Condylar alterations and facial growth in children with juvenile idiopathic arthritis.

PURPOSE: The aim of this retrospective study was to evaluate facial growth in children with juvenile idiopathic arthritis (JIA) by means of lateral head cephalometric radiographs and relate the findings to temporomandibular joint (TMJ) condylar changes on panoramic radiographs. METHODS: Radiographic and medical records were evaluated in 65 children with JIA. Cephalometric and panoramic analyses were performed for the impact of condylar changes on facial growth. We compared children with condylar alterations, minor or major, with those without condylar alterations. RESULTS: Based on panoramic radiographs, no condylar alterations were seen in 27 of the 65 children and condylar alterations were seen in 38 children (i.e., 23 had minor and 15 major condylar alterations). The cephalometric analyses of the children with condylar changes showed significant growth disturbances with a more retrognathic mandible (SNB; p = 0.03), retruded chin position (SNPog; p = 0.02), larger mandibular angulation (ML/NSL; p = 0.009) and maxillary angulation (NL/NSL; p = 0.03) compared with children without condylar alterations. Children with minor condylar alterations had a significantly more retruded chin position (SNPog) than those with no condylar changes (p = 0.04). CONCLUSIONS: Condylar changes in the TMJ, judged on panoramic radiography, in children with JIA, have impact on craniofacial growth. Even minor alterations seem to have an impact.

Orofacial pain and its relationship with oral health-related quality of life and psychological distress in middle-aged women.

Objective: To investigate the relationship between subjective symptoms of orofacial pain and oral health-related quality of life (OHRQoL), as well as psychological distress in population-based middle-aged women.Material and methods: The two study samples comprised 1059 women, 38 and 50 years old, in representative cross-sectional studies. Women with long-lasting, frequent pain or headaches, related to temporomandibular disorders (TMD), with moderate-to-high estimates were analysed in relation to the non-case group. OHRQoL was measured using the Oral Health Impact Profile (OHIP-5). Psychological distress was measured using the Hospital Anxiety and Depression Scale (HADS) and Sense of Coherence (SOC-13).Results: Women with orofacial pain (n = 82, 7.7%) had a significantly higher mean score on the OHIP-5, HADS-A and HADS-D and a lower mean score for SOC-13. In a multivariable logistic regression, orofacial pain was statistically significantly associated with poorer OHRQoL (OR = 1.2) and signs of depression (HADS-D) (OR = 2.0). A higher score for SOC-13 protected from the experience of orofacial pain (OR = 0.95).Conclusion: Orofacial pain was associated with poorer OHRQoL and signs of psychological distress. In interpreting the value of SOC, women with orofacial pain also appear to have a poorer adaptive capacity.

Cerebral palsy and bruxism: Effects of botulinum toxin injections-A randomized controlled trial.

Objective: Cerebral palsy (CP) includes disturbances in muscular control caused by perinatal brain injury. Masticatory muscle involvement hampers functions such as chewing and talking. Bruxism and temporomandibular disorders are overrepresented. Neuromuscular blocks with botulinum toxin type A (BTX-A) may alleviate problems due to muscular hyperactivity. The aim was to evaluate masticatory muscle BTX-A injections in subjects with CP and bruxism. Methods: A prospective, parallel, randomized, placebo-controlled, and double-blind trial in 12 patients with CP was performed. End points were alterations in objective and subjective oral capacities after two BTX-A or corresponding placebo injections. Matched, healthy references were also evaluated. Results: The reference group demonstrated stronger and more efficient oral functions compared with the CP group. Subjective and objective oral capacities appeared to vary considerably between CP patients and also over time in this patient group and were poorly correlated. No significant effect of BTX-A compared with placebo on outcome variables was observed at group level, but continued treatment with BTX-A was requested by the majority of the patients. Conclusion: The evidence is unable to support the use of BTX-A for the treatment of affected masticatory muscles in CP, but the findings are inconclusive in certain respects. Larger, more homogeneous groups of CP patients need to be evaluated in future trials.

Occurrence of signs of osteoarthritis/arthrosis in the temporomandibular joint on panoramic radiographs in Swedish women.

OBJECTIVES: To determine the prevalence and incidence of radiographic signs of osteoarthritis/osteoarthrosis (OA) in the temporomandibular joint (TMJ) among middle-aged and older women. METHODS: Data were collected from ongoing representative, longitudinal and repeated cross-sectional studies in Gothenburg, Sweden. Panoramic radiographs (PAN) have been taken regularly since 1968. The cohorts were systematically selected from the female population at the ages of 38, 50, 62 and 74. Condylar alterations indicative of OA (flattening/osteophyte/erosion) were evaluated in a total of 5234 PANs by one examiner under standardized conditions. Intra-examiner reliability was good. Sensitivity was poor, and specificity was acceptable in relation to computed tomography. RESULTS: The prevalence of signs of OA in the TMJ was 18% on panoramic radiographs at the age of 38, gradually increasing with age. At the age of 62, the prevalence was 38%, and it was stable around 45% in the older age groups. The highest incidence rate of OA was between the ages of 55 and 65. Bilateral OA was uncommon. Flattening was the most prominent finding. CONCLUSION: The prevalence of signs of OA in the TMJ, including remodeling, evaluated on panoramic radiographs in representative cohorts of women, increases substantially with age. Around one in every five middle-aged women and almost every second woman of older ages can be expected to have some radiographic alteration in the TMJ. The highest proportion with new findings of OA is to be found among older middle-aged women.

Relation between osteoporosis and radiographic and clinical signs of osteoarthritis/arthrosis in the temporomandibular joint: a population-based, cross-sectional study in an older Swedish population.

OBJECTIVE: The aim was to elucidate the relation between osteoporosis and osteoarthritis/arthrosis (OA) in the temporomandibular joint (TMJ). BACKGROUND: General epidemiological data support the hypothesis that osteoporosis and OA are inversely correlated but is not conclusively investigated in the TMJ. MATERIALS AND METHODS: A group of 114 representative elderly women and men, randomised from a comprehensive population study in Gothenburg, Sweden, had bone mineral density established with whole-body, dual-energy X-ray absorptiometry (DXA) as part of a health survey. In addition, dental examinations were performed, including panoramic radiographs exposed as an overview of the TMJ's and jaws. In 88 of the 80-year-old participants (48 women and 40 men), a clinical orofacial examination according to the RDC/TMD system was performed. RESULTS: A diagnosis of osteopenia/osteoporosis was found in 36% of the 114, with a statistically different greater proportion of women. Condylar alterations evaluated from panoramic radiographs were observed in 34%, with no significant gender difference. No significant differences were found in the proportion of individuals with osteopenia/osteoporosis and any condylar radiographic alteration or not. Forty-one of the clinically examined subjects, 47%, fulfilled the criteria for an RDC/TMD diagnosis with no gender difference. All participants graded the orofacial pain as low chronic pain. An opening capacity of <40 mm denoted a higher risk of having pain in the temporomandibular system. No association was found between clinical diagnosis of RDC/TMD and osteopenia/osteoporosis. CONCLUSION: The prevalence of osteopenia/osteoporosis appears not to be of importance for radiological or clinical findings of OA in the TMJ.

A randomised, open-label, crossover study of the dopamine agonist, pramipexole, in patients with sleep bruxism.

Sleep bruxism bears several similarities to restless legs syndrome, and a link to changes in central dopamine activity has been considered in both conditions. The dopamine agonist pramipexole is currently indicated for the symptomatic treatment of restless legs. The effect of pramipexole on sleep bruxism was investigated in subjects with 'probable bruxism' recruited at the Orofacial Pain Clinic. Thirteen patients underwent polysomnographic recordings, including bilateral masseter electromyographic activity. Following habituation to the recording equipment, a baseline registration was used to confirm bruxism [total episodes per hour, mean 11.3 (6.3)]. Following randomisation, subjects received no treatment or pramipexole titrated from 0.09 to 0.54 mg, o.d., for 3 weeks according to a crossover procedure. A polysomnographic-electromyographic registration was performed at the end of each period. Pramipexole was associated with more frequent awakenings and a reduction in rapid eye movement sleep (both P ≤ 0.02). Sleep apnea decreased marginally after pramipexole (apnea-hypopnea index 17.1 compared with control 21.5, P ≤ 0.05). The number of bruxism episodes, phasic, tonic and mixed per hour, remained unchanged after pramipexole [total episodes per hour 12.7 (8.5) and 9.8 (5.2) during pramipexole and control conditions, respectively]. It is concluded, from this pilot study, that sleep bruxism is not affected by the dopaminergic agent, pramipexole.

Temporomandibular condylar alterations in juvenile idiopathic arthritis most common in longitudinally severe disease despite medical treatment.

BACKGROUND: Juvenile idiopathic arthritis (JIA) is an autoimmune, heterogeneous disease and the temporomandibular joint (TMJ) can be affected, with consequences for mandibular growth and function. The aim of this study was to evaluate the importance of longitudinal medical treatment and the burden of disease activity on the development of temporomandibular condylar alterations as judged on panoramic radiographs. METHODS: The study was a retrospective evaluation of dental and medical records in consecutive JIA patients referred to three specialist dental clinics in Sweden during an eight-year period. Data on the total pharmacological treatment and disease activity were evaluated longitudinally from disease onset to the time of the panoramic examination, during a median observation period of 2.5 years. The radiographs were analysed in terms of structural and shape alterations in the condyles and judged dichotomously. RESULTS: Panoramic examinations were analysed in 158 patients from 266 referrals diagnosed with JIA. Condylar alterations (shape or structural) were seen in 68 patients (43%). Patients with condylar alterations were more extensively treated over time compared with those without condylar alterations. Powerful disease activity and/or potent medication at any time during the course of the disease implied an increased risk of alterations. CONCLUSIONS: Patients with JIA who require more intensive medication over time run the greatest risk of condylar alterations. As yet, current medical programmes have not been specified for the TMJ and more knowledge in this area is needed.

Temporomandibular signs, symptoms, joint alterations and disease activity in juvenile idiopathic arthritis - an observational study.

BACKGROUND: Juvenile idiopathic arthritis (JIA) is a heterogeneous disease that frequently affects also the temporomandibular joint (TMJ) and associated structures. The main aim of this observational study was to describe systematically orofacial clinical signs and subjective symptoms in JIA patients, classified according to the International League of Associations for Rheumatology (ILAR) criteria, and to relate the findings to disease activity and radiological TMJ condyle lesions. METHODS: The study was a retrospective evaluation of dental and medical records in consecutive JIA patients referred to one of three dental specialist clinics in Sweden during an eight-year period. Data concerning temporomandibular signs, symptoms and general disease activity were collected and condylar alterations were judged on panoramic radiographs. RESULTS: All ILAR categories of JIA were represented among the 266 referrals included in the study. The distribution of patients among categories resembled the pattern seen in epidemiological studies. Persistent oligoarthritis was the largest category with 36.5% of the patients. Temporomandibular clinical signs (mild, moderate or severe) occurred in 57.7% to 92.0%, and subjective symptoms (mild or severe) in 32.0% to 76.0% of the patients in all categories. Patients in the juvenile psoriatic arthritis category had the largest number of orofacial signs and symptoms, and patients in the persistent oligoarthritis category had the fewest signs and symptoms. There were significant associations between clinical signs as well as subjective symptoms and overall disease activity. Half of all the patients had undergone panoramic examinations and 37.9% of those were judged to have condylar alterations after a mean of 2.9 years after onset. No associations between radiological findings and variables, such as signs, symptoms or disease activity, were found. CONCLUSIONS: Temporomandibular signs and symptoms can be expected to a varying degree, including severe cases, in all JIA categories. Clinical and subjective orofacial involvement appears to be related to disease activity but not to condylar lesions.

Psychometric evaluation of a Swedish version of the Functional Outcomes of Sleep Questionnaire, FOSQ.

OBJECTIVE: The Functional Outcomes of Sleep Questionnaire, FOSQ, is a self-administered 30 item questionnaire, designed to assess the impact of disorders of excessive sleepiness on activities of daily living. The aim was to evaluate the psychometric properties of a Swedish translation of the English original. MATERIALS AND METHODS: A Swedish version of the FOSQ was answered by 75 consecutive patients, diagnosed with obstructive sleep apnea syndrome and in need of treatment. The Short Form Health Survey (SF-36) and Epworth Sleepiness Scale (ESS) were also answered at the same time to evaluate validity. The first 25 patients answered the FOSQ a second time, 3 weeks later, to assess reliability. RESULTS: The test-re-test reliability and intra-class correlation of the different sub-scales in the FOSQ varied between 0.71-0.92 and was 0.92 for the total scale, all statistically significant. Cronbach's alpha, calculated as a measure of internal consistency, varied between 0.84-0.92 for FOSQ sub-scales and was 0.96 for the total score. Statistically significant correlations between FOSQ sub-scales and the eight sub-scales in the SF-36 supported the validity. Discriminant validity, calculated by splitting responders with high and low ESS scores, revealed that FOSQs scores differed significantly between the groups. CONCLUSIONS: The results suggest that the Swedish version of the FOSQ has psychometric qualities in line with the original. It might, therefore, be a potentially useful, reliable and valid instrument for clinicians and researchers when measuring variables related to quality-of-life in sleep disorders in this language area.

No effect of glucosamine sulfate on osteoarthritis in the temporomandibular joints--a randomized, controlled, short-term study.

OBJECTIVE: The aim of this study was to evaluate the clinical effects of oral glucosamine sulfate, compared with placebo, on osteoarthritis in the temporomandibular joints (TMJs). STUDY DESIGN: Fifty-nine patients, consecutive referrals fulfilling the research diagnostic criteria for temporomandibular disorder for TMJ osteoarthritis, confirmed roentgenographically, were randomized to the daily intake of 1,200 mg glucosamine sulfate or identical placebo capsules in this double-blind trial. Pain on visual and verbal rating scales and opening capacity were registered before and after 6 weeks of medication. RESULTS: The signs and symptoms were similar in the groups initially and they were ameliorated over time. No differences in improvement between groups after treatment were indicated. Eight patients in the glucosamine group and 2 in the placebo group stopped the medication prematurely. Gastrointestinal side effects were reported by a total of 10 and 3 patients, respectively. CONCLUSIONS: Oral glucosamine sulfate was not superior to placebo in reducing signs and symptoms of osteoarthritis in the TMJs in this short-term trial.

Perceived symptoms of psychological distress and salivary cortisol levels in young women with muscular or disk-related temporomandibular disorders.

OBJECTIVE: To assess any differences in psychological and endocrine variables between homogeneous core groups of young women with well-defined muscle- or disk-related temporomandibular disorders (TMDs) and matched controls. MATERIAL AND METHODS: Fifteen women, aged 18-24 years, fulfilling the TMD Research Diagnostic Criteria I a/b (but not II or III) and 15 fulfilling the II a/b and III criteria were consecutively selected from referrals to an orofacial pain/TMD clinic. Thirty consecutive healthy age-matched women attending yearly routine check-ups at a general dental clinic served as controls. All 60 subjects answered a questionnaire, the Profile of Fatigue Related Symptoms (PFRS), and salivary samples on waking were collected for analysis of cortisol levels. RESULTS: Symptom duration and pain levels were similar irrespective of muscle- or disk-related symptoms. Both diagnostic groups obtained scores that were similar and significantly higher than those of controls in all four scales of the PFRS: fatigue, emotional distress, cognitive difficulties and somatic symptoms. Salivary cortisol levels on waking did not differ between patients and controls. CONCLUSIONS: Patients with TMDs, irrespective of diagnosis, appeared to be more psychologically distressed than controls evaluated psychometrically, which is in line with earlier findings. A corresponding difference was not reflected in a single measurement of morning salivary cortisol. A more comprehensive evaluation of endocrine variables is probably necessary to reveal whether any differences actually exist in this respect.

Temporomandibular disorders and oral health-related quality of life. A systematic review.

OBJECTIVE: Oral health-related quality of life (OHRQoL) is considered an important aspect of different oral conditions. It has also gained increased attention in temporomandibular disorders (TMDs) in recent years. The purpose of this study was to systematically review the literature on OHRQoL and TMDs. MATERIAL AND METHODS: A systematic search of the dental literature was performed using the Medline and Cochrane Library databases, supplemented by a hand search. Various combinations of search terms related to OHRQoL and TMDs were used. Among numerous titles found in Medline, abstracts and eventually full papers of potential interest were reviewed. Twelve papers fulfilled the inclusion criteria and were included in the review. RESULTS: Most studies used the Oral Health Impact Profile, an instrument with good psychometric properties, for evaluation. All articles described a substantial impact on OHRQoL in TMD patients. Only a small proportion of all patients, a few percent, reported no impact at all. The difference between men and women was small and not significant. The impact appeared to be more pronounced in patients with more signs and symptoms. The perceived impact of pain on OHRQoL seems to be substantial. Two studies found that the impact increased with age among TMD patients. CONCLUSIONS: The reviewed studies convincingly demonstrated that OHRQoL was negatively affected among TMD patients.

Utilization of pharmaceuticals among patients with temporomandibular disorders: a controlled study.

OBJECTIVE: Pharmaceuticals are among factors that might be associated with temporomandibular disorders (TMDs), but knowledge about their utilization is limited. The purpose was to systematically register the regular use of medication in general among TMD patients and matched controls to enable comparisons to be made. MATERIAL AND METHODS: Three hundred consecutive patients referred for diagnosis and treatment of TMDs and fulfilling the Research Diagnostic Criteria were examined prospectively and any medication recorded. Matched controls were registered parallel in time. The pharmaceuticals used were categorized according to the Anatomical Therapeutic Chemical Classification System (ATC). RESULTS: Forty-four percent of the patients received a main diagnosis of "muscle disorder", 39% "disk disorder", and 17% "joint disorder". Fifty-one percent of all patients used some medication on a regular basis compared to 36% of the controls (p<0.001). The average number of ATC categories used among all patients was 0.9 and among controls 0.5 (p<0.001). Of the female patients with the diagnosis "muscle disorder", 23% used antidepressants (N06A), 6% tranquilizers (N05B), and 7% sleep medication or sedatives (N05C) significantly more frequently than controls. Of the female patients diagnosed with a "joint disorder", 26% used antidepressants (N06A) significantly more frequently than controls. All other ATC categories differed non-significantly. CONCLUSIONS: The results suggest that the use of pharmaceuticals differs between patients and controls. TMD patients, particularly women diagnosed with "muscle" or "joint" disorders, appear to use drugs for depression more frequently than ordinary dental patients.