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The classification of temporomandibular disorders (TMD) is still controversial. Consensus methods such as the Delphi technique, a method that polls experts' anonymous opinion in an iterative process with controlled feedback and statistical aggregation of group response, could be valuable to improve this challenging topic. The article illustrates the application of the Delphi technique for deciding whether the terms myalgia or myofascial pain should be used in a TMD classification system and discusses the technique's potential for TMD classification in general. In three Delphi rounds, 14 TMD experts from the Division of TMD and Orofacial Pain of the University of Minnesota reached a consensus about which TMD diagnoses should be included in a TMD classification system. They preferred the term myofascial pain over myalgia. The Delphi technique has the potential to provide answers to complex questions in TMD classification, e.g., TMD nomenclature and range as well as scope of conditions included in a future TMD classification system., (© 2010 Blackwell Publishing Ltd.)

This 2·5-day workshop was organized by the International RDC/TMD Consortium Network of the International Association for Dental Research and the Orofacial Pain Special Interest Group of the International Association for the Study of Pain. Workshop participation was by invitation based on representation within the field, which included the Consortium Network, the Orofacial Pain Special Interest Group, the National Institute for Dental and Craniofacial Research, American Academy of Orofacial Pain, the European Academy of Craniomandibular Disorders, and the International Headache Society; other disciplines included radiology, psychology, ontology, and patient advocacy. The workshop members were divided into workgroups that reviewed core literature describing the properties of the RDC/TMD, provided recommendations for revision, and suggested relevant research directions. The goals of this workshop were to (i) finalize the revision of the RDC/TMD into a Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), which would be more appropriate for routine clinical implementation, (ii) provide a broad foundation for the further development of suitable diagnostic systems for not only TMD but also oro-facial pain as well, and (iii) provide research recommendations oriented towards improving our understanding of TMD and oro-facial pain. This report provides the full description of the workshop and Executive Summary, and it acknowledges the participants and sponsors., (© 2010 Blackwell Publishing Ltd.)

This study describes the in vivo biocompatibility of intra-articular poly(DL-lactic-co-glycolic acid) (PLGA) microparticle (MP) formulations in the rat temporomandibular joint (TMJ). To our knowledge, this is the first intra-articular microparticle-based drug delivery system for the TMJ. The impact of PLGA MP concentration on rat TMJ function was quantified via computerized meal pattern analysis; in this non-invasive technique, previously validated markers of TMJ pain or nociception (specifically, meal duration and food intake) were recorded by computer-monitored pellet feeders. Bilateral intra-articular injection of 15, 30, or 50 mg/mL PLGA MPs had no impact on meal duration or food intake over 6 days, compared with controls that did not receive injections. Histological analysis showed that the MPs were retained within the synovial lining. These findings indicate that the PLGA MPs described herein are biocompatible and suitable for intra-articular delivery to the rat TMJ, a finding that has significant implications for the improvement of TMJ therapeutics.

Objectives: The relationship between the rate of chronic pain-related disability and depression and somatization levels as well as the influence of pain duration on Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) axis II findings were assessed in a three centre investigation., Methods: The study sample (N=1149; F:M 4.1:1, m.a. 38.6 years) consisted of patients seeking for TMD treatment and undergoing RDC/TMD axis II psychosocial assessment to be rated in chronic pain-related disability (Graded Chronic Pain Scale, GCPS), depression (Symptoms Checklist-90[SCL-90] scale for depression, DEP) and somatization levels (SCL-90 scale for non-specific physical symptoms, SOM). The null hypotheses to be tested were that (1) no correlation existed between GCPS categories and DEP and SOM scores, and (2) no differences emerged between patients with pain from more or less than 6 months as for the prevalence of the different degrees of pain-related impairment, depression, and somatization., Results: In the overall sample, the prevalence of high pain-related disability (GCPS grades III or IV), severe depression and somatization was 16.9%, 21.4%, and 28.5%, respectively. A correlation was shown between GCPS and both DEP and SOM categories (Spearman's correlation test, p<0.001). A significant association between pain lasting from more than 6 months and high GCPS scores was shown (chi(2), p<0.001), while no association was found between DEP and SOM scores and pain duration in the overall sample (chi(2), p=0.742 and p=0.364, respectively)., Conclusions: Pain-related disability was found to be strongly related with depression and somatization levels as well as associated with pain duration. Depression and somatization scores were not associated with pain duration., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Purpose: The present study estimated the prevalence of temporomandibular disorders (TMDs) in patients with gastroesophageal reflux disease (GERD)., Patients and Methods: A study group consisting of 60 adult patients (34 women and 26 men) diagnosed with GERD was matched by age and gender to a control group of 60 patients without any signs or symptoms of GERD. The diagnosis of TMD was established using the Research Diagnostic Criteria for Temporomandibular Disorders., Results: Of the 60 patients in the study group, 22 (36.6%) had TMD compared with 11 (18.3%) in the control group (P = .025). Most patients with TMD in both groups were diagnosed with myofascial pain: 19 (31.7%) in the study group versus 9 (15%) in the control group (P = .031)., Conclusions: The increased TMD prevalence in patients with GERD should be explored further to better characterize the association between TMD and GERD. The physicians treating the 2 disorders should consider the clinical implications of this association., (Copyright 2010 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Aims: To estimate the clinically important change (CIC) on a 100-mm visual analog scale for pain intensity (VAS-PI) by relating it to the patient's global impression of change (PGIC) in patients with chronic temporomandibular disorder (TMD) pain and to assess the dependency of the CIC on their baseline pain scores., Methods: Data from a prospective cohort study with 588 patients with chronic TMD pain were analyzed. The CIC was estimated over a 3-month period, and receiver operating characteristic methods were used to assess the optimal cut-off point. The PGIC category of "much improved" served as an external criterion. Dependency of absolute and percent change on baseline VAS-PI scores was determined by linear regression analysis., Results: A VAS-PI change score of -19.5 mm and a percent change score of -37.9% were best associated with the concept of CIC. Since patients with high baseline pain required greater absolute reductions in pain to reach a clinically important improvement, percent change scores performed better in classifying improved patients., Conclusion: Providing a standard definition of the CIC adds to the interpretability of study results, ie, the estimates will aid in understanding individual patient outcomes.

Objective: The purpose of this study was to investigate clinical and psychological characteristics of temporomandibular disorders (TMD) patients with trauma history., Materials and Methods: The clinical and psychological characteristics of 34 TMD patients with trauma history were compared with those of 340 TMD patients without trauma history. Craniomandibular index (CMI) was used for clinical characteristics of TMD patients. Symptom severity index (SSI) was used to assess the multiple dimensions of pain. Symptom checklist-90-revision (SCL-90-R) was used for psychological evaluation., Results: Temporomandibular disorders patients with trauma history displayed significantly higher CMI and palpation index. TMD patients with trauma history also exhibited higher values in duration, sensory intensity, affective intensity, tolerability, scope of symptom, and total SSI score. In addition, these patients showed significantly higher values in symptom dimensions of somatization, depression, anxiety, phobic anxiety, and paranoid ideation. Among the symptom dimensions of SCL-90-R, somatization showed the most significant correlations with CMI and SSI., Conclusions: Temporomandibular disorders patients with trauma history displayed more severe subjective, objective, and psychological dysfunction than those without trauma history. Pain of myogenous origin, history of physical trauma, and psychosocial dysfunction were all closely related.

Chronic orofacial pain (COFP) is an umbrella term used to describe painful regional syndromes with a chronic, unremitting pattern. This is a convenience term, similar to chronic daily headaches, but is of clinically questionable significance: syndromes that make up COFP require individually tailored diagnostic approaches and treatment. Herein we describe the three main categories of COFP: musculoskeletal, neurovascular, and neuropathic. For many years, COFP and headache have been looked upon as discrete entities. However, we propose the concept that because COFP and headaches share underlying pathophysiological mechanisms, clinical characteristics, and neurovascular anatomy, they should be classified together.

The aim of this work was to describe the prevalence of signs and symptoms of temporomandibular disorders (TMD) in children of the State of Puebla, Mexico. A descriptive observational study was performed. After calculating sample size, children who met the following selection criteria were included: registered at an official elementary school, either sex, ages between 8 and 12 years, who accept to participate in the study and whose parents have signed the informed consent forms. The Research Diagnostic Criteria for Temporomandibular Disorders were used by calibrated researchers (Kappa 90) under the same conditions. Descriptive statistics were applied by using SPSSv15 software. The study included 235 children, 129 (54.9%) female and 106 (45.1%) male, of average age 9.31 + 1.2 years. Prevalence of signs and symptoms was 33.2%, and predominately muscular (82%), 48.1% showed signs of muscular pain and 19.1% joint pain. 63.4% showed signs of alteration in the mouth opening pattern, 39.1% presented joint sounds on opening or closing the mouth and 20.4% on mandibular excursions. The high prevalence of signs and symptoms related to temporomandibular disorders, in particular in children with mixed dentition, shows the importance of TMD evaluation during this period, when morphological changes associated to growth and craniofacial development prevail.

Pain is one of the most common reasons for which patients seek dental and medical care. Orofacial pain conditions consist of a wide range of disorders including odontalgia (toothache), temporomandibular disorders, trigeminal neuralgia and others. Most of these conditions are either inflammatory or neuropathic in nature. This chapter provides an overview of the commonly used models to study inflammatory and neuropathic orofacial pain.

The psychometric properties of the modified Symptom Severity Index were investigated to assess the relationships among dimensions of pain in temporomandibular disorders (TMD). The 15-item instrument is composed of ordinal scales assessing five pain dimensions (intensity, frequency, duration, unpleasantness and difficulty to endure) as experienced in three locations (temple, temporomandibular joint (TMJ), masseter). In 108 closed-lock subjects, Cronbach's alpha was used to measure internal consistency resulting in 31 of the 105 pair-wise comparisons >or=0.71. Multilevel exploratory factor analysis was used to assess dimensionality between items. Two factors emerged, termed temple pain and jaw pain. The jaw pain factor comprised the TMJ and masseter locations, indicating that subjects did not differentiate between these two locations. With further analysis, the jaw pain factor could be separated into temporal aspects of pain (frequency, duration) and affective dimensions (intensity, unpleasantness, endurability). Temple pain could not be further reduced; this may have been influenced by concurrent orofacial pains such as headache. Internal consistency was high, with alphas >or=0.92 for scales associated with all factors. Excellent test-retest reliability was found for repeat testing at 2-48 h in 55 subjects (Intra-class correlation coefficients = 0.97, 95%CI 0.96-0.99). In conclusion, the modified Symptom Severity Index has excellent psychometric properties for use as an instrument to measure pain in subjects with TMD. The most important characteristic of this pain is location, while the temporal dimensions are important for jaw pain. Further research is needed to confirm these findings and assess relationships between dimensions of pain as experienced in other chronic pain disorders.

Facial pain has a considerable impact on quality of life. Accurate incidence estimates in the general population are scant. The aim was therefore to estimate the incidence rate (IR) of trigeminal neuralgia (TGN), postherpetic neuralgia (PHN), cluster headache (CH), occipital neuralgia (ON), local neuralgia (LoN), atypical facial pain (AFP), glossopharyngeal neuralgia (GPN) and paroxysmal hemicrania (PH) in the Netherlands. In the population-based Integrated Primary Care Information (IPCI) medical record database potential facial pain cases were identified from codes and narratives. Two medical doctors reviewed medical records, questionnaires from general practitioners and specialist letters using criteria of the International Association for the Study of Pain. A pain specialist arbitrated if necessary and a random sample of all cases was evaluated by a neurologist. The date of onset was defined as date of first specific symptoms. The IR was calculated per 100,000PY. Three hundred and sixty-two incident cases were ascertained. The overall IR [95% confidence interval] was 38.7 [34.9-42.9]. It was more common among women compared to men. Trigeminal neuralgia and cluster headache were the most common forms among the studied diseases. Paroxysmal hemicrania and glossopharyngeal neuralgia were among the rarer syndromes. The IR increased with age for all diseases except CH and ON, peaking in the 4th and 7th decade, respectively. Postherpetic neuralgia, CH and LoN were more common in men than women. From this we can conclude that facial pain is relatively rare, although more common than estimated previously based on hospital data.

Aims: To assess whether pain-related awakenings occur with persistent orofacial pain conditions and whether it is related to pain severity., Methods: Reports of pain-related awakening were prospectively collected at initial interview, prior to treatment, during a 24-month period from 328 patients with orofacial pain. The pain conditions were diagnosed according to the International Headache Society, the American Academy of Orofacial Pain,and the Research Diagnostic Criteria for Temporomandibular Disorders., Results: Pain-related awakening was significantly correlated to pain intensity (odds ratio [OR] 1.5, 95% confidence intervals [CI] 1.3-1.8; P < .001), the total muscle tenderness score (OR 1.1, 95% CI 1.01-1.14; P = .03), and the presence of lacrimation (OR 4.6, 95% CI 1.7-12.3; P = .002) but not to the clinical diagnosis. Two groups of patients were specifically examined; patients with masticatory myofascial pain (MMP) and patients with classical trigeminal neuralgia (CTN). Twenty-eight of the 120 MMP patients (23.3%) reported pain-related awakening and this was associated with a high muscle tenderness score (OR 1.13, 95% CI 1.01-1.3; P = .02) and unilaterality of pain (OR 3.9, 95% CI 1.2-12.3; P = .02). Seven of the 31 patients with CTN (22.6%) reported pain-related awakenings. Continuous background pain was the most significant parameter associated with awakening (OR 26, 95% CI 1.1-594; P < .05)., Conclusion: Persistent orofacial pain often induced pain-related awakening and this was significantly associated with pain intensity.

The aim of this study was to evaluate the ability of a preliminary intravenous diagnostic test to classify chronic orofacial pain patients into different subgroups. Patients with chronic orofacial pain conditions that could not be unambiguously diagnosed. A retrospective evaluation of series of conducted pharmacodiagnostic tests, consisting of the consecutive intravenous administration of drugs. Visual analogue scale scores were retrieved from all patients, based on which they were classified into different responder groups. In total, 46 pain profiles were analysed. Of these, 16 patients (35%) could be classified into one or more pain categories, while 30 patients (65%) could not be classified into any pain category. The pain duration or medication use did not influence the classification. Based on the results of this retrospective study, it seems that classification into subgroups is possible after intravenous testing in a minority of clinically unclassifiable patients. In patients where there is a substantial need for additional diagnostic information, these results may be of value. Recommendations are made for further research, which should include validation in patients with known pain mechanisms.

The aim of this study was (i) to examine the effect of light tooth contact as in diurnal tooth clenching on the tactile detection threshold (TDT), the filament-prick pain detection threshold (FPT) and the pressure pain threshold (PPT) in the oro-facial region and (ii) to examine the possible gender difference in this effect on the tactile and pain perception. Twenty healthy volunteers participated. The TDT and the FPT were measured by means of Semmes-Weinstein monofilaments, on the cheek skin (CS) overlying the masseter muscles (MM) and on the skin overlying the palm side of the thenar skin (TS). The PPT was measured at the central part of the MM using a pressure algometer. Each parameter was measured before and after keeping light tooth contact for 5 min (session 1) and after keeping the jaw relaxed for 5 min (session 2) as a control. Although there were no significant session effects on any of the parameters, there were significant effects of experimental condition on the TDT in both men and women (P < 0.001). Men had a significant higher FPT of the left CS (P < 0.05) and TS (P < 0.01) and a significant higher PPT of the MM than women (P < 0.001). These results illustrate that sensitivity to pain (FPT, PPT) was higher in women than in men. Although there were no significant gender differences in habituation of sensory perception, the increase of TDT after clenching/no clenching was larger in women, which warrants further study.

The aim of this study was to observe the prevalence of diagnostic groups of temporomandibular disorders (TMD) in patients who were referred or sought treatment for TMD and/or orofacial pain in a private clinic. The clinical records of 357 patients were evaluated and selected based on inclusion/exclusion criteria; the mean age was 32 years. A clinical examination was performed and the diagnosis was based on the American Academy of Orofacial Pain criteria. Results showed that 86.8% of patients were women and 93.3% of the patients presented more than one diagnosis. The most frequent chief complaint (n = 216, chi2 = 30.68, p = 0.001) and total diagnosis realized (n = 748, chi2 = 14.14, p = 0.001) were muscle related. We concluded that women seek treatment for dysfunction/disorders of orofacial structures more than men do; patients seeking specialized treatment have more than one diagnosis and muscle dysfunction is more prevalent than intra-articular disorders.

Purpose of Review: Review current literature in the field of chronic nondental facial pain as recent clinical research findings need to be put into practise., Recent Findings: The areas covered include epidemiology and risk factors for facial pain, management of temporomandibular disorders, burning mouth syndrome, atypical odontalgia and trigeminal neuralgia., Summary: There is an increasing awareness that facial pain is common and has similar risk factors to other chronic pain conditions. Some oral pain conditions are now being recognized as being probably neuropathic in origin rather than being due to psychological factors. A more biopsychosocial approach to management of these conditions is essential. The first international guidelines on management of trigeminal neuralgia have now been published and should help all clinicians seeing these patients.

Purpose: The purpose of this study was to evaluate the long-term stability of the improvement of symptoms associated with temporomandibular joint (TMJ) disorders after intraoral vertical ramus osteotomy for the treatment of mandibular prognathism., Materials and Methods: A total of 217 patients who had undergone bilateral intraoral vertical ramus osteotomy (BIVRO) from 1998 to 2005 were evaluated preoperatively and 1, 3, 6, 12, 18, and 24 months postoperatively regarding mouth opening, clicking, and pain of the TMJ. A retrospective study was conducted based on the results., Results: Remarkable improvement of TMJ symptoms after BIVRO was reliable. Preoperative TMJ sounds disappeared after BIVRO in 94.3% of joints, and most of the joints that were sound free preoperatively remained without TMJ sounds postoperatively (98.2%). However, 19 joints exhibited recurrence, and transient TMJ sounds were observed in 35 joints. Preoperative TMJ pain had improved in 97.9% of joints at 1 month postoperatively, and TMJ pain was not observed in any joints at 18 months after surgery. Joints that were pain free before surgery remained without pain, although there were 20 joints that exhibited transient TMJ pain. The mean mouth opening was 50.0 mm before surgery, which decreased to 34.92 mm at 1 month postoperatively. This was followed by an increase to 44.44 mm to 48.75 mm at 6 months postoperatively, and thereafter mouth opening showed 94.72% to 97.5% recovery compared with the preoperative state., Conclusions: BIVRO can be used as a method of choice for relieving undesirable TMJ symptoms such as sound and pain, as well as for repositioning the condyle head to its physiologic position. Such favorable effects of BIVRO on the TMJ were not remarkably affected with time.

Intractable neuropathic face pain is a syndrome of unremitting severe pain that stems from abnormal nociceptive processing at various levels of the trigeminal system. Treatment of this debilitating condition has long presented a challenge for physicians due to its refractoriness to standard pharmacologic therapies. With few viable treatments, surgical procedures such as motor cortex stimulation (MCS) and deep brain stimulation (DBS) provide additional options. This article reviews the current literature and practices regarding patient selection criteria, potential mechanisms of action, surgical technique, and outcome of patients with neuropathic face pain treated with MCS and DBS.

Unlabelled: This study examined the associations between acculturation and orofacial pain and healthcare among Hispanic adults. Understanding the effects of acculturation on Hispanic oral health may improve understanding of oral health disparities in the United States. Data were collected from 911 Hispanic adults reporting tooth pain and painful oral sores who were part of a larger study of South Florida residents conducted using random-digit dialing methodology. The survey was conducted in Spanish or English by bilingual interviewers per the choice of each respondent. Greater use of the Spanish language was associated with disparities in healthcare visits for orofacial pain, not having a usual dentist, having greater pain, increased difficulty eating and sleeping, and more depression. Respondents' and their parents' nativity (families that had been in the United States longer) and those identifying more closely to Hispanic culture were also predictive of several of the outcomes. Gender, financial status, and age, independent of acculturation, were also associated with orofacial pain, accessing health care, and pain-related loss of functioning among Hispanics. The data support the hypothesis that Hispanics with less acculturation are less able to access needed oral health care. This study highlights the need for outreach programs targeting recent Hispanic immigrants focusing on oral health care., Perspective: This study found that lower levels of acculturation, particularly less frequent use of English, were associated with greater oral pain and depression for Hispanics adults. This emphasizes the need to provide Hispanic patients with information in Spanish and the importance of having bilingual materials and staff in dental clinics.

The aim was to apply diagnostic criteria, as published by the International Headache Society (IHS), to the diagnosis of orofacial pain. A total of 328 consecutive patients with orofacial pain were collected over a period of 2 years. The orofacial pain clinic routinely employs criteria published by the IHS, the American Academy of Orofacial Pain (AAOP) and the Research Diagnostic Criteria for Temporomandibular Disorders (RDCTMD). Employing IHS criteria, 184 patients were successfully diagnosed (56%), including 34 with persistent idiopathic facial pain. In the remaining 144 we applied AAOP/RDCTMD criteria and diagnosed 120 as masticatory myofascial pain (MMP) resulting in a diagnostic efficiency of 92.7% (304/328) when applying the three classifications (IHS, AAOP, RDCTMD). Employing further published criteria, 23 patients were diagnosed as neurovascular orofacial pain (NVOP, facial migraine) and one as a neuropathy secondary to connective tissue disease. All the patients were therefore allocated to predefined diagnoses. MMP is clearly defined by AAOP and the RDCTMD. However, NVOP is not defined by any of the above classification systems. The features of MMP and NVOP are presented and analysed with calculations for positive (PPV) and negative predictive values (NPV). In MMP the combination of facial pain aggravated by jaw movement, and the presence of three or more tender muscles resulted in a PPV = 0.82 and a NPV = 0.86. For NVOP the combination of facial pain, throbbing quality, autonomic and/or systemic features and attack duration of > 60 min gave a PPV = 0.71 and a NPV = 0.95. Expansion of the IHS system is needed so as to integrate more orofacial pain syndromes.

Aims: To develop the Jaw Functional Limitation Scale (JFLS), comprising 3 constructs and a global scale, based on a preliminary instrument, and to investigate content validity of the overall functional limitation construct, reliability, and generalizability. A temporomandibular disorders (TMD) patient group, compared to other diagnostic groups, was hypothesized to report further limitation in each of the 3 new proposed constructs., Methods: One hundred thirty-two consecutive patients from 5 diagnostic groups (TMD, primary Sjogren syndrome, burning mouth syndrome, skeletal malocclusion, and healthy controls) participated in a known-groups validity design. Fifty-two jaw functional limitation items were identified by an expert panel for content validity. Rasch methodology was used for item reduction and assessment of model fit. The instrument was retested 1 to 2 weeks later., Results: Three constructs (mastication, vertical jaw mobility, and emotional and verbal expression) comprising a total of 20 items were identified along with a global scale (the JFLS-20), and each exhibited excellent psychometric properties with respect to modeled variance, item fit, reliability, and internal consistency. The psychometric properties of each construct remained satisfactory when analyzed separately among the 5 diagnostic groups. Temporal stability was satisfactory. A shorter 8-item form (JFLS-8) also proved useful for assessing global functional jaw limitation., Conclusion: The JFLS-20 is an organ-specific instrument comprising 3 constructs for assessing functional status of the masticatory system; the 3 scales exhibit properties that are ideal for both research and patient evaluation in patient groups with a range of functional limitations of the jaw. The JFLS-8 emerged as a short form for measuring global functional limitation of the jaw.

Objectives: To investigate the short-term effects of maxillary distraction osteogenesis (DO) on temporomandibular joint (TMJ) function in 21 subjects with cleft lip and palate (CLP). Design - Morphological changes in the maxillofacial region were measured using lateral cephalometric radiographs taken immediately before (pre-DO) and after DO (post-DO) and 1 year after DO (1-year follow-up). A questionnaire was evaluated using a visual analog scale. A chi-square test was used to compare the prevalence of TMJ symptoms between pre-DO and 1-year follow-up. The Spearman correlation coefficient was used to determine the correlation between changes in cephalometric variables and TMJ symptoms in association with maxillary DO. Statistical significance was set at p < 0.05. Results - The ANB (anteroposterior relationship of the maxilla with the mandible) angle and the mandibular plane angle at pre-DO, post-DO, and 1-year follow-up were -4.3 degrees , +5.8 degrees , +4.3 degrees and 32.1 degrees , 33.5 degrees , 33.6 degrees , respectively. The average amounts of anterior and downward movement of the maxilla at post-DO and 1-year follow-up were 8.3, -1.3 and 0.9, 1.1 mm, respectively. The prevalence of TMJ symptoms showed no significant increase in association with maxillary DO. Moreover, there was no significant correlation between changes in cephalometric variables and TMJ symptoms. Conclusion - These results suggest that there was no short-term (i.e., up to 1 year after DO) effect of maxillary DO on TMJ function in subjects with CLP.

This article focuses on chronic myogenous pains affecting the masticatory muscles, including focal myalgia, regional myalgia, myofascial pain, and fibromyalgia. The probable mechanisms are discussed and treatment options, including self-directed treatment, physical medicine modalities, and several types of pharmacologic agents, are presented.

This article highlights the process of making the proper orofacial pain diagnosis. A classification is presented based on the clinical characteristics of the pain complaint and the structure by which it emanates. It is meant to serve as a road map for the clinician, which will help him or her establish the correct diagnosis, thereby allowing the selection of the proper treatment.

Ten patients (one man and nine women, mean age 48.8 +/- 20.1) presented with a stereotypical and undescribed type of head pain. They complained of strictly unilateral, shooting pain paroxysms starting in a focal area of the posterior parietal or temporal region and rapidly spreading forward to the ipsilateral eye (n = 7) or nose (n = 3) along a lineal or zigzag trajectory, the complete sequence lasting 1-10 s. Two patients had ipsilateral lacrimation, and one had rhinorrhoea at the end of the attacks. The attacks could be either spontaneous or triggered by touch on the stemming area (n = 2), which could otherwise remain tender or slightly painful between the paroxysms (n = 5). The frequency ranged from two attacks per month to countless attacks per day, and the temporal pattern was either remitting (n = 5) or chronic (n = 5). This clinical picture might be a variant of an established headache or represent a novel syndrome.

The use of androgenic anabolic steroids (AAS) has increased significantly among athletes in Brazil and other countries. These drugs alter the physiological behavior of bone and muscles, also affecting these structures in masticatory system. This paper aims to evaluate bone and dental changes in users of AAS, as well as the incidence of temporomandibular dysfunction (TMD), compared to athletes not using AAS. Eight athletes were equally divided in two groups, AAS users and non-users. The groups were evaluated using Helkimo index, McNamara cephalometric tracing and cast analysis. The AAS users presented more intense TMD signs and symptoms (Di total value, P = 0.096, Mann-Whitney test), increased cephalometric measures (Co-A, P = 0.020, Mann-Whitney test) and Angle Class II malocclusion, compared to the non-users. These results suggested that the use of AAS alters masticatory structures and increases the incidence of TMD.

The current epidemiological data indicate that at least 20% of the adult population suffer from frequent and returning headaches. The latest classification elaborated by the International Headache Society (IHS) distinguishes more than 80 different kinds of headaches in 14 groups (the second edition). The statistics show that about 30-78% of the cause of these disorders is the tension-type headache (NBG), which turns into chronic state (PNBG) of about 3%. The etiology and the likelihood mechanism of rising this kind of pain is being discussed for many years now and it awakes many controversies. At present, the research workers agree that the peripheral pain mechanism is responsible for rising NBG however at the base of PNBG lies the persistent activation of the peripheral nociceptors by intervention of which it comes to stimulation of central neurons. In confirmation of the muscular origin of NBG and the attempt of stating the new course to take with patients there are works of Simons and co-workers that describe myofascial pain. Myofascial pain is explained as a state of functional disorders which is bred by active trigger points (which breed pain after a fixed pattern) and latent points that being about disorders without pain effect. The treatment of myofascial pain is based on restoring the proper biochemistry and physiological length of the myofascials elements.

Orofacial pain and altered nerve sensation may be the initial sign of oropharyngeal or nasopharyngeal cancer. This article focuses on the most common orofacial pain conditions and neurosensory alterations that affect cancer patients, such as neuropathic pain, muscle spasm or contractures, mucositis, and increased or decreased sensory discrimination in the affected area. The various pharmacotherapeutic modalities for cancer pain management ranging from non steroidal anti-inflammatory drugs (NSAIDs) for mild pain to opioids for severe pain are discussed in detail.

This study tested the hypothesis that a habit reversal program emphasizing awareness and reduction of masticatory muscle activity would significantly reduce pain in patients diagnosed with chronic temporomandibular disorder (TMD) and would be a competitive alternative to a behaviorally-modified dental intervention. Eight individuals diagnosed with TMD were randomly assigned to a splint therapy or habit reversal group. Patients in the splint group received an interocclusal appliance (splint) fabricated from acrylic and were instructed to wear the splint day and night up to a maximum of 20 h per day. Patients in the habit reversal group were given a pager and instructed to check tooth position and masticatory muscle tension when paged. Paging occurred approximately once every 2 h during the day, but not at night. Both groups were instructed to avoid tooth contact and relax the masticatory muscles during the 4 weeks of active treatment. Outcome data were collected at 1 month and 1 year post-treatment intervals. Pain decreased significantly for both groups and did not differ between groups. Habit reversal may be as effective as a behaviorally-modified splint therapy for TMD-related pain.

Aims: To determine orofacial pain (OFP) characteristics, associated disability, and effect on quality of life in elderly community-dwelling Chinese people., Methods: A cross-sectional survey involving elderly people registered with the Family Medicine Unit of the University of Hong Kong served as the sampling frame. Elderly people with recent OFP symptoms and a comparison control group without OFP participated. Standard questions were asked about OFP conditions in the previous month and the Oral Health Impact Profile (OHIP-14), General Health Questionnaire (GHQ-12), and pain-related disability questions were administered prior to a standard clinical examination., Results: Ninety-five people with OFP and 100 people without OFP participated. The median number of pain symptoms per subject was 2.0. Toothache was the most common symptom (58.9%); shooting pain across the face and muscle tenderness were the least common (6.3%). More than half of the pain participants described moderate to severe OFP. The prevalences of patients with neurological/vascular (NV), musculoligamentous/soft tissue (MST), or dentoalveolar (DA) OFP were 35.8%, 33.7%, and 30.5%, respectively. Chronic OFP was common (80%). The mean OHIP-14 summary score was significantly higher in OFP subjects than controls (P < .001) and significantly higher in the MST and DA subgroups than in the NV subgroup (P < .001). GHQ scores of > or = 4, indicating greater psychological distress, were more common in OFP subjects than controls (P < .01). Twenty percent of OFP subjects indicated that their conditions interfered with daily life activities, and in 9.9% it affected ability to work., Conclusion: OFP had a substantial detrimental impact on daily life activities, psychological distress level, and quality of life in Chinese elders. MST and DA conditions had the greatest adverse impact on quality of life.

Objective: The aim of this study was to characterize the association between clinical and psychosocial factors as they related to perceptions by parents and adolescents to the adolescent's oral health status and treatment need. Additionally, the degree to which adolescent's and parent's perceptions of oral health and treatment need were related was examined., Methods: Data from the Pennsylvania oral health needs assessment for 530 parent-adolescent pairs were used to address the objectives of this study. Comparisons between clinical oral health measures, psychosocial factors, and the parent- and adolescent-reported perceptions of the adolescent's oral health status were made using descriptive and inferential statistics, including exploratory factor analysis and path analysis., Results: Parents and adolescents exhibited only modest concordance on ratings of the adolescent's oral health status and need for dental treatment. Furthermore, parents tended to rate their adolescent's oral health status as better than did the adolescent. The results of the path analysis showed that adolescents based their ratings of oral health status more on oral symptoms, while parents rated their adolescent's oral health more on esthetic or psychosocial factors., Conclusions: Adolescents and parents based their perceptions of oral health status and treatment need on different underlying factors. Additionally, adolescents' perceptions of their oral health status and treatment needs did not appear to be communicated to their parents.

Aim: To develop and validate a questionnaire-based tool which would enable classification of idiopathic orofacial pain in the general population., Methods: A postal questionnaire-based cross-sectional survey was made of 4200 randomly selected adults who were registered with a general medical practice in North West England. The questionnaire collected information on a number of factors: demographics (age, gender), orofacial pain (duration, descriptors, site, pattern, intensity, disability, and consultation behavior), and comorbidities (reporting of other unexplained symptoms and psychosocial factors). Subjects reporting orofacial pain were interviewed by an examiner blinded to their exposure status and classified into 1 of 3 categories: (a) dentoalveolar, (b) musculoligamentous/soft tissue, and (c) idiopathic orofacial pain., Results: A high adjusted response rate of 72% was achieved (crude response rate 60%). Of those who reported orofacial pain and were eligible for interview (n=218), 197 (88%) were interviewed. Subjects classified by interview into the idiopathic category were more likely to report aching, nagging, and chronic pain pain at multiple sites. They were also more likely to report facial trauma and other chronic symptoms and to have consulted multiple health-care workers. Variables that most strongly predicted membership into the idiopathic category were female gender, nagging, aching pain which was worse when stressed, and topography (pain at multiple sites and unilateral pain)., Conclusion: The classification criteria developed for idiopathic orofacial pain can be used as a screening tool for subjects with this condition in the general population.

Objective: To investigate the prevalence of Helicobacter pylori (HP) in the nasal cavity of patients with chronic rhinosinusitis (CRS) and to correlate it with the severity of CRS., Study Design and Setting: Intranasal HP was investigated using rapid urease (CLO) testing and immunohistochemical (IHC) analysis and confirmed with transmission electron microscopy. To evaluate the severity of sinusitis, CT scans were graded according to the Lund-MacKay scoring system, and CRS symptom scores were recorded., Results: Twelve of 48 patients (25.0%) were positive, but only 1 of 29 (3.4%) controls was positive for both CLO testing and IHC analysis (P = 0.025). The mean preoperative CT grade (P = 0.439) and symptom scores (P = 0.515) were not related to the severity of CRS., Conclusions: Intranasal HP was more prevalent in patients with CRS than healthy controls. However, there was no significant correlation observed between the severity of sinusitis and intranasal HP colonization., Significance: HP has a limited role in pathogenesis of CRS.

The orofacial pain clinician must understand the difference between peripheral and central mechanisms of pain. Particularly, one has to understand the process of central sensitization as it relates to the various orofacial pain conditions to understand orofacial pain. Understanding leads to more effective treatment.

The diagnostic process for temporomandibular disorders (TMD) is complicated by the multifactorial etiology and multiplicity of clinical signs and symptoms characterizing such disorders. Several electronic instruments and radiological techniques have been proposed over the years in the attempt to integrate clinical evaluation of TMD patients. Nonetheless, literature data still suggest that TMD diagnosis should be based on a thorough clinical assessment and international classifying scheme, also rely on standardized clinical tests to categorize TMD patients. Imaging techniques should be used to gain a better insight within the temporomandibular joint, reserving magnetic resonance to the depiction of soft tissues and computerized tomography to bone structures. EMG-based devices failed to prove effective in improving the diagnostic process for TMD, since a lack of correlation between instrumental signs and patients' symptoms has been showed. The TMD diagnostic process also relies on a psychosocial assessment of patients, which can be useful to detect a psychosocial impairment that needs to be addressed at the therapeutical level.

Dental practitioners as well as general practitioners are frequently confronted with patients complaining of pain in the orofacial region. Diagnosing these pains often poses a challenge to the clinician. Currently, the diagnosis of orofacial pains is biaxial. In determining a diagnosis, it is important to consider, in addition to the condition which is causing the pain (axis I-diagnosis), the impact of the pain on the patient's ability to function (axis II-diagnosis). The compilation of a thorough medical history represents the most important diagnostic tool and basis for clinical examination. Based on the axis I-diagnosis several treatment options are suggested; the strategy for managing the pain is, however, largely determined by the axis II-diagnosis.

The etiology of craniomandibular disorders (CMD) is multi-factorial and the treatment should be selected with recognition of the different factors. The aim of the study was to investigate the influence of occlusion splint therapy (Michigan splint), physical exercises and transcutaneous nerve stimulation (TENS) on CMD symptomatology. At the Clinic of Maxillofacial Surgery in Belgrade, in the period from May, 2001-December, 2003, 168 patients were examined by the CMD working group. This group, comprised of different specialties (maxillofacial surgeon, prosthodontist, orthodontist, neurologist, psychiatrist and physiatrician), enabled multidisciplinary treatment of CMD patients according to the guidelines given by American Academy for Craniomandibular Dysfunctions. In all, a total of 30 patients with prevalent muscular tensions among other CMD symptoms were included in this study. The examination form according to Fricton and Shiffman for Craniomandibular Index (CMI) was used in order to evaluate the function of Craniomandibular system before and after therapy.A statistically significant difference (t = 8,735; P < 0,001) between the average values for CMI of patients before (0,2297 +/- 0,0827) and after therapy (0,1002 +/- 0,0479) was observed. Performed treatment resulted in complete response (pain relief and absence of CMD symptoms and signs) in over than 80% of patients and could be considered as a method of choice in reversible occlusal therapy.

Differential diagnosis of pain in the face as the presenting complaint can be difficult. We propose an approach based on history and neurological examination, which allows a working diagnosis to be made at the bedside, including aetiological hypotheses, leading to a choice of investigations. Neuralgias are characterised by stabs of short lasting, lancinating pain, and, although neuralgias are often primary, imaging may be needed to exclude symptomatic forms. Facial pain with cranial nerve symptoms and signs is almost exclusively of secondary origin and requires urgent examination. Facial pain with focal autonomic signs is mostly primary and belongs to the group of the idiopathic trigeminal autonomic cephalalgias, but can occasionally be secondary. Pure facial pain is most often due to sinusitis and the chewing apparatus, but also a multitude of other causes. The pain can also be idiopathic. Imaging as well as non-neurological specialist assessment is often necessary in these cases.

Background: Recurrent or chronic facial pain may be a diagnostic challenge. Applying the diagnostic criteria of the second edition of the International Classification of Headache Disorders (ICHD-II) leaves a considerable number of patients unclassifiable., Objective: The aim of this study was to establish and evaluate revised criteria of trigeminal neuralgia and persistent idiopathic facial pain., Methods: Based on the diagnostic value of 12 clinical features of trigeminal neuralgia and 15 features of persistent idiopathic facial in 97 patients referred for facial pain to a neurological tertiary care centre we established revised criteria for persistent idiopathic facial pain and additional criteria for probable trigeminal neuralgia and probable idiopathic facial pain., Results: Applying the newly proposed criteria reduced the number of patients with facial pain not classifiable by more than 50%. The new criteria improved the sensitivity, particularly in idiopathic facial pain and did not cause a relevant decrease in specificity compared to ICHD-II., Conclusion: This study suggests that amendments to the ICHD-II criteria improve the diagnostic classification of facial pain.

The aim of this study was to examine the diagnostic spectrum of facial pain and to evaluate the clinical features relevant to the differential diagnosis in a neurological tertiary care centre. This is the first investigation comparing the first with the second edition of the International Classification of Headache Disorders (ICHD-I, ICHD-II) in consecutively referred patients comprising a broad spectrum of disorders without restricting the inclusion to certain diagnoses. Studying 97 consecutive patients referred for facial pain, we found trigeminal neuralgia or other types of cranial neuralgia in 38% and 39% according to ICHD-I and ICHD-II, respectively; persistent idiopathic facial pain was diagnosed in 27% and 21%, respectively. The proportion of patients who could not be classified was 24% in ICHD-I and 29% in ICHD-II. Six per cent of the patients had cluster headache or chronic paroxysmal hemicrania, the remaining 5% had various other disorders. The agreement between ICHD-I and ICHD-II was very good to perfect. In ICHD-II, sensitivity and specificity were similar to ICHD-I, the specificity and negative predictive value were imrpoved in single features of trigeminal neuralgia, but were widely unchanged in persistent idiopathic facial pain. The number of patients who could not be classified was larger in ICHD-II than in ICHD-I. Modifying the diagnostic criteria for different types of facial pain, in particular changes in the criteria of persistent idiopathic facial pain, might be helpful in reducing the number of patients with unclassifiable facial pain.