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Two cases of pain evoked by cold food ingestion, following root canal therapy, are presented. The source of pain was detected when cold application to the vestibular, periapical area corresponding to the teeth involved evoked strong pain of about 30-second durations. In the first case, the patient suffered from strong pain in the mandibular right area over the last 4 months. After successive root canal therapy of three mandibular right teeth, the spontaneous pain eased significantly, but strong pain evoked by cold food ingestion persisted. Cold application to the vestibular periapical area of teeth involved identified the source of pain, which was abolished by 80 mg/day of slow-release propranolol. In the second case, cold allodynia developed after root canal therapy. The root canal therapy was performed for prosthetic reasons with no prior pain. Pain could be duplicated by cold application to the vestibular area of the treated tooth. The patient preferred no treatment when the source of pain was explained. In both cases cold application did not produce any pain in other intraoral locations, including the contralateral vestibular area or the mid soft or hard palate. Pain mechanisms, neurovascular and neuropathic, which differ for each case are discussed. Keywords: cold allodynia, ice-cream headache, neuropathic oral pain, neurovascular orofacial pain

Objectives: Sedation is commonly utilized for individuals otherwise unable to receive dental treatment, such as those with disabilities, medically complex conditions, and dentophobics. The aim was to characterize the profiles of patients receiving various types of sedation and assess the corresponding success rates. Method and materials: This was a 5-year records-based retrospective study. Data regarding the indication for sedation, medical history, sedation type, and treatments performed were recorded. Results: In total, 103 patients underwent 389 treatment sessions under sedation; 42.7% of the patients were disabled. The most commonly administered sedation was moderate sedation, (49.4%), followed by deep (36.8%) and inhaled sedation (13.9%). Successful treatment results were achieved in 96.1% of sessions, with no adverse effects noted during recovery. The high success rates were independent of patient age, sex, and sedation type. There was a positive association between the indication for sedation and the type of sedation. The medically complex patients and the dentophobic patients received mainly moderate sedation (85.3% and 58.2%, respectively), whereas the disabled patients received deep sedation (51.2%). In total, 94% of patients were returning (re-visiting) patients. A statistically significant association was found between the type of sedation administered and the success rate during the first and last sessions (P < .001). The success rate at the first session may be predictive of the success in subsequent sessions. Conclusion: A significant positive correlation was found between patient characteristics and the chosen sedation type leading to a high success rate across the various sedation modalities. Keywords: dentophobia, disabled patients, medically complex patients, oral care, sedation

Objectives: Burning mouth syndrome is an intraoral chronic pain condition characterized by a moderate to severe sensation of burning from the oral mucosa. No clinical signs are found and there is no efficient treatment. Method and materials: This pilot study included 10 women that were resistant to other previous treatments or noncompliant to systemic medications. Patients were asked to apply tretinoin gel 0.05% on their tongues twice daily for 14 days. Treatment effectiveness was assessed by completing a pre-study psychologic questionnaire and recording a daily wellbeing and pain log. Results: Significant pain-score decrease in 50% of the patients (delta numerical rating score –3.15 ± 3.02, P value = .005) was recorded. This finding was in concordance with the verbal statements including major quality-of-life improvement (P value = .05), without any treatment positive or negative predictive factors. Conclusions: Topical tretinoin exhibits potential efficacy in patients with treatment resistant burning mouth syndrome and may also be used as a primary treatment modality. Keywords: burning mouth syndrome, tretinoin, retinoids, vitamin A

Objective: Occlusal stabilization splints (OSSs) are first-line therapy for temporomandibular disorder (TMD) and sleep-related-bruxism (SRB). The main goal of this study was to quantify adherence rates to OSS therapy in TMD patients and among non-painful conditions such as clenching and bruxism. It was hypothesized that adherence rates would be similar to those for other chronic conditions. Method and materials: Medical records of 99 patients seen in the Orofacial Pain Clinic between 2006 and 2014 were reviewed. Patients meeting the inclusion criteria were interviewed over the telephone regarding OSS adherence. Results: Of the 99 patients interviewed, 80 had chronic orofacial pain related to TMD and 19 received OSS due to (non-painful) SRB. Patients were divided according to usage; the USER group (58 patients, 58.6%) used their OSS for more than 1 year; the NUSE group was the remaining 41 (41.4%) patients who used their device for less than 1 year. Of the patients with pain as the reason for OSS use, 50 (62.5%) were in the USER group and 30 (37.5%) were in the NUSE group. The most common diagnosis was masticatory muscle disorders (MMD) with a 71.4% adherence rate, representing 60.3% of the USER group, which was significantly higher than those with SRB and other facial pain (P = .039). The most common reasons for non-adherence were sleep difficulties with OSS (31.6%) and resolution of the problem (25%). Conclusions: Patients reporting mild to major pain reduction had higher adherence rates than those with complete pain relief or none at all. Patients with MMD exhibited higher adherence rates than those with other facial pain types and SRB. Keywords: adherence, masticatory muscle disorders, occlusal stabilization splint, temporomandibular disorders

Aims: To test and re-examine the diagnostic criteria for neurovascular orofacial pain (NVOP) compared to posttraumatic trigeminal neuropathy (PTTN). Methods: Pain and patient characteristics were compared in patients with NVOP, PTTN, and NVOP initiated by trauma (PT-NVOP). NVOP criteria were based on prior studies, and PTTN was defined according to the International Classification of Headache Disorders, version 3 beta. Results: Of the 170 patients in the cohort, 90 had PTTN, 51 had NVOP, and 29 had PT-NVOP. None of the tested parameters in the NVOP and PT-NVOP patients were significantly different, and therefore these patients were combined into one group (T-NVOP). T-NVOP differed significantly from PTTN (P .001) in periodic pain patterns, presence of autonomic and systemic signs, throbbing pain quality, and frequency of bilaterality. Pain quality in PTTN was more burning/stabbing than in NVOP (P = .003). Pain severity, waking from sleep, muscle sensitivity to palpation, and demographics were comparable. Conclusion: NVOP differs from PTTN in parameters essential to diagnosis: periodicity of pain, presence of autonomic and systemic accompanying signs, throbbing pain quality, and bilateral presentation. NVOP is amenable to abortive and prophylactic antimigraine therapies, distinguishing NVOP from PTTN in clinical features, treatment, and prognosis. Keywords: migraine, neurovascular orofacial pain, persistent idiopathic facial pain, post traumatic trigeminal neuropathy

Aims: To analyze cervical tenderness scores (CTS) in patients with various temporomandibular disorders (TMD) and in controls and to examine associations of CTS with demographic and clinical parameters. Methods: This case-control study included 192 TMD patients and 99 controls diagnosed based on a questionnaire and a clinical examination following the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) guidelines. CTS, adapted from the widely used total tenderness score, was the mean sum of the palpation scores from the suboccipital, sternocleidomastoid, and trapezius muscles. Depending on the variables, data were analyzed using Pearson chi-square, analysis of variance, t test, Bonferroni post hoc adjustment, and/or multivariate linear regression analyses. Results: CTS was higher in TMD patients compared to controls (P .001). Across TMD subgroups, CTS was notable only in those with a myogenous TMD diagnosis, but not in arthrogenous TMD (P = .014). CTS was positively associated with: female sex (P = .03), whiplash history, higher verbal pain scores, comorbid headaches, body pain, increased pain on mouth opening, and higher masticatory muscles tenderness scores (MTS) (P .001 for all). Sex (P .001), MTS (P .001), comorbid headache (P = .042), and pain on opening (mild: P = .031; moderate: P = .022) retained significant associations with CTS in the multivariate analysis, and these main effects were influenced by interactions with whiplash history and comorbid body pain. Conclusion: CTS differentiated between TMD patients and controls and between TMD diagnoses. Specific patient and pain characteristics associated with poor outcome in terms of CTS included effects of interactions between myogenous TMD, female sex, whiplash history, comorbid body pain and headaches, and pain on opening. It can therefore be concluded that routine clinical examination of TMD patients should include assessment of the cervical region. Keywords: cervical muscle tenderness, masticatory muscle disorders, muscle tenderness score, temporomandibular disorders

Aims: To evaluate and compare the pharmacotherapeutic efficacies of two tricyclic antidepressant (TCA) drugs for masticatory myofascial pain (MFP): nortriptyline (NOR) and amitriptyline (AMI). Methods: Fifty patients with chronic MFP were included in the study; 30 were medicated with AMI only, and 20 took NOR after discontinuing AMI due to adverse effects. Pain diaries recording verbal pain scores (VPS) were utilized to compare posttreatment scores to baseline scores. Chi-square and t tests were used to analyze the data. Results: Across both groups, the mean ± standard deviation VPS score at the end of treatment (2.92 ± 3.2) was significantly lower compared to baseline (6.4 ± 1.75; P .0001) and was a clinically meaningful (≥ 50%) difference. Initial VPS scores were similar in the AMI and NOR groups (6.27 ± 1.92 and 6.78 ± 1.98). At the end of the study, NOR patients reported a lower final VPS compared to AMI patients (2.83 ± 3.06 vs 4.55 ± 2.92; P = .039). The 50% improvement rate with NOR treatment was better than with AMI treatment (P = .036). The same maximal dosages were used by the patients who achieved a ≥ 50% success rate (20.96 ± 5.036 mg) than those who did not (21.667 ± 5.036 mg). Conclusion: TCAs are effective in reducing pain in patients with chronic MFP. NOR seems more effective and better tolerated than AMI, but due to study limitations, more data are needed to confirm these results. Keywords: amitriptyline, myalgia, myofascial pain, orofacial pain

Objective: In this review article, the role of the dentist in the evaluation and treatment of snoring and Obstructive Sleep Apnea Syndrome (OSAS) in children is described. Snoring and OSAS in children is receiving increased awareness, with reported rates approximating 10% of children who regularly snore, and up to 4% who suffer from OSAS. OSAS in children may have serious developmental and behavioral consequences. Apnea Hypopnea Index (AHI) is the main outcome of the polysomnography test, but its diagnostic values differ from children to adults, as do treatment approaches. Data Sources and Study Selection: A comprehensive literature search of publications from 1973 to 2017 in the PubMed Direct databases was performed to collect information about snoring and OSAS in children. The search was limited to peer-reviewed articles written in English with a few exceptions in other languages. Conclusion: Dentists play a significant role in early detection of OSAS, helping in reducing and preventing its serious consequences. A multidisciplinary treatment team, which manages and treats OSAS, should include the dentist in addition to the sleep specialist and the ENT physician. Keywords: adenoidectomy, obstructive sleep apnea, pediatric, sleep-disordered breathing, snoring, tonsillectomy

Aims: To measure sleep quality in temporomandibular disorder (TMD) patients, to compare it with that of control subjects, and to analyze its association with disease characteristics and oral health-related quality of life (OHRQoL). Methods: The collected data included demographics, tobacco use, the Pittsburgh Sleep Quality Index (PSQI), trauma history, presence of coexisting headaches and/or body pain, parafunctional habits, pain scores, muscle tenderness to palpation scores, and the Oral Health Impact Profile-14 (OHIP-14). Differences between groups were examined with Pearson chi-square test for categorical variables and independent t test and analysis of variance (ANOVA) for numeric variables. Significant differences were then further tested with multivariate backward stepwise linear regression analysis. Results: The final analysis was performed on 286 individuals (187 TMD patients and 99 controls). Poor sleep (PSQI global score > 5) was exhibited in 43.3% of the TMD group and in 28.3% of the control group (P = .013) (mean ± standard deviation [SD] PSQI score = 5.53 ± 2.85 for TMD patients and 4.41 ± 2.64 for controls, P = .001). TMD patients had significantly worse scores in the sleep quality component of the PSQI questionnaire (P = .006). Higher PSQI global scores and poor sleep were positively associated with whiplash history (P = .009 and P = .004, respectively), coexisting headaches (P = .005 and P = .002), body pain (P = .001 and P .001), clenching habit (P = .016 and P = .006), reduced unassisted (P = .014 and P = .042) and assisted (P = .005 and P = .006) mouth opening, higher muscle tenderness scores, higher pain scores, and higher OHIP-14 global and dimension scores. Conclusion: TMD patients had poorer sleep than controls. Sleep quality was positively associated with TMD disease characteristics, comorbid pain conditions, and poorer OHRQoL. Assessing sleep quality should be a routine part of the diagnostic work-up of TMD patients. A multidisciplinary management approach is needed to address all the factors-including sleep-that modulate pain experience. Keywords: Oral Health Impact Profile-14 (OHIP-14), oral health-related quality of life (OHRQoL), orofacial pain, pain, Pittsburgh Sleep Quality Index (PSQI), sleep, temporomandibular disorders (TMD)

Chronic osteomyelitis of the jaws presents a diagnostic and therapeutic challenge. A 45-year-old woman presented with episodic pain in the right mandible of two and a half years' duration. During active periods, lasting for 2 to 3 weeks, the pain woke the patient from sleep at a regular time, and had features mimicking a variant of cluster headache. However, clinical, radiologic, and histologic findings confirmed the diagnosis of chronic sclerosing osteomyelitis. Conservative treatment, including 6 weeks of intravenous antibiotics, relieved the pain with no signs of recurrence at the 1-year follow-up. We emphasize the importance of including chronic osteomyelitis in the differential diagnosis of idiopathic orofacial pain disorders, particularly in the mandibular area. Keywords: chronic sclerosing osteomyelitis, osteomyelitis of the jaw, osteosclerosis