in duplicate on specific study characteristics. DATA SYNTHESIS: The overall evidence for this systematic review was considered low. The trials included in this review had unclear or high risk of bias. Thus, the evidence was generally downgraded based on assessments of risk of bias. Most of the effect sizes were low to moderate, with no clear indication of superiority of exercises versus other conservative treatments for TMD. However, MT alone or in combination with exercises at the jaw or cervical level showed promising effects. LIMITATIONS: Quality of the evidence and heterogeneity of the studies were limitations of the study. CONCLUSIONS: No high-quality evidence was found, indicating that there is great uncertainty about the effectiveness of exercise and MT for treatment of TMD.

Relationship Between Disease Characteristics and Oral Radiologic Findings in Systemic Sclerosis: Results From a Canadian Oral Health Study.

OBJECTIVE: Systemic sclerosis (SSc; scleroderma) is associated with a wide periodontal ligament (PDL) and mandibular erosions. We investigated the clinical correlates of SSc with these radiologic abnormalities. METHODS: Subjects from the Canadian Scleroderma Research Group cohort underwent detailed radiologic examinations. Associations between radiologic abnormalities and clinical manifestations of SSc were examined with univariate and multivariate analyses. RESULTS: The study included 159 subjects; 90.6% were women, the mean ± SD age was 56 ± 10 years, diffuse disease was present in 28.3%, and mean ± SD disease duration was 13.7 ± 8.4 years. Widening of the PDL involving at least 1 tooth was present in 38% of subjects, and 14.5% had at least 1 site in the mandible with an erosion. In analyses adjusting for age, disease duration, sex, smoking, and education, we found significant associations between the number of teeth with widening of the PDL and disease severity assessed by the physician global assessment (PGA) (relative risk [RR] 1.19, 95% confidence interval [95% CI] 1.02-1.39, P = 0.028). Analyses replacing the PGA with the skin score, disease subset, or anti-topoisomerase I antibodies confirmed the relationship with indices of disease severity. There was no relationship between either the number of teeth with periodontal disease or the number of missing teeth, and the number of teeth with wide PDL. A smaller interdental distance (RR 0.89, 95% CI 0.82-0.97, P = 0.006), but not disease severity, facial skin score, or ischemia was associated with a larger number of erosions. CONCLUSION: In SSc, a wide PDL may reflect generalized overproduction of collagen, and mandibular erosions are related to local factors in the oral cavity.

The Canadian Systemic Sclerosis Oral Health Study IV: oral radiographic manifestations in systemic sclerosis compared with the general population.

OBJECTIVE: The aim of this study was to compare oral radiologic abnormalities associated with systemic sclerosis (SSc) against abnormalities in the general population. STUDY DESIGN: Patients with SSc and healthy controls were enrolled in a multi-site cross-sectional study. Included in the radiology examination were a panoramic radiograph, four bitewings, and an anterior mandibular periapical radiograph. Radiographs were evaluated by two oral and maxillofacial radiologists tested for interobserver and intraobserver reliability. Chi-squared tests, Fisher exact tests, and Mann Whitney U tests were used to summarize the radiologic manifestations of patients and controls. RESULTS: We assessed 163 SSc patients and 231 controls. Widening of the periodontal ligament space (PLS) (P < .001), with higher percentage of teeth with PLS widening (P < .001), was significantly more frequent in patients with SSc than in controls. The most significant differences between the two groups were found in the molars and premolars (P < .001). Moreover, 26% of the patients with SSc had a periapical PLS greater than 0.19 mm compared with 13% of the controls (P = .003). Patients with SSc had significantly more erosions compared with controls (14.5% vs. 3.6%; P < .001), mostly in the condyles (P = .022), coronoid processes (P = .005) and other locations (P = .012). CONCLUSION: Patients with SSc had more teeth with PLS widening and erosions of the mandible compared with controls.

The Canadian systemic sclerosis oral health study II: the relationship between oral and global health-related quality of life in systemic sclerosis.

OBJECTIVE: Both oral and global health-related quality of life (HRQoL) are markedly impaired in SSc. In this study we aimed to determine the degree of association between oral HRQoL and global HRQoL in SSc. METHODS: Subjects were recruited from the Canadian Scleroderma Research Group registry. Global HRQoL was measured using the Medical Outcomes Trust 36-item Short Form Health Survey (SF-36) and oral HRQoL with the Oral Health Impact Profile (OHIP). The Medsger Disease Severity Score was used to determine organ involvement. Multivariate regression models determined the independent association of the OHIP with the SF-36 after adjusting for confounders. RESULTS: This study included 156 SSc subjects. The majority (90%) were women, with a mean age of 56 years, mean disease duration 13.8 years (s.d. 8.5) and 29% of the subjects had dcSSc. Mean total OHIP score was 40.8 (s.d. 32.4). Mean SF-36 mental component summary (MCS) score was 49.7 (s.d. 11.1) and physical component summary (PCS) score was 37.0 (s.d. 10.7). In adjusted analyses, the total OHIP score was significantly associated with the SF-36 MCS and PCS, accounting for 9.7% and 5.6% of their respective variances. Measures of disease severity were not related to OHIP score. CONCLUSION: Oral HRQoL in SSc is independently associated with global HRQoL. Oral HRQoL, however, is not related to physician-assessed disease severity. This suggests that physicians may be disregarding issues related to oral health. HRQoL is an additional dimension of HRQoL not captured by generic instruments such as the SF-36.

Relationship between disease characteristics and orofacial manifestations in systemic sclerosis: Canadian Systemic Sclerosis Oral Health Study III.

OBJECTIVE: Systemic sclerosis (SSc; scleroderma) is associated with decreased saliva production and interincisal distance, more missing teeth, and periodontal disease. We undertook this study to determine the clinical correlates of SSc with these oral abnormalities. METHODS: Subjects were recruited from the Canadian Scleroderma Research Group cohort. Detailed dental and clinical examinations were performed according to standardized protocols. Associations between dental abnormalities and selected clinical and serologic manifestations of SSc were examined. RESULTS: One hundred sixty-three SSc subjects were included: 90% women, mean ± SD age 56 ± 11 years, mean ± SD disease duration 14 ± 8 years, 72% with limited cutaneous disease, and 28% with diffuse cutaneous disease. Decreased saliva production was associated with Sjögren's syndrome-related autoantibodies (ß = -43.32; 95% confidence interval [95% CI] -80.89, -5.75), but not with disease severity (ß = -2.51; 95% CI -8.75, 3.73). Decreased interincisal distance was related to disease severity (ß = -1.02; 95% CI -1.63, -0.42) and the modified Rodnan skin thickness score (ß = -0.38; 95% CI -0.53, -0.23). The number of missing teeth was associated with decreased saliva production (relative risk [RR] 0.97; 95% CI 0.94, 0.99), worse hand function (RR 1.52; 95% CI 1.13, 2.02), and the presence of gastroesophageal reflux disease (GERD; RR 1.68 [95% CI 1.14, 2.46]). No clinical or serologic variables were correlated with periodontal disease. CONCLUSION: In SSc, diminished interincisal distance is related to overall disease severity. Decreased saliva production is related to concomitant Sjögren's syndrome antibodies. Tooth loss is associated with poor upper extremity function, GERD, and decreased saliva. The etiology of excess periodontal disease is likely multifactorial and remains unclear.

The Canadian systemic sclerosis oral health study: orofacial manifestations and oral health-related quality of life in systemic sclerosis compared with the general population.

OBJECTIVE: The aim of this study was to compare oral abnormalities and oral health-related quality of life (HRQoL) of patients with SSc with the general population. METHODS: SSc patients and healthy controls were enrolled in a multisite cross-sectional study. A standardized oral examination was performed. Oral HRQoL was measured with the Oral Health Impact Profile (OHIP). Multivariate regression analyses were performed to identify associations between SSc, oral abnormalities and oral HRQoL. RESULTS: We assessed 163 SSc patients and 231 controls. SSc patients had more decayed teeth (SSc 0.88, controls 0.59, P = 0.0465) and periodontal disease [number of teeth with pocket depth (PD) >3 mm or clinical attachment level (CAL) ≥5.5 mm; SSc 5.23, controls 2.94, P < 0.0001]. SSc patients produced less saliva (SSc 147.52 mg/min, controls 163.19 mg/min, P = 0.0259) and their interincisal distance was smaller (SSc 37.68 mm, controls 44.30 mm, P < 0.0001). SSc patients had significantly reduced oral HRQoL compared with controls (mean OHIP score: SSc 41.58, controls 26.67, P < 0.0001). Multivariate regression analyses confirmed that SSc was a significant independent predictor of missing teeth, periodontal disease, interincisal distance, saliva production and OHIP scores. CONCLUSION: Subjects with SSc have impaired oral health and oral HRQoL compared with the general population. These data can be used to develop targeted interventions to improve oral health and HRQoL in SSc.

Morphologic and functional changes in the temporomandibular joint and stomatognathic system after transmandibular surgery in oral and oropharyngeal cancers: systematic review.

BACKGROUND: Interruption of mandibular continuity in transmandibular (mandibulotomy and mandibulectomy) surgery for tumour resection in the oral cavity and oropharynx may alter oral and temporomandibular joint (TMJ) morphology and function. OBJECTIVE: To critically analyze available evidence regarding the effects of transmandibular surgeries on morphologic and functional changes in the TMJ and stomatognathic system. DATA SOURCES: Electronic search of Medline, Embase, Evidence-Based Medicine Reviews, Ovid HealthStar, and Scopus and hand searches. INCLUSION CRITERIA: Any article investigating the TMJ morphologic changes and/or functional outcomes following transmandibular surgeries. RESULTS AND SYNTHESIS METHODS: Two hundred seventy-one articles were obtained through the electronic database scan and six articles via a hand search. Twelve full articles were initially selected as potentially meeting the eligibility for this review; however, only five articles finally fulfilled the study inclusion criteria and were analyzed for their methodology. All articles used clinical records and/or patient reports to evaluate TMJ pain, motion, dental occlusion, mouth opening, and deflection during opening as outcome measures. In only four articles was a clinical examination conducted after surgery, with associated patients' interviews and reports. The quality of all included articles was considered poor with a high risk of bias according to the Research Triangle Institute item bank quality of assessment. CONCLUSION: Based on the limited available evidence for this systematic review and a high risk of bias of the analyzed articles, no firm conclusions can be established regarding the effects of transmandibular surgery on morphologic and functional changes in the TMJ and stomatognathic system.

Electromyography in diagnosing temporomandibular disorders.

BACKGROUND: Although electromyography (EMG) has been used extensively in dentistry to assess masticatory muscle impairments in several conditions, especially temporomandibular disorders (TMDs), many investigators have questioned its psychometric properties and accuracy in diagnosing TMD. TYPES OF STUDIES REVIEWED: The authors conducted a systematic review to analyze the literature critically and determine the accuracy of EMG in diagnosing TMDs. They conducted an electronic search of MEDLINE, Embase, all Evidence-Based Medicine Reviews, Allied and Complementary Medicine, Ovid HealthSTAR and SciVerse Scopus. The authors selected abstracts that fulfilled the inclusion criteria, retrieved the original articles, verified the inclusion criteria and hand searched the articles' references. They used a methodological tool (Quality Assessment of Diagnostic Accuracy Studies [QUADAS]) to evaluate the quality of the selected articles. RESULTS: The electronic database search resulted in a total of 130 articles. The authors selected eight articles as potentially meeting eligibility for the review. Of these eight articles, only two fulfilled the study inclusion criteria, and the authors analyzed them. Investigators in both studies reported low sensitivity (values ranged from 0.15 to 0.40 in one study and a mean of 0.69 in the second study). In addition, investigators in the two studies reported contradictory levels of specificity (values ranged from 0.95 to 0.98 in one study, and the mean value in the second study was 0.67). The likelihood ratios and predictive values were not helpful in diagnosing TMD by means of EMG. The quality of the two studies was poor on the basis of the QUADAS checklist. CLINICAL IMPLICATIONS: The authors of this systematic review found no evidence to support the use of EMG for the diagnosis of TMD.

Topical nonsteroidal anti-inflammatory medications for treatment of temporomandibular joint degenerative pain: a systematic review.

AIMS: To evaluate the efficacy of topical nonsteroidal anti-inflammatory drugs (NSAID) to relieve temporomandibular joint (TMJ) degenerative joint disease (DJD) pain. METHODS: A search of the literature was made using electronic databases complemented with a manual search. Clinical trials comparing topical NSAID with either placebo or an alternative active treatment to treat TMJ DJD pain were identified. Outcomes evaluated were pain reduction/pain control and/or incidence of side effects. RESULTS: A single study (double-blind randomized placebo-controlled trial) with 20 patients was identified that evaluated the efficacy of a topically prepared NSAID over a 12-week duration, measuring functional pain intensity, voluntary and assisted mouth opening, pain disability index, and a brief pain inventory analysis. This study revealed a pain intensity decrease within treatment groups but no significant difference between treatment groups. CONCLUSION: Presently, there is insufficient evidence to support the use of topically applied NSAID medications to palliate TMJ DJD pain.

Patients with temporomandibular disorders have increased fatigability of the cervical extensor muscles.

OBJECTIVES: To determine whether patients with myogenous and mixed temporomandibular disorders (TMD) have greater fatigability of the cervical extensor muscles while performing a neck extensor muscle endurance test (NEMET) when compared with healthy controls. METHODS: A total of 151 individuals participated in this study. Of these 47 were healthy controls, 57 patients had myogenous TMD, and 47 patients had mixed TMD. All patients performed the NEMET. The patients were instructed to maintain a prone lying position with the neck unsupported as long as possible, stopping at signs of fatigue or any discomfort. Electromyographic activity of the cervical extensor muscles during the NEMET and the holding time were collected for all patients and were compared across groups. A 1-way analysis of variance was used to evaluate the differences in holding time between patients with TMD and healthy controls. A mixed model analysis was used to evaluate the differences in normalized median frequency at different times (fatigue index) for the cervical extensor muscles while performing the NEMET between patients with TMD and controls. RESULTS: There were statistically significant differences (P<0.05) in the slopes of the normalized median frequency between patients with TMD and healthy controls at 10, 30, 40, 50, 60, 70, 80, 90, and 100 seconds of the NEMET. Holding time was significantly reduced in both patients with myogenous TMD and mixed TMD when compared with healthy controls (P<0.05). DISCUSSION: These results highlight the fact that alterations of endurance capacity of the extensor cervical muscles could be implicated in the neck-shoulder disturbances presented in patients with TMD.

Head and cervical posture in patients with temporomandibular disorders.

AIM: To determine whether patients with myogenous or mixed (ie, myogeneous plus arthrogeneous) temporomandibular disorders (TMD) had different head and cervical posture measured through angles commonly used in clinical research settings when compared to healthy individuals. METHODS: One hundred fifty-four persons participated in this study. Of these, 50 subjects were healthy, 55 subjects had myogenous TMD, and 49 subjects had mixed TMD (ie, arthrogenous plus myogenous TMD). A lateral photograph was taken with the head in the self-balanced position. Four angles were measured in the photographs: (1) Eye-Tragus-Horizontal, (2) Tragus-C7-Horizontal, (3) Pogonion-Tragus-C7, and (4) Tragus-C7-Shoulder. Alcimagen software specially designed to measure angles was used in this study. All of the measurements were performed by a single trained rater, a dental specialist in orthodontics, blinded to each subject's group status. RESULTS: The only angle that reached statistical significance among groups was the Eye-Tragus-Horizontal (F = 3.03, P = .040). Pairwise comparisons determined that a mean difference of 3.3 degrees (95% confidence intervals [CI]: 0.15, 6.41) existed when comparing subjects with myogenous TMD and healthy subjects (P = .036). Postural angles were not significantly related to neck disability, jaw disability, or pain intensity. Intrarater and interrater reliability of the measurements were excellent, with intraclass correlation coefficient (ICC) values ranging between 0.996-0.998. CONCLUSION: The only statistically significant difference in craniocervical posture between patients with myogenous TMD and healthy subjects was for the Eye-Tragus-Horizontal angle, indicating a more extended position of the head. However, the difference was very small (3.3 degrees) and was judged not to be clinically significant.

Electromyographic activity of the cervical flexor muscles in patients with temporomandibular disorders while performing the craniocervical flexion test: a cross-sectional study.

BACKGROUND: Most patients with temporomandibular disorders (TMD) have been shown to have cervical spine dysfunction. However, this cervical dysfunction has been evaluated only qualitatively through a general clinical examination of the cervical spine. PURPOSE: The purpose of this study was to determine whether patients with TMD had increased activity of the superficial cervical muscles when performing the craniocervical flexion test (CCFT) compared with a control group of individuals who were healthy. DESIGN: A cross-sectional study was conducted. METHODS: One hundred fifty individuals participated in this study: 47 were healthy, 54 had myogenous TMD, and 49 had mixed TMD. All participants performed the CCFT. Data for electromyographic activity of the sternocleidomastoid (SCM) and anterior scalene (AS) muscles were collected during the CCFT for all participants. A 3-way mixed-design analysis of variance for repeated measures was used to evaluate the differences in EMG activity for selected muscles while performing the CCFT under 5 incremental levels. Effect size values were calculated to evaluate the clinical relevance of the results. RESULTS: Although there were no statistically significant differences in electromyographic activity in the SCM or AS muscles during the CCFT in patients with mixed and myogenous TMD compared with the control group, those with TMD tended to have increased activity of the superficial cervical muscles. LIMITATIONS: The results obtained in this research are applicable for the group of individuals who participated in this study under the protocols used. They could potentially be applied to people with TMD having characteristics similar to those of the participants of this study. CONCLUSION: This information may give clinicians insight into the importance of evaluation and possible treatment of the deep neck flexors in patients with TMD. However, future research should test the effectiveness of this type of program through a randomized controlled trial in people with TMD in order to determine the real value of treating this type of impairment in this population.

Reduced endurance of the cervical flexor muscles in patients with concurrent temporomandibular disorders and neck disability.

Subjects with temporomandibular disorders (TMDs) have been found to have clinical signs and symptoms of cervical dysfunction. Although many studies have investigated the relationship between the cervical spine and TMD, no study has evaluated the endurance capacity of the cervical muscles in patients with TMD. Thus the objective of this study was to determine whether patients with TMD had a reduced endurance of the cervical flexor muscles at any level of muscular contraction when compared with healthy subjects. One hundred and forty-nine participants provided data for this study (49 subjects were healthy, 54 had myogenous TMD, and 46 had mixed TMD). There was a significant difference in holding time at 25% MVC between subjects with mixed TMD when compared to subjects with myogenous TMD and healthy subjects. This implies that subjects with mixed TMD had less endurance capacity at a lower level of contraction (25% MVC) than healthy subjects and subjects with myogenous TMD. No significant associations between neck disability, jaw disability, clinical variables and neck flexor endurance test were found.

Is maximal strength of the cervical flexor muscles reduced in patients with temporomandibular disorders?

OBJECTIVE: To determine whether there was a difference in maximal cervical flexor muscle strength in subjects with temporomandibular disorders (mixed and myogenous) compared with healthy subjects. DESIGN: Cross-sectional study. SETTING: Orthopedics/sports laboratory at the University of Alberta. PARTICIPANTS: Subjects (N=149) of whom 50 were healthy, 54 had myogenous temporomandibular disorders (TMD), and 45 had mixed TMD. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Maximal cervical flexor strength, pain. RESULTS: There was no statistically significant difference in maximal cervical flexor strength among groups (P>.05). Subjects' body weight was significantly associated with strength. No significant association between jaw disability with maximal cervical flexor strength was found. A significant but weak association between neck disability and maximal cervical flexors strength was found. CONCLUSIONS: These results indicated that strength evaluation is one of several assessment factors that need to be addressed when evaluating musculoskeletal painful conditions such as TMD and neck disorders, but strength evaluation cannot be considered as a direct measure of disability. Future studies should explore evaluation of strength in other muscular groups such as cervical extensors, rotators, and lateral flexors, and also under different conditions such as rapid movements, and in patients with more severe jaw disability.

Analgesic action of gabapentin on chronic pain in the masticatory muscles: a randomized controlled trial.

Chronic masticatory myalgia (CMM) can be defined as constant pain in the masticatory muscles for more than 6 months and is influenced by the central nervous system. The antiepileptic agent gabapentin acts centrally and is used for managing different types of chronic pain conditions. The objective of this study was to evaluate the analgesic action of gabapentin on CMM. In this 12-week randomized controlled clinical trial 50 patients were randomly allocated into two study groups: 25 received gabapentin and 25 received placebo. The outcome measures utilized were pain reported on a VAS (VAS-pain), Palpation Index (PI) and impact of CMM on daily functioning reported on a VAS (VAS-function). Thirty-six patients completed the study. Gabapentin showed to be clinically and statistically superior to placebo in reducing pain reported by patients (gabapentin=51.04%; placebo=24.30%; P=0.037), masticatory muscle hyperalgesia (gabapentin=67.03%; placebo=14.37%; P=0.001) and impact of CMM on daily functioning (gabapentin=57.70%; placebo=16.92%; P=0.022). It can be concluded from this study that gabapentin is effective for the management of CMM.

The association between the cervical spine, the stomatognathic system, and craniofacial pain: a critical review.

AIMS: Craniofacial pain is a term that encompasses pain in the head, face, and related structures. Multiple etiologies and factors may be related to craniofacial pain; however, the association between the cervical spine and its related structures and craniofacial pain is still a topic of debate. The objective of this critical review was to present and analyze the evidence of the associations between the cervical spine, stomatognathic system, and craniofacial pain. METHODS: A search of the databases Medline, PubMed, Embase, Web of Sciences, Cochrane Library, Cinahl, and HealthStar was conducted for all publications related to the topic in the English and Spanish languages. Relevant information was also derived from reference lists of the retrieved publications. The key words used in the search were cervical spine, cervical vertebrae, neck pain, neck injuries, neck muscles, craniofacial pain, orofacial pain, facial pain, temporomandibular joint pain, and temporomandibular joint disorders. RESULTS: The search provided information referring to the biomechanical, anatomical, and pathological association between craniofacial pain, the stomatognathic system and the cervical spine. CONCLUSION: The information provided by this review suggests an association between the cervical spine, stomatognathic system, and craniofacial pain, but most of this information is not conclusive and was derived from poor-quality studies (levels 3b, 4, and 5 based on Sackett's classification). Better designed studies are needed in order to clarify the real influence that the cervical spine has in relation to the stomatognathic system and craniofacial pain.

The association between head and cervical posture and temporomandibular disorders: a systematic review.

AIMS: To carry out a systematic review to assess the evidence concerning the association between head and cervical posture and temporomandibular disorders (TMD). METHODS: A search of Medline, Pubmed, Embase, Web of Science, Lilacs, and Cochrane Library databases was conducted in all languages with the help of a health sciences librarian. Key words used in the search were posture, head posture, cervical spine or neck, vertebrae, cervical lordosis, craniomandibular disorders or temporomandibular disorders, temporomandibular disorders, and orofacial pain or facial pain. Abstracts which appeared to fulfill the initial selection criteria were selected by consensus. The original articles were retrieved and evaluated to ensure they met the inclusion criteria. A methodological checklist was used to evaluate the quality of the selected articles and their references were hand-searched for possible missing articles. RESULTS: Twelve studies met all inclusion criteria and were analyzed in detail for their methodology and information quality. Nine articles that analyzed the association between head posture and TMD included patients with mixed TMD diagnosis; 1 article differentiated among muscular, articular, and mixed symptomatology; and 3 articles analyzed information from patients with only articular problems. Finally, 2 studies evaluated the association between head posture and TMD in patients with muscular TMD. Several methodological defects were noted in the 12 studies. CONCLUSION: Since most of the studies included in this systematic review were of poor methodological quality, the findings of the studies should be interpreted with caution. The association between intra-articular and muscular TMD and head and cervical posture is still unclear, and better controlled studies with comprehensive TMD diagnoses, greater sample sizes, and objective posture evaluation are necessary.

Triptans for treatment of acute pediatric migraine: a systematic literature review.

The purpose of this article is to evaluate the effectiveness and safety of triptans for the treatment of acute migraine in children and adolescents. Randomized and open label trials of triptans in acute pediatric patients (ages 6-18 years) were identified by Medline (1966-2002) and PubMed (1991-2002). Additional reports were identified from the reference list of the retrieved studies. To study effectiveness, only randomized controlled trials were included, but open label studies were also included to study adverse effects. Pharmacokinetic studies of triptans in pediatric patients were also searched. Four randomized controlled trials were identified. One study reported oral sumatriptan, another oral rizatriptan, and two studies reported nasal spray sumatriptan. Rizatriptan is well tolerated but not clearly beneficial when used in adolescents. Effectiveness of nasal spray sumatriptan in acute pediatric migraine where other medications had failed was supported. Effectiveness of oral sumatriptan was not established. Adverse effects were minor for oral sumatriptan and rizatriptan and nasal sumatriptan. Pharmacokinetics of sumatriptan in pediatric patients has not been established. In conclusion, nasal spray sumatriptan should be considered in acute pediatric migraine in patients not experiencing adequate relief with other interventions.

Topical review: sleep bruxism and the role of peripheral sensory influences.

Sleep bruxism (SB) is an unusual orofacial movement described as a parafunction in dentistry and as a parasomnia in sleep medicine. Since several peripheral influences could be involved in sleep-wake regulation and the genesis of rhythmic jaw movements, the authors have reviewed the relevant literature to facilitate understanding of mechanisms possibly involved in SB genesis. Various animal and human studies indicate that during either wakefulness or anesthesia, orofacial sensory inputs (e.g., from periodontium, mucosa, and muscle) could influence jaw muscle activity. However, the role of these sensory inputs in jaw motor activity during sleep is unclear. Interestingly, during sleep, the jaw is usually open due to motor suppression; tooth contact most likely occurs in association with sleep arousal. Recent physiologic evidence supports an association between sleep arousal and SB; a sequential change from autonomic (cardiac) and brain cortical activities precede SB-related jaw motor activity. This suggests that the central and/or autonomic nervous systems, rather than peripheral sensory factors, have a dominant role in SB genesis. However, some peripheral sensory factors may exert an influence on SB through their interaction with sleep-wake mechanisms. The intent of this review is to integrate various physiologic concepts in order to better understand the mechanisms underlying the genesis of SB.