An electromyographic study on the sequential recruitment of bilateral sternocleidomastoid and masseter muscle activity during gum chewing.

Mandibular functions are associated with electromyographic activity of the jaw muscles and also the sternocleidomastoid muscle (SCM). The precise spatiotemporal relation of SCM and masticatory muscles activities during chewing is worthy of investigation. To analyse the sequential recruitment of SCM and masseter activities during chewing as indicated by the spatiotemporal locations of their activity peaks. Jaw movements and bilateral surface electromyographic activity of SCM and masseter were recorded during gum chewing in 20 healthy subjects. The timing order was decided by comparing the length of time from the time when the opening started to the time when the surface electromyographic activity reached its peak value. Spatial order was analysed by locating the peak electromyographic activity onto a standard chewing cycle which was created based on 15 unilateral chewing cycles. Paired t-test, one-way ANOVA and Student-Newman-Keuls post-test were used for comparisons. Although the Time to Peak for the balancing side SCM appeared shorter than for the other three tested muscles, most often it did not reach a level of significance. However, the location of the balancing side SCM's peak activity was further from the terminal chewing position (TCP) than the working side SCM and bilateral masseters (P < 0·05). The balancing side SCM activity reached its peak significantly further away from TCP than the other three tested muscles during chewing. Further studies with spatiotemporal variables included should be helpful to understand the roles of the head, neck and jaw muscles in orofacial and cervical dysfunctional problems.

Unbalanced lateral mandibular deviation associated with TMJ sound as a sign in TMJ disc dysfunction diagnosis.

The aim was to study the characteristics of lateral mandibular horizontal deviations during opening-closing movements and their association with TMJ sounds of the clicking type. Subjects were 28 healthy volunteers and 38 patients diagnosed with MRI imaging as having TMJ disc dysfunction, 22 with disc displacement without (DD) and 16 as having disc displacement with reduction (DDR). TMJ sounds were recorded with miniature microphones placed in the ear canals, and jaw movements were documented with a kinesiograph. A sign, unbalanced lateral deviation (ubd) was defined as a rapid, short duration, change in jaw movement direction from, and back to, a smooth deviation path in the horizontal plane. The hypotheses were that degrees of maximal deviations, proportions of unbalanced deviation (ubd) and such deviation associated with TMJ sounds (ubdS), differ between healthy subjects and patients with DD or DDR. Comparisons between groups were made using one-way anova and chi-square analysis, as appropriate. No differences were found between groups regarding degree of lateral deviation per se. The proportions of ubd and ubdS were significantly higher in patients with DDR than in healthy subjects and than in patients with DD (P < 0·001), but no such differences were found between healthy subjects and patients with DD. For prediction of DDR, the sensitivity and specificity of the sign ubdS were found to be 68·8% and 89·3%, respectively. For the sign ubd, they were 100·0% and 64·3%. This indicates that the sign ubdS has diagnostic value in screening for DDR.

SEMG activity of jaw-closing muscles during biting with different unilateral occlusal supports.

The aim of this study was to test the hypothesis that experimental and reversible changes of occlusion affect the levels of surface electromyographic (SEMG) activity in the anterior temporalis and masseter areas during unilateral maximal voluntary biting (MVB) in centric and eccentric position. Changes were achieved by letting 21 healthy subjects bite with and without a cotton roll between the teeth. The placement alternated between sides and between premolar and molar areas. The SEMG activity level was lower when biting in eccentric position without than with a cotton roll between teeth (P < 0.043). It was always lower with premolar than with molar support when biting with a cotton roll (P < 0.013). In the anterior temporalis areas, the SEMG activity was always lower on the balancing than on the working side (P < 0.001). Such a difference was also found in the masseter areas but only during molar-supported centric biting (P = 0.024). No differences were found when comparing the SEMG levels in masseter areas between centric and eccentric biting (P > 0.05). In the anterior temporalis area, the balancing side SEMG activity was lower in eccentric than in centric but only in molar-supported biting (P = 0.026). These results support that the masseter and anterior temporalis muscles have different roles in keeping the mandible in balance during unilateral supported MVB. Changes in occlusal stability achieved by biting with versus without a cotton roll were found to affect the SEMG activity levels.

Asymmetric muscle function in patients with developmental mandibular asymmetry.

The aim was to test the hypothesis that developmental mandibular asymmetry is associated with increased asymmetry in muscle activity. Patients with mandibular condylar and/or ramus hyperplasia having unilateral cross-bite were compared with healthy subjects with normal occlusion. Muscle activity was recorded with surface electrodes in the masseter, suprahyoid, sternocleidomastoid muscle (SCM) and upper trapezius areas during jaw opening-closing-clenching, head-neck flexion-extension, and elevation-lowering of shoulders. Root mean square (RMS) and mean power frequency (MPF) values were calculated and analysed using anova and t-tests with P < 0.05 chosen as significance level. The SCM and masseter muscles showed co-activation during jaw and head movements, significantly more asymmetric in the patients than in the healthy subjects. The RMS and MPF values were higher in the patients than in the controls in the SCM and suprahyoid areas on both sides during jaw opening-closing movement. The results indicate that the ability to perform symmetric jaw and neck muscle activities is disturbed in patients with developmental mandibular asymmetry. This is of clinical interest because asymmetric activity may be an etiologic factor in temporomandibular joint and cervical pain. The results support that co-activation occurs between jaw and neck muscles during voluntary jaw opening and indicate that postural antigravity reflex activity occurs in the masseter area during head extension. Further studies, where EMG recordings are made from the DMA patients at early stages are motivated to verify activity sources and test if the asymmetric activity is associated with muscle and joint pain in the jaw and cervical areas.

Limitation of the diagnostic value of MR images for diagnosing temporomandibular joint disorders.

OBJECTIVES: Many studies have shown that MRI findings are reliable when experienced calibrated observers work as a group. The hypothesis was that MRI findings can be used as the gold standard also when evaluation is made by single expert observers. STUDY DESIGN: Temporomandibular joint (TMJ) MRIs of 34 patients were evaluated independently by four reviewers with expert knowledge of radiology for the presence of 13 specified pathologic entities, as well as the quality of the images, on a 5-step scale from "Sure Yes" to "Sure No". Intraclass correlation coefficients were calculated to estimate the rating reliability of the examiners. A coefficient of at least 0.8 was deemed good, between 0.60 and 0.80 was deemed acceptable, and less than 0.60 was considered poor. Additionally, weighted kappa statistics were used for pair-wise comparisons across all four reviewers. RESULTS: The hypothesis was not supported by the results. None of the 13 correlation coefficients for comparisons between single examiner evaluations of pathologic entities was good and 8 were poor. CONCLUSION: A diagnosis of TMD based on MRI examination protocols made by a single examiner should not be accepted as a gold standard with regard to TMJ disorders.

The dynamic range of TMJ sounds.

It is of clinical interest to record the amplitudes of temporomandibular joint (TMJ) sounds. The aim was to test the hypothesis that sealing the meatus, when placing a microphone in the ear canal affects such recording by increasing the sound pressure level (SPL). Bilateral recordings of 249 TMJ clickings were made from three subjects, using sampling rates of 48 or 96 kHz and 24 bits A/D conversion, with and without the ear canals sealed by Silicone putty. The peak-to-peak equivalent sound pressure level (peSPL) was higher (P < 0.001) when the ear canal was sealed (range of mean differences was 8.3-24.9 dB peSPL). This means that the signal to noise ratio can be improved by sealing the meatus because the electronic noise level is not increased. Most important is that the dynamic range of the clicking sounds was 62 dB that is larger than the effective dynamic range of a 16 bits sound card. Future studies are needed to establish normative peSPL values. However, cards with at least 24 bits A/D conversion will be required, especially in patients with suspected disc displacement with reduction, where the difference in loudness between opening and closing clicking often is large.

The frequency range of TMJ sounds.

There are conflicting opinions about the frequency range of temporomandibular joint (TMJ) sounds. Some authors claim that the upper limit is about 650 Hz. The aim was to test the hypothesis that TMJ sounds may contain frequencies well above 650 Hz but that significant amounts of their energy are lost if the vibrations are recorded using contact sensors and/or travel far through the head tissues. Time-frequency distributions of 172 TMJ clickings (three subjects) were compared between recordings with one microphone in the ear canal and a skin contact transducer above the clicking joint and between recordings from two microphones, one in each ear canal. The energy peaks of the clickings recorded with a microphone in the ear canal on the clicking side were often well above 650 Hz and always in a significantly higher area (range 117-1922 Hz, P < 0.05 or lower) than in recordings obtained with contact sensors (range 47-375 Hz) or in microphone recordings from the opposite ear canal (range 141-703 Hz). Future studies are required to establish normative frequency range values of TMJ sounds but need methods also capable of recording the high frequency vibrations.

Localization of TMJ sounds to side.

Differential diagnosis depends in cases with disk displacement on accurate identification of sound source. Mistakes may occur when clicking from one temporomandibular joint (TMJ) is heard on both sides of the head at auscultation and neither examiner nor patient, is sure about side. The hypothesis was that the head tissues affect spectral characteristics of TMJ sounds and that differences due to different positioning of sensors can be used in localization of source. The aim was to compare bilateral electronic recordings of unilateral TMJ sounds to obtain and compare attenuation, phase shift and time delay. Recordings were made from 12 subjects with unilateral clicking. Small electret condenser microphones, bandwidth 40-20 000 Hz, were placed at the openings of the auditory canals and the sounds were recorded at a sampling rate of 48 000 Hz. The head tissues acted as a filter causing a frequency dependent attenuation and phase shift. There was a time difference between the ipsi- and the contra lateral recordings, the latter always having a longer delay time (range 0.2-1.2 ms, group mean 0.68 ms, s.d. 0.292 ms). In conclusion, spectral analysis of bilateral electronic TMJ sound recordings is of diagnostic value when bilateral clicking is heard at auscultation and can help to avoid diagnosing a silent joint as clicking.

Acoustic characteristics of sounds from temporomandibular joints with and without effusion: an MRI study.

Joint effusion has been associated with temporomandibular joint (TMJ) pain but can only be diagnosed by magnetic resonance imaging (MRI). For screening of patients with suspected effusion a simple and less expensive method would be desirable. We recorded joint sounds during jaw opening and closing movement from 34 TMJs with internal derangement (ID). Seventeen joints had joint effusion seen on MRI. Spectrograms of the sounds were displayed as waterfall plots showing profiles of the consecutive Hamming windows. If the profiles were similar, as judged by initial evaluation, the displayed pattern was classified as stable. If some profiles were distinctly deviating in their pattern, this was classified as unstable. Joints with effusion showed unstable sound pattern more often than joints without effusion (P < 0.001). It was concluded that TMJ sound analyses have a potential to identify joints with effusion based on their unstable sound pattern.

Computerized classification of temporomandibular joint sounds.

Sounds, such as clicking and/or crepitation, evoked in the temporomandibular (jaw) joint during function may indicate pathology. Analysis of the reduced interference time-frequency distribution of these sounds is of diagnostic value. However, visual evaluation is expensive and error prone, and there is, thus, a need for automated analysis. The aim of this study was to find the optimal signal representation and pattern recognition method for computerized classification of temporomandibular joint sounds. Concepts of time-shift invariance with and without scale invariance were employed and mutually compared. The automated analysis methods provided classification results that were similar to previous visual classification of the sounds. It was found that the classifier performance was significantly improved when scale invariance was omitted. This behavior occurred because scale invariance interfered with the frequency content of the signal. Therefore, scale invariance should not be pursued in the classification scheme employed in this study.

Crepitation and clicking as signs of TMD in preschool children.

Children [N = 540, age 5.1 +/- 0.72 (SD)], were tested for association between temporomandibular (TM) joint sounds and symptoms of TM disorder (TMD). The prevalence of TMJ sounds as found by auscultation and confirmed by self-report was 16.7%. There was significant association after Bonferroni correction between the presence of TM joint sounds, as reported by the children, and all but one of the eleven pain/dysfunction variables. There was significant association also between crepitation as heard at auscultation and palpation tenderness in the TMJ and masseter areas (p < 0.001), but not between clicking and any of the TMD variables. Agreement between subjects and examiners regarding the presence of TMJ sounds was poor (kappa = 0.097). The results indicate that joint sounds and TMD symptoms are common already in small children and thus demonstrate a possible early onset of TMD. Patients' own reports of TMJ sounds may have more clinical relevance than auscultation findings.

False localization of TMJ sounds to side is an important source of error in TMD diagnosis.

The results of the study indicate that the head tissues act as a band pass filter that is far from flat. Instead there seems to be strong frequency variations in attenuation of transmitted sounds. The sounds are subject to phase shift and time delay, which can be used to decide from which TMJ the sound comes. Bilateral electronic recording with high sampling rate (>> 44 kHz) is needed to accurately and consistently identify the origin of a TMJ sound. Further studies on autopsy specimens and large subject groups are motivated.

Amplitude and frequency spectrum of temporomandibular joint sounds from subjects with and without other signs/symptoms of temporomandibular disorders.

Temporomandibular joint (TMJ) sound is one of the most commonly recognized signs in patients with temporomandibular disorders (TMD) but is also frequently seen in asymptomatic individuals. Sound recording is therefore only meaningful if the sounds from a normal healthy joint can be differentiated from those in patients. In this study, the amplitude and power spectrum of the TMJ sounds from symptomatic patients and asymptomatic individuals were recorded and compared. The result showed that TMJ sounds from symptomatic patients had a larger amplitude than sounds from asymptomatic subjects. A significant proportion of sounds had frequencies between 2000 and 3000 Hz. It was concluded that the characteristic amplitude is worthy of further study as a sign of possible diagnostic value. Secondly, the bandwidth of the sensors used at electronic TMJ sound recording should not be less than 3000 Hz.

Use and abuse of bite splints.

Bite splints are often used in the treatment of patients with oral parafunctions, temporomandibular joint (TMJ) dysfunction, or temporomandibular disorders. The most common reasons for prescribing a bite splint are to protect the teeth in patients with bruxism, to improve jaw-muscle and TMJ function, and to relieve related pain. The risk for negative side effects is small in conservative bite splint treatment. Complications from long-term use of splints, however, can be severe and irreversible. The risks are especially high when mandibular advancement splints, or splints that make contact only with parts of the opposing dentition, are used for more than 4 to 6 weeks without appropriate supervision. As a general rule, a dentist should not encourage a patient to use any type of splint for more than a few months except for cases in which the teeth need to be protected because of persistent oral parafunctions. Appropriate record keeping, including signed consent forms, is necessary; when neglected, it becomes difficult for the dentist to defend himself from false accusations of malpractice.

Bilateral sound propagation characteristics in electronic TMJ sound recording.

Temporomandibular Joint (TMJ) sounds, clicking and crepitation, are important signs of possible TM disorder or dysfunction (TMD). The sound are usually recorded and observed by stethoscope auscultation or palpation. Sound from one TMJ may propagate through head tissues and be recorded on the contra lateral side misleading the examiner to classify both joints as non-silent. Errors in localization of sound source may lead to an erroneous diagnosis. Widmalm et al. (1997) suggested a mathematical model for estimation of the sound propagation characteristics through the head tissues. A modified model applying the auto-spectral density and cross-spectral density of the signal was used to estimate the bilateral sound propagation characteristics of temporomandibular joint sounds from two subjects. The result indicates that the head tissues act as a bandpass filter causing strong attenuation in some frequency areas with little attenuation in others. The phase response of the transfer function provides a good mean to estimate the latency in time between sounds.

Automatic recognition of the source of temporomandibular joint sounds.

Sounds evoked in the temporomandibular joint (TMJ) during jaw movements may indicate pathology. They are in dental clinics usually recorded by auscultation and noted in protocols by verbal, subjective descriptions. Time-frequency analysis of electronically recorded TMJ sounds makes possible a more objective and sophisticated analysis. Such sounds were recorded from four subjects and grouped into two sets. One was used for training a classifier, while the other was used for testing its ability to relate a given sound to the subject from which it was recorded. Both scale and time-shift invariant representations, as well as only time-shift invariant representations of the Reduced Interference Distributions of the TMJ sounds were used for pattern recognition. The nearest neighbor, zero-subspace and nearest constrained linear combination classification methods were employed. It was observed that TMJ sound patterns could be very typical for a given person. This indicates that our classification approach can be developed into a useful diagnostic tool by obtaining training sets from patients where a definitive diagnosis of TMJ pathology has been obtained.

Classification of temporomandibular joint sounds based upon their reduced interference distribution.

Temporomandibular joint (TMJ) sounds were recorded in 98 orthodontic retention patients, mean age 19 +/- 8.6 (s.d.) years, by interview, auscultation and electronic recording. Sounds were found by auscultation in 41% and by interview in 32% of the subjects, more often in females than in males (P < 0.05). A new method for time-frequency analysis, the reduced interference distribution (RID), was used to classify the electronic sound recordings into five subclasses, RID types 1-5, based upon location and number of their energy peaks. RID types 1-3 had a few energy peaks close in time. RID types 4-5, typical of subjects with crepitation, had multiple energy peaks occurring close in time for a period of 20-300 ms. RID type 1, found in 45% of the subjects, typical of patients with clicking, had its dominant energy peak located in a frequency range < 600 Hz and was significantly more common in the female than in the male subjects (P < 0.01). RID type 2, found in 68% of the subjects, with the dominant peak in the range 600-1200 Hz, and RID type 3, found in 38% of the subjects, with the peak in the frequency range > 1200 Hz, were found to have a similar gender distribution. RID type 4, found in 49% of the subjects, had the energy peaks distributed in the frequency range < 600 Hz. RID type 5, found in 43% of the subjects, more often in females than in males (P < 0.05), had the peaks distributed over the whole frequency range from about 30 Hz up to about 3000 Hz. In conclusion, a more detailed classification could be made of the TMJ sounds by displaying the RIDs than by auscultation. This suggests that RID classification methods may provide a means for differentiating sounds indicating different types of pathology.

The wave forms of temporomandibular joint sound clicking and crepitation.

The aim of the present study was to determine the sound wave forms which correspond to auscultatory findings of temporomandibular joint (TMJ) clicking and crepitation. Such knowledge is important when selecting parts of digital recordings for spectral analysis. Electronic digital recordings were made with a sampling rate of 44,100 Hz from 60 subjects, including 51 patients referred for suspected rheumatological disease and nine healthy subjects. Accelerometers with the bandwidth 20-3600 Hz were used for all subjects and complementary recordings were made from a subgroup of nine subjects using a measurement microphone with the bandwidth 20-20,000 Hz. The clicking sounds could be classified into different types according to differences in temporal period duration (T) as measured on the analogue display. One type of clicking, found in 51% of the patients, had a T of 2-20 ms. Another type, found in 70% of the subjects, had a T of less than 1 ms, often as low 0.2 ms. This type of clicking was not seen at all in the analogue display if the sampling rate was below 3,000 Hz. The character of the two types of clicking differed: the short duration sounds had a very high pitch, while the pitch of the longer duration sound was lower. Crepitation was found in 63% of the subjects and was observed to be composed of a series of short duration sounds, occurring with brief (less than 10 ms) intervals. It is concluded that the accelerometer (or microphone) bandwidth should cover the entire audible range (20-20,000 Hz), and that sampling rates must be much higher than 3000 Hz, and preferably greater than 10,000 Hz, before the true significance of electronically recorded joint sounds/vibrations can be determined.

Oral parafunctions as temporomandibular disorder risk factors in children.

Oral parafunctions are generally considered to be important factors in the etiology of temporomandibular disorders (TMDs) and many reports have been published about their prevalence in adults and schoolchildren. However, few have included significant numbers of children below the age of 7. The aim of this study was to examine the association between parafunctions and oral/facial TMD-related pain in preschool children. Bruxism, nail biting, and thumb sucking were found to be significantly associated with important oral/facial pain symptoms of clinical interest in the diagnoses of TMD indicating that those parafunctions are risk factors. The study included 525 4- to 6-year-old African-American and Caucasian children, mean age 5.1 +/- 0.65 (SD). An alpha level of 5% was chosen for comparison with a Pearson Chi-Square test. Bonferroni correction was made and a p-value of < 0.005 was accepted as significance level. Only 28% of the children had no history of any parafunction. More girls (82%) than boys (63%) in the Caucasian subgroup had at least one parafunction (p approximately 0.00017). No such difference was found in the African-American subgroup where the corresponding figures were 71% for girls and 73% for boys. Thumb sucking was reported by 57% of the children, more often by Caucasian girls (69%) than by Caucasian boys (43%) (p < 0.00001). Thirty percent still had the habit. Forty-one percent had a history of nail biting. Bruxism was noted in 20% of the children, but occurred mostly in combination with other parafunctions and was seldom (in 3.4%) the only parafunction. Of the 10 pain variables, bruxism was significantly associated with eight, thumb sucking with three, and nail biting with two. Analysis with logistic regression confirmed the results. Association does not, however, tell if a parafunction is the cause or the consequence of pain, or if a third factor is causing both pain and increased prevalence of oral parafunctions. Further prospective longitudinal studies including higher age groups are needed to clarify those relations and to determine if there are long-term effects of childhood parafunctions.